Kozier & Erb_s Fundamentals of Nursing Plus MyNursing Lab with Pearson eText Access Card Package, 10 by Ace Test Banks

Kozier & Erb_s Fundamentals of Nursing Plus MyNursing Lab with Pearson eText -- Access Card Package, 10E By Audrey T Berman

Email: richard@qwconsultancy.com

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 01 Question 1 Type: SEQ 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). Standard Text: Click and drag the options below to move them up or down. Choice 1. The Order of Deaconesses opens a small hospital in Kaiserswerth, Germany. Choice 2. The Knights of St. Lazarus dedicate themselves to the care of people with leprosy, syphilis, and chronic skin conditions. Choice 3. Harriet Tubman provides care to slaves fleeing on the Underground Railroad. Choice 4. The Cadet Nurse Corps is established. Choice 5. Florence Nightingale administers to soldiers during the Crimean War. Correct Answer: 2, 1, 5, 3, 4 Rationale 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. Rationale 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. Rationale 3: During the American Civil War (1861–1865), Harriet Tubman (among other nurses) administered to the care of slaves and injured soldiers. Rationale 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. Rationale 5: During the Crimean War (1854–1856), Ms. Nightingale administered to the solders following a request by Sir Sidney Herbert of the British War Department.

Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.C. 3. Value the perspectives and expertise of all health team members AACN Essentials Competencies: I. 9. Value the ideal of lifelong learning to support excellence in nursing practice NLN Competencies: Knowledge and Science; Knowledge; The state of science in nursing Nursing/Integrated Concepts: Nursing Process: Planning Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 1. Discuss historical factors and nursing leaders, female and male, influencing the development of nursing. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 3 Question 2 Type: MCSA 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’s first patient care experiences were during a time of war. 3. The patient decided to leave the profession after serving in the war. 4. The patient contracted long-term illnesses from being overseas in a war. Correct Answer: 2 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. There is no evidence that the patient did not continue in the role of a nurse after the war. Rationale 4: 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. There is no evidence that the patient contracted long-term illnesses from serving in the war. .

Learning Outcome: 1. Discuss historical factors and nursing leaders, female and male, influencing the development of nursing. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 4 Question 3 Type: MCSA The nurse is reviewing public health and health promotion roles for 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 Correct Answer: 4 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.C. 3. Value the perspectives and expertise of all health team members AACN Essentials Competencies: I. 9. Value the ideal of lifelong learning to support excellence in nursing practice NLN Competencies: Knowledge and Science; Knowledge; The state of science in nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Discuss historical factors and nursing leaders, female and male, influencing the development of nursing. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 6 Question 4 Type: MCSA 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. Margaret Higgins Sanger 4. Virginia Henderson Correct Answer: 2 Rationale 1: Mary Breckinridge established the Frontier Nursing Service. Rationale 2: 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. Rationale 3: Margaret Higgins Sanger is considered the founder of Planned Parenthood. Rationale 4: Virginia Henderson was one of the first modern nurses to define nursing.

NLN Competencies: Knowledge and Science; Knowledge; The state of science in nursing Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1. Discuss historical factors and nursing leaders, female and male, influencing the development of nursing. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 7 Question 5 Type: MCSA While a nurse is 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 health care needs. 3. The person is a collaborator in his or her care. 4. The individual is using a service or commodity. Correct Answer: 1 Rationale 1: 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 health care needs. The term client presents the recipient of health care 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. Rationale 2: 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 health care needs. The term client presents the recipient of health care 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. Rationale 3: 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 health care needs. The term client presents the recipient of health care 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. Rationale 4: 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 health care needs. The term client presents the recipient of health care as a collaborator in that Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.C. 3. Value the perspectives and expertise of all health team members AACN Essentials Competencies: I. 9. Value the ideal of lifelong learning to support excellence in nursing practice NLN Competencies: Knowledge and Science; Knowledge; The state of science in nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe how the definition of nursing has evolved since Florence Nightingale. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 13 Question 6 Type: MCSA 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 disease 3. Exercise class for clients who have had a stroke 4. Home accident prevention Correct Answer: 4 Rationale 1: 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 disease. Teaching clients about recovery activities, such as exercises that accelerate recovery after a stroke, would focus on health restoration. Rationale 2: 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 disease. Teaching clients about recovery activities, such as exercises that accelerate recovery after a stroke, would focus on health restoration. Rationale 3: 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, Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 disease. Teaching clients about recovery activities, such as exercises that accelerate recovery after a stroke, would focus on health restoration. Rationale 4: 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 disease. Teaching clients about recovery activities, such as exercises that accelerate recovery after a stroke, would focus on health restoration.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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. Describe the expanded career roles of nurses and their functions.. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 14 Question 7 Type: MCSA The nurse is offering free occult blood screening at 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 Correct Answer: 3 Rationale 1: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: 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. Rationale 3: 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. Rationale 4: 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.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: 8. Describe the roles of nurses. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 14 Question 8 Type: MCSA The nurse has starting working in a state other than the one in which the nursing education program was located. Which of the following 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 Correct Answer: 4 Rationale 1: Nurse practice acts regulate the practice of nursing in the United States and Canada. Each state and each province has its own act. Nurses are responsible for knowing their state's nurse practice act, as it governs Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Rationale 2: Nurse practice acts regulate the practice of nursing in the United States and Canada. Each state and each province has 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. Rationale 3: Nurse practice acts regulate the practice of nursing in the United States and Canada. Each state and each province has 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. Rationale 4: Nurse practice acts regulate the practice of nursing in the United States and Canada. Each state and each province has 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.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A. 2. Describe scopes of practice and roles of health care team members AACN Essentials 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: 7. Identify the purposes of nurse practice acts and standards of professional nursing practice. MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 15 Question 9 Type: MCSA A seasoned nurse is a mentor for a new graduate. Which of the standards of professional performance is the seasoned nurse practicing? 1. Collaboration 2. Leadership 3. Collegiality 4. Evaluation Correct Answer: 3 Rationale 1: Collegiality describes interaction with and contributions to the professional development of peers and colleagues, which is what a mentoring relationship would involve. Collaboration involves working with the Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

client, the family, and others in the conduct of nursing practice. Leadership provides direction in a professional practice setting, and evaluation involves a comparison between one's own nursing practice and professional practice standards. Rationale 2: Collegiality describes interaction with and contributions to the professional development of peers and colleagues, which is what a mentoring relationship would involve. Collaboration involves working with the client, the family, and others in the conduct of nursing practice. Leadership provides direction in a professional practice setting, and evaluation involves a comparison between one's own nursing practice and professional practice standards. Rationale 3: Collegiality describes interaction with and contributions to the professional development of peers and colleagues, which is what a mentoring relationship would involve. Collaboration involves working with the client, the family, and others in the conduct of nursing practice. Leadership provides direction in a professional practice setting, and evaluation involves a comparison between one's own nursing practice and professional practice standards. Rationale 4: Collegiality describes interaction with and contributions to the professional development of peers and colleagues, which is what a mentoring relationship would involve. Collaboration involves working with the client, the family, and others in the conduct of nursing practice. Leadership provides direction in a professional practice setting, and evaluation involves a comparison between one's own nursing practice and professional practice standards.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A. 2. Describe scopes of practice and roles of health care team members AACN Essentials 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: 10. Discuss the criteria of a profession and the professionalization of nursing. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 18 Question 10 Type: MCSA The nurse ensures that a patient is covered during a bath. In which nursing role is the nurse functioning? 1. Caregiver 2. Communicator 3. Teacher 4. Client advocate Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1 Rationale 1: 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 health care 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. Rationale 2: 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 health care 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. Rationale 3: 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 health care 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. Rationale 4: 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 health care 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.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A. 2. Describe scopes of practice and roles of health care team members AACN Essentials 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: 8. Describe the roles of nurses. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 15 Question 11 Type: MCSA 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." Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. "The family must be involved in this decision." 4. "Let's educate the family about the consequences of this decision." Correct Answer: 1 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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. . Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: II.A. 2. Describe scopes of practice and roles of health care team members AACN Essentials Competencies: VI. 2. Use inter- and intraprofessional 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: 8. Describe the roles of nurses. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 15 Question 12 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Delegating activities to other nurses 3. Evaluating the performance of ancillary workers 4. Identifying areas of client concern or problems Correct Answer: 1 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A. 2. Describe scopes of practice and roles of health care team members AACN Essentials 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: 8. Describe the roles of nurses. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 16 Question 13 Type: MCSA The manager identifies that a nurse is practicing professionalism. What did the manager observe to come to this conclusion? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 2 Rationale 1: Professionalism refers to professional character, spirit, or methods. It is a set of attributes and a way of life that implies responsibility and commitment. Florence Nightingale influenced nursing professionalism a great deal, but simply learning about her influence does not constitute professionalism because professionalism 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. Rationale 2: Professionalism refers to professional character, spirit, or methods. It is a set of attributes and a way of life that implies responsibility and commitment. Florence Nightingale influenced nursing professionalism a great deal, but simply learning about her influence does not constitute professionalism because professionalism 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. Rationale 3: Professionalism refers to professional character, spirit, or methods. It is a set of attributes and a way of life that implies responsibility and commitment. Florence Nightingale influenced nursing professionalism a great deal, but simply learning about her influence does not constitute professionalism because professionalism 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. Rationale 4: Professionalism refers to professional character, spirit, or methods. It is a set of attributes and a way of life that implies responsibility and commitment. Florence Nightingale influenced nursing professionalism a great deal, but simply learning about her influence does not constitute professionalism because professionalism 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.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.C. 5. Respect the unique attributes that members bring to a team, including variations in professional orientations and accountabilities AACN Essentials 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: 10. Discuss the criteria of a profession and the professionalization of nursing. MNL Learning Outcome: 1.1.3. Consider how values impact the practice of nursing. Page Number: 17 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 14 Type: MCSA 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 Correct Answer: 2 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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.

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: 8. Describe the roles of nurses. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 17 Question 15 Type: MCSA The student nurse contacts a number of other students to create a study group. What behavior is the student nurse demonstrating? 1. Governance 2. Socialization 3. Service orientation 4. Specialized education Correct Answer: 2 Rationale 1: Governance is the establishment and maintenance of social, political, and economic arrangements by which practitioners control their practice, working conditions, and professional affairs. Rationale 2: Socialization 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 socialization is interacting with fellow students and becoming bound together by feelings of mutual cooperation, support, and solidarity. Rationale 3: Service orientation differentiates nursing from an occupation pursued primarily for profit. Rationale 4: Specialized education is an important aspect of professional status and is focused on the course of study and curriculum particular to the profession.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.C. 5. Respect the unique attributes that members bring to a team, including variations in professional orientations and accountabilities AACN Essentials 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: 8. Describe the roles of nurses. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 17 Question 16 Type: MCSA The nursing instructor is explaining the present economic challenges in health care to students in a community health course. What should the instructor emphasize as being important for the students to be aware of? 1. Passage of the Affordable Care Act 2. Consumer presence on the boards of nursing associations and regulatory agencies 3. Diagnostic-related groups (DRGs) 4. Advances in science and technology Correct Answer: 1 Rationale 1: With the passage of the Affordable Care Act (ACA) in 2010, health care delivery shifted in focus from acute care to primary preventive care and treatment of chronic conditions using health care teams and information technology. 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 this is an aspect of economic factors affecting nursing, it is not the underlying cause of more personnel being employed in community-based settings. Rationale 2: With the passage of the Affordable Care Act (ACA) in 2010, health care delivery shifted in focus from acute care to primary preventive care and treatment of chronic conditions using health care teams and information technology. 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 this is an aspect of economic factors affecting nursing, it is not the underlying cause of more personnel being employed in community-based settings. Rationale 3: With the passage of the Affordable Care Act (ACA) in 2010, health care delivery shifted in focus from acute care to primary preventive care and treatment of chronic conditions using health care teams and information technology. 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 this is an aspect of economic factors affecting nursing, it is not the underlying cause of more personnel being employed in community-based settings. Rationale 4: With the passage of the Affordable Care Act (ACA) in 2010, health care delivery shifted in focus from acute care to primary preventive care and treatment of chronic conditions using health care teams and information technology. 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 this is an aspect of economic factors affecting nursing, it is not the underlying cause of more personnel being employed in community-based settings.

Cognitive Level: Applying Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A. 4. Recognize contributions of other individuals and groups in helping patient/family achieve health goals AACN Essentials 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 economic policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Describe factors influencing contemporary nursing practice. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 19 Question 17 Type: MCSA The community health nurse is caring for teenage 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 Correct Answer: 4 Rationale 1: Teenage mothers have the normal needs of teenagers as well as those of new mothers, with motherhood compounding the difficulties of adolescence. Although many teenage 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. Rationale 2: Teenage mothers have the normal needs of teenagers as well as those of new mothers, with motherhood compounding the difficulties of adolescence. Although many teenage 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. Rationale 3: Teenage mothers have the normal needs of teenagers as well as those of new mothers, with motherhood compounding the difficulties of adolescence. Although many teenage 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. Rationale 4: Teenage mothers have the normal needs of teenagers as well as those of new mothers, with motherhood compounding the difficulties of adolescence. Although many teenage 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.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; Knowledge; family dynamics Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9. Describe the expanded career roles of nurses and their functions. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 19 Question 18 Type: MCSA 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." Correct Answer: 3 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: VI.A. 4. Describe examples of how technology and information management are related to the quality and safety of patient care AACN Essentials 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: 9. Describe the expanded career roles of nurses and their functions. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 20 Question 19 Type: MCSA 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 Correct Answer: 4 Rationale 1: Promoting health and wellness may involve 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 and injury in the home and workplace. Rationale 2: The goal of illness prevention programs is to maintain optimal health by preventing disease. Rationale 3: Restoring health focuses on the ill client, and it extends from early detection of disease through helping the client during the recovery period. Rationale 4: 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.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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: 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: 6. Identify the four major areas of nursing practice. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 14 Question 20 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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.

Cognitive Level: Applying Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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: Quality and Safety; Ethical Comportment; Engage in lifelong learning to keep professional knowledge current Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Explain the importance of continuing nursing education. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 12 Question 21 Type: MCSA 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. An advanced leadership role 2. Case manager 3. Wound care specialist 4. Intravenous therapy specialist Correct Answer: 1 Rationale 1: The emphasis of master’s degree programs is on preparing nurses for advanced leadership roles in administration, clinical, or teaching. Rationale 2: The emphasis of master’s degree programs is on preparing nurses for advanced leadership roles in administration, clinical, or teaching. A case manager does not necessarily need to have a master’s degree. Rationale 3: The emphasis of master’s degree programs is on preparing nurses for advanced leadership roles in administration, clinical, or teaching. A wound care specialist does not necessarily need a master’s degree.. Rationale 4: The emphasis of master’s degree programs is on preparing nurses for advanced leadership roles in administration, clinical, or teaching An intravenous therapy specialist does not necessarily need a master’s degree.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B. 2. Initiate plan for self-development as a team member 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: Quality and Safety; Ethical Comportment; Engage in lifelong learning to keep professional knowledge current Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Describe the different types of educational programs for nurses. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 11 Question 22 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: 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. The league does not offer assistance with getting into graduate school. Rationale 3: 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. The league does not provide scholarships. Rationale 4: 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. The league does not provide assistance with finding employment.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B. 2. Initiate plan for self-development as a team member 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: Quality and Safety; Ethical Comportment; Engage in lifelong learning to keep professional knowledge current Nursing/Integrated Concepts: Nursing Process: Planning Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 13. Explain the functions of national and international nurses’ associations.. MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies. Page Number: 22 Question 23 Type: MCSA 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 practitioner 2. Clinical nurse specialist 3. Nurse educator 4. Nurse entrepreneur Correct Answer: 2 Rationale 1: 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 an advanced education, is a graduate of a nurse practitioner program, and usually deals with nonemergency acute or chronic illness and provides primary ambulatory care. The nurse educator is responsible for classroom and often clinical teaching. A nurse entrepreneur usually has an advanced degree, manages a health-related business, and may be involved in education, consultation, or research. Rationale 2: 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 an advanced education, is a graduate of a nurse practitioner program, and usually deals with nonemergency acute or chronic illness and provides primary ambulatory care. The nurse educator is responsible for classroom and often clinical teaching. A nurse entrepreneur usually has an advanced degree, manages a health-related business, and may be involved in education, consultation, or research. Rationale 3: 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 an advanced education, is a graduate of a nurse practitioner program, and usually deals with nonemergency acute or chronic illness and provides primary ambulatory care. The nurse educator is responsible for classroom and often clinical teaching. A nurse entrepreneur usually has an advanced degree, manages a health-related business, and may be involved in education, consultation, or research. Rationale 4: 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 an advanced education, is a graduate of a nurse practitioner program, and usually deals with nonemergency acute or chronic illness and provides primary ambulatory care. The nurse educator is responsible for classroom and often clinical teaching. A nurse Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

entrepreneur usually has an advanced degree, manages a health-related business, and may be involved in education, consultation, or research.

Cognitive Level: Analysis Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B. 2. Initiate plan for self-development as a team member 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: Quality and Safety; Ethical Comportment; Engage in lifelong learning to keep professional knowledge current Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Discuss the evolution of nursing education and entry into professional nursing practice.. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 16 Question 24 Type: MCSA 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 Correct Answer: 3 Rationale 1: 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. Rationale 2: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: 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. Rationale 4: 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.

Correct Answer: 1, 2, 5, 6 Rationale 1: Adaptive; client-centered; art; science; holistic; caring; concerned with health promotion, health maintenance, and health restoration; and a helping profession are themes that are common to many definitions formulated about nursing. In 1973, the American Nurses Association (ANA) described nursing practice as goaloriented and adaptable to the needs of the individual, the family, and the community (not just the client). In 1980, the ANA's definition was changed to "Nursing is the diagnosis and treatment of the human responses to actual or potential health problems." Diagnosis and treatment of disease is a definition of the medical model. Rationale 2: Adaptive; client-centered; art; science; holistic; caring; concerned with health promotion, health maintenance, and health restoration; and a helping profession are themes that are common to many definitions formulated about nursing. In 1973, the American Nurses Association (ANA) described nursing practice as goaloriented and adaptable to the needs of the individual, the family, and the community (not just the client). In 1980, the ANA's definition was changed to "Nursing is the diagnosis and treatment of the human responses to actual or potential health problems." Diagnosis and treatment of disease is a definition of the medical model. Rationale 3: Adaptive; client-centered; art; science; holistic; caring; concerned with health promotion, health maintenance, and health restoration; and a helping profession are themes that are common to many definitions formulated about nursing. In 1973, the American Nurses Association (ANA) described nursing practice as goaloriented and adaptable to the needs of the individual, the family, and the community (not just the client). In 1980, the ANA's definition was changed to "Nursing is the diagnosis and treatment of the human responses to actual or potential health problems." Diagnosis and treatment of disease is a definition of the medical model. Rationale 4: Adaptive; client-centered; art; science; holistic; caring; concerned with health promotion, health maintenance, and health restoration; and a helping profession are themes that are common to many definitions formulated about nursing. In 1973, the American Nurses Association (ANA) described nursing practice as goaloriented and adaptable to the needs of the individual, the family, and the community (not just the client). In 1980, the ANA's definition was changed to "Nursing is the diagnosis and treatment of the human responses to actual or potential health problems." Diagnosis and treatment of disease is a definition of the medical model. Rationale 5: Adaptive; client-centered; art; science; holistic; caring; concerned with health promotion, health maintenance, and health restoration; and a helping profession are themes that are common to many definitions formulated about nursing. In 1973, the American Nurses Association (ANA) described nursing practice as goaloriented and adaptable to the needs of the individual, the family, and the community (not just the client). In 1980, the ANA's definition was changed to "Nursing is the diagnosis and treatment of the human responses to actual or potential health problems." Diagnosis and treatment of disease is a definition of the medical model. Rationale 6: Adaptive; client-centered; art; science; holistic; caring; concerned with health promotion, health maintenance, and health restoration; and a helping profession are themes that are common to many definitions formulated about nursing. In 1973, the American Nurses Association (ANA) described nursing practice as goaloriented and adaptable to the needs of the individual, the family, and the community (not just the client). In 1980, the ANA's definition was changed to "Nursing is the diagnosis and treatment of the human responses to actual or potential health problems." Diagnosis and treatment of disease is a definition of the medical model.

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: Knowledge and Science; Knowledge; Relationships between knowledge/science and excellence in nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe how the definition of nursing has evolved since Florence Nightingale. MNL Learning Outcome: 1.2.4. Compare the frameworks of care. Page Number: 13 Question 26 Type: MCSA A registered nurse is supervising several LPNs who provide patient care. Which responsibility should the registered nurse expect to complete? 1. Evaluating the care provided to the client 2. Administering intramuscular (IM) medications 3. Performing dressing changes 4. Delegating appropriate tasks to unlicensed client care providers (such as a nurse’s aide) Correct Answer: 1 Rationale 1: The RN has the knowledge and skill to make more sophisticated nursing judgments, and is responsible for assessing the client’s condition, planning care, and evaluating the effect of the care provided. Rationale 2: LPNs practice under the supervision of an RN in a hospital, nursing home, rehabilitation center, or home health agency, and usually provide basic, direct technical care to clients that can include the administration of scheduled IM medications if the institution includes that in the LPN’s job description. Rationale 3: LPNs practice under the supervision of an RN in a hospital, nursing home, rehabilitation center, or home health agency, and usually provide basic, direct technical care to clients that can include dressing changes. Rationale 4: LPNs practice under the supervision of an RN in a hospital, nursing home, rehabilitation center, or home health agency, and usually provide basic, direct technical care to clients that can include appropriate delegation of tasks to unlicensed client care providers.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.C. 2. Appreciate importance of intra- and inter-professional collaboration. 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: Knowledge and Science; Knowledge; Relationships between knowledge/science and excellence in nursing Nursing/Integrated Concepts: Nursing Process: Planning Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 8. Describe the roles of nurses. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 9 Question 27 Type: MCSA 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. Ability to work in critical care areas 2. Easier transition to graduate school 3. Better opportunity for career advancement 4. Liberal arts education Correct Answer: 3 Rationale 1: RNs, regardless of their education level, can work in critical care areas. Rationale 2: There are some programs offering RN-to-MSN completion studies at this point in time. Rationale 3: The nurse who holds a baccalaureate degree enjoys greater autonomy, responsibility, participation in institutional decision making, and career advancement. Rationale 4: A liberal arts education is also a positive point, although not as major of an incentive.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A. 2. Describe scopes of practice and roles of health care 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: Knowledge and Science; Knowledge; Relationships between knowledge/science and excellence in nursing Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Discuss the evolution of nursing education and entry into professional nursing practice. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 11 Question 28 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The ANA’s proposal for entry level for professional practice initiated debate among nurses. Which nurse would be at greatest risk if the ANA proposal were implemented? 1. An RN with an associate degree who has a head nurse position 2. An RN with a BSN who is a staff nurse 3. An RN with a diploma who works overtime 4. An RN with an associate degree who is currently in school Correct Answer: 1 Rationale 1: According to the ANA’s proposal, only the baccalaureate graduate would be licensed under the legal title registered nurse. The graduate with an associate degree or diploma would be considered an associate nurse. If the ANA proposal were implemented, nurses who are currently licensed and educated in associate degree or diploma programs would have to be considered under a grandfather clause, provided that their performance met established standards. If an institution required a minimum of a baccalaureate degree for the position of head nurse, an RN who was currently employed as a head nurse but who did not hold a baccalaureate degree would have no guarantee of retaining that position. Rationale 2: According to the ANA’s proposal, only the baccalaureate graduate would be licensed under the legal title registered nurse. The graduate with an associate degree or diploma would be considered an associate nurse. If the ANA proposal were implemented, nurses who are currently licensed and educated in associate degree or diploma programs would have to be considered under a grandfather clause, provided that their performance met established standards. If an institution required a minimum of a baccalaureate degree for the position of head nurse, an RN who was currently employed as a head nurse but who did not hold a baccalaureate degree would have no guarantee of retaining that position. Rationale 3: According to the ANA’s proposal, only the baccalaureate graduate would be licensed under the legal title registered nurse. The graduate with an associate degree or diploma would be considered an associate nurse. If the ANA proposal were implemented, nurses who are currently licensed and educated in associate degree or diploma programs would have to be considered under a grandfather clause, provided that their performance met established standards. If an institution required a minimum of a baccalaureate degree for the position of head nurse, an RN who was currently employed as a head nurse but who did not hold a baccalaureate degree would have no guarantee of retaining that position. Rationale 4: According to the ANA’s proposal, only the baccalaureate graduate would be licensed under the legal title registered nurse. The graduate with an associate degree or diploma would be considered an associate nurse. If the ANA proposal were implemented, nurses who are currently licensed and educated in associate degree or diploma programs would have to be considered under a grandfather clause, provided that their performance met established standards. If an institution required a minimum of a baccalaureate degree for the position of head nurse, an RN who was currently employed as a head nurse but who did not hold a baccalaureate degree would have no guarantee of retaining that position.

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: Knowledge and Science; Knowledge; Relationships between knowledge/science and excellence in nursing Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify the purposes of nurse practice acts and standards of professional nursing practice. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 11 Question 29 Type: SEQ A nurse is considering additional education to become a nurse researcher. To prepare for this role the nurse is reviewing the evolution of research in nursing. In which order should the nurse review this information? Put these events in chronological order, starting with the earliest (1) and proceeding to the most recent (4): Standard Text: Click and drag the options below to move them up or down. Choice 1. Centers for nursing research established Choice 2. Research focused on the study of nursing education Choice 3. Early stage of development Choice 4. Studies focused on the knowledge behind nursing practice Choice 5. Research focused on practice-related issues Correct Answer: 3, 1, 2, 4, 5 Rationale 1: Increasing research in nursing is contributing to nursing practice. In the 1940s, nursing research was at a very early stage of development. In the 1950s, increased federal funding and professional support helped establish centers for nursing research. Most early research was directed at the study of nursing education. In the 1960s, studies were often related to the nature of the knowledge base underlying nursing practice. Since the 1970s, nursing research has focused on practice-related issues. Rationale 2: Increasing research in nursing is contributing to nursing practice. In the 1940s, nursing research was at a very early stage of development. In the 1950s, increased federal funding and professional support helped establish centers for nursing research. Most early research was directed at the study of nursing education. In the 1960s, studies were often related to the nature of the knowledge base underlying nursing practice. Since the 1970s, nursing research has focused on practice-related issues. Rationale 3: Increasing research in nursing is contributing to nursing practice. In the 1940s, nursing research was at a very early stage of development. In the 1950s, increased federal funding and professional support helped establish centers for nursing research. Most early research was directed at the study of nursing education. In the 1960s, studies were often related to the nature of the knowledge base underlying nursing practice. Since the 1970s, nursing research has focused on practice-related issues.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Increasing research in nursing is contributing to nursing practice. In the 1940s, nursing research was at a very early stage of development. In the 1950s, increased federal funding and professional support helped establish centers for nursing research. Most early research was directed at the study of nursing education. In the 1960s, studies were often related to the nature of the knowledge base underlying nursing practice. Since the 1970s, nursing research has focused on practice-related issues. Rationale 5: Increasing research in nursing is contributing to nursing practice. In the 1940s, nursing research was at a very early stage of development. In the 1950s, increased federal funding and professional support helped establish centers for nursing research. Most early research was directed at the study of nursing education. In the 1960s, studies were often related to the nature of the knowledge base underlying nursing practice. Since the 1970s, nursing research has focused on practice-related issues. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and research NLN Competencies: Knowledge and Science; Knowledge; Defining the relationships between research and science building, and between research and EBP Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe the expanded career roles of nurses and their functions. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 17 Question 30 Type: MCSA 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. CCNE (Commission on Collegiate Nursing Education) 3. NCLEX® (National Council Licensure Examination) 4. NCSBN (National Council of State Boards of Nursing) Correct Answer: 2 Rationale 1: 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. Rationale 2: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: 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. Rationale 4: 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.

Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B. 2. Initiate plan for self-development as a team member 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: Quality and Safety; Ethical Comportment; Engage in lifelong learning to keep professional knowledge current Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Discuss the evolution of nursing education and entry into professional nursing practice. MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies Page Number: 21 [New Questions: ] Question 31 Type: MCMA The student nurse is reviewing the code of ethics prior to beginning a clinical assignment. On what areas should the nurse focus when providing client care? Standard Text: 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. Correct Answer: 2, 3, 4 Rationale 1: Lifelong learning would be a personal goal or plan. Rationale 2: When providing care, the student nurse should focus on client safety. Rationale 3: When providing care, the student nurse should focus on client confidentiality. Rationale 4: When providing care, the student should ensure professionalism. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: Collaboration with students and faculty would promote professional development.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials 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: 7. Identify the purposes of nurse practice acts and standards of professional nursing practice. MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing. Page Number: 17 Question 32 Type: MCMA The nurse is interested in specializing in forensics. What should the nurse expect to learn prior to assuming the role of a forensics nurse? Standard Text: 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 Correct Answer: 1, 2, 4, 5 Rationale 1: The forensic nurse provides specialized care for individuals who are victims and/or perpetrators of trauma. Forensic nurses have knowledge of the legal system and skills in injury identification, evaluation, and documentation. After tending to the client’s medical needs, the forensic nurse collects evidence, provides medical testimony in court, and consults with legal authorities. Rationale 2: The forensic nurse provides specialized care for individuals who are victims and/or perpetrators of trauma. Forensic nurses have knowledge of the legal system and skills in injury identification, evaluation, and documentation. After tending to the client’s medical needs, the forensic nurse collects evidence, provides medical testimony in court, and consults with legal authorities. Rationale 3: Budgeting, staffing, and planning programs are functions of a nurse administrator. Rationale 4: The forensic nurse provides specialized care for individuals who are victims and/or perpetrators of trauma. Forensic nurses have knowledge of the legal system and skills in injury identification, evaluation, and documentation. After tending to the client’s medical needs, the forensic nurse collects evidence, provides medical testimony in court, and consults with legal authorities.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: The forensic nurse provides specialized care for individuals who are victims and/or perpetrators of trauma. Forensic nurses have knowledge of the legal system and skills in injury identification, evaluation, and documentation. After tending to the client’s medical needs, the forensic nurse collects evidence, provides medical testimony in court, and consults with legal authorities.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B. 2. Initiate plan for self-development as a team member 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: Quality and Safety; Ethical Comportment; Engage in lifelong learning to keep professional knowledge current Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9. Describe the expanded career roles of nurses and their functions. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 16

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 02 Question 1 Type: SEQ 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): Standard Text: Click and drag the options below to move them up or down. Choice 1. The National Center for Nursing Research was created. Choice 2. The National Institute for Nursing Research was created. Choice 3. The journal Nursing Research was established. Choice 4. End-of-life/palliative care research was conducted. Correct Answer: 2, 3, 1,4 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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.

AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and research NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and methods of scientific inquiry Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Apply the steps of change used in implementing evidence-based practice. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 27 Question 2 Type: MCSA A nursing student is assigned to develop a research question using a quantitative approach. Which question should the student write that demonstrates this approach? 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? Correct Answer: 2 Rationale 1: Qualitative research most often explores the subjective experiences of human beings. Rationale 2: 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. Rationale 3: Qualitative research most often explores the subjective experiences of human beings. Rationale 4: Qualitative research most often explores the subjective experiences of human beings.

Type: MCSA 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 the client false information about his or her participation 4. Providing the client's name as a participant in the study Correct Answer: 4 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: III.C. 2. Value the need for ethical conduct of research and quality improvement AACN Essentials Competencies: III. 3. Advocate for the protection of human subjects in the conduct of research NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and methods of scientific inquiry 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: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 34 Question 4 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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 Correct Answer: 2 Rationale 1: The right of full disclosure is the act of making clear the client's role in a research situation. Rationale 2: 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. Rationale 3: The right of self-determination means that participants should feel free from undue influence. Rationale 4: Risk of harm is exposure to the possibility of injury going beyond everyday situations.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.C. 2. Value the need for ethical conduct of research and quality improvement AACN Essentials Competencies: III. 3. Advocate for the protection of human subjects in the conduct of research NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and methods of scientific inquiry 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: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 34 Question 5 Type: MCSA The nurse researcher is considering whether the findings of a project may present uncertain results in the clinical area. Upon which criteria is the researcher reflecting? 1. Significance Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Researchability 3. Confidentiality 4. Variables Correct Answer: 2 Rationale 1: Significance deals with whether the research problem has the potential to contribute to nursing science by enhancing nursing care. Rationale 2: 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. Rationale 3: Confidentiality is one of the research participant's rights. Rationale 4: Quantitative research problems address relationships between independent and dependent variables. . Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and research NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and methods of scientific inquiry Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Apply the steps of change used in implementing evidence-based practice. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 29 Question 6 Type: MCSA A 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 to use? 1. Significance 2. Researchability 3. Feasibility 4. Interest Correct Answer: 1 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: 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. Rationale 2: Researchability means that the problem can be subjected to scientific investigation, without ambiguity or uncertainty. Rationale 3: Feasibility pertains to the time and material as well as human resources needed to investigate a problem or question. Rationale 4: Interest can be a factor for successful completion, depending on the attitude of the researcher.

Rationale 3: This option is an example of an independent variable, or something that can cause or have an influence on the dependent variable. Rationale 4: The option is an example of an independent variable, or something that can cause or have an influence on the dependent variable.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and research NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and methods of scientific inquiry Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Outline the steps of the research process. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 30 Question 8 Type: MCSA 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. Correct Answer: 3 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: 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.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and research NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and methods of scientific inquiry Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Differentiate the quantitative approach from the qualitative approach in nursing research. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 30 Question 10 Type: MCSA 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 Correct Answer: 4 Rationale 1: The school system would be more representative of the population, which includes all possible members of the group who meet the criteria for the study. Rationale 2: The children would be more representative of the population, which includes all possible members of the group who meet the criteria for the study. Rationale 3: The parents would be more representative of the population, which includes all possible members of the group who meet the criteria for the study. Rationale 4: The sample is the segment of the population from which the data will actually be collected—in this case, single-parent families.

MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 30 Question 11 Type: MCSA The nurse researcher is using an instrument that provides similar results each time it's implemented. Which term should the researcher use to describe the quality of this instrument? 1. Validity 2. Reliability 3. Consistency 4. Variability Correct Answer: 2 Rationale 1: Validity is the degree to which an instrument measures what it is supposed to measure. Rationale 2: 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. Rationale 3: Consistency is a component of reliability. Rationale 4: Variability does not describe instrument measurement, but variances in data.

1. Mean, median, and mode 2. Range, variance, and standard deviation 3. Mean, range, and standard deviation 4. Measures of central tendency Correct Answer: 2 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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.

3. Chance occurrences 4. Generalized Correct Answer: 1 Rationale 1: 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. Rationale 2: Values greater than .05 are considered to be statistically insignificant and there is a greater probability that the results were due to chance occurrences. Rationale 3: Values greater than .05 are considered to be statistically insignificant and there is a greater probability that the results were due to chance occurrences. Rationale 4: It is not known what the generalized findings would be.

Rationale 2: 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 student is able to incorporate research into practice. Rationale 3: Explaining what EBP is to someone else does not demonstrate the ability to put into practice that which is learned. Rationale 4: Attempting to find other problems to implement EBP does not demonstrate the ability to put into practice that which is learned.

Rationale 4: Substantive dimension is not a research tradition, rather a way to critique research reports.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and research NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and methods of scientific inquiry Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Differentiate the quantitative approach from the qualitative approach in nursing research. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 29 Question 16 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Comparative analysis involves assessing study findings for their implementation potential. Three factors are considered: (1) how the study’s findings compare to findings from other studies about the problem, (2) how the study’s findings will transfer from the research conditions to the clinical practice conditions in which they will be used, and (3) practical or feasibility considerations that need to be addressed when applying the findings in practice. Rationale 3: Comparative analysis involves assessing study findings for their implementation potential. Three factors are considered: (1) how the study’s findings compare to findings from other studies about the problem, (2) how the study’s findings will transfer from the research conditions to the clinical practice conditions in which Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

they will be used, and (3) practical or feasibility considerations that need to be addressed when applying the findings in practice. Rationale 4: Comparative analysis involves assessing study findings for their implementation potential. Three factors are considered: (1) how the study’s findings compare to findings from other studies about the problem, (2) how the study’s findings will transfer from the research conditions to the clinical practice conditions in which they will be used, and (3) practical or feasibility considerations that need to be addressed when applying the findings in practice. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and research NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and methods of scientific inquiry Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Describe research-related roles and responsibilities for nurses. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 31 Question 17 Type: MCSA 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 Correct Answer: 3 Rationale 1: All nurses, including new graduates, could help to identify clinical problems in direct client care. Rationale 2: Nurse managers would most likely use research findings to develop policies and procedures and may not necessarily have an advanced degree. Rationale 3: The nurse practitioner, having a graduate-level education as well as prior nursing experience, would most likely be analyzing and interpreting research for application. Rationale 4: All nurses, including new graduates, could participate in data collection.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and research NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and methods of scientific inquiry Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe research-related roles and responsibilities for nurses. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 28 Question 18 Type: MCMA A nurse researcher is exploring and formulating research problems. Which criteria should the nurse researcher consider in this process? Standard Text: Select all that apply. 1. Significance 2. Confidentiality 3. Researchability 4. Design 5. Feasibility 6. Interest to the researcher Correct Answer: 1, 3, 5, 6 Rationale 1: 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. Confidentiality is one of the rights of the participant in research, and design focuses on how the research is done. Rationale 2: Confidentiality is one of the rights of the participant in research. Rationale 3: When formulating a research problem, researchability (the problem can be subjected to scientific investigation) should be considered. Rationale 4: Design focuses on how the research is done. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: When formulating a research problem, feasibility (the availability of time as well as material and human resources, space, money, etc.) should be considered. Rationale 6: 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.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and research NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and methods of scientific inquiry Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Outline the steps of the research process. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 29 Question 19 Type: SEQ 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? Standard Text: Click and drag the options below to move them up or down. Choice 1. Design practice change. Choice 2. Assess the need for a change in practice. Choice 3. Integrate and maintain change in practice. Choice 4. Implement and evaluate the change. Choice 5. Critically analyze the evidence. Choice 6. Locate the best evidence. Correct Answer: 2, 6, 5, 1, 4, 3 Rationale 1: 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. Rationale 2: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: 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. Rationale 4: 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. Rationale 5: 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. Rationale 6: 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.

Rationale 1: Research might be expensive in many incidences but not in all cases, and cost is not recognized as a negative factor at this time. Rationale 2: Research is often done under very controlled circumstances, which is very different from the real world of health care delivery. Rationale 3: Research evidence suggests that there is one best solution to a problem for all clients. This limited perspective stifles creativity. Rationale 4: EBP appears to have greater relevance for physiological problems than for psychological, social, or spiritual ones. Rationale 5: Implementing EBP may not take into consideration organizational culture and ethnic characteristics. . Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and research NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and methods of scientific inquiry 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: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 27 [New Questions: ] Question 21 Type: MCMA 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 health care need. What actions should the nurse take before implementing these findings? Standard text: 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 Rationale 1: Integrate the findings with clinical expertise and client/family preferences and values. Each nurse must determine how the evidence fits with the clinical condition of the client, available resources, institutional policies, and the client’s wishes. Only then can an appropriate intervention be established. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Evidence must not be automatically applied to the care of individual clients. Rationale 3: Integrate the findings with clinical expertise and client/family preferences and values. Each nurse must determine how the evidence fits with the clinical condition of the client, available resources, institutional policies, and the client’s wishes. Only then can an appropriate intervention be established. Rationale 4: Integrate the findings with clinical expertise and client/family preferences and values. Each nurse must determine how the evidence fits with the clinical condition of the client, available resources, institutional policies, and the client’s wishes. Only then can an appropriate intervention be established. Rationale 5: Integrate the findings with clinical expertise and client/family preferences and values. Each nurse must determine how the evidence fits with the clinical condition of the client, available resources, institutional policies, and the client’s wishes. Only then can an appropriate intervention be established.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: When using the PICO format, the nurse should identify the problem of interest, consider interventions to use, compare the interventions, and determine the outcome of the interventions. The individuals to perform the actions are not identified when using the PICO format. Rationale 3: When using the PICO format, the nurse should identify the problem of interest, consider interventions to use, compare the interventions, and determine the outcome of the interventions. The individuals to perform the actions are not identified when using the PICO format. Rationale 4: When using the PICO format, the nurse should identify the problem of interest, consider interventions to use, compare the interventions, and determine the outcome of the interventions. The individuals to perform the actions are not identified when using the PICO format. Rationale 5: When using the PICO format, the nurse should identify the problem of interest, consider interventions to use, compare the interventions, and determine the outcome of the interventions. The individuals to perform the actions are not identified when using the PICO format.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 03 Question 1 Type: MCSA Nursing students have been assigned to develop their own theory of nursing. What should they include in their theory, often referred to as the metaparadigm for nursing? 1. Society, medicine, nursing, and biology 2. Patient, facility, health, and nursing 3. Organization, discipline, nursing, and client 4. Client, environment, health, and nursing Correct Answer: 4 Rationale 1: These options do not include the "pattern" associated with the four concepts that comprise a metaparadigm. Rationale 2: These options do not include the "pattern" associated with the four concepts that comprise a metaparadigm. Rationale 3: These options do not include the "pattern" associated with the four concepts that comprise a metaparadigm. Rationale 4: Four major concepts—person (or client), environment, health, and nursing—can be superimposed on almost any theoretical work in nursing. They are collectively referred to as a metaparadigm for nursing.

Type: MCSA Nursing students are researching how cultural practices affect the dying process of terminal cancer clients. For their research, which theory will the students most likely explore? 1. Critical theory 2. Midlevel theories 3. Grand theories 4. Stability models Correct Answer: 1 Rationale 1: Critical theory research used in nursing helps explain how structures such as race, gender, sexual orientation, and economic class affect patient experiences and health outcomes. In this scenario (the influences of culture on the dying process), research on critical theory would help in understanding how these structures affect the human experience of death. Rationale 2: Midlevel theories focus on exploring concepts such as pain, self-esteem, and learning. Rationale 3: Grand theories are only occasionally used in nursing research. The stability model describes the dominant view of nursing theories. Rationale 4: The stability model describes the dominant view of nursing theories.

1. Dorothea Orem 2. Martha Rogers 3. Florence Nightingale 4. Jean Watson Correct Answer: 3 Rationale 1: Dorothea Orem's theory focused on self-care and doesn’t apply here. Rationale 2: Rogers's theory is the science of unitary human beings and doesn’t apply here. Rationale 3: Florence Nightingale defined nursing more than 100 years ago as "the act of utilizing the environment of the patient to assist him in his recovery." Attending to the client's surroundings, including the lighting and atmosphere, is being attentive to the client's environment. Deficiencies in environmental factors (especially air, water, drainage, cleanliness, and light) have produced lack of health or illness. Rationale 4: Jean Watson defined nursing in relationship to caring and doesn’t apply here.

4. Dorothea Orem Correct Answer: 2 Rationale 1: Florence Nightingale's theory focused on environmental controls. Rationale 2: Hildegard Peplau, a psychiatric nurse, introduced a theory in which a therapeutic relationship between the nurse and client is central. Rationale 3: Jean Watson's theory has caring as its central theme. Rationale 4: Dorothea Orem's theory focused on self-care deficit.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 40 Question 5 Type: MCSA During a hospital stay, the client has taken control of her recovery and rehabilitation and is utilizing available resources for her needs. In which level of Peplau's model should the nurse determine that this patient is functioning? 1. Orientation 2. Identification 3. Exploitation 4. Resolution Correct Answer: 3 Rationale 1: Orientation is the first phase, in which the client seeks help and the nurse provides the client with understanding and assistance.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Identification is the second phase, in which the client assumes dependence, interdependence, or independence in relation to the nurse. Rationale 3: The nurse–client relationship is described in four phases, according to Peplau's interpersonal relations model. The exploitation phase occurs when the client derives full value from what the nurse offers through the relationship, using available services based on self-interest and needs. Power shifts from the nurse to the client. Rationale 4: The last phase is resolution, in which old needs and goals are put aside and new ones adopted.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 40 Question 6 Type: MCSA A Department of Nursing within a medical center is adopting the theory that is founded on 14 fundamental needs of individuals. Which nurse theorist is this department using to guide client care? 1. Dorothea Orem 2. Florence Nightingale 3. Martha Rogers 4. Virginia Henderson Correct Answer: 4 Rationale 1: Dorothea Orem's theory on self-care deficit does not contain 14 fundamental needs. Rationale 2: Florence Nightingale's theory centered around the client's environment does not contain 14 fundamental needs. Rationale 3: Martha Rogers related her theory to multiple scientific disciplines, and it does not contain 14 fundamental needs. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Henderson conceptualized the nurse's role as assisting sick or healthy individuals to gain independence in meeting 14 fundamental needs, from breathing normally to discovering the curiosity that leads to normal development and health.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 40 Question 7 Type: MCSA A nurse has implemented the use of noncontact therapeutic touch. Which theorist is the nurse using as a basis for this intervention? 1. Florence Nightingale 2. Martha Rogers 3. Virginia Henderson 4. Rosemarie Parse Correct Answer: 2 Rationale 1: Rogers states that humans are dynamic energy fields. Nurses applying Rogers's theory seek to promote interaction between the two energy fields. The use of noncontact therapeutic touch is based on the concept of human energy fields. Nightingale's theory centered on the client's environment. Henderson conceptualized the nurse's role as assisting individuals to gain independence in meeting 14 fundamental needs. Rosemarie Parse's theory revolves around human becoming. Rationale 2: Rogers states that humans are dynamic energy fields. Nurses applying Rogers's theory seek to promote interaction between the two energy fields. The use of noncontact therapeutic touch is based on the concept of human energy fields. Nightingale's theory centered on the client's environment. Henderson conceptualized the nurse's role as assisting individuals to gain independence in meeting 14 fundamental needs. Rosemarie Parse's theory revolves around human becoming. Rationale 3: Rogers states that humans are dynamic energy fields. Nurses applying Rogers's theory seek to promote interaction between the two energy fields. The use of noncontact therapeutic touch is based on the Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

concept of human energy fields. Nightingale's theory centered on the client's environment. Henderson conceptualized the nurse's role as assisting individuals to gain independence in meeting 14 fundamental needs. Rosemarie Parse's theory revolves around human becoming. Rationale 4: Rogers states that humans are dynamic energy fields. Nurses applying Rogers's theory seek to promote interaction between the two energy fields. The use of noncontact therapeutic touch is based on the concept of human energy fields. Nightingale's theory centered on the client's environment. Henderson conceptualized the nurse's role as assisting individuals to gain independence in meeting 14 fundamental needs. Rosemarie Parse's theory revolves around human becoming.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 41 Question 8 Type: MCSA The nurse is teaching health and wellness principles to junior high students. According to Orem's theory, which category of self-care requisite is the nurse using to guide this teaching? 1. Universal 2. Developmental 3. Health deviation 4. Deficit Correct Answer: 2 Rationale 1: Universal requisites are common to all people and include nutrition, hydration, elimination, and rest. Rationale 2: Developmental requisites result from maturation or are associated with conditions or events, such as adjusting to a change in body image (adolescent maturation, in this case) or to the loss of a spouse. Rationale 3: Health deviation requisites result from illness, injury, or disease or its treatment. They include actions such as seeking health care assistance, carrying out prescribed therapies, and learning to live with the effects of illness or treatment. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Self-care deficit is not a self-care requisite, but it results when self-care agency is not adequate to meet the known self-care demand.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify the role of nursing theory in nursing education, research, and clinical practice. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 41 Question 9 Type: MCSA The nurse is caring for clients in Stage II/III Alzheimer's disease. If Orem’s theory is applied, which type of nursing system should the nurse use when providing client care? 1. Supportive 2. Educative 3. Partly compensatory 4. Wholly compensatory Correct Answer: 4 Rationale 1: Supportive systems (developmental) are designed for persons who need to learn to perform self-care measures and need assistance to do so. This would not be attainable for this group of clients. Rationale 2: Educative systems (developmental) are designed for persons who need to learn to perform self-care measures and need assistance to do so. This would not be attainable for this group of clients. Rationale 3: Partly compensatory systems are designed for individuals who are unable to perform some, but not all, self-care activities. Because the clients are in the end stage of the disease, their ability to care for themselves is greatly diminished. Some would not be able to care for themselves at all. Rationale 4: Wholly compensatory systems are required for individuals who are unable to control and monitor their environment and process information. This would describe clients with Stage II/III Alzheimer's—those who need constant supervision and at some point in the near future, total care with all activities of daily living (ADLs).

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 41 Question 10 Type: MCSA A nurse educator incorporates stress, power, authority, and personal space along with other concepts and considers these concepts essential knowledge for use by nurses. From which theorist is the educator applying principles into the curriculum? 1. Dorothea Orem 2. Imogene King 3. Jean Watson 4. Hildegard Peplau Correct Answer: 2 Rationale 1: Orem's theory focuses on self-care/self-care deficit and is not applicable here. Rationale 2: Imogene King's theory of goal attainment is based on 15 concepts from nursing literature she selected as essential knowledge for use by nurses: self, role, perception, communication, interaction, transaction, growth and development, stress, time, personal space, organization, status, power, authority, and decision making. Rationale 3: Jean Watson's theory centers on caring interaction and is not applicable here. Rationale 4: Hildegard Peplau's theory centers on the use of a therapeutic relationship between the nurse and client and is not applicable here.

AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 41 Question 11 Type: MCSA The nurse is applying Neuman's systems model during client care. Which response should the nurse identify as an intrapersonal stressor to a client? 1. Inadequate health insurance coverage 2. Family members who quarrel frequently about the client's care 3. Adverse reaction to medication 4. Expectations regarding rehab Correct Answer: 3 Rationale 1: Extrapersonal stressors are those that occur outside the person (e.g., financial/insurance concerns). Rationale 2: Interpersonal stressors are those that occur between individuals (e.g., family members who quarrel). Rationale 3: Neuman categorizes stressors as intrapersonal when they occur within the individual (e.g., a drug reaction). Rationale 4: Neuman categorizes stressors as interpersonal when they occur between individuals (e.g., expectations regarding rehabilitation).

Page Number: 42 Question 12 Type: MCSA A client is being seen in the clinic for the final follow-up appointment after an extensive course of rehabilitation. According to Neuman's model, which level of intervention should the nurse realize this patient is experiencing? 1. Primary prevention 2. Secondary prevention 3. Resistant prevention 4. Tertiary prevention Correct Answer: 4 Rationale 1: Primary prevention focuses on protecting the normal line of defense and strengthening the flexible line of defense. Rationale 2: Secondary prevention focuses on strengthening internal lines of resistance, reducing the reaction, and increasing resistance factors. Rationale 3: Secondary prevention focuses on strengthening internal lines of resistance, reducing the reaction, and increasing resistance factors. Rationale 4: According to Neuman's model, nursing interventions focus on retaining or maintaining system stability and are carried out on three preventive levels: primary, secondary, and tertiary. Tertiary prevention focuses on readaptation and stability and protects reconstitution or return to wellness following treatment. A final follow-up appointment following extensive rehabilitation would be an example of tertiary prevention. . Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 42 Question 13 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA A client with a postoperative infection is afebrile but still receiving IV antibiotics. The nurse should realize that this client is receiving which level of prevention? 1. Primary 2. Secondary 3. Tertiary 4. Critical Correct Answer: 2 Rationale 1: Primary prevention focuses on protecting the normal line of defense and strengthening the flexible line of defense. Rationale 2: Secondary prevention focuses on strengthening internal lines of resistance (fighting the infection with IV antibiotics), reducing the reaction, and increasing resistance factors. The fact that the client is now afebrile shows that the treatment is working to improve the client's condition. Rationale 3: Tertiary prevention focuses on readaptation and stability and protects reconstitution or return to wellness following treatment. Rationale 4: Critical prevention is not part of Neuman's model.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 42 Question 14 Type: MCSA A group of nursing students is helping to set up an immunization clinic. In which level of prevention are these students functioning? 1. Educational Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Primary 3. Secondary 4. Tertiary Correct Answer: 2 Rationale 1: Educational is not one of Neuman's levels of prevention. Rationale 2: Primary prevention focuses on protecting the normal line of defense. Providing immunizations would be doing just that—protecting the body's normal response to disease by helping it to build antibodies. Rationale 3: Secondary prevention focuses on strengthening internal lines of resistance. Rationale 4: Tertiary prevention focuses on readaptation and stability. . Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 42 Question 15 Type: MCSA The nurse is preparing to complete a spiritual assessment with a client. Which theorist should the nurse review before completing this assessment? 1. Roy 2. Neuman 3. Nightingale 4. Peplau Correct Answer: 1 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Sr. Callista Roy's work focuses on the increasing complexity of person and environment and the relationship between and among persons, the universe, and what can be considered a supreme being or God. She uses characteristics of "creation spirituality" in her work and philosophy. Rationale 2: Neuman developed her model based on the individual's relationship to stress. Rationale 3: Nightingale's theory focuses on environmental manipulation. Rationale 4: Peplau's theory centers on the therapeutic relationship between nurse and client. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 42 Question 16 Type: MCSA The nurse observes a client working to include the spouse in the treatment and recovery process of an illness. Which of Roy's modes should the nurse recognize that this client is demonstrating? 1. Physiologic 2. Self-concept 3. Role function 4. Interdependence Correct Answer: 4 Rationale 1: The physiologic mode involves the body's basic physiologic needs and ways of adapting with regard to function of the body's systems. Rationale 2: The self-concept mode includes the physical self and the personal self. Rationale 3: The role function mode is determined by the need for social integration and refers to the performance of duties based on given positions within society. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The goal of Roy's model is to enhance life processes through adaptation in four adaptive modes. The interdependence mode involves one's relations with significant others and support systems that provide help, affection, and attention. Involving a spouse with the treatment and recovery process would be an example of this mode.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 43 Question 17 Type: MCSA A client is experiencing metabolic acidosis, a condition that involves the body's pH level, carbon dioxide level, and bicarbonate balance. According to Roy's model, to which mode should the nurse realize that this client is responding? 1. Physiologic 2. Self-concept 3. Role function 4. Interdependence Correct Answer: 1 Rationale 1: The physiologic mode involves the body's basic physiologic needs and ways of adapting with regard to fluid and electrolytes, activity and rest, circulation and oxygen, nutrition and elimination, protection, the senses, and neurologic and endocrine function. The pH level as well as levels of the carbon dioxide and bicarbonate ion would be physiologic mechanisms at work in the body. Rationale 2: The self-concept mode includes the physical self and the personal self. Rationale 3: The role function mode is determined by the need for social integration and refers to the performance of duties based on given positions within society. Rationale 4: The interdependence mode involves one's relations with significant others and support systems that provide help, affection, and attention. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 43 Question 18 Type: MCSA A nurse has agreed to delay a client's treatment until the matriarch of the family can be present. Understanding that this is an important consideration for this client's cultural practices, which of Leininger’s intervention modes is the nurse implementing? 1. Preservation and maintenance 2. Accommodation, negotiation 3. Restructuring 4. Repatterning Correct Answer: 2 Rationale 1: The preservation and maintenance mode does not involve the scenario described here. Rationale 2: By allowing flexibility in scheduling client treatment in order to allow for the client's family member to be present—which in this case is an important aspect of the family’s cultural practices—the nurse accommodates the client's needs. Rationale 3: Restructuring does not involve the scenario described here. Rationale 4: Repatterning does not involve the scenario described here.

NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 43 Question 19 Type: MCSA The nurse implements being authentically present to clients by supporting them in their beliefs and helping to instill hopefulness in their recovery. Which theorist is the nurse using when performing these actions? 1. Florence Nightingale 2. Hildegard Peplau 3. Jean Watson 4. Rosemarie Parse Correct Answer: 3 Rationale 1: Nightingale's theory involved environmental manipulation. Rationale 2: Peplau focused on the therapeutic relationship between nurse and client. Rationale 3: Jean Watson believes the practice of caring is central to nursing and has developed nursing interventions referred to as clinical caritas processes. Of these, "being authentically present, and enabling and sustaining the deep belief system and subjective life world of self and one-being cared for" is an example. Rationale 4: Parse developed the theory of human becoming.

Question 20 Type: MCSA The nurse struggling with a demanding client focuses on experiencing a sense of true empathy for the client's situation. Which assumption of Parse’s human becoming theory is the nurse using? 1. Meaning 2. Rhythmicity 3. Intersubjectivity 4. Cotranscendence Correct Answer: 4 Rationale 1: Meaning arises from a person's interrelationship with the world. Rationale 2: Rhythmicity is the movement toward greater diversity. Rationale 3: Intersubjectivity is not one of Parse's assumptions. Rationale 4: Cotranscendence is the process of reaching out beyond the self, which would be what the nurse in this scenario has implemented.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify the role of nursing theory in nursing education, research, and clinical practice. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 44 Question 21 Type: MCSA When a client who had a stroke gives up all hope of any amount of recovery, the nurse solicits a visit from a former stroke client who has physical limitations but has since gone back to work and, through adaptation, can function independently at home. This nurse has fulfilled which role, according to Parse? 1. Mobilizing transcendence Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Synchronizing rhythm 3. Illuminating meaning 4. True presence Correct Answer: 3 Rationale 1: Mobilizing transcendence is dreaming of possibilities and planning to reach them. Rationale 2: Synchronizing rhythm involves leading through discussion to recognize harmony. Rationale 3: According to Parse's theory, illuminating meaning refers to uncovering what was and what will be. In this situation, the stroke is what was, and the client who is now independent is what could be for the nurse's current client. Rationale 4: Nurses must provide a "true presence" to their clients, but this is not a role in Parse's theory; it is a behavior.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify the role of nursing theory in nursing education, research, and clinical practice. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 44 Question 22 Type: MCSA The pediatric nurse implements Watson's assumption regarding a caring environment. Which action did the nurse take to implement this assumption? 1. Providing for all needs and cares of the nurse's clients 2. Ensuring that a zone of professionalism is present between the nurse and client 3. Allowing the clients to have choices, as appropriate, in their care 4. Selecting games and activities that are age appropriate for the clients Correct Answer: 3 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: The nurse may not need to provide for all of the needs and cares of clients. Rationale 2: Being conscientious of a zone of professionalism (i.e., keeping distant) would not be a characteristic of caring according to Watson. Rationale 3: A caring environment, according to Watson's assumptions of caring, offers the development of potential while allowing the person to choose the best action for the self at a given point in time. Rationale 4: Taking choices away from clients by making selections for them is not a good example of true caring, as defined by Watson.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Identify the role of nursing theory in nursing education, research, and clinical practice. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 44 Question 23 Type: MCMA Nursing students have been studying the "stability model" of nurse theorists. What phrases or terms should the students use to describe this model? Standard Text: Select all that apply. 1. Dominant 2. Systems framework 3. Stress/adaptation framework 4. Martha Rogers's theory 5. Caring/complexity framework 6. Callista Roy's theory Correct Answer: 1, 2, 3, 6 Rationale 1: The dominant view of nursing theories is considered the "stability model." Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: The dominant view of nursing theories is considered the "stability model," and may include systems as a framework. Rationale 3: The dominant view of nursing theories is considered the "stability model," and may include stress/adaptation as a framework. Rationale 4: The emerging view is considered the "growth model," with theories using caring or complexity as frameworks. This model includes the theory of Martha Rogers. Rationale 5: The emerging view is considered the "growth model," with theories using caring or complexity as frameworks. Rationale 6: The dominant view of nursing theories is considered the "stability model" and may include the theory of Callista Roy.

Rationale 1: Some nursing scholars think that grounding research in theories from other disciplines detracts from the development of nursing as a separate discipline. Rationale 2: Some nursing scholars think that grounding research in theories from other disciplines makes nursing research less relevant. Rationale 3: Some scholars believe that bringing insights and perspectives from other disciplines helps to broaden values of the profession. Rationale 4: Other disciplines are attentive to the human condition. Rationale 5: Other disciplines regularly share research findings, and it does not detract from the professional source.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 5. Identify one positive and one negative effect of using theory to understand clinical practice. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 38 Question 25 Type: MCMA The nurse is implementing Watson’s Assumptions of Caring philosophy. Which actions demonstrate that the nurse is using this philosophy? Standard Text: Select all that apply. 1. Asking the client to explain the impact that his culture and religion will have on required nursing care 2. Asking clients when they prefer to be given the opportunity to bathe 3. Feeling empathy toward the client’s loss of mobility as a result of a fractured hip 4. Always assuring that the client has an unobstructed view out his room’s window 5. Arranging to fulfill a client’s request to stay with him during a painful diagnostic test Correct Answer: 2, 3, 5 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: This is more relevant to Leininger’s Cultural Care Diversity and Universality Theory. Rationale 2: Watson proposes that a caring environment offers the development of potential while allowing the person to choose the best action for the self at a given point in time. Rationale 3: Watson proposes that human caring in nursing is not just an emotion, concern, attitude, or benevolent desire. Caring connotes a personal response such as empathy. Rationale 4: This is more relevant to Roy’s Adaptation Model. Rationale 5: Watson proposes that caring occasions involve action and choice by nurse and client. If the caring occasion is transpersonal, the limits of openness expand, as do human capacities.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 44 Question 26 Type: MCMA The nurse is using the central concepts of nursing when providing client care. What actions is this nurse performing? Standard Text: Select all that apply. 1. Including a client’s family in discussions regarding the client’s discharge health needs 2. Assessing a physically dependent client’s spouse for indications of caregiver stress 3. Asking clients to define what “healthy and well” means to them 4. Suggesting wound care supplies with the priority of cost 5. Advocating for a client who is not responding to current pain control treatment Correct Answer: 1, 2, 3, 5

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: One of the recognized central concepts of nursing is that the recipients of nursing care include individuals, families, groups, and communities. Rationale 2: One of the recognized central concepts of nursing is that the nurse addresses the client’s environmental surroundings, including people in the physical environment, such as families, friends, and significant others, for unmet needs that ultimately affect the client. Rationale 3: One of the recognized central concepts of nursing is that health is the degree of wellness or wellbeing that the client experiences. Rationale 4: Although important, economic frugality is not a central concept of nursing care. Rationale 5: One of the recognized central concepts of nursing is that the nurse provides care on behalf of, or in conjunction with, the client.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 38 Question 27 Type: MCMA The nurse is planning client care while keeping in mind Orem’s self-care deficit theory. Which methods of helping should the nurse include when determining the best care for the client? Standard Text: Select all that apply. 1. Balancing rest 2. Teaching 3. Supporting 4. Guiding 5. Preventing hazards to life Correct Answer: 2, 3, 4, 5 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Balancing rest and preventing hazards to life are part of the universal requisites of Orem’s self-care needs. Rationale 2: Orem’s self-care deficit theory explains not only when nursing is needed, but also how people can be assisted through methods of helping that include teaching. Rationale 3: Orem’s self-care deficit theory explains not only when nursing is needed, but also how people can be assisted through methods of helping that include supporting. Rationale 4: Orem’s self-care deficit theory explains not only when nursing is needed, but also how people can be assisted through methods of helping that include guiding. Rationale 5: Preventing hazards to life is part of the universal requisites of Orem’s self-care needs. . Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 41 [New Questions: ] Question 28 Type: MCMA After completing a health history the nurse reviews the content to determine metaparadigms that contribute to the client’s health. Which metaparadigm should the nurse categorize as being a part of the client’s environment? Standard Text: Select all that apply. 1. Diet 2. Family 3. Friends 4. Blood pressure 5. Significant others Correct Answer: 2, 3, 5 Rationale 1: Health is the degree of wellness or well-being that the client experiences. This can be measured by diet and blood pressure. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: The environment is the internal and external surroundings that affect the client. This includes people in the physical environment, such as families, friends, and significant others. Rationale 3: The environment is the internal and external surroundings that affect the client. This includes people in the physical environment, such as families, friends, and significant others. Rationale 4: Health is the degree of wellness or well-being that the client experiences. This can be measured by diet and blood pressure. Rationale 5: The environment is the internal and external surroundings that affect the client. This includes people in the physical environment, such as families, friends, and significant others.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of practice AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Identify the components of the metaparadigm for nursing. MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the provision of nursing care. Page Number: 38 Question 29 Type: MCMA The nurse is planning interventions for a client based upon Henderson’s fundamental needs. Which interventions should the nurse include in the plan of care? Standard Text: Select all that apply. 1. Sleep 4 to 5 hours each night. 2. Attend to spiritual needs as desired. 3. Wear clothing suitable for the weather. 4. Bathe and keep the body well-groomed. 5. Restrict fluids with an elevated body temperature. Answer: 2, 3, 4 Rationale 1: Henderson did not limit the number of hours of sleep. Rationale 2: Henderson conceptualizes the nurse’s role as assisting sick or healthy individuals to gain independence in meeting 14 fundamental needs, which include worshipping according to one’s faith, selecting suitable clothes, and keeping the body clean and well-groomed.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Henderson conceptualizes the nurse’s role as assisting sick or healthy individuals to gain independence in meeting 14 fundamental needs, which include worshipping according to one’s faith, selecting suitable clothes, and keeping the body clean and well-groomed. Rationale 4: Henderson conceptualizes the nurse’s role as assisting sick or healthy individuals to gain independence in meeting 14 fundamental needs, which include worshipping according to one’s faith, selecting suitable clothes, and keeping the body clean and well-groomed. Rationale 5: According to Henderson, food and liquids should be adequate for the individual.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 04 Question 1 Type: MCSA A client was given 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 Correct Answer: 4 Rationale 1: Common law is a type of law enacted by different entities. Rationale 2: Public law is a type of law enacted by different entities. Rationale 3: Administrative law is a type of law enacted by different entities. Rationale 4: 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.

Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials 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: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 48 Question 2 Type: MCSA The nurse is notified about new state practice act regulations. Which type of law should the nurse expect to implement and enforce the nurse practice act regulations? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Statutory law 2. Administrative law 3. Common law 4. Public law Correct Answer: 2 Rationale 1: Statutory laws are laws enacted by any legislative body. Rationale 2: 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. Rationale 3: Common law refers to laws evolved from court decisions. Rationale 4: Public law refers to the body of law that deals with relationships between individuals and the government and governmental agencies.

Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials 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: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 48 Question 3 Type: MCSA The admitting nurse explains the process of signing forms to allow for the client's insurance company to be billed for services. If the insurance fails to pay for services, the client is responsible for payment. Which type of law did the nurse explain to the client? 1. Contract law 2. Tort law 3. Statutory law 4. Administrative law Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1 Rationale 1: 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 health care services makes the client responsible for cost, regardless of insurance payment. Rationale 2: Tort law defines and enforces duties and rights among private individuals that are not based on contractual agreements. Rationale 3: Statutory laws are laws enacted by any legislative body. Rationale 4: Administrative laws give administrative agencies the authority to create rules and regulations to enforce statutory laws.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Negligence is an example of a tort law. Negligence occurs when something is accidental and harm results, as in this case. Another example of negligence would be if surgical instruments or bandages are accidentally left in a client during surgery. Rationale 4: Criminal intent implies preplanned actions that are illegal.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials 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/battery, false imprisonment, invasion of privacy, defamation) and unintentional torts (professional negligence). MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 49 Question 5 Type: MCSA A client is suing the hospital for malpractice. Before the case goes to court, the attorney meets with staff and reads the medical record. The nurse realizes that the attorney is performing which activity? 1. Burden of proof 2. Complaint 3. Discovery 4. Civil action Correct Answer: 3 Rationale 1: Burden of proof falls to the plaintiff and is the duty to prove wrongdoing. Rationale 2: A complaint is a document filed by a person (plaintiff) who claims that his or her legal rights have been infringed on by one or more persons (defendants). Rationale 3: Discovery is an effort by both parties to obtain all the facts of the situation. It occurs before the trial. Rationale 4: A civil action is a legal action that deals with the relationships among individuals in society.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials 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: 1. List sources of law and types of laws. MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 49 Question 6 Type: MCSA Before applying for re-licensure, 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 Correct Answer: 3 Rationale 1: Licensure is the process of granting a legal permit to practice or engage in a profession, such as nursing. Rationale 2: Competency is a level of acceptable performance, and credentialing ensures this in licensure. Certification is also part of credentialing. It validates that an individual has met minimum standards of nursing competency in a specialty area. Rationale 3: 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. Rationale 4: Certification validates that an individual has met minimum standards of nursing competency in a specialty area.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Compare and contrast the state-based licensure model and the mutual recognition model for multistate licensure. MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 49 Question 7 Type: MCSA 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. NLNAC 3. CCNE 4. ANA Correct Answer: 1 Rationale 1: All states require that all schools of nursing in the state are approved/accredited by the state board of nursing. Rationale 2: Some but not all states require that programs be both state approved and accredited by a national accrediting agency such as NLNAC. Rationale 3: Some but not all states require that programs be both state approved and accredited by a national accrediting agency such as CCNE. Rationale 4: Voluntary accreditation is not required by all states and is a means of informing the public and prospective students that the nursing program has met certain criteria. The ANA (American Nurses Association) is nursing's professional organization.

Question 8 Type: MCSA 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 Correct Answer: 4 Rationale 1: Even though the physician wrote the order incorrectly, the primary responsibility in question is the administration of the medication, and so the responsibility is not the physician’s. Rationale 2: Even though the pharmacist filled an incorrect order, the primary responsibility in question is the administration of the medication, and so the responsibility is not the pharmacist’s. Rationale 3: Assuming policies and procedures were written and accessible, the hospital is not legally responsible in this case. Rationale 4: 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.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

A hospital receives notice of being sued for an action performed by a nurse. The nurse realizes that which doctrine is being implemented in this case? 1. Contractual relationship 2. Stare decisis 3. Respondeat superior 4. Res ipsa loquitur Correct Answer: 3 Rationale 1: A contractual relationship is not a doctrine; it is what the nurse and hospital, for example, enter into when the hospital hires the nurse as an employee. Rationale 2: "To stand by things decided," or stare decisis, is the same thing as following precedent, or applying the same rules to a situation as were applied in similar situations. Rationale 3: "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. Rationale 4: "The thing speaks for itself," or res ipsa loquitur, is a doctrine in cases where harm occurs but cannot be traced to a specific health care provider or standard. . Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials 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: Evaluation Learning Outcome: 7. Recognize the nurse’s legal responsibilities with selected aspects of nursing practice. MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 62 Question 10 Type: MCSA A client being prepared for an invasive procedure questions some of the terminology in the consent form. Which response should the nurse make? 1. "Just sign the form, and I'll make sure your physician talks to you before he begins the procedure." Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. "I'll explain whatever you don't understand." 3. "You should have asked your physician when he was in here." 4. "I'll call your physician back in the room to answer your questions." Correct Answer: 4 Rationale 1: If the client has questions, he should not sign the form. These questions require the physician’s attention before the consent is signed. Rationale 2: If the client has questions, he should not sign the form, and it is not the nurse's responsibility to answer the questions. Rationale 3: Telling the client what he "should have" done is demeaning and not an appropriate therapeutic response. Rationale 4: 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.

4. Compliance Correct Answer: 3 Rationale 1: Informed consent is an agreement by a client to accept a course of treatment or a procedure after being provided complete information, including the benefits and risks of treatment, and generally requires the client’s signature (written consent) Rationale 2: Express consent may be either an oral or written agreement. In this case, there were neither spoken words nor a written consent form for the IV initiation. Rationale 3: Implied consent exists 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. Rationale 4: Compliance occurs when clients agree to follow the recommended treatment, usually by their own actions as in taking prescribed medications or following a prescribed diet.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials 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: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 54 Question 12 Type: MCSA An adult client who cannot read needs surgery and is competent to make his own 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. Correct Answer: 2 Rationale 1: Telling the client in words other than what is on the consent form is not appropriate, as some meaning and information may be lost in the transfer. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: 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. Rationale 3: The physician should explain the procedure to the client, regardless of the client's literacy. Rationale 4: Because the client is a competent adult, he must be the one giving consent. Illiteracy does not make one incompetent.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials 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: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 55 Question 13 Type: MCSA 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 client's wife 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. Correct Answer: 1 Rationale 1: 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 that sedated him, the wife would be appropriate for giving consent for the surgical procedure. Rationale 2: Waiting until the effects of the medication wear off would not be in the best interest of the client. Rationale 3: Thorough explanation may or may not matter in this case because the client is considered functionally incompetent. Besides, it is the physician's responsibility to obtain informed consent. Rationale 4: Implied consent may be used in a medical emergency, but in this case, there is an appropriate option available. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials 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: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 55 Question 14 Type: MCSA A client is brought to the emergency department after being involved in a motor vehicle crash. Although the client is conscious, her condition is critical and will require emergency surgery. The client does not speak English. Which action should the nurse take? 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. Correct Answer: 3 Rationale 1: Reading the consent form to someone who doesn't understand the words is pointless. Rationale 2: There is a better option available than using pictures and gestures in the hope of explaining the procedure. Rationale 3: If the client does not speak the same language as the health professional who is providing the information, an interpreter must be present. Rationale 4: Implied consent indicates that the person understands what will be done.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe the purpose and essential elements of informed consent. MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 55 Question 15 Type: MCSA 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 Correct Answer: 2 Rationale 1: 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—is not fully assumed by the UAP. Rationale 2: 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. Rationale 3: Although taking vital signs was an appropriate task to delegate to the UAP, the full responsibility of the action—in this case, the inaction, as the vitals were recorded inaccurately—is not shared by both the UAP and the nurse. Rationale 4: Delegating this task was not the responsibility of the team leader and thus he or she has no responsibility for this action.

A nurse is caring for a client in the emergency department (ED) who was brought in by her adult child for vague, flu-like symptoms. While helping the client to change into a gown, the nurse notices numerous bruises on the client's back and arms. When questioned, the client is distracted and ambiguous with her answers. Which action should the nurse take? 1. Report the situation to law enforcement. 2. Report the situation to social services. 3. Question the adult child who brought the client to the ED. 4. File a written report in the client's chart. Correct Answer: 2 Rationale 1: In this case, social services should be notified. Law enforcement would be notified if the results of social services' investigation warrant it. Rationale 2: 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. Rationale 3: Questioning the client's adult child is appropriate, but the incident needs to be reported regardless of the questioning. Rationale 4: Documentation in the chart is extremely important, but this would be part of the nurse's notes, not a separate written report.

able to mobilize with a wheelchair and has no cognitive or psychological deficits. The nurse wants to return to the same position held prior to the injury. Under the guidelines of the ADA, what should the hospital do? 1. The hospital is required to accommodate the nurse. 2. The hospital must find another job for the nurse. 3. The hospital should claim undue hardship to accommodate this nurse. 4. The hospital terminate the nurse's employment. Correct Answer: 3 Rationale 1: The act’s provisions state that the disabled must be able to perform the responsibilities of the job with reasonable accommodations. 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. Rationale 2: 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. However, the hospital could help find another position that utilizes the nurse's experience and desire to continue in the field of nursing, but this would have to be a collaborative effort with the nurse and a reasonable request regarding the hospital’s needs and resources. Rationale 3: 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. Rationale 4: Terminating employment may or may not occur, but not until all other options have been explored.

2. Send an anonymous letter to the director of nursing. 3. Let other co-workers know about the situation. 4. Report the situation, then let management take care of it. Correct Answer: 1 Rationale 1: As a mandatory reporter, the nurse is required to report situations where co-workers 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. Rationale 2: The nurse should take responsibility for the report by being open about it, not making an anonymous report to the higher level of management. Rationale 3: The nurse should obtain support from at least one other trustworthy person before filing the report. This doesn't mean telling the whole unit, which could be detrimental to both the nurse reporting the incident and the co-worker. Rationale 4: After the report is made, the nurse should see the problem through, not assume that management will take care of the situation.

Correct Answer: 3 Rationale 1: Ignoring the situation is not addressing the situation in an assertive manner. Rationale 2: Reporting the incident to the nurse manager would be an appropriate second step if the behavior doesn't stop after the nurse's approach. Rationale 3: Nurses must develop skills of assertiveness to deter sexual harassment in the workplace. Telling the co-worker to stop, and why, is the first step in putting an end to the situation. Rationale 4: Asking to be scheduled opposite this person is not addressing the situation in an assertive manner.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials 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: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 58 Question 20 Type: MCSA A nurse who is opposed to abortion works in a hospital where abortions are performed. According to the Supreme Court's conscience clause, which action should the nurse take? 1. The nurse should not take action, because the nurse cannot interfere with a woman's constitutional right to privacy. 2. The nurse should voluntarily terminate employment. 3. The nurse should counsel women before they have an abortion. 4. The nurse should refuse to participate in abortions. Correct Answer: 4 Rationale 1: The nurse cannot interfere with a woman's right to privacy, which includes control over her own body to the extent that she can abort her fetus. Rationale 2: The conscience clause states that nurses, as well as other health care personnel, have a right to refuse to participate in abortions.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Counseling a woman prior to an abortion would not be an appropriate action because the nurse has chosen to work in a hospital where these procedures are done. Rationale 4: 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 health care personnel, have a right to refuse to participate in abortions and hospitals have the right to deny admission to abortion clients. . Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials 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: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 59 Question 21 Type: MCSA A client woke in the middle of the night, confused and unaware of the surroundings. Although the call light was within reach, the client got out of bed unassisted, tripped on the bedside chair, and fell. Which element of malpractice should the client’s attorney realize is missing in this case? 1. Foreseeability 2. Damages 3. Injury 4. Duty Correct Answer: 1 Rationale 1: 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. Rationale 2: Damages may well be present, but these probably are not due to any action or inaction on the nurse's part. Rationale 3: Injury may well be present, but this probably is not due to any action or inaction on the nurse's part. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Duty was addressed this case because the call light was within reach.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials 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: 8. Discriminate between negligence and professional negligence/malpractice. MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 65 Question 22 Type: MCSA A client scheduled for surgery has signed the consent form but refuses to have a Foley catheter placed, saying "That's not part of the surgery." What should the nurse do? 1. Explain that this is part of the surgical prep and continue with the procedure. 2. Explain that the client has already signed the consent, and place the catheter. 3. Respect the client's wishes and document accordingly. 4. Offer to call the physician. Correct Answer: 3 Rationale 1: Battery exists when there is not consent, even if the client was not asked. In this case, the client has the right to refuse other treatment surrounding pre- and post-op care. Rationale 2: Battery exists when there is not consent, even if the client was not asked. In this case, the client has the right to refuse other treatment surrounding pre- and post-op care. Rationale 3: 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 placement of a catheter should be respected. The nurse should document the incident and not continue with the procedure. Rationale 4: Calling the physician is not inappropriate.

AACN Essentials 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: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 54 Question 23 Type: MCSA The nurse documents in a client's 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 Correct Answer: 3 Rationale 1: Defamation is verbal communication that is false or made with a careless disregard for the truth and that results in injury to the reputation of a person. Rationale 2: Slander is defamation by the spoken word. Rationale 3: 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. Rationale 4: Incompetence relates to the ineffective or improper execution of nursing tasks.

Question 24 Type: MCSA 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. Giving first aid to a child injured in a sporting event 3. Permitting a nursing student to try to insert an airway in an unconscious client 4. Leaving the scene of an emergency to call for help 5. Helping deliver the baby of a neighbor during a snowstorm Correct Answer: 5 Rationale 1: The Good Samaritan acts are laws designed to protect health care 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. 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. Rationale 2: The Good Samaritan acts are laws designed to protect health care 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. 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. Rationale 3: The Good Samaritan acts are laws designed to protect health care 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. 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. Rationale 4: The Good Samaritan acts are laws designed to protect health care 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. 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Rationale 5: The Good Samaritan acts are laws designed to protect health care 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. 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.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials 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: 12. Describe the laws and strategies that protect the nurse from litigation. MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 67 Question 25 Type: MCMA When providing client care the nurse demonstrates practices that are designed to provide legal protections from liability. Which actions is the nurse demonstrating? Standard Text: 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 can not 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 can’t personally perform 5. Reviewing the five rights of medication administration when the client states, “This doesn’t look like my usual pill” Correct Answer: 1, 2, 3, 5 Rationale 1: Legal protection for nurses is best assured by always checking the identity of the client to make sure it is the right client.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Legal protection for nurses is best assured by asking for assistance and/or supervision in situations in which the nurse feels inadequately prepared. Rationale 3: Legal protection for nurses is best assured by maintaining clinical competence. Rationale 4: Delegation is a nursing responsibility that is designed to help provide quality and timely nursing care, but that is not its sole focus. Rationale 5: Legal protection for nurses is best assured by checking any order that a client questions.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials 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. Describe the laws and strategies that protect the nurse from litigation. MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 68 Question 26 Type: MCMA The clinical nursing 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? Standard Text: Select all that apply. 1. Prepared to discuss the client’s medical diagnosis in pre-conference 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 Correct Answer: 1, 2, 5 Rationale 1: 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. Rationale 2: Nursing students are held to the same standards as licenses nursed, and therefore need to make sure that they are prepared to provide the necessary care to assigned clients. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Although offering to stay with a client during a painful procedure shows compassion, it is not a behavior representative of legal responsibility. Rationale 4: Although showing respect for staff and clients demonstrates professionalism, it is not a behavior that is representative of legal responsibility. Rationale 5: It is important that nursing students ask for help or supervision in situations for which they feel inadequately prepared.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials 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: 13. Discuss the legal responsibilities of nursing students. MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 70 [New Questions: ] Question 27 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 3, 5 Rationale 1: Actions to ensure the client’s privacy include securing the medical record. Rationale 2: Sharing the client’s care with the media violates the client’s privacy. Rationale 3: Actions to ensure the client’s privacy include removing the client’s name from the door. Rationale 4: Permitting family to view the client’s record violates the client’s privacy. Rationale 5: Actions to ensure the client’s privacy include faxing information with a cover sheet.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials 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: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 66 Question 28 Type: MCMA The nurse manager is concerned that a staff nurse’s care demonstrates gross negligence. What actions did the manager use to make this determination? Standard Text: 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 Correct Answer: 1, 2, 4, 5 Rationale 1: Gross negligence involves extreme lack of knowledge, skill, or decision making that the person clearly should have known would put others at risk for harm. Removing a client’s central line would be gross negligence. Rationale 2: Gross negligence involves extreme lack of knowledge, skill, or decision making that the person clearly should have known would put others at risk for harm. Reconnecting contaminated intravenous tubing would be gross negligence. Rationale 3: Accessing the computer documentation system with a password demonstrates compliance with HIPAA. Rationale 4: Gross negligence involves extreme lack of knowledge, skill, or decision making that the person clearly should have known would put others at risk for harm. Walking a patient with an unsafe blood pressure is gross negligence. Rationale 5: Gross negligence involves extreme lack of knowledge, skill, or decision making that the person clearly should have known would put others at risk for harm. Inappropriately delegating a skill is gross negligence.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials 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: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 62

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 05 Question 1 Type: MCSA A student is attending a school with a high first-time pass rate on the NCLEX®. Which student statement articulates a belief that the nursing 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 Correct Answer: 3 Rationale 1: The option expresses an attitude. Attitudes are mental positions or feelings that continue over time. This option describes how the student feels about the faculty. Rationale 2: The option expresses an attitude. Attitudes are mental positions or feelings that continue over time. This option describes how the student feels about the faculty. Rationale 3: 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. Rationale 4: The option expresses an attitude. Attitudes are mental positions or feelings that continue over time. This option describes describe how the student feels about the faculty.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: 5. Discuss the advocacy role of the nurse. MNL Learning Outcome: 1.1.3. Consider how values impact the practice of nursing. Page Number: 73 Question 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA A nurse manager has a staff nurse who observes certain religious holidays. The manager tries to make sure that these observances can be met if possible. Which value is the manager practicing? 1. Human dignity 2. Social justice 3. Autonomy 4. Altruism Correct Answer: 4 Rationale 1: Human dignity is respect for the inherent worth and uniqueness of individuals and populations. That is not the value described here. Rationale 2: Social justice is upholding moral, legal, and humanistic principles. That is not the value described here. Rationale 3: Autonomy is the right to self-determination, and professional practice reflects autonomy when the nurse respects patients' rights to make decisions about their health care. That is not the value described here. Rationale 4: 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.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: 1.1.3. Consider how values impact the practice of nursing. Page Number: 74 Question 3 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Respecting the parents' decision 3. Referring the parents to social services 4. Asking to be assigned to a different client Correct Answer: 2 Rationale 1: A nurse can show respect for the family without respecting the decision of the parents. Rationale 2: Autonomy is the right to self-determination, and professional practice reflects autonomy when the nurse respects patients' rights to make decisions about their health care. Rationale 3: Referring the parents to another entity points to feelings of unease about the parents' choice. Rationale 4: Asking to be assigned to another client does not honor the right of patients and families to make decisions about health care.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Human dignity is respect for the worth and uniqueness of individuals and populations. That is not the value described here. Rationale 2: Altruism is concern for the welfare and well-being of others. That is not the value described here. Rationale 3: 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 health care. Rationale 4: Integrity is acting in accordance with an appropriate code of ethics and accepted standards of practice. That is not the value described here.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: 3. When presented with an ethical situation, identify the moral issues and principles involved. MNL Learning Outcome: 1.1.3. Consider how values impact the practice of nursing. Page Number: 74 Question 5 Type: MCSA A nurse mistakenly gave a client who was NPO a morning breakfast tray. After realizing the mistake, the nurse notified the physician as well as the client; explained the consequences of this mistake, which included a delay in the client's scheduled procedure; and documented the situation in the client's medical record. What did this nurse demonstrate? 1. Altruism 2. Integrity 3. Social justice 4. Human dignity Correct Answer: 2 Rationale 1: Altruism is a concern for the welfare and well-being of others. That is not the value described here. Rationale 2: Integrity is acting in accordance with an appropriate code of ethics and accepted standards of practice. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Social justice is upholding moral, legal, and humanistic principles. That is not the value described here. Rationale 4: Human dignity is respect for the worth and uniqueness of individuals and populations. That is not the value described here.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct NLN Competencies: Context and Environment; Practice; 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: 1.1.4. Consider how ethics impact the practice of nursing. Page Number: 74 Question 6 Type: MCSA A pregnant client says her main concern is that her baby will be born healthy, even though she 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 Correct Answer: 2 Rationale 1: Values transmission means that values are learned through observation and experience and are influenced by sociocultural environment and traditions. Rationale 2: Behavior that indicates unclear values includes ignoring a health professional's advice, such as using alcohol during pregnancy. Rationale 3: Morals refer to personal standards of what is right and wrong. Rationale 4: Ethics refers to the practices or beliefs of a certain group.

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: 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: 4. Discuss common ethical issues currently facing health care professionals. MNL Learning Outcome: 1.1.3. Consider how values impact the practice of nursing. Page Number: 74 Question 7 Type: MCSA A client who has been blinded as result of an injury informs the rehabilitation staff of planning to return to her counseling practice and working full-time. The nurse should realize that this client is demonstrating which aspect of values clarification? 1. Choosing 2. Prizing 3. Acting 4. Clarifying Correct Answer: 3 Rationale 1: Choosing is a cognitive action. Beliefs are chosen freely without outside pressure, from among alternatives, and after reflecting and considering consequences. That is not the aspect of values clarification described in the stem. Rationale 2: Prizing is an affective action where chosen beliefs are prized and cherished. That is not the aspect of values clarification described in the stem. Rationale 3: 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. Rationale 4: Clarifying values is the process in which choosing, prizing, and acting are accomplished. That is not the aspect of values clarification described in the stem.

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: 1.1.3. Consider how values impact the practice of nursing. Page Number: 74 Question 8 Type: MCSA A client has been complaining of pain, even though the nurse has given the client the maximum amount of medication as ordered 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 co-workers that this client has no pain tolerance 4. Believing the client is drug seeking Correct Answer: 2 Rationale 1: This option does not exemplify the nurse's respect for or consideration of the client's situation. Rationale 2: 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. Rationale 3: This option does not exemplify the nurse's respect for or consideration of the client's situation. Rationale 4: This option does not exemplify the nurse's respect for or consideration of the client's situation.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: 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: 1.1.3. Consider how values impact the practice of nursing. Page Number: 76 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 9 Type: MCSA A client has chosen to discontinue hemodialysis. His family is not supportive of his decision. Which statement should the nurse make that demonstrates the theory of principles-based reasoning? 1. "This client is of sound mind and is capable of making his own decisions regarding health care. 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." Correct Answer: 1 Rationale 1: Principles-based theories stress individual rights, such as autonomy. The client has the ability to make the decision and it is his right to autonomy to do that. Rationale 2: Caring theories, or relationship theories, stress courage, generosity, commitment, and the need to nurture and maintain relationships. Caring theories promote the common good or the welfare of the group. Trying to help the family understand the client's decision is an example of a caring-based theory in practice. Rationale 3: Consequence-based theories look at the outcomes of an action in judging whether that action is right or wrong. Rationale 4: Consequence theories are exemplified by the nurse looking at the outcomes of the client's decision.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The administration of a hospital, along with nursing services, is planning to incorporate a struggling private clinic into the infrastructure of the hospital. Although relocating the clinic may cause transportation difficulty for some clients, keeping the clinic running will allow current employees as well as clients the continued benefit of the clinic. Which moral framework did the hospital leadership use to make this decision? 1. Teleological theory 2. Deontological theory 3. Utilitarianism 4. Caring theory Correct Answer: 3 Rationale 1: Teleological theories look at the outcomes of an action and judge it to be right or wrong. Rationale 2: Deontological theories, which are principles based, emphasize individual rights, duties, and obligations. In this situation, numerous people are involved with the clinic, not just one person. Rationale 3: 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. Rationale 4: Caring theories stress courage, generosity, commitment, and the need to nurture and maintain relationships.

2. Justice 3. Beneficence 4. Nonmaleficence Correct Answer: 4 Rationale 1: Autonomy refers to the right to make one's own decisions. That is not what the nurse is having an ethical dilemma about. Rationale 2: Justice is often referred to as fairness. That is not what the nurse is having an ethical dilemma about. Rationale 3: Beneficence means "doing good." In this case the benefits are not known, making the harm more real. Although aggressive cancer therapy is difficult to endure and given the age of the client, this case suggests beneficence, but there is a more appropriate option available. Rationale 4: 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.

Correct Answer: 1 Rationale 1: 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. Rationale 2: Saying that the nurse will everything possible not to hurt the child will not negate the fact that it will hurt. A needle going into a vein is not a comfortable procedure. Rationale 3: Saying that the nurse will perform the task quickly is not a sufficient answer to the parent. A needle going into a vein is not a comfortable procedure. The nurse really doesn't know how bad it will hurt the child. Rationale 4: Telling the parent not to worry is pointless.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Fidelity means to be faithful to agreements and promises. That it not the value exhibited by the student nurse. Rationale 3: Responsibility refers to the liability associated with the performance of the duties of a particular role. The student had the responsibility to provide safe care to the client (i.e., make sure the call light was within reach) but did not follow through with it. That it not the value exhibited by the student nurse. Rationale 4: Accountability means "answering to oneself and others for one's own actions." By admitting that double checking should be done, the student showed accountability.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct NLN Competencies: Context and Environment; Practice; 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: 1.1.4. Consider how ethics impact the practice of nursing. Page Number: 77 Question 14 Type: MCSA The nurse is reviewing the ANA (American Nurses Association) Code of Ethics for Nurses. What should the nurse identify as a characteristic of this code? 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. Correct Answer: 5 Rationale 1: A code of ethics is a formal statement of a group's ideals and values. It is a set of ethical principles that (a) is shared by members of the group, (b) reflects their moral (not legal) judgments over time, and (c) serves as a standard for their professional actions. Codes of ethics usually have higher requirements than legal standards, and they are never lower than the legal standards of the profession. Rationale 2: A code of ethics is a formal statement of a group's ideals and values. It is a set of ethical principles that (a) is shared by members of the group, (b) reflects their moral (not legal) judgments over time, and (c) serves Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

as a standard for their professional actions. Codes of ethics usually have higher requirements than legal standards, and they are never lower than the legal standards of the profession. Rationale 3: A code of ethics is a formal statement of a group's ideals and values. It is a set of ethical principles that (a) is shared by members of the group, (b) reflects their moral (not legal) judgments over time, and (c) serves as a standard for their professional actions. Codes of ethics usually have higher requirements than legal standards, and they are never lower than the legal standards of the profession. Rationale 4: A code of ethics is a formal statement of a group's ideals and values. It is a set of ethical principles that (a) is shared by members of the group, (b) reflects their moral (not legal) judgments over time, and (c) serves as a standard for their professional actions. Codes of ethics usually have higher requirements than legal standards, and they are never lower than the legal standards of the profession. Rationale 5: A code of ethics is a formal statement of a group's ideals and values. It is a set of ethical principles that (a) is shared by members of the group, (b) reflects their moral (not legal) judgments over time, and (c) serves as a standard for their professional actions. Codes of ethics usually have higher requirements than legal standards, and they are never lower than the legal standards of the profession.

Correct Answer: 1 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Passive euthanasia involves the withdrawal of extraordinary means of life support and is never an easy decision. Rationale 2: 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. Rationale 3: Active euthanasia and assisted suicide are in violation of the Code for Nurses, according to the position statement by the ANA. Rationale 4: Some states and countries have laws permitting assisted suicide for clients who are severely ill, are near death, and wish to commit suicide.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct NLN Competencies: Context and Environment; Practice; apply ethical decision making models Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Discuss common ethical issues currently facing health care professionals. MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing. Page Number: 82 Question 17 Type: MCSA A client with terminal cancer is refusing food and fluids, and pushes the caregiver's hands away when attempts are made to feed the client or offer any kind of fluid. The family is considering placing a gastrostomy tube because they feel the client is "starving to death." 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. Correct Answer: 3 Rationale 1: Clients, not their families, should make decisions about their own health care and treatment. Rationale 2: The physician may or may not be involved, but not to disregard the client's refusal. Rationale 3: A 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 patients' refusal of food and fluids. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 health care and treatment. In this case, the client has made a decision and it should be honored. Rationale 4: An ethics committee is usually considered when there is an ethical dilemma and more input is needed to make a decision. In this case, the client has made a decision. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct NLN Competencies: Context and Environment; Practice; 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: 1.1.4. Consider how ethics impact the practice of nursing. Page Number: 78 Question 18 Type: MCSA A client with a sexually transmitted illness (STI) asks the nurse to not tell anyone about the diagnosis. According to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, 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. Correct Answer: 4 Rationale 1: Nurses should not make promises to keep necessary information private. Rationale 2: Nurses are entrusted with sensitive information that, at times, must be revealed to other health care personnel in order to provide appropriate health care. Rationale 3: Nurses are entrusted with sensitive information that, at times, must be revealed to other health care personnel in order to provide appropriate health care. Clients must be able to trust that their information is secure and will only be shared with appropriate entities. Rationale 4: 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 health care personnel in order to provide appropriate health care. In this case, the nurse may be required to report information to the state health department. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct NLN Competencies: Context and Environment; Knowledge; HIPAA Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Discuss common ethical issues currently facing health care professionals. MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing. Page Number: 83 Question 19 Type: MCSA 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 she needs to take the prescribed amount. 3. Report the situation to the physician. 4. Weigh the client on a weekly basis to monitor weight gain or loss. Correct Answer: 1 Rationale 1: Resource allocation and financial considerations are major issues in home health care. 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 the treatment needs met. Rationale 2: The client already knows she should take the prescribed amount. Rationale 3: Telling the physician will not help to solve the situation. Rationale 4: Weighing the client merely assesses the need, which has already been established.

Learning Outcome: 5. Discuss the advocacy role of the nurse. MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing. Page Number: 83 Question 20 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 2, 5, 6 Rationale 1: Promotion of health is one of the fundamental responsibilities of nurses according to the International Council of Nurses Code of Ethics. Rationale 2: Restoration of health is one of the fundamental responsibilities of nurses according to the International Council of Nurses Code of Ethics. Rationale 3: Informing the public about minimum standards of nursing conduct is not one of the fundamental responsibilities of nurses that is included in the preamble of the International Council of Nurses Code of Ethics. Rationale 4: Providing self-regulation in the profession is not one of the fundamental responsibilities of nurses that is included in the preamble of the International Council of Nurses Code of Ethics. Rationale 5: Preventing illness is one of the fundamental responsibilities of nurses according to the International Council of Nurses Code of Ethics. Rationale 6: The alleviation of suffering is one of the fundamental responsibilities of nurses according to the International Council of Nurses Code of Ethics.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct NLN Competencies: Context and Environment; Practice; 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: 1.1.4. Consider how ethics impact the practice of nursing. Page Number: 78 Question 21 Type: MCMA 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? Standard Text: Select all that apply. 1. Reporting a medication error that he was responsible for making 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 health care provider to clarify a confusing prescription for a client’s pain Correct Answer: 2, 3, 4, 5 Rationale 1: This is more reflective of the nurse’s responsibility and accountability for personal nursing practice. Rationale 2: The nurse advocates for client health and safety when reporting the impaired nurse. Rationale 3: The nurse advocates for client rights when protecting confidentiality. Rationale 4: The nurse advocates for client health and safety when protecting the participants in a research project. Rationale 5: The nurse advocates for client health and safety when clarifying confusing orders or questionable medical practices.

NLN Competencies: Context and Environment; Practice; apply ethical decision making models Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Discuss the advocacy role of the nurse. MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing. Page Number: 83 Question 22 Type: SEQ The nurse is addressing an ethical issue. In which order should the nurse implement the steps of this decisionmaking process? Standard Text: Click and drag the options below to move them up or down. Choice 1. Interviewing the client regarding details of the problem Choice 2. Discussing the various results of the identified possible actions to resolve the problem Choice 3. Determining what, if any, ethical issues exist Choice 4. Determining whether affected parties are in ethical conflict Choice 5. Assessing all involved parties concerning their ethical beliefs regarding the problem Correct Answer: 1, 3, 5, 4, 2 Rationale 1: Gathering additional information to clarify the situation is the first step in this model. Rationale 2: Identifying the range of actions with anticipated outcomes is the final step in this process among the available options. Rationale 3: Identifying the ethical issues in the situation occurs immediately after the information concerning the problem is obtained. Rationale 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. Rationale 5: Identifying moral positions of key individuals involved occurs after information has been gathered and it is determined that an ethical problem exists.

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: 1.1.4. Consider how ethics impact the practice of nursing. Page Number: 81 [New Questions: ] Question 23 Type: MCMA 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? Standard Text: Click and drag the options below to move them up or down. 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. Correct Answer: 2, 5, 1, 6, 3, 4 Rationale 1: The nurse should ask if the client has a say in the decision in the third step of the process. Rationale 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. . Rationale 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.

Rationale 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. Rationale 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. Rationale 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.

NLN Competencies: Context and Environment; Practice; 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: 1.1.4. Consider how ethics impact the practice of nursing. Page Number: 74 Question 24 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 3, 4, 5 Rationale 1: Nurses’ professional values are acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers. Rationale 2: Ethical issues cannot be avoided in nursing or health care. This is not a viable approach for the professor to use. Rationale 3: Nurses’ professional values are acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers. Rationale 4: Nurses’ professional values are acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers. Rationale 5: Nurses’ professional values are acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers. . Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct NLN Competencies: Context and Environment; Practice; 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: 1.1.4. Consider how ethics impact the practice of nursing. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 74

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 06 Question 1 Type: MCSA The nurse is reviewing the Healthy People 2020 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 Correct Answer: 2 Rationale 1: Healthy People 2020 has four overarching goals: (1) Increase quality and years of healthy life, (2) achieve health equity and eliminate health disparities, (3) create healthy environments for everyone, and (4) promote health and quality life across the life span. Free screening to schoolchildren is already being done in most states. Rationale 2: Healthy People 2020 has four overarching goals: (1) Increase quality and years of healthy life, (2) achieve health equity and eliminate health disparities, (3) create healthy environments for everyone, and (4) promote health and quality life across the life span. Opening a wellness clinic focuses on bettering health, which would be in line with goal 1. Rationale 3: Healthy People 2020 has four overarching goals: (1) Increase quality and years of healthy life, (2) achieve health equity and eliminate health disparities, (3) create healthy environments for everyone, and (4) promote health and quality life across the life span. Developing insurance control was a goal of health care reform during the Clinton administration. Rationale 4: Ongoing development of pharmacological treatments is not a new initiative.

Learning Outcome: 1. Differentiate health care services based on primary, secondary, and tertiary disease prevention categories. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 89 Question 2 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Providing immunization clinics is an example of illness prevention, not health promotion. Rationale 3: Evaluating industrial centers for pollution is an example of illness prevention, not health promotion. Rationale 4: Teaching smoking cessation classes is an example of illness prevention, not health promotion.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Differentiate health care services based on primary, secondary, and tertiary disease prevention categories. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 89 Question 3 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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 Correct Answer: 4 Rationale 1: Rehabilitation is a process of restoring ill or injured people to optimum and functional levels of wellness, emphasizing the importance of assisting clients to function adequately in the physical, mental, social, economic, and vocational areas of their lives. That is not the service this client requires. Rationale 2: Health restoration is service that helps bring ill or injured clients back to their former state of health. That is not the service this client requires. Rationale 3: Acute care is the typical service provided in a hospital. That is not the service this client requires. Rationale 4: 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.

1. State health department 2. Local health department 3. Local hospital 4. Federal government Correct Answer: 2 Rationale 1: State health organizations are responsible for assisting the local health departments. This is not the agency to provide the assistance the nurses are looking for. Rationale 2: 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. Rationale 3: Local hospitals provide the majority of acute care services in a community. This is not the agency to provide the assistance the nurses are looking for. Rationale 4: The U.S. Department of Health and Human Services is an agency at the federal level whose functions include conducting research and providing training in the health field, providing assistance to communities in planning and developing health facilities, and assisting states and local communities through financing and provision of trained personnel. This is not the agency to provide the assistance the nurses are looking for.

2. Specialty hospital 3. Long-term care hospital 4. Short-term hospital Correct Answer: 1 Rationale 1: 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. Rationale 2: Hospitals are classified by the services they provide as well as by their ownership. Some hospitals offer only specialty services, such as psychiatric or pediatric. This does not describe the facility in this scenario. Rationale 3: Hospitals are classified by the services they provide as well as by their ownership. Long-term care hospitals provide services for longer periods—sometimes years or for the remainder of the client's life. This does not describe the facility in the scenario. Rationale 4: Acute care (or short-term) hospitals provide assistance to clients whose illness and need for hospitalization are relatively short term, such as several days. This does not describe the facility in the stem.

4. Go to a nursing home. Correct Answer: 3 Rationale 1: An acute care hospital stay is no longer required because the needs of the client could be met in another facility. Rationale 2: The antibiotic therapy and custodial care can be provided in a more suitable facility. Rationale 3: 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. Rationale 4: The client may require a nursing home or long-term care facility at some point, but it is too early in the recovery to make this decision. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the functions and purposes of the health care agencies outlined in this chapter. MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies. Page Number: 92 Question 7 Type: MCSA An older client has no family in the same community, lives alone in a small house, and is having greater difficulty with mobility due to advanced osteoarthritis. Cognitively, this client is alert, is able to manage her own business matters, and does her own cooking, but does not enjoy "cooking for one." The home health nurse who visits has noticed that the client is losing weight and does not have as much energy or interest in activities as on previous visits. What should the nurse recommend for this client? 1. See a psychiatrist because the client appears to be 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. Correct Answer: 4 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Diagnosing depression is outside the scope of nursing practice. Other interventions can be implemented before this action is considered. It also does not meet the client’s immediate needs. Rationale 2: Joint replacement may or may not be an option, but it would not be the nurse's responsibility to recommend this, nor does it meet the client’s immediate needs. Rationale 3: This client does not show any indications of requiring long-term care at this point. Rationale 4: 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.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the functions and purposes of the health care agencies outlined in this chapter. MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies. Page Number: 92 Question 8 Type: MCSA The spouse of a client diagnosed with Stage I/II Alzheimer's disease must continue to work full-time. The spouse tells the occupational health nurse that 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. Correct Answer: 3

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Placing a client from an independent home situation to long-term care would be more detrimental than a gradual progression of care. Rationale 2: Telling the spouse to consider early retirement is neither therapeutic nor realistic. Rationale 3: 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. Rationale 4: Increasing medications is a decision that needs to be made by the client's primary caregiver, not the nurse, nor does it address the spouse’s concerns regarding care. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the functions and purposes of the health care agencies outlined in this chapter. MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies. Page Number: 93 Question 9 Type: MCSA 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." Correct Answer: 1 Rationale 1: 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. Rationale 2: Acute care may be warranted as the client's condition changes. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: The place of hospice care varies, but includes home, hospital, or skilled nursing facilities. Rationale 4: Hospice care may well be cheaper, but this is not the main reason for referral to hospice services.

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the functions and purposes of the health care agencies outlined in this chapter. MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies. Page Number: 93 Question 10 Type: MCSA 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 Correct Answer: 3 Rationale 1: The term paramedical technologist includes laboratory technologists, radiological technologists, and nuclear medicine technologists. This title is given to those professionals having some connection with medicine. This referral would not meet the client’s needs regarding independent living. Rationale 2: A physical therapist helps clients regain physical strength and mobility. In this case, the client would probably also see a physical therapist, but not for the focus on independent living. Rationale 3: 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.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: A case manager's role is to ensure that clients receive fiscally sound, appropriate care in the best setting. This client may well have a case manager to coordinate all the necessary care, but the question focuses on the return to independent living.

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the functions and purposes of the health care agencies outlined in this chapter. MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies. Page Number: 94 Question 11 Type: MCSA A 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 Correct Answer: 2 Rationale 1: Lack of social support contributes to health problems in general. Rationale 2: 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. Rationale 3: Improper nutrition contributes to health problems in general. Rationale 4: Few personal resources contributes to health problems in general.

Cognitive Level: Applying Client Need: Physiological Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify the roles of various health care professionals. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 98 Question 12 Type: MCSA A 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 Correct Answer: 1 Rationale 1: Managed care describes a health care system whose goals are to provide cost-effective, quality care that focuses on decreased costs and improved outcomes for groups of clients. Rationale 2: Case management describes a range of models for integrating health care services for individuals or groups. This is not the model described in the scenario. Rationale 3: 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 is not the model described in the scenario. Rationale 4: Patient-focused care is a delivery model that brings all services and care providers to the client. This is not the model described in the scenario.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe the factors that affect health care delivery. MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies. Page Number: 98 Question 13 Type: MCSA The manager of a small clinic has cross-trained the nurses to provide basic nursing care, and perform ECG testing, phlebotomy, and some respiratory therapy interventions. Which type of care delivery model has the manager implemented? 1. Managed care 2. Case management 3. Patient-focused care 4. Critical pathways Correct Answer: 3 Rationale 1: Managed care focuses on cost-effective, quality care that results in decreased costs and improved outcomes. This is not the model described in the scenario. Rationale 2: Case management is a way to integrate health care services for individuals or groups and involves multidisciplinary teams that assume collaborative responsibility for planning, assessing needs, and coordinating, implementing, and evaluating care. This is not the model described in the scenario. Rationale 3: Client-focused care is a delivery model that provides services according to the clients’ needs. Rationale 4: Critical pathways are used to track the client's progress in case management. This is not the model described in the scenario. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 5. Describe frameworks for the delivery of nursing care. MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies. Page Number: 100 Question 14 Type: MCSA 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. Shared governance 3. Differentiated practice 4. Managed care Correct Answer: 3 Rationale 1: Patient-focused care is a delivery model that brings all services and care providers to the client. This is not the model described in the scenario. Rationale 2: Shared governance is an organizational model in which nursing staff are cooperative with administrative personnel in making, implementing, and evaluating client care policies. This is not the model described in the stem. Rationale 3: 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. Rationale 4: Managed care focuses on cost containment, consumer satisfaction, health promotion, and preventive services. This is not the model described in the scenario.

Page Number: 99 Question 15 Type: MCSA 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. Shared governance 3. Functional method 4. Team nursing Correct Answer: 4 Rationale 1: The case method is a client-centered model where one nurse is assigned to and responsible for the comprehensive care of a group of clients during a shift. In this method a client has consistent contact with one nurse during a shift, but may have different nurses on other shifts. This is not the model described in the scenario. Rationale 2: Shared governance is an organizational model in which nursing staff are cooperative with administrative personnel in making, implementing, and evaluating client care policies. This is not the model described in the scenario. Rationale 3: The functional nursing method focuses on the jobs to be completed. It is a task-oriented approach in which personnel with less preparation than the professional nurse perform less complex care requirements. This is not the model described in the scenario. Rationale 4: 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.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 99 Question 16 Type: MCSA A seasoned RN 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Team nursing is the delivery of individualized nursing care to clients by a team led by a professional nurse and consisting of RNs, LPNs, and UAPs. This is not the model described in the scenario. Rationale 3: Differentiated practice is a system in which the best possible use of nursing personnel is based on their education preparation and resultant skill sets. This is not the model described in the scenario. Rationale 4: The case method is also referred to as total care, in which one nurse is assigned to and is responsible for the comprehensive care of a group of clients during an 8- or 12-hour shift. This is not the model described in the scenario. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify the roles of various health care professionals. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 100 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 17 Type: MCSA 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." Correct Answer: 3 Rationale 1: Ignoring the client's concerns by telling him not to worry is not therapeutic communication and does little, if anything, to confront the client's concerns. Rationale 2: Ignoring the client's concerns by telling him not to worry is not therapeutic communication and does little, if anything, to confront the client's concerns. Rationale 3: 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. Rationale 4: Giving the concern to the business office is merely "passing the buck." Nurses should have some knowledge about the payment sources of their clients, especially those who have automatic coverage with Medicare because of their age. Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Compare various systems of payment for health care services. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 100 Question 18 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 3 Rationale 1: Medicare provides insurance coverage for people over age 65. This is not the legislation described in the scenario. Rationale 2: Medicaid provides service to people who require financial assistance for health care. This is not the legislation described in the scenario. Rationale 3: In 1978, the Rural Health Clinics Act provided for the development of health care in medically underserved rural areas. This act opened the door for nurse practitioners to provide primary care. Rationale 4: The National Health Planning and Resources Development Act established health systems agencies throughout the United States for the development of health care in medically underserved rural areas. This is not the legislation described in the scenario. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Describe frameworks for the delivery of nursing care. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 93 Question 19 Type: MCSA 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? 1. Individuals will be fined if they do not have health insurance. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 1, 2, 3, 4 Rationale 1: A provision within the Affordable Care Act is that individuals will be fined if they do not have health insurance. Rationale 2: A provision within the Affordable Care Act is that employers must offer health insurance if they meet identified requirements. Rationale 3: A provision within the Affordable Care Act is that insurance can be purchased through exchanges. Rationale 4: A provision within the Affordable Care Act is that individuals with preexisting health conditions cannot be denied health insurance coverage. Rationale 5: Health insurance is not free. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe frameworks for the delivery of nursing care. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 100 Question 20 Type: MCSA 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 health care benefits, so don't worry." 2. "Both the HMO and PPO are covered by your employer, so it's really not your concern."

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. "Your PPO offered you a choice in your health care 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 expense." Correct Answer: 3 Rationale 1: Telling the client not to worry does not address the client's question, which is to explain the difference. Rationale 2: Telling the client not to worry does not address the client's question, which is to explain the difference. Rationale 3: 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 health care 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 health care providers and services. Rationale 4: Even though telling the client that she will have little out-of-pocket expense may be truthful, it doesn't answer the question.

3. Increase in the number of elderly 4. Decrease in chronic disease 5. Technological advances 6. Economics Correct Answer: 2, 3, 5, 6 Rationale 1: Although there is an increase in complementary and alternative medicine use, this does not affect how health care is delivered. Rationale 2: With the improved availability of health-related information, consumers are more knowledgeable, and play an active role in their health care. Rationale 3: People over age 85 are projected to be the fastest-growing population in the United States. Rationale 4: Chronic illness is prevalent in this group. Rationale 5: Technology related to health care is rapidly increasing, and includes improved diagnostic procedures and equipment that permits early recognition of diseases. Rationale 6: Inflation increases all costs, and paying for health care services is becoming a greater problem.

1. Health care 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 Correct Answer: 1, 2, 4, 5, 6 Rationale 1: The total population is growing, especially the older adult segment that tends to have greater health care needs compared to younger persons. Rationale 2: The uninsured numbers are on the rise: 17% of persons under age 65. Rationale 3: Birth rates have dropped in the last 20 years, and so do not have a major impact on health care costs. Rationale 4: The cost of prescription drugs is increasing, and represents 19% of total health care expenditures in the United States. Rationale 5: Inflation increases all costs. Rationale 6: The total population is growing, especially the older adult segment that tends to have diagnosed chronic illnesses.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

In order to comply with the U.S. Department of Health and Human Services’ most current health care goals as stated in Healthy People 2020, what should the nurse do? Standard Text: 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 health care for those with no private insurance coverage. 4. Organize a park “cleanup day” to assure that 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. Correct Answer: 1, 3, 4, 5 Rationale 1: The federal-government-funded Healthy People 2020 has as one of its primary goals promoting health and quality life across the life span. Rationale 2: This intervention is not directed toward the federal government’s primary health goals as stated in Healthy People 2020. Rationale 3: The federal-government-funded Healthy People 2020 has among its primary goals achieving health equity and eliminating health disparities. Rationale 4: The federal-government-funded Healthy People 2020 has as one of its primary goals creating healthy environments for everyone. Rationale 5: The federal-government-funded Healthy People 2020 has as one of its primary goals increasing quality and years of healthy life.

Question 24 Type: MCMA The nurse is reviewing sources of federal funding for health care services provided to clients. For which clients should the nurse recognize as most likely having health care paid through a federal funding source? Standard Text: 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 Correct Answer: 2, 4 Rationale 1: This patient would be on a private insurance plan like Blue Cross and Blue Shield. Rationale 2: This patient would be on a federally funded insurance plan like Medicare. Rationale 3: This patient would be on a private insurance plan like Blue Cross and Blue Shield. Rationale 4: This patient would be on a federally funded insurance plan like Medicaid. Rationale 5: This patient would be on a prepaid group plan: a health maintenance organization (HMO).

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? Standard Text: 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. Correct Answer: 3, 4 Rationale 1: There is no reason for intravenous fluids to not be paid. Rationale 2: There is no reason for x-rays to not be paid. Rationale 3: In efforts to decrease cost and encourage attention to preventable conditions, for discharges occurring after October 1, 2008, hospitals no longer receive additional payment for cases in which one of several identified preventable conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present. Examples of hospital-acquired conditions (HACs) are pressure ulcers and urinary tract infections following catheterization. Rationale 4: In efforts to decrease cost and encourage attention to preventable conditions, for discharges occurring after October 1, 2008, hospitals no longer receive additional payment for cases in which one of several identified preventable conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present. Examples of hospital-acquired conditions (HACs) are pressure ulcers and urinary tract infections following catheterization. Rationale 5: There is no reason for physical therapy treatments to not be paid.

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? Standard Text: 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 Correct Answer: 3, 4, 5 Rationale 1: Ventilatory support would be considered a critical illness and most likely not provided through home care. Rationale 2: A health and wellness visit can be conducted in a community clinic or health care provider’s office. Home care would not be needed. Rationale 3: Home health care nurses and other staff offer education to clients and families and also provide comprehensive care to clients who are acutely, chronically, or terminally ill. This would include teaching about surgical wound care. Rationale 4: Home health care nurses and other staff offer education to clients and families and also provide comprehensive care to clients who are acutely, chronically, or terminally ill. This would include providing intravenous antibiotics daily. Rationale 5: Home health care nurses and other staff offer education to clients and families and also provide comprehensive care to clients who are acutely, chronically, or terminally ill. This would include teaching about self-management of a disease process.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 07 Question 1 Type: MCSA A nurse educator is explaining primary health care (PHC) and the extension of its boundaries beyond traditional health care 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 Correct Answer: 2 Rationale 1: 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 health care that led to the global health strategy of primary health care. Rationale 2: 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 health care that led to the global health strategy of primary health care. Rationale 3: 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 health care that led to the global health strategy of primary health care. Rationale 4: 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 health care that led to the global health strategy of primary health care. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Discuss factors influencing health care reform. MNL Learning Outcome: 1.2.4. Compare the frameworks of care. Page Number: 106 Question 2 Type: MCSA After a community was hit by a tornado, the nurses of the local Red Cross Chapter 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 Correct Answer: 4 Rationale 1: Social control refers to the way in which order is maintained in a community. Rationale 2: Social interparticipation refers to community activities that are designed to meet people’s needs for companionship. Rationale 3: Mutual support refers to the community’s ability to provide resources at a time of illness or disaster. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation 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: 1.2.4. Compare the frameworks of care. Page Number: 108 Question 3 Type: MCSA 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 Correct Answer: 3 Rationale 1: Socialization refers to the process of transmitting values, knowledge, culture, and skills to others. Rationale 2: Social control refers to the way in which order is maintained in a community. Rationale 3: Social interparticipation refers to community activities that are designed to meet people's needs for companionship. Rationale 4: Mutual support refers to the community's ability to provide resources at a time of illness or disaster. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 4. Differentiate community-based nursing from traditional institutional-based nursing. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 108 Question 4 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: A community is a group of people or a social system in which the members interact formally or informally and form networks that operate for the benefit of all people in the community. A grade school class is a community. Rationale 3: A community is a group of people or a social system in which the members interact formally or informally and form networks that operate for the benefit of all people in the community. Graduating nursing students is an example of a community. Rationale 4: A community is a group of people or a social system in which the members interact formally or informally and form networks that operate for the benefit of all people in the community. Employees at a local plant are an example of a community. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 6. Explain essential aspects of collaborative health care: definitions, objectives, benefits, and the nurse’s role. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 108 Question 5 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: Understanding the major illnesses present in the community is not a part of the community assessment. Rationale 3: Identifying boundaries is part of a community assessment; however, it is not the first stage. Rationale 4: Community resources include types of dwellings, education system, safety and transportation services, politics and government, health and social services, communication, economics, and recreation. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe various community-based health care frameworks, including integrated health care systems, community initiatives and conditions, and case management. MNL Learning Outcome: 1.2.4. Compare the frameworks of care. Page Number: 108 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 6 Type: MCSA While completing a community assessment, the nurse needs to learn the location of main health facilities and the number of 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 Correct Answer: 3 Rationale 1: The police department has statistics regarding incidence of crime, vandalism, and drug addiction. Rationale 2: The city health planning board has information about health needs and practices. Rationale 3: 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. Rationale 4: The state census data describe population composition and characteristics. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Explain essential aspects of collaborative health care: definitions, objectives, benefits, and the nurse’s role. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 109 Question 7 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Public and university libraries 3. Recreational directors 4. Teachers and school nurses Correct Answer: 4 Rationale 1: The chamber of commerce can supply statistics about employment, major industries, and primary occupations. Rationale 2: Public and university libraries contain district social and cultural research reports. Rationale 3: Recreational directors provide information about programs and participation levels. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Explain essential aspects of collaborative health care: definitions, objectives, benefits, and the nurse’s role. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 109 Question 8 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 3 Rationale 1: Online computer services may provide access to public documents related to community health. Rationale 2: Recreational directors have information about programs provided and participation levels. Rationale 3: Local newspapers contain information—including date and time—about community activities related to health and wellness, such as health lectures or health fairs. Rationale 4: The telephone book would include the location of social, recreational, and health organizations, as well as committees and facilities. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Describe the role of the nurse in providing continuity of care. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 109 Question 9 Type: MCSA Several nurses at the county health department are involved in planning community health. 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 Correct Answer: 1 Rationale 1: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Physicians and other nurses may not understand the community’s health needs. Rationale 3: Members of the chamber of commerce and community governing board may not understand the community’s health needs. Rationale 4: The nurses may not understand the community’s health needs. The plan should include members of the community so that all members are represented and have a voice in planning. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Describe various community-based health care frameworks, including integrated health care systems, community initiatives and conditions, and case management. MNL Learning Outcome: 1.2.4. Compare the frameworks of care. Page Number: 109 Question 10 Type: MCSA 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. Health care providers at the community level 2. Hospital and clinic personnel who administered health care needs 3. Health care providers, consumers, community leaders, and politicians 4. Those consumers who were directly affected by the services provided Correct Answer: 3 Rationale 1: 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. Rationale 2: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

nurse is the agent of evaluation, collecting and assessing data that determine the effectiveness of implemented programs. Rationale 3: 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. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Explain essential aspects of collaborative health care: definitions, objectives, benefits, and the nurse’s role. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 109 Question 11 Type: MCSA 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 health care as being? 1. Community-based setting 2. Integrated health care system 3. Wellness center 4. Community outreach center Correct Answer: 2 Rationale 1: Community-based settings are provided in county and state health departments and may include day-care centers, senior centers, storefront clinics, homeless shelters, and the like. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: An integrated health care 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). Rationale 3: A wellness center provides services such as health promotion, maintenance education, counseling, and screening. Rationale 4: Community outreach centers are small, freestanding clinics providing services similar to those traditionally provided by large public health clinics, but focused on a narrower population. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Describe various community-based health care frameworks, including integrated health care systems, community initiatives and conditions, and case management. MNL Learning Outcome: 1.2.4. Compare the frameworks of care. Page Number: 109 Question 12 Type: MCSA 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 Correct Answer: 4 Rationale 1: A counselor discusses health issues and problems with individuals and makes home, hospital, and nursing home visits as needed. Rationale 2: An educator works to support individuals through health education activities that promote an understanding of the relationship between values, attitudes, lifestyle, faith, and well-being. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: A referral source is a liaison to other congregations and community resources. Rationale 4: A facilitator recruits and coordinates volunteers within the congregation and develops support groups. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the health care 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 health care 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: 1.2.1. Explore the various roles in nursing practice. Page Number: 111 Question 13 Type: MCSA A parish nurse is helping a group of new parents within the congregation find appropriate health care providers within the community who specialize in infant/child and family health care needs. In which role is the nurse functioning? 1. Health educator 2. Referral source 3. Facilitator 4. Integrator Correct Answer: 2 Rationale 1: A health educator supports individuals through health education activities that promote understanding of the relationship between values, attitudes, lifestyle, faith, and well-being. Rationale 2: A referral source acts as a liaison to other congregational and community resources. Helping new parents find appropriate sources for health care would be an example of a referral source. Rationale 3: A facilitator recruits and coordinates volunteers within the congregation and develops support groups. Rationale 4: An integrator brings the entities of faith and health together. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the health care 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 health care 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: 1.2.1. Explore the various roles in nursing practice. Page Number: 111 Question 14 Type: MCSA A public health nurse is working with a group of home health nurses in an isolated, mountainous region where access to smaller communities and individuals is quite difficult, especially in the winter and early spring—seasons when the health needs of these individuals are quite high. The public health nurse has set up video conferencing and video clinics for these home health nurses regarding various client teaching and health promotion activities. What activity did the public health nurse conduct? 1. Community-based nursing 2. Parish nursing 3. Telenursing 4. Collaborative health care Correct Answer: 3 Rationale 1: Community-based nursing is nursing care directed toward specific individuals. Rationale 2: Parish nursing focuses on integrating aspects of faith and members of a particular congregation and health care or nursing needs. Rationale 3: Telehealth projects use communication and information technology to provide health information and health care services to people in rural, remote, or underserviced areas. Video conferences and video clinics enable health care workers to provide distant consultation to assess and treat ambulatory clients who have a variety of health care needs. Telenursing enables nurses to provide client teaching and health promotion to distant clients. Rationale 4: Collaborative health care describes a process of teamwork in providing comprehensive health care. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; 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 health care frameworks, including integrated health care systems, community initiatives and conditions, and case management. MNL Learning Outcome: 1.2.4. Compare the frameworks of care. Page Number: 111 Question 15 Type: MCSA Several nurses are working with other health care 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 Correct Answer: 1 Rationale 1: Collaboration means a collegial working relationship with other health care providers to supply patient care. Collaborative practice requires the discussion of diagnoses and management in the delivery of care. Rationale 2: Case management involves one person overseeing the needs and requirements of a particular individual's health. Rationale 3: Health promotion activities include disease prevention and healthy lifestyle interventions. Rationale 4: Health education would be included in this particular situation but collaboration is a more inclusive definition of what is occurring with these individuals and the care they require. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Reduction of Risk Potential QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the health care team AACN Essentials Competencies: VI. 2. Use inter-and intraprofessional communication and collaborative skills to deliver evidence-based, 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: Nursing Process: Assessment Learning Outcome: 6. Explain essential aspects of collaborative health care: definitions, objectives, benefits, and the nurse’s role. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 112 Question 16 Type: MCSA A nurse is working in collaboration with a group of health care providers in a community clinic setting. They have defined 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 Correct Answer: 4 Rationale 1: Mutual respect occurs when two or more people show or feel honor or esteem toward one another. Rationale 2: Trust occurs when a person is confident in the actions of another person. Rationale 3: Communication is necessary in effective collaboration. It occurs only if the involved parties are committed to understanding each other's professional roles and appreciating each other as individuals. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the health care team AACN Essentials Competencies: VI. 2. Use inter-and intraprofessional communication and collaborative skills to deliver evidence-based, 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: Nursing Process: Assessment Learning Outcome: 2. Describe various community-based health care frameworks, including integrated health care systems, community initiatives and conditions, and case management. MNL Learning Outcome: 1.2.4. Compare the frameworks of care. Page Number: 112 Question 17 Type: MCSA 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. Correct Answer: 2 Rationale 1: Signing a consent form for information to be released is necessary to share information, but this would not ensure the privacy aspect of HIPAA—only the disclosure aspect. Rationale 2: Case manager nurses need to maintain vigilance to protect the privacy of client health care 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. Rationale 3: Sending information through the mail takes time and does not ensure the privacy of the information. Rationale 4: Phone conversations and information taken during the conversation must be protected and taken in a secured way to ensure HIPAA privacy aspects have not been breached. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: VI. B. 5. Employ communication technologies to coordinate care for patients Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 health care: definitions, objectives, benefits, and the nurse’s role. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 113 Question 18 Type: MCSA 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 Correct Answer: 1 Rationale 1: Effective discharge planning necessitates health team conferences and family conferences and gives the client, family, and health care 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. Rationale 2: Effective discharge planning necessitates health team conferences and family conferences and gives the client, family, and health care professionals the opportunity to plan care and set goals The physician, pharmacist, and social worker may also be included, but by their own decision—not necessarily by the nurse's invitation. Rationale 3: Effective discharge planning necessitates health team conferences and family conferences and gives the client, family, and health care professionals the opportunity to plan care and set goals. The physician, pharmacist, and social worker may also be included, but by their own decision—not necessarily by the nurse's invitation. Rationale 4: Effective discharge planning necessitates health team conferences and family conferences and gives the client, family, and health care professionals the opportunity to plan care and set goals. The physician, pharmacist, and social worker may also be included, but by their own decision—not necessarily by the nurse's invitation. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe the role of the nurse in providing continuity of care. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 114 Question 19 Type: MCSA 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 Correct Answer: 3 Rationale 1: Activity restrictions are important; however, it would not be possible for the client to demonstrate the expectation to the nurse. Rationale 2: Knowing when to follow up with a health care provider is important; however, it would not be possible for the client to demonstrate the expectation to the nurse. Rationale 3: 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 health care 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. Rationale 4: Signs of complications are important; however, it would not be possible for the client to demonstrate the expectation to the nurse. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Describe the role of the nurse in providing continuity of care. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 115 New Questions: Question 20 Type: MCMA A multi-organization medical system is designing a community-based facility to support the health care needs of members who live in an urban area. What should the medical system keep in mind when designing the new facility? Standard text: Select all that apply. 1. Affordable 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 health care providers Correct Answer: 1, 2, 4, 5 Rationale 1: To be effective, a community-based health care system needs to be affordable. Rationale 2: To be effective, a community-based health care system needs to provide easy access to care. Rationale 3: To be effective, a community-based health care system needs to focus on the needs of all community members and not just on mothers and children. Rationale 4: To be effective, a community-based health care system needs to be flexible in responding to the care needs of individuals and families. Rationale 5: To be effective, a community-based health care system needs to promote care between and among health care agencies through improved communication mechanisms. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Differentiate community health care settings from traditional settings. MNL Learning Outcome: 1.2.4. Compare the frameworks of care. Page Number: 108 Question 21 Type: MCMA The community health nurse is identifying approaches to support a community’s health care needs. Which programs should the nurse select to support community-based health care? Standard Text: 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 Correct Answer: 1, 2, 3 Rationale 1: Community-based care is holistic and involves a broad range of services designed not only to restore health but also to promote health, prevent illness, and protect the public. This would include smoking cessation classes. Rationale 2: Community-based care is holistic and involves a broad range of services designed not only to restore health but also to promote health, prevent illness, and protect the public. This would include personal safety classes for women. Rationale 3: Community-based care is holistic and involves a broad range of services designed not only to restore health but also to promote health, prevent illness, and protect the public. This would include blood pressure measurement clinics. Rationale 4: The traditional health care system focuses on the ill and injured. An outpatient clinic for minor ailments would be a traditional health care program. Rationale 5: The traditional health care system focuses on the ill and injured. An allergy clinic on weekends would be a traditional health care program. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 08 Question 1 Type: MCMA 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? 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 Correct Answer: 2, 3 Rationale 1: A common misconception about home health nursing is that it is custodial in its scope of practice. Rationale 2: Factors that have contributed to the growth of home care services include third-party payers that favor home care to control costs. Rationale 3: Factors that have contributed to the growth of home care services include the increase in the older population. Rationale 4: Acute care has not decreased, but the length of stay in acute care has. Rationale 5: The focus of home health care nursing is individuals and their families. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare the characteristics of home health nursing to those of institutional nursing care. MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 118 Question 2 Type: MCSA 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 health care 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 Correct Answer: 2 Rationale 1: Community health nursing focuses on individuals, families, and aggregate groups. Rationale 2: The focus of home health care nursing is individuals and their families. Rationale 3: Hospice nursing supports the care of the dying client and the client's family; this is not the focus of home health nursing. Rationale 4: A home setting identifies the location of home health nursing, but not the focus. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare the characteristics of home health nursing to those of institutional nursing care. MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies. Page Number: 118 Question 3 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

To help a home health client with a difficult medication regime, 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 Correct Answer: 4 Rationale 1: Hands-on care includes physical assessments, dressing changes, and managing IV sites for therapies, which is not the scenario described here. Rationale 2: Direct care is the same as hands-on care, which is not the scenario described here. Rationale 3: Client advocacy is not the scenario described here. Rationale 4: Indirect care is provided by the home health nurse to the client each time the nurse consults with other health care providers about ways to improve nursing care for the client. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe the roles of the home health nurse. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 120 Question 4 Type: MCSA 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 write the order for the client to receive home care? 1. Physician Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Nurse 3. Social worker 4. Physical therapist Correct Answer: 1 Rationale 1: A client may be referred to home health care 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. Rationale 2: A client may be referred to home health care by providers, nurses, social workers, and therapists, but home care cannot begin with a nurse’s order. Rationale 3: A client may be referred to home health care by providers, nurses, social workers, and therapists, but home care cannot begin with a social worker’s order. Rationale 4: A client may be referred to home health care by providers, nurses, social workers, and therapists, but home care cannot begin with a social worker’s order. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe the types of home health agencies, including referral and reimbursement sources. MNL Learning Outcome: 1.2.4. Compare the frameworks of care. Page Number: 119 Question 5 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Within 48 hours of the nurse's visit Correct Answer: 3 Rationale 1: Completing the initial assessment identifies but does not initiate client care. Rationale 2: The client agreeing to care indicates the client’s involvement in the process but does not initiate care. Rationale 3: 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. Rationale 4: Care might begin within 48 hours but initiation is dependent on many other factors. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare the characteristics of home health nursing to those of institutional nursing care. MNL Learning Outcome: 1.2.4. Compare the frameworks of care. Page Number: 119 Question 6 Type: MCSA 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 Correct Answer: 2 Rationale 1: Case coordination is essential but is not a physician responsibility. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Because clients often require the services of several professionals, case coordination is essential and generally rests with the registered nurse. Rationale 3: Case coordination is not the responsibility of a social worker. Rationale 4: Case coordination is not the responsibility of a home health agency. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Describe the roles of the home health nurse. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 121 Question 7 Type: MCSA 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 Correct Answer: 4 Rationale 1: Institution-based agencies operate under a parent organization such as a hospital and are funded by the same sources as the parent. That is not the situation described here. Rationale 2: Private, proprietary agencies are for-profit organizations and are governed by either individual owners or national corporations. That is not the situation described here. Rationale 3: Not-for-profit or voluntary agencies are supported by donations, endowments, charities such as the United Way, and third-party reimbursement. That is not the situation described here. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Official or public agencies are operated by state or local governments and financed primarily by tax funds. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the types of home health agencies, including referral and reimbursement sources. MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies. Page Number: 120 Question 8 Type: MCSA 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 Correct Answer: 3 Rationale 1: Supplies that the client uses and cannot be reused are not considered DME. Rationale 2: Supplies that the client uses and cannot be reused are not considered DME. Rationale 3: 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. Rationale 4: Visits by the home health nurse are paid through a different aspect of the client’s health care plan. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the types of home health agencies, including referral and reimbursement sources. MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies. Page Number: 120 Question 9 Type: MCSA 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 Correct Answer: 4 Rationale 1: Living with a spouse is allowed for reimbursement by insurance companies. Rationale 2: Needing skilled care is allowed for reimbursement by insurance companies. Rationale 3: Needing intermittent care is allowed for reimbursement by insurance companies. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the types of home health agencies, including referral and reimbursement sources. MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies. Page Number: 120 Question 10 Type: MCSA A client who has been the recipient of home health care has made the decision to discontinue hemodialysis. The client understands all the consequences of this decision and is not supported by his family. The nurse is meeting with the family to help them understand the significance of the client's decision and to help them support the client during this difficult time. In which role is the nurse functioning? 1. Caregiver 2. Advocate 3. Educator 4. Counselor Correct Answer: 2 Rationale 1: The home health nurse's major role as caregiver is to assess and diagnose the client's actual and potential health problems. That is not the role described here. Rationale 2: As a client advocate, the nurse explores and supports the client's choices in health care. Advocacy includes having discussions about the client's rights, advance medical directives, living wills, and durable power of attorney for health care. 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. Rationale 3: The educator role focuses on teaching illness care, prevention of problems, and promotion of optimal wellness or well-being. That is not the role described here. Rationale 4: Counselor is not a role for the home health nurse. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe the roles of the home health nurse. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 120 Question 11 Type: MCSA During a home visit, the client with terminal cancer undergoes respiratory arrest. The client has agreed to a DNR (do not resuscitate) order; however, the spouse tells the nurse to call 911. What action should the nurse take? 1. Assess vital signs. 2. Call 911. 3. Start CPR. 4. Remind the spouse of the client's desires. Correct Answer: 4 Rationale 1: Assessment of vital signs does not address the immediate situation. Rationale 2: 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. Calling 911 would not support the client’s desires. Rationale 3: 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. Starting CPR would not support the client’s desires. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe the roles of the home health nurse. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 121 Question 12 Type: MCSA 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 hooks the client to the medication infusion. Which role is the nurse performing at this time? 1. Caregiver 2. Advocate 3. Educator 4. Coordinator Correct Answer: 3 Rationale 1: The role of caregiver involves assessing and diagnosing actual or potential health problems, planning care, and evaluating the client's outcomes. That is not the role described here. Rationale 2: The advocate role ensures that the rights and desires of the client are upheld. That is not the role described here. Rationale 3: 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. Rationale 4: The home health nurse coordinates the activities of all other home health team members involved in the client's treatment plan. That is not the role described here. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe the roles of the home health nurse. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 121 Question 13 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA While assessing a client's environment for safety concerns, the nurse finds that most of the rooms in the house have only one outlet with various cords entering the outlet. When this concern is shared with the client and spouse, they state that "this is the way we've lived for years." What should the nurse do? 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. Correct Answer: 4 Rationale 1: Although not inappropriate, this option is not likely to be acted upon by the client. Rationale 2: Home health nurses cannot expect to change a family's living space and lifestyle, and such an intervention may be resented by the client. Rationale 3: The nurse has an obligation to bring safety issues to the client’s attention. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; 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: 4.1.1. Recognize factors that affect client safety. Page Number: 121 Question 14 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 2 Rationale 1: Making suggestions for the client to relocate may be a possibility, but this might be premature to suggest at this point. Rationale 2: 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. Rationale 3: Having all of the client's medical information in one place is a helpful idea but does not address the concern of effective means of communication. Rationale 4: 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. Making suggestions for the client to relocate may be a possibility, but this might be premature to suggest at this point. Having emergency numbers in a visible spot is a helpful idea but does address the concern of effective means of communication. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; 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: 4.1.1. Recognize factors that affect client safety. Page Number: 122 Question 15 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 1 Rationale 1: 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. Rationale 2: Calling ahead to the client's home is routine practice, regardless of where the client lives. Rationale 3: Having the client meet the nurse at the agency is inappropriate, especially if the client meets the criteria for home care. Rationale 4: Taking a second nurse along may not be a realistic intervention. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; 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: 4.1.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 122 Question 16 Type: MCSA A home health nurse has a weekly visit to a client living in less than desirable cleanliness. The client has a central venous access device and requires weekly infusion therapy. 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Suggest that the client have a housekeeper come on the morning of the infusion. Correct Answer: 2 Rationale 1: This intervention will not directly impact the minimization of the risk for infection because the client is not performing the infusion. Rationale 2: 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. Rationale 3: Even if the client's environment is not clean, that doesn't necessarily mean the client is unclean. There is another option that will impact the risk of infection. Rationale 4: Teaching about health practices that prevent infection is important, but the nurse cannot expect to change the client's lifestyle. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Practice; conduct population-based transcultural health assessments and interventions 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: 4.1.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 123 Question 17 Type: MCMA 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? 1. The home appears cluttered. 2. The spouse expresses feelings of anger. 3. The spouse reports decreased energy. 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 2, 3 Rationale 1: Evidence of caregiver role strain would be dramatic change in the home environment’s appearance. Clutter would not be a dramatic change. Rationale 2: Feelings of anger are evidence of caregiver role strain. Rationale 3: Reports of declining physical energy and insufficient time for caregiving indicate caregiver role strain. Rationale 4: Learning how to manage finances is a positive statement and would not indicate caregiver role strain. Rationale 5: Asking when the nurse will make the next visit is not an indication of caregiver role strain. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Identify ways the nurse can recognize and minimize caregiver role strain. MNL Learning Outcome: 4.1.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 123 Question 18 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Although this may be true in some situations, it is not the reason that education is a focus of home health nursing care. Not all home care clients come from acute care, and education is still implemented in this setting. Rationale 3: Not all home clients are willing or ready to learn, even though they are in their own home environment. Rationale 4: Client education is considered a skill reimbursed by Medicare. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Identify the essential aspects of the home visit. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 124 Question 19 Type: MCSA 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 Correct Answer: 2 Rationale 1: Once the client is at home, the need for the devices will be immediate and the client may have to wait unnecessarily for the required items. Rationale 2: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Waiting a few days is a delay that is not beneficial for the client, who requires these items upon arriving home. Rationale 4: Waiting until the spouse is able to help is a delay that is not beneficial for the client, who requires these items upon arriving home. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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 settingsNLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Describe the roles of the home health nurse. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 119 Question 20 Type: MCSA 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 Correct Answer: 2 Rationale 1: Even though the client may become independent in self-care skills, assurance is not the client’s responsibility. Rationale 2: 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. Rationale 3: Even though the physician has responsibilities to the client, assurance in this area is not one of them. Rationale 4: Even though family members may assume responsibility for a client’s care, it is not their responsibility to assure appropriate care. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Describe the roles of the home health nurse. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 121 Question 21 Type: MCMA The nurse is attending a seminar that focuses on the changes within the home health care industry. Which statements that the nurse makes indicate an understanding of home care as a primary health service delivery system? Standard Text: 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 health care 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.” Correct Answer: 2, 3, 4, 5 Rationale 1: Health preventative screening can be accomplished as a part of home care when needed. Rationale 2: Numerous factors have contributed to trend toward home health care; among them is the increasing number of aging adult clients. Rationale 3: Numerous factors have contributed to the trend toward home health care; among them is rising health care costs. Rationale 4: Numerous factors have contributed to the trend toward home health care; among them is the growing emphasis on managing chronic illness. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: Numerous factors have contributed to the trend toward home health care; among them is the growing emphasis on managing stress for the chronically ill. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Compare the characteristics of home health nursing to those of institutional nursing care. MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies. Page Number: 118 Question 22 Type: MCMA 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? Standard Text: 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 teenager 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 Correct Answer: 1, 3, 4 Rationale 1: Home care today involves a wide range of health care professionals providing services, such as physical therapy, in the home setting to people who are recovering from an acute illness or injury, are disabled, or have a chronic condition. Rationale 2: Pregnancy education would not be addressed in the home setting unless the pregnancy required bed rest.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Home care today involves a wide range of health care professionals providing services, such as assistive devices, in the home setting to people who are recovering from an acute illness or injury, are disabled, or have a chronic condition. Rationale 4: Home care today involves a wide range of health care professionals providing services, such as nursing care, in the home setting to people who are recovering from an acute illness or injury, are disabled, or have a chronic condition. Rationale 5: Home care does not include non-professional services such as grocery delivery. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Define home health care. MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies. Page Number: 119 New Questions: Question 23 Type: MCMA 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? Standard Text: Select all that apply. 1. Call off from work to provide care to both parents. 2. Adjust his or her 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. Correct Answer: 4, 5 Rationale 1: A particular challenge exists when the nurse is in a position to be a caregiver to a family member. The nurse may feel obligated to provide care, even when this is over and above regular employment responsibilities. The nurse should not call off from work to provide care to both parents. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: A particular challenge exists when the nurse is in a position to be a caregiver to a family member. The nurse may feel obligated to provide care, even when this is over and above regular employment responsibilities. The nurse should not adjust his or her personal schedule to provide care to the parents. Rationale 3: A particular challenge exists when the nurse is in a position to be a caregiver to a family member. The nurse may feel obligated to provide care, even when this is over and above regular employment responsibilities. Moving in with the parents should not be done. Rationale 4: A particular challenge exists when the nurse is in a position to be a caregiver to a family member. The nurse may feel obligated to provide care, even when this is over and above regular employment responsibilities. The nurse must have the opportunity to step back and experience the role and emotions of being a family member—not only those of being a nurse. Determining if custodial support is needed would be appropriate because the nurse is unable to provide this level of care. Rationale 5: A particular challenge exists when the nurse is in a position to be a caregiver to a family member. The nurse may feel obligated to provide care, even when this is over and above regular employment responsibilities. The nurse must have the opportunity to step back and experience the role and emotions of being a family member—not only those of being a nurse. Finding out when the home care nurse is scheduled to arrive would be appropriate. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe the roles of the home health nurse. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 123 Question 24 Type: MCMA 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? Standard Text: Select all that apply. 1. Laminated floors 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Answer: 1, 2 Rationale 1: Highly polished floors can be a safety hazard and increase the client’s risk of falling. Rationale 2: Scatter rugs are a safety hazard and can increase the client’s risk of falling. Rationale 3: Although a safety hazard, a low smoke detector battery will not increase this client’s risk of falling. Rationale 4: Although a safety hazard, placing a caustic substance in an unlabeled jar will not increase the client’s risk of falling. Rationale 5: Although a safety hazard, expired medications will not increase the client’s risk of falling. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; 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: 4.1.1. Recognize factors that affect client safety. Page Number: 122

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 09 Question 1 Type: MCSA 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 web site 3. Review the online hospital policies about client safety 4. Complete a literature review on client safety Correct Answer: 1 Rationale 1: Nursing has benefited from the computer revolution in the form of computer-assisted 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. Rationale 2: Reading information from a web site does not necessarily indicate completion of education on client safety. Rationale 3: Reviewing policies online does not necessarily indicate completion of education on client safety. Rationale 4: Completing a literature review on client safety would not indicate that education on this topic has been completed. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Describe the uses of computers and technology in nursing education. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 131 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 2 Type: MCSA A 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 Correct Answer: 4 Rationale 1: A database is used to manage detailed information. That is not the application described here. Rationale 2: Word processing is one of the most commonly used computer applications. Documents are checked for spelling and grammar, and individualized to include pictures, charts, and designs. That is not the application described here. Rationale 3: Graphics programs have become popular for their ability to create charts, tables, and pictures. That is not the application described here. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Identify computer applications used in client assessment and care. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 130 Question 3 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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." Correct Answer: 4 Rationale 1: Although being involved in one’s care is desirable, there are concerns related to information accessed on the Internet. Rationale 2: This statement is not necessarily true, although there are concerns about information accessed on the Internet. Rationale 3: Although this statement isn’t incorrect, the client should be able to access reliable information in order to be well informed. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Identify computer applications used in client assessment and care. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 130 Question 4 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Google search engine gives a variety of sites, both health-related and non-health-related, but there are no controls for accuracy with this database. Rationale 3: The Educational Resources Information Center (ERIC) would include all areas of academia, not just nursing. Rationale 4: PsychINFO includes only psychological abstracts. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Use Databases for practice, administrative, education, and/or research purposes; 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: 1.2.3. Examine the factors affecting health care delivery. Page Number: 131 Question 5 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Videos 3. CAI 4. Workbook with written study guides Correct Answer: 3 Rationale 1: Taking field trips might not be economically feasible. Rationale 2: Videos also provide instruction, but not simulation. Rationale 3: 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. Rationale 4: Written study guides allow for learning, but not "hands-on" experience. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Describe the uses of computers and technology in nursing education. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 131 Question 6 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 2 Rationale 1: Classroom technology is just one piece of distance learning. Rationale 2: 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. Rationale 3: Computer-assisted instruction (CAI), a method to allow for practice and simulation via CD-ROM, is only one component of distance learning. Rationale 4: Nursing informatics is the science of using computer information systems in the practice of nursing, not necessarily the education of nursing. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1. Describe the uses of computers and technology in nursing education. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 132 Question 7 Type: MCSA A nurse educator has taught the same courses for the past 5 years and each year implements a few minor changes. Over this time, the educator has stored the grade data, including homework and assignment scores, in order to track trends following the implemented changes. What is the educator using to maintain this information? 1. Informatics 2. Student record management 3. Data warehousing 4. Management information system (MIS) Correct Answer: 3 Rationale 1: Informatics is the use of computer technology in nursing practice. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Student and course record management are programs that help maintain results of students' grades or attendance using spreadsheets. Rationale 3: 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). Rationale 4: A management information system (MIS) is designed to facilitate the organization and application of data used to manage an organization or department. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the uses of computers and technology in nursing education. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 132 Question 8 Type: MCSA The nurse accesses previous hospitalization information to learn more about the 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 Correct Answer: 4 Rationale 1: There are at least four ways the EHR can improve health care. Accessing previous hospitalization information is not being done to monitor quality. Rationale 2: There are at least four ways the EHR can improve health care. Accessing previous hospitalization information is not being done to support data warehousing. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: There are at least four ways the EHR can improve health care. Accessing previous hospitalization information is not being done to share client information. Rationale 4: There are at least four ways the EHR can improve health care. Accessing previous hospitalization information is being done to review the client’s information to aid with planning for this current hospitalization. Global Rationale:

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; 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: 1.2.3. Examine the factors affecting health care delivery. Page Number: 134 Question 9 Type: MCSA 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." Correct Answer: 2 Rationale 1: Information in a computer data system may not always be safe, and it would be inappropriate for the nurse to say this. Rationale 2: 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. Rationale 3: Nurses need to be involved with the design, implementation, and evaluation of client-based patient records (CPRs) to maximize their use and effectiveness, but this does not ensure security. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Reminding the client that there is indeed cause for privacy concerns is not therapeutic. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; 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: 1.2.3. Examine the factors affecting health care delivery. Page Number: 131 Question 10 Type: MCMA 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? Standard Text: Select all that apply. 1. ANA 2. HIPAA 3. NANDA 4. The Omaha system 5. HHCC 6. NOC Correct Answer: 3, 4, 5, 6 Rationale 1: The ANA has a position statement on privacy, confidentiality of medical records, and the nurse's role, but it is not one of the classification systems used in the United States. Rationale 2: HIPAA is a piece of legislation that addressed privacy of and access to health records. Rationale 3: The ANA Nursing Information and Data Set Evaluation Center (NIDSEC) has established guidelines for the use of nursing terminology by companies that are creating software programs for nursing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

application. In doing this, NIDSEC recognizes the classification systems that include North American Nursing Diagnosis Association (NANDA) taxonomy. Rationale 4: The ANA Nursing Information and Data Set Evaluation Center (NIDSEC) has established guidelines for the use of nursing terminology by companies that are creating software programs for nursing application. In doing this, NIDSEC recognizes the classification systems that include the Omaha System. Rationale 5: The ANA Nursing Information and Data Set Evaluation Center (NIDSEC) has established guidelines for the use of nursing terminology by companies that are creating software programs for nursing application. In doing this, NIDSEC recognizes the classification systems that include the Home Health Care Classification (HHCC). Rationale 6: The ANA Nursing Information and Data Set Evaluation Center (NIDSEC) has established guidelines for the use of nursing terminology by companies that are creating software programs for nursing application. In doing this, NIDSEC recognizes the classification systems that include the Nursing Outcomes Classification (NOC). Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; 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: 1.2.3. Examine the factors affecting health care delivery. Page Number: 135 Question 11 Type: MCMA 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? Standard Text: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 1, 3, 5 Rationale 1: Nursing education is supported by the use of computerized library services, especially when learning is conducted using the distance learning model. Rationale 2: This is not a learning-focused requirement but rather an organizational requirement. Rationale 3: Nursing education is supported by the use of computerized documentation, such as journaling, because it aids in organization, writing skills, and computer use. Rationale 4: This is not an appropriate way to support learning except in an online learning environment, in which case all assignments would be computer-generated. Rationale 5: Nursing education is supported by the use of computerized testing options, as it helps advance the learners’ comfort and skill with online testing. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the uses of computers and technology in nursing education. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 132 Question 12 Type: MCMA A nurse educator believes computers can enhance student learning. Which actions should the instructor take to demonstrate this belief? Standard Text: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 1, 2, 3, 4 Rationale 1: Computers enhance academics for students in at least four ways, including access to nursing literature. Rationale 2: Computers enhance academics for students in at least four ways, including computer-assisted instruction modules. Rationale 3: Computers enhance academics for students in at least four ways, including teaching strategies employing PowerPoint presentations. Rationale 4: Computers enhance academics for students in at least four ways, including online collaborative projects. Rationale 5: Any form of graphics—not necessarily computer-generated ones—would be effective in this application. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the uses of computers and technology in nursing education. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 131 New Questions: Question 13 Type: MCMA The nurse is beginning a physical assessment of a client who is freelance computer information technologist. On which areas should the nurse place particular emphasis during this assessment? Standard Text: Select all that apply. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Vision 2. Hearing 3. Back flexibility 4. Hand range of motion 5. Range of motion of arms Correct Answer: 1, 3, 4, 5 Rationale 1: There are many issues of concern related to frequent and extended use of computers by clients of all ages. In particular, eye strain can occur from computer monitor viewing. Rationale 2: There are many issues of concern related to frequent and extended use of computers by clients of all ages. Hearing is not a concern with computer use. Rationale 3: There are many issues of concern related to frequent and extended use of computers by clients of all ages. In particular, musculoskeletal damage is related to inadequate ergonomic arrangement of desk chairs, surface height, and monitor placement. Rationale 4: There are many issues of concern related to frequent and extended use of computers by clients of all ages. In particular, repetitive motion injuries (especially of the hand) can occur with extensive typing and use of the computer mouse. Rationale 5: There are many issues of concern related to frequent and extended use of computers by all clients of ages. In particular, musculoskeletal damage is related to inadequate ergonomic arrangement of desk chairs, surface height, and monitor placement. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Discuss the advantages of and concerns about computerized client documentation systems. MNL Learning Outcome: 4.3.2. Recognize factors that affect movement and immobility. Page Number: 139 Question 14 Type: MCMA The nurse is participating in the development of a research study. What elements of the computer should the nurse ensure are in place before the study begins? Standard Text: Select all that apply. 1. Computer speed adequate Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Print drivers installed 3. Word processing program 4. Computer storage capacity adequate 5. Appropriate software programs Correct Answer: 1, 3, 4, 5 Rationale 1: Computer resources are an important component of the planning phase of any research project. The speed must be adequate for the amount and type of data that will be collected. Rationale 2: Installation of print drivers is not identified as a need prior to beginning a research study. Rationale 3: Computer resources are an important component of the planning phase of any research project. Computerized word processing is an integral component in the publication and dissemination of research. Rationale 4: Computer resources are an important component of the planning phase of any research project. The storage capacity must be adequate for the amount and type of data that will be collected. Rationale 5: Computer resources are an important component of the planning phase of any research project. The proper software programs must be in place to manage and analyze the data. Computerized word processing is also an integral component in the publication and dissemination of research. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; 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: 1.2.3. Examine the factors affecting health care delivery. Page Number: 138

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 10 Question 1 Type: MCSA 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 Correct Answer: 2 Rationale 1: Administering IV meds (even to critically ill clients) does not require much reasoning. There are standard procedures to follow and, most of the time, clear answers about the rationale. Rationale 2: 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. Rationale 3: Teaching new parents about car seat safety does not require much reasoning. There are standard procedures to follow and, most of the time, clear answers about the rationale. Rationale 4: Teaching correct use of crutches does not require much reasoning. There are standard procedures to follow and, most of the time, clear answers about the rationale. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 144 Question 2 Type: MCSA 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." Correct Answer: 4 Rationale 1: Explaining the rationale for doing or not doing the exercises is not using creativity. It is merely explaining the reason. Rationale 2: This shows no creativity and merely dismisses the client’s concerns and feelings. Rationale 3: This shows no creativity and merely dismisses the client’s feelings. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementing Learning Outcome: 2. Describe the actions of clinical reasoning in the implementation of the nursing process. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 145 Question 3 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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." Correct Answer: 1 Rationale 1: 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 their 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. Rationale 2: This option does not address the reason creativity is a major component of critical thinking, and appears to dismiss the student’s statement. Rationale 3: This option doesn’t address the reason for creativity in nursing and merely trivializes its importance. Rationale 4: This option doesn’t address the reason for creativity in nursing and merely provides a personal motive for creativity. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementing Learning Outcome: 1. Describe the significance of developing critical thinking abilities in order to practice safe, effective, and professional nursing care. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 145 Question 4 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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?" Correct Answer: 1 Rationale 1: 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). Rationale 2: Asking about ways to study would be a question about the problem (studying), which is not an example of Socratic questioning. Rationale 3: Asking about the effects of studying is questioning about implications and consequences, which is not an example of Socratic questioning. Rationale 4: Asking about the effects of studying is questioning about implications and consequences, which is not an example of Socratic questioning. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 146 Question 5 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Socratic questioning 4. Critical analysis Correct Answer: 1 Rationale 1: 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. Rationale 2: Inductive reasoning would be making a generalization from a set of facts or observation. In this case, the nurse using inductive reasoning could presume that the client has bronchitis or a bacterial respiratory infection. Rationale 3: Socratic questioning looks beneath the surface and asks questions to come to a conclusion about the situation; that is not what is described in this scenario. Rationale 4: Critical analysis looks beneath the surface and asks questions to come to a conclusion about the situation. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 147 Question 6 Type: MCSA 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. The client also states that he has a rare form of a neurological disorder. 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?" Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. "Describe what tests you've had and explain the symptoms of this disorder." Correct Answer: 4 Rationale 1: Asking "why" questions make clients very defensive, and doing so does not utilize critical thinking skills. Rationale 2: Asking a "yes/no" question offers little other information, and doing so does not utilize critical thinking skills. Rationale 3: Asking the client what he wants does not help to find out more information about the client's situation or prior history, and doing so does not utilize critical thinking skills. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 147 Question 7 Type: MCSA A nurse educator has always believed that lectures with focused outlines are the best way to present theory content in class. A colleague, who teaches the same group of students, but a different subject, utilizes group work and in-class activities to teach difficult content and finds that students perform as well, or better, on their tests. The first educator in this situation is starting to rethink her position. What behavior is the first educator demonstrating? 1. Integrity 2. Perseverance 3. Fair-mindedness 4. Humility Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1 Rationale 1: 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. Rationale 2: Perseverance is determination that enables critical thinkers to clarify concepts and sort out related issues, in spite of difficulties and frustrations. Rationale 3: Fair-mindedness is assessing all viewpoints with the same standards and not basing judgments on personal or group bias or prejudice. Rationale 4: Intellectual humility means having an awareness of the limits of one's own knowledge. Critical thinkers are willing to admit what they do not know, seek new information, and rethink their conclusions in light of new knowledge. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Describe the actions of clinical reasoning in the implementation of the nursing process. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 149 Question 8 Type: MCSA 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 Correct Answer: 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Fair-mindedness means assessing all viewpoints with the same standards and not basing judgments on personal or group bias or prejudice. Rationale 2: 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. Rationale 3: Intellectual humility means having an awareness of the limits of one's own knowledge. Rationale 4: Intellectual courage to challenge the status quo and rituals is taking a fair examination of one's own ideas or views, especially those to which one may have a strongly negative reaction. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 148 Question 9 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Courage to challenge the status quo comes from recognizing that sometimes beliefs are false or misleading. Integrity requires that individuals apply the same rigorous standards of proof to their own knowledge and beliefs; that is not what is described in the scenario. Rationale 3: Integrity requires that individuals apply the same rigorous standards of proof to their own knowledge and beliefs; that is not what is described in the scenario. Rationale 4: Confidence is the self-assurance to act on one’s own beliefs; that is not what is described in the scenario. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 148 Question 10 Type: MCSA The nurse questions the practice of administering rectal suppositories to residents in a long-term care facility at bedtime, rather than earlier in the day. When told that this is the best time for staff and that's the routine that has been practiced for a long time, the nurse continues to research whether there would be a better time, especially in the best interest of the residents. Which critical thinking attitude is this nurse demonstrating? 1. Confidence 2. Perseverance 3. Curiosity 4. Integrity Correct Answer: 3 Rationale 1: Confidence comes from cultivating reasoning and examining arguments. In this case, the nurse did not reason anything out, but is asking questions.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Perseverance happens from determination in clarifying concepts and sorting out related issues, in spite of difficulties and frustrations. This nurse is asking questions, not making any changes in spite of difficulties or frustrations. Rationale 3: 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. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 149 Question 11 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Context is an essential consideration in nursing because care must always be individualized, taking knowledge and applying it to real people, but that is not what is described in the scenario. Rationale 3: Dialogue is a purposed exchange of information, but that is not what is described in the scenario. Rationale 4: The attribute of time is a part of reflection. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 151 Question 12 Type: MCSA 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 Correct Answer: 2 Rationale 1: Reflection involves being able to determine what data are relevant and to make connections between that data and the decisions reached. Rationale 2: Context is being considerate of the whole situation—including relationships, background, and environment—and its relevant to the current situation. Rationale 3: Dialogue, which need not involve other persons, refers to the process of serving as both teacher and student in learning from situations. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Time emphasizes the value of using past learning in current situations that then guide future actions. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 146 Question 13 Type: MCSA A client complaining of shortness of breath has no pallor, cyanosis, or use of accessory muscles with respirations. The client's respiratory rate is 16 breaths per minute. The nurse is concerned that the client's report and the physical findings conflict. Which standard of critical thinking is the nurse using? 1. Clarity 2. Accuracy 3. Logical reasoning 4. Significance Correct Answer: 3 Rationale 1: Clarity provides examples. That is not the process described in the scenario. Rationale 2: Accuracy is asking if something is true. That is not the process described in the scenario. Rationale 3: 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. Rationale 4: Significance is prioritizing the facts. That is not the process described in the scenario. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe the actions of clinical reasoning in the implementation of the nursing process. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 146 Question 14 Type: MCSA The nurse enters the room of a critically ill child after sensing that "something" isn't right. Once the nurse determines the child is stable, the nurse continues to perform a check of all the lines and equipment in the room 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 Correct Answer: 2 Rationale 1: Trial and error is solving problems through a number of approaches until a solution is found. Rationale 2: 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. Rationale 3: Judgment is not part of problem solving. Rationale 4: The scientific method requires that the nurse evaluate potential solutions to a given problem in an organized, formal, and systematic approach. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 146 Question 15 Type: MCSA The nurse systematically tries a variety of products to help with healing of a client’s wound. Which problemsolving method is the nurse using? 1. Intuition 2. Scientific method 3. Research process 4. Trial and error Correct Answer: 4 Rationale 1: Intuition is the learning of things without conscious use of reasoning—also known as the sixth sense, hunch, or instinct. Rationale 2: The scientific method is a formalized, systematic, and logical approach to solving problems. Rationale 3: The research process is a formalized, systematic, and logical approach to solving problems. Rationale 4: Trial and error is solving problems by utilizing a number of approaches. Trial-and-error 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. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 148 Question 16 Type: MCSA A client with unstable cardiac dysrhythmias has orders for medications, one of which is by oral route, the other by IV delivery. The nurse realizes that the IV route would be fastest, but is also concerned about the side effects that this drug may produce and the fact that the client has never taken the drug, so any adverse effect is unknown. Which part of the decision-making process is the nurse using? 1. Identify the purpose 2. Seek alternatives 3. Project 4. Implement Correct Answer: 2 Rationale 1: Identifying the purpose, in this case, would be determining that the client needs intervention to control the dysrhythmia. Rationale 2: In this step, the decision maker (nurse) identifies possible ways to meet the criteria. Alternatives considered are which by route to give a certain medication: IV versus oral. The nurse is utilizing his experience, taking what he knows about cardiac problems and pharmacology, and will make a selection based on that information. Rationale 3: Projecting is when the nurse applies creative thinking and skepticism to determine what might go wrong as a result of a decision and develops plans to prevent, minimize, or overcome any problems. Rationale 4: Implementation is taking the plan into action. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Describe the components of clinical reasoning. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 146 Question 17 Type: MCSA 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 Correct Answer: 4 Rationale 1: Setting criteria is based on three questions: What is the desired outcome? What needs to be preserved? What needs to be avoided? Rationale 2: Examining alternatives ensures that there is an objective rationale in relation to the established criteria for choosing one strategy over another. Rationale 3: Implementation is putting a plan into action. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Describe the components of clinical reasoning. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 150 Question 18 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Parents ask why invasive diagnostic tests were prescribed for their ill child. The nurse has just gotten out of report and has not had a chance to review additional information. 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." Correct Answer: 1 Rationale 1: 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. Rationale 2: Telling the parents to agree with the physician before the nurse knows all the facts might be premature, even if he is the best physician in the area. Rationale 3: Nurses should not give advice or counsel. Rationale 4: It would be premature to tell the parents to get another opinion. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe the components of clinical reasoning. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 146 Question 19 Type: MCSA A client complaining of "extreme" low back pain is pale and diaphoretic and walks bent at the waist. Before taking vital signs, the nurse suspects that the blood pressure and heart rate will be elevated. What thought process did the nurse use to come to this conclusion? 1. Fact Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Inference 3. Judgment 4. Opinion Correct Answer: 2 Rationale 1: A fact can be verified through investigation. In this case, facts would be the elevated pulse and blood pressure readings. Rationale 2: 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. Rationale Judgment is evaluating facts and information that reflect values or other criteria; it is a type of opinion. Because the nurse understands the pathophysiology of pain, thinking about changes in vital signs is more than a judgment—it is an inference. Rationale 4: Opinions are beliefs formed over time and include judgments that may fit facts or be in error. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 146 Question 20 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Evaluate Correct Answer: 3 Rationale 1: Assessment is the process of collecting data. Rationale 2: Diagnosing is putting a label on the problem. Rationale 3: The planning portion of the nursing process involves setting criteria, weighting the criteria, and seeking/examining alternatives when compared to the decision-making process. Rationale 4: Evaluating is reviewing the outcome. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 148 Question 21 Type: MCSA 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 Correct Answer: 3 Rationale 1: Inferences are conclusions drawn from the facts, going beyond facts to make a statement about something not currently known. Rationale 2: Judgment is an evaluation of facts or information that reflects values or other criteria. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: 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. Rationale 4: Evaluation is considering the results or outcome. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 147 Question 22 Type: MCSA 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 thinking is this nurse demonstrating? 1. Curiosity 2. Clinical reasoning 3. Setting priorities 4. Developing rationales Correct Answer: 4 Rationale 1: Curiosity is questioning the status quo. The curious nurse may value tradition but is not afraid to examine traditions to be sure they are still valid. Rationale 2: Clinical reasoning is the analysis of a clinical situation as it unfolds or develops. Rationale 3: Setting priorities is determining what needs to be completed in a specific order to support client care needs. Rationale 4: Developing rationales is when the nurse transfers nursing knowledge to the clinical situation to justify the plan of care. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 151 Question 23 Type: MCSA 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 Correct Answer: 2 Rationale 1: Trial and error uses a number of approaches until a solution is found. Rationale 2: 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. Rationale 3: The research process is a systematic, analytical, and logical way to problem solve. Rationale 4: Experience is part of intuition, but by itself, not a particular way to problem solve. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 148 Question 24 Type: MCMA The nurse desires to improve critical thinking skills when providing client care. On which attributes should the nurse focus when developing these skills? Standard Text: Select all that apply. 1. Independence 2. Egocentricity 3. Intellectual humility 4. Fair-mindedness 5. Confidence 6. Perseverance Correct Answer: 1, 3, 4, 5, 6 Rationale 1: Attributes that foster critical thinking include independence. Rationale 2: Attributes that foster critical thinking include insight into egocentricity (which is open to the possibility that biases or social pressures and customs can affect one's thinking) but not egocentricity itself. Rationale 3: Attributes that foster critical thinking include intellectual humility. Rationale 4: Attributes that foster critical thinking include fair-mindedness. Rationale 5: Attributes that foster critical thinking include confidence. Rationale 6: Attributes that foster critical thinking include perseverance. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Describe the components of clinical reasoning. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 148 Question 25 Type: MCMA 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? Standard Text: 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 commonsense thinking to provide quality, appropriate nursing care.” 4. “With health care 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.” Correct Answer: 1, 2, 4, 5 Rationale 1: Patients are sicker, with multiple problems, and so nursing care requires a more critical form of thinking in order to meet their nursing needs. Rationale 2: Redesigning care delivery is useless if nurses don’t have the thinking skills required to deal with today’s world. Rationale 3: Although this might be true, medicine and nursing have evolved tremendously, and so has the need for nurses to be critical thinkers. Rationale 4: Consumers and payers demand to see evidence of benefits, efficiency, and results. Rationale 5: Today’s progress often creates new problems that can’t be solved by old ways of thinking. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 144 Question 26 Type: MCMA The nurse manager determines that a new staff nurse is demonstrating characteristics of a critical thinker. What did the manager observe the nurse perform? Standard Text: 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. Correct Answer: 1, 3, 4, 5 Rationale 1: Empathetic listening shows the ability to imagine others’ feelings and difficulties, which is characteristic of critical thinking. Rationale 2: Proactive anticipation of consequences, planning ahead, and acting as opportunities and events require are characteristic of real thinking. Rationale 3: Courageously advocating for others demonstrates attributes characteristic of critical thinking. Rationale 4: Flexible changing of approaches as needed to get the best results is a characteristic of critical thinking. Rationale 5: Sensitivity to diversity, expressing appreciation of human differences related to values and culture, is a characteristic of critical thinking. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 146 New Questions: Question 27 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 3, 5 Rationale 1: 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. Rationale 2: Concept mapping is a technique that uses a graphic depiction of nonlinear and linear relationships to represent critical thinking. Concept maps provide an opportunity to visualize things. Rationale 3: Concept mapping is a technique that uses a graphic depiction of nonlinear and linear relationships to represent critical thinking. A general benefit of these maps is that they are quicker than note taking. Rationale 4: Concept mapping is a technique that uses a graphic depiction of nonlinear and linear relationships to represent critical thinking. It is easy to learn and does not take years of study. Rationale 5: Concept mapping is a technique that uses a graphic depiction of nonlinear and linear relationships to represent critical thinking. 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. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Describe the process of concept mapping to enhance critical thinking and clinical reasoning for the provision of nursing care. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 151 Question 28 Type: MCMA 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? Standard Text: Select all that apply. 1. Spider 2. Systems 3. Flowchart 3. Definitions 5. Hierarchical Correct Answer: 1, 2, 5 Rationale 1: Spider maps depict the interrelatedness of the concept and its attributes in the map. Rationale 2: Systems maps use inputs and outputs that illustrate relationships among the concept and its attributes. Rationale 3: Flowchart maps are linear diagrams demonstrating sequence or cause-and-effect relations. Rationale 4: Definitions is not a type of concept map. Rationale 5: In a hierarchical map, the concept and attributes are arranged in a hierarchical pattern and typically constructed in a descending order of importance. Relationships are identified between and among a concept and its attributes. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 11 Question 1 Type: MCSA 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. Correct Answer: 3 Rationale 1: Delivery of organized care is not part of the nursing process, although each phase is interrelated. Rationale 2: The nursing process is not part of the medical model, as nurses treat the client's response to the disease or problem. Rationale 3: The purpose of the nursing process is to identify a client's health status and actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs. Rationale 4: The nursing process is individualized for each client's care plan. It is not about standardizing care. Global Rationale:

Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Diagnosis is identifying the client's response to the problem. Implementation is what the nurse does to help the client reach a goal, and then the goal is evaluated. Rationale 3: Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment. Rationale 4: The goal of the intervention is evaluated, but that is not what is being described in this scenario. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify the four major activities associated with the assessing phase. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 159 Question 3 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Restlessness 2. "Leave me alone" 3. Not talkative 4. Pale and diaphoretic Correct Answer: 2 Rationale 1: Restlessness is observable so it is not subjective data. Rationale 2: 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. Rationale 3: Not being talkative is observable so it is not subjective data. Rationale 4: Paleness with diaphoresis is observable so this is not subjective data. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 160 Question 4 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 3 Rationale 1: Inference is making a judgment, and that is not what is described in the question. Rationale 2: The information provided by the spouse is not subjective because it is an observation by someone familiar with the client’s usual behavior. Rationale 3: 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. Rationale 4: The information provided by the spouse is not subjective because it is an observation by someone familiar with the client’s usual behavior. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 160 Question 5 Type: MCSA 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 Correct Answer: 3 Rationale 1: Assessment is gathering data, and this is not what is described in the question.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Diagnosis is identifying patterns and making inferences, and this is not what is described in the question. Rationale 3: Implementation is that part of the nursing process in which the nurse applies knowledge to perform interventions. Rationale 4: Evaluation is making criterion-based evaluations, and this is not what is described in the question. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe the phases of the nursing process. MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the nursing process. Page Number: 159 Question 6 Type: MCSA 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 Correct Answer: 4 Rationale 1: The Joint Commission requires that each client have an initial assessment consisting of a history and physical performed and documented within a specific time period, but not 1 hour. Rationale 2: The Joint Commission requires that each client have an initial assessment consisting of a history and physical performed and documented within a specific time period, but not 12 hours. Rationale 3: The Joint Commission requires that each client have an initial assessment consisting of a history and physical performed and documented within a specific time period, but not 48 hours. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10. Contrast various frameworks used for nursing assessment. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 159 Question 7 Type: MCSA 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 Correct Answer: 3 Rationale 1: The baby's birth record is able to provide necessary information, but not to the same extent as the parents. Rationale 2: Although the grandmother can support the parents during this time and may be able to offer some helpful information, she would not be the best source. Rationale 3: 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.). Rationale 4: The admitting physician will be able to provide necessary information, but not to the same extent as the parents. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 161 Question 8 Type: MCSA 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." Correct Answer: 2 Rationale 1: Before asking more questions, the nurse should review what is already at hand. Rationale 2: 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. Rationale 3: This option does not address the client’s legitimate concern, nor does it acknowledge the client’s feelings. Rationale 4: Telling the client "we're only doing our jobs" is belittling to the client and doesn't offer a therapeutic response. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe important aspects of the interview setting. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 163 Question 9 Type: MCSA 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 Correct Answer: 4 Rationale 1: Examining is the major method used in the physical health assessment. Rationale 2: Interviewing is used mainly while taking the nursing health history. Rationale 3: Listening is only one part of observing. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 164 Question 10 Type: MCSA A 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. Co-orkers discussing their clients' conditions Correct Answer: 3 Rationale 1: Nurses often need to focus on specific data in order not to be overwhelmed by a multitude of data. Observing involves discriminating data in a meaningful manner (i.e., noticing things that may indicate cause for concern or action on the nurse's part). Listening to a client's breathing helps the nurse become attentive to changes in breathing patterns. Rationale 2: Nurses often need to focus on specific data in order not to be overwhelmed by a multitude of data. Observing involves discriminating data in a meaningful manner (i.e., noticing things that may indicate cause for concern or action on the nurse's part). A client's moans of pain should never become easy to listen to. Rationale 3: 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. Rationale 4: Nurses often need to focus on specific data in order not to be overwhelmed by a multitude of data. Observing involves discriminating data in a meaningful manner (i.e., noticing things that may indicate cause for concern or action on the nurse's part). Listening to coworkers discuss other clients on the unit is helpful in case the nurse has to attend to any one of them. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10. Contrast various frameworks used for nursing assessment. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 165 Question 11 Type: SEQ 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). Standard Text: Click and drag the options below to move them up or down. Choice 1. The family is at the bedside. Choice 2. The IV pump is running on battery. Choice 3. The ECG monitor shows tachycardia. Choice 4. The client reports being restless. Choice 5. O2 tubing is not attached to wall regulator. Correct Answer: 3, 4, 5, 2, 1 Rationale 1: Has no apparent bearing on client’s symptoms Rationale 2: Indicates an issue worth observing Rationale 3: Indicates an objective cardiac symptom Rationale 4: Indicates a subjective symptom Rationale 5: Indicates a possible cause of the client’s symptoms Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify the purpose of assessing. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 164 Question 12 Type: MCSA 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?" Correct Answer: 2 Rationale 1: Simply noting the concern, without dealing with it, can leave the impression that the nurse does not care about the client's concerns or dismisses them as unimportant. Rationale 2: The nurse should use a combination of directive and nondirective approaches during the interview to determine areas of concern for the client. Rationale 3: Passing the questions off for the doctor would leave the impression that the nurse does not care about the client's concerns or dismisses them as unimportant. Rationale 4: A closed question (Have you had surgery before?) does not allow the client to offer much information, besides yes/no or one-word answers. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 164 Question 13 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA The nurse is completing a health history with a client who has complications from chronic asthma. Which openended 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?" Correct Answer: 1 Rationale 1: 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. Open-ended questions invite long answers—longer than one or two words. Rationale 2: Closed questions can be answered with short, factual, and specific information. Rationale 3: Closed questions can be answered with short, factual, and specific information. Rationale 4: Closed questions can be answered with short, factual, and specific information. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 164 Question 14 Type: MCSA 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?" Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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?" Correct Answer: 3 Rationale 1: Closed questions can be answered with one or two words. Rationale 2: A neutral question is open-ended and is used in nondirective interviews, which is what would be used if the nurse didn't understand the reason for the client's visit. Rationale 3: An open-ended question would be beneficial to explore more about the client's experience and should be asked with a "how" or "what." Rationale 4: A leading question is usually closed and directs the client's answer (the nurse stating how the client is feeling, for example). Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 164 Question 15 Type: MCSA A client is coming in to 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1 Rationale 1: 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. Rationale 2: Sitting behind a desk creates a formal arrangement that suggests a business meeting between a superior and subordinate. Rationale 3: Standing and looking down at a client who is in a chair risks intimidating the client. Rationale 4: Standing and taking notes infers that the nurse is not really interested in the client. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe important aspects of the interview setting. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 165 Question 16 Type: MCSA 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. Correct Answer: 3 Rationale 1: Having the client wait may cause an unnecessary delay in treatment. Rationale 2: Having the client wait and fill out paperwork may cause an unnecessary delay in treatment. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: 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. Rationale 4: Making sure the client's back is to the rest of the room is not acceptable. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Compare directive and nondirective approaches to interviewing. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 165 Question 17 Type: MCSA 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 Correct Answer: 2 Rationale 1: Interviews should be planned when the client is physically comfortable and free of pain, and when interruptions by the family are minimal. Rationale 2: 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. Rationale 3: Interviews should be planned when the client is physically comfortable and free of pain, and when interruptions by the family are minimal. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Medication may affect the client's ability to think clearly, so getting as much information as quickly as possible is important. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9. Describe important aspects of the interview setting. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 165 Question 18 Type: MCSA 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. Correct Answer: 2 Rationale 1: Nurses must be cautious when asking family members, client visitors, or agency nonprofessional staff to assist with translation. Issues of confidentiality or gender mismatch can interfere with effective communication. Rationale 2: 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. Rationale 3: Nurses must be cautious when asking family members, client visitors, or agency nonprofessional staff to assist with translation. Issues of confidentiality or gender mismatch can interfere with effective communication. Rationale 4: Using hand gestures is not an appropriate way to communicate with a client when other options are available. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 166 Question 19 Type: MCSA 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.” Correct Answer: 1 Rationale 1: 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 name, is especially good in establishing rapport. Rationale 2: Telling a hospitalized client he or she is lucky is probably not the best therapeutic comment. Rationale 3: 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. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 166 Question 20 Type: MCSA 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?” Correct Answer: 1 Rationale 1: 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. Rationale 2: This would be part of the body of the interview—questions designed to gather the most information about the situation. Rationale 3: This would be part of the body of the interview—questions designed to gather the most information about the situation. Rationale 4: This would be part of the body of the interview—questions designed to gather the most information about the situation. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 167 Question 21 Type: MCSA 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 Correct Answer: 4 Rationale 1: Cognitive perceptual patterns describe sensory-perceptual and cognitive patterns. Rationale 2: Coping/stress-tolerance patterns describe the client's general coping pattern and the effectiveness of the patterns in terms of stress tolerance. Rationale 3: Health-perception/health-management pattern describes the client's perceived pattern of health and well-being and how health is managed. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 10. Contrast various frameworks used for nursing assessment. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 170 Question 22 Type: MCSA 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 Correct Answer: 3 Rationale 1: Cues are subjective or objective data that can be directly observed by the nurse. Rationale 2: Validation is the act of "double-checking" or verifying data to confirm that they are accurate and factual. Rationale 3: 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. Rationale 4: Judgment is not part of validation. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Compare directive and nondirective approaches to interviewing. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 172 Question 23 Type: MCMA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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?

Standard Text: 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. Correct Answer: 1, 2, 5 Rationale 1: Diagnosing is analyzing and synthesizing data in order to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions as well as developing a list of nursing and collaborative problems. Rationale 2: Diagnosing is analyzing and synthesizing data in order to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions as well as developing a list of nursing and collaborative problems. Rationale 3: Developing a plan is part of the planning phase. Rationale 4: Specifying goals and outcomes is part of the planning phase. Rationale 5: Diagnosing is analyzing and synthesizing data in order to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions as well as developing a list of nursing and collaborative problems. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1. Describe the phases of the nursing process. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 156 Question 24 Type: MCSA 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 Correct Answer: 3 Rationale 1: Diagnosis is problem identification. Rationale 2: Implementation is carrying out (or delegating) the planned nursing interventions. Wound care would be the implementation of this particular case. Rationale 3: 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. Rationale 4: Assessment is collecting and organizing data. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1. Describe the phases of the nursing process. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 156 Question 25 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 3 Rationale 1: Initial assessment is performed within a specific time after admission to a health care agency. Rationale 2: Problem-focused assessment is an ongoing process integrated with nursing care. Rationale 3: An emergency assessment is performed during any physiologic or psychologic crisis of the client to identify life-threatening problems. Rationale 4: Time-lapsed assessment occurs several months after the initial assessment to compare the client's current status to baseline data previously obtained. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 161 Question 26 Type: MCSA 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. What should the nurse do to validate this data? 1. Retake the vital signs. 2. Call the physician. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Continue with the physical assessment as soon as possible. 4. Report the findings to the charge nurse. Correct Answer: 1 Rationale 1: 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. Rationale 2: Calling the physician would be premature. Rationale 3: The physical assessment should be done as soon as possible anyway, but not until after the vital signs have been validated. Rationale 4: Reporting the findings to the charge nurse before they have been validated would be premature. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 171 Question 27 Type: MCMA A nurse is performing an initial assessment on a new admission. What information should the nurse consider as being a part of the database? Standard Text: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

5. Information about the client's cultural preferences 6. Discharge instructions Correct Answer: 1, 2, 4, 5 Rationale 1: The database is all the information about a client. It includes the nursing health history, physical assessment, the physician's history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. Rationale 2: The database is all the information about a client. It includes the nursing health history, physical assessment, the physician's history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. Rationale 3: The database is all the information about a client. It includes the nursing health history, physical assessment, the physician's history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. It would not include the physician's orders for this admission, or discharge instructions. Rationale 4: The database is all the information about a client. It includes the nursing health history, physical assessment, the physician's history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. Current medications would be a part of this database. Rationale 5: The database is all the information about a client. It includes the nursing health history, physical assessment, cultural preferences, the physician's history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. Rationale 6: The database is all the information about a client. It includes the nursing health history, physical assessment, the physician's history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. It would not include discharge instructions. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions 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: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 160 Question 28 Type: MCMA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The nurse is conducting an interview with a new client. Which actions indicate that the nurse is implementing effective communication guidelines? Standard Text: 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 Correct Answer: 1, 4, 5 Rationale 1: Communication guidelines for a therapeutic interview would include establishing eye contact, as doing so shows interest and a focus on the client. Rationale 2: Communication guidelines for a therapeutic interview would not include the avoidance of silence, as silence has therapeutic value. Rationale 3: Communication guidelines for a therapeutic interview would not include personal experiences or opinions, as they can be viewed as a form of pressure by the client. Rationale 4: Communication guidelines for a therapeutic interview would include sitting at the client’s eye level, as doing so helps create a sense of equality between the nurse and client. Rationale 5: Communication guidelines for a therapeutic interview would include assuming a relaxed posture, as doing so conveys a nonthreatening environment. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9. Describe important aspects of the interview setting.. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 165 Question 29 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCMA The nurse manager observes a staff nurse perform actions within the nursing process. Which activities did the manager observe the nurse perform? Standard Text: 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 Correct Answer: 1, 2, 3, 4 Rationale 1: The nursing process has distinctive characteristics that include being dynamic so as to respond to clients’ ever-changing needs. Rationale 2: The nursing process has distinctive characteristics that include being client-centered, as evidenced by actions such as acting as the client’s advocate. Rationale 3: The nursing process has distinctive characteristics that include decision making that enables the nurse to respond to the changing health status of the client. Rationale 4: The nursing process has distinctive characteristics that include universal applicability of care. Rationale 5: This is a nursing responsibility but not necessarily a characteristic of the nursing process. Global Rationale: Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 02 Identify major characteristics of the nursing process. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 2. Identify major characteristics of the nursing process. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 158 New Questions: Question 30 Type: MCMA 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? Standard text: 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 Correct Answer: 3, 4, 5 Rationale 1: Allergies is a part of the past history. Rationale 2: Immunization record is a part of the past history. Rationale 3: When the symptoms started is a part of the history of present illness. Rationale 4: The location of the problem is a part of the history of present illness. Rationale 5: Things that aggravate the problem is a part of the history of present illness. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10. Contrast various frameworks used for nursing assessment. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 162 Question 31 Type: MCMA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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? Standard Text: 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 Correct Answer: 3, 5 Rationale 1: Reviewing client records is a part of the assessment phase of the nursing process. Rationale 2: Establishing a database is a part of the assessment phase of the nursing process. Rationale 3: Performing nursing actions is a part of the implementation phase of the nursing process. Rationale 4: Reviewing nursing literature is a part of the assessment phase of the nursing process. Rationale 5: Determining the client’s strengths, risks, and problems is a part of the diagnosis phase of the nursing process. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Identify the four major activities associated with the assessing phase. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 158

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 12 Question 1 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: A nursing diagnosis, although familiar to other health care professionals, is nursing focused. Rationale 3: The nursing diagnosis statement is specific to nursing and nurses and does not include the medical diagnosis. Rationale 4: The nursing diagnosis, like the plan of care, is specific to each individual client and the client’s situation. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B. 4. Function competently within own scope of practice as a member of the health care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Compare nursing diagnoses, medical diagnoses, and collaborative problems. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 177 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 2 Type: MCSA A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. Which type of diagnosis should the nurse select for this client? 1. Risk nursing diagnosis 2. Syndrome diagnosis 3. Wellness diagnosis 4. Actual diagnosis Correct Answer: 3 Rationale 1: A risk diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene—that is not what is described in this scenario. Rationale 2: A syndrome diagnosis is associated with a cluster of other diagnoses—that is not what is described in this scenario. Rationale 3: A wellness diagnosis describes the human response to levels of wellness in an individual. This client is seeking information about behavior changes and improvement to assist him in making choices and changes to enhance his life. Rationale 4: An actual diagnosis is a client problem that is present at the time of the nursing assessment. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: II.B. 4. Function competently within own scope of practice as a member of the health care 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; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1. Differentiate nursing diagnoses according to status. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 183 Question 3 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Syndrome diagnosis 2. Risk nursing diagnosis 3. Actual diagnosis 4. Wellness diagnosis Correct Answer: 1 Rationale 1: 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). Rationale 2: A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless the nurse intervenes. Rationale 3: An actual diagnosis is a client problem that is present at the time of the nursing assessment. Rationale 4: A wellness diagnosis describes human responses to levels of wellness in an individual, family, or community that has a readiness for enhancement. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B. 4. Function competently within own scope of practice as a member of the health care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1. Differentiate nursing diagnoses according to status. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 176 Question 4 Type: MCSA The nurse is preparing to write nursing diagnoses for a client. What should the nurse recall about the NANDA label? 1. Must contain three components 2. Describes the health problem for which nursing therapy is given 3. Helps define medical diagnoses for nursing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Promotes a taxonomy of nursing Correct Answer: 4 Rationale 1: The diagnosis contains three components: the problem and its definition, the etiology, and the defining characteristics. Rationale 2: The problem statement, or diagnostic label, describes the client’s health problem or response for which nursing therapy is given. Rationale 3: The nursing diagnosis is not equated with or defined by medical diagnoses. Rationale 4: The purpose of the NANDA label is to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses. This label describes the health problem or response by the client for which nursing therapy is given. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B. 4. Function competently within own scope of practice as a member of the health care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2. Identify the components of a nursing diagnosis. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 176 Question 5 Type: MCSA 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. Correct Answer: 2

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Nurses draw on knowledge and experience to compare client data to standards and norms and to identify significant and relevant observations. A sleeping client would not necessarily be recognized as a significant or relevant observation. Rationale 2: 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. Rationale 3: Nurses draw on knowledge and experience to compare client data to standards and norms and to identify significant and relevant cues. A client’s spouse asleep in a chair would not necessarily be recognized as a significant or relevant observation. Rationale 4: Nurses draw on knowledge and experience to compare client data to standards and norms and to identify significant and relevant cues. A television playing loudly would not necessarily be recognized as a significant or relevant observation. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B. 4. Function competently within own scope of practice as a member of the health care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1. Differentiate nursing diagnoses according to status. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 178 Question 6 Type: MCSA The nurse selects the nursing diagnosis of Enhanced readiness for 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1 Rationale 1: A wellness diagnosis describes human responses to levels of wellness in an individual family or community that has a readiness for enhancement or improvement. The data cluster that describes the questioning, searching, and reflecting would support an attitude of readiness. Rationale 2: A wellness diagnosis describes human responses to levels of wellness in an individual family or community that has a readiness for enhancement or improvement. This option merely shows activities but no real interest in improvement. Rationale 3: A wellness diagnosis describes human responses to levels of wellness in an individual family or community that has a readiness for enhancement or improvement. This option merely shows activities but no real interest in improvement on the part of only specific family members. Rationale 4: A wellness diagnosis describes human responses to levels of wellness in an individual family or community that has a readiness for enhancement or improvement. This option merely shows activities but no real interest in improvement. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1. Differentiate nursing diagnoses according to status. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 176 Question 7 Type: MCSA 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. Correct Answer: 3 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Learning from peers is helpful, but does not take the place of didactic information. Rationale 2: Learning from seasoned nurses is helpful, but does not take the place of didactic information. Rationale 3: 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. Rationale 4: Experience teaches much information, but it never takes the place of concrete, scientific theory. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify the basic steps in the diagnostic process. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 179 Question 8 Type: MCSA 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. Correct Answer: 1 Rationale 1: Establishing strengths, resources, and ability to cope will help the client develop a more wellrounded self-concept and self-image. Strengths can be an aid to mobilizing health and regenerative processes. Rationale 2: The client may be more active in the plan; however, this does not explain why the client will be more active. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Looking at what will be easier for the nurse is not the reason strengths are included in the client's plan. Rationale 4: Looking at what will be time effective for only the nurse is not the reason strengths are included in the client's plan. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify the basic steps in the diagnostic process. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 181 Question 9 Type: MCSA 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 Correct Answer: 2 Rationale 1: 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.” Rationale 2: 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. Rationale 3: Making an assumption that the cause is psychosomatic is not within the nurse’s scope of practice. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The third part of the nursing diagnosis statement is manifested by the (S) portion, which includes the signs and symptoms, not a generalized statement. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1. Differentiate nursing diagnoses according to status. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 182 Question 10 Type: MCSA A client is diagnosed with pneumonia and has been hospitalized for several days. Which nursing diagnosis should the nurse identify as a priority for this client? 1. Altered oral mucous membranes, related to dry mouth 2. Activity intolerance, related to oxygen supply imbalance 3. Knowledge deficit, related to medication regimen 4. Ineffective airway clearance, related to increased secretions Correct Answer: 4 Rationale 1: Prioritizing care must begin with the basic needs. This option is appropriate but does not match the primary need. Rationale 2: Prioritizing care must begin with the basic needs. This option is appropriate but does not match the primary need. Rationale 3: Prioritizing care must begin with the basic needs. This option is appropriate but does not match the primary need. Rationale 4: Prioritizing care must begin with the basic needs, in this case, the airway. Global Rationale: Cognitive Level: Applying Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1. Differentiate nursing diagnoses according to status. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 185 Question 11 Type: MCSA 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 breast-feeding, related to lack of motivation, secondary to exhaustion 4. Altered urinary elimination, secondary to childbirth Correct Answer: 3 Rationale 1: “Manifested” is not appropriate wording of the NANDA statement. Rationale 2: “Because of” is not appropriate wording of the NANDA statement. Rationale 3: The problem statement is listed first (NANDA label), 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. Rationale 4: The problem statement is listed first (NANDA label), followed by the etiology—factors that contribute to or are the cause of the client’s response—which is lacking in this option. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 6. List guidelines for writing a nursing diagnosis statement. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 182 Question 12 Type: MCSA 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 Correct Answer: 4 Rationale 1: This option poorly describes the causing factors. Rationale 2: This option poorly describes the causing factors. Rationale 3: This option limits the description of causing factors. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 6. List guidelines for writing a nursing diagnosis statement. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 182 Question 13 Type: MCSA 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 vs. what is not normal 2. Verifying 3. Consulting resources 4. Basing diagnoses on patterns Correct Answer: 2 Rationale 1: Nurses must apply knowledge from various areas to recognize cues and patterns to understand what is normal and not normal. This comes from principles of chemistry, anatomy, and pharmacology—not the client or the family. Rationale 2: 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. Rationale 3: Both novices and experienced nurses should consult appropriate resources whenever in doubt about a diagnosis; that is not what is described in the scenario. Rationale 4: Diagnoses should be based on patterns and behavior over time, not an isolated incident. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. List guidelines for writing a nursing diagnosis statement. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 184 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 14 Type: MCSA After formulating several diagnoses, the nurse does not understand the reason for some of the discrepancies in the client's lab 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. Correct Answer: 3 Rationale 1: Verifying the information with the client would be inappropriate because the information does not come from subjective data, but rather from testing and lab values. Rationale 2: The nurse already has compared the findings to the norms and standards. Rationale 3: 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. Rationale 4: Critical-thinking skills help the nurse be aware of and avoid errors. This comes with experience and is a learned and practiced process. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify the basic steps in the diagnostic process. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 184 Question 15 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 4 Rationale 1: There are steps in the process that precede the formulation of diagnostic statements. Rationale 2: Verifying the data should be done at the end of the assessment/interview phase. Rationale 3: Researching collaborative and nursing-related interventions comes after setting goals or outcomes and is not part of the diagnostic process, but rather part of the implementation phase. Rationale 4: The step that follows data analysis is identification of the client's health problems, health risks, and strengths. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 4. Identify the basic steps in the diagnostic process. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 179 Question 16 Type: MCSA The nurse has formulated the following diagnosis: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Reports of fatigue 4. Physical activity Correct Answer: 3 Rationale 1: “Activity intolerance” is the NANDA label and identifies the problem, but “reports of fatigue” is the defining characteristic. Rationale 2: “Weakness and debilitation” are the etiology (underlying cause), but “reports of fatigue” is the defining characteristic. Rationale 3: The defining characteristics are those reports given by the client, or the signs and symptoms. Rationale 4: “Physical activity” is what brings on the reports of the defining characteristic, but “reports of fatigue” is the defining characteristic. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2. Identify the components of a nursing diagnosis. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 182 Question 17 Type: MCSA A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia. What is the etiology of this diagnosis? 1. Unfamiliarity of disease process 2. Anxiety 3. Restlessness 4. Tachycardia Correct Answer: 1 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: 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. Rationale 2: “Anxiety” is the NANDA label—the problem identified. Rationale 3: “Restlessness” is a defining characteristic that the client exhibits. Rationale 4: “Tachycardia” is a defining characteristic that the client exhibits. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2. Identify the components of a nursing diagnosis. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 182 Question 18 Type: MCSA The nurse formulates the nursing diagnosis: 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. Correct Answer: 2 Rationale 1: This option is not collaborative but rather nurse mediated, which the nurse can implement independently. Rationale 2: Collaboration occurs between the nurse, physician, and other health care 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: This option is not collaborative but rather nurse mediated, which the nurse can implement independently. Rationale 4: This option is not collaborative but rather nurse mediated, which the nurse can implement independently. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Differentiate nursing diagnoses according to status. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 183 Question 19 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 2, 5, 6 Rationale 1: Data that support this problem are clustered around the condition of the client's skin. Rationale 2: Data that support this problem are clustered around the condition of the client's skin. Rationale 3: The fact that the client does not drive does not play a part in this client's skin condition. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The fact that the client does not use alcohol or drugs does not play a part in this client's skin condition. Rationale 5: Data that support this problem are clustered around the condition of the client's clothes. Rationale 6: Data that support this problem are clustered around the condition of the client's general appearance. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 4. Identify the basic steps in the diagnostic process. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 179 Question 20 Type: MCSA 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 Correct Answer: 3 Rationale 1: This is not considered and so is not an area of difference. Rationale 2: This is not considered and so is not an area of difference. Rationale 3: Nursing focus is an area that differs. Rationale 4: This is not considered and so is not an area of difference. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Compare nursing diagnoses, medical diagnoses, and collaborative problems. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 176 Question 21 Type: MCMA The nurse is using the Taxonomy II nursing diagnoses system. What axes should the nurse realize are coded within this system? Standard Text: Select all that apply. 1. Gordon's health pattern groupings 2. Age 3. Time 4. Health status 5. Gender 6. Location Correct Answer: 2, 3, 4, 6 Rationale 1: The diagnoses are no longer grouped by Gordon’s patterns. Rationale 2: The Taxonomy II system codes diagnoses according to seven axes that include age. Rationale 3: The Taxonomy II system codes diagnoses according to seven axes that include time. Rationale 4: The Taxonomy II system codes diagnoses according to seven axes that include health status. Rationale 5: Gender is not an axis upon which diagnoses are coded. Rationale 6: The Taxonomy II system codes diagnoses according to seven axes that includes location. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 5. Describe various formats for writing nursing diagnoses. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 185 Question 22 Type: MCMA 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? Standard Text: 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 Correct Answer: 1,3,4,6 Rationale 1: This option reflects an accepted guideline for formulating nursing diagnoses. Rationale 2: A nursing diagnosis statement must be stated in terms of a problem, not a need. Rationale 3: This option reflects an accepted guideline for formulating nursing diagnoses. Rationale 4: This option reflects an accepted guideline for formulating nursing diagnoses. Rationale 5: Nursing terminology rather than medical terminology is used to describe the client's response and the probable cause of the client's response. Rationale 6: This option reflects an accepted guideline for formulating nursing diagnoses. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 6. List guidelines for writing a nursing diagnosis statement. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 184 Question 23 Type: MCSA The nurse wants to propose a new nursing diagnosis. What action should the nurse take first? 1. Using the proposed nursing diagnosis when constructing client care plans 2. Getting permission for the proposed nursing diagnosis to be implemented by a nursing facility 3. Submitting the diagnosis to NANDA’s Diagnostic Review Committee 4. Presenting the proposed nursing diagnosis at the local AMA (American Medical Association) meeting. Correct Answer: 3 Rationale 1: This option is inappropriate because only approved nursing diagnoses should be used to direct nursing care. Rationale 2: This is not the appropriate method for having a new nursing diagnosis included for use. Rationale 3: This is the recognized procedure for initiating the approval of a new nursing diagnosis. Rationale 4: This option is inappropriate because nursing diagnoses are not a part of medical care. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I1.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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 7. Describe the evolution of the nursing diagnosis movement, including work currently in progress. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 185 Question 24 Type: MCMA The nurse is providing care to a client. Which nursing diagnoses can the nurse apply when providing client care? Standard Text: Select all that apply. 1. Ineffective Breathing Pattern 2. Risk of Infection 3. Readiness for Enhanced Nutrition 4. Readiness for Enhanced Family Coping 5. Anxiety Correct Answer: 1, 5 Rationale 1: 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. Rationale 2: A risk nursing diagnosis is a clinical judgment that a problem does not exist but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. Rationale 3: A health promotion diagnosis relates to the client’s preparedness for implementing behaviors to improve his or her health condition. These diagnosis labels begin with the phrase “readiness for enhanced.” Rationale 4: A wellness diagnosis describes human responses to levels of wellness in an individual, family, or community. These diagnosis labels begin with the phrase “readiness for enhanced.” Rationale 5: 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Differentiate nursing diagnoses according to status. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 176 Question 25 Type: MCMA The nurse is using the PES model to write a nursing diagnosis. Which nursing diagnoses demonstrate that the nurse used this model appropriately? Standard Text: 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 ten pounds 5. Ineffective Breathing Pattern as evidenced by cyanotic lips Correct Answer: 1, 4 Rationale 1: The basic three-part nursing diagnosis statement is called the PES format and includes the problem, etiology, and signs and symptoms. Rationale 2: The basic three-part nursing diagnosis statement is called the PES format and includes the problem, etiology, and signs and symptoms; this diagnosis is lacking the signs and symptoms. Rationale 3: The basic three-part nursing diagnosis statement is called the PES format and does not support the use of “risk for” diagnosis because the client does not have signs and symptoms of the diagnosis. Rationale 4: The basic three-part nursing diagnosis statement is called the PES format and includes the problem, etiology, and signs and symptoms. Rationale 5: The basic three-part nursing diagnosis statement is called the PES format and includes the problem, etiology, and signs and symptoms; this diagnosis is lacking the etiology. Global Rationale: Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 05 Describe various formats for writing nursing diagnoses. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Describe various formats for writing nursing diagnoses. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 182 New Questions: Question 26 Type: MCMA 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? Standard Text: Select all that apply. 1. Moving 2. Choosing 3. Perceiving 4. Anticipating 5. Communicating Correct Answer: 1, 2, 3, 5 Rationale 1: For the client requesting information for chronic low back pain, the human response pattern of moving would be appropriate because it addresses activity. Rationale 2: For the client requesting information for chronic low back pain, the human response pattern of choosing would be appropriate because it addresses a selection of alternatives. Rationale 3: For the client requesting information for chronic low back pain, the human response pattern of perceiving would be appropriate because it addresses the reception of information. Rationale 4: Anticipating is not a human response pattern. Rationale 5: For the client requesting information for chronic low back pain, the human response pattern of communicating would be appropriate because it addresses the sending of messages. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I1.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Compare nursing diagnoses, medical diagnoses, and collaborative problems. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 185 Question 27 Type: MCMA The nurse formulates nursing diagnoses for a client with chronic renal failure. Which statements indicate the nurse appropriately used a two-part format? Standard Text: Select all that apply. 1. Pruritis related to toxin build-up 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 Rationale 1: The nursing diagnosis should not include medical diagnoses such as pruritis. Rationale 2: The nursing diagnosis should not include medical diagnoses such as hypertension. Rationale 3: 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.” Rationale 4: A personal care challenge is not a nursing diagnostic problem. Rationale 5: 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.” Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 13 Question 1 Type: MCSA 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 Correct Answer: 3 Rationale 1: The continuation of the client’s care plan is not the sole responsibility of the admitting nurse. Rationale 2: Although this is true, there is another option that better answers the item. Rationale 3: 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. Rationale 4: Although it is important for the client and the client's support people and caregivers to be involved in the plan of care, there is an option that better answers this item. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Identify activities that occur in the planning process. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 189 Question 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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 Correct Answer: 4 Rationale 1: An informal nursing care plan is a strategy for action that exists only in the nurse's mind; this does not meet the needs expressed in the item. Rationale 2: A formal nursing care plan is a written or computerized guide that organizes information about the client's care; this does not meet the needs expressed in the item. Rationale 3: A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be individualized and used in creating a comprehensive nursing care plan. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 190 Question 3 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Informal nursing care plan 2. Formal nursing care plan 3. Standardized care plan 4. Individualized care plan Correct Answer: 3 Rationale 1: An informal nursing care plan is a strategy for action that exists in the nurse's mind. Rationale 2: A formal nursing care plan is a written or computerized guide that organizes information about the client's care. Rationale 3: 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. Rationale 4: An individualized care plan is tailored to meet the unique needs of a specific client—needs not addressed by the standardized plan. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be individualized and used in creating a comprehensive nursing care plan. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 190 Question 4 Type: MCMA 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? 1. Making sure all clients have the same types of care 2. Ensuring that minimally accepted standards are met Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Promoting efficient use of the nurse's time 4. Eliminating care disparities among clients 5. Ensuring medication errors do not occur Correct Answer: 2, 3 Rationale 1: Ensuring that all clients receive the same type of care is not appropriate, as care must be individualized to meet the client's needs. Rationale 2: Standards of care, standardized care plans, protocols, policies, and procedures are developed and accepted by the nursing staff in order to ensure that minimally acceptable criteria are met. Rationale 3: Standards of care, standardized care plans, protocols, policies, and procedures are developed and accepted by the nursing staff in order to promote efficient use of nurses’ time by removing the need to author common activities that are done repeatedly for many of the clients on a nursing unit. Rationale 4: Standardized documents will not eliminate care disparities among clients. Rationale 5: Standardized documents will not ensure that medication errors do not occur. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be individualized and used in creating a comprehensive nursing care plan. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 191 Question 5 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Policy and procedure manual Correct Answer: 2 Rationale 1: Standardized care plans are preprinted guides for the nursing care of a client who has a need that arises frequently in the agency—or all nursing diagnoses associated with a particular medical condition. In this situation, the nurse is not working from the written care plan, as the baby has just been admitted. Rationale 2: Protocols are preprinted to indicate the actions commonly required for a particular group of clients. Protocols may include both physicians' orders and nursing interventions. Rationale 3: Standards of care describe nursing actions for clients with similar medical conditions rather than individuals, and they describe achievable rather than ideal nursing care. Rationale 4: Policies and procedures are developed to govern the handling of frequently occurring situations. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be individualized and used in creating a comprehensive nursing care plan. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 191 Question 6 Type: MCSA 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 Correct Answer: 4 Rationale 1: A STAT order is one that must be carried out immediately. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: A one-time order is for an action to be done only once. Rationale 3: “prn” is pro re nata–Latin for "as needed." Rationale 4: Standing orders are a written document about policies, rules, regulations, or orders regarding client care. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be individualized and used in creating a comprehensive nursing care plan. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 191 Question 7 Type: MCSA 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. Make sure that he or she is able to get to the client's home. 2. Assist the client in finding an alternative plan for the 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. Correct Answer: 2 Rationale 1: Driving 80 miles two times a day may not be feasible, but perhaps there are other alternatives that could be considered. Rationale 2: 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). Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Telling the client that the therapy is impossible is premature at this point in time. Rationale 4: Making arrangements for the client to move is premature at this point in time. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Identify factors that the nurse must consider when setting priorities. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 195 Question 8 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. "Ambulate freely" does not give a time frame; therefore it is not as specific. Rationale 3: Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Goals stated as "will not fall" are too vague, have no time limit, and do not give the nurse a good set of criteria to evaluate the goal. Rationale 4: Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Having freer movement in daily activities is too vague. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8. Identify guidelines for writing goals/desired outcomes. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 197 Question 9 Type: MCSA The nurse identifies for a client the nursing diagnosis “Fluid volume deficit, related to active fluid loss, secondary to diarrhea.” What would be and 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. Correct Answer: 4 Rationale 1: The goal statement must be specific with observable outcomes in order for the nurse to evaluate client progress. Modifiers like "more" could be more specific. Rationale 2: The goal statement must be specific with observable outcomes in order for the nurse to evaluate client progress. Modifiers like "good" could be more specific, and all options must have a time frame for evaluating the desired performance. Rationale 3: 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. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8. Identify guidelines for writing goals/desired outcomes. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 197 Question 10 Type: MCSA 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 Correct Answer: 3 Rationale 1: The nursing diagnosis statement must follow the NANDA format. Rationale 2: Goal setting is part of the planning, but the NOC outcome is narrower in use than general planning. Rationale 3: The Nursing Outcomes Classification (NOC) describes client outcomes that respond to nursing interventions seen in traditional care plans. Rationale 4: Implementation is compared to the Nursing Interventions Classification (NIC) taxonomy. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 197 Question 11 Type: MCSA The nurse is caring for a client with Parkinson’s 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. Correct Answer: 2 Rationale 1: Providing assistance and attending to the client's space would be independent interventions. Rationale 2: 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. Rationale 3: 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. Attending to the client's space would be an independent intervention. Rationale 4: Administering medications would be a dependent intervention. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 201 Question 12 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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 Correct Answer: 4 Rationale 1: This is an example of an independent intervention: those activities that the nurse is licensed to initiate on the basis of knowledge and skills. Rationale 2: This is an example of an independent intervention: those activities that the nurse is licensed to initiate on the basis of knowledge and skills. Rationale 3: This is an example of an independent intervention: those activities that the nurse is licensed to initiate on the basis of knowledge and skills. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 201 Question 13 Type: MCSA One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60 to 90 degrees) during feeding times. What should the nurse identify as the modifier in this intervention? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. 60 to 90 degrees during feeding times 2. Position in chair 3. Upright in a chair 4. Impaired swallowing Correct Answer: 1 Rationale 1: 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 to 90 degrees and "during feeding times" gives when this should be done. Rationale 2: The word "position" is not descriptive enough for modifiers. Rationale 3: The word ""upright" is not descriptive enough for modifiers. Rationale 4: “Impaired swallowing” is the NANDA label. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 198 Question 14 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 3 Rationale 1: Prevention interventions prescribe the care needed to avoid complications or reduce risk factors. Turning and repositioning would help prevent any further skin breakdown. Rationale 2: Prevention interventions prescribe the care needed to avoid complications or reduce risk factors. Cushioning bony prominences would help prevent any further skin breakdown. Rationale 3: 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. Rationale 4: Application of lotion or other treatments to areas of skin impairment would be considered a treatment intervention. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 202 Question 15 Type: MCSA 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. Correct Answer: 2 Rationale 1: This option lacks some of the required components of a well-written intervention.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: 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. Rationale 3: This option lacks some of the required components of a well-written intervention. Rationale 4: "Client will ambulate in the hallway" is a goal statement, not an intervention. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 201 Question 16 Type: MCSA 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 Correct Answer: 2 Rationale 1: The NIC taxonomy may or may not help with documentation. Rationale 2: 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. Rationale 3: Although it would utilize standard language for all nurses and offer suggestions of interventions for each diagnosis, finding the most appropriate interventions still requires individualization for each client. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: This taxonomy is general and standardized and must be tailored to fit the needs, outcomes, and goals of the individual client. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 202 Question 17 Type: MCSA 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's position to prevent reflux. 4. Provide frequent assessment for presence of obstructive material in mouth and throat. Correct Answer: 3 Rationale 1: 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. This intervention does not explain “why” it is being done. Rationale 2: 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. This intervention does not explain “why” it is being done. Rationale 3: 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 to 45 degrees helps prevent the risk of reflux (food/liquids returning up through the esophagus after having been swallowed).

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: 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. This intervention does not explain “why” it is being done. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 192 Question 18 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 2, 3, 4, 5 Rationale 1: This is a recognized guideline when writing care plans. Rationale 2: This is a recognized guideline when writing care plans. Rationale 3: This is a recognized guideline when writing care plans. Rationale 4: This is a recognized guideline when writing care plans. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: This is a recognized guideline when writing care plans. Rationale 6: Care plans are not both standardized and generalized for all clients. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify essential guidelines for writing nursing care plans. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 194 Question 19 Type: MCMA The nursing staff is reviewing standards of care, standardized care plans, protocols, policies, and procedures for a multi-system health care facility. Why are these documents important to the nursing staff when providing client care? Standard Text: Select all that apply. 1. To make sure all clients have the same type of care 2. To ensure that minimally accepted standards of care are met 3. To promote efficient use of the nurse’s time 4. To eliminate care disparities among clients 5. To minimize health care costs Correct Answer: 2, 3 Rationale 1: Although standardized approaches to care planning are common in many health care agencies, ensuring that all clients receive the same type of care is not appropriate, as care must be individualized to meet the client's needs. Rationale 2: Ensuring that minimally accepted standards of care are met is a reason for the actions mentioned in the scenario. Rationale 3: Ensuring that nurses’ time is used efficiently is a reason for the actions mentioned in the scenario. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Not all clients require the same care, and so disparities are not a concern. Rationale 5: Although cost containment is important, it is not the focus of standardized approaches to care planning. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be individualized and used in creating a comprehensive nursing care plan. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 190 Question 20 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 4, 5 Rationale 1: This is a recognized guideline. Rationale 2: This is a recognized guideline. Rationale 3: The plan must be based on nursing knowledge and experience or knowledge from relevant sciences (based on rationale). Rationale 4: This is a recognized guideline. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: This is a recognized guideline. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 201 Question 21 Type: MCMA The nurse is reviewing a client’s plan of care. Which statements indicate that this care plan has been completed accurately and appropriately? Standard Text: 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. Correct Answer: 1, 2, 3, 4 Rationale 1: The care plan is often organized into sections that include nursing diagnoses. Rationale 2: The care plan is often organized into sections that include goals/outcomes. Rationale 3: The care plan is often organized into sections that include evaluations. Rationale 4: The care plan is often organized into sections that include nursing interventions. Rationale 5: Although this might be a desirable behavior, it is not written as a goal. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Identify essential guidelines for writing nursing care plans. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 198 Question 22 Type: MCMA 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? Standard Text: 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.” Correct Answer: 1, 3, 5 Rationale 1: The nurse can look up a client’s nursing diagnosis to see which nursing interventions are suggested. Rationale 2: Each nursing diagnosis contains suggestions for several interventions, so nurses need to select the appropriate interventions based on their judgment and knowledge of the client. Rationale 3: All NIC interventions have been linked to NANDA nursing diagnostic labels. Rationale 4: When writing individualized nursing interventions on a care plan, the nurse should record customized activities rather than broad intervention labels. Rationale 5: 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. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 202 New Questions: Question 23 Type: MCMA 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? Standard Text: 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 newly diagnosed health problem. Correct Answer: 3, 4 Rationale 1: The client’s current treatment plan is not a part of discharge planning. Rationale 2: The client’s current health status is not a part of discharge planning. Rationale 3: Effective discharge planning begins at first client contact and involves comprehensive and ongoing assessment to obtain information about the client’s ongoing needs. The lack of a scale at home for daily weights indicates that the nurse is planning ahead for the client’s needs once discharged. Rationale 4: Effective discharge planning begins at first client contact and involves comprehensive and ongoing assessment to obtain information about the client’s ongoing needs. Concern about the client’s activity level at home indicates planning ahead for the client’s needs once discharged. Rationale 5: The client’s personality and desire to learn more about the health problem is not a part of discharge planning. Global Rationale: Cognitive Level: Analyzing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Compare and contrast initial planning, ongoing planning, and discharge planning. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 189 Question 24 Type: MCMA The nurse is creating goals for a client’s plan of care. For what reasons should the nurse expect to use these goals? Standard Text: 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 Correct Answer: 1, 2, 3, 5 Rationale 1: Desired outcomes/goals serve as the criteria for judging the effectiveness of nursing interventions and client progress in the evaluation step. Rationale 2: Desired outcomes/goals enable the client and nurse to determine when the problem has been resolved. Rationale 3: 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. Rationale 4: Desired outcomes/goals are not used as measuring sticks to limit the use of hospital resources. Rationale 5: 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. State the purposes of establishing client goals/desired outcomes. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 197

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 14 Question 1 Type: MCSA 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 Correct Answer: 4 Rationale 1: Technical skills are "hands-on" skills such as manipulating equipment, giving injections, bandaging, and moving, lifting, and repositioning clients. Rationale 2: Interpersonal skills are all of the activities, verbal and nonverbal, people use when interacting directly with one another. Rationale 3: Creativity is part of cognitive skill. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe three categories of skills used to implement nursing interventions. MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the nursing process. Page Number: 208 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 2 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Cognitive skills are intellectual skills that involve problem solving, decision making, critical thinking, and creativity. Rationale 3: Interpersonal skills are necessary for nursing activities: caring, comforting, advocating, referring, counseling, and supporting, to name a few. Rationale 4: Academic skills would fall under the category of cognitive skills. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe three categories of skills used to implement nursing interventions. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 209 Question 3 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 2 Rationale 1: Cognitive skills are intellectual skills and include problem solving, decision making, critical thinking, and creativity. Rationale 2: 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. Rationale 3: Technical skills are "hands-on" skills such as manipulating equipment, giving injections, bandaging, and repositioning clients. Rationale 4: All nursing skills should be therapeutic. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe three categories of skills used to implement nursing interventions. MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the nursing process. Page Number: 209 Question 4 Type: MCMA The nurse is preparing to provide care planned for a client. What actions should the nurse complete during this phase of client care? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 2, 4, 5 Rationale 1: Evaluating the outcome of the interventions is part of the evaluation phase. Rationale 2: Other components of the implementation process include reassessing the client. Rationale 3: Documentation of the history and physical is part of the initial assessment. Rationale 4: Other components of the implementation process include supervising delegated care. Rationale 5: Other components of the implementation process include implementing the nursing interventions. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Discuss the five activities of the implementing phase. MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the nursing process. Page Number: 209 Question 5 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Supervising delegated care 4. Reassessing the client Correct Answer: 4 Rationale 1: 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 and so the planned intervention should not be initiated. Rationale 2: In this situation, the nurse does not need assistance. Rationale 3: This is not a situation where the nurse must supervise care that has been delegated. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Discuss the five activities of the implementing phase. MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the nursing process. Page Number: 209 Question 6 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 3 Rationale 1: Explaining is helpful, but does not provide the clients with a sense of independence and control in the situation. Rationale 2: 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. Watching a video is helpful, but does not provide the clients with a sense of independence and control in the situation. Rationale 3: 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. Rationale 4: Giving advice or suggestions is helpful, but does not provide the clients with a sense of independence and control in the situation. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify guidelines for implementing nursing interventions. MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the nursing process. Page Number: 210 Question 7 Type: MCSA During teaching, the nurse makes sure the client understands how to activate the safety mechanism on the syringe to prevent needlestick 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. Correct Answer: 4 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Adapting activities would involve understanding the client's beliefs, values, age, health status, and environment as factors that can affect the success of a nursing action. Rationale 2: Encouraging clients to participate enhances their sense of independence and control. Rationale 3: The nurse must be aware of the scientific rationale for, as well as possible side effects or complications of, all interventions so that implementation centers on specific knowledge and care standards. Rationale 4: Showing the client how to avoid injury with injections is part of implementing safe care. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify guidelines for implementing nursing interventions. MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the nursing process. Page Number: 210 Question 8 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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). Rationale 2: Reading and reviewing the policy and procedure are important, but should be followed up with asking for assistance. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: "Doing the best the nurse can" would not be acceptable. Rationale 4: Asking for a different assignment would not be acceptable. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify guidelines for implementing nursing interventions. MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the nursing process. Page Number: 210 Question 9 Type: MCSA 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. Correct Answer: 2 Rationale 1: Following the physician's order is important, but the nurse is still responsible to know and understand the medication, its action, and its adverse actions as well as its interactions with other medications. Rationale 2: 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. Rationale 3: The client should be informed about the medications and treatments, but the nurse does not utilize the client for scientific knowledge and professional standards of care.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The pharmacist would be the most appropriate reference point for this nurse to begin to research this problem. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify guidelines for implementing nursing interventions. MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the nursing process. Page Number: 210 Question 10 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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 self-esteem. Rationale 2: It is not necessary, nor appropriate, to provide all care at all times. Rationale 3: Telling peers and other staff members that a client is demanding is the nurse's opinion and should not be part of the reporting process. Rationale 4: Information should be presented to other family members only with the consent of the client. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Discuss the five activities of the implementing phase. MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the nursing process. Page Number: 210 Question 11 Type: MCSA 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. Correct Answer: 3 Rationale 1: This option does not describe the appropriate nursing actions that come at the end of client care activities. Rationale 2: Reporting to the charge nurse would be done at the end of the shift, unless the client's condition is not stable. Rationale 3: After carrying out the nursing activities, the nurse completes the implementing phase by recording the interventions and client responses in the progress notes. Rationale 4: This option does not describe the appropriate nursing actions that come at the end of client care activities. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Discuss the five activities of the implementing phase. MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the nursing process. Page Number: 210 Question 12 Type: MCSA 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. Correct Answer: 4 Rationale 1: Although assessment is the first phase of the nursing process, it is carried out during all phases. Rationale 2: Evaluation is carried out at the end of the process; however, this is not the major difference between assessment and evaluation. Rationale 3: Although the two processes overlap, there is a difference between the data collected. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Explain how evaluating relates to other phases of the nursing process. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 211 Question 13 Type: MCSA 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?" Correct Answer: 2 Rationale 1: This option does not address the client’s pain level. Rationale 2: 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. Rationale 3: This option does not clearly define the level of the client’s pain, so evaluating the effectiveness of the treatment is not possible. Rationale 4: This option does not address the client’s pain level. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Describe five components of the evaluation process. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 211 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 14 Type: MCSA 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. Correct Answer: 3 Rationale 1: If the client can only state one aspect or it takes longer than a week, then the goal could be partially met. Rationale 2: If the client can only state one aspect or it takes longer than a week, then the goal could be partially met. Rationale 3: 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. Rationale 4: Using the word "incomplete" is not appropriate for the evaluation statement. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8. Describe three components of quality evaluation: structure, process, and outcomes. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 211 Question 15 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 1 Rationale 1: 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. Rationale 2: Telling the client that his or her lungs are clear is not relating the intervention to the outcome because no mention of the intervention is made. Rationale 3: Documenting does not show the effectiveness of the intervention. Rationale 4: Writing an evaluation statement does not show the effectiveness of the intervention. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Explain how evaluating relates to other phases of the nursing process. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 211 Question 16 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 2 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Describe the steps involved in reviewing and modifying the client’s care plan. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 212 Question 17 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

A client with terminal cancer has this nursing diagnosis: Pain related to neuromuscular involvement of disease process. The goal statement is as follows: 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. Correct Answer: 3 Rationale 1: The goal statement is written accurately and is inclusive of all required components. Rationale 2: Dependent interventions would be appropriate in this situation. Rationale 3: 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. Rationale 4: The interventions are clearly written. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Identify guidelines for implementing nursing interventions. MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the nursing process. Page Number: 213 Question 18 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 4 Rationale 1: Perhaps this diagnosis is appropriate for this client, but there are not enough data presented to know that for sure. Rationale 2: Once data are complete, the diagnosis and information need to be directly related to each other. Rationale 3: Once data are complete, the diagnosis and information need to be relevant to each other. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Identify guidelines for implementing nursing interventions. MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the nursing process. Page Number: 213 Question 19 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Modify the whole nursing plan. 4. Discard the nursing plan and start over from the assessment phase. Correct Answer: 2 Rationale 1: The data presented are relevant for the diagnosis selected in this case. Rationale 2: 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. Rationale 3: The data presented are relevant for the diagnosis selected in this case, and it is not necessary to modify the whole plan. Rationale 4: The data presented are relevant for the diagnosis selected in this case, and it is not necessary to discard the whole plan and start over. Modifications may be the key to a successful outcome for the client. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Describe the steps involved in reviewing and modifying the client’s care plan. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 213 Question 20 Type: MCSA 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? 1. Methods 2. Structure 3. Finances 4. Process Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

5. Outcome Correct Answer: 2, 4, 5 Rationale 1: Quality assurance is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients. It requires evaluation of three consistent components of care. Each type of evaluation requires different criteria and methods. Rationale 2: Quality assurance is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients. It requires evaluation of three components of care, with structure being one of them. Rationale 3: Quality assurance is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients. It requires evaluation of three components of care; finance is not one of them. Rationale 4: Quality assurance is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients. It requires evaluation of three components of care, with process being one of them. Rationale 5: Quality assurance is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients. It requires evaluation of three components of care, with outcome being one of them. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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 health care NLN Competencies: Quality and Safety; Practice; Contribute to assessment of outcome achievement Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8. Describe three components of quality evaluation: structure, process, and outcomes. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 214 Question 21 Type: MCSA 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 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Process 4. Outcome Correct Answer: 2 Rationale 1: Management is not one of the three components of quality assurance evaluation. Rationale 2: 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. Rationale 3: Process evaluation focuses on how the care was given. Rationale 4: Outcome evaluation focuses on demonstrable changes in the client's health status as a result of nursing care. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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 health care NLN Competencies: Quality and Safety; Practice; Contribute to assessment of outcome achievement Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8. Describe three components of quality evaluation: structure, process, and outcomes. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 214 Question 22 Type: MCSA 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 Correct Answer: 3 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Competency is not one of the components of quality assurance evaluation. Rationale 2: Structure evaluation focuses on the setting in which the care is given. Rationale 3: 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. Rationale 4: Outcome evaluation focuses on demonstrable changes in the client's health status as a result of nursing care. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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 health care NLN Competencies: Quality and Safety; Practice; Contribute to assessment of outcome achievement Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8. Describe three components of quality evaluation: structure, process, and outcomes. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 214 Question 23 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Peer review is a type of evaluation where nurses functioning in the same capacity perform the audit. Peer review is based on pre-established standards or criteria. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: An individual audit focuses on the performance of an individual nurse. Rationale 4: Concurrent audits are reviews of a client's health care and occur while the client is still receiving the care. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Describe the steps involved in reviewing and modifying the client’s care plan. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 215 Question 24 Type: MCSA 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 Correct Answer: 4 Rationale 1: A concurrent audit is the evaluation of a client's health care while the client is still receiving the care from an agency. Rationale 2: A nursing audit is a type of peer review, in which the audit focuses on evaluating a specific nurse’s nursing care through the review of records. Rationale 3: A nursing audit is a type of peer review, in which the audit focuses on evaluating a specific nurse’s nursing care through the review of records.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9. Differentiate quality improvement from quality assurance. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 216 Question 25 Type: MCSA The nurse assigns unlicensed 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. 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 Correct Answer: 4 Rationale 1: The nurse did delegate to the appropriate staff, as securing vital signs is within the scope of practice for unlicensed assistive personnel. Rationale 2: The nurse did delegate an appropriate task, as securing vital signs is within the scope of practice for unlicensed assistive personnel. Rationale 3: There was no indication given that the clients were not appropriately selected for this task. Rationale 4: The nurse has two responsibilities in delegating and assigning duties: (1) appropriate delegation of duties (that is, 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 an unlicensed person a duty that was appropriate. Unlicensed assistive personnel completed the duty and documented the findings. The nurse is still Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify guidelines for implementing nursing interventions. MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the nursing process. Page Number: 210 Question 26 Type: MCMA 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? Standard Text: 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 Correct Answer: 2, 4, 5 Rationale 1: Evaluating the outcome of the interventions is part of the evaluation phase. Rationale 2: This is a component of the implementation process. Rationale 3: Documentation of the history and physical is part of the initial assessment. Rationale 4: This is a component of the implementation process. Rationale 5: This is a component of the implementation process. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Discuss the five activities of the implementing phase. MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the nursing process. Page Number: 209 Question 27 Type: MCMA 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? Standard Text: Select all that apply. 1. Purposeful activity 2. Nursing accountability 3. Continuous 4. Judgments 5. Opinion Correct Answer: 1, 2, 3, 4 Rationale 1: Evaluating is a planned, ongoing, purposeful activity in which clients and health care professionals determine the client's progress toward achievement of goals/outcomes and the effectiveness of the nursing care plan. Rationale 2: Through evaluating, nurses demonstrate responsibility and accountability for their actions. Rationale 3: Evaluation is continuous and done while or immediately after implementing a nursing order. Rationale 4: To evaluate is to judge or appraise. Through evaluation, the nurse is able to establish whether nursing interventions should be terminated, continued, or changed. Rationale 5: Evaluation does not rest on opinion. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Describe five components of the evaluation process. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 210 Question 28 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 3, 4 Rationale 1: 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. Rationale 2: Successful evaluation depends on the effectiveness of the steps that precede it so that the nurse can formulate appropriate nursing diagnoses. Rationale 3: Data are collected for different purposes at different points in the nursing process. Rationale 4: 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. Rationale 5: During the assessment phase, the nurse collects data for the purpose of making diagnoses. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain how implementing relates to other phases of the nursing process. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 211 Question 29 Type: MCMA 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? Standard Text: 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? Correct Answer: 2, 3, 4 Rationale 1: The degree of difficulty in changing the care plan is not a consideration for its change. Rationale 2: This condition must be met before consideration is given to altering a client’s care plan. Rationale 3: This condition must be met before consideration is given to altering a client’s care plan. Rationale 4: This condition must be met before consideration is given to altering a client’s care plan. Rationale 5: The medical provider is generally not involved in the formation or alteration of a nursing care plan. Global Rationale: Cognitive Level: Applying Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Describe the steps involved in reviewing and modifying the client’s care plan. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 212 New Questions: Question 30 Type: MCMA The nurse is evaluating care provided to a client. Which nursing actions indicate that the phases of evaluation were completed by the nurse appropriately? Standard Text: 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 Correct Answer: 1, 2, 3, 4 Rationale 1: The evaluation phase has five components. Updating the client problems indicates that the plan of care was modified. Rationale 2: The evaluation phase has five components. One phase is ensuring that the collected data are related to the NOC indicators. Rationale 3: The evaluation phase has five components. One phase is comparing the data with desired outcomes. Rationale 4: The evaluation phase has five components. One phase is changing the interventions on the care plan to meet the client’s needs or changes in health status. Rationale 5: The evaluation phase has five components. Notifying the physician of changes in the care plan is not a phase of the evaluation process. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Describe five components of the evaluation process. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 211 Question 31 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2 Rationale 1: Root cause analysis is a process for identifying the factors that bring about deviations in practices that lead to the event. It focuses primarily on systems and processes, not individual performance. Rationale 2: A sentinel event is an unexpected occurrence involving death. Such events are called “sentinel” because they signal the need for immediate investigation and response. Rationale 3: Quality assurance focuses on structure, process, and outcome. Rationale 4: Quality assurance focuses on structure, process, and outcome. Rationale 5: Quality assurance focuses on structure, process, and outcome. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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 health care NLN Competencies: Quality and Safety; Practice; Contribute to assessment of outcome achievement Nursing/Integrated Concepts: Nursing Process: Evaluation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 9. Differentiate quality improvement from quality assurance. MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client. Page Number: 215

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 15 Question 1 Type: MCSA A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with him, as it's his record. 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." Correct Answer: 2 Rationale 1: The doctor’s permission is not a requirement for the release of a client’s medical record. Rationale 2: 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 his own 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. Rationale 3: The client does have a legal right concerning his medical record, so this option doesn’t adequately address the question. Rationale 4: This option is not correct; the client does have a legal right to access his medical records. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Nursing Process: Implementation Learning Outcome: 1. List the measures used to maintain confidentiality and security of computerized client records. MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 221 Question 2 Type: MCSA 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." Correct Answer: 3 Rationale 1: This option is not correct; the laws do apply to students. Rationale 2: Although this may or may not be a true statement, it is not an appropriate response to the student’s question. Rationale 3: 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. Rationale 4: Although this is true, the nursing instructor should not imply that the laws of confidentiality don’t apply to students. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Nursing Process: Implementation Learning Outcome: 1. List the measures used to maintain confidentiality and security of computerized client records. MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 222 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 3 Type: MCSA 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? 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 Correct Answer: 1, 3, 5 Rationale 1: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. Guidelines for confidentiality and security of computerized records include the installation of a firewall to protect from unauthorized access. Rationale 2: Guidelines for confidentiality and security of computerized records include assignment of a personal password to enter and log off computer files. The password should not be shared with anyone, including other team members. Rationale 3: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. The nurse should learn to never leaving a monitor unattended after logging on. Rationale 4: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. Turning the monitor away from view is not a sufficient safeguard. Rationale 5: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. Guidelines for confidentiality and security of computerized records include shredding all confidential information. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Nursing Process: Implementation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 1. List the measures used to maintain confidentiality and security of computerized client records. MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 222 Question 4 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: This would not necessarily result in the problem related to reimbursement because it is a reasonable diagnostic test to perform in this situation. Rationale 3: This would not necessarily result in the problem related to reimbursement. Rationale 4: This would not necessarily result in the problem related to reimbursement. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Discuss purposes for client records. MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery. Page Number: 222 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 5 Type: MCSA When attempting to locate recent lab results, the new nurse employee 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: In the problem-oriented medical record, the data are arranged according to the problems the client has rather than the source of the information. Rationale 3: Case management uses a multidisciplinary approach to documenting client care, called critical pathways. Rationale 4: Focus charting is intended to make the client and client concerns the focus of care, utilizing a threecolumn format. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Knowledge and Science; Practice; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problemoriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1.5.3. Distinguish the legal and ethical considerations related to the different types of documentation. Page Number: 223 Question 6 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 3 Rationale 1: Problem-oriented recording is arranging the data according to the problem the client has. Rationale 2: Source-oriented recording is arranged in separate sections for each department that contributes to the client's care. The plan of care is part of the problem-oriented medical record. Rationale 3: 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. Rationale 4: The plan of care is part of the problem-oriented medical record. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problemoriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1.5.2. Differentiate general documentation activities, including discharge planning and for long-term care. Page Number: 223 Question 7 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Database 2. Problem list 3. Plan of care 4. Progress notes Correct Answer: 3 Rationale 1: The database consists of all known information about the client upon admission. Rationale 2: The problem list includes all identified problems, listed in the order in which they are identified. Rationale 3: 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. Rationale 4: Progress notes are chart entries made by all health professionals involved in the client's care. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problemoriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1.5.2. Differentiate general documentation activities, including discharge planning and for long-term care. Page Number: 225 Question 8 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Progress notes Correct Answer: 2 Rationale 1: The database includes information about the client when admitted to the facility. Rationale 2: 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. Rationale 3: The plan of care is made with reference to the active problems. Rationale 4: Progress notes are chart entries made by all health professionals involved in a client's care. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problemoriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1.5.2. Differentiate general documentation activities, including discharge planning and for long-term care. Page Number: 224 Question 9 Type: MCSA The client states: "I really don't want anyone to visit me who has not been cleared by me first." If utilizing SOAP format, in which category should the nurse document this statement? 1. Subjective data 2. Objective data 3. Assessment 4. Planning Correct Answer: 1 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Subjective data consist of information obtained from what the client says. When possible, the nurse quotes the client's words; otherwise, they are summarized. Rationale 2: Objective data consist of information that is measured or observed. Rationale 3: Assessment is the interpretation or conclusion drawn about the subjective and objective data. This is the area where the problems are documented initially. Then the client's condition and level of progress are subsequently described. Rationale 4: Planning is the care designed to resolve the problem. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problemoriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1.5.2. Differentiate general documentation activities, including discharge planning and for long-term care. Page Number: 225 Question 10 Type: MCSA 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 Correct Answer: 2 Rationale 1: The problem statement is labeled "P" and referred to by number.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: The interventions employed to manage the problem are labeled "I" and numbered according to the problem. Rationale 3: The "E" is the evaluation of the effectiveness of the intervention and is labeled and numbered according to the problem. Rationale 4: Progress notes are not part of the identified labels of PIE charting. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problemoriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1.5.2. Differentiate general documentation activities, including discharge planning and for long-term care. Page Number: 226 Question 11 Type: MCSA 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 Correct Answer: 4 Rationale 1: Computerized documentation is a way to manage the volume of information required in a client's chart, and different systems may include a variety of setups and programs. Rationale 2: Focus charting is organized into data, action, and response sections, referred to as DAR.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: SOAP charting is a way to organize data and information in the client's record: S = subjective data; O = objective data; A = assessment; P = plan. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problemoriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1.5.2. Differentiate general documentation activities, including discharge planning and for long-term care. Page Number: 227 Question 12 Type: MCSA 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. Correct Answer: 3 Rationale 1: It is never a good idea to leave blanks in any charting area because it implies that the area was ignored. Rationale 2: It is never a good idea to leave blanks in any charting area. Adding the information in the progress notes is not an appropriate use of that section.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: 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. Rationale 4: Passing information along in the report is a good way to ensure continuity of care for clients, but this would only be an oral report, not written documentation. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problemoriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1.5.1. Demonstrate how to ensure the accuracy of documentation in a client’s record. Page Number: 227 Question 13 Type: MCSA 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 Correct Answer: 2 Rationale 1: 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 not referred to as an unattainable goal because a change in the client’s care plan may result in success. Rationale 2: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Rationale 3: 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 not referred to as an error in care planning because the success of a goal is dependent on specific interventions and individual client response. Rationale 4: 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 not referred to as an error in implementation because the success of a goal is not solely dependent on the implementation of a single intervention. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Evaluation 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: 1.5.1. Demonstrate how to ensure the accuracy of documentation in a client’s record. Page Number: 230 Question 14 Type: MCSA 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 Correct Answer: 1

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: 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. Rationale 2: Traditional care plans are written for each client, are specific, and are individualized for that client. Rationale 3: Critical pathways are used in case management, involving a multidisciplinary approach to planning and documenting client care. Rationale 4: The Kardex is a concise method of organizing and recording data about a client, making information quickly accessible for all health professionals. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation 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: 1.5.1. Demonstrate how to ensure the accuracy of documentation in a client’s record. Page Number: 231 Question 15 Type: MCSA 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 Correct Answer: 4 Rationale 1: The medical record contains this type of information, but the complete chart is lengthy and would take the student more time to review. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: The MAR includes only those medications that are prescribed or scheduled to be administered during the client's stay. It would not include other information like diagnostic tests, daily care, and so on. Rationale 3: The written care plan may be utilized, but there is another more effective option available. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation 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: 1.5.1. Demonstrate how to ensure the accuracy of documentation in a client’s record. Page Number: 231 Question 16 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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.” Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: 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.” Rationale 3: 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.” Rationale 4: 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.” Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Compare and contrast the documentation needed for clients in acute care, long-term care, and home health care settings. MNL Learning Outcome: 1.5.2. Differentiate general documentation activities, including discharge planning and for long-term care. Page Number: 232 Question 17 Type: MCSA 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 Correct Answer: 1 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: 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. Rationale 2: Laws influencing the kind and frequency of documentation required are the Health Care Financing Administration and the Omnibus Budget Reconciliation Act (OBRA) of 1987. Rationale 3: CBE stands for charting by exception and is not the form of documentation used for this type of assessment. Rationale 4: Kardex is a system of organizing client information so it can be accessed quickly. It is usually used in the acute care area. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Compare and contrast the documentation needed for clients in acute care, long-term care, and home health care settings. MNL Learning Outcome: 1.5.2. Differentiate general documentation activities, including discharge planning and for long-term care. Page Number: 232 Question 18 Type: MCSA 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. Correct Answer: 3 Rationale 1: It should never be assumed that the client fell out of bed. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: It should never be assumed that the client fell out of bed, became tangled in bedding, or anything else. Rationale 3: 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. Rationale 4: It should never be assumed that the client became tangled in bedding, or anything else. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss guidelines for effective recording that meet legal and ethical standards. MNL Learning Outcome: 1.5.3. Distinguish the legal and ethical considerations related to the different types of documentation. Page Number: 235 Question 19 Type: MCSA 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. Correct Answer: 4 Rationale 1: Erasure, blotting out, or correction fluid should not be used. Rationale 2: Erasure, blotting out, or correction fluid should not be used. Rationale 3: When a mistake is recorded, the correction applies to only the erroneous information, not the entire page. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss guidelines for effective recording that meet legal and ethical standards. MNL Learning Outcome: 1.5.3. Distinguish the legal and ethical considerations related to the different types of documentation. Page Number: 235 Question 20 Type: MCMA 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? Standard Text: 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. Correct Answer: 2, 3, 5, 6 Rationale 1: This system is not inexpensive to maintain. Rationale 2: This is considered a positive aspect of this type of charting. Rationale 3: This is considered a positive aspect of this type of charting. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The effectiveness of this system to protect a client’s privacy is dependent upon the personnel using it. Rationale 5: This is considered a positive aspect of this type of charting. Rationale 6: This is considered a positive aspect of this type of charting. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1. List the measures used to maintain confidentiality and security of computerized client records. MNL Learning Outcome: 1.5.3. Distinguish the legal and ethical considerations related to the different types of documentation. Page Number: 227 Question 21 Type: MCSA 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) Correct Answer: 3 Rationale 1: The data (D) section reflects the assessment phase of the nursing process, and consists of observations of client status and behaviors, including data from flow sheets. Rationale 2: The action (A) category reflects planning and implementation, and includes immediate and future nursing action. Rationale 3: The response (R) category reflects the evaluation phase of the nursing process, and describes the client's response to any nursing and medical care. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Planning is a subcategory of the action (A) category. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problemoriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1.5.1. Demonstrate how to ensure the accuracy of documentation in a client’s record. Page Number: 227 Question 22 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 4, 5 Rationale 1: Documentation guidelines include charting a change in a client’s condition and showing that followup actions were taken. Rationale 2: Documentation guidelines include not using vague terms (e.g., “appears to be comfortable”). Rationale 3: Documentation guidelines include not leaving a blank space for a colleague to chart later. Rationale 4: Documentation guidelines include recording the client’s actual words by putting quotation marks around the words. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: Documentation guidelines include the idea that a late entry is better than no entry. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Nursing Process: Implementation Learning Outcome: 6. Discuss guidelines for effective recording that meet legal and ethical standards. MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice. Page Number: 233 Question 23 Type: MCMA 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? Standard Text: 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.” Correct Answer: 1, 2, 5 Rationale 1: This is a commonly used and accepted abbreviation for temperature, pulse, and respirations (vital signs). Rationale 2: This is a commonly used and accepted abbreviation for a treatment dressing. Rationale 3: Mcg (micrograms) is not an accepted abbreviation, as it can be confused with mg (milligrams), resulting in a one thousand–fold overdose. Rationale 4: MS is not an accepted abbreviation for morphine sulfate, as it can be confused with magnesium sulfate, resulting in a drug error. Rationale 5: This is a commonly used and accepted abbreviation for four times a day. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Identify prohibited abbreviations, acronyms, and symbols that cannot be used in any form of clinical documentation. MNL Learning Outcome: 1.5.1. Demonstrate how to ensure the accuracy of documentation in a client’s record. Page Number: 234 New Questions: Question 24 Type: MCMA

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? Standard Text: 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.” Correct Answer: 1, 2, 4, 5 Rationale 1: This statement provides background information. Rationale 2: This statement serves as an introduction Rationale 3: This statement is an opinion and has no place when using I-SBAR communication. Rationale 4: This statement provides the situation. Rationale 5: This statement provides the assessment. Global Rationale: Cognitive Level: Analyzing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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 evidence-based, 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: Nursing Process: Evaluation Learning Outcome: 8. Identify essential guidelines for reporting client data. MNL Learning Outcome: 4.1.2. Implement strategies for the maintenance of safety in the health care facility. Page Number: 238 Question 25 Type: MCMA A client’s condition has deteriorated and the nurse needs to notify the health care provider. What information should the nurse include when providing a telephone report on this client? Standard Text: 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 Correct Answer: 1, 4, 5 Rationale 1: 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. Rationale 2: When giving a telephone report to a primary care provider, it is important that the nurse be concise and accurate. The name of the unit nurse manager is not information provided during a telephone report. Rationale 3: When giving a telephone report to a primary care provider, it is important that the nurse be concise and accurate. The names of visitors are not information provided during a telephone report. Rationale 4: When giving a telephone report to a primary care provider, it is important that the nurse be concise and accurate. The nurse should begin with his or her name and relationship to the client. Rationale 5: When giving a telephone report to a primary care provider, it is important that the nurse be concise and accurate. A telephone report usually includes changes in nursing assessment, vital signs related to baseline vital signs, and significant laboratory data. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Management of Care 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 evidence-based, 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: Nursing Process: Implementation Learning Outcome: 8. Identify essential guidelines for reporting client data. MNL Learning Outcome: 4.1.2. Implement strategies for the maintenance of safety in the health care facility. Page Number: 238

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 16 Question 1 Type: MCSA 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 Correct Answer: 3 Rationale 1: In the individualized care context, the nurse becomes acquainted with the client as an individual, referring to the total care principles and using those principles that apply to this person at this time. Rationale 2: In the individualized care context, the nurse becomes acquainted with the client as an individual, referring to the total care principles and using those principles that apply to this person at this time. Rationale 3: 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. Rationale 4: The person’s self-identity is part of the individual health dimension of any one client. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Explain the relationship of individuality and holism to nursing practice. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 244 Question 2 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 1 Rationale 1: 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. Rationale 2: This option is only focused on the physiology of the person’s condition. Rationale 3: This option is only focused on the physiology of the person’s condition. Rationale 4: This option is only focused on the physiology of the person’s condition. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain the relationship of individuality and holism to nursing practice. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 244 Question 3 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. An elderly person who has just moved to a long-term care facility 4. A young adult who is in a long-term relationship Correct Answer: 4 Rationale 1: Psychologic homeostasis is acquired or learned through the experience of living and interacting with others. Individuals can develop psychologic homeostasis if they are in a stable physical environment where they feel safe and secure. A child who is alone while getting ready for school may not feel safe and secure. Rationale 2: 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. Having friends of the same age who are parents may eliminate healthy adult role models for the teenager. Rationale 3: 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. Moving into a long-term care facility can be a huge adjustment for some people, which may affect feelings of safety and security. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. List four main characteristics of homeostatic mechanisms. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 246 Question 4 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Safety and security 3. Love and belonging 4. Self-esteem Correct Answer: 4 Rationale 1: Physiological needs include air, food, water, rest, and sleep. Rationale 2: Safety and security needs are those things, both psychological and physiological, that help the person feel safe. Rationale 3: Love and belonging needs include giving and receiving affection, attaining a place in a group, and maintaining the feeling of belonging. Rationale 4: 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 selfesteem level of Maslow’s model. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify Maslow’s characteristics of the self-actualized person. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 247 Question 5 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 2 Rationale 1: Risk for Injury would be the lower-priority need. Rationale 2: 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. Rationale 3: Self-Care Deficit would fall in the fourth level—self-esteem needs. Rationale 4: Powerlessness is part of the need to develop one’s maximum potential. It falls into the fifth and highest level of self-actualization. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify Maslow’s characteristics of the self-actualized person. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 247 Question 6 Type: MCSA 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 homosexual 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 Correct Answer: 1 Rationale 1: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: A client who “wants to be on the team” is exhibiting characteristics of love and belonging needs; mentioned in Maslow’s original five-level hierarchy. Rationale 3: Striving to be in charge of a company is part of self-actualization, mentioned in Maslow’s original five-level hierarchy. Rationale 4: Sleep is one of the basic physiological needs mentioned in Maslow’s original five-level hierarchy. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify Maslow’s characteristics of the self-actualized person. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 247 Question 7 Type: MCSA A nurse is delivering a workshop regarding health promotion to a group of elderly clients. In describing Healthy People 2010, which goal should the nurse emphasize for this group? 1. Eliminating health disparities 2. Believing that individual health is closely related to community health 3. Increasing quality and years of life 4. Developing partnerships between individual and community health Correct Answer: 3 Rationale 1: The second goal of Healthy People 2010 is to eliminate health disparities, which reflects the diversity of the entire population, not just the elderly. Rationale 2: The foundation for this document is the belief that individual health is closely linked to community health, and the reverse, but this applies to the entire population, not just the elderly. Rationale 3: Healthy People 2010 has four main goals. The first is to increase quality and years of healthy life, which applies to the clients who will be the focus of this workshop. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The foundation for this document is the belief that individual health is closely linked to community health, and the reverse. In order to bring this about, partnerships are important to improve the health of individuals and communities, but this applies to the entire population, not just the elderly. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 5. Describe the vision, mission, and goals of Healthy People 2020 to help improve the health of a community. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 248 Question 8 Type: MCSA 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 Correct Answer: 2 Rationale 1: Health promotion is behavior motivated by the desire to increase well-being and actualize human health potential. Rationale 2: 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. Rationale 3: Tertiary prevention focuses on restoration and rehabilitation—it is not a behavior. Rationale 4: Primary prevention focuses on health promotion—it is not a behavior. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: Evaluation Learning Outcome: 6. Differentiate health promotion from health protection or illness prevention. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 249 Question 9 Type: MCMA A community health nurse wants to provide health promotion classes through the local hospital. Which topics should the nurse include in this endeavor? Standard Text: 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 Correct Answer: 1, 2, 4 Rationale 1: Health promotion activities include those items that increase well-being and overall health. Rationale 2: Health promotion activities include those items that increase well-being and overall health. Rationale 3: Teaching about exercise following a stroke focuses on rehabilitation, not health promotion. Rationale 4: Health promotion activities include those items that increase well-being and overall health. Rationale 5: Performing self-examination of the breasts is a health protection activity. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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: Planning Learning Outcome: 7. Identify various types and sites of health promotion programs. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 248 Question 10 Type: MCSA A client has joined a fitness club and is working with the nurse to design a program for weight reduction and increased muscle tone. The client has tried exercise in the past with success, but has not been participating in a program for some time. In order to assess the potential for success with this client, the nurse should evaluate which of the behavior-specific cognitions? 1. Interpersonal influences 2. Perceived benefits of action 3. Situational influences 4. Perceived self-efficacy Correct Answer: 2 Rationale 1: Interpersonal influences are a person’s perceptions concerning the behaviors, beliefs, or attitudes of others—including family, peers, and health professionals—who can influence their success. Rationale 2: 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, he or she may be motivated to success. Rationale 3: Situational influences are direct and indirect influences on health-promoting behaviors and include perceptions of options, demand characteristics, and the aesthetic features of the environment. Rationale 4: Perceived self-efficacy refers to the conviction that a person can successfully carry out the behavior necessary to achieve a desired outcome. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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: Assessment Learning Outcome: 7. Identify various types and sites of health promotion programs. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 251 Question 11 Type: MCSA A client has been working hard in rehabilitation following a traumatic brain injury. She has a weak support system in that her family lives a far distance away and her coworkers are not involved. On which behaviorspecific 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 Correct Answer: 4 Rationale 1: Situational influences are direct and indirect influences on health-promoting behaviors and include perceptions of available options, demand characteristics, and the aesthetic features of the environment. Rationale 2: Perceived benefits of action affect the person’s plan to participate in health-promoting behaviors and may facilitate continued practice. Rationale 3: Perceived barriers to action may be real or imagined and may affect health-promoting behaviors by decreasing the individual’s commitment to a plan of action. Rationale 4: 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). Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Identify various types and sites of health promotion programs. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 252 Question 12 Type: MCSA A client is learning how to manage his asthma. In providing teaching, the nurse stresses 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 Correct Answer: 1 Rationale 1: 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. It’s really his choice—either he uses it or he doesn’t. Rationale 2: Competing demands are behaviors over which an individual has a low level of control; something unexpected competes with a planned activity. Rationale 3: Situational influences are direct and indirect influences on health-promoting behaviors and include perceptions of available options, demand characteristics, and the aesthetic features of the environment. Rationale 4: Interpersonal influences are a person’s perceptions concerning the behaviors, beliefs, or attitudes of others. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 8. Discuss the Health Promotion Model. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 252 Question 13 Type: SEQ 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: Standard Text: Click and drag the options below to move them up or down. Choice 1. Preparation stage Choice 2. Contemplation stage Choice 3. Maintenance stage Choice 4. Precontemplation stage Choice 5. Termination stage Choice 6. Action Stage Correct Answer: 4, 2, 1, 6, 3, 5 Rationale 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. Rationale 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). Rationale 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. Rationale 4: This is the first stage, where the client is not contemplating change for at least 6 months. Rationale 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. Rationale 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. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: Planning Learning Outcome: 9. Explain the stages of health behavior change. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 252 Question 14 Type: MCSA Several nursing students have been discussing the benefits of joining a study group. They realize the importance of applying nursing knowledge to the clinical area and determine that together they may be more effective in retaining this information than if they continued in their individual settings. Which stage of behavior change are they exemplifying? 1. Termination stage 2. Preparation stage 3. Contemplation stage 4. Action stage Correct Answer: 3 Rationale 1: The termination stage is the ultimate goal, where the individual has complete confidence that the problem is no longer a temptation or threat. Rationale 2: The preparation stage occurs when the person undertakes cognitive and behavioral activities that prepare the person for change. Rationale 3: 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 haven’t started a group nor have they made any preparation toward it; they have merely been talking about it. Rationale 4: The action stage occurs when the person actively implements behavioral and cognitive strategies to interrupt previous behavior patterns and adopt new ones. Global Rationale: Cognitive Level: Analyzing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Health Promotion and Maintenance Client Need Sub: 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. Explain the stages of health behavior change. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 252 Question 15 Type: MCSA A client with diabetes wants to have better control over her blood sugar levels. She has set a goal that she will have laboratory values that reflect this, and she has been monitoring her blood sugar twice a day for the past month. Along with regular checks, she has kept all appointments with her nutritionist. This client is modeling which stage of health behavior change? 1. Termination stage 2. Maintenance stage 3. Contemplation stage 4. Action stage Correct Answer: 4 Rationale 1: The termination stage occurs when the individual has complete confidence that the problem is no longer a temptation or a threat. Rationale 2: The maintenance stage is where the person integrates adopted behavior patterns into his or her lifestyle. This stage lasts until the person no longer has temptation to return to previous unhealthy behaviors. Rationale 3: In the contemplation stage, the person acknowledges having a problem, seriously considers changing a specific behavior, actively gathers information, and verbalizes plans to change the behavior in the near future. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Explain the stages of health behavior change. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 252 Question 16 Type: MCSA The health nurse of a busy university campus is implementing a health promotion activity by placing posters about proper hand washing 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 Correct Answer: 2 Rationale 1: Environmental control programs have been developed as a result of the continuing increase of contaminants of human origin that have been introduced into the environment. Rationale 2: 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. Rationale 3: Health risk appraisal and wellness assessment programs are used to describe risk factors to people and motivate them to reduce specific risks and develop positive health habits. Rationale 4: Lifestyle and behavior change programs require participation of the individual and are geared toward enhancing the quality of life and extending the life span. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Identify various types and sites of health promotion programs. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 253 Question 17 Type: MCSA 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 Correct Answer: 3 Rationale 1: A facilitator is involved in the assessment, implementation, and evaluation of health goals. Rationale 2: The advocate helps implement changes that promote a healthy environment. Rationale 3: The teaching role focuses on self-care strategies such as enhancing fitness, improving nutrition, managing stress, and enhancing relationships. Rationale 4: A coordinator helps to guide and reinforce the client’s development in effective problem solving and decision making as well as reinforces personal and family health-promoting behaviors. Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Discuss the nurse’s role in health promotion. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: 10. Discuss the nurse’s role in health promotion. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 253 Question 18 Type: MCSA 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 Correct Answer: 4 Rationale 1: Lifestyle assessment focuses on the personal lifestyle and habits of the client as they affect health. Rationale 2: A social support systems review takes into account the social context in which a person lives and works and is important in health promotion. This includes individuals, groups, and interpersonal relationships that provide comfort, assistance, encouragement, and information. Rationale 3: A health beliefs review is a clarification of those beliefs that determine how a person maintains control of his or her own health status. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11. Describe components of health assessment that pertain to health promotion. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 255 Question 19 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 1 Rationale 1: 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. Rationale 2: A social support systems review takes into account the social context in which a person lives and works. Rationale 3: A lifestyle assessment focuses on the personal lifestyle habits of the client as they affect health. Rationale 4: A health beliefs review provides information about how much clients believe they can influence or control health through personal behaviors. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: Assessment Learning Outcome: 11. Describe components of health assessment that pertain to health promotion. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 256 Question 20 Type: MCSA The client is a high school student who is also a single parent. She is attending parenting classes while studying full time and living in an apartment with her child. The student also meets twice a week with a teen peer group and participates in a nutrition program through the county. Which is the most appropriate diagnosis for this client? 1. Risk for Situational Low Self-Esteem Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. High Risk for Caregiver Role Strain 3. Readiness for Enhanced Coping 4. Readiness for Enhanced Nutrition Correct Answer: 3 Rationale 1: The information given in the scenario does not indicate that the client is experiencing problems with low self-esteem. Rationale 2: The information given in the scenario does not indicate that the client is experiencing problems with caregiver role strain. Rationale 3: Wellness diagnoses describe the human responses to levels of wellness in an individual. In this situation, even though the client is young and single, she is making every effort to be well in her situation. Attending parenting classes, meeting with peers, and learning about nutrition all point to a person who has a positive outlook but requires teaching. Rationale 4: The client is doing much more than just learning about nutrition. She is learning how to cope and be well in her life and the life of her child. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: Diagnosis Learning Outcome: 12. Discuss nursing diagnosing, planning, implementing, and evaluating as they relate to health promotion. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 256 Question 21 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Community Correct Answer: 2 Rationale 1: Primary prevention is true health promotion and precedes disease or dysfunction. Rationale 2: 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. Rationale 3: Tertiary prevention begins after an illness, when a defect or disability is fixed, stabilized, or determined to be irreversible. Rationale 4: Community health is a broad category that includes many facets. It is not a level of prevention. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 8. Discuss the Health Promotion Model. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 249 Question 22 Type: MCSA A client has had a severe brain injury and has been in a rehabilitation hospital for several months. Recently, the client developed 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 Correct Answer: 2 Rationale 1: Primary prevention is true health promotion and provides specific interventions against disease. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: 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. Rationale 3: All cares related to rehabilitation following the brain injury would be tertiary prevention. Tertiary prevention focuses on rehabilitating individuals to an optimum level of functioning. Rationale 4: Acute care is a part of health care, but not one of the levels of prevention. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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: 8. Discuss the Health Promotion Model. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 249 Question 23 Type: MCSA A 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 Correct Answer: 2 Rationale 1: Rest and exercise are life span considerations of children. Rationale 2: 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. Rationale 3: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

be of prime importance in maintaining optimal function and quality of life. Rest and exercise and high obesity percentages are life span considerations of children. Rationale 4: Safety promotion and injury prevention are life span considerations for adolescents. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: Planning Learning Outcome: 8. Discuss the Health Promotion Model. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 250 Question 24 Type: MCSA A nurse is working with various cultures while implementing health promotion activities for the community center. Bringing the minister of the church into the planning stage of these activities would be sensitive to which cultural groups? 1. Latino American 2. Asian American 3. Native American 4. African American Correct Answer: 4 Rationale 1: Latino Americans view the family as being a major social support system. Rationale 2: Asian Americans view the family as being a major social support system. Rationale 3: Native American people live in social networks that foster mutual assistance and support. Rationale 4: In the African American community, the family and church have been major providers of social support. Global Rationale: Cognitive Level: Applying Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Psychosocial Integrity Client Need Sub: 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: 12. Discuss nursing diagnosing, planning, implementing, and evaluating as they relate to health promotion. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 253 Question 25 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 2, 3, 4 Rationale 1: Homeostatic mechanisms are self-regulating. Rationale 2: Homeostatic mechanisms are compensatory. Rationale 3: Homeostatic mechanisms are regulated by negative feedback systems. Rationale 4: Homeostatic mechanisms can require several feedback mechanisms to correct a physiologic imbalance. Rationale 5: Homeostatic mechanisms are not related to a closed system. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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: Assessment Learning Outcome: 2. List four main characteristics of homeostatic mechanisms. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 245 Question 26 Type: MCMA The nurse is an advocate for health promotion activities. Which nursing actions demonstrate this nurse’s advocacy? Standard Text: 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 creating of a walking path in the city park. 5. Encouraging an anxious client to practice relaxation techniques. Correct Answer: 1, 3, 4, 5 Rationale 1: The nurse’s role in health promotion includes modeling healthy lifestyle behaviors and attitudes. Rationale 2: This is not an example of active role modeling. Rationale 3: The nurse’s role in health promotion includes assisting clients, families, and communities to develop and choose health-promoting options. Rationale 4: The nurse’s role in health promotion includes advocating in the community for changes that promote a healthy environment. Rationale 5: The nurse’s role in health promotion includes teaching clients self-care strategies to enhance fitness, improve nutrition, manage stress, and enhance relationships. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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: 10. Discuss the nurse’s role in health promotion. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 249 Question 27 Type: MCMA The nurse is reviewing information collected while providing client care. Which findings should the nurse identify as being a homeostatic mechanism? Standard Text: 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. Correct Answer: 1, 2, 4 Rationale 1: Homeostatic mechanisms have characteristics that include self-regulation, such as automatically increased respiratory rates. Rationale 2: Homeostatic mechanisms have characteristics that include compensatory actions, such as shivering to create body heat. Rationale 3: This is not an example of a homeostatic mechanism; they are self-regulation, compensation, negative feedback, and utilization of multiple mechanisms to correct a physiological imbalance. Rationale 4: Homeostatic mechanisms have characteristics that include regulation by negative feedback systems. Rationale 5: This is not an example of a homeostatic mechanism; they are self-regulation, compensation, negative feedback, and utilization of multiple mechanisms to correct a physiological imbalance. Global Rationale: Page Reference: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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: Assessment Learning Outcome: 2. List four main characteristics of homeostatic mechanisms. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 245 New Questions: Question 28 Type: MCMA The nurse is structuring activities that take a client’s developmental stage into consideration. Which activities should the nurse include? Standard Text: 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 Correct Answer: 4, 5 Rationale 1: 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. Implementing seizure precautions is not an activity that uses developmental stages. Rationale 2: 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. Creating a schedule for daily wound care is not an activity that uses developmental stages. Rationale 3: 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. Monitoring intake, output, and daily weights is not an activity that uses developmental stages. Rationale 4: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: Planning Learning Outcome: 3. Identify theoretical frameworks used in individual health promotion. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 248 Question 29 Type: MCMA 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? Standard Text: Select all that apply. 1. Flexibility 2. Range of motion 3. Body composition 4. Muscle endurance 5. Cardiorespiratory endurance Correct Answer: 1, 3, 4, 5 Rationale 1: During an evaluation of physical fitness, the nurse assesses several components of the body’s physical functioning, including flexibility. Rationale 2: During an evaluation of physical fitness, the nurse assesses several components of the body’s physical functioning. Range of motion is not assessed during this evaluation. Rationale 3: During an evaluation of physical fitness, the nurse assesses several components of the body’s physical functioning, including body composition. Rationale 4: During an evaluation of physical fitness, the nurse assesses several components of the body’s physical functioning, including muscle endurance.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: During an evaluation of physical fitness, the nurse assesses several components of the body’s physical functioning, including cardiorespiratory endurance. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: Planning Learning Outcome: 11. Describe components of health assessment that pertain to health promotion. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 254

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 17 Question 1 Type: MCSA A client is attending classes on building positive relationships with significant others as well as learning skills to be open-minded and respectful to those whose opinions are different. The nurse realizes that this client is focusing on which component of wellness? 1. Physical 2. Social 3. Emotional 4. Environment Correct Answer: 2 Rationale 1: The physical component of wellness is the ability to carry out daily tasks, achieve fitness of all body systems, and practice positive lifestyle habits. Rationale 2: The social component of wellness focuses on the ability to interact successfully with people and within the environment of which each person is a part, to develop and maintain intimacy with significant others, and to develop respect and tolerance for those with different opinions and beliefs. Rationale 3: The emotional component deals with the ability to manage stress and express emotions appropriately. Rationale 4: The environmental component focuses on the health measures that improve the standard of living and quality of life in the community. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience AACN Essentials Competencies: VII. 1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe five components of wellness. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 263 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 2 Type: MCSA The nurse is assisting a client and his family after the client had a stroke and is no longer able to return to his previous employment. The nurse has made a referral to vocational rehabilitation for assistance in retraining the client in a different occupation. With which component of wellness is the nurse assisting this client? 1. Intellectual 2. Environmental 3. Occupational 4. Emotional Correct Answer: 3 Rationale 1: The intellectual component focuses on learning and using information effectively for personal, family, and career development. It also involves striving for continued growth and learning to deal with new challenges effectively. Rationale 2: Environmental components focus on standards of living and quality of life in the community and include basic human needs such as water, air, and food. Rationale 3: Occupational components deal with a balance between work and leisure time. A person's beliefs about education, employment, and home influence personal satisfaction and relationships with others. Assisting a client in retraining to find gainful employment and to attain satisfaction in his work is part of the occupational component of wellness. Because the client requires retraining, he must learn anew those aspects of a job that allow for growth, which would better fit under the occupational component of wellness. Rationale 4: Emotional components of wellness involve the ability to manage stress and express emotions appropriately. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe five components of wellness. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 264 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 3 Type: MCSA A nurse educator is explaining the concept of health and parallels this with interruption of body systems and symptoms of disease or injury. This educator is interpreting health according to which model? 1. Health–illness continua 2. Eudemonistic 3. Adaptive 4. Clinical Correct Answer: 4 Rationale 1: The health–illness continua is often used to measure a person's perceived level of wellness in which health and illness are at opposite ends of a health continuum. Rationale 2: The eudemonistic model incorporates a comprehensive view of health, where health is seen as a condition of actualization or realization of a person's potential. Rationale 3: In the adaptive model, health is seen as a creative process and disease is seen as a failure in adaptation or maladaptation. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Compare the various models of health outlined in this chapter. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 264 Question 4 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

A nurse is working in a rehabilitation center with a client who had a serious injury. Part of the client's care plan includes working on coping with her current limitations since the injury. This nurse is working within which model of health? 1. Role performance 2. Adaptive 3. Eudemonistic 4. Clinical Correct Answer: 2 Rationale 1: The role performance model defines health in terms of the individual's ability to fulfill societal roles or to perform work. According to this model, people who fulfill their roles are healthy, even though they may have an illness. Rationale 2: 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. Rationale 3: The eudemonistic model incorporates a comprehensive view of health, which is seen as a condition of actualization or realization of a person's potential. Rationale 4: The clinical model is a narrow interpretation of health, which is defined by the absence of disease. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Compare the various models of health outlined in this chapter. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 264 Question 5 Type: MCSA A nurse is conducting a community assessment to determine which diseases are prevalent and most likely to occur. The nurse is basing the assessment on which model of health? 1. Role performance Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Eudemonistic 3. Ecological 4. Adaptive Correct Answer: 3 Rationale 1: The role performance model defines health according to how individuals are able to fulfill their roles or perform their work. Rationale 2: The eudemonistic model incorporates a comprehensive view of health, which is seen as a condition of actualization or realization of a person's potential. Rationale 3: 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. Rationale 4: The adaptive model defines health as a creative process and disease as a maladaptation. The aim of treatment is restoration of the person's ability to cope. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Compare the various models of health outlined in this chapter. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 264 Question 6 Type: MCSA A nurse is assessing a client who practices yoga for relaxation, is following a nutritionally sound diet, and has supportive, sound relationships with her spouse and children. 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. High-level wellness in a favorable environment Correct Answer: 4 Rationale 1: 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. Emergent high-level wellness in a favorable environment is not part of Dunn's four quadrants of health and wellness. Rationale 2: 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. Emergent high-level wellness in an unfavorable environment would be exemplified by a client who has the knowledge to implement healthy lifestyles, but does not implement them because of family responsibilities, job demands, or other factors. Rationale 3: 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. Protected health in a favorable environment is not part of Dunn's four quadrants of health and wellness. Rationale 4: 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. High-level wellness in a favorable environment involves biopsychosocial, spiritual, and economic resources that support healthy lifestyles. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify variables affecting health status, beliefs, and practices. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 265 Question 7 Type: MCSA A nurse has volunteered to go on a health mission to rural Haiti, where the majority of the people do not have access to health care 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Protected poor health in an unfavorable environment Correct Answer: 3 Rationale 1: 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. Emergent high-level wellness in an unfavorable environment would include clients who have the knowledge to implement healthy lifestyle practices, but cannot implement them because of other factors or demands. Rationale 2: 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. Protected poor health in a favorable environment is where clients have an illness but their needs are met by the health care system. These clients have adequate access to appropriate medications, diet, and health care instruction. Rationale 3: 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. Rationale 4: 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. Protected poor health in an unfavorable environment is not one of Dunn's quadrants. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify variables affecting health status, beliefs, and practices. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 265 Question 8 Type: MCSA The nurse educator is reviewing internal variables that affect people's health status. On which variables is this nurse focusing? Standard Text: Select all that aply. 1. Genetic makeup Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Age 3. Developmental level 4. Environment 5. Spiritual and religious beliefs Correct Answer: 1, 2, 3, 5 Rationale 1: Internal variables that affect people's health include biologic, psychologic, and cognitive dimensions. Biologic dimensions include genetic makeup. Rationale 2: Internal variables that affect people's health include biologic, psychologic, and cognitive dimensions. Biologic dimensions include age. Rationale 3: Internal variables that affect people's health include biologic, psychologic, and cognitive dimensions. Biologic dimensions include developmental level. Rationale 4: Internal variables that affect people's health include biologic, psychologic, and cognitive dimensions. Environment is an example of an external variable that affects a person's health. Rationale 5: Internal variables that affect people's health include biologic, psychologic, and cognitive dimensions. Cognitive dimensions include spiritual and religious beliefs. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify variables affecting health status, beliefs, and practices. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 267 Question 9 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 1 Rationale 1: People who hold management positions are in stressful occupational roles that predispose them to stress-related diseases. Rationale 2: Working as a custodian would not pose the same type of stress as the management position. Rationale 3: Working longer shifts would not pose the same type of stress as the management position. Rationale 4: Working longer shifts would not pose the same type of stress as the management position. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify variables affecting health status, beliefs, and practices. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 267 Question 10 Type: MCSA A 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 Correct Answer: 1 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: 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 health care and to be more knowledgeable about their health. They are also more likely to adhere to prescribed health care regimens such as taking medication, making and keeping appointments with physicians, maintaining diets, and giving up smoking. Rationale 2: People who believe their health is largely controlled by outside forces (chance or others) are referred to as externals. Rationale 3: People who believe their health is largely controlled by outside forces (chance or others) are referred to as externals. Rationale 4: People who believe their health is largely controlled by outside forces (chance or others) are referred to as externals. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify variables affecting health status, beliefs, and practices. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 269 Question 11 Type: MCSA 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. Correct Answer: 1 Rationale 1: Adherence to a particular therapy can be compromised if the therapy is expensive or if the duration of the proposed therapy is long. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Adherence is the extent to which an individual’s behavior coincides with medical or health advice. If no lifestyle changes are expected, then adherence should not be an issue. Rationale 3: Adherence is the extent to which an individual’s behavior coincides with medical or health advice. If the client understands the regimen, adherence is not an issue. Rationale 4: Adherence is the extent to which an individual’s behavior coincides with medical or health advice. Following Western medicine is not an adherence issue. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe factors affecting health care adherence. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 270 New Questions: Question 12 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 3 Rationale 1: A chronic illness is one that lasts for an extended period, usually 6 months or longer, and often for the person’s life. Rationale 2: Chronic illnesses usually have a slow onset and often have periods of remission, when the symptoms disappear. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: With chronic illnesses clients often need to modify activities of daily living. Rationale 4: An acute illness may subside with the help of over-the-counter medication. Rationale 5: Symptoms of an acute illness appear abruptly and subside quickly after intervention. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Differentiate illness from disease and acute illness from chronic illness. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 271 Question 13 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 2, 3, 4 Rationale 1: In the medical care contact stage the client seeks reassurance that the illness can be treated and the outcome predicted. Rationale 2: In the medical care contact stage the client wants validation of a real illness. Rationale 3: In the medical care contact stage the client wants the symptoms explained in understandable terms. Rationale 4: In the medical care contact stage the client may deny the diagnosis and seek the other of other health care professionals. Rationale 5: In the dependent client role the client becomes dependent on the professional for help. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8. Explain Suchman’s stages of illness. MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health. Page Number: 272

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 18 Question 1 Type: MCMA 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? Standard Text: Select all that apply. 1. Child and adult immunizations 2. Cardiovascular disease 3. Chronic lower respiratory disease 4. Stroke 5. Infant mortality Correct Answer: 1, 2, 5 Rationale 1: REACH: 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. Rationale 2: REACH: 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. Rationale 3: REACH: Racial and Ethnic Approaches to Community Health is an initiative of the Centers for Disease Control and Prevention. Chronic lower respiratory disease is not a topic within the REACH initiative. Rationale 4: REACH: Racial and Ethnic Approaches to Community Health is an initiative of the Centers for Disease Control and Prevention. Stroke is not a topic within the REACH initiative. Rationale 5: REACH: Racial and Ethnic Approaches to Community Health is an initiative of the Centers for Disease Control and Prevention. Topics within the REACH initiative include infant mortality. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe the role of federal agencies and initiatives regarding the provision of culturally responsive health care. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 279 Question 2 Type: MCSA A new graduate nurse is working in a busy emergency department of a hospital, situated 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 health care 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 health care. 4. Continuously strive to be culturally competent. Correct Answer: 1 Rationale 1: 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. Rationale 2: To understand and attend to the total context of the client's situation, using knowledge, attitudes, and skills, is a general nursing expectation and does not address cultural sensitivity directly. Rationale 3: To possess the underlying background knowledge that will provide these clients with the best possible health care is a general nursing expectation and does not address cultural sensitivity directly. Rationale 4: Becoming culturally competent is an ongoing process in which an individual develops along a continuum until diversity is accepted as a norm and the nurse has acquired greater understanding and capacity in a diverse environment. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment.. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 288 Question 3 Type: MCSA A client is the child of an African American father and Asian American mother. The client 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 Correct Answer: 3 Rationale 1: Diversity refers to the fact or state of being different. Rationale 2: A subculture is usually composed of people who have a distinct identity yet are related to a larger cultural group. Rationale 3: Multicultural is used to describe a person who has multiple patterns of identification or crosses several cultures, lifestyles, and sets of values. Rationale 4: Nurses demonstrate cultural sensitivity when they possess some basic knowledge of and constructive attitudes toward the health traditions observed among the diverse cultural groups found in a setting in which they are practicing. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Assessment Learning Outcome: 1. Describe concepts related to culture such as race, ethnicity, and acculturation. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 277 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 4 Type: MCSA A nurse is working with a home health client whose spouse was not born in the United States. During the home visit, the nurse realizes that the client has acquired the identity of her spouse's culture and has adopted some of the health practices of that culture. Which process should the nurse identify as occurring with the spouse? 1. Acculturation 2. Assimilation 3. Diversity 4. Heritage consistency Correct Answer: 2 Rationale 1: Acculturation occurs when people adapt to or borrow traits from another culture. Acculturation can also be defined as the changes of one's cultural patterns to those of the host society. Rationale 2: 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. Rationale 3: Diversity is the fact or state of being different. Rationale 4: Heritage consistency relates to the observance of beliefs and practices of a person's traditional cultural system. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Assessment Learning Outcome: 1. Describe concepts related to culture such as race, ethnicity, and acculturation. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 279 Question 5 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 3 Rationale 1: Making an assumption that all members of each culture are alike describes stereotypical behavior. Rationale 2: Believing that all culture members have the same beliefs describes stereotypical behavior. Rationale 3: 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. Rationale 4: Taking general knowledge from literature and applying it to the situation is a form of stereotyping. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Evaluation Learning Outcome: 8. Create self-awareness of your own culture, beliefs, biases, and assumptions. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 278 Question 6 Type: MCSA A new graduate nurse is moving from a small rural college town to a metropolitan area to begin work in a county hospital. The nurse has had limited prior experience with the various cultural groups that are served by the hospital. What might be this nurse’s greatest challenge? 1. Prejudice 2. Stereotyping Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Discrimination 4. Assimilation Correct Answer: 4 Rationale 1: Prejudice is a negative belief or preference that is generalized about a group and leads to "prejudging." Rationale 2: Stereotyping is assuming that all members of a culture or ethnic group are alike. Rationale 3: Discrimination occurs when a person acts on prejudice and denies another person one or more of the fundamental rights. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Assessment Learning Outcome: 8. Create self-awareness of your own culture, beliefs, biases, and assumptions. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 279 Question 7 Type: MCSA A client has requested that she have a special item present in her room and explains that it gives her 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 Correct Answer: 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Culture is a learned behavior and depends on underlying societal traits, including knowledge, beliefs, art, law, morals, and customs. Rationale 2: 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. Rationale 3: Ethnicity describes the traits and common religious customs and language of a group within the social system. Rationale 4: Socialization is the process of being raised within a culture and acquiring the characteristics of that group. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Assessment Learning Outcome: 1. Describe concepts related to culture such as race, ethnicity, and acculturation. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 277 Question 8 Type: MCSA Before a client goes to surgery, he requests to have his spiritual leader present and pray over him. 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 Correct Answer: 3 Rationale 1: Methods of maintaining HEALTH include following a proper diet, wearing proper clothing, concentrating and using the mind, and practicing one's religion.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Traditional methods of protecting HEALTH include wearing protective objects such as amulets, avoiding people who may cause trouble, and placing religious objects in the home. Rationale 3: 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. Rationale 4: Changing HEALTH is not one of the traditional methods in the HEALTH traditions model. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe health views from culturally diverse perspectives. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 281 Question 9 Type: MCSA A client makes the following statement: "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 Correct Answer: 1 Rationale 1: 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. Rationale 2: The holistic health belief holds that the forces of nature must be maintained in balance or harmony. Human life is one aspect of nature that must be in harmony with the rest of nature. Rationale 3: Biomedical health belief, also termed scientific belief, is based on the belief that life and life processes are controlled by physical and biochemical processes that can be manipulated by humans. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Folk medicine is defined as those beliefs and practices related to illness prevention and healing that derive from cultural traditions rather than from modern medicine's scientific base. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Assessment Learning Outcome: 5. Describe health views from culturally diverse perspectives. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 282 Question 10 Type: MCSA A Chinese client 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 Correct Answer: 4 Rationale 1: In this case, the fever would be considered a "hot" illness and the client is not likely to select this treatment. Rationale 2: In this case, the fever would be considered a "hot" illness and the client is not likely to select this treatment. Rationale 3: In this case, the fever would be considered a "hot" illness and the client is not likely to select this treatment. Rationale 4: 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. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Assessment Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 282 Question 11 Type: MCSA A community health nurse works with a variety of cultures providing health care 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 does not have a job 2. A family who has numerous relatives in a Spanish-American sector of the city 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 Correct Answer: 1 Rationale 1: Folk medicine is defined as beliefs and practices that relate illness prevention and healing to cultural traditions rather than modern medicine's scientific base. People who have limited access to scientific health care may turn to folk medicine or folk healing. 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 has limited access to scientific health care. Rationale 2: There is no evidence to suggest that this family would prefer to use folk medicine. Rationale 3: There is no evidence to suggest that this client would prefer to use folk medicine. Rationale 4: There is no evidence to suggest that this client would prefer to use folk medicine. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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: Nursing Process: Assessment Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 282 Question 12 Type: MCSA A female client is being discharged after a lengthy hospitalization. The family is from a male-dominated culture. 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. Correct Answer: 2 Rationale 1: Regardless of cultural considerations, it's always necessary to make sure that the instructions are understood. Rationale 2: 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 health care discussions. In this situation, we do not know if the nurse is male or female, so the best answer given with the information that is known is to arrange for teaching when the spouse is available. Rationale 3: This will not address the cultural issue of male dominance. Rationale 4: This will not address the issue of male dominance. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 283 Question 13 Type: MCSA A newly immigrated client is constantly attended to by family members. This has presented a problem to 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. Correct Answer: 2 Rationale 1: Telling the client he has to limit visitors or having the physician do this may be in conflict with cultural values and is not helpful to the client. Rationale 2: 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. Rationale 3: It would be more appropriate to question the client, not the family members, about the positive benefits of the family interactions because the family members are obviously supportive of their presence. Rationale 4: This is a nursing issue and should be managed by the nurse. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Implementation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 283 Question 14 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: Even if the explanation is given, clients from some cultures may still find questions of a personal nature offensive so early in the nurse–client association. Rationale 3: The sensitive issue is not necessarily one of language or communication barriers. Rationale 4: Waiting to complete the assessment is not a good idea as there is certain, initial information that needs to be collected from the client. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 9. Identify methods of cultural assessment. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 284 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 15 Type: MCSA A non-English-speaking client is needs to have an emergency surgical procedure. The hospital has an interpreter available. When the interpreter arrives to explain the procedure and help with the consent form, the nurse provides the best support when 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. Correct Answer: 2 Rationale 1: 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. Rationale 2: 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. Rationale 3: The questions should be addressed to the client, not the interpreter. Rationale 4: The questions should be addressed to the client, not the family, unless the client is incapable of answering. Global Rationale: Page Reference: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 7. Describe ways culture influences communication patterns and how to provide linguistically appropriate care. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 284 Question 16 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

During the admission interview, the culturally diverse client averts her eyes and refrains from answering questions for long periods of time. The culturally sensitive nurse should take which action? 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. Correct Answer: 3 Rationale 1: The nursing interview is the nurse’s responsibility and should not be postponed for what the nurse perceives as the client’s reluctance to communicate. Rationale 2: The nurse is responsible for the admission interview and it should not be avoided for reasons of discomfort. Rationale 3: 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. Rationale 4: The admission history can not be postponed in order for the nurse to improve his or her cultural awareness. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 7. Describe ways culture influences communication patterns and how to provide linguistically appropriate care. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 285 Question 17 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The school nurse is conducting head lice screenings. Before checking the head of an Asian child, 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: The nurse should explain the reason for the touching to all children. Rationale 3: Nurses should always wear gloves for this type of screening process. Rationale 4: Asking the child to wait until last to avoid embarrassment is not appropriate and does not address the cultural issue. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 286 Question 18 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 1 Rationale 1: 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. Rationale 2: Explaining the assessment only while performing the procedure and not before is likely to cause the client anxiety and thus negatively affect the assessment values. Rationale 3: This option is not addressing the sensitivity issues appropriate for this scenario. Rationale 4: This option is not addressing the sensitivity issues appropriate for this scenario. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 286 Question 19 Type: MCSA 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 AM and 4 PM. 4. Suggest that the dressing change can be performed whenever the client chooses, as long as it gets done twice daily. Correct Answer: 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: This option does not assure the dressing changes will occur as prescribed. Rationale 2: 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 AM and 4 PM, but will provide for a dressing change twice daily. Rationale 3: This option is not likely to be followed by a client who is “present oriented.” Rationale 4: This option does not comply with the intended order for the dressing changes. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 286 Question 20 Type: MCSA 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 Correct Answer: 2 Rationale 1: The eating of milk products and meat products at the same meal is prohibited. Rationale 2: This menu is in accordance with the kosher tradition because there is no pork being served and dairy and meat are not served together. Rationale 3: Orthodox Judaism and Islam prohibit the ingestion of pork or pork products (ham and sausage). Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The eating of milk products and meat products at the same meal is prohibited. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 287 . Question 21 Type: MCSA 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." Correct Answer: 3 Rationale 1: The appropriate introduction should 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. This option does not fulfill these requirements. Rationale 2: The appropriate introduction should 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. This option does not fulfill these requirements. Rationale 3: 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.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The appropriate introduction should 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. This option does not fulfill these requirements. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 7. Describe ways culture influences communication patterns and how to provide linguistically appropriate care. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 288 Question 22 Type: MCSA A home health client participates in cultural health practices that the nurse feels may be detrimental to his health. 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 try to persuade him 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 his preferences. 4. Try to negotiate with the client by exploring his views and then provide relevant scientific information. Correct Answer: 4 Rationale 1: "Right" and "wrong" terms should be avoided in culturally sensitive areas and where differing views are present. Rationale 2: The nurse, not the physician, is the caregiver in this situation, so it is the nurse's responsibility to teach and see that the plan of care is carried out. Rationale 3: If the client's views can lead to harmful behavior or outcomes, then an attempt is made to shift the client's perspectives to the scientific view.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 10. Create a culturally responsive nursing care plan. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 290 Question 23 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: Extending the time frame may not be as helpful as looking at the cultural practices—including dietary ones—of the client. Rationale 3: Checking how the client understands the importance of the goal may not be as helpful as looking at the cultural practices—including dietary ones—of the client. Rationale 4: Selecting a different goal may not be as helpful as looking at the cultural practices—including dietary ones—of the client. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Evaluation Learning Outcome: 10. Create a culturally responsive nursing care plan. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 291 Question 24 Type: MCSA A nurse educator uses Madeleine Leininger's model and describes a formal area of study and practice focused on comparative human-care differences and similarities of the beliefs, values, and patterned lifeways of cultures to provide culturally congruent, meaningful, and beneficial health care to people. What type of nursing is the educator practicing? 1. Transcultural nursing 2. Cultural competence 3. Cultural knowledge 4. Competent nursing Correct Answer: 1 Rationale 1: Transcultural nursing focuses on providing care within the differences and similarities of the beliefs, values, and patterns of cultures. Rationale 2: Cultural competence is a life-long process in which the nurse continuously strives to achieve the ability and availability to effectively work within the cultural context of a client (individual, family, community). Rationale 3: Cultural knowledge reflects the presences of a sound educational foundation concerning the various worldviews of different cultures. Rationale 4: Transcultural nursing is a component of competent nursing. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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: Nursing Process: Evaluation Learning Outcome: 4. Describe cultural models of care, such as cultural competency. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 280 Question 25 Type: MCMA The community health nurse is using the Heritage Assessment Interview tool with a group of community members. Which data indicate heritage consistent? Standard Text: 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 of his family to earn a college degree. Correct Answer: 1, 3, 4 Rationale 1: 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 ethic neighborhood. Rationale 2: The tool is not designed to assess such nonculturally oriented events. Rationale 3: The tool is designed to enhance the process of determining whether clients are identifying with their traditional cultural heritage (heritage consistent), such as by attending a religiously affiliated school. Rationale 4: The tool is designed to enhance the process of determining whether clients are identifying with their traditional cultural heritage (heritage consistent), such as by attending and participating in religious and cultural events. Rationale 5: The tool is not designed to assess such nonculturally oriented events. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: 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: Nursing Process: Assessment Learning Outcome: 9. Identify methods of cultural assessment. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 288 Question 26 Type: MCMA The nurse is planning to provide culturally responsive care to a minority client and family. What actions should the nurse perform when providing this care? Standard Text: 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 Correct Answer: 1, 3, 4, 5 Rationale 1: Culturally responsive care that involves family appropriately includes self-reflection to identify your personal assumptions, biases, attitudes, prejudices, and stereotypes. Rationale 2: Determine the cultural expectations related to the hierarchy of the family. Rationale 3: 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. Rationale 4: Culturally responsive care that involves family appropriately includes asking about the client’s use of cultural or alternative approaches to healing. Rationale 5: 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. Global Rationale: Cognitive Level: Applying Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Assessment Learning Outcome: 9. Identify methods of cultural assessment. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 288 Question 27 Type: MCMA 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? Standard Text: 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.” Correct Answer: 4, 5 Rationale 1: Race has been a term used to refer to groupings of people according to common origin or background and associated with perceived biological markers. Rationale 2: Diversity occurs not only between cultural groups but also within cultural groups. Rationale 3: A subculture is usually composed of people who have a distinct identity and yet are related to a larger cultural group. Rationale 4: Culture is the thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Rationale 5: Macro- and micro-cultures combine to shape the individual’s worldview and influence interaction with the others. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Assessment Learning Outcome: 1. Describe concepts related to culture such as race, ethnicity, and acculturation. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 276 New Questions: Question 28 Type: MCMA After an assessment, the nurse determines that a client of African American descent is experiencing disparities that are a part of behavioral health determinants. What assessment data did the nurse use to come to this conclusion? Standard Text: 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 Correct Answer: 2, 4 Rationale 1: Asthma would be included as an environmental determinant of health. Rationale 2: Behavioral determinants of health include obesity. Rationale 3: Employment status influences social determinants of health. Rationale 4: Behavioral determinants of health include use of drugs, tobacco, or alcohol. Rationale 5: Family health history is a part of biological and genetic determinants of health. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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: Nursing Process: Assessment Learning Outcome: 2. Examine factors that contribute to health disparities among racial and ethnic groups. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 278 Question 29 Type: MCMA The nurse is concerned that many ethnically diverse clients are not receiving a consistently high level of health care within a community. What information should the nurse access to learn how to improve these clients’ level of health care? Standard Text: 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 Correct Answer: 1, 2, 3, 4 Rationale 1: 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 Rationale 2: The National Partnership for Action to End Health Disparities (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 racial and ethnic minorities and other underserved groups reach their full health potential. Rationale 3: The Office of Minority Health, in collaboration with other organizations, developed the National Standards for Culturally and Linguistically Appropriate Services in Health Care. These CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for health and health care 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. Rationale 4: 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. It plans, reviews, coordinates, evaluates, translates, and disseminates all minority health and health disparities research and activities of the National Institutes of Health.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Commented [KB1]: AU: pls add

Rationale 5: The Centers for Disease Control and Prevention has an Office of Minority Health and Health Equity to help eliminate health disparities within vulnerable populations. Job opportunities would not help the nurse improve the inequity of health services among community members. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Assessment Learning Outcome: 2. Examine factors that contribute to health disparities among racial and ethnic groups. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 278-279

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 9/E Chapter 19 Question 1 Type: MCSA A nurse is helping a hospice client who has had difficulty with making end-of-life decisions. The nurse has encouraged the client to focus on her self-worth, her accomplishments, and having positive self-esteem in order to process through some of these decisions. The nurse is helping the client to achieve balance in which component? 1. Environmental 2. Physical 3. Mental 4. Spiritual Correct Answer: 3 Rationale 1: Environmental aspects include physical, biologic, economic, social, and political conditions. Rationale 2: Physical aspects include optimal functioning of all body systems. Rationale 3: 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. Rationale 4: Spiritual aspects involve moral values, a meaningful purpose in life, and a feeling of connectedness to others and a divine source. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Give examples of healing environments. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 296 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 2 Type: MCSA A home health nurse is working with a client who has had to quit his job after a serious injury and whose future employability is uncertain. The client states that his life has no meaning or purpose anymore and that he feels lonely and abandoned. What is an appropriate nursing diagnosis for this client? 1. Body Image Disturbance 2. Health-Seeking Behavior 3. Altered Family Processes 4. Spiritual Distress Correct Answer: 4 Rationale 1: 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 NANDA label Spiritual Distress is defined as disruption of the life principle that pervades one's biological and psychosocial nature. The feelings the client expresses have little to do with his body image. Rationale 2: 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 NANDA label Spiritual Distress is defined as disruption of the life principle that pervades one's biological and psychosocial nature. The client is not expressing the desire to increase his level of well-being. Rationale 3: 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 NANDA label Spiritual Distress is defined as disruption of the life principle that pervades one's biological and psychosocial nature. The feelings the client expresses have little to do with family processes. Rationale 4: 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 NANDA label Spiritual Distress is defined as disruption of the life principle that pervades one's biological and psychosocial nature. The feelings the client expresses have little to do with his body image or family processes, and he is not expressing the desire to increase his level of well-being. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1. Describe the basic concepts of alternative practices. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 296 Question 3 Type: MCSA The nurse is working with a client who, during her interview, expresses feelings of groundedness. The nurse interprets this to mean that the client 1. is full of energy. 2. feels connected to her reality. 3. is focused on her center of energy. 4. feels "down in the dumps." Correct Answer: 2 Rationale 1: Energy is viewed as the force that integrates the body, mind, and spirit and doesn’t relate to groundedness. Rationale 2: Grounding relates to one's connection with reality. Being grounded suggests stability, security, independence, having a solid foundation, and living in the present. Rationale 3: Centering refers to the process of bringing oneself to the center or middle and doesn’t relate to groundedness. Rationale 4: This relates more closely with sadness or depression than groundedness. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Give examples of healing environments. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 296 Question 4 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA After having a difficult time saying "no" when asked to work yet 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. Correct Answer: 4 Rationale 1: Identification of things that are important, meaningful, and valuable is part of clarifying values and beliefs and may help, but there is a more specific option available. Rationale 2: Identifying and setting goals may help, but there is a more specific option available. Rationale 3: Stress management may help, but there is a more specific option available. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Give examples of healing environments. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 296 Question 5 Type: MCSA 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?

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Traditional Chinese medicine 2. Native American healing 3. Ayurveda 4. Curanderismo Correct Answer: 1 Rationale 1: 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, t'ai chi, and nutritional counseling. Rationale 2: Native American healing is very connected to spirituality, and health is viewed as a balance or harmony of body and mind. Rationale 3: Ayurveda emphasizes the interdependence of the health of the individual and the quality of societal life. Rationale 4: Curanderismo is a cultural healing tradition found in Latin American cultures and utilizes Western biomedical beliefs, treatment, and practices. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the basic principles of health care practices such as Ayurveda, traditional Chinese medicine, Native American healing, and curanderismo. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 297 Question 6 Type: MCSA The 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." Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. "Are there specific ones you're wondering about?" 4. "Everything is good in moderation." Correct Answer: 3 Rationale 1: Not all plant life is beneficial. Rationale 2: There are cautions and contraindications with some herbal preparations and over-the-counter (OTC) as well as prescription drugs. The use of such treatments may be helpful but should be discussed with a health care provider in order to minimize the risk of interactions. Rationale 3: 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. Rationale 4: Not all plant life is beneficial. This option is not a sufficient answer to the client’s question. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Give examples of healing environments. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 298 Question 7 Type: MCSA A client comes to the family planning clinic for follow-up and is currently taking an oral contraceptive. During the interview assessment, the client states she has been using some "natural medicines." Which herbal preparation should alert the nurse to a possible interaction with oral contraceptives? 1. Valerian 2. Echinacea 3. Garlic Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Milk thistle Correct Answer: 4 Rationale 1: Valerian may increase the sedative effects of antianxiety medication. Rationale 2: Echinacea may reduce the effectiveness of immunosuppressants. Rationale 3: Garlic may cause a need for an increased dose of antihypertensives. Rationale 4: Milk thistle reduces the effectiveness of oral contraceptives. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 299 Question 8 Type: MCSA A client who has a long-standing history of depression has been on a prescribed antidepressant for several months and states that he has also been 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 Correct Answer: 4 Rationale 1: St. John's wort would not affect the hypothalamus. Rationale 2: St. John's wort would not affect the respiratory system. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: St. John's wort would not affect the respiratory system. Rationale 4: St. John's wort may potentiate antidepressant medications, causing severe agitation, nausea, confusion, and possible cardiac problems. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 299 Question 9 Type: MCSA 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 Correct Answer: 1 Rationale 1: Ginseng may interact with caffeine and cause irritability and may also decrease the effectiveness of glaucoma medication. Rationale 2: Echinacea may reduce the effectiveness of immunosuppressants but does not appear to affect glaucoma medication. Rationale 3: Valerian may increase the sedative effects of antianxiety medication but does not appear to affect glaucoma medication. Rationale 4: St. John's wort may potentiate antidepressant medications, causing severe agitation, nausea, confusion, and possible cardiac problems. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Learning Outcome: 10 Teach clients the uses and safety precautions regarding alternative therapies. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 299 Question 10 Type: MCSA A client diagnosed with hypertension has had well-controlled follow-up of her blood pressure for the past 6 months. At today's clinic appointment, the client's blood pressure is 98/58. The client insists she has been taking her prescribed antihypertensive medication as prescribed, but also added an "herbal" tablet because she heard it was supposed to be good for her. Which is most likely interfering with the client's antihypertensive? 1. Valerian 2. Milk thistle 3. Ginseng 4. Garlic Correct Answer: 4 Rationale 1: Valerian may increase the sedative effects of antianxiety medication but does not appear to affect antihypertensive medication. Rationale 2: Milk thistle reduces the effectiveness of oral contraceptives but does not appear to affect antihypertensive medication. Rationale 3: Ginseng may decrease the effectiveness of glaucoma medications but does not appear to affect antihypertensive medication. Rationale 4: Garlic reduces high blood pressure. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 299 Question 11 Type: MCSA 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 Correct Answer: 3 Rationale 1: This type of alternative therapy does not appear to affect blood pressure. Rationale 2: This type of alternative therapy does not appear to affect the cardiac system. Rationale 3: Some oils can trigger bronchial spasms, so persons with asthma should consult their primary health care provider before using oils. Rationale 4: This type of alternative therapy does not appear to affect cancer. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 299 Question 12 Type: MCSA A client with degenerative joint disease comes to the clinic and states that he has been reading a lot about essential oils that are 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 Correct Answer: 1 Rationale 1: Chamomile oil soothes muscle aches, sprains, and swollen joints and is helpful as a GI antispasmodic. Rationale 2: Eucalyptus feels cool to the skin and warm to muscles; decreases fever; relieves pain; and acts as an anti-inflammatory, antiseptic, antiviral, and expectorant to the respiratory system in a steam inhalation. It can also boost the immune system. Rationale 3: Lavender oil is calming and is used as a sedative for insomnia. It may be massaged around the temples for headache, inhaled to speed recovery from colds or flu, and massaged into the chest to decrease congestion. It can also be used to heal burns. Rationale 4: Tea tree oil is good for athlete's foot as an antifungal. It can be used to soothe insect bites, stings, cuts, and wounds. It can be bathed in for yeast infection, and drops on a handkerchief can be used for coughs or congestion. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 300 Question 13 Type: MCMA A client asks the nurse about chiropractic medicine. What should the nurse explain as being among the goals of this type of health intervention? Standard Text: Select all that apply. 1. Improvement of blood and lymph flow through the body 2. Stimulation of specific points to help with pain relief, cures certain illnesses, and promote wellness 3. Reduce or eliminate pain 4. Correct spinal dysfunction 5. Preventive maintenance Correct Answer: 3, 4, 5 Rationale 1: Massage therapy improves blood flow and lymph fluid through the body. Rationale 2: Acupressure and acupuncture are techniques of applying pressure or stimulation to specific points on the body in order to relieve pain, cure certain illnesses, and promote wellness. Rationale 3: The first clinical goal of chiropractic care is to reduce or eliminate pain. Rationale 4: 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. Rationale 5: Preventive maintenance of chiropractic medicine ensures that the problem does not recur. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Discuss the principles of naturopathic medicine. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 301 Question 14 Type: MCSA A client who resides in a long-term care facility has no family or visitors. Her only social contacts are with the staff. The client is confined to bed and is not able to communicate verbally. As part of the client's care plan, the nurses provide 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 Correct Answer: 3 Rationale 1: Massage would be an appropriate intervention to address this option but it is not the main benefit the client will experience. Rationale 2: Massage would be an appropriate intervention to address this option but it is not the main benefit the client will experience. Rationale 3: 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. Rationale 4: Massage would be an appropriate intervention to address this option but it is not the main benefit the client will experience. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Discuss the principles of naturopathic medicine. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 301 Question 15 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Therapeutic touch and Reiki use the hands to alter the bio-field or energy field. Rationale 3: Aromatherapy and naturopathic remedies utilize essential oils and plants for health benefits. Rationale 4: Chiropractic and massage therapy are examples of manual healing methods. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Identify the role of manual healing methods in health and illness. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 301 Question 16 Type: MCSA 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." Which nursing diagnosis should the nurse identify for this client? 1. Energy-field disturbance 2. Powerlessness 3. Hopelessness 4. Anxiety Correct Answer: 1 Rationale 1: 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. Rationale 2: Powerlessness is defined as a perception that one's own actions will not significantly affect an outcome. Rationale 3: Hopelessness is a subjective state in which an individual sees no alternatives or personal choices available and is unable to mobilize energy on his or her own behalf. Rationale 4: Anxiety is defined as a vague, uneasy feeling, the source of which is often nonspecific or unknown to the individual. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 6. Identify the role of manual healing methods in health and illness. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 301 Question 17 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Aromatherapy is the use of essential oils that, when absorbed into the body, produce physiologic or psychologic benefit. Rationale 3: Homeopathy is a self-healing system in which doses of natural compounds stimulate a person's selfhealing capacity. Rationale 4: Yoga includes ethical models for behavior and mental and physical exercises aimed at producing spiritual enlightenment. Global Rationale:

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 7. Describe the goals that yoga, meditation, hypnotherapy, guided imagery, qigong, and tai chi have in common. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 303 Question 18 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

A client has been undergoing therapy as a victim of severe emotional abuse. The goal of the client's therapy is to gain self-control of the situation, improve self-esteem, and become self-sufficient. Which application should the nurse suggest become a part of the client's therapy sessions? 1. Yoga 2. Meditation 3. Hypnotherapy 4. Guided imagery Correct Answer: 3 Rationale 1: Yoga includes ethical models for behavior and mental and physical exercises aimed at producing spiritual enlightenment. Rationale 2: Meditation is a general term for a wide range of practices that involve relaxing the body and easing the mind. Rationale 3: Hypnotherapy is an advanced form of relaxation and can be used to help people gain self-control, improve self-esteem, and become more autonomous. Rationale 4: Guided imagery is a state of focused attention, much like hypnosis, that encourages changes in attitudes, behavior, and physiologic reactions. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe the goals that yoga, meditation, hypnotherapy, guided imagery, qigong, and tai chi have in common. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 303 Question 19 Type: MCSA A client has been diagnosed with post-traumatic stress syndrome 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Guided imagery 2. Hypnotherapy 3. Yoga 4. Meditation Correct Answer: 1 Rationale 1: 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. Rationale 2: Hypnotherapy is an advanced form of relaxation and can be used to help people gain self-control, improve self-esteem, and become more autonomous. Rationale 3: Yoga includes ethical models for behavior and mental and physical exercises aimed at producing spiritual enlightenment. Rationale 4: Meditation is a general term for a wide range of practices that relax the body and help ease the mind. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe the goals that yoga, meditation, hypnotherapy, guided imagery, qigong, and tai chi have in common. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 303 Question 20 Type: MCSA A nurse who works in a busy neonatal intensive care unit 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Qigong 4. Aromatherapy Correct Answer: 3 Rationale 1: Guided imagery is a state of focused attention that encourages changes in attitudes, behavior, and physiologic reactions. Rationale 2: Hypnotherapy is an advanced form of relaxation and can be used to help people gain self-control, improve self-esteem, and become more autonomous. Rationale 3: 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. Rationale 4: Aromatherapy is the use of essential oils that, when absorbed into the body, produce physiologic or psychologic well-being. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe the goals that yoga, meditation, hypnotherapy, guided imagery, qigong, and tai chi have in common. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 304 Question 21 Type: MCSA A nurse working on an Alzheimer's unit notes that just before the supper hour, many of the residents become more anxious and confused—exhibiting typical "sundowner's syndrome"—making the evening meal an unpleasant ordeal. As a method to try to decrease their turmoil during this time, which therapy should the nurse introduce into the daily routine? 1. Biofeedback 2. Music therapy 3. Pilates Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Spiritual therapy Correct Answer: 2 Rationale 1: Biofeedback is a relaxation technique that uses electronic equipment to amplify the electrochemical energy produced by body responses. Rationale 2: 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 on the unit. Rationale 3: Pilates is a method of physical movement and exercises designed to stretch, strengthen, and balance the body. Rationale 4: Spiritual therapy includes prayer and faith practices to promote healing. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Identify the role of manual healing methods in health and illness. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 305 Question 22 Type: MCSA A client comes to the clinic with a chief complaint of feeling "dirty inside" and asks the nurse how colonics would work to improve the client's 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." Correct Answer: 2

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Although colon cleansing is a controversial method of detoxification, and there tends to be no middle group in the beliefs about the usefulness of colonics, that option does not appropriately address the client’s concerns. Rationale 2: Although colon cleansing is a controversial method of detoxification, establishing a baseline regarding the client’s knowledge regarding the process is most appropriate. Rationale 3: Colonics is the procedure for washing the inner wall of the colon by filling it with water or herbal solutions and then draining it. Colon cleansing is a controversial method of detoxification and the issue requires further discussion. Rationale 4: This option defers the client’s concerns to the doctor, which is inappropriate because the nurse should be prepared to discuss the issue with the client. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Identify types of detoxification therapies. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 306 Question 23 Type: MCSA A client was in a motor vehicle crash where he sustained injury to his spinal cord that has resulted in difficulty with balance and holding his posture. Which should the nurse suggest the client consider? 1. Animal-assisted therapy 2. Hypnotherapy 3. Chelation therapy 4. Detoxification Correct Answer: 1 Rationale 1: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Hypnotherapy is an advanced form of relaxation and can be used to help people gain self-control, improve self-esteem, and become more autonomous. Rationale 3: Chelation therapy is the introduction of chemicals into the bloodstream that bind with heavy metals in the body. Rationale 4: Detoxification is based on the belief that physical impurities and toxins must be cleared from the body to achieve better health. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Discuss uses of animals, prayer, and humor as treatment modalities. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 306 Question 24 Type: MCSA A client living in a long-term care center has been withdrawn and subdued, and does not eat in the dining room because of embarrassment about her 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 Correct Answer: 2 Rationale 1: Chelation therapy is the introduction of chemicals into the bloodstream that bind with heavy metals in the body. Rationale 2: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Meditation is a wide range of practices that relax the body and heal the mind. Rationale 4: Pilates is a method of physical movement and exercise designed to stretch, strengthen, and balance the body. Global Rationale: Page Reference: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Discuss uses of animals, prayer, and humor as treatment modalities. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 306 Question 25 Type: MCMA 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? Standard Text: Select all that apply. 1. Naturopathic medicine 2. Homeopathic medicine 3. Aromatherapy 4. Chiropractic 5. Hypnosis Correct Answer: 1, 2, 3, 4 Rationale 1: Naturopathic medicine is a self-healing system that utilizes remedies to stimulate a person’s selfhealing capacity. Rationale 2: Homeopathy is a self-healing system that utilizes remedies to stimulate a person's self-healing capacity. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: 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. Rationale 4: Chiropractic is a type of manual healing method. Rationale 5: Hypnosis is not considered a system of healing. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe the basic concepts of alternative practices. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 299, 300 Question 26 Type: MCMA The nurse is teaching a client regarding the use of herbal preparations. Which statements should the nurse include in this teaching? Standard Text: 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.” Correct Answer: 1, 2, 3, 4 Rationale 1: Although it is believed by some to enhance the immune system, echinacea can reduce the effectiveness of immunosuppressants. Rationale 2: Gingko can increase the anticoagulant effects of aspirin and anticoagulant medications. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Ginger can increase the anticoagulant effects of aspirin and anticoagulant medications. Rationale 4: Ginseng can decrease the effectiveness of glaucoma medications. Rationale 5: St. John’s wort can potentiate antidepressant medications, causing severe agitation and nausea. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Explain how herbs are similar to many prescription drugs. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 299 Question 27 Type: MCMA The nurse is instructing a client on meditation and relaxation. Which information should the nurse include in this teaching? Standard Text: 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.” Correct Answer: 1, 2, 3, 4 Rationale 1: 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. Rationale 2: Avoid a lying position, because it increases the tendency to fall asleep. Rationale 3: Progressively tighten and relax each muscle group in the body. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: A quiet, comfortable place, devoid of distractions, is helpful. Rationale 5: Practice these techniques daily for 10- to 20-minute periods. Global Rationale: Learning Outcome: 06 Identify the role of manual healing methods in health and illness. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Identify the role of manual healing methods in health and illness. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 303 New Questions: Question 28 Type: MCMA A client tells the nurse about an appointment to see an Ayurveda health care practitioner for a specific chronic health problem. What should the nurse instruct the client to expect when visiting this practitioner? Standard Text: 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 Correct Answer: 1, 3, 5 Rationale 1: Specific lifestyle interventions are a major preventive and therapeutic approach in Ayurveda. Each person is prescribed an individualized diet. Rationale 2: Sweat lodges are a part of Native American healing. Rationale 3: Specific lifestyle interventions are a major preventive and therapeutic approach in Ayurveda. Each person is prescribed an individualized exercise program. Rationale 4: Acupuncture is an approach used in Chinese medicine.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: In Ayurveda, herbal preparations are added to the diet for preventive or regenerative purposes as well as for the treatment of specific disorders. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe the basic principles of health care practices such as Ayurveda, traditional Chinese medicine, Native American healing, and curanderismo. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 297 Question 29 Type: MCMA While completing a health history and assessment, the nurse suspects that a client of Latino descent uses curanderismo for health care. What client information did the nurse use to make this determination? Standard Text: Select all that apply. 1. The client stated that the health care provider prescribes specific herbs. 2. The client stated that the same health care 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 health care provider visits the home to pray with the family members 5. The client stated that specific areas of the body are pressed by the health care provider to increase energy. Correct Answer: 1, 2, 4 Rationale 1: 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. Rationale 2: 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. Rationale 3: The use of small needles describes acupuncture, which is a Chinese medicine approach. Rationale 4: 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. Rationale 5: Pressing areas of the body describes acupressure, which is not a part of curanderismo. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Describe the basic principles of health care practices such as Ayurveda, traditional Chinese medicine, Native American healing, and curanderismo. MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health. Page Number: 298

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 20 Question 1 Type: MCSA 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 Correct Answer: 3 Rationale 1: Development is an increase in the complexity of function and skill progression. It is the capacity and skill of a person to adapt to the environment. Rationale 2: Health is a dynamic process with varying definitions, all of which point to well-being. Rationale 3: Growth refers to physical change and increase in size. Indicators include height, weight, bone size, and dentition. Rationale 4: Bone size is one of the indicators of growth. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Differentiate between the terms growth and development. MNL Learning Outcome: 2.1.2. Analyze the school-age child and adolescent’s physiologic and psychosocial development. Page Number: 312 Question 2 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

A parent brings a 16-month-old child to the clinic for a well-child checkup. During the assessment, the nurse finds that the child cannot stand next to furniture and does not try to pull himself up from a sitting position. In which process should the nurse identify that this child is lagging? 1. Growth 2. Development 3. Height 4. Behavior Correct Answer: 2 Rationale 1: Growth is physical change and increase in size. Rationale 2: 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. Rationale 3: Height is one of the indicators of growth. Rationale 4: Behavior is a component of the developmental stage. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Differentiate between the terms growth and development. MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 312 Question 3 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Environment 4. Culture Correct Answer: 1 Rationale 1: Temperament is the way individuals respond to their external and internal environment and sets the stage for the interactive dynamics of growth and development. Rationale 2: Physical characteristics include eye color and potential height and do not affect how children interact, for the most part. Rationale 3: Environment includes family, religion, climate, culture, school, community, and nutrition and would not play as big of a role in how the child responds to peers as temperament does. Rationale 4: Culture is part of environmental factors. Global Rationale: Page Reference: 355 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain the concept of temperament. MNL Learning Outcome: 2.1.2. Analyze the school-age child and adolescent’s physiologic and psychosocial development. Page Number: 312 Question 4 Type: MCSA A parent is concerned that her child is unable to sit alone. The nurse explains that development is based on inborn timetables and the child will be most likely able to meet this milestone at a specific time. Upon which theory did the nurse base the response to the client? 1. Havighurst's theory 2. Task theory 3. Psychosocial theory 4. Maturational theory Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 4 Rationale 1: Havighurst, in his developmental task theory, described growth and development occurring during six stages, each associated with 6 to 10 tasks to be learned. Rationale 2: Havighurst, in his developmental task theory, described growth and development occurring during six stages, each associated with 6 to 10 tasks to be learned. Rationale 3: Psychosocial theory is focused on the development of personality, not physical development. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe the stages of growth and development according to various theorists. MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 313 Question 5 Type: MCSA A toddler shows fear and begins to cry when her parent leaves her 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 Correct Answer: 3 Rationale 1: This task is part of the middle childhood age period and would not be appropriate for this child. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: This task is part of the middle childhood age period and would not be appropriate for this child. Rationale 3: 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. Rationale 4: This task is part of the middle childhood age period and would not be appropriate for this child. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Identify developmental tasks associated with Havighurst’s six age periods. MNL Learning Outcome: 2.1.1 Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 316 Question 6 Type: MCSA A parent is concerned that her 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." Correct Answer: 4 Rationale 1: Assuring the parent that this is a normal part of development is the best response. Rationale 2: Assuring the parent that this is a normal part of development is the best response. This response would lead the parent to believe that the child’s behavior is abnormal. Rationale 3: Assuring the parent that this is a normal part of development is the best response. This response would lead the parent to believe that the child’s behavior is abnormal.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe characteristics and implications of Freud’s five stages of development. MNL Learning Outcome: 2.1.2 Analyze the school-age child and adolescent’s physiologic and psychosocial development. Page Number: 315 Question 7 Type: MCSA A young adult has never lived away from his parents and feels unable to make decisions on his own. 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 Correct Answer: 3 Rationale 1: The phallic stage is from 4 to 6 years of age, and fixation would be related to the individual’s genital organs and the pleasure sensations they create. Rationale 2: The latency stage is 6 years to puberty. Energy is directed to physical and intellectual activities. Sexual impulses tend to be repressed. Rationale 3: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The anal stage is from 11/2 to 3 years. The anus and bladder are the sources of pleasure (sensual satisfaction, self-control). Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Describe characteristics and implications of Freud’s five stages of development. MNL Learning Outcome: 2.1.3 Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 315 Question 8 Type: MCSA 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 dealing with which task of development? 1. Initiative versus guilt 2. Industry versus inferiority 3. Intimacy versus isolation 4. Identity versus role confusion Correct Answer: 4 Rationale 1: Initiative versus guilt is the late childhood stage and occurs from age 3 to 5 years. Industry versus inferiority occurs from 6 to 12 years, during the school-age stage. Rationale 2: Industry versus inferiority occurs from 6 to 12 years, during the school-age stage. Rationale 3: Intimacy versus isolation is the task during young adulthood and occurs from 18 to 25 years. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify Erikson’s eight stages of development. MNL Learning Outcome: 2.1.2 Analyze the school-age child and adolescent’s physiologic and psychosocial development. Page Number: 316 Question 9 Type: MCSA A client who has a terminal diagnosis has been using her time to help family members deal with her impending death. Among her activities, she collected 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 Correct Answer: 2 Rationale 1: Body transcendence versus body preoccupation calls for the individual to adjust to decreasing physical capacities and at the same time maintain feelings of well-being. Rationale 2: 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. Rationale 3: Ego differentiation versus work-role preoccupation maintains that an adult's identity and feelings of worth are highly dependent on that person's work role. Rationale 4: Erikson proposed integrity versus despair, not Peck. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9. Compare Peck’s and Gould’s stages of adult development. MNL Learning Outcome: 2.1.4 Analyze the older adult’s physiologic and psychosocial development. Page Number: 316 Question 10 Type: MCSA A college-age client shares that he is struggling with feelings of both independence and dependence regarding his family. 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Roger Gould studied adult development and described seven stages. Stage 3 (ages 22–28) is when individuals feel established as adults and autonomous from their families. They see themselves as well defined, but still feel the need to prove themselves to their parents. Rationale 3: Roger Gould studied adult development and described seven stages. Stage 4 (ages 29–34) is when marriage and careers are well established. Individuals question what life is all about and wish to be accepted as they are, no longer finding it necessary to prove themselves. Rationale 4: Roger Gould studied adult development and described seven stages. Stage 5 (ages 35–43) is a period of self-reflection. Individuals question values and life itself. They see time as finite, with little time left to shape the lives of adolescent children. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9. Compare Peck’s and Gould’s stages of adult development. MNL Learning Outcome: 2.1.3 Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 317 Question 11 Type: MCSA A parent reports to the nurse that his 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 Correct Answer: 2 Rationale 1: The intuitive thought phase is from age 4 to 7 years and is where egocentric thinking diminishes. The child thinks of one idea at a time and includes others in the environment. Rationale 2: Ages 2 to 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. Rationale 3: The concrete operations phase, ages 7 to 11, is where the child solves concrete problems. The child also begins to understand relationships such as size and right and left, and is cognizant of viewpoints. Rationale 4: During the formal operations phase (ages 11 to 15), the child uses rational thinking, and reasoning is deductive and futuristic. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11. Explain Piaget’s theory of cognitive development. MNL Learning Outcome: 2.1.1 Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 319 Question 12 Type: MCSA 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. Correct Answer: 2 Rationale 1: Ritual is important for the child of the tertiary circular reaction stage, age 12 to 18 months. Rationale 2: 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. Rationale 3: Crying when parents leave the unit and not cooperating with certain medical treatments is normal behavior for children of various ages, especially when hospitalized, and would not indicate lags in development. Rationale 4: Not cooperating with certain medical treatments is normal behavior for children of various ages, especially when hospitalized, and would not indicate lags in development. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11. Explain Piaget’s theory of cognitive development. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 2.1.1 Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 319 Question 13 Type: MCSA 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 Correct Answer: 3 Rationale 1: Vygotsky explored the concept of cognitive development within a social, historical, and cultural context, arguing that adults guide children to learn and that development depends on the use of language, play, and extensive social interaction. Rationale 2: Skinner's research led to the term "operant conditioning," and most of his work was with laboratory animals. Rationale 3: Lawrence Kohlberg's theory specifically addresses the moral development of children and adults. Rationale 4: Piaget developed the cognitive theory of development. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12. Compare Kohlberg’s and Gilligan’s theories of moral development. MNL Learning Outcome: 2.1.3 Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 321 Question 14 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

A nurse educator believes that teaching students without caring about them is an exercise in futility. This educator also believes that in meeting the students' needs, educators must also work to take care of themselves and care for their own needs. From which stage of Gilligan’s theory is the educator approaching the teaching of students? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4 Correct Answer: 3 Rationale 1: Stage 1 is caring for oneself. Rationale 2: Stage 2 is caring for others. Rationale 3: Gilligan's stage 3—caring for self and others—is the last stage of development, where a person sees the need for a balance between caring for others and caring for the self. Rationale 4: Gilligan does not describe more than three stages in her theory. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Compare Kohlberg’s and Gilligan’s theories of moral development. MNL Learning Outcome: 2.1.3 Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 22 Question 15 Type: MCSA A nurse educator is working with students and assisting them in addressing their clients' spiritual needs. The educator understands that most traditional, second-year college students are aware of their own spiritual development or working to develop their own system of spirituality. The educator realizes that the students are in which stage of Fowler’s developmental theory? 1. Mythic-lyrical Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Intuitive-projective 3. Universalizing 4. Individuating-reflexive Correct Answer: 4 Rationale 1: Mythical-lyrical describes the person between ages 7 and 12, in a private world of fantasy and wonder. Rationale 2: The intuitive-projective stage, ages 4 to 6 years, is a combination of images and beliefs given by trusted others, mixed with the child's own experience and imagination. Rationale 3: Universalizing, which may never be reached by an individual, is a stage of becoming incarnate of the principles of love and justice. Rationale 4: Fowler describes this as a stage in which the person is constructing his or her own explicit system with a high degree of self-consciousness. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13. Compare Fowler’s and Westerhoff’s stages of spiritual development. MNL Learning Outcome: 2.1.3 Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 323 Question 16 Type: MCSA A client with an acute, serious illness has been hospitalized. Upon entering the room, the nurse observes the client praying. The client states to the nurse: "I don't know how people manage to get through difficult times without their faith. It's where I get my strength." With which theorist should the nurse associate this client’s belief? 1. Fowler 2. Westerhoff 3. Gilligan Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Kohlberg Correct Answer: 2 Rationale 1: Fowler's theory describes the development of faith as a force that gives meaning to a person's life. Rationale 2: 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. Rationale 3: Gilligan is not a spiritual theorist. Rationale 4: Kohlberg is not a spiritual theorist. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13. Compare Fowler’s and Westerhoff’s stages of spiritual development. MNL Learning Outcome: 2.1.3 Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 323 Question 17 Type: SEQ 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? Standard Text: Click and drag the options below to move them up or down. Choice 1. Owned faith Choice 2. Affiliative faith Choice 3. Experienced faith Choice 4. Searching faith Correct Answer: 4, 2, 1, 3

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 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. Rationale 2: Actively participates in activities that characterize a particular faith tradition; experiences awe and wonderment; feels a sense of belonging is Stage 2. Rationale 3: Experiences faith through interaction with others who are living a particular faith tradition is Stage 1. Rationale 4: Through a process of questioning and doubting own faith, acquires a cognitive as well as an affective faith is Stage 3. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Compare Fowler’s and Westerhoff’s stages of spiritual development. MNL Learning Outcome: 2.1.3 Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 323 Question 18 Type: MCSA A nurse is working with a school-age client who is learning how to use a peak flow meter to monitor his asthma. The child has been frustrated at first, but now is able to give the reason to use the meter on a daily basis. Remembering the growth and development characteristics of the adolescent, how should the nurse respond 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." Correct Answer: 1 Rationale 1: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: This phrase does not support the child’s growth and development. Rationale 3: This phrase does not support the child’s growth and development. Rationale 4: This phrase does not support the child’s growth and development. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe essential principles related to growth and development. MNL Learning Outcome: 2.1.2 Analyze the school-age child and adolescent’s physiologic and psychosocial development. Page Number: 314 Question 19 Type: MCSA A 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. Correct Answer: 2 Rationale 1: Providing as much care as possible does not meet the independence need required in this age group. Rationale 2: 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. Rationale 3: Safety measures should be applied in the middle-old age group, age 75 to 84 years. Rationale 4: Peer interactions become important in the young-old stage, age 65 to 74 years. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe essential principles related to growth and development. MNL Learning Outcome: 2.1.4 Analyze the older adult’s physiologic and psychosocial development. Page Number: 314 Question 20 Type: MCSA 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 Correct Answer: 4 Rationale 1: This task is appropriate for the 6- to 12-year-old school-age child. Rationale 2: This task is appropriate for the adolescent 12 to 20 years old. Rationale 3: This task is appropriate for the 18- to 24-year-old young adult. Rationale 4: Adulthood, age 25 to 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Identify Erikson’s eight stages of development. MNL Learning Outcome: 2.1.3 Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 316 Question 21 Type: MCSA A parent brings her baby 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: Positive resolution would indicate a safe feeling when the parents leave the child with someone they are familiar with and can trust. Negative resolution would indicate mistrust, withdrawal, and estrangement. Rationale 3: Willfulness and defiance are negative indicators of the early childhood stage. Rationale 4: Playing with other children is part of the self-esteem and self-expression of the early childhood years. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 2. Describe essential principles related to growth and development. MNL Learning Outcome: 2.1.1 Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 315 Question 22 Type: MCSA A parent tells the nurse that his child is quite 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 Correct Answer: 2 Rationale 1: Stage 5, 12 to 18 months, is characterized by discovery of new goals and ways to attain goals. Rituals are important in this stage. Rationale 2: 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. Rationale 3: The preconceptual phase, 2 to 4 years, is when the child uses an egocentric approach to accommodate the demands of an environment. Rationale 4: The concrete operations phase, 7 to 11 years, is where the child is able to solve concrete problems and begins to understand relationships such as size and right and left, and is cognizant of viewpoints. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11. Explain Piaget’s theory of cognitive development. MNL Learning Outcome: 2.1.1 Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 319 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 23 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 3 Rationale 1: Taking on civic responsibilities is one of Havighurst’s early adulthood tasks. Rationale 2: Developing adult leisure-time activities is not a part of the middle-age period. Rationale 3: Getting started in an occupation is one of Havighurst’s early adulthood tasks. Rationale 4: Relating oneself to one's spouse as a person is not a part of the middle-age period. Rationale 5: Managing a home is one of Havighurst’s early adulthood tasks. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Identify developmental tasks associated with Havighurst’s six age periods. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 316 Question 24 Type: MCMA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The nurse is discussing human growth and development with the parents of a newborn. What should the nurse include in this discussion? Standard Text: 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. Correct Answer: 1, 3, 5 Rationale 1: Growth is physical change and increase in size. Rationale 2: Development is an increase in the complexity of function and skill progression. Rationale 3: The pattern of physiologic growth is similar for all people. Rationale 4: Development skills include the ability to adapt to one’s environment. Rationale 5: Growth can be measured quantitatively. Indicators of growth include height, weight, bone size, and dentition. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe essential principles related to growth and development.. MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 313 Question 25 Type: MCMA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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? Standard Text: 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 Correct Answer: 1, 2, 3 Rationale 1: The genetic inheritance of an individual is established at conception. It remains unchanged throughout life, and determines such characteristics as gender and physical characteristics (e.g., eye color, potential height). Rationale 2: Temperament sets the stage for the interactive dynamics of growth and development. Rationale 3: Adequate nutrition is an essential component of growth and development. Rationale 4: Although adequate family income allows for sufficient nutrition, housing, and other needs, it is not generally considered a factor affecting growth and development. Rationale 5: Being cared for by individuals other than one’s parents is not generally considered as a factor unless care is neglected by whoever is responsible. Global Rationale: Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 03 List factors that influence growth and development. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. List factors that influence growth and development. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 312 New Questions: Question 26 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 4, 5 Rationale 1: 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. Rationale 2: Bowlby believed that attachment served as a protective or survival mechanism for the infant. Characteristics of Bowlby’s attachment theory include the desire to be near the attachment figure. Rationale 3: Bowlby believed that attachment served as a protective or survival mechanism for the infant. Characteristics of Bowlby’s attachment theory do not include a plan to separate from the attachment figure. Rationale 4: Bowlby believed that attachment served as a protective or survival mechanism for the infant. Characteristics of Bowlby’s attachment theory include returning to the attachment figure when threatened. Rationale 5: Bowlby believed that attachment served as a protective or survival mechanism for the infant. Characteristics of Bowlby’s attachment theory include expressing anxiety (separation anxiety) when the attachment figure is absent. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10. State the four characteristics of Bowlby’s attachment theory. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 319 Question 27 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 3 Rationale 1: Defense mechanisms or adaptive mechanisms are the result of anxiety created by the conflicts due to social and environmental restrictions. Rationale 2: Activation of the conscience is a function of the superego. Rationale 3: Defense mechanisms or adaptive mechanisms are the result of conflicts between the id’s impulses. Rationale 4: Immediate pleasure and gratification is a function of the id. Rationale 5: The underlying motivation for development is the libido. Global Rationale: Defense mechanisms or adaptive mechanisms are the result of conflicts between the id’s impulses and the anxiety created by the conflicts due to social and environmental restrictions Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Describe characteristics and implications of Freud’s five stages of development. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 315

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 21 Question 1 Type: MCSA A client comes to the women's clinic, stating she has had a positive home pregnancy test. The client states that her 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 Correct Answer: 4 Rationale 1: The fetal phase of development is characterized by a period of rapid growth in the size of the fetus and corresponds to the second trimester of pregnancy. Rationale 2: The fetal phase of development is characterized by a period of rapid growth in the size of the fetus and corresponds to the second trimester of pregnancy. Rationale 3: The third trimester is the last 3 months of the pregnancy period. Rationale 4: 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 the human. This period is considered to encompass the first 8 weeks of pregnancy. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 328 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 2 Type: MCSA 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." Correct Answer: 2 Rationale 1: This option, although not incorrect, doesn’t adequately address the parents’ question. Rationale 2: 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. Rationale 3: This option dismisses the parents’ question. Rationale 4: This option is insensitive and does not answer the parents’ question. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 329 Question 3 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 3 Rationale 1: Protein sources are important for overall health but do not increase intake of folic acid. Rationale 2: 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. Rationale 3: 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. Rationale 4: Protein sources and low-fat foods are important for overall health but do not increase intake of folic acid. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 329 Question 4 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Smoking 3. Having low levels of folic acid 4. Genetic history Correct Answer: 2 Rationale 1: Teratogens are medications known to adversely affect normal cellular development in the embryo or fetus. Rationale 2: Exposure to environmental tobacco smoke has been associated with preterm births, stillbirth, miscarriage, and low-birth-weight infants. Rationale 3: Folic acid is necessary for normal neural tube development. Rationale 4: Genetic history does not affect the risk for spontaneous abortion. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 329 Question 5 TYPE: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 3, 5 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Adolescents between the ages of 11 and 15 begin the formal operations stage of cognitive development. They are able to think logically. Rationale 2: Adolescents between the ages of 11 and 15 begin the formal operations stage of cognitive development. They are able to think futuristically. Rationale 3: Adolescents between the ages of 11 and 15 begin the formal operations stage of cognitive development. They are able to think rationally. Rationale 4: A trial-and-error process is a cognitive approach used by toddlers. Rationale 5: Adolescents between the ages of 11 and 15 begin the formal operations stage of cognitive development. They can conceptualize things as they could be rather than as they are. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain cognitive development according to Piaget from infancy through adolescence. MNL Learning Outcome: 2.1.2. Analyze the school-age child and adolescent’s physiologic and psychosocial development. Page Number: 347 Question 6 Type: MCSA At birth a baby weighed 8 lb. What should the nurse expect this baby to weight at the age of 1? 1. 32 lb 2. 16 lb 3. 20 lb 4. 24 lb Correct Answer: 4 Rationale 1: This weight is above the expected weight for this infant at 1 year of age.. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: This weight is well below the expected weight for this infant at 1 year of age. Rationale 3: This weight is below the expected weight for this infant at 1 year of age. Rationale 4: 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 to 7 ounces weekly for 6 months. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 330 Question 7 Type: MCSA Parents of a newborn ask the nurse why their newborn’s head seems lopsided and not round, as they thought it should be. How should the nurse respond to these parents? 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." Correct Answer: 2 Rationale 1: This option dismisses the parents’ concerns. Rationale 2: 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. Rationale 3: This condition is not abnormal and does not need to be referred to the doctor; rather, the nurse needs to reassure the parents that nothing is wrong. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: This option is not necessarily true, nor does it adequately address the parents’ concerns. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 331 Question 8 Type: MCSA 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." Correct Answer: 3 Rationale 1: This is not necessarily correct information because we don't know what they "see" or how it looks to them. Rationale 2: At 5 months, the infant reaches for objects, but starts tracking them much sooner. Rationale 3: 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. Rationale 4: We don't know what newborns "see" or how it looks to them. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 331 Question 9 Type: MCSA The parents of a newborn male ask the nurse about pain during circumcision. What should the nurse respond to these parents? 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." Correct Answer: 4 Rationale 1: Newborns certainly do feel pain. Rationale 2: Newborns certainly do feel pain and it is important to comfort the child, but this option does not answer the parents' question. Nurses who care for newborns should be able to explain expected reactions to the parents. Rationale 3: Nurses who care for newborns should be able to explain expected reactions to the parents. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 332 Question 10 Type: MCMA An expectant parent asks the nurse about health problems of newborns. On what should the nurse provide information to this client? Standard Text: Select all that apply. 1. Infant colic 2. Respiratory tract infections 3. Failure to thrive 4. Injuries 5. SIDS Correct Answer: 1, 3, 5 Rationale 1: Health problems of newborns include infant colic. Rationale 2: Respiratory tract infections are more common for toddlers and school-age children. Rationale 3: Health problems of newborns include failure to thrive. Rationale 4: Injuries are more problematic as the child grows, especially in the school-age child. Rationale 5: Health problems of newborns include SIDS. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 333 Question 11 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: The CDC utilizes growth charts for physical assessment, but these do not address developmental issues. Rationale 3: The school system assessment tools would be focused on the school-age child. Rationale 4: The Apgar scoring system is used to provide information about the baby's physiologic adaptation within minutes after birth. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Identify tasks characteristic of different stages of development from infancy through adolescence. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 335 Question 12 Type: MCSA The parents of a toddler are concerned that their child is so messy during eating, so they feed him instead of allowing him to feed himself. 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." Correct Answer: 3 Rationale 1: This option reflects parental action that will interfere with the child’s development; assuring the parents that this will improve may help them with their patience during the messy times. Rationale 2: This option does not address the developmental need for the child to attempt feeding himself. Rationale 3: 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. Rationale 4: Simply doing the skill for the child will allow no room for practice and error. However, the nurse must be careful in how this is worded, so as not to sound "scolding" to the parents. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Identify tasks characteristic of different stages of development from infancy through adolescence. MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 336 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 13 Type: MCSA 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." Correct Answer: 2 Rationale 1: Regressive behavior is not based on physiology and, unless it lasts, would not have to be further investigated. Rationale 2: Regression is reverting to an earlier development stage (bed-wetting, 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. Rationale 3: Strict discipline may not be the best solution over understanding and caring. Rationale 4: This option does not provide the parents with an understanding of the root of the problem. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Identify tasks characteristic of different stages of development from infancy through adolescence. MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 337 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 14 Type: MCSA A kindergarten class is being screened by a group of nursing students using a Snellen E chart. Few of the children have 20/20 vision. Most have 20/30, and some have 20/40. What should the nursing students report to the instructor about these children’s vision? 1. "These children have normal vision abilities." 2. "We should check into the health of these children. Maybe their diets are lacking in essential vitamins because they all have poor eyesight." 3. "These kids will all be wearing glasses when we come back next year." 4. "We should use a different eye chart. Maybe the kids would understand it better." Correct Answer: 1 Rationale 1: 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. Rationale 2: Unless there are other concerns, these findings should be considered normal and further investigation would be unnecessary. Rationale 3: This option does not reflect an understanding of normal physical development of a child. Rationale 4: The Snellen E chart should be used to assess the preschooler's vision. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 338 Question 15 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

During an auditory screening of third graders, the school nurse identifies a hearing deficit for one of the students. When the parents ask the nurse 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." Correct Answer: 2 Rationale 1: The follow-up for these findings should not be postponed. Rationale 2: 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. Rationale 3: Auditory testing should be done in a quiet environment or none of the testing is accurate. Rationale 4: The child's hearing test could be affected by a number of physiological variables (e.g., recent respiratory illness or excess cerumen in the ears), and telling the parents their child needs a hearing aid is both premature and not within the nurse's realm of practice. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 2.1.2. Analyze the school-age child and adolescent’s physiologic and psychosocial development. Page Number: 339 Question 16 Type: MCSA A school nurse is working with teachers in helping them address 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 4 Rationale 1: Gross motor skills should be the focus of the preschool child. Understanding diversity, role preference, and performance is the task of the adolescent. Rationale 2: Make-believe and pretend opportunities should be the focus of the preschool child. Rationale 3: Understanding diversity, role preference, and performance is the task of the adolescent. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Trace psychosocial development according to Erikson from infancy through adolescence. MNL Learning Outcome: 2.1.2. Analyze the school-age child and adolescent’s physiologic and psychosocial development. Page Number: 342 Question 17 Type: SEQ The parents of a school-age child are concerned about the child learning right from wrong. In which order should the nurse instruct the parents of a school-age child that moral development will develop in their child? Standard Text: Click and drag the options below to move them up or down. Choice 1. Punishment and obedience Choice 2. Law-and-order orientation Choice 3. Instrumental-relativist orientation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Choice 4. "Good boy–nice girl" stage Correct Answer: 1, 4, 2, 3 Rationale 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. Rationale 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. Rationale 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. Rationale 4: Stage 3 is the “good boy–nice girl” stage. The child shifts from the concrete interests of individuals to the interests of groups. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe moral development according to Kohlberg from childhood through adolescence. MNL Learning Outcome: 2.1.2. Analyze the school-age child and adolescent’s physiologic and psychosocial development. Page Number: 343 Question 18 Type: MCSA A school health nurse is working on education programs for high school students. As part of the plan, the nurse wants to address health concern topics 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 Correct Answer: 1 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Suicide in adolescents has declined in recent years, but continues to be a significant problem. Older adolescents, males, and non-Hispanic American Indians and Alaskan Natives have the highest rates of suicides among adolescents. 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. Rationale 2: Injury prevention should be the focus in the school-age child. Rationale 3: Cancer and heart disease are not prevalent problems among high-school-age students. Rationale 4: Normal physiological changes would not address the health problems of this age group, but rather would give general information. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 2.1.2. Analyze the school-age child and adolescent’s physiologic and psychosocial development. Page Number: 348 Question 19 Type: MCSA 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." Correct Answer: 3 Rationale 1: Ejaculation does not mean the same thing as fertility, which does occur before sexual maturity. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Fertility follows several months later, with sexual maturity achieved by age 18. Ejaculation does not mean the same thing as fertility, which does occur before sexual maturity. Rationale 3: 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. Rationale 4: The nurse, in presenting topics of a sensitive nature, should be able to answer questions regarding the topic, not refer the audience to a physician. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 2.1.2. Analyze the school-age child and adolescent’s physiologic and psychosocial development. Page Number: 345

Question 20 TYPE: MCMA 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? Standard Text: 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 Correct Answer: 3, 4, 5 Rationale 1: Imitating behavior demonstrated by parents is a behavior of a preschool-age child. Rationale 2: Conceptualizing angels and devils with the use of imagination is a behavior demonstrated by a preschool-age child. Rationale 3: The adolescent may reconcile differences in spiritual beliefs by compartmentalizing the differences.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The adolescent may reconcile differences in spiritual beliefs by deciding which differences are right or wrong. Rationale 5: The adolescent may reconcile differences in spiritual beliefs by obtaining advice from a priest. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 2.1.2. Analyze the school-age child and adolescent’s physiologic and psychosocial development. Page Number: 347 Question 21 Type: MCSA A teenage girl spends most of her free time with friends. In sharing their concerns about this behavior with the school nurse, the parents are worried about their child seeming to draw away from them. 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?" Correct Answer: 2 Rationale 1: This option reflects any overly pessimistic view regarding the child’s behavior. Rationale 2: 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. Rationale 3: Parents should try not to increase controls, as this may cause more rebellion in the child. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: This option reflects any overly pessimistic view regarding the child’s behavior. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Identify tasks characteristic of different stages of development from infancy through adolescence. MNL Learning Outcome: 2.1.2. Analyze the school-age child and adolescent’s physiologic and psychosocial development. Page Number: 345 Question 22 Type: MCSA An adolescent comes to the school nurse's office seeking advice about his friends and feeling pressure to participate in activities with which he isn't comfortable, 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. Correct Answer: 2 Rationale 1: Giving directions may turn the student away from seeking help. Rationale 2: 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. Rationale 3: Suggesting counseling may turn the student away from seeking help. Rationale 4: Just giving written information on a particular topic will not address the complete situation the student seeks assistance with. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 2.1.2. Analyze the school-age child and adolescent’s physiologic and psychosocial development. Page Number: 345 Question 23 Type: MCSA A nurse is teaching a class to new parents on how to handle some of the behaviors that could be demonstrated by toddlers. One of the parents asks what to do when her 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." Correct Answer: 3 Rationale 1: Sometimes, even with all the best intentions, toddlers throw tantrums. Parents should not be made to feel like it was something they did wrong or could have prevented. Rationale 2: Placing the child away from supervision (in a room alone) could increase the risk of injury. Rationale 3: Making sure of safety, then walking away is part of fostering the toddler's psychosocial development. Rationale 4: Holding the child tight will only add to the child's frustration and possibly increase the behavior. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 336 Question 24 Type: MCSA A 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 Correct Answer: 4 Rationale 1: Appropriate psychosocial activities for the adolescent include activities to stimulate interest in careers. Rationale 2: Establishing peer groups would be part of psychosocial development of the school-age child. Rationale 3: Learning to play a musical instrument would be motor development for the school-age child. Rationale 4: Appropriate psychosocial activities for the adolescent include activities to help establish an appropriate value system. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: 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: 2.1.2. Analyze the school-age child and adolescent’s physiologic and psychosocial development. Page Number: 346 Question 25 Type: MCSA 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 Correct Answer: 1 Rationale 1: Flaccid muscle tone = 0. Regular respirations = 2. Crying = 2. Heart rate of 85 = 1. Blue extremities = 1. Total = 6. Rationale 2: Flaccid muscle tone = 0. Regular respirations = 2. Crying = 2. Heart rate of 85 = 1. Blue extremities = 1. Total = 6. Rationale 3: Flaccid muscle tone = 0. Regular respirations = 2. Crying = 2. Heart rate of 85 = 1. Blue extremities = 1. Total = 6. Rationale 4: Flaccid muscle tone = 0. Regular respirations = 2. Crying = 2. Heart rate of 85 = 1. Blue extremities = 1. Total = 6. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe usual physical development from infancy through adolescence. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 334 Question 26 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 4 Rationale 1: Events occurring concurrently during the first 3 weeks include the embryo’s being implanted in the endometrium of the uterus. Rationale 2: Events occurring concurrently during the first 3 weeks include fetal membranes’ differentiating into the chorion—the precursor to the placenta—and the amnion, the precursor to the amniotic sac. Rationale 3: At the end of the second trimester, or 6 lunar months, a protective covering called vernix caseosa begins to develop over the skin. Rationale 4: Events occurring concurrently during the first 3 weeks include the function of the placenta. Rationale 5: At the end of the second trimester, or 6 lunar months, lanugo—a fine downy hair—covers the body. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 328 Question 27 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 2, 4 Rationale 1: Development is assessed when the child is able to print letters and numbers by 5 years of age. Rationale 2: Development is assessed when the child is able to cooperate in doing simple chores by 5 years of age. Rationale 3: This is a developmental task more appropriate for school-age children. Rationale 4: Development is assessed when the child is able to perform simple hygiene measures by 5 years of age. Rationale 5: This is a developmental task more appropriate for a school-age child. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 7. Identify assessment activities and expected characteristics from birth through late childhood. MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and psychosocial development. Page Number: 339

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 22 Question 1 Type: MCSA The nurse is providing pre-employment physicals to a group of adults, aged 30 to 40. In which generation should the nurse categorize these adults? 1. Baby Boomers 2. Generation X 3. Generation Y 4. Millennials Correct Answer: 2 Rationale 1: The Baby Boomers were born in the years 1945 to 1964. Rationale 2: Generation X includes individuals born in the years 1965 to 1978. Rationale 3: Generation Y includes individuals born between the years 1979 and 2000. Rationale 4: Millennials were born between the years 1979 and 2000. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Compare and contrast the following generational groups: baby boomers, Generation X, and Generation Y. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 353 Question 2 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

A colleague is telling the community health nurse that his adult child has just moved back in with him and his wife. They are finding this situation somewhat difficult to adjust to. The nurse offers support and listens, while understanding that which factor is least likely contributing to this particular trend? 1. Maladaptive behavior 2. High unemployment rate 3. High housing costs 4. High incidence of chronic disease Correct Answer: 4 Rationale 1: These young adults, known as "Boomerang Kids," have moved back into their parents' homes after an initial period of independent living. A factor that has contributed to this trend is maladaptive behavior. Rationale 2: These young adults, known as "Boomerang Kids," have moved back into their parents' homes after an initial period of independent living. A factor that has contributed to this trend is high unemployment rates. Rationale 3: These young adults, known as "Boomerang Kids," have moved back into their parents' homes after an initial period of independent living. A factor that has contributed to this trend is high housing costs. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Compare and contrast the following generational groups: baby boomers, Generation X, and Generation Y. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 354 Question 3 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Commented [KB1]: AU/ED: pls check seems that correct rationale s/b a factor that has not contributed to this trend Commented [D2]: See rationale 4 below

1. Formal operational stage 2. Postformal thought process 3. Kohlberg's theory of moral development 4. Fowler's spiritual development theory Correct Answer: 2 Rationale 1: Young adults are able to use formal operations, characterized by the ability to think abstractly. Rationale 2: 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. Rationale 3: Young adults enter the postconventional level of Kohlberg's moral theory. Rationale 4: This would not be considered a spiritual dilemma, so Fowler's theory would not be utilized. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify characteristic tasks of psychosocial development during young and middle adulthood. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 355 Question 4 Type: MCSA 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? 1. Decreased interest in work 2. Weight loss 3. Depression Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Brain dysfunction, including tumors 5. Sleep disturbances Correct Answer: 1, 2, 3, 5 Rationale 1: The nurse’s role in the prevention of suicide includes identifying behaviors that may indicate potential problems, including decreased interest in work roles. Rationale 2: The nurse’s role in the prevention of suicide includes identifying behaviors that may indicate potential problems, including weight loss. Rationale 3: The nurse’s role in the prevention of suicide includes identifying behaviors that may indicate potential problems, including depression. Rationale 4: Brain tumors are not an indicator for suicide. Rationale 5: The nurse’s role in the prevention of suicide includes identifying behaviors that may indicate potential problems, including sleep disturbances. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify selected health risks associated with young and middle-aged adults. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 356 Question 5 Type: MCSA 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. White females Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 2 Rationale 1: Hypertension is a problem for males and females equally.

Commented [KB3]: AU: pls check--should the rationale have "major problem" for only the correct answer? Commented [D4]: See edits to rationales

Rationale 2: Hypertension is a major problem for young African American adults, particularly men. The causes for this are unknown. Rationale 3: Hypertension is not a major problem for Asian American females. Rationale 4: Hypertension is not a major problem for White females. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify selected health risks associated with young and middle-aged adults. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 356 Question 6 Type: MCSA 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, the nurse plans to: 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. Correct Answer: 1 Rationale 1: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Commented [KB5]: AU: pls check--if this is correct answer, s/b "help the group become more aware of"?

Rationale 2: The nurse's role regarding smoking does not include making judgment statements. Rationale 3: There is not current research to support the role of tobacco in the development of liver and esophagus cancers. Rationale 4: The nursing role in this situation is to educate, not counsel. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Identify selected health risks associated with young and middle-aged adults. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 356 Question 7 Type: MCSA 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." Correct Answer: 2 Rationale 1: The nurse should educate clients regarding physical changes occurring in their bodies. Statements that generalize weight loss with all other age groups are neither accurate nor helpful to the person asking the question. Rationale 2: 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. Rationale 3: There are other factors in addition to exercise that can affect weight in this age group. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Statements that generalize weight loss with all other age groups are neither accurate nor helpful to the person asking the question. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. List examples of health promotion topics for young and middle adulthood. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 358 Question 8 Type: MCSA 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. Correct Answer: 3 Rationale 1: There is no current evidence to support such work as a risk factor for such symptoms. Rationale 2: There is no current evidence to support smoking as a risk factor for such symptoms. Rationale 3: 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. Rationale 4: Men who have risk factors for testicular cancer should discuss monthly testicular self-examination with their primary care provider. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Identify developmental assessment guidelines for young and middle-aged adults. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 358 Question 9 Type: MCSA 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 the client? 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?" Correct Answer: 3 Rationale 1: Generalized questions about life do not adequately address the client’s needs during this assessment. Rationale 2: Generalized questions about life problems do not adequately address the client’s needs during this assessment. Rationale 3: A 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. Rationale 4: Generalized questions about family life do not adequately address the client’s needs during this assessment. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify selected health risks associated with young and middle-aged adults. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 355 Question 10 Type: MCSA 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, the nurse should explain that it is important for these women to 1. do monthly breast self-exams. 2. have a 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 health care provider. Correct Answer: 4 Rationale 1: Breast self-exam is no longer recommended for all women. Rationale 2: Yearly mammography for all women over the age of 40 is encouraged, as it decreases mortality from breast cancer. Rationale 3: Although a family history of breast cancer is a risk factor, it is not the sole reason to monitor for breast cancer. Rationale 4: The American Cancer Society recommends that a health care practitioner perform a breast examination at a yearly physical exam. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. List examples of health promotion topics for young and middle adulthood. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 357 Question 11 Type: MCSA 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 Correct Answer: 2 Rationale 1: There is not current evidence to support this option. Rationale 2: 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. Rationale 3: There is not current evidence to support this option. Rationale 4: There is not current evidence to support this option. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Identify developmental assessment guidelines for young and middle-aged adults. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 357 Question 12 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: Recommended immunizations for this age group include tetanus-diphtheria booster every 10 years. Rationale 2: The hepatitis B series would not be recommended for travel within the United States. Rationale 3: Recommended immunizations for this age group include the meningococcal vaccine if not given in early adolescence. Rationale 4: There are recommended immunizations for this age group. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Identify developmental assessment guidelines for young and middle-aged adults. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 358 Question 13 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Assisting the group members to look at their life accomplishments Correct Answer: 1 Rationale 1: 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. Rationale 2: Peer socialization is a task of the young adult and adolescent. Rationale 3: Finding civic responsibility is a task of the young adult and adolescent. Rationale 4: Taking inventory of past accomplishments is the task of the older adult. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Identify characteristic tasks of psychosocial development during young and middle adulthood. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 359 Question 14 Type: MCSA 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 Correct Answer: 1 Rationale 1: Erikson identifies this stage as generativity versus stagnation. Generative middle-aged persons are able to feel a sense of comfort in their lifestyle and receive gratification from charitable endeavors. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: This option identifies tasks associated with the young adult stage. Rationale 3: This option identifies tasks associated with the young adult stage. Rationale 4: This option identifies tasks associated with the young adult stage. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify characteristic tasks of psychosocial development during young and middle adulthood. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 359 Question 15 Type: MCSA 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. Correct Answer: 3 Rationale 1: Cognitive and intellectual abilities change very little during this time. Rationale 2: Transition into middle life can be as critical as during adolescence. Some refer to the "midlife crisis" and call the decade between 35 and 45 years the "deadline decade." Rationale 3: Physical capabilities and functions do decrease with age, but mental and social capacities actually increase in the latter part of life. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Cognitive and intellectual abilities change very little during this time. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Identify developmental assessment guidelines for young and middle-aged adults. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 359 Question 16 Type: MCSA 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." Correct Answer: 2 Rationale 1: According to Kohlberg, the extensive experience of personal moral choice and responsibility is required to move into the postconventional level. A statement about work not being so bad shows a complacency about work that is not reflective of the postconventional level. Rationale 2: According to Kohlberg, the extensive experience of personal moral choice and responsibility is required to move into the postconventional level. Movement from a law-and-order 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. Rationale 3: Stating that the person has pride about work and the time spent doing it would be an example of Erikson's stage of integrity versus despair. Rationale 4: According to Kohlberg, the extensive experience of personal moral choice and responsibility is required to move into the postconventional level. A statement about not wanting to talk about work shows complacency about work that is not reflective of the postconventional level. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe moral development according to Kohlberg throughout adulthood. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 360 Question 17 Type: MCSA 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. Correct Answer: 4 Rationale 1: Cancer is the second leading cause of death among people between the ages of 25 and 64 years. Rationale 2: Coronary heart disease is the leading cause of death among all age groups in the United States. Rationale 3: There is no evidence to support this statement regarding suicide. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe moral development according to Kohlberg throughout adulthood. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 360 Question 18 Type: MCSA 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." Correct Answer: 4 Rationale 1: Telling a client who is struggling not to worry is not therapeutic and does not address the problem. Rationale 2: Advice about medications is not within nurses' scope of practice, as they do not prescribe. Rationale 3: Comparing this client's situation to her mother's is neither relevant nor therapeutic. Her mother's age group was going through experiences in a different time and culture. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. List examples of health promotion topics for young and middle adulthood. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 360 Question 19 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: This option does not necessarily address the concerns of this specific age group. Rationale 3: Although this information is not incorrect, is the nurse's responsibility to provide general information, education, and sources for clients seeking improvement in their nutrition that would include but not be limited to encouragement to check with their physician before dieting. Rationale 4: Although encouraging the individuals to write for information is not incorrect, in this situation it is the nurse's responsibility to provide information, education, and resources for clients seeking improvement in their nutrition. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Identify selected health risks associated with young and middle-aged adults. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 361 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 20 Type: MCMA The nurse is working with young adults in the community. What should the nurse realize as being the psychosocial developmental tasks of this population? Standard Text: 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 Correct Answer: 1, 2, 4 Rationale 1: Selecting a mate is a task appropriate for this age group. Rationale 2: Rearing children is a task appropriate for this age group. Rationale 3: Achieving civic responsibility is a task of the middle-aged adult. Rationale 4: Finding a congenial social group is a task appropriate for this age group. Rationale 5: Developing adult leisure-time activities is a task of the middle-aged adult. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify characteristic tasks of psychosocial development during young and middle adulthood. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 354 Question 21 . Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 21 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 2, 4, 5 Rationale 1: The middle-aged adult’s cognitive and intellectual abilities change very little. Reaction time during the middle years stays much the same. Rationale 2: The middle-aged adult’s cognitive and intellectual abilities change very little. Memory is maintained during middle adulthood. Rationale 3: The middle-aged adult’s cognitive and intellectual abilities change very little. Learning continues and can be enhanced with motivation. Rationale 4: The middle-aged adult’s cognitive and intellectual abilities change very little. Problem-solving ability is maintained during middle adulthood. Rationale 5: The middle-aged adult’s cognitive and intellectual abilities change very little. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Explain changes in cognitive development throughout adulthood. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 359 Question 22 Type: MCMA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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? Standard Text: 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 Correct Answer: 1, 2, 4 Rationale 1: The psychosocial development of a young adult would include keeping good health habits. Rationale 2: The psychosocial development of a young adult would include the ability to cope with stressors appropriately. Rationale 3: The psychosocial development of a middle-aged adult would include pursuing charitable and altruistic activities. Rationale 4: The psychosocial development of a young adult would include having a realistic self-concept. Rationale 5: The psychosocial development of a middle-aged adult would include accepting his aging body. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify characteristic tasks of psychosocial development during young and middle adulthood. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 354 New Question: Question 23 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 5 Rationale 1: 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. Rationale 2: 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. Rationale 3: Comparing characteristics of various religions is a characteristic of an earlier stage of development. Rationale 4: Questioning the purpose of religion in one’s life is a characteristic of an earlier stage of development. Rationale 5: 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 illness. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Development Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Describe spiritual development according to Fowler throughout adulthood. MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial development. Page Number: 360

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 23 Question 1 Type: MCSA 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 Correct Answer: 3 Rationale 1: Those of age 65 to 74 years are referred to as the young-old. Rationale 2: Those of age 75 to 84 are the middle-old. Rationale 3: Those of age 85 to 100 are the old-old. Rationale 4: Individuals over 100 are considered the elite-old. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Identify the different categories of older adults as they range from 65 to 100 years of age. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 365

Question 2 Type: MCMA The nurse is planning care for an older adult client. On what should the nurse focus if following the Functional Consequences Theory on aging? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Standard Text: 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. Correct Answer: 1, 3 Rationale 1: Miller developed the Functional Consequences Theory in 1990. Functional consequences are agerelated changes, actions that have placed the client at risk for illness or injury, and risk factors for disease. The nurse should design interventions that promote safety. Rationale 2: In the Nursing Theory of Successful Aging developed by Flood, the client experiences spiritual connections and a sense of meaning and worth. Nurses must target interventions for the older adult in the promotion of mental health throughout the aging process. Rationale 3: Miller developed the Functional Consequences Theory in 1990. Functional consequences are agerelated changes, actions that have placed the client at risk for illness or injury, and risk factors for disease. The nurse should design interventions that improve the client’s quality of life. Rationale 4: In the Nursing Theory of Successful Aging developed by Flood, the client experiences spiritual connections and a sense of meaning and worth. Nurses must target interventions for the older adult in the promotion of spiritual health throughout the aging process. Rationale 5: The Theory of Thriving asserts that nurses must intervene to promote the older adult’s growth and development. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. List the common biological theories of aging. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 369 Question 3 Type: MCSA A 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: Because elderly persons have a loss of subcutaneous fat, their tolerance of cold is decreased and they would not be comfortable in a temperature suited to a younger individual. Rationale 2: Because elderly persons have a loss of subcutaneous fat, their tolerance of cold is decreased and they typically do not enjoy cooler temperatures. Rationale 3: Because elderly persons have a loss of subcutaneous fat, their tolerance of cold is decreased and they typically enjoy warmer temperatures. Rationale 4: If the environment is not comfortable to the audience, they will be distracted and not be able to focus or concentrate on the presentation and any information the nurse shares. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the demographic, socioeconomic, ethnicity, and health characteristics of older adults in the United States. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 370 Question 4 Type: MCSA In the review of an elderly 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Bleeding and bruising tendencies 4. Lack of strength and tiring easily Correct Answer: 4 Rationale 1: Sarcopenia is not generally related to weight loss or nausea. Rationale 2: Alopecia is loss of hair. Rationale 3: Thrombocytopenia may cause bleeding and bruising. Rationale 4: 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 elders to often complain about their lack of strength and how quickly they tire. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Describe the usual physical changes that occur during older adulthood. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 370 Question 5 Type: MCSA 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." Correct Answer: 1 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: There is evidence that an older adult's muscles can be strengthened through exercise and training, with concomitant improvements in functional status. Rationale 2: It would be inappropriate for the nurse to assume that there is no room for improvement. Rationale 3: Physical changes associated with the aging process are normal, but not something that can't be improved upon. Rationale 4: There is evidence that an older adult's muscles can be strengthened through exercise and training, with concomitant improvements in functional status. It would be inappropriate for the nurse to suggest that the client is a suitable candidate for long-term care. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe the usual physical changes that occur during older adulthood. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 371 Question 6 Type: MCSA 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. Correct Answer: 2 Rationale 1: Exercise and proper nutrition will not reverse the effects of aging, nor will they eliminate the risk for osteoporosis. Rationale 2: Programs of physical activity and proper nutrition will slow bone density loss and decrease muscle atrophy and stiffness that occurs with aging. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Exercise and proper nutrition will not reverse the effects of aging, nor will they eliminate the risk for osteoporosis. Rationale 4: Pathologic fractures occur spontaneously, without a fall or trauma to the bone. Many are a result of low bone density or tumor. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8. Describe the usual physical changes that occur during older adulthood. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 372 Question 7 Type: MCSA A 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. Correct Answer: 3 Rationale 1: Not all elderly people need glasses or hearing aids. Rationale 2: 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. Wearing darker glasses will not increase the brightness of the home. Rationale 3: 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. Rationale 4: Exercise and nutrition do not address sensory problems. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15. Describe selected health problems associated with older adults. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 372 Question 8 Type: MCSA A school nurse is bringing a group of students to a nursing home for a social exchange 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. Correct Answer: 4 Rationale 1: This option assumes that all residents have significant hearing loss, which is ageism. Rationale 2: This option assumes that all residents have significant hearing loss, which is ageism. Rationale 3: This option assumes that all residents have significant hearing loss, which is ageism. Rationale 4: Hearing loss in the elderly 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe the usual physical changes that occur during older adulthood. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 373 Question 9 Type: MCSA A 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 to this group? 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: Emergency numbers by the phone is a good idea, but does not address sensory changes. Rationale 3: Telephones that utilize a blinking light are used for people who are significantly hearing impaired. Rationale 4: It is not necessary for someone to do cooking for this age group, although they may be inclined to use more salt due to decreased sense of smell and taste. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16. List examples of health promotion topics for older adulthood. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 382 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 10 Type: MCSA An elderly client comes to the clinic after checking his blood pressure several times in the local discount store. The nurse checks the blood pressure and finds that it is 146/80. 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." Correct Answer: 2 Rationale 1: Current 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. Rationale 2: 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. Rationale 3: Current 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. Rationale 4: It would be up to the physician or primary care provider whether or not to treat. The nurse does not make this decision. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15. Describe selected health problems associated with older adults. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 370 Question 11 Type: MCSA The elderly client comes to the clinic reporting gastrointestinal problems, including frequent constipation and indigestion, but denies any recent weight loss. The nurse initially recognizes that these symptoms Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. indicate a concern and could be caused by cancer. 2. indicate the need for an upper and lower GI x-ray series. 3. could be related to normal changes in muscle tone and activity. 4. are probably indicative of a gastric ulcer or colitis. Correct Answer: 3 Rationale 1: It would be premature, as well as outside the scope of nursing practice, for the nurse to consider any other pathology. Rationale 2: 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. It would be premature, as well as outside the scope of nursing practice, for the nurse to tell the client that there is a need for invasive testing. Rationale 3: 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. Rationale 4: It would be premature, as well as outside the scope of nursing practice, for the nurse to consider any other pathology. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Describe the usual physical changes that occur during older adulthood. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 371 Question 12 Type: MCSA An older adult client comes to the clinic with reports of not being able to hold her urine, stating: "I feel so terrible. This shouldn't happen at my age." How should the nurse respond? 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." Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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." Correct Answer: 4 Rationale 1: This option inappropriately attempts to minimize the client’s concerns. Rationale 2: Incontinence briefs are useful products for people who have urinary incontinence (UI), but the cause for all cases must be investigated. Rationale 3: The client already feels badly—the nurse only makes this feeling worse by adding to it. Rationale 4: Elders 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15. Describe selected health problems associated with older adults. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 371 Question 13 Type: MCSA An older male client comes to the clinic and states to the nurse that he hasn't been interested in sexual intercourse lately. He states: "I guess this is part of getting old, too." 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. Correct Answer: 4 Rationale 1: Libido may decrease but not disappear. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: If an older man reports a loss in sexual interest, the nurse should be as concerned as when a younger man reports a loss of interest in sexual activity. Rationale 3: Decrease in hormone secretion and activity is a normal aging process, but there may be treatment measures that can help if this is the case. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe the usual physical changes that occur during older adulthood. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 374 Question 14 Type: MCSA In planning any health program for elderly adults, the nurse will implement Erikson's theory of task development. The nurse realizes that in this stage of life, the successful completion of the task allows the person to 1. have a feeling of satisfaction from past accomplishments. 2. make connections with the younger generation. 3. wish he or she could live life over again. 4. live out his or her last years in physical health. Correct Answer: 1 Rationale 1: 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. Rationale 2: Making connections with the younger generation is part of the task of the middle-adult age group. Rationale 3: People who despair often believe they made poor choices during life and wish they could live life over. Rationale 4: Physical health is not part of psychosocial development. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 10. Describe developmental tasks of the older adult. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 375 Question 15 Type: MCSA 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 Correct Answer: 3 Rationale 1: Those who have been concerned only with the accomplishments of their children can be left with a feeling of emptiness when the children leave. Rationale 2: People who have been concerned only with the paycheck and their job status can be left with a feeling of emptiness when the job no longer exists. Rationale 3: People who learned early in life to live well-balanced and fulfilling lives are generally more successful in retirement. Rationale 4: People who attempt suddenly to refocus and enrich their lives at retirement usually have difficulty. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10. Describe developmental tasks of the older adult. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 375 Question 16 Type: MCSA 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. Correct Answer: 3 Rationale 1: Assuming that all supplies are covered by Medicare when ordered by a physician is erroneous. Rationale 2: Assuming that all supplies are covered by Medicare and/or supplemental insurance is erroneous. Rationale 3: 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 health care and use supplies that are as economical as possible. Rationale 4: The nurse should assist the client to apply for whatever assistance programs are available. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 5. Describe the development of gerontological nursing and the roles of the gerontological nurse. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 376 Question 17 Type: MCMA 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? 1. Adult foster care 2. Group homes 3. Retirement villages 4. Long-term care facilities 5. Adult day-care centers Correct Answer: 1, 2, 5 Rationale 1: Adult foster care offers services to individuals who can care for themselves but require some form of supervision for safety purposes. Rationale 2: Group homes offer services to individuals who can care for themselves but require some form of supervision for safety purposes. Rationale 3: Retirement villages provide social support, but do not provide assistance with medication and activities of daily living (ADLs). Rationale 4: Long-term care facilities provide all care when elderly persons are no longer able to care for themselves; they are not considered "assistance" living. Rationale 5: 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. Global Rationale:

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe the different care settings for older adults. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 377 Question 18 Type: MCSA An elderly 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. Correct Answer: 1 Rationale 1: 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 decisionmaking process, but always and foremost, to include the client. Rationale 2: Nurses need to acknowledge the older client's ability to think, reason, and make decisions. This option does not reflect an understanding of the client’s right to autonomy. Rationale 3: This option does not reflect an understanding of the client’s right to autonomy. It would be quite appropriate to include the physician or primary care provider, social worker, as well as the family in the decisionmaking process, but always and foremost, to include the client. Rationale 4: This option does not reflect an understanding of the client’s right to autonomy. Nurses need to acknowledge the older client's ability to think, reason, and make decisions. 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe the development of gerontological nursing and the roles of the gerontological nurse. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 377 Question 19 Type: MCSA 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. Correct Answer: 2 Rationale 1: There is much diversity among older clients, and nurses should be wary of stereotyping this group. Rationale 2: Older people appreciate the same thoughtfulness, consideration, and acceptance of their abilities as younger people do. Rationale 3: The aging client may be slower and less meticulous in many activities, and many young people err in thinking they are helpful to older people when they take over for them and do the job much faster and more efficiently. This is an unprofessional belief and disregards the client’s right to autonomy and independence. Rationale 4: This is not a practice that a nurse educator would encourage because all clients, regardless of age, are treated respectfully. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe the usual physical changes that occur during older adulthood. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 377 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 20 Type: MCSA A 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 Correct Answer: 2 Rationale 1: Independence established prior to the loss of a mate makes adjustment easier. Rationale 2: 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. Rationale 3: Not participating in functions offered may indicate feelings of inadequacy or insecurity after a death has occurred. Rationale 4: Becoming more dependent on the staff may indicate feelings of inadequacy or insecurity after a death has occurred. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11. Describe psychosocial changes to which the older adult adjusts during the aging process. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 377 Question 21 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

A 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. The nurse should 1. remember that memory loss is a normal, age-related change. 2. investigate for possible physiologic 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. Correct Answer: 2 Rationale 1: 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. Rationale 2: 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. Rationale 3: This option does not address the loss of function the client is experiencing. Rationale 4: This option is premature and not within the scope of nursing practice. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12. Explain changes in cognitive abilities that occur during the aging process. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 378 Question 22 Type: MCSA 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." Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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." Correct Answer: 3 Rationale 1: There are no cures, but some medications may help to slow the progression. Rationale 2: Family members must be educated on the course of dementia and be encouraged to learn as much about coping skills as possible. Rationale 3: 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. Rationale 4: There are no cures, but some medications may help to slow the progression. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Explain changes in cognitive abilities that occur during the aging process. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 378 Question 23 Type: MCSA A client has had Alzheimer's dementia for a period of time and continues to live at home with his 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 2 Rationale 1: Medication prescription is not a nursing responsibility. Rationale 2: 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. Rationale 3: It is important for the nurse to do an ongoing assessment of both the client and the caregiver as the client's condition deteriorates. Rationale 4: The nurse's responsibility is to provide supportive nursing care, accurate information, and referral assistance, if necessary, but finding a suitable long-term facility is not a nursing responsibility. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe the development of gerontological nursing and the roles of the gerontological nurse. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 380 Question 24 Type: MCSA 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.” Correct Answer: 3 Rationale 1: Both dementia and delirium have many of the same characteristics. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Delirium is an acute, reversible syndrome; dementia is not. Rationale 3: Once the underlying pathology is treated, the delirium disappears. Rationale 4: Both dementia and delirium have many of the same characteristics. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15. Describe selected health problems associated with older adults. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 380 Question 25 Type: MCSA A hospitalized older client is recovering from an acute illness. As the client nears the end of his hospitalization, he questions the nurse about medications and care after discharge. The gerontological nurse should 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. Correct Answer: 2 Rationale 1: Informing the physician that the client needs long-term care is inappropriate at this point. Rationale 2: 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 his hospitalization and his fears and hopes about being discharged from the hospital setting. Rationale 3: Telling the client not to worry is not therapeutic and does not address his concerns. Rationale 4: The client is a capable adult and should be included in all decision-making situations, not have them deferred to the family. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe the development of gerontological nursing and the roles of the gerontological nurse. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 381

New Questions Question 26 Type: MCSA 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 upon 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Approaching moral decisions based upon the consequences to self does not exemplify development of moral reasoning for the older adult client. Rationale 3: Following society’s rules of conduct in response to the expectations of others is a belief of Kohlberg; however, this does not demonstrate the development of moral reasoning for an older adult. Rationale 4: Basing moral judgments on connectedness to others and the value of relationships is a belief of Gilligan, who identified this approach to moral behavior in women. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 27 Type: MCMA The nurse is identifying health promotion needs for an older adult client. What should the nurse consider for this client? Standard Text: 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 Correct Answer: 2, 3, 5 Rationale 1: Appropriate health promotion practices would encourage such a vaccine for the client 65 years of age or older. Rationale 2: Appropriate health promotion practices would encourage depression screenings for older adult clients. Rationale 3: Appropriate health promotion practices would encourage smoking cessation classes for older adult clients. Rationale 4: Appropriate health promotion practices would encourage such screening for older adult clients only until the age of 75. Rationale 5: Appropriate health promotion practices would include regular measuring of both height and weight for older adult clients. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16. List examples of health promotion topics for older adulthood. MNL Learning Outcome: 2.1.4. Analyze the older adult’s physiologic and psychosocial development. Page Number: 382 Question 28 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 3, 5 Rationale 1: Health care problems of the older adult population include risk for injuries, especially from falls. Rationale 2: Health care problems of the older adult population include alcohol abuse/misuse. Rationale 3: Health care problems of the older adult include dementia. Rationale 4: Although discussing such plans might become necessary, it is not considered a health problem topic for general discussion. Rationale 5: Health care problems of the older adult population include drug abuse/misuse. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 24 Question 1 Type: MCSA A client is asked during an admission interview to describe her family. She proceeds to list parents, siblings, grandparents, aunts, uncles, and cousins. Which type of family should the nurse document for this client? 1. Nuclear 2. Extended 3. Traditional 4. Blended Correct Answer: 2 Rationale 1: The nuclear family contains parents and offspring. Rationale 2: The extended family includes parents and offspring (nuclear) along with relatives such as grandparents, aunts, and uncles. Rationale 3: A traditional family is viewed as one in which both parents reside in the home with their children— the mother assuming the nurturing role and the father providing the necessary economic resources Rationale 4: A blended family consists of existing family units joined together to form new families, also known as stepfamilies or reconstituted families. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: II.C. 4. Respect the centrality of the patient/family as core members of any health care 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: Nursing Process: Assessment Learning Outcome: 2. Describe different types of families. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 386 Question 2 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

A nurse is working with a particular cultural group in which it is not uncommon for grandparents to live with their married children and to assist with child-rearing 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 Correct Answer: 3 Rationale 1: A two-career family is one where both partners are employed. Rationale 2: A blended family occurs when existing family units join together to form new families. Rationale 3: In some cultures and as people live longer, more than two generations may live together in an intragenerational setting, as described. Rationale 4: A traditional family is viewed as an autonomous unit in which both parents reside in the home. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: II.C. 4. Respect the centrality of the patient/family as core members of any health care 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: Nursing Process: Assessment Learning Outcome: 2. Describe different types of families. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 388 Question 3 Type: MCSA Two nursing students, both single parents, have decided to move into a larger house. Part of their rationale includes providing support for studying and sharing the responsibilities of parenting. Which type of living arrangement are these students implementing? 1. Cohabiting family Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Blended family 3. Foster family 4. Intragenerational family Correct Answer: 1 Rationale 1: 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. Rationale 2: A blended family occurs when existing family units join together to form new families, also known as stepfamilies or reconstituted families. Rationale 3: Foster family situations occur when children can no longer live with their birth parents and require placement with a family that has agreed to include them temporarily. Rationale 4: Intragenerational families occur when more than two generations live together. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: II.C. 4. Respect the centrality of the patient/family as core members of any health care 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: Nursing Process: Assessment Learning Outcome: 2. Describe different types of families. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 388 Question 4 Type: MCMA The nurse is planning to complete a family assessment. For which reasons is the nurse completing this assessment? Standard Text: Select all that apply. 1. Determine the level of family functioning. 2. Identify family strengths and weaknesses. 3. Provide legal guidelines for consent to health care. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Clarify family interaction patterns. 5. Describe the health status of individual members. Correct Answer: 1, 2, 4, 5 Rationale 1: The purpose of family assessment is to determine the level of family functioning. Rationale 2: The purpose of family assessment is to identify family strengths and weaknesses. Rationale 3: Legal guidelines regarding health care issues such as insurance coverage and the right to consent for health care are important when working with same-sex couples. Rationale 4: The purpose of family assessment is to clarify family interaction patterns. Rationale 5: The purpose of family assessment is to describe the health status of the family and its individual members. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: II.C. 4. Respect the centrality of the patient/family as core members of any health care 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: Nursing Process: Assessment Learning Outcome: 4. Identify the components of a family health assessment. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 389 Question 5 Type: MCSA A 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 2 Rationale 1: An ecomap provides a visualization of how the family unit interacts with the external community— for example, schools, religious commitments, occupational duties, and recreational pursuits. Rationale 2: 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. Rationale 3: A cultural assessment will provide information about the health beliefs and health practices of a particular family. Rationale 4: Family communication patterns determine the family's ability to function as a cooperative, growthproducing unit. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: II.C. 4. Respect the centrality of the patient/family as core members of any health care 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: Nursing Process: Assessment Learning Outcome: 4. Identify the components of a family health assessment. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 389 Question 6 Type: MCSA 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 Correct Answer: 1

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: 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. Rationale 2: Impaired Verbal Communication means that the members are not able to communicate because of complications with speaking or saying the words, which is not the case in this situation. Rationale 3: Ineffective Family Coping must be related to an etiology, so this option is not worded correctly. Rationale 4: Knowledge Deficiency is not correct, as the family does recognize the problem because members of the family seek assistance from outside sources, as stated in the scenario. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: II.C. 4. Respect the centrality of the patient/family as core members of any health care 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: Nursing Process: Diagnosis Learning Outcome: 6. Develop nursing diagnoses, outcomes, and interventions pertaining to family functioning. MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process. Page Number: 392 Question 7 Type: MCSA A 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. Correct Answer: 4 Rationale 1: Even though some members are more vocal, at least all are participating in the discussion.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Nonverbal communication is important because it gives valuable clues about what people are feeling. Even though some members are more vocal, at least all are participating in the discussion. Verbal communication should be congruent with nonverbal cues. Rationale 3: Listening is an art, and not all members of a family need to speak in the same setting. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: Nursing Process: Assessment Learning Outcome: 4. Identify the components of a family health assessment. MNL Learning Outcome: 3.1.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 389 Question 8 Type: MCSA The nurse has been working with 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. Correct Answer: 2 Rationale 1: The baby may have an untreated condition, but chronic cold symptoms are not evidence of abuse. Rationale 2: A child who doesn't speak and is watchful when parents are near would be a significant indicator of a possible abuse situation. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Dirty clothes or clothes not meeting the nurse's standards are not signs of abuse—maybe for this family, appearance is not a high priority. Rationale 4: Not having a regular physician would be a concern for health promotion and maintenance, but not for abuse. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Assessment Learning Outcome: 5. Identify common risk factors for family health problems. MNL Learning Outcome: 3.1.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 391 Question 9 Type: MCSA 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. Correct Answer: 3 Rationale 1: The elderly couple is active and so is not at as high of risk simply because of age. Rationale 2: Just because the family is led by a teenage mother, even though maturity is one of the factors the nurse will assess in this situation, does not necessarily indicate that a health risk exists. Rationale 3: Tay-Sachs is a neurodegenerative disease that occurs primarily in descendants of Eastern European Jews. Simply because of this family's ethnicity, they are at risk for developing this health problem.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Although poverty is a major problem that affects the family, the fact that there is health insurance is a positive sociologic factor. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify common risk factors for family health problems. MNL Learning Outcome: 3.1.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 392 Question 10 Type: MCSA 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. When one of their children is hospitalized, the nurse should 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. Correct Answer: 3 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Rationale 4: This option reflects an inappropriate assumption that only the mother can provide consent to treat. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify the components of a family health assessment. MNL Learning Outcome: 3.1.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 390 Question 11 Type: MCSA A family member is hospitalized with an illness. What should the nurse assess to determine the impact this illness will have on the family? 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 Correct Answer: 1, 2, 4, Rationale 1: Factors that determine the impact of illness on the family include the nature of the illness. Rationale 2: Factors that determine the impact of illness on the family include the duration of the illness. Rationale 3: The cause of the illness is not a factor that determines the impact on the family. Rationale 4: Factors that determine the impact of illness on the family include the financial impact of the illness.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: Factors that determine the impact of illness on the family include the effect of the illness on future family functioning. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify common risk factors for family health problems. MNL Learning Outcome: 3.1.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 393 Question 12 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: Families need support from extended family members, their community, and spiritual advisers. Rationale 3: This option is not considered a "normal" pattern of family grieving, and the nurse should be alert for problems that may develop if these feelings are present. Rationale 4: Seclusion is not considered a "normal" pattern of family grieving, and the nurse should be alert for problems that may develop if this response is present. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify common risk factors for family health problems. MNL Learning Outcome: 3.1.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 393 Question 13 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: The scenario correctly assumes that families will periodically experience stress. Rationale 3: The question is not focused on who is stressed but rather how stress is handled by the family. Rationale 4: The question is not focused on the general function of the family but rather how stress is handled by the family. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify the components of a family health assessment. MNL Learning Outcome: 3.1.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 388 Question 14 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 3, 4 Rationale 1: External support includes extended family members. Rationale 2: External support includes extended family members. Rationale 3: External support includes social services. Rationale 4: External support includes religious organizations. Rationale 5: Individual family members, along with knowledge, skills, and effective communication patterns, provide internal support. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe the functions of the family. MNL Learning Outcome: 3.1.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 389 Question 15 Type: MCMA The nurse is confident that a family is functioning appropriately. What findings did the nurse use to make this determination? Standard Text: Select all that apply. 1. The teenage son keeps the money he earns from cutting grass for his “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. Correct Answer: 1, 3, 4, 5 Rationale 1: An appropriately functioning family has the economic resources needed by the family secured by adult members. Rationale 2: An appropriately functioning family provides support, understanding, and encouragement to all members without rigid expectations that unnecessarily force decisions. Rationale 3: An appropriately functioning family creates an atmosphere that influences the cognitive and psychosocial growth of its members. Rationale 4: In an appropriately functioning family, the members support each other and the family unit. Rationale 5: 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. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1. Describe the functions of the family. MNL Learning Outcome: 3.1.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 391 Question 16 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 4 Rationale 1: 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. Rationale 2: It is appropriate to consider the effect of the illness on future family functioning. Rationale 3: The age of the affected member will generally not have a large impact, as such an illness at any age will affect family functioning. Rationale 4: It is appropriate to consider 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. Rationale 5: The number of members in the family has little impact on the overall change an illness will cause. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify the components of a family health assessment. MNL Learning Outcome: 3.1.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 393

Question 17 Type: MCMA 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? Standard Text: Select all that apply. 1. Family members work together towards 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. Correct Answer: 1, 2, 3, 4 Rationale 1: In systems theory, family members work together to achieve specific purposes and goals. Rationale 2: In systems theory, family members seek out health care information and use community resources. Rationale 3: In systems theory, family members interact with and are influenced by other systems in the community. Rationale 4: In systems theory, boundaries regulate the input from other systems that interact with the family system. Rationale 5: In systems theory, family members are encouraged to adapt beliefs and practices to meet the changing demands of society. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify theoretical frameworks used in family health promotion. MNL Learning Outcome: 3.1.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 388 Question 18 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 3, 5 Rationale 1: The structural-functional theory focuses on family structure and function. The structural component of the theory addresses the membership of the family. Rationale 2: 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. Rationale 3: The structural-functional theory focuses on family structure and function. The structural component of the theory addresses the relationships among family members. Rationale 4: Outside influences on the family would be a part of systems theory. Rationale 5: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 25 Question 1 Type: MCSA The student nurse is following a preceptor on the assigned clinical shift. Which behavior of the nurse should the student interpret 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 Correct Answer: 4 Rationale 1: Caring is more than just performing skills adequately or even efficiently. Rationale 2: Caring is more than just performing skills adequately or even efficiently. Rationale 3: Caring is more than just performing skills adequately or even efficiently. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Evaluation Learning Outcome: 4. Describe how nurses demonstrate caring in practice. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 398 Question 2 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The nurse is reviewing Mayeroff’s philosophy of caring prior to providing care to a client. What should the nurse include to demonstrate caring to the client? 1. Honesty 2. Trust 3. Humility 4. Professionalism 5. Courtesy Correct Answer: 1, 2, 3 Rationale 1: Mayeroff defines major ingredients of caring that provide structure and further description of this process. Honesty includes awareness and openness to one’s own feelings and a genuineness in caring for the other person. Rationale 2: Mayeroff defines major ingredients of caring that provide structure and further description of this process. Trust involves letting go, to allow the other to grow in his or her own way and own time. Rationale 3: Mayeroff defines major ingredients of caring that provide structure and further description of this process. Humility means acknowledging that there is always more to learn, and that learning may come from any source. Rationale 4: Professionalism and courtesy are not ingredients described by Mayeroff. Rationale 5: Professionalism and courtesy are not ingredients described by Mayeroff. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 2. Identify nursing theories that focus on caring. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 398 Question 3 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The nurse is emulating the characteristics of caring, as described by Mayeroff. Which action demonstrates knowing, in relationship to caring? 1. Seeing that a client is withdrawn and sullen, and spending extra time when providing cares or treatments 2. Understanding the reason a client's lab values are elevated 3. Seeing the connection between the pathophysiology of the cardiac condition and treatment and giving the rationale for certain medications when the client asks 4. Getting an extra blanket when the client says he is cold Correct Answer: 1 Rationale 1: Knowing means understanding the other's needs and how to respond to those needs. Sensing that a client is withdrawn and sullen, the nurse knows that spending extra time can sometimes allow the client to feel comfortable in talking about what might be bothering him. Rationale 2: Understanding the reason for elevated lab values is an example of knowing in the didactic sense. Rationale 3: Seeing the connection between the pathophysiology and treatment of a condition is an example of knowing in the didactic sense. Rationale 4: Getting an extra blanket is responding to client needs after being told what those needs are, not sensing or understanding them. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Evaluation Learning Outcome: 2. Identify nursing theories that focus on caring. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 398 Question 4 Type: MCSA A nurse manager has been dealing with staffing problems and high patient acuity on the unit. The director of nursing unit has been sensitive to other issues in the past, so the nurse manager decides to approach her with these new concerns. Which aspect of caring is the nurse manager demonstrating? 1. Knowing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Trust 3. Humility 4. Courage Correct Answer: 4 Rationale 1: Knowing means understanding the other's needs and how to respond to these needs. Rationale 2: Trust involves letting go, to allow the other to grow in his or her own way and own time. Rationale 3: Humility means acknowledging that there is always more to learn, and that learning may come from any source. Rationale 4: Courage is the sense of going into the unknown, informed by insight from past experiences. Because the manager had prior experience that was positive from the director of nursing, the manager will use this information to address a problem that has not been introduced before. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Evaluation Learning Outcome: 2. Identify nursing theories that focus on caring. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 398 Question 5 Type: MCSA A new nurse has just started work on an oncology unit. One of the clients has decided to discontinue treatment, even though he understands that his life will be shortened extensively if he does. The nurse is having difficulty with this situation and decides to approach a seasoned nurse for insight and a way to help support this particular client. The nurse is exemplifying which aspect of caring? 1. Hope 2. Humility 3. Honesty 4. Patience Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 3 Rationale 1: Hope is belief in the possibilities of the other's growth. Rationale 2: Humility means acknowledging that there is always more to learn, and that learning may come from any source. Rationale 3: Honesty includes awareness of and openness to one's own feelings and genuineness in caring for the other. In this situation, the nurse has her own feelings about what the client should do, but truly wants to provide good care, so she seeks out assistance from someone who may be able to enlighten her. Rationale 4: Patience enables the other to grow in his or her own way and time. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Evaluation Learning Outcome: 2. Identify nursing theories that focus on caring. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 398 Question 6 Type: MCSA The nurse is researching the concept of caring as it relates to specific situations in the clinical area. More specifically, the nurse is interested in caring as it relates to cultural differences. Of the following theorists, which would be of the most help to this nurse researcher? 1. Florence Nightingale 2. Jean Watson 3. Dorothea Orem 4. Madeline Leininger Correct Answer: 4 Rationale 1: Nightingale's theory focuses on the environment. Rationale 2: Watson's theory focuses on caring in itself. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Orem's theory is about self-care and deficit. Rationale 4: Leininger's theory of culture care diversity and universality is based on the assumption that nurses must understand different cultures in order to function effectively. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Assessment Learning Outcome: 2. Identify nursing theories that focus on caring. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 399 Question 7 Type: MCMA The nurse is planning to provide care according to Leininger's theory of culturally congruent care. What should the nurse include when providing care to the client? 1. Care should be influenced by the organizational structure. 2. The client's familiar lifeways are preserved. 3. Accommodations should be satisfying to clients. 4. Nursing care must be repatterned to help the client move toward wellness. 5. Care should be structured to fit the nurse’s needs Correct Answer: 2, 3, 4 Rationale 1: Care influenced by organizational structure is in line with Ray's theory of bureaucratic caring. Rationale 2: Culturally congruent care involves three action-decision care approaches, one of which is preservation of the client’s familiar lifeways. Rationale 3: Culturally congruent care involves three action-decision care approaches, one of which is ensuring accommodations that help clients adapt to or negotiate for satisfying care. Rationale 4: Culturally congruent care involves three action-decision care approaches, one of which is repatterning nursing care to help the client move toward wellness. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: Structuring care to meet the nurse’s needs is not an aspect of culturally congruent care. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Planning Learning Outcome: 2. Identify nursing theories that focus on caring. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 399 Question 8 Type: MCSA While evaluating how care is delivered at various hospitals, the nurse identifies a facility where caring in the emergency department is perceived differently than caring in the rehabilitation unit. Whose theory of caring is the nurse observing in action? 1. Leininger 2. Ray 3. Roach 4. Boykin and Schoenhofer Correct Answer: 2 Rationale 1: Leininger's theory is focused on cultural congruency. Rationale 2: Ray's theory of bureaucratic caring suggests that caring in nursing is contextual and is influenced by the organizational structure. Each unit had its own specific meaning of caring and how it was influenced. Rationale 3: Roach focuses on the philosophical concept of caring and proposes that caring is the human mode of being. Rationale 4: Boykin and Schoenhofer's theory suggests that caring is a lifelong process, lived moment to moment by the nurse and constantly unfolding. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: 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: Nursing Process: Assessment Learning Outcome: 2. Identify nursing theories that focus on caring. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 399 Question 9 Type: MCSA The nurse is working in a busy intensive care unit. A client is admitted with extensive medical problems and requires a ventilator. Because the nurse already has two other clients assigned to his care, he requests that the nurse manager change assignments so that appropriate attention can be given to this new admission. According to Roach's six C's of caring, which one is the nurse emulating? 1. Compassion 2. Confidence 3. Commitment 4. Conscience Correct Answer: 4 Rationale 1: Compassion is about being aware of one's relationship to others; sharing joys, sorrows, pain, and accomplishments; and participating in the experience of another. Rationale 2: Confidence is the quality that fosters trust. It means the nurse has comfort with himself, his clients, and his family. Rationale 3: Commitment is a convergence between one's desires and obligations and the deliberate choice to act in accordance with them. Rationale 4: 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 when he is already busy enough and makes an appropriate request for a change in assignment. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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: Nursing Process: Assessment Learning Outcome: 2. Identify nursing theories that focus on caring. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 399 Question 10 Type: MCSA A nurse has been working a 12-hour shift in a labor and delivery unit. A client was admitted early in the shift and is now ready to deliver. The client had a difficult labor experience, was worried and anxious throughout, and had physiological problems with blood pressure as well as pain management. The nurse decides to stay until the delivery is over, after having it approved by her manager. What is this nurse demonstrating? 1. Compassion 2. Competence 3. Confidence 4. Conscience Correct Answer: 1 Rationale 1: 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. Rationale 2: Competence is having the knowledge, skills, energy, experience, and motivation to respond adequately to others, within the demands of the professional responsibilities. Rationale 3: Confidence is the quality that fosters trusting relationships. It is comfort with self, patient, and family. Rationale 4: Conscience is focused on morals, ethics, and an informed sense of right and wrong. Awareness of personal responsibility is part of conscience. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Describe how nurses demonstrate caring in practice. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 399 Question 11 Type: MCSA A nurse educator is teaching students about the philosophy of caring in nursing and states that nurses can only be truly caring if they are true to themselves first. This action then emphasizes the importance of nurses knowing themselves, which brings about a process that allows the nurse to be with another person. Whose theory is the educator using to teach the concept of caring? 1. Roach 2. Ray 3. Boykin and Schoenhofer 4. Watson Correct Answer: 3 Rationale 1: Roach's theory focuses on caring as a philosophical concept and proposes that caring is the human mode of being, or the "most common, authentic criterion of humanness." Rationale 2: Ray's theory of caring focuses on caring in organizations and is influenced by the organizational structure. Rationale 3: Boykin and Schoenhofer emphasize the importance of the nurse knowing oneself as caring. Through knowing oneself as a caring person, the nurse can be authentic to self, freeing oneself to truly be with others. Rationale 4: Watson views caring as the essence and the moral ideal of nursing. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Evaluation Learning Outcome: 2. Identify nursing theories that focus on caring. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 400 Question 12 Type: MCSA 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 Correct Answer: 1 Rationale 1: Swanson defines caring as a nurturing way of relating to a valued "other" toward whom one feels a personal sense of commitment and responsibility. Rationale 2: Watson views caring as the essence and moral ideal of nursing. Rationale 3: Roach identifies caring as a philosophical concept and proposes that caring is the human mode of being. Rationale 4: Benner describes caring as the essence of excellence in nursing. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 2. Identify nursing theories that focus on caring. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 401 Question 13 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 2 Rationale 1: Aesthetic knowledge is the art of nursing and is expressed by nurses in their creativity and style in meeting the needs of clients. Rationale 2: Empirical knowing ranges from factual, observable phenomena to theoretical analysis. Empirical knowledge is systematic and helps to describe, explain, and predict phenomena. Rationale 3: Personal knowledge is concerned with the knowing, encountering, and actualizing of the concrete, individual self. Rationale 4: Creativity is part of aesthetic knowledge. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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: Nursing Process: Evaluation Learning Outcome: 3. Analyze the importance of different types of knowledge in nursing. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 401 Question 14 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Read about the same topic from a variety of sources. 4. Spend time in the clinical area with seasoned nurses. Correct Answer: 4 Rationale 1: Studying harder improves empirical knowledge. Rationale 2: Taking better notes improves empirical knowledge. Rationale 3: Reading about the same topic from a variety of sources improves empirical knowledge. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 3. Analyze the importance of different types of knowledge in nursing. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 401 Question 15 Type: MCSA 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 Correct Answer: 4

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Empirical knowledge is systematically organized into laws and theories for the purpose of describing, explaining, and predicting phenomena. Rationale 2: Personal knowledge promotes wholeness and integrity in the personal encounter. Rationale 3: Aesthetic knowledge 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. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered 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: Nursing Process: Implementation Learning Outcome: 3. Analyze the importance of different types of knowledge in nursing. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 401 Question 16 Type: MCSA 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." Correct Answer: 2 Rationale 1: All options are true, but a nurse must possess all four types of knowledge.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: The nurse who practices effectively is able to integrate all types of knowledge to understand situations more holistically. Rationale 3: All options are true, but a nurse must possess all four types of knowledge. Rationale 4: All options are true, but a nurse must possess all four types of knowledge. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 3. Analyze the importance of different types of knowledge in nursing. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 401 Question 17 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Being with is being emotionally present to another person. Rationale 3: Doing for is providing for others as they would do for themselves if it were possible. Rationale 4: Enabling is facilitating the other's passage through life transitions and unfamiliar events. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Evaluation Learning Outcome: 2. Identify nursing theories that focus on caring. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 401 Question 18 Type: MCSA 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 Correct Answer: 4 Rationale 1: Knowing is striving to understand an event as it has meaning in the life of the other. If this were the case in this situation, the nurse would be asking the students to explain what they are going through, or what it feels like to lose a friend. Rationale 2: Being with is being emotionally present to the other. Rationale 3: Doing for is providing for others as they would do for themselves if it were possible. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: 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: Nursing Process: Evaluation Learning Outcome: 2. Identify nursing theories that focus on caring. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 401 Question 19 Type: MCSA The nurse 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 Correct Answer: 4 Rationale 1: Technical skills focus on the competency of the nurse. Rationale 2: Giving routine back rubs focuses on comfort. Rationale 3: Writing abilities focus on the competency of the nurse. Rationale 4: Attention to spiritual needs is part of compassionate care, particularly in the face of death and bereavement. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Evaluation Learning Outcome: 1. Discuss the meaning of caring. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 403 Question 20 Type: MCSA 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 his elderly parents as well as providing care to his immediate family Correct Answer: 1 Rationale 1: It is imperative that nurses attend to their own needs, because caring for self is central to caring for others. Rationale 2: As nurses take on multiple commitments to family, work, school, and community, they risk exhaustion, burnout, and stress. Rationale 3: This nurse is trying to stay on top of the many tasks involved in a daily routine. Rationale 4: This nurse is caring for other people. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Evaluation Learning Outcome: 5. Evaluate the importance of self-care for the professional nurse. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 404 Question 21 Type: MCSA The nurse has adopted a healthy lifestyle. What action demonstrates that the nurse is being successful in this endeavor? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 3 Rationale 1: Nutrition and exercise are necessary for a healthy lifestyle, but key words to remember are balance and moderation. Exercising every day for at least an hour an half does not demonstrate balance. Rationale 2: Completely avoiding a certain nutrient or keeping the nutritional aspects of one's life so strict that there can be no variance is difficult and indicates more of a compulsive nature than a healthy one. Rationale 3: Nutrition and exercise are necessary for a healthy lifestyle, but key words to remember are balance and moderation. Rationale 4: Exercising more on days when feeling guilty about a snack is not permitting variation or balance. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: Nursing Process: Evaluation Learning Outcome: 5. Evaluate the importance of self-care for the professional nurse. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 404 Question 22 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 4 Rationale 1: Bike riding is an exercise. Rationale 2: Cake decorating would be recreation. Rationale 3: Reading would be recreation. Rationale 4: Mind–body therapies include storytelling, which is a complementary therapy that brings balance to thoughts and emotions. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Assessment Learning Outcome: 5. Evaluate the importance of self-care for the professional nurse. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 405 Question 23 Type: MCSA 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 her instructor, the student fielded these questions as best she could. 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 Correct Answer: 3 Rationale 1: Meditation is quieting the mind and focusing it on the present. It helps the individual release fears, worries, and doubts. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Guided imagery is a mind–body intervention that uses the power of imagination as a therapeutic tool. Rationale 3: 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. Rationale 4: Music therapy includes listening, singing, rhythm, and body movement. It is often used to induce relaxation. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 6. Identify the value of reflective practice in nursing. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 406 Question 24 Type: MCSA 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 Correct Answer: 1 Rationale 1: Doing for is providing for the client as she would do for herself if it were possible. Subdimensions of this process include preserving dignity. Rationale 2: Drying the client completely, if she is able to do some herself, would not be part of doing for. Rationale 3: Sensing that the client is uncomfortable fits in the subdimension of knowing (sensing cues). Rationale 4: Touching the client's shoulder is comforting, a subdimension of being with. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Assessment Learning Outcome: 2. Identify nursing theories that focus on caring. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 401 Question 25 Type: MCMA The nurse is identifying strategies to support a client’s empowerment. What strategies should the nurse use? Standard Text: 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” Correct Answer: 1, 2, 4 Rationale 1: This nursing intervention supports and thus empowers the client to continue expressing herself and experiencing life in spite of a chronic disease. Rationale 2: This nursing intervention supports and thus empowers the client by helping her to maintain her selfesteem and pride in her appearance. Rationale 3: This nursing intervention might be premature, and so might deny the client the independence and autonomy she is due. Rationale 4: This nursing intervention supports and thus empowers the client by helping her to maintain her autonomy and independence longer. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: This nursing intervention might be premature, and so might deny the client the independence and autonomy she is due. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 4. Describe how nurses demonstrate caring in practice. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 403 Question 26 Type: MCMA The new graduate nurse has committed to improving self-care activities. Which behaviors exemplify that the nurse is following through on this personal commitment? Standard Text: Select all that apply. 1. Using meditation to de-stress 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 Correct Answer: 1, 2, 5 Rationale 1: Self-care is described as helping oneself grow and actualize one’s possibilities. Managing stress in a healthy manner is certainly a positive behavior directed at self-care. Rationale 2: Self-care is described as helping oneself grow and actualize one’s possibilities. Eating a low-fat diet, especially when one has an increased risk for heart disease, is certainly a positive behavior directed at self-care. Rationale 3: Although self-care is described as helping oneself grow and actualize one’s possibilities, this action is more related to one’s professional, not personal, life. Rationale 4: Although this action reflects caring, it is directed at another rather than toward the self. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: Self-care is described as helping oneself grow and actualize one’s possibilities. Engaging in enjoyable activities in a healthy manner is certainly a positive behavior directed at self-care. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 5. Evaluate the importance of self-care for the professional nurse. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 404

Question 27 Type: MCMA 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? Standard Text: 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. Correct Answer: 3, 4 Rationale 1: Positive affirmations can lead to greater self-esteem and control self-doubt. Focusing on a new career is not a positive affirmation. Rationale 2: Positive affirmations can lead to greater self-esteem and control self-doubt. Focusing on study habits in school is not a positive affirmation. Rationale 3: Positive affirmations can lead to greater self-esteem and control self-doubt. Stating what brings joy is a positive affirmation. Rationale 4: Positive affirmations can lead to greater self-esteem and control self-doubt. Realizing the situation is an opportunity to grow is a positive affirmation.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: Positive affirmations can lead to greater self-esteem and control self-doubt. Focusing on the inability to remember everything is not a positive affirmation. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 5. Evaluate the importance of self-care for the professional nurse. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 405 Question 28 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 2, 3, 4 Rationale 1: When developing a plan of intentional knowing, the nurse should seek cues from the client. Rationale 2: When developing a plan of intentional knowing, the nurse should thoroughly assess the client. Rationale 3: When developing a plan of intentional knowing, the nurse should avoid assumptions about the client. Rationale 4: When developing a plan of intentional knowing, the nurse should center on actions that the client needs. Rationale 5: When developing a plan of intentional knowing, the nurse should avoid assumptions such as assuming that the client wants to be alone. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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: Nursing Process: Implementation Learning Outcome: 4. Describe how nurses demonstrate caring in practice. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 402

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 26 Question 1 Type: MCSA A 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 Correct Answer: 3 Rationale 1: Pace helps indicate interest, anxiety, boredom, or fear—all of which modify the feeling and impact of the message. Rationale 2: Intonation helps indicate interest, anxiety, boredom, or fear—all of which modify the feeling and impact of the message. Rationale 3: Simplicity includes the use of commonly understood words, brevity, and completeness. A "bowel prep" may be completely meaningless to a client, but telling him that he 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. Rationale 4: Clarity and brevity imply that the message is direct and simple—saying precisely what is meant and using the fewest words necessary. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Discuss the various aspects that nurses need to consider when using the different forms of communication. MNL Learning Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 413 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 2 Type: MCSA 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 doesn’t support the response. Which aspect of communication should this nurse improve? 1. Adaptability 2. Credibility 3. Timing and relevance 4. Clarity and brevity Correct Answer: 1 Rationale 1: Adaptability is adjusting tone of speech and facial expression to match the spoken message. Clearly, if the nurse's face doesn't match his words, the client will identify a problem with the situation. Rationale 2: Credibility means worthiness of belief, trustworthiness, and reliability. Rationale 3: Timing and relevance affect how the message is taken or heard. Rationale 4: Clarity and is preciseness and brevity is use of few words. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the components of the communication process. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 413 Question 3 Type: MCSA A nurse is working on a telemetry unit when one of the clients has a cardiac arrest. The client's spouse is in the room when the code team arrives. Which statement by the nurse to the spouse is the best in this situation? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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." Correct Answer: 2 Rationale 1: Dealing with the spouse's fears and concerns right now is not the priority need—the client's emergency situation is. Rationale 2: Clarity and brevity provide a message that is simple and clear. Rationale 3: In this situation, taking time to explain and/or address all of the spouse's needs and concerns is inappropriate. Not only will the client be unable to process extra information, but the nurse doesn't have time to give long, drawn-out explanations about the situation. Rationale 4: In this situation, taking time to explain and/or address all of the spouse's needs and concerns is inappropriate. Not only will the client be unable to process extra information, but the nurse doesn't have time to give long, drawn-out explanations about the situation. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Discuss the various aspects that nurses need to consider when using the different forms of communication. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 413 Question 4 Type: MCSA 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?" Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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?" Correct Answer: 4 Rationale 1: This option does not address the nonverbal cues. The phone off the hook should lead the nurse to at least consider that perhaps the client had an upsetting phone call. This should be addressed by the nurse. Rationale 2: This option does not address the nonverbal cues. Rationale 3: This option does not address the nonverbal cues. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe factors influencing the communication process. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 414 Question 5 Type: MCSA A client has been sullen and withdrawn since receiving the news of her cancer diagnosis. As the nurse enters the room, the client 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." Correct Answer: 3 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Telling the client that she might feel better if she looks better implies that the client's looks are objectionable. Rationale 2: Suggesting that washing away the "gloom and doom" minimizes the client’s concerns. Rationale 3: 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. Rationale 4: A change in grooming habits may signal that the client is feeling better, but the nurse must be careful in this situation that the focus is not on the client's spouse, but on the client. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe factors influencing the communication process. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 415 Question 6 Type: MCSA A 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. Correct Answer: 2 Rationale 1: The nurse should not talk over or around the child, just because of her age, but include her in conversation and communication. Rationale 2: 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.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Before any treatment or therapy, explanation should be given. Otherwise the child will be frightened and the treatment will not be effective. Rationale 4: Nurses should always be prepared to give explanations and teaching to their clients. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe factors influencing the communication process. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 416 Question 7 Type: MCSA A nurse is giving a demonstration of new equipment to the rest of the nursing unit. Which level of proxemics should the nurse use? 1. Intimate 2. Personal 3. Social 4. Public Correct Answer: 3 Rationale 1: Intimate distance is touching or up to 11/2 feet. This would be appropriate when cuddling a baby, touching a sightless client, repositioning a client, observing an incision, and restraining a toddler for an injection. Rationale 2: Personal distance is 11/2 to 4 feet and is less overwhelming than intimate distance. Much communication between nurses and clients occurs at this distance, such as sitting with a client, giving medications, or establishing an IV. Rationale 3: Social distance is characterized by a clear, visual perception of the whole person and generally 4 to 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.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Public distance is 12 to 15 feet and requires loud, clear vocalizations. It is used most often with a group of people or in the community. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe factors influencing the communication process. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 416 Question 8 Type: MCSA A 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 Correct Answer: 2 Rationale 1: Personal distance is 11/2 to 4 feet and is less overwhelming than intimate distance. Much communication between nurses and clients occurs at this distance, such as sitting with a client, giving medications, or establishing an IV infusion. Rationale 2: 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 11/2 feet. Rationale 3: Social distance is characterized by clear visual perception of the whole person and is important in accomplishing the business of the day. Rationale 4: Public distance requires loud, clear vocalizations and is used for groups of people or in the community for presentations. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe factors influencing the communication process. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 416 Question 9 Type: MCSA A nurse enters a client's room and asks about his level of pain. The client, grimacing, says "It's fine." Which communication factor is the client struggling with? 1. Territoriality 2. Environment 3. Congruence 4. Attitude Correct Answer: 3 Rationale 1: Territoriality is a concept of the space and things that an individual considers as belonging to the self. Rationale 2: The environment involved in communication must be comfortable. Otherwise it may distract and impair communication. Rationale 3: In congruent communication, the verbal and nonverbal aspects of the message match. Saying his pain level is "fine," but then showing with facial grimacing that it is not, would be in conflict. Rationale 4: Attitudes can convey beliefs, thoughts, and feelings about people and events—not what is described in this scenario. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe factors influencing the communication process. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 418 Question 10 Type: MCSA A 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." Correct Answer: 1 Rationale 1: 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. Rationale 2: Telling the client that he needs to go to a nursing home is insensitive. Rationale 3: Noting that the children love their father is not an example of elderspeak, but merely the nurse making observations to the client. Rationale 4: Making comments about the wife's adjustments to the illness is not an example of elderspeak, but merely the nurse making observations to the client. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Compare and contrast therapeutic communication techniques that facilitate communication and focus on client concerns. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 418 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 11 Type: MCSA A client has just lost her 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." Correct Answer: 4 Rationale 1: The client's feelings must be validated, not dismissed. Rationale 2: Asking about genetic counseling implies that the client could have done something to possibly prevent this situation. Rationale 3: Therapeutic communication promotes understanding and is client directed. Nurses need to respond to the feelings expressed by the client. The nurse has no way of knowing how this client feels, and saying so is just insensitive. Rationale 4: 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 their feelings and the best thing the nurse can provide is presence and listening. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Compare and contrast therapeutic communication techniques that facilitate communication and focus on client concerns. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 419 Question 12 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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?" Correct Answer: 3 Rationale 1: This is an example of clarifying. Rationale 2: This is an example of clarifying. Rationale 3: 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." Rationale 4: This is an example of clarifying. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Discuss how nurses use communication skills in each phase of the nursing process. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 419 Question 13 Type: MCMA The nurse is engaging a client in the introductory phase of the helping relationship. Which stages will be completed during this phase? Standard Text: Select all that apply. 1. Opening the relationship 2. Clarifying the problem Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Structuring and formulating the contract 4. Planning before the interview 5. Understanding thoughts and feelings Correct Answer: 1, 2, 3 Rationale 1: The introductory phase, also referred to as the orientation phase or prehelping phase, sets the tone for the rest of the relationship. The relationship opens during this phase. Rationale 2: The introductory phase, also referred to as the orientation phase or prehelping phase, sets the tone for the rest of the relationship. Clarifying the problem occurs during this phase. Rationale 3: The introductory phase, also referred to as the orientation phase or prehelping phase, sets the tone for the rest of the relationship. Structuring and formulating the contract occurs during this phase. Rationale 4: Planning before the interview is part of the preinteraction phase. Rationale 5: Understanding thoughts and feelings occurs during the working phase of the helping relationship. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe the four phases of the helping relationship. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 423 Question 14 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1 Rationale 1: The working phase has two major stages. Exploring and understanding thoughts and feelings would occur during the working relationship. Rationale 2: Conveying respect and an attitude that demonstrates the client’s opinions are being taken seriously would not be completed during the facilitating and taking action phase. Rationale 3: Confrontation is a skill required for the first phase. Rationale 4: Concreteness is a skill required for the first phase. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Describe the four phases of the helping relationship. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 423 Question 15 Type: MCSA Several nurses have been assigned to develop a rotation schedule that provides adequate staffing of all shifts. In which type of group are these nurses functioning? 1. Self-help group 2. Task group 3. Teaching group 4. Therapy group Correct Answer: 2 Rationale 1: A self-help group is a small, voluntary organization composed of individuals who share a similar health, social, or daily living problem. Rationale 2: The task group is one of the most common types of work-related groups to which nurses belong. The focus of such groups is the completion of a specific task. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: A teaching group has as its major purpose to impart information to the participants. Rationale 4: A therapy group works toward self-understanding, more satisfactory ways of relating or handling stress, and changing patterns of behavior toward health. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Identify types of groups helpful in promoting health and comfort. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 426 Question 16 Type: MCSA 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 Correct Answer: 1 Rationale 1: The picture board would be of assistance because it does not rely on verbal communication. Rationale 2: The client is nonverbal, so speaking en face does not address the client's ability to communicate. Rationale 3: The client is nonverbal, so using an interpreter does not address the client's ability to communicate. Rationale 4: The client is nonverbal, so using the client's dominant language does not address the client's ability to communicate. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Compare and contrast therapeutic communication techniques that facilitate communication and focus on client concerns. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 429 Question 17 Type: MCSA A 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 Correct Answer: 2 Rationale 1: Client communication is a type of communication that does not provide a vehicle for evaluation. Rationale 2: 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. Rationale 3: Therapeutic communication does not provide a vehicle for evaluation. Rationale 4: Verbal communication does not provide a vehicle for evaluation. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9. Discuss how nurses use communication skills in each phase of the nursing process. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 430

New Question 18 Question 18 Type: MCMA During a health history, a client admits to taking nutritional supplements instead of prescribed medication. Which responses by the nurse indicate effective communication? Standard Text: 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.” Correct Answer: 4, 5 Rationale 1: Saying that the client was wrong is passing judgment, a common communication barrier. Rationale 2: Asking the client “who do you think you are” is testing, a common communication barrier. Rationale 3: Saying that the client should not have done that is passing judgment, a common communication barrier. Rationale 4: Asking the client to tell more about the supplements is an open-ended statement and encourages communication. Rationale 5: Asking the client to explain the reasoning behind the decision is an open-ended statement and encourages communication. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Recognize barriers to communication. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 420 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 19 Type: MCSA 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." Correct Answer: 4 Rationale 1: An important characteristic of assertive communication includes the use of "I" statements versus "you" statements. "You" statements place blame and put the listener in a defensive position. Rationale 2: An important characteristic of assertive communication includes the use of "I" statements versus "you" statements. "You" statements place blame and put the listener in a defensive position. " Rationale 3: An important characteristic of assertive communication includes the use of "I" statements versus "you" statements. " “We” statements are not a part of assertive communication. Rationale 4: An important characteristic of assertive communication includes the use of "I" statements versus "you" statements. "I" statements encourage discussion. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 12. Discuss the differences between nurse and physician communication and how to address these differences. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 434 Question 20 Type: MCSA The nurse wants to gain information about a client's situation. Which question should the nurse use to maximize communication with this patient? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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?" Correct Answer: 1 Rationale 1: 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.... Rationale 2: This question can be answered with one word or a yes/no response. Rationale 3: This question can be answered with one word or a yes/no response. Rationale 4: This question can be answered with one word or a yes/no response. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Compare and contrast therapeutic communication techniques that facilitate communication and focus on client concerns. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 420 Question 21 Type: MCMA The nurse is communicating with an older client. Which actions demonstrate that the nurse understands the best approaches to communicate with this client? Standard Text: 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” Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Consistently arranging for the client to have her hair done 5. Managing to get a copy of the client’s favorite magazine Correct Answer: 1, 2, 5 Rationale 1: Good communication with the client will result in knowing what makes a difference to her. With this valuable knowledge, the nurse can reduce vulnerability and enhance the quality of life. Rationale 2: Good communication with the client will result in knowing what makes a difference to her. With this valuable knowledge, the nurse can reduce vulnerability and enhance the quality of life. Rationale 3: This would be effective only if the nurse knew that going for a walk was important to the client. Rationale 4: This would be effective only if the nurse knew that getting her hair done was important to the client. Rationale 5: Good communication with the client will result in knowing what makes a difference to her. With this valuable knowledge, the nurse can reduce vulnerability and enhance the quality of life. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 10. State why effective communication is imperative among health professionals. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 423 Question 22 Type: MCMA The nurse is beginning a helping relationship with a newly admitted client. Which behaviors should the nurse demonstrate that support this type of relationship? Standard Text: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

5. Asking to remain with the client when he is experiencing symptoms of the flu Correct Answer: 1, 3, 4, 5 Rationale 1: A caring relationship consists of four phases; preparing for the relationship is part of the preinteraction phase. Rationale 2: Although an appropriate nursing intervention for this client, this activity does not necessarily assist in developing a caring relationship. Rationale 3: A caring relationship consists of four phases; gaining trust is part of the introductory phase. Rationale 4: A caring relationship consists of four phases; showing respect for a client and his wishes is part of the ongoing maintaining phase. Rationale 5: A caring relationship consists of four phases; showing concern for a client and his wishes is part of the ongoing maintaining phase. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 06 Describe the four phases of the helping relationship. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe the four phases of the helping relationship. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 423 Question 23 Type: MCMA 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? Standard Text: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 3, 4, 5 Rationale 1: Pairing the graduate with a seasoned nurse to assist with learning new skills demonstrates supportiveness. Rationale 2: Asking the graduate to participate in client rounds with the new interns on the care area demonstrates teamwork. Rationale 3: Confronting the graduate by stating that refusing an assignment is grounds for dismissal is bullying behavior. It is intended to intimidate the graduate. Rationale 4: 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. Rationale 5: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11. Describe the following disruptive behaviors and how they affect the health care environment and client safety: incivility, lateral violence, and bullying. Outcome: 1.3.1. Apply appropriate communication skills required to conduct the health history interview of a client. Page Number: 432

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 27 Question 1 Type: MCSA 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." Correct Answer: 1 Rationale 1: 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're prescribed and improves the possibility for following the prescribed regimen. Rationale 2: Statements of prior knowledge do not necessarily lead to compliance. Rationale 3: Following the advice of the health care prescriber does not necessarily lead to compliance. Rationale 4: Following the advice of the health care prescriber does not necessarily lead to compliance. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1. Discuss the importance of the teaching role of the nurse. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 440 Question 2 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

A nurse is planning a community health education project that deals with organ donation, and the target audience is a group of adults. When following andragogy concepts, the nurse should make sure that the teaching includes which information? 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 Correct Answer: 3 Rationale 1: An adult is more oriented to learning when the material is useful immediately, not sometime in the future. Rationale 2: Written information may or may not be helpful, depending on what types of learners are included in the group. Rationale 3: 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. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare and contrast andragogy, pedagogy, and geragogy. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 440 Question 3 Type: MCSA The nurse is instructing a client on self-administration of a subcutaneous injection. The nurse is using which theoretical construct of learning? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Thorndike's behaviorism 2. Skinner's positive reinforcement 3. Pavlov's conditioning response 4. Bandura's imitation Correct Answer: 4 Rationale 1: Edward Thorndike originally advanced the theory of behaviorism and maintained that learning should be based on the learner's behavior. Rationale 2: Skinner focused his work on conditioning behavioral responses to a stimulus that causes the response or behavior. Rationale 3: Pavlov focused his work on conditioning behavioral responses to a stimulus that causes the response or behavior. Rationale 4: Bandura claims that most learning comes from observation and instruction. Imitation is the process by which individuals copy or reproduce what they have observed. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Discuss the learning theories of behaviorism, cognitivism, and humanism and how nurses can use each of these theories. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 440 Question 4 Type: MCSA A nursing student is presenting a teaching project to the class using each of Bloom's domains. The student has several activities included in the project. Which activity is an example of the affective domain? 1. Each member of the class must identify two attitudinal changes that have occurred in their lives since beginning their nursing education. 2. All members must list the technical skills they've learned. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Members must demonstrate a favorite nursing skill at the end of the class period. 4. Members must read a paragraph about a new clinical trial, summarize the information, and present it to the rest of the class. Correct Answer: 1 Rationale 1: 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. Rationale 2: Listing technical skills and reading or summarizing information is part of the "thinking" domain, which includes knowing, comprehending, application, analysis, synthesis, and evaluation. Rationale 3: The psychomotor domain is the "skill" domain and includes hands-on motor skills such as demonstration. Rationale 4: Listing technical skills and reading or summarizing information is part of the "thinking" domain, which includes knowing, comprehending, application, analysis, synthesis, and evaluation. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe the three learning domains. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 440 Question 5 Type: MCSA A client is practicing using an incentive spirometer after surgery. The nurse has explained the use, demonstrated how it works, and also given the rationale for the client to continue to use this device. 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 2 Rationale 1: Cognitive abilities include the "thinking" process that begins with knowing, comprehending, and applying knowledge. Rationale 2: The psychomotor domain is the "skill" domain and includes motor skills, such as being able to use an incentive spirometer. Rationale 3: The affective domain involves attitudes or emotional responses and includes feelings, emotions, interests, and appreciations. Rationale 4: Imitation is not one of Bloom's domains of learning. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Describe the three learning domains. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 440 Question 6 Type: MCSA A 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 Correct Answer: 3 Rationale 1: Clients who struggle with rules or following prescribed courses of treatment are not motivated to learn the best reason for their particular plan of action. They may be "bucking" the system.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: The client who is already waiting to go home may be motivated for that, but not to the extent of being ready to learn how to achieve this end. Rationale 3: 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. Rationale 4: Motivation must be experienced by the client, not by someone else (as in being a "coach" for newcomers). Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify factors that affect learning. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 441 Question 7 Type: MCSA A nurse is working in a neonatal intensive care unit, teaching parents how to care for their tiny 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?" Correct Answer: 2 Rationale 1: Statements about fear of the situation need to be addressed so the fear will not inhibit the learning process. Rationale 2: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Wanting to wait until the baby is older reflects uncertainty and possibly fear and should be addressed before learning can occur. Rationale 4: Wanting to wait until discharge reflects uncertainty and possibly fear and should be addressed before learning can occur. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Identify factors that affect learning. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 441 Question 8 Type: MCSA The nurse is instructing a client on self-administration of insulin. Which statement regarding feedback will be most beneficial 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." Correct Answer: 3 Rationale 1: Ridicule or sarcasm can lead to withdrawal from learning, as in reminding an adult client that a child can perform the task or of not being discharged until the skill is learned. Rationale 2: Statements about having somebody else learn the technique may also cause the learner to avoid the teaching moment and to avoid learning the technique altogether. Rationale 3: Feedback should be meaningful to the learner and should support the desired behavior through praise, positively worded corrections, and suggestions of alternative methods. Rationale 4: Ridicule or sarcasm can lead to withdrawal from learning, as in reminding an adult client that a child can perform the task or of not being discharged until the skill is learned. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Identify factors that affect learning. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 442 Question 9 Type: MCSA A home health client having difficulty keeping his medication schedule organized says "There are so many pills and the names are all confusing to me. I don't even understand what they're for." What should the nurse do? 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 his medications. Correct Answer: 1 Rationale 1: 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. Rationale 2: Learning generic and trade names is memorization and may not make sense for this client. Rationale 3: Filling a pill box or bar is not helping the client learn about his meds; it merely puts them into an order without information. Rationale 4: Nurses must rely on their own creativity and resourcefulness, not depend on physician input. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Identify factors that affect learning. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 442 Question 10 Type: MCSA At the end of a busy clinical day a staff nurse asks the instructor if a student would like to administer a Z-track injected medication. This is a skill that the students have not yet been exposed to yet. What should the instructor respond to the staff nurse 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." Correct Answer: 2 Rationale 1: After a busy day in the clinical area, students may not be ready for the learning experience, even though it would be a good opportunity for them. Taking time to explain the procedure first might put the learning moment in the wrong time and environment, and the students may not retain the information as best they could. Rationale 2: Allowing them to observe the staff nurse, then coming back when they are more refreshed would allow a better learning experience for the students. Rationale 3: Simply declining the opportunity doesn't make for good rapport with the staff nurse. Rationale 4: Allowing a student to simply volunteer puts the instructor's license at risk, especially if it is a skill the student has not learned or practiced. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Assess learning needs of learners and the learning environment. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 442 Question 11 Type: MCSA 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." Correct Answer: 4 Rationale 1: This statement shows interest as well as realism in attitude toward learning. The nurse should be attentive to cues that may enhance the learning experience, such as amount of time spent on the process. Rationale 2: This statement shows interest as well as realism in attitude toward learning. The nurse should be attentive to cues that may enhance the learning experience, such as having the spouse available to learn along with the client. Rationale 3: This statement shows interest as well as realism in attitude toward learning. The nurse should be attentive to cues that may enhance the learning experience, such as giving thorough explanations about the rationale for the treatment. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Identify factors that affect learning. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 442 Question 12 Type: MCSA A 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, the nurse should 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. Correct Answer: 2 Rationale 1: It is important to provide written material, but the first priority is ascertaining any belief conflicts that may interfere with the treatment. Rationale 2: If the prescribed treatment conflicts with the client/family's cultural healing beliefs, the client may not be compliant with the recommended treatments. To be effective, nurses must deal directly with any conflicts and differing values held by the client. Rationale 3: If the prescribed treatment conflicts with the client/family's cultural healing beliefs, the client may not be compliant with the recommended treatments. Rationale 4: The client who does not understand will learn little, and providing an interpreter to assist with communication is extremely important in this situation. However, if the prescribed treatment conflicts with the client/family's cultural healing beliefs, the client may not be compliant with the recommended treatments. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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: Nursing Process: Implementation Learning Outcome: 12. Discuss strategies to use when teaching clients of different cultures. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 443 Question 13 Type: MCSA 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. Correct Answer: 3 Rationale 1: Teaching a spouse is demeaning and does not support the client's wishes for independence. Rationale 2: Scheduling injections and visits to coincide is demeaning and does not support the client's wishes for independence. Rationale 3: 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 self-administration, 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. Rationale 4: Scheduling injections and visits to coincide when the dose is due is demeaning and does not support the client's wishes for independence. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Assess learning needs of learners and the learning environment.. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 443 Question 14 Type: MCSA A client has been diagnosed with diabetes mellitus and must learn how to do his own finger stick blood sugar analysis as part of his treatment. The client 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 Correct Answer: 4 Rationale 1: Demonstrating the procedure on the nurse may or may not help the client become interested in the learning process. Rationale 2: Offering to do the procedure only allows the client's current state of mind to continue. Rationale 3: Giving the responsibility to someone else does not encourage the client to learn it. Rationale 4: Nurses can increase a client's motivation in several ways, including encouragement of self-direction and independence. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Identify factors that affect learning. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 447 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 15 Type: MCSA The nurse is working with a group of older clients through a community senior citizens center. Utilizing an understanding of health literacy, the nurse will make sure that 1. information given to this group is written at a third-grade level. 2. teaching includes a variety of approaches. 3. information includes pictures. 4. there is ample time for teaching. Correct Answer: 4 Rationale 1: The average reading ability of many American adults is at the fifth-grade level. Information provided to this group should be presented at the fifth- to sixth-grade reading level. Rationale 2: A variety of approaches should be included regardless of the audience, as people learn by different methods. Rationale 3: A variety of approaches should be included regardless of the audience, as people learn by different methods. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Discuss the implications of low health literacy skills. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 446 Question 16 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

A client being discharged after a myocardial infarction has been prescribed several new medications and a low-fat diet. The client states: "I'm never going to understand what to do, when to do it, and why I should be doing all these things." Which nursing diagnosis should the nurse formulate for this client? 1. Health-Seeking Behavior related to desire to prevent heart problems 2. Deficient Knowledge (diet and medication regimen) related to inexperience 3. Noncompliance related to situational factors 4. Risk for Myocardial Infarction related to deficient knowledge Correct Answer: 2 Rationale 1: Health-Seeking Behavior is a diagnostic label used when the client is seeking health information. Rationale 2: 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 (diet and medication regimen) should always be included in the diagnosis. Rationale 3: Noncompliance is used when the client or caregiver fails to follow a plan, which is too early to tell in this case. Rationale 4: Risk for Myocardial Infarction is not a NANDA label. If a risk exists, the label could be Risk for Noncompliance related to deficient knowledge. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 9. Identify nursing diagnoses, outcomes, and interventions that reflect the learning needs of clients. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 448 Question 17 Type: MCSA The nursing diagnosis Readiness for Enhanced Knowledge (Nutrition) related to desire to improve nutritional intake has been formulated for a client who has decided to change his eating habits to be more nutritionally sound. What would be an appropriate outcome for this client? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: Learning outcomes, like client outcomes, must be specific and observable so they can be measured. Words like "understand" are not measurable and are not observable. Rationale 2: "Be able to lose weight" is not specific enough, and with the information given, it is not known if that is really what the client wants to attain. Rationale 3: Learning outcomes, like client outcomes, must be specific and observable so they can be measured. Rationale 4: Words like "appreciate" are not measurable and are not observable. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9. Identify nursing diagnoses, outcomes, and interventions that reflect the learning needs of clients. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 451 Question 18 Type: MCSA A home health nurse is working with 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Client will have a positive attitude about the diagnosis by the end of the month. Correct Answer: 1 Rationale 1: 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. Rationale 2: This outcome cannot be measured. Rationale 3: In this case, the physiological need of learning how to administer medication takes priority over activity needs. Rationale 4: In this case, the physiological need of learning how to administer medication takes priority over attitudinal needs. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9. Identify nursing diagnoses, outcomes, and interventions that reflect the learning needs of clients. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 452 Question 19 Type: MCMA A school nurse is putting together a program for adolescents about positive lifestyle choices. What should the nurse keep in mind when preparing content to present to this age group? Standard Text: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

5. Consistent with the teaching topics Correct Answer: 1, 2, 3, 5 Rationale 1: 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. Rationale 2: 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 current. Rationale 3: 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 adjusted to the learner's age. Rationale 4: 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 selected with consideration of how much time and what resources are available for teaching. Rationale 5: 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 consistent with the information that the nurse is teaching. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Assess learning needs of learners and the learning environment. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 452 Question 20 Type: MCSA 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. When organizing the teaching/learning experience, the nurse should 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. make sure the client's spouse is present before the teaching session begins. Correct Answer: 3 Rationale 1: Going over information already taught and learned isn't practicing good time management for the nurse or the client. Rationale 2: Unless the client has attention problems or may be elderly, breaking up the sessions may not be necessary. Rationale 3: 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. Rationale 4: Having the spouse present is always a good idea, but may not be possible all the time. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Assess learning needs of learners and the learning environment. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 453 Question 21 Type: MCSA A client needs discharge teaching regarding the use of a walker before going home. 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 3 Rationale 1: Noise or interruptions can interfere with concentration, whereas a comfortable environment can promote learning. The hospital lobby does not provide privacy and can be noisy. There also would be little time to reinforce any teaching needs that might be necessary. Rationale 2: Noise or interruptions can interfere with concentration, whereas a comfortable environment can promote learning. Rationale 3: 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. Rationale 4: Not all hospitals have a physical therapist available to help implement teaching for clients. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Assess learning needs of learners and the learning environment. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 454 Question 22 Type: MCSA A community health nurse runs a clinic that provides health screening to mainly Mexican American and Native American clients. The nurse wants to have a class on smoking cessation for interested adults of this group. In order to adjust to their time orientation, what is the best action of the nurse? 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. Correct Answer: 2 Rationale 1: Cultures with a predominant orientation to the present include the Mexican American and Navajo Native American. Schedules have to be very flexible in present-oriented societies. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: 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. Rationale 3: Time constraints are not significant for cultures that are oriented to the present, so advertising about specific classes may not be effective. Rationale 4: Time constraints are not significant for cultures that are oriented to the present, so advertising about specific classes may not be effective. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Implementation Learning Outcome: 12. Discuss strategies to use when teaching clients of different cultures. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 457 Question 23 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Using only the return demonstration is one sided. The evaluation is of the bandaging technique, and it may or may not be covering a wound. Rationale 3: Focusing on the nurse's satisfaction with the client's performance is one sided. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The evaluation is of the bandaging technique, and it may or may not be covering a wound. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 13. Identify methods to evaluate learning. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 458 Question 24 Type: MCMA The nurse has completed a teaching session for a client with a tracheostomy. Documentation of the session should include what information? Standard Text: Select all that apply. 1. Diagnosed learning needs 2. Supplies required 3. Client outcomes 4. Need for additional teaching 5. Topics taught Correct Answer: 1, 3, 4, 5 Rationale 1: The parts of the teaching process that should be documented in the client's chart include diagnosed learning needs. Rationale 2: The parts of the teaching process that should be documented in the client's chart include resources provided. Rationale 3: The parts of the teaching process that should be documented in the client's chart include client outcomes. Rationale 4: The parts of the teaching process that should be documented in the client's chart include need for additional teaching. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: The parts of the teaching process that should be documented in the client's chart include topics taught. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14. Describe effective documentation of teaching–learning activities. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 458 Question 25 Type: MCMA When making an assessment of the client’s learning needs, the nurse will focus on which elements? Standard Text: 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 Correct Answer: 2, 3, 4, 5 Rationale 1: The nurse’s own knowledge of common learning needs is a source of information but not part of the nurse’s assessment of the client’s learning needs. Rationale 2: The client’s age provides information on the person’s developmental status that might indicate health teaching content and teaching approaches. Rationale 3: The client’s understanding of health problems might indicate deficient knowledge or misinformation. Rationale 4: Sensory acuity is part of the psychomotor ability of which the nurse must be aware when planning a teaching session. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: Learning style identifies the client’s best way to learn so that the nurse can adapt teaching accordingly. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Assess learning needs of learners and the learning environment. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 444 Question 26 Type: MCMA A school nurse is planning a program for adolescents about positive lifestyle choices. The nurse should keep in mind that content presented to this age group must be Standard Text: 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. Correct Answer: 1, 2, 3, 5 Rationale 1: Whatever sources the nurse chooses, content should be based on learning outcomes. Rationale 2: Whatever sources the nurse chooses, content should be current. Rationale 3: Whatever sources the nurse chooses, content should be adjusted to the learners’ age. Rationale 4: Nurses can select among many sources of information, not just those available within the school system. Rationale 5: Whatever sources the nurse chooses, content should be accurate. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Assess learning needs of learners and the learning environment. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 452 Question 27 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 2, 3 Rationale 1: 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. Rationale 2: Discharge plans must include information about what the client has been taught. Rationale 3: Discharge plans must include what the client still needs to learn when discharged. Rationale 4: The nurse does not need to check the client’s insurance for hospitalization coverage when preparing discharge instructions. Rationale 5: The nurse does not call the client’s prescriptions in to the client’s local pharmacy when preparing discharge instructions. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Assess learning needs of learners and the learning environment. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 438 Question 28 Type: MCMA The nurse serves as an educator of other health care personnel. In what capacity will this nurse participate in education? Standard Text: 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 Correct Answer: 1, 2, 3 Rationale 1: Nurses are involved in the instruction of professional colleagues, such as functioning as preceptors for new graduate nurses. Rationale 2: Nurses with specialized knowledge and experience may share that knowledge and experience with nurses by instructing a part of the critical care course. Rationale 3: Nurses in nursing practice settings are often involved in the clinical instruction of nursing students. Rationale 4: One-to-one teaching of clients is not an example of being an educator of other health care personnel. Rationale 5: Teaching grandparents how to care for children is not an example of being an educator of other health care personnel. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Discuss the importance of the teaching role of the nurse. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 439 Question 29 Type: MCMA The nurse planning an educational session for adult clients should include which andragogy concepts? Standard Text: 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. Correct Answer: 1, 2, 3, 4 Rationale 1: An andragogy concept about adult learners is that as people mature, they move from dependence to independence. Rationale 2: An andragogy concept about adult learners is that an adult’s previous experiences can be used as a resource for learning. Rationale 3: An andragogy concept about adult learners is that learning is related to an immediate need or problem. Rationale 4: An andragogy concept about adult learning is that learning is reinforced by prompt feedback. Rationale 5: An andragogy concept about adult learning is that an adult is more oriented to learning when the material is useful immediately, and not sometime in the future. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare and contrast andragogy, pedagogy, and geragogy. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 440 Question 30 Type: MCMA The nurse is utilizing humanistic theory when instructing a client. What will the nurse demonstrate when utilizing this theory? Standard Text: 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 Correct Answer: 1, 2, 3 Rationale 1: Conveying empathy is a characteristic of humanism. Rationale 2: Encouraging the client to establish goals is a characteristic of humanism. Rationale 3: Encouraging the client to participate in self-directed learning is a characteristic of humanism. Rationale 4: Selecting multisensory teaching strategies is a characteristic of cognitivism. Rationale 5: Providing a physical environment conducive to learning is a characteristic of cognitivism. Global Rationale: Cognitive Level: Applying Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Discuss the learning theories of behaviorism, cognitivism, and humanism and how nurses can use each of these theories. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 441 Question 31 Type: MCSA A client tells the nurse that he has no questions about his illness, as he did a search for information on the Internet. 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: The nurse needs to ask the client to share the information, and not just document that the client has received instruction. The nurse does not know what instruction the client has received. Rationale 3: The Internet is a source of information, and not just a form of entertainment. Rationale 4: The client did not refuse instruction. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss the implications of using the Internet as a source of health information. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 444 Question 32 Type: MCMA The nurse instructs the older client to access the Internet to complete a post-hospitalization survey and update health information. The client tells the nurse that he does not have a computer and would not know how to use one. What should the nurse do? Standard Text: 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. Correct Answer: 1, 2 Rationale 1: 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. Rationale 2: The nurse should provide times for the older client to attend basic computer use classes though the community learning center. Rationale 3: The client who does not have a computer or does not know how to use one is not resistant to instruction. Rationale 4: The physician does not need to be notified. The client is not refusing to adhere to medical instruction as planned. Rationale 5: The client who does not have a computer or does not know how to use one is not being noncompliant with instruction. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss the implications of using the Internet as a source of health information. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 444 Question 33 Type: MCMA The nurse suspects a client has low literacy. What did the nurse assess to come to this conclusion? Standard Text: 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 Correct Answer: 1, 2, 3 Rationale 1: The nurse should suspect a literacy problem when a client incorrectly completes forms. Rationale 2: The nurse should suspect a literacy problem when a client refuses to sign forms because of lack of eyeglasses. Rationale 3: The nurse should suspect a literacy problem when appointments are missed. Rationale 4: A score of 6 on the Newest Vital Sign assessment tool indicates adequate literacy. Rationale 5: Questioning a medication would indicate that the client read the prescription, and would not suggest a literacy problem. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Assess learning needs of learners and the learning environment. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 447 Question 34 Type: MCMA 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? Standard Text: Select all that apply. 1. Demonstration 2. Practice 3. Modeling 4. Discovery 5. Role playing Correct Answer: 1, 2, 3 Rationale 1: Demonstration is used to learn a psychomotor skill. Rationale 2: Practice is used to learn a psychomotor skill. Rationale 3: Modeling is used to learn a psychomotor skill. Rationale 4: Discovery is used to learn concepts within the affective and cognitive domains. Rationale 5: Role playing is used to learn concepts within the affective and cognitive domains. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Describe the three learning domains. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 453 Question 35 Type: MCMA The nurse instructs a client on self-care for a new ostomy. Which client behaviors demonstrate that instruction has been effective? Standard Text: 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 tells the nurse that he does not want to do the care. 5. Client asks his wife to learn how to perform the care so he will not have to do it. Correct Answer: 1, 2 Rationale 1: 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. Rationale 2: In cognitive learning, the client demonstrates acquisition of knowledge by responding appropriately to oral questions. Rationale 3: The inability to identify changes in the skin around the stoma would indicate that instruction has not been effective. Rationale 4: The client’s stating he does not want to perform self-care to the ostomy would indicate that effective learning did not occur. Rationale 5: The client’s asking his wife to learn the care would indicate that effective learning did not occur. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 13. Identify methods to evaluate learning. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 453 Question 36 Type: MCMA The nurse is documenting the teaching plan for a client. What should be included in this documentation? Standard Text: 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 Correct Answer: 1, 2, 3, 4 Rationale 1: The written teaching plan that the nurse uses to guide future teaching sessions can include the actual information to be taught. Rationale 2: The written teaching plan that the nurse uses to guide future teaching sessions can include the teaching strategies to use. Rationale 3: The written teaching plan that the nurse uses to guide future teaching sessions can include the skills to be taught. Rationale 4: The written teaching plan that the nurse uses to guide future teaching sessions can include the amount of time needed to teach each topic. Rationale 5: Vital signs before and after each teaching session do not need to be included in the client’s teaching plan. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14. Describe effective documentation of teaching–learning activities. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 451 Question 37 Type: MCMA The nurse has completed a teaching session for a client with a tracheostomy. What should the documentation include? Standard Text: Select all that apply. 1. Diagnosed learning needs 2. Supplies required 3. Client outcomes 4. Need for additional teaching 5. Topics taught Correct Answer: 1, 3, 4, 5 Rationale 1: The parts of the teaching process that should be documented in the client's chart include diagnosed learning needs. Rationale 2: The supplies needed for instruction do not need to be documented. Rationale 3: The parts of the teaching process that should be documented in the client's chart include client outcomes. Rationale 4: The parts of the teaching process that should be documented in the client's chart include need for additional teaching. Rationale 5: The parts of the teaching process that should be documented in the client's chart include topics taught. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14. Describe effective documentation of teaching–learning activities. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 458 Question 38 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 3, 5 Rationale 1: Elements of a teaching plan include the content. Rationale 2: Elements of a teaching plan include learning outcomes. Rationale 3: Elements of a teaching plan include teaching strategies. Rationale 4: Evaluation of the effectiveness of the teaching occurs after the teaching has been completed. Rationale 5: Elements of a teaching plan include the time frame needed for teaching. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10. Describe the essential aspects of a teaching plan. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 451 Question 39 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 2, 4, 5 Rationale 1: The nurse should start with something that the client is concerned about. Rationale 2: The nurse should assess what the client knows and then proceed to the unknown. This gives the learner confidence. Rationale 3: Issues that are causing anxiety should be addressed first. A high level of anxiety can impair learning. Rationale 4: The nurse should teach the basics before proceeding to variations, adjustments, or complicated steps. Rationale 5: The nurse should schedule time for the review of content and any questions the client may have to clarify information. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Discuss guidelines for effective teaching. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 453

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 28 Question 1 Type: MCMA According to the National Council of State Boards of Nursing (NCSBN), which "rights" of delegation should the nurse follow? Standard Text: Select all that apply. 1. Supervision 2. Evaluation 3. Client 4. Time 5. Task Correct Answer: 1, 2, 5 Rationale 1: According to the NCSBN, the nurse delegates the right task under the right circumstances to the right person with the right direction and communication and the right supervision and evaluation. Rationale 2: According to the NCSBN, the nurse delegates the right task under the right circumstances to the right person with the right direction and communication and the right supervision and evaluation. Rationale 3: The right client is a part of the rights of medication administration. Rationale 4: The right time is a part of the rights of medication administration. Rationale 5: According to the NCSBN, the nurse delegates the right task under the right circumstances to the right person with the right direction and communication and the right supervision and evaluation. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. List the five rights of delegation. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 468 Question 2 Type: MCSA An unlicensed assistive person (UAP) 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. An unlicensed assistive person may not delegate tasks. Correct Answer: 4 Rationale 1: Taking and recording vital signs is an appropriate task for the registered nurse to delegate to the UAP. Rationale 2: Assisting with bathing is an appropriate task for the registered nurse to delegate to the UAP. Rationale 3: Making a bed is an appropriate task for the registered nurse to delegate to the UAP. Rationale 4: The unlicensed person may not delegate tasks to another person. Delegation is part of the registered nurse's role. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe the characteristics of tasks appropriate to delegate to unlicensed and licensed assistive personnel. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 468 Question 3 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

An 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, 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 Correct Answer: 4 Rationale 1: The nurse manager did not delegate the task of vital signs and therefore is not responsible for the time lapse between discovery and action. Rationale 2: The aide did not delegate the task of vital signs and therefore is not responsible for the time lapse between discovery and action. Rationale 3: The client did not delegate the task of vital signs and therefore is not responsible for the time lapse between discovery and action. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Discuss the roles and functions of nurse managers. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 471 Question 4 Type: MCSA A nurse manager has the reputation of being an autocratic leader. Which of the following statements 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." Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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." Correct Answer: 3 Rationale 1: This option is more reflective of a democratic-style leader. Rationale 2: This option is more reflective of a democratic-style leader. Rationale 3: 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. Rationale 4: This option is more reflective of a democratic-style leader. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast different leadership styles. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 463 Question 5 Type: MCSA 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." This leader is best identified as which of the following? 1. Democratic leader 2. Permissive leader 3. Bureaucratic leader 4. Situational leader Correct Answer: 2

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: The democratic leader encourages group discussion and decision making, provides constructive criticism, offers information, makes suggestions, and asks questions. Rationale 2: The permissive leader recognizes the group's need for autonomy and self-regulation 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. Rationale 3: The bureaucratic leader relies on the organization's rules, policies, and procedures to direct the group's work efforts. Rationale 4: A situational leader is one who adapts his or her leadership style to the situation. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast different leadership styles. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 464 Question 6 Type: MCSA A nurse manager allows the staff members to make their own schedules and do their own client assignments on their shifts. However, during a code situation, the nurse 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 Correct Answer: 3 Rationale 1: Permissive leaders assume a "hands-off" approach. Rationale 2: The democratic leader encourages group discussion and decision making.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: 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. Rationale 4: A bureaucratic leader relies on the organization's rules, policies, and procedures to direct the group's work efforts. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast different leadership styles. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 464 Question 7 Type: MCSA A group of community health nurses work together in the same office. They are each responsible for their own caseloads and scheduling of appointments. Their 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 Correct Answer: 2 Rationale 1: A charismatic leader is characterized by an emotional relationship between the leader and group members. Rationale 2: 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. Rationale 3: A transformational leader fosters creativity, risk taking, commitment, and collaboration by empowering the group to share in the organization's vision.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: A transactional leader has a relationship with followers based on an exchange for some resource valued by the followers. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast different leadership styles. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 464 Question 8 Type: MCSA A 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 Correct Answer: 3 Rationale 1: Upper-level (same as top-level) managers are organizational executives who are primarily responsible for establishing goals and developing strategic plans. Rationale 2: Middle-level managers supervise a number of first-level managers and are responsible for the activities in the departments they supervise. Rationale 3: 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). Rationale 4: Upper-level (same as top-level) managers are organizational executives who are primarily responsible for establishing goals and developing strategic plans. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Compare and contrast the levels of management. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 465 Question 9 Type: SEQ The nurse manager is implementing risk management for a client-care issue. In what order will the manager implement risk management? Standard Text: Click and drag the options below to move them up or down. Choice 1. Analyzing, classifying, and prioritizing risks Choice 2. Evaluating and modifying risk reduction programs Choice 3. Anticipating and seeking sources of risk Choice 4. Developing a plan to avoid and manage risk Choice 5. Gathering data that indicate success at avoiding or minimizing risk Correct Answer: 3, 1, 4, 5, 2 Rationale 1: Analyzing, classifying, and prioritizing risks is the second step of the risk management process. Rationale 2: Evaluating and modifying risk reduction programs is the fifth step of the risk management process. Rationale 3: Anticipating and seeking sources of risk is the first step of the risk management process. Rationale 4: Developing a plan to avoid and manage risk is the third step in the risk management process. Rationale 5: Gathering data that indicate success at avoiding or minimizing risk is the fourth step of the risk management process. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe the four functions of management. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 466 Question 10 Type: MCSA A 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 Correct Answer: 2 Rationale 1: Planning involves assessing a situation, establishing goals and objectives that identify priorities, delineating who is responsible, determining deadlines, and describing how the intended outcome is to be achieved and evaluated. Rationale 2: 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. Rationale 3: Directing is the process of getting the organization's work accomplished. Coordinating is the process of ensuring that plans are carried out and evaluating outcomes. Rationale 4: Coordinating is the process of ensuring that plans are carried out and evaluating outcomes. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe the four functions of management. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 466 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 11 Type: MCSA 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 Correct Answer: 4 Rationale 1: Authority is defined as the right to direct the work of others. Rationale 2: Responsibility is an obligation to perform a task. Rationale 3: Coordination is a function of management, not one of the principles. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe the four functions of management. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 466 Question 12 Type: MCSA A 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Critical thinking 2. Communication 3. Networking 4. Responsibility Correct Answer: 2 Rationale 1: Critical thinking is a creative process that includes problem solving and decision making. Rationale 2: Good communication skills are essential to managers and include assertiveness, clear expression of ideas, accuracy, and honesty. Rationale 3: Networking is a process whereby professional links are established through which people can share ideas, knowledge, and information; offer support and direction to each other; and facilitate accomplishment of professional goals. Rationale 4: Responsibility is one of the principles of management, not a management skill. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify the skills and competencies needed by a nurse manager. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 467 Question 13 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 4 Rationale 1: A mentor acts in a more nurturing role, perhaps for a longer period of time, and provides support, guidance, assistance, advice, and inspiration to a younger nurse. Rationale 2: A manager is a different type of management role. Rationale 3: A team leader is a different type of management role. Rationale 4: The preceptor is a person of experience who assists a "new" nurse in improving clinical skills and nursing judgment. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss the roles and functions of nurse managers. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 467 Question 14 Type: MCSA 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 Correct Answer: 1 Rationale 1: An overt change is one that is planned and that people are aware of. Implementing a new computer system is certainly a planned, purposeful event. Rationale 2: Covert change is hidden or occurs without the individual's awareness—it may be gradual, subtle, and unplanned.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: An unplanned change is an alteration imposed by external events or persons and occurs when unexpected events force a reaction. Rationale 4: Drift is a type of unplanned change in which change occurs without effort on anyone's part. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10. Describe the role of the leader/manager in planning for and implementing change. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 471 Question 15 Type: MCSA 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 Correct Answer: 2 Rationale 1: Refreezing is when the change is integrated and stabilized. Rationale 2: 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. Rationale 3: During the second stage, moving, participants agree that the status quo is undesirable and the actual change is planned in detail and implemented. Rationale 4: Drift is a type of unplanned change in which change occurs without effort on anyone's part. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Describe the role of the leader/manager in planning for and implementing change. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 471 Question 16 Type: MCMA Prior to delegating a task, the nurse reviews the "rights" of delegation; these include which rights? Standard Text: Select all that apply. 1. Supervision 2. Evaluation 3. Client 4. Time 5. Task Correct Answer: 1, 2, 5 Rationale 1: According to the National Council of State Boards of Nursing (NCSBN), right supervision is one of the "rights" of delegation. Rationale 2: According to the National Council of State Boards of Nursing (NCSBN), right evaluation is one of the "rights" of delegation. Rationale 3: The right client is not one of the "rights" of delegation. Rationale 4: The right time is not one of the "rights" of delegation. Rationale 5: According to the National Council of State Boards of Nursing (NCSBN), right task is one of the "rights" of delegation. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. List the five rights of delegation. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 468 Question 17 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 2, 3, 4 Rationale 1: The nurse manager is responsible for efficiently accomplishing the goals of the organization. Rationale 2: The nurse manager is responsible for efficiently using the organization’s resources. Rationale 3: The nurse manager is responsible for ensuring effective client care. Rationale 4: The nurse manager is responsible for ensuring compliance with regulatory standards. Rationale 5: The nurse leader manages relationships. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Discuss the roles and functions of nurse managers. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 462 Question 18 Type: MCMA A nurse is identified as being an effective leader. With this designation, the nurse will most likely demonstrate which characteristics? Standard Text: Select all that apply. 1. Self-aware 2. Focus on people 3. Excellent communicator 4. Mentor to others 5. Focus on systems Correct Answer: 1, 2, 3, 4 Rationale 1: The nurse as leader is self-aware. Rationale 2: The nurse as leader is focused on people. Rationale 3: The nurse as leader is an excellent communicator. Rationale 4: The nurse as leader mentors others. Rationale 5: The nurse as manager is focused on systems. Global Rationale: Page Reference: 521 Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Identify characteristics of an effective leader. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 462 Question 19 Type: MCMA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

A staff nurse has been identified by others as being an effective leader. With this designation, the nurse implements which principles? Standard Text: Select all that apply. 1. Vision 2. Influence 3. Serve as a role model 4. Planning 5. Organizing Correct Answer: 1, 2, 3 Rationale 1: Principles of effective leadership include vision, which is a mental image of a possible and desirable future state. Rationale 2: Principles of effective leadership include influence, which is an informal strategy used to gain the cooperation of others without exercising formal authority. Rationale 3: Principles of effective leadership include role modeling, an example of which is demonstrating caring toward coworkers and clients. Rationale 4: Planning is a function of management. Rationale 5: Organizing is a function of management. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Compare and contrast leadership and management. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 462 Question 20 Type: MCMA The nurse is reviewing feedback from other staff members on leadership behaviors. Which characteristics are consistent with being an effective leader? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Standard Text: Select all that apply. 1. Energetic 2. Creative 3. Optimistic 4. Open 5. Risk taking Correct Answer: 1, 2, 3, 4 Rationale 1: Being energetic is a characteristic of an effective leader. Rationale 2: Creativity is a characteristic of an effective leader. Rationale 3: Optimism is a characteristic of an effective leader. Rationale 4: Being open is a characteristic of an effective leader. Rationale 5: Risk taking is a characteristic of a transformational leader. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Identify characteristics of an effective leader. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 465 Question 21 Type: MCMA 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? Standard Text: Select all that apply. 1. Supervisor 2. Nurse manager Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Head nurse 4. Primary care nurse 5. Vice president Correct Answer: 1, 2, 3 Rationale 1: Middle-level managers may be called supervisors. Rationale 2: Middle-level managers may be called nurse managers. Rationale 3: Middle-level managers may be called head nurses. Rationale 4: First-level managers may be called primary care nurses. Rationale 5: Upper-level managers may be called vice presidents. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Compare and contrast the levels of management. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 465 Question 22 Type: MCMA 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? Standard Text: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1, 2, 3 Rationale 1: Managers are responsible for effective utilization of resources. Rationale 2: Managers are responsible for communication to subordinates. Rationale 3: Managers are responsible for the implementation of organizational goals and objectives. Rationale 4: Problem solving is a skill associated with critical thinking. Rationale 5: Managing the work team is a skill associated with building and managing teams. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify the skills and competencies needed by a nurse manager. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 466 Question 23 Type: MCMA The nurse is determining whether an activity can be delegated to a UAP. What will the nurse use to make this determination? Standard Text: 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. Correct Answer: 1, 2, 3, 4 Rationale 1: The right task is one of the five “rights” of delegation. Rationale 2: The right circumstance is one of the five “rights” of delegation. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: The right person is one of the five “rights” of delegation. Rationale 4: The right communication is one of the “five rights” of delegation. Rationale 5: Enough time is not one of the five “rights” of delegation. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Describe the characteristics of tasks appropriate to delegate to unlicensed and licensed assistive personnel. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 468 Question 24 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 4, 5 Rationale 1: Change agents are self-confident and are able to take risks and inspire trust in themselves and others. Rationale 2: Change agents are skilled in teaching. Rationale 3: Change agents are able to make decisions. Hesitancy is not a characteristic of a change agent. Rationale 4: Change agents have excellent communication skills with all levels and types of individuals. Rationale 5: Change agents have knowledge of available resources and know how to use them wisely. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 10. Describe the role of the leader/manager in planning for and implementing change. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 471 Question 25 Type: MCMA 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? Standard Text: 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 Correct Answer: 3, 5 Rationale 1: Bathing can safely be delegated to unlicensed assistive personnel. Rationale 2: Weights can safely be delegated to unlicensed assistive personnel. Rationale 3: Client education may not be delegated to unlicensed assistive personnel. Rationale 4: Transferring and ambulation can be safely delegated to unlicensed assistive personnel. Rationale 5: The care of invasive lines may not be delegated to unlicensed assistive personnel. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Teamwork; Practice; and manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8. Describe the characteristics of tasks appropriate to delegate to unlicensed and licensed assistive personnel. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 468 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 29 Question 1 Type: MCSA An older client has an oral temperature reading of 97.2 degrees 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. Correct Answer: 4 Rationale 1: If a client is anxious or stressed, this response stimulates the sympathetic nervous system. This in turn increases the production of epinephrine and norepinephrine, which increases metabolic and heat production, causing the temperature to rise. Rationale 2: Women experience more hormonal fluctuations than men, and this is usually true with the secretion of progesterone at the time of ovulation. Because this client is older, hormone fluctuations and ovulation will not impact the temperature. Rationale 3: Exercise, which represents hard work or strenuous activity, increases body temperature. That is not the case with this client. No reference has been made to a therapy session, and the temperature is decreased. Rationale 4: This client is older and research shows that older people are at risk for hypothermia. When one ages, subcutaneous fat is lost. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Identify the variations in normal body temperature, pulse, respirations, and blood pressure that occur from infancy to old age. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 3.3.1. Explain the body’s regulation of temperature, pulse, respirations, and blood pressure. Page Number: 479 Question 2 Type: MCSA 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 health care 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. Correct Answer: 1 Rationale 1: If the equipment is not working properly, no accuracy will be obtained in the readings. Rationale 2: The type of equipment or method that is chosen will dictate client position, not the position of the health care provider. Rationale 3: If the equipment is not working properly, no accuracy will be obtained in the readings. The type of equipment or method that is chosen will dictate client position, not the position of the health care provider. In order to use a chemical disposable thermometer, the client's skin must be dry for the thermometer to adhere to the skin. Rationale 4: The recommended time to wait to assess an oral temperature is 30 minutes after one smokes, not 10 minutes. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Verbalize the steps used in: a. Assessing body temperature. MNL Learning Outcome: 3.3.1. Explain the body’s regulation of temperature, pulse, respirations, and blood pressure. Page Number: 484 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 3 Type: MCSA 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 Correct Answer: 2 Rationale 1: The axilla is the preferred site for newborns, not adults. Rationale 2: 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. Rationale 3: The popliteal site would not be used given the history of heart disease. There could be circulatory issues that might affect accurate reading because this site is much farther away from the heart. Rationale 4: The rectal site would be contraindicated in this client given the history of heart disease. With the diagnosis of heart disease, the nurse would need to assess for the presence of hemorrhoids. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Verbalize the steps used in: a. Assessing body temperature. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 482 Question 4 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: Bathing the client in ice water would lower the client's temperature too fast, possibly causing hypothermia. Rationale 2: Giving a client an antipyretic requires a doctor's order. Rationale 3: 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. Rationale 4: Dropping the temperature of the room would lower the client's temperature too fast, possibly causing hypothermia. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implemenation Learning Outcome: 4. Describe appropriate nursing care for alterations in vital signs. MNL Learning Outcome: 3.3.4. Compare expected and unexpected outcomes. Page Number: 481 Question 5 Type: MCSA 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 to 3 seconds of capillary refilling time. How would the nurse explain these findings? 1. A change in the client's health status has occurred. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 4 Rationale 1: The information provided gives no indication that any health change has occurred. Rationale 2: The assessment data given (warm, pink, etc.) are not symptoms of a blood clot. Rationale 3: There is no data given in regard to equipment malfunction, such as the nurse’s watch. Rationale 4: 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, making contact with the cones in the foot. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Verbalize the steps used in: b. Assessing a peripheral pulse. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 488 Question 6 Type: MCSA The RN 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. Correct Answer: 3 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: If one nurse is having difficulty with the pulse and accuracy, getting another nurse is not going to be the best choice. Rationale 2: Just documenting the findings does not address the problem of getting an accurate pulse reading. Rationale 3: Obtaining a Doppler ultrasound stethoscope is the appropriate action to take. The Doppler will ensure accuracy by helping to exclude environmental sounds. Rationale 4: Waiting until later may be harmful to the client, creating an unsafe environment. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Verbalize the steps used in: b. Assessing a peripheral pulse. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 488 Question 7 Type: MCSA When assessing a client's peripheral pulse, the health care provider is also assessing which of the following? 1. Depth 2. Rhythm 3. Sound 4. Stress Correct Answer: 2 Rationale 1: Depth is a term used when assessing edema. Rationale 2: When assessing peripheral pulses, one of the characteristics being assessed is rhythm, along with rate, volume, and equality. Rationale 3: Heart sounds are assessed with the apical pulse.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Stress will affect the rate of both pulse and respiration, but it is not a characteristic of pulse assessment. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. List the characteristics that should be included when assessing pulses. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 489 Question 8 Type: MCSA The nurse is going to assess the apical-radial pulse of a client with a cardiovascular disorder. Which rationale did the RN 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. Correct Answer: 4 Rationale 1: A forceful radial pulse would be ideal for assessing a client's peripheral pulse. Rationale 2: Arteriole and venous sounds would be detected when using the Doppler, but there is no indication for Doppler use given this situation. Rationale 3: A bounding pulse is not easily obliterated. Rationale 4: Knowing there is a history of a cardiovascular disorder would alert the RN 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. Global Rationale: Cognitive Level: Analyzing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify nine sites used to assess the pulse and state the reasons for their use. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 494 Question 9 Type: MCSA 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 Correct Answer: 2 Rationale 1: Exercise increases respiration rates. Rationale 2: Factors that decrease respirations include increased intracranial pressure. Rationale 3: Increased environmental temperatures increase respiration rates. Rationale 4: Stress increases respiration rates. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 7. Describe the mechanics of breathing and the mechanisms that control respirations. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 495 Question 10 Type: MCSA 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's 3. Side-lying 4. Supine Correct Answer: 2 Rationale 1: The prone position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the client's respirations. Rationale 2: Persons in a semi-Fowler's position will better aid themselves and the nurse to assess their respiratory status. Rationale 3: The side-lying position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the client's respirations. Rationale 4: The supine position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the client's respirations. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Verbalize the steps used in: d. Assessing respirations. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 498 Question 11 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA A client is being treated for congestive heart failure. Which physical finding would lead the RN 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 Correct Answer: 4 Rationale 1: A temperature reading of 98.6°F is a normal finding and not an indication of heart failure. Rationale 2: A moderate amount of clear mucus is a normal finding and not an indication of heart failure. Rationale 3: A pulse oximetry reading of 96% is a normal finding and not an indication of heart failure. Rationale 4: Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic of congestive heart failure. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Describe the mechanics of breathing and the mechanisms that control respirations. MNL Learning Outcome: 3.3.4. Compare expected and unexpected outcomes. Page Number: 497 Question 12 Type: MCSA Which determinant of blood pressure would explain a client's blood pressure reading of 120/100? 1. Blood viscosity 2. Blood volume Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Pumping action of the heart 4. Peripheral vascular resistance Correct Answer: 4 Rationale 1: Determinants of blood pressure such as blood viscosity mainly affect the systolic reading portion of the blood pressure. Rationale 2: Determinants of blood pressure such as blood volume mainly affect the systolic reading portion of the blood pressure. Rationale 3: Determinants of blood pressure such as pumping action of the heart mainly affect the systolic reading portion of the blood pressure. Rationale 4: Peripheral vascular resistance especially affects diastolic blood pressure readings. A reading of 120/100 would be indicative of peripheral vascular resistance. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 3.3.4. Compare expected and unexpected outcomes. Page Number: 500 Question 13 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1 Rationale 1: Phase 2 produces a muffled, whooshing, or swishing sound. Rationale 2: Phase 5, the final phase, is where the sound disappears. Rationale 3: Phase 1 of Korotkoff's sounds starts with a faint, clear tapping sound. Rationale 4: Phase 3 is marked by an increased intensity of sound. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Verbalize the steps used in: e. Assessing blood pressure. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 503 Question 14 Type: MCSA 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 Correct Answer: 1 Rationale 1: The brachial is the most common artery used to assess a blood pressure reading because it is the most accessible. Rationale 2: The femoral is not as accessible as the brachial. Rationale 3: The radial could be used but it is not as accurate as the brachial artery. Rationale 4: The ulnar could be used but it is not as accurate as the brachial artery. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Verbalize the steps used in: e. Assessing blood pressure. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 503 Question 15 Type: MCSA 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 Correct Answer: 3 Rationale 1: Assessing the pulse before the cuff is inflated is not the pressure. Rationale 2: This is not the client’s blood pressure if the cuff is just being deflated. Rationale 3: 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. Rationale 4: If the second pulsation is recorded, that would be an inaccurate reading. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Verbalize the steps used in: e. Assessing blood pressure. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 503 Question 16 Type: MCSA Which condition would lead the RN to 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 Correct Answer: 4 Rationale 1: To assess an altered level of consciousness, the nurse would most likely assess the client’s apical pulse. Rationale 2: To assess for decreased urine output, the nurse would most likely assess the apical pulse. Rationale 3: For an irregular radial pulse, the nurse would most likely assess the apical pulse. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify nine sites used to assess the pulse and state the reasons for their use. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 488 Question 17 Type: MCSA When assessing a client’s oxygen saturation reading, the nurse realizes that what will affect this reading? 1. Activity 2. Environmental conditions 3. Nutrition 4. Skin color Correct Answer: 1 Rationale 1: 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. Rationale 2: Environmental conditions do not affect an accurate oxygen saturation reading. Rationale 3: Nutrition does not affect an oxygen saturation reading. Rationale 4: Skin color does not affect an oxygen saturation reading. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Verbalize the steps used in: f. Assessing blood oxygenation using pulse oximetry. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 507 Question 18 Type: MCSA As the RN 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 4 Rationale 1: Allowing the client to take a few deep breaths will help but not quickly enough to compensate for the hypoxia experienced. Rationale 2: Continuing to suction continuously or intermittently will only decrease the saturation levels more. Rationale 3: Leaving the catheter in place obstructs air flow, thus compromising an already poor situation. Rationale 4: Not only does suctioning remove secretions, but it also removes the client's air. By stopping suctioning, the RN 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Verbalize the steps used in: f. Assessing blood oxygenation using pulse oximetry. MNL Learning Outcome: 3.3.4. Compare expected and unexpected outcomes. Page Number: 509 Question 19 Type: MCSA The RN 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 of 2 days from gallbladder surgery Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1 Rationale 1: The cardiac catheterization client will need a thorough assessment because she is 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. Rationale 2: The COPD client is a chronic condition client, and her vital signs would be considered routine. Rationale 3: The client with pneumonia nearing discharge would be considered medically stable. Therefore, assisting this client is within the UAP’s capability. Rationale 4: The client who is 2 days post-op from gallbladder surgery would be considered medically stable. Therefore, assisting this client is within the UAP’s capability. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Recognize when it is appropriate to delegate measurement of vital signs to unlicensed assistive personnel. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 478 Question 20 Type: MCMA Prior to assessing a client’s blood pressure, the nurse reviews factors that could affect the reading. Which factors could impact blood pressure? Standard Text: Select all that apply. 1. Stress 2. Race 3. Obesity 4. Medications 5. Employment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1, 2, 3, 4 Rationale 1: Stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of the arterioles, increasing the blood pressure reading. Rationale 2: African Americans over 35 years of age tend to have higher blood pressures than do European Americans of the same age. Rationale 3: Both childhood and adult obesity predispose to hypertension. Rationale 4: Many medications, including caffeine, can increase or decrease the blood pressure. Rationale 5: Employment is not a factor that affects blood pressure. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe factors that affect the vital signs and accurate measurement of them. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 500 Question 21 Type: MCMA The nurse is planning to assess a client’s pulse. What characteristics should the nurse include in this assessment? Standard Text: Select all that apply. 1. Rate 2. Rhythm 3. Volume 4. Tone 5. Viscosity Correct Answer: 1, 2, 3 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: When assessing the pulse, the nurse collects data about the rate. Rationale 2: When assessing the pulse, the nurse collects data about the rhythm. Rationale 3: When assessing the pulse, the nurse collects data about the volume. Rationale 4: Tone is not a characteristic of a pulse. Rationale 5: Viscosity is not a characteristic of a pulse. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. List the characteristics that should be included when assessing pulses. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 489 Question 22 Type: MCMA When assessing a client’s respirations, the nurse realizes that the respiratory centers and chemoreceptors respond to changes in which factors? Standard Text: Select all that apply. 1. Oxygen concentration 2. Carbon dioxide concentration 3. Hydrogen ions 4. Potassium level 5. Serum calcium level Correct Answer: 1, 2, 3 Rationale 1: The respiratory centers and chemoreceptors respond to changes in the concentration of oxygen.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: The respiratory centers and chemoreceptors respond to changes in the concentration of carbon dioxide. Rationale 3: The respiratory centers and chemoreceptors respond to changes in the concentration of hydrogen ions. Rationale 4: The respiratory centers and chemoreceptors do not respond to changes in the potassium level. Rationale 5: The respiratory centers and chemoreceptors do not respond to changes in the serum calcium level. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Describe the mechanics of breathing and the mechanisms that control respirations. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 496 Question 23 Type: MCMA Even though a UAP is available to assist with vital sign assessment, the nurse is going to conduct these assessments independently in which situations? Standard Text: 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 Correct Answer: 1, 2, 3, 4 Rationale 1: When a client reports symptoms such as chest pain, the nurse should conduct the assessment. Rationale 2: When a client returns from surgery, the nurse should conduct the assessment. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: When the client is prescribed a medication that could affect the vital signs, the nurse should conduct the assessment. Rationale 4: When the client reports symptoms such as dizziness after ambulation, the nurse should conduct the assessment. Rationale 5: When the client is being admitted to a care area, the nurse could delegate the vital sign assessment to the UAP. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Recognize when it is appropriate to delegate measurement of vital signs to unlicensed assistive personnel. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 478 Question 24 Type: MCSA 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 Correct Answer: 1 Rationale 1: When documenting the temperature in the client record, an axillary temperature should be recorded with an AX. Rationale 2: The letter O is not used when documenting a client’s temperature. Rationale 3: The letter R would indicate a rectal temperature and not an axillary temperature. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The letters SL are not used when documenting a client’s temperature. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Demonstrate appropriate documentation and reporting of vital signs. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 484 Question 25 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: The diastolic blood pressure is not documented before the systolic blood pressure. Rationale 3: The systolic blood pressure and diastolic blood pressure are not separated by a minus sign. Rationale 4: This places the diastolic reading first and uses the minus sign, which is incorrect to use. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Demonstrate appropriate documentation and reporting of vital signs. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 503 Question 26 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 3, 4, 5 Rationale 1: Persons experiencing heat stroke may be delirious. Rationale 2: Heat exhaustion is a result of excessive heat and dehydration. Signs of heat exhaustion include paleness and dizziness. Rationale 3: Persons experiencing heat stroke generally have warm, flushed skin. Rationale 4: Persons experiencing heat stroke often do not sweat. Rationale 5: Persons experiencing heat stroke generally have been exercising in hot weather. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe appropriate nursing care for alterations in vital signs. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 3.3.4. Compare expected and unexpected outcomes. Page Number: 479 Question 27 Type: MCMA 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? Standard Text: 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 re-measuring. 5. The cuff bladder was placed over the brachial artery. Correct Answer: 2, 3 Rationale 1: The valve on the bulb needs to be closed to pump up the cuff. Rationale 2: The adult client should be sitting with both feet on the floor. Crossed legs can cause elevations in systolic and diastolic blood pressures. Rationale 3: 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. Rationale 4: After taking a measurement, 1 to 2 minutes should transpire before making any further measurements. Rationale 5: The cuff should be placed evenly around the upper arm and the bladder center placed directly over the artery. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8. Recognize when it is appropriate to delegate measurement of vital signs to unlicensed assistive personnel. MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client. Page Number: 504

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 30 Question 1 Type: MCSA 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 Correct Answer: 3 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: o. Assessing the abdomen. MNL Learning Outcome: 3.2.4. Apply the proper techniques and considerations to perform auscultation. Page Number: 514 Question 2 Type: MCSA The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. The nurse should document this as being 1. cyanosis. 2. jaundice. 3. pallor. 4. erythema. Correct Answer: 2 Rationale 1: Cyanosis is a bluish color to the skin, mucous membranes, or nails. Rationale 2: Jaundice is a yellow tinge that is abnormal and is often noticed in the sclera of the eye. Rationale 3: Pallor is a term used to describe paleness. Rationale 4: Erythema is a term used to describe redness. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Demonstrate appropriate documentation and reporting of health assessment.. MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection. Page Number: 524 Question 3 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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 Correct Answer: 3 Rationale 1: Erythema is a term used to describe redness. Rationale 2: Cyanosis is a term used to describe a bluish cast to the skin, nails, or mucous membranes. Rationale 3: Hyperthyroidism can cause exophthalmos, a protrusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or staring expression. Rationale 4: Normocephalic is a term used to describe a normal sized head. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: e. Assessing the skull and face. MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection. Page Number: 533 Question 4 Type: MCSA The nurse is preparing for morning rounds. What should the nurse avoid delegating to unlicensed assistive personnel? 1. Vital signs Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Filling of water pitchers 3. Skull and face assessment 4. Ambulation of surgical clients Correct Answer: 3 Rationale 1: Vital signs can appropriately be delegated to unlicensed assistive personnel. Rationale 2: Filling of water pitchers can be appropriately delegated to unlicensed assistive personnel. Rationale 3: Assessment of the skull and face may not be delegated to unlicensed assistive personnel. Rationale 4: Ambulation of surgical clients can be appropriately delegated to unlicensed assistive personnel. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Recognize when it is appropriate to delegate assessment skills to unlicensed assistive personnel. MNL Learning Outcome: 4.1.1. Recognize factors that affect client safety. Page Number: 533 Question 5 Type: MCSA 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 Correct Answer: 3 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Symmetrical chest expansion is an expected finding. Rationale 2: Bilaterally equal breath sounds is a normal assessment finding. Rationale 3: Chest expansion should be symmetrical. Rationale 4: Bilaterally equal vocal fremitus is a normal assessment finding. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: k. Assessing the thorax and lungs. MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection. Page Number: 557 Question 6 Type: MCSA 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 Correct Answer: 2 Rationale 1: This is not the correct angle. Rationale 2: The nurse should place the client in the semi-Fowler's position (30- to 45-degree angle) while inspecting the jugular veins for distention. Rationale 3: This is not the correct angle. Rationale 4: This is not the correct angle. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: l. Assessing the heart and central vessels. MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection. Page Number: 566 Question 7 Type: MCSA 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 Correct Answer: 3 Rationale 1: Bilateral equal pulses is a normal assessment finding. Rationale 2: Full pulsations is a normal assessment finding. Rationale 3: Thready, weak, or decreased pulses are abnormal and should be reported to the physician. Rationale 4: Bilaterally present pulses is a normal assessment finding. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: m. Assessing the peripheral vascular system. MNL Learning Outcome: 3.2.2. Apply the proper techniques and considerations to perform palpation. Page Number: 567 Question 8 Type: MCSA 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. Correct Answer: 3 Rationale 1: The findings are all normal, so the nurse does not need to notify the charge nurse. Rationale 2: The findings are all normal, so the nurse does not need to notify the physician. Rationale 3: The findings are all normal, so the nurse would document the assessment in the nurse's notes as normal. Rationale 4: The findings are all normal, so the nurse would not document the findings as abnormal. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 3. Identify expected findings during health assessment; 8. Demonstrate appropriate documentation and reporting of health assessment. MNL Learning Outcome: 3.2.2. Apply the proper techniques and considerations to perform palpation. Page Number: 572 Question 9 Type: MCSA The nurse is preparing a client for an abdominal examination. What should the nurse done 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. Correct Answer: 1 Rationale 1: The nurse should ask the client to urinate because an empty bladder makes the assessment more comfortable. Rationale 2: Drinking fluids will cause the client’s bladder to fill and cause discomfort. Rationale 3: The client’s vital signs do not need to be assessed prior to an abdominal examination. Rationale 4: The client does not need to have an apical heart rate assessed prior to having an abdominal assessment. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: o. Assessing the abdomen. MNL Learning Outcome: 3.2.2. Apply the proper techniques and considerations to perform palpation. Page Number: 574 Question 10 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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. Correct Answer: 1 Rationale 1: This is the technique to assess muscle grip strength. Rationale 2: This is a technique to assess muscle strength but not grip strength. Rationale 3: This is a technique to assess muscle strength but not grip strength. Rationale 4: This is a technique to assess muscle strength but not grip strength. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: p. Assessing the musculoskeletal system. MNL Learning Outcome: 3.2.2. Apply the proper techniques and considerations to perform palpation. Page Number: 579 Question 11 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Affective and memory functions 4. Affective and knowledge functions Correct Answer: 1 Rationale 1: Cognitive (intellectual) and affective (emotional) functions are assessed. Rationale 2: There are no effective functions. Rationale 3: The mental status assessment does not include an assessment of memory. Rationale 4: A mental status assessment does not include a knowledge assessment. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: a. Assessing appearance and mental status. MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection. Page Number: 581 Question 12 Type: MCSA The nurse is caring for a client following a cerebrovascular accident (stroke). The client is able to comprehend what is being said to him; however, he 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 Correct Answer: 4

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Clients with auditory aphasia have lost the ability to understand the symbolic content associated with sounds. Rationale 2: This is the same as auditory aphasia. Rationale 3: Sensory or receptive aphasia is the loss of the ability to comprehend written or spoken words. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: q. Assessing the neurologic system. MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection. Page Number: 581 Question 13 Type: MCSA 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 Correct Answer: 3 Rationale 1: Sterile gloves are not needed to test reflexes. Rationale 2: Clean gloves are not needed to test reflexes. Rationale 3: A percussion hammer is used to test reflexes. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: A penlight is not used to test reflexes. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: q. Assessing the neurologic system. MNL Learning Outcome: 3.2.3. Apply the proper techniques and considerations to perform percussion. Page Number: 582 Question 14 Type: MCSA 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 health care provider to perform? 1. Pap test 2. Breast exam 3. Rectal exam 4. Abdominal exam Correct Answer: 1 Rationale 1: For sexually active adolescent and adult women, a Papanicolaou test (Pap test) is used to detect cancer of the cervix. Rationale 2: A breast examination is not done specifically for sexually active clients. Rationale 3: A rectal exam is not done specifically for sexually active clients. Rationale 4: An abdominal exam is not done specifically for sexually active clients. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: r. Assessing the female genitals and inguinal area. MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection. Page Number: 589 Question 15 Type: MCSA 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 Correct Answer: 3 Rationale 1: The UAP cannot perform a neurological assessment. Rationale 2: The UAP cannot perform a musculoskeletal assessment. Rationale 3: The nursing assistant can only assess vital signs. Rationale 4: The UAP cannot perform a female genital assessment. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 7. Recognize when it is appropriate to delegate assessment skills to unlicensed assistive personnel. MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice. Page Number: 520 Question 16 Type: MCSA 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 Correct Answer: 2 Rationale 1: The nurse does not need to assess the client’s respiratory rate before providing the medication. Rationale 2: The apical pulse should be assessed before administering any cardiotonic medication. Rationale 3: The client’s popliteal pulse does not need to be assessed prior to receiving this medication. Rationale 4: The client’s capillary blanching does not need to be assessed prior to receiving this medication. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: l. Assessing the heart and central vessels. MNL Learning Outcome: 3.2.4. Apply the proper techniques and considerations to perform auscultation. Page Number: 514 Question 17 Type: MCMA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The nurse is preparing to complete a physical examination on a client. What should the nurse realize as being the purpose for this examination? Standard Text: 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. Correct Answer: 1, 2, 3 Rationale 1: One purpose of the physical examination is to obtain baseline data. Rationale 2: One purpose of the physical examination is to obtain data to help determine nursing diagnoses. Rationale 3: One purpose of the physical examination is to identify areas for disease prevention. Rationale 4: The physical examination is not done to identify the client’s employment status. Rationale 5: The physical examination is not done to obtain data about a client’s leisure activities. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Identify the purposes of the physical examination. MNL Learning Outcome: 3.0.1. Assessing Health Status Page Number: 514 Question 18 Type: MCMA A client has been receiving a new medication to address specific symptoms. The nurse will perform a physical examination to determine Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Standard Text: Select all that apply. 1. the progress of the client’s health problem. 2. the physiological impact of the prescribed medication. 3. baseline data. 4. data to support nursing diagnoses. 5. areas for health promotion. Correct Answer: 1, 2 Rationale 1: The nurse will perform a physical examination on a client to determine the progress of the client’s health problem. Rationale 2: The nurse will perform a physical examination on a client to determine the physiological impact of the prescribed medication. Rationale 3: The nurse will not be performing a physical examination to collect baseline data. Rationale 4: The nurse will not be performing a physical examination to support nursing diagnoses. Rationale 5: The nurse will not be performing a physical examination to identify areas for health promotion. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Identify the purposes of the physical examination. MNL Learning Outcome: 3.0.1. Assessing Health Status Page Number: 514 Question 19 Type: MCMA 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? Standard Text: Select all that apply. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 1, 2, 3 Rationale 1: When using inspection, the nurse will visually observe a body area. Rationale 2: In addition to visual observation, olfactory cues are noted. Rationale 3: In addition to visual observation, auditory cues are noted. Rationale 4: Examining the body through use of touch describes palpation. Rationale 5: Striking the body to elicit a sound from a body part describes percussion. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Explain the four techniques used in physical examination: inspection, palpation, percussion, and auscultation. MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection. Page Number: 517 Question 20 Type: MCMA 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? Standard Text: Select all that apply. 1. Place the middle finger of the nondominant hand on the client’s skin. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 1, 2, 3, 4 Rationale 1: Placing the middle finger of the nondominant hand on the client’s skin is the first step when performing indirect percussion. Rationale 2: 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. Rationale 3: The nurse should perform a striking motion by moving the wrist. Rationale 4: The nurse should perform short, rapid, firm blows. Rationale 5: Using a stethoscope to transmit sounds to the ears is done during auscultation, not indirect percussion. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Explain the four techniques used in physical examination: inspection, palpation, percussion, and auscultation. MNL Learning Outcome: 3.2.3. Apply the proper techniques and considerations to perform percussion. Page Number: 518 Question 21 Type: MCMA The nurse is assessing the nose and sinuses of a client. Which findings should the nurse identify as being within normal limits? Standard Text: Select all that apply. 1. Nose straight Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Nares symmetrical 3. No tenderness over the bridge 4. Air movement restricted in one nare 5. Clear drainage from one nare Correct Answer: 1, 2, 3 Rationale 1: A straight nose is a normal finding. Rationale 2: Symmetrical nares are a normal finding. Rationale 3: No tenderness over the nose bridge is a normal finding. Rationale 4: Air movement restricted in one nare is an abnormal finding. Rationale 5: Clear drainage from one nare is an abnormal finding. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: h. Assessing the nose and sinuses. MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection. Page Number: 533 Question 22 Type: MCSA 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, lower extremities 2. Neck, head, vital signs, chest and back 3. Lower extremities, abdomen, upper extremities, chest and back Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Head, neck, lower extremities, abdomen Correct Answer: 1 Rationale 1: 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. Rationale 2: The neck should not be examined before the head. Vital signs are assessed before the head is examined. Rationale 3: The lower extremities and abdomen would not be assessed before the upper extremities or the chest and back. Rationale 4: The lower extremities would not be assessed before the abdomen. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe suggested sequencing to conduct a physical health examination in an orderly fashion. MNL Learning Outcome: 3.0.1. Assessing Health Status Page Number: 514 Question 23 Type: MCSA 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 Correct Answer: 1

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: In some older clients, arteries may be palpated more easily because of the loss of supportive surrounding tissues. Rationale 2: The most distal pulses of the lower extremities are more difficult to palpate, not easier to palpate, because of decreased arterial perfusion. Rationale 3: The number of varicosities increases in the older client. Rationale 4: The systolic blood pressure might increase. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: l. Assessing the heart and central vessels. MNL Learning Outcome: 3.2.2. Apply the proper techniques and considerations to perform palpation. Page Number: 569 Question 24 Type: MCMA The nurse is preparing to perform an eye assessment. What equipment should the nurse have available to complete this assessment? Standard Text: Select all that apply. 1. Penlight 2. Snellen’s chart 3. Sterile gloves 4. Gauze square 5. Millimeter ruler Correct Answer: 1, 2, 4, 5 Rationale 1: When performing an eye examination, the nurse will need a penlight. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: When performing an eye examination, the nurse will need a Snellen’s chart. Rationale 3: Sterile gloves are not needed to perform an eye assessment. Rationale 4: When performing an eye examination, the nurse will need a gauze square. Rationale 5: When performing an eye examination, the nurse will need a millimeter ruler. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: f. Assessing the eye structures and visual acuity. MNL Learning Outcome: 3.0.1. Assessing Health Status Page Number: 535 Question 25 Type: MCMA The nurse is preparing to conduct an assessment of the heart. Where should the nurse place the stethoscope to auscultate heart sounds? Standard Text: Select all that apply. 1. Aortic region 2. Pulmonic region 3. Tricuspid valve region 4. Abdomen 5. Mitral valve region Correct Answer: 1, 2, 3, 5 Rationale 1: The nurse will auscultate heart sounds over the aortic region. Rationale 2: The nurse will auscultate heart sounds over the pulmonic region. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: The nurse will auscultate heart sounds over the tricuspid valve region. Rationale 4: The abdomen is not assessed during the assessment of the heart. Rationale 5: The nurse will auscultate sounds over the mitral valve region. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: l. Assessing the heart and central vessels. MNL Learning Outcome: 3.2.4. Apply the proper techniques and considerations to perform auscultation. Page Number: 562 Question 26 Type: MCMA The nurse is preparing to assess a client with the Glasgow Coma Scale. Which areas is the nurse assessing in this patient? Standard Text: Select all that apply. 1. Eye response 2. Motor response 3. Verbal response 4. Orientation 5. Musculoskeletal response Correct Answer: 1, 2, 3 Rationale 1: The Glasgow Coma Scale tests in three major areas: eye response, motor response, and verbal response. Rationale 2: The Glasgow Coma Scale tests in three major areas: eye response, motor response, and verbal response. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: The Glasgow Coma Scale tests in three major areas: eye response, motor response, and verbal response. Rationale 4: The Glasgow Coma Scale is not used to assess orientation. Rationale 5: The Glasgow Coma Scale is not used to assess musculoskeletal response. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: q. Assessing the neurologic system. MNL Learning Outcome: 3.2.1. Apply the proper techniques and considerations to perform inspection. Page Number: 582 Question 27 Type: MCMA A client is experiencing abdominal pain. What assessments should the nurse perform to assess this complaint? Standard Text: Select all that apply. 1. Inspect the abdomen. 2. Auscultate the abdomen. 3. Palpate the abdomen. 4. Assess vital signs. 5. Assess peripheral pulses. Correct Answer: 1, 2, 3, 4 Rationale 1: The nurse should inspect the client’s abdomen. Rationale 2: The nurse should auscultate the abdomen. Rationale 3: The nurse should auscultate the abdomen. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The nurse should assess vital signs. Rationale 5: Although peripheral pulses may be palpated, this is not specific to a client with abdominal pain. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: o. Assessing the abdomen. MNL Learning Outcome: 3.0.1. Assessing Health Status Page Number: 576 Question 28 Type: MCMA 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? Standard Text: Select all that apply. 1. Lordosis 2. Genu valgus 3. Genu varum 4. Pronation of the feet 5. Asymmetric leg abduction Correct Answer: 1, 2 Rationale 1: Lordosis (swayback) is common in children before age 5. Rationale 2: Genu valgus (knock-knee) is normal in preschool and early-school-age children. Rationale 3: Genu varum (bowleg) is normal in children for about 1 year after beginning to walk. Rationale 4: Pronation and “toeing in” of the feet are common in children between 12 and 30 months of age. Rationale 5: Asymmetric abduction of the legs (Ortolani and Barlow tests) assesses for developmental dysplasia of the hip in infants. Global Rationale: Cognitive Level: Analyzing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Discuss variations in examination techniques appropriate for clients of different ages. MNL Learning Outcome: 3.0.1. Assessing Health Status Page Number: 580 Question 29 Type: MCMA 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? Standard Text: Select all that apply. 1. White spots 2. Curved nails 3. Deep purple areas 4. Spoon-shaped nails 5. Bands across the nails Correct Answer: 1, 4, 5 Rationale 1: White spots may indicate zinc deficiency. Rationale 2: Curved nails may be a normal finding or indicate a breathing difficulty. Rationale 3: Deep purple areas indicate an injury to the nail region. Rationale 4: Spoon-shaped nails may indicate iron deficiency. Rationale 5: Bands across the nails may indicate protein deficiency. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 6. Discuss variations in examination techniques appropriate for clients of different ages. MNL Learning Outcome: 3.0.1. Assessing Health Status Page Number: 532

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 31 Question 1 Type: MCSA 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 Correct Answer: 4 Rationale 1: Disinfecting an item is an example of medical asepsis, not surgical asepsis. Rationale 2: If sterile gloved hands fall below the waist, they are considered to be unsterile. Rationale 3: Suctioning the oral cavity of a client is considered contaminating. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain the concepts of medical and surgical asepsis. MNL Learning Outcome: 4.2.3. Apply the principles of surgical asepsis as indicated in the client's plan of care. Page Number: 625 Question 2 Type: MCSA The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate? 1. Administering parenteral medications Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Changing a dressing 3. Performing a urinary catheterization 4. Using personal protective equipment Correct Answer: 4 Rationale 1: Administering parenteral medications requires surgical asepsis. Rationale 2: Changing a dressing requires surgical asepsis. Rationale 3: Performing a urinary catheterization requires surgical asepsis. Rationale 4: Using personal protective equipment demonstrates medical asepsis. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain the concepts of medical and surgical asepsis. MNL Learning Outcome: 4.2.2. Apply the principles of medical asepsis in the care of the client. Page Number: 636 Question 3 Type: MCSA 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 Correct Answer: 4 Rationale 1: A client in the emergency department with abdominal pain has just arrived in the facility, and not enough time has elapsed for this client to be considered to have a nosocomial infection. If this client has an infection, it would be community acquired. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: The 19-year-old female who is pregnant is at a low risk. Rationale 3: The 72-year-old male with COPD is at a lower risk for infection than the 82-year-old because the older client has a weakened immune system because of taking steroids. Rationale 4: 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 86-year-old client is also on steroid therapy, which compromises the immune system. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify risks for nosocomial and health care–associated infections. MNL Learning Outcome: 4.2.4. Integrate safe practices in the care of the client to prevent the spread of infection. Page Number: 609 Question 4 Type: MCSA 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. Correct Answer: 3 Rationale 1: Increasing intake of fruits and vegetables would increase vitamin C, which helps with wound healing, but more protein would be the best choice. Rationale 2: Applying lubricating lotion to the edges of a wound would impede the healing process. Rationale 3: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Irrigating with hydrogen peroxide would break down good granulating tissue, so this would not increase healing. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Identify signs of localized and systemic infections and inflammation. MNL Learning Outcome: 4.2.4. Integrate safe practices in the care of the client to prevent the spread of infection. Page Number: 607 Question 5 Type: MCSA 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, nausea, and vomiting 3. Palpitations, irritability, and heat intolerance 4. Tingling, numbness, and cramping of the extremities Correct Answer: 2 Rationale 1: Edema, rubor, heat, and pain are symptoms of a local infection. Rationale 2: Fever, malaise, anorexia, nausea, and vomiting are symptoms of a systemic infection. Rationale 3: Palpitations, irritability, and heat intolerance are symptoms of a thyroid condition. Rationale 4: Tingling, numbness, and cramping of the extremities are symptoms of hypocalcemia. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 1. Conduct comprehensive and 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Identify signs of localized and systemic infections and inflammation. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 610 Question 6 Type: MCSA 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 Correct Answer: 4 Rationale 1: Active bowel sounds would indicate the body is able to defend itself against an infection. Rationale 2: Dry intact skin is a factor that would help the body defend against an infection. Rationale 3: Intact mucous membranes is a factor that would help the body defend against infection. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify factors influencing a microorganism’s capability to produce an infectious process. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 620 Question 7 Type: MCSA 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 Correct Answer: 4 Rationale 1: Heavy smoking does not defend the body from microorganisms; it destroys the cilia in the nose that help to filter organisms. Rationale 2: Moisturizing the skin can allow microorganisms to enter the body. Rationale 3: Breakdown of the skin can allow microorganisms to enter the body. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify anatomic and physiological barriers that defend the body against microorganisms. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 607 Question 8 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 2 Rationale 1: Receiving an injection for tetanus is an example of acquired passive immunity. Rationale 2: When the client has the disease, the body stimulates the process of acquired active immunity. Rationale 3: Receiving an injection for rabies is an example of artificially acquired passive immunity. Rationale 4: Receiving an injection of gamma globulin is an example of artificially acquired passive immunity. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Differentiate active from passive immunity.. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 608 Question 9 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 2 Rationale 1: A tetanus toxoid injection is not specific for rabies. Rationale 2: Receiving an immunization for rabies is an example of artificially acquired passive immunity. Rationale 3: An injection of immunoglobulin is not specific for rabies. Rationale 4: Mother's breast milk is another example of passive immunity, but not for rabies. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Differentiate active from passive immunity. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 608 Question 10 Type: MCSA 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. Correct Answer: 3 Rationale 1: Assessing vital signs is important but should occur more frequently than once daily. Rationale 2: Raising the temperature in a client's room would contribute to the growth of microorganisms. Rationale 3: Washing hands is always the first and best way to stop the spread of microorganisms, which cause infections. Rationale 4: Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is airborne and the client is in isolation. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8. Identify interventions to reduce risks for infections. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 612 Question 11 Type: MCSA 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 (PPE) sparingly. 4. Wear gloves at all times. Correct Answer: 1 Rationale 1: Covering the mouth and nose when sneezing prevents airborne droplets from escaping into the air for others to contract in the chain of infection. Rationale 2: Placing linens in a paper bag would allow germs to come out through the bag, and the linen would act as a fomite, thus allowing the chain to continue. Rationale 3: PPE, according to OSHA standards, has to be used whenever the situation dictates, not sparingly. Rationale 4: Gloves have to be worn but are to be changed between clients and hands washed. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Identify measures that break each link in the chain of infection. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 612 Question 12 Type: MCSA 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. Correct Answer: 4 Rationale 1: When the water is turned on, it should be adjusted so it does not splatter even if the flow is not very forceful. Rationale 2: Cleaning the faucet after use would defeat the whole purpose of washing the hands. If the sink needs cleaning, clean it before washing the hands. Rationale 3: Holding the hands upward under the faucet is incorrect. They should be held downward so the soap, germs, and water are washed downward from the hands and down the sink. Rationale 4: Approximately 1 teaspoon of soap should be used when performing proper hand-washing technique. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: a. Performing hand hygiene. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 615 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 13 Type: MCSA 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. Correct Answer: 4 Rationale 1: Bending the strip at the top of the mask is done when applying a mask. Rationale 2: Looping the ties over the ears is done when applying a mask. Rationale 3: Tying the strings in a bow under the chin is done when applying a mask. Rationale 4: Touching the mask by the strings is the appropriate intervention because the mask is considered contaminated. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Applying and removing a gown, face mask, eyewear, and clean gloves. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 623 Question 14 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Grasp the outside of the nondominant glove. 4. Hook the bare thumb inside the other glove. Correct Answer: 3 Rationale 1: Dropping the gloves in the appropriate waste receptacle occurs after the gloves are removed. Rationale 2: Easing the fingers into the glove is done when applying gloves. Rationale 3: In order to remove gloves after use, one must grasp the outside of the nondominant glove. Rationale 4: Hooking the bare thumb inside the other glove is done after the gloves are removed. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Applying and removing a gown, face mask, eyewear, and clean gloves. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 622 Question 15 Type: MCSA 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 Correct Answer: 4 Rationale 1: Grasping the edge of the outermost flap and opening it away from oneself will maintain the sterility of a field. Rationale 2: Keeping objects on the field 1 inch from the edge will maintain the sterility of a field. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Keeping the sterile field in eyesight will maintain the sterility of a field. Rationale 4: Transferring a sterile object onto a sterile field with a gloved hand would render the field unsterile only if the gloves are not sterile. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 11. Verbalize the steps used in: c. Establishing and maintaining a sterile field. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 627 Question 16 Type: MCSA 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 Correct Answer: 3 Rationale 1: A cabinet stocked with gloves and gowns would be on the outside of the room. Rationale 2: Cards and records should never be taken into an isolation room. Rationale 3: Paper towels and a sink for hand washing 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. Rationale 4: The sign explaining the kind of isolation should be on the outside of the door to alert the staff of what is needed to enter. Global Rationale: Cognitive Level: Applying Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Compare and contrast category-specific, disease-specific, standard, and transmissionbased isolation precaution systems. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 620 Question 17 Type: MCSA The RN 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. 2. Encourage bleeding. 3. Initiate first aid. 4. Wash the area with soap and water. Correct Answer: 2 Rationale 1: This is not the first step. It can be done later. Rationale 2: Encouraging bleeding is the first step. Rationale 3: Initiating first aid is not the first step. Rationale 4: Washing the area with soap and water is not the first step. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Describe the steps to take in the event of a bloodborne pathogen exposure. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 636 Question 18 Type: MCSA 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. Correct Answer: 4 Rationale 1: Gloves are not left on while taking off a soiled gown. Rationale 2: The neck ties are untied after the ties at the waist are untied. Rationale 3: To leave an isolation room where a gown has been worn, one must untie the gown at the waist first, not at the neck. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Applying and removing a gown, face mask, eyewear, and clean gloves. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 622 Question 19 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 2 Rationale 1: Needles should never be cut, bent, or altered in any way, as this would place the health care provider at risk of being stuck. Rationale 2: Disposal of blood-contaminated materials in a biohazard container is a standard precaution. Rationale 3: Gloves should be worn when providing client care whether body secretions are seen or not. Rationale 4: Masks need not be worn when giving routine direct client care unless the client's condition so warrants. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Compare and contrast category-specific, disease-specific, standard, and transmissionbased isolation precaution systems. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 626 Question 20 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Wash the hands only after leaving the room. 4. Wear a mask when exiting the room. Correct Answer: 1 Rationale 1: When a client has an airborne disease and must go elsewhere in the hospital, the client must wear a mask. Rationale 2: Supplies to prevent transmission of disease should be stocked at the end of the shift so that adequate supplies will be available for the next health care provider. Rationale 3: Hands should be washed before and after client care. Rationale 4: The mask should be removed just as the staff leaves the client's room, not when coming out of the room. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9. Identify measures that break each link in the chain of infection. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 626 Question 21 Type: MCMA The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this clinical decision? Standard Text: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1, 2, 3 Rationale 1: Bacteremia can occur from an intravascular line. Rationale 2: The client could develop an infection from an invasive procedure or device such as an indwelling urinary catheter. Rationale 3: After surgery, the client’s health status is compromised, lowering the client’s defenses to fight infection. Rationale 4: Receiving pain medication does not increase the client’s risk for developing a nosocomial infection. Rationale 5: Ambulation does not increase the client’s risk for developing a nosocomial infection. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify risks for nosocomial and health care–associated infections. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 604 Question 22 Type: MCMA 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? Standard Text: 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 upon how the organisms get inside the body to cause a disease.” 4. “It depends upon where the person is at the time the disease is present.” 5. “It depends upon where the person works.” Correct Answer: 1, 2, 3, 4 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: “It depends on the number of organisms present to cause a disease” addresses the number of microorganisms present. Rationale 2: “It depends on how aggressive the organisms are to cause a disease” addresses the virulence and potency of the microorganisms. Rationale 3: “It depends upon how the organisms get inside the body to cause a disease” addresses the ability of the microorganisms to enter the body. Rationale 4: “It depends upon where the person is at the time the disease is present” addresses the susceptibility of the host and the ability of the microorganisms to live in the host’s body. Rationale 5: “It depends upon where the person works” does not explain a factor for the development of an infection. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify factors influencing a microorganism’s capability to produce an infectious process. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 605 Question 23 Type: MCMA The nurse determines that a client has adequate physiological barriers to defend the body against infection. What did the nurse assess in this client? Standard Text: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1, 2, 3 Rationale 1: Intact skin is the body’s first line of defense against microorganisms. Rationale 2: Intact mucous membranes are the body’s first line of defense against microorganisms. Rationale 3: Peristalsis tends to move microbes out of the body. Rationale 4: Nasal congestion would mean that the nasal passages would be ineffective in filtering microorganisms from inspired air. Rationale 5: Urinary retention would cause the urine to remain in the body, possibly leading to an infection. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify anatomic and physiological barriers that defend the body against microorganisms. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 607 Question 24 Type: MCSA 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 Correct Answer: 1 Rationale 1: Social Isolation would be appropriate for the client who needs to be separated from others during a contagious episode.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Anxiety would be appropriate if the client were demonstrating apprehension regarding a change in life activities because of the communicable disease. Rationale 3: Acute Pain would be appropriate if the client were experiencing discomfort. Rationale 4: Imbalanced Nutrition: Less Than Body Requirements would be appropriate if the client were too ill to eat adequately. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: 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: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 611 Question 25 Type: MCSA 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 Correct Answer: 1 Rationale 1: Anxiety is appropriate because the client is discussing the impact of the communicable disease on work and home life. Rationale 2: Acute Pain is not appropriate, as the client is not experiencing discomfort. Rationale 3: Social Isolation is not appropriate, as the client has not been placed in transmission precaution at this time. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Low Self-Esteem is incorrect because the client is not expressing negative comments about himself. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: 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: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 611 Question 26 Type: MCMA A client is being discharged after a surgical procedure. On what should the nurse instruct the client to reduce the risk of infection? Standard Text: Select all that apply. 1. Hand-washing 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 Correct Answer: 1, 2, 3 Rationale 1: The nurse should instruct the client on the correct hand-washing technique to reduce the risk of infection. Rationale 2: The nurse should instruct the client on the importance of adequate nutrition to reduce the risk of infection. Rationale 3: The nurse should instruct the client to cover the mouth and nose when coughing or sneezing to reduce the risk of infection.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The nurse should instruct the client to minimize exposure to others when recovering from surgery to reduce the risk of infection. Rationale 5: The nurse should instruct the client to get adequate rest and sleep when recovering from surgery to reduce the risk of infection. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Identify interventions to reduce risks for infections. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 611 Question 27 Type: MCSA A client in isolation ambulates with assistance to the bathroom. After toileting, what should the unlicensed assistive personnel do? 1. Assist the client with hand washing. 2. Assist the client back to bed. 3. Change the client’s bed. 4. Leave the client’s room. Correct Answer: 1 Rationale 1: The client should utilize good hand washing after going to the bathroom. The unlicensed assistive personnel should assist the client with hand washing. Rationale 2: After handwashing, the unlicensed assistive personnel should assist the client back to bed. Rationale 3: The client’s bed can be changed at any time. Rationale 4: The unlicensed assistive personnel should not leave the client’s room until the client has washed her hands and has been assisted back to bed. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Identify interventions to reduce risks for infections. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 612 Question 28 Type: MCSA 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 to 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. Correct Answer: 1 Rationale 1: After an exposure to the mucous membranes, the area should be flushed for 5 to 10 minutes with saline or water. Rationale 2: The client was not identified as being HIV-positive. Rationale 3: Washing the area with soap and water would be appropriate for a puncture or laceration. Rationale 4: Being tested for hepatitis B would be appropriate after a puncture or laceration but not for a splash to the mucous membranes. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Describe the steps to take in the event of a bloodborne pathogen exposure. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 636 Question 29 Type: MCMA The nurse is reviewing the agents available to disinfect the hands after providing client care. Which agents should the nurse consider using? Standard Text: Select all that apply. 1. Triclosan 2. Chlorine (bleach) 3. Isopropyl alcohol 4. Hydrogen peroxide 5. Chlorhexidine gluconate Correct Answer: 1, 3, 5 Rationale 1: Triclosan is an agent that can be used on the hands as a disinfectant. Rationale 2: Chlorine bleach is used to clean blood spills. Rationale 3: Isopropyl alcohol is an agent that can be used on the hands as a disinfectant. Rationale 4: Hydrogen peroxide is used to clean surfaces. Rationale 5: Chlorhexidine gluconate is an agent that can be used on the hands as a disinfectant. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8. Identify interventions to reduce risks for infections. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 618 Question 30 Type: SEQ The nurse needs to apply personal protective equipment before entering a client’s room. In which order should the nurse perform the following actions? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Standard Text: 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. Correct Answer: 5, 3, 4, 2, 1 Rationale 1: Gloves are applied last. Rationale 2: Protective eyewear is applied after the face mask. Rationale 3: The gown is applied after hand hygiene. Rationale 4: The face mask is applied after the gown. Rationale 5: Before applying personal protective equipment, hand hygiene should be performed. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Applying and removing a gown, face mask, eyewear, and clean gloves. MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurse's role, and types of precautions during client care. Page Number: 621

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 32 Question 1 Type: MCSA 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 Correct Answer: 1 Rationale 1: Falls, burns, and pedestrian and motor vehicle crashes are safety hazards in older adults. Rationale 2: Drowning and poisoning are seen in the toddler-age client. Rationale 3: Drowning and poisoning are seen in the toddler-age client. Rationale 4: Suffocation is a hazard in newborns and infants. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Identify common potential hazards throughout the life span. MNL Learning Outcome: 4.1.3. Implement safety measures throughout the life span. Page Number: 641 Question 2 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Drowning 3. Pedestrian accidents 4. Suffocation in the crib Correct Answer: 4 Rationale 1: Exposure to alcohol consumption is a safety hazard to a fetus. Rationale 2: Drowning is a safety hazard in toddlers and preschoolers. Rationale 3: Pedestrian accidents are safety hazards in the older adult. Rationale 4: Suffocation in the crib is a safety hazard for both newborns and infants. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Identify common potential hazards throughout the life span. MNL Learning Outcome: 4.1.3. Implement safety measures throughout the life span. Page Number: 641 Question 3 Type: MCSA 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 Correct Answer: 4 Rationale 1: Banging into objects is what a toddler would be likely to do, not an expectant mother. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Bicycle rides and recreational activities would be good for the developing fetus; the mother should stay as active as possible during the pregnancy. Physical activity promotes good health. Rationale 3: Physical activity promotes good health. Rationale 4: Exposure to x-rays in the first trimester could cause harm to the developing fetus. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify common potential hazards throughout the life span. MNL Learning Outcome: 4.1.3. Implement safety measures throughout the life span. Page Number: 641 Question 4 Type: MCSA The nurse would like to improve communication among caregivers. How should the nurse use the Joint Commission 2013 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. Correct Answer: 3 Rationale 1: Annually reviewing a list of look-alike/sound-alike drugs is used to improve the safety of use of medication in an organization, not to improve communication. Rationale 2: Using a verification process to confirm that the correct procedure for the correct client is to be performed is another way to improve the accuracy of client identification. Rationale 3: Reporting critical results of tests and diagnostic procedures on a timely basis is one way the National Patient Safety Goals improve the communication among caregivers. Rationale 4: Using the client's room number as an identifier is a passive technique that would improve the accuracy of client identification. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Discuss the National Patient Safety Goals. MNL Learning Outcome: 4.2.2. Implement strategies for the maintenance of safety in the health care facility. Page Number: 645 Question 5 Type: MCSA The nurse is planning care for a client who is prone to falling. Which nursing diagnoses should the nurse use for this client? 1. Deficient Knowledge 2. Risk for Injury 3. Risk for Disuse Syndrome 4. Risk for Suffocation Correct Answer: 2 Rationale 1: Deficient Knowledge deals with injury prevention. A client who is already prone to falls may not have the cognitive ability for a knowledge deficient. Rationale 2: Risk for Injury is a state in which the individual is at risk as a result of environmental conditions such as a fall. Rationale 3: Risk for Disuse Syndrome is a deterioration of body system as the result of prescribed or unavoidable musculoskeletal inactivity. Rationale 4: Risk for Suffocation is inadequate air available for inhalation. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 5. Give examples of nursing diagnoses, outcomes, and interventions for a client at risk for accidental injury. MNL Learning Outcome: 4.2.2. Implement strategies for the maintenance of safety in the health care facility. Page Number: 640 Question 6 Type: MCSA The nurse is identifying care goals for a client who is prone to getting hurt. Which care goal should the nurse select for this client? 1. Assess the client's mental status. 2. Keep the client dependent on the staff for all care. 3. Make all choices for the client. 4. Remain free from injury. Correct Answer: 4 Rationale 1: The nurse will need to assess the client's mental status to help accomplish this goal. Rationale 2: Keeping the client dependent on the staff for care does not encourage independence. Rationale 3: Making all choices for the client does not encourage independence. Rationale 4: The major goal for a client who is at risk for injury is for the client to remain injury-free. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Give examples of nursing diagnoses, outcomes, and interventions for a client at risk for accidental injury. MNL Learning Outcome: 4.2.2. Implement strategies for the maintenance of safety in the health care facility. Page Number: 649 Question 7 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: Displaying the phone number to the nurses’ station is a way to call for help. Rationale 2: Electrical cords should only be used if necessary, and the maintenance department can help if any of them present a hazard. Rationale 3: Keeping the environment tidy and free of clutter will go a long way in preventing falls. Rationale 4: Reading label directions will prevent the wrong use of substances given to the client, but would not directly prevent falls. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.2. Implement strategies for the maintenance of safety in the health care facility. Page Number: 651 Question 8 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Place socks on feet. 4. Turn the light on after getting out of bed. Correct Answer: 2 Rationale 1: Vision can be a cause of falls, but it should be checked at least once a year; every 5 years is not often enough. Rationale 2: The client needs to exercise regularly to maintain strength, flexibility, mobility, and balance, which prevents falls. Rationale 3: Older clients should have something on their feet when walking, but not socks that will allow them to fall. A nonskid-type sock or shoe will help prevent falls. Rationale 4: The client should be able to turn the light on before getting out of bed, as inadequate lighting is another cause for falls. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.3. Implement safety measures throughout the life span. Page Number: 651 Question 9 Type: MCSA 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. Correct Answer: 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: A child of 2 years should still be taking a nap, and that poses a dangerous situation, at naptime or bedtime, if the child is still crawling out of the crib. Rationale 2: 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. Rationale 3: Just removing objects off the floor from around the crib would not prevent a child from climbing out of a crib. Rationale 4: Restraining the child would be dangerous and contribute even more to his determination of getting out of the crib. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.3. Implement safety measures throughout the life span. Page Number: 665 Question 10 Type: MCSA 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. Correct Answer: 2 Rationale 1: Research has found that more injury can occur to the client if the caregiver tries to place anything in the mouth during the seizure. Rationale 2: Loosening any clothing around the neck and chest prevents constriction that might occur during the seizure that could compromise the airway. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: A client should never be restrained during a seizure. The nurse should stay with the client and call for assistance, if needed. Rationale 4: If possible, the client should be turned to the lateral position, not supine, to allow for any secretions to drain out of the mouth. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Discuss implementation of seizure precautions. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 655 Question 11 Type: MCSA The nurse is considering the use of restraints for a client. In which situation can the nurse apply restraints to a client? 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. Correct Answer: 2 Rationale 1: Restraints cannot be used for the convenience of the care staff. Rationale 2: In this situation, the client’s actions could hinder his or her health status and a restraint would be indicated. Rationale 3: This situation would not call for the client to be restrained. The care staff needs to be more attentive to the client’s needs. Rationale 4: This client would not be a candidate for restraints. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9. Discuss the use and legal implications of restraints. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 659 Question 12 Type: MCSA The nurse is applying restraints to a client. After securing a health care 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. Correct Answer: 2 Rationale 1: The restraints should be assessed according to agency policy but no less frequently than every 2 hours. Rationale 2: Padding bony prominences will prevent possible skin breakdown. Rationale 3: Restraints are never tied to a side rail. The ends should be secured to the part of the bed that moves to elevate the head. Rationale 4: When a restraint is secured in place, a clove-hitch knot should be used, not a square knot. The clovehitch knot will not tighten when pulled. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 12. Verbalize the steps for: c. Applying restraints. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 660 Question 13 Type: MCSA An older client diagnosed with Alzheimer's 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. Correct Answer: 2 Rationale 1: Explaining procedures would not be appropriate with this client. Rationale 2: Alzheimer's 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. Rationale 3: Orienting to surroundings would not be appropriate with this client. Rationale 4: Using relaxation techniques would not be appropriate with this client. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Describe alternatives to restraints. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 652 Question 14 Type: MCSA The nurse is caring for a client who is confused and wanders. Which alternative to a restraint can the nurse use for this client? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 2 Rationale 1: Assigning the client to the farthest room from the nurses' station would be an unsafe move for the client; closer would be safer than farther. Rationale 2: 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. Rationale 3: Pulling up all of the side rails is a restraint, so that action would not be an alternative. Rationale 4: Keeping pillows wedged against the side rails will not keep the client from wandering. She is not in the bed. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Describe alternatives to restraints. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 551 Question 15 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 2 Rationale 1: The client may resent limitations and act out in such a way as to cause injury. Rationale 2: 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. Rationale 3: Making uninformed choices about one's health would be unsafe instead of safe for the client. Rationale 4: A routine should be established for medication administration with correct dosage to prevent the possibility of overdose toxicity. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.3. Implement safety measures throughout the life span. Page Number: 666 Question 16 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: Not knowing which plants are poisonous and which are not may pose a serious problem for children in the home. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Always avoid overloading outlets at any time because this can cause a fire. Rationale 4: Do not remove container labels or reuse empty containers to store different substances. Laws mandate that the labels of all substances specify an antidote. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 659 Question 17 Type: MCSA The nurse is attending a seminar on bioterrorism. What should the nurse identify as being the highest concern for homeland security? 1. Cancer 2. Seasonal flu 3. Tuberculosis 4. Smallpox Correct Answer: 4 Rationale 1: Cancer does not pose a threat to homeland security. Rationale 2: Seasonal flu does not pose a threat to homeland security. Rationale 3: Tuberculosis does not pose a threat to homeland security. Rationale 4: Smallpox, anthrax, botulism, plague, viral hemorrhagic fevers, and tularemia are the agents that are of highest concern with bioterrorism. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 643 Question 18 Type: MCSA 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. Correct Answer: 1 Rationale 1: The first step is to ask if the person is choking. Rationale 2: Five back blows are reserved for an infant who is choking. Rationale 3: If he indicates he is choking, the next step would be to perform the Heimlich maneuver. Rationale 4: Chest compressions would be given if the person was unconscious; this person is not. He is clutching his throat. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 657 Question 19 Type: MCSA 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. Correct Answer: 3 Rationale 1: The environment should be clutter-free because any clutter can cause the client to fall. Rationale 2: Wearing terry-cloth slippers would allow the client to fall. The client should have rubber skidresistant soles. Rationale 3: Providing adequate lighting will help prevent the client from falling. Rationale 4: Noise should be kept to a minimum, but turning off alarms would endanger a client. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 641 Question 20 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCMA The nurse is determining a client’s risk for injury. What should the nurse assess in this client? Standard Text: Select all that apply. 1. Age 2. Mobility 3. Hearing 4. Vision 5. Dietary intake Correct Answer: 1, 2, 3, 4 Rationale 1: The ability of a person to protect him- or herself from injury is dependent upon age. Rationale 2: The ability of a person to protect him- or herself from injury is dependent upon mobility. Rationale 3: The ability of a person to protect him- or herself from injury is dependent upon hearing. Rationale 4: The ability of a person to protect him- or herself from injury is dependent upon vision. Rationale 5: The ability of a person to protect him- or herself from injury is not dependent upon dietary intake. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe methods to assess a client’s risk for injury. MNL Learning Outcome: 4.2.1. Recognize factors that affect client safety. Page Number: 640 Question 21 Type: MCMA An older client is observed having difficulty moving from a sitting to standing position, and has an unsteady gait. What should the nurse assess in this client to promote home safety? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Standard Text: 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 Correct Answer: 1, 2, 3 Rationale 1: For home safety, it would be beneficial for the client with difficulty moving from a sitting to standing position to have grab bars in the bathroom. Rationale 2: For home safety, it would be beneficial for the client with an unsteady gait not to have scatter rugs on the floor. Rationale 3: For home safety, it would be beneficial for the client with an unsteady gait to be able to use a cane correctly. Rationale 4: The ability to stand in place for a minute before ambulating would be applicable if the client were demonstrating signs of orthostatic hypotension. Rationale 5: The use of alcohol with prescribed medications would be beneficial if the client were prescribed sedatives or hypnotics. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Explain interventions to prevent falls. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 641 Question 22 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 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. Correct Answer: 4 Rationale 1: The nurse is responsible for communicating the client’s medications to the long-term care facility, and documents this communication. Rationale 2: The client’s medications will not be filled prior to going to the long-term care facility. Rationale 3: It is not the client’s responsibility to communicate medications to the nurses at the long-term care facility. Rationale 4: The nurse should communicate the client’s medications to the nurses at the long-term care facility and document that this communication occurred. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 648 Question 23 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. It helps when the client is brushing her teeth. Correct Answer: 1 Rationale 1: 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. Rationale 2: If the client were having difficulty swallowing liquids, oral suction already would be in the client’s room. Rationale 3: Placing a piece of equipment in a client’s room that is not needed is not a good utilization of resources. Rationale 4: Having oral suction equipment available for teeth brushing is not the best use of the equipment. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8. Discuss implementation of seizure precautions. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 655 Question 24 Type: MCSA 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 Correct Answer: 1 Rationale 1: The installation and use of a smoke alarm in the home would indicate that home safety instruction has been effective. Rationale 2: Scatter rugs would indicate that instruction on home safety has not been effective. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Cords for appliances stretching across major walkways would indicate that instruction on home safety has not been effective. Rationale 4: Inadequate lighting in major rooms of the home would indicate that instruction on home safety has not been effective. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 656 Question 25 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: The sensor should be placed under the mattress at the buttocks area, not the shoulder area. Rationale 3: Time delays should be between 1 and 12 seconds. Rationale 4: Connecting the sensor pad to the control unit is the last step when installing the bed safetymonitoring device. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Verbalize the steps for: a. Using a bed or chair exit safety monitoring device. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 653 Question 26 Type: SEQ A client is prescribed to have wrist restraints applied. Place in order the steps the nurse will take to apply these restraints. Standard Text: Click and drag the options below to move them up or down. Choice 1. Pad bony prominences on the wrist. Choice 2. Apply the padded portion of the restraint around the wrist. Choice 3. Pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight. Choice 4. Attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot. Correct Answer: 1, 2, 3, 4 Rationale 1: Prior to applying the wrist restraint, the client’s bony prominences should be padded. Rationale 2: The nurse should apply the padded portion of the restraint around the wrist. Rationale 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. Rationale 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Verbalize the steps for: c. Applying restraints. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 664 Question 27 Type: MCSA The nurse is identifying activities and skills to delegate to unlicensed assistive personnel (UAP). 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. Correct Answer: 3 Rationale 1: Providing oral fluid to a newly extubated client should be done first by the nurse, so the client can be assessed for ability to safely swallow. Rationale 2: Irrigating an indwelling urinary catheter is beyond the scope for UAP. Rationale 3: 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. Rationale 4: Administering medication is beyond the scope for UAP. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13. 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: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 663 Question 28 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

A client is prescribed seizure precautions. What can the nurse safely delegate to UAP 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 Correct Answer: 2 Rationale 1: Tongue blades are not used as part of seizure precautions, and should not be placed at the head of the bed. Rationale 2: The nurse can safely delegate the padding of the bed to UAP. Rationale 3: The nurse should install the oxygen. Rationale 4: The nurse should check the oral suction apparatus. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13. 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: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 654 Question 29 Type: MCSA After ambulating a client to the bathroom, the unlicensed 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Client fell out of bed; bed safety-monitoring device not activated. Correct Answer: 4 Rationale 1: The bed safety device was not activated. It was not malfunctioning. Rationale 2: The client did not remove the leg band of the monitoring device. Rationale 3: The nurse needs to report the fall to the primary care physician. Rationale 4: The nurse needs to document what occurred with the client and why. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14. Demonstrate appropriate documentation and reporting of using a bed or chair exit safety monitoring device, seizure precautions, and applying restraints. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 654 Question 30 Type: MCMA 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? Standard Text: 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 Correct Answer: 2, 3, 4 Rationale 1: It is not important for the nurse to name the individuals who assisted the client back to bed. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Documentation should include where the client was when the seizure occurred. Rationale 3: Documentation should include the duration of the seizure. Rationale 4: Documentation should include the status of the client’s airway and use of oxygen. Rationale 5: It is not important for the nurse to name the individual who found the client having a seizure. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14. Demonstrate appropriate documentation and reporting of using a bed or chair exit safety monitoring device, seizure precautions, and applying restraints. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 655 Question 31 Type: MCMA 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? Standard Text: Select all that apply. 1. Cognitive awareness 2. Mobility 3. Nursing history 4. Physical examination 5. Health status Correct Answer: 3, 4 Rationale 1: Cognitive awareness, mobility, and health status are factors affecting safety. Rationale 2: Cognitive awareness, mobility, and health status are factors affecting safety. Rationale 3: A nursing history and physical examination are methods to assess a client at risk for injury. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: A nursing history and physical examination are methods to assess a client at risk for injury. Rationale 5: Cognitive awareness, mobility, and health status are factors affecting safety. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 643 Question 32 Type: MCMA The nurse is appointed to be a member of committee whose focus is to identify and address workplace safety issues. Which issues should the nurse recommend for analysis by this committee? Standard Text: Select all that apply. 1. Lifting clients 2. Inadequate lighting 3. Bending and walking 4. Exposure to infectious agents 5. Exposure to hazardous medications Correct Answer: 1, 3, 4, 5 Rationale 1: The U.S. Bureau of Labor Statistics (2012) reports that nursing has many hazards. Some of the hazards include lifting. Rationale 2: Inadequate lighting would be a safety issue in a home or community neighborhood. Rationale 3: The U.S. Bureau of Labor Statistics (2012) reports that nursing has many hazards. Some of the hazards include bending and walking. Rationale 4: The U.S. Bureau of Labor Statistics (2012) reports that nursing has many hazards. Some of the hazards include exposure to infectious agents. Rationale 5: The U.S. Bureau of Labor Statistics (2012) reports that nursing has many hazards. Some of the hazards include exposure to hazardous compounds. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 642 Question 33 Type: MCMA 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? Standard Text: Select all that apply. 1. Unscreened windows 2. Electrical outlets uncovered 3. Yard with a built-in pool unfenced 4. Cleaning solution in the bottom cabinet 5. Pots on stove with handles turned inward Correct Answer: 1, 2, 3, 4 Rationale 1: Unscreened windows would be a safety hazard for a toddler. Rationale 2: Uncovered electrical outlets would be a safety hazard for a toddler. Rationale 3: Having a backyard pool without a fence is a safety hazard for a toddler. Rationale 4: Cleaning solution in the bottom cabinet can be easily reached by a toddler, creating a safety hazard. Rationale 5: Pots on stove with the handles turned inward is the appropriate way to maintain safety in a home with a toddler. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4.2.4. Use the nursing process to maintain a safe and effective client care environment. Page Number: 647

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 33 Question 1 Type: MCSA 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 Correct Answer: 4 Rationale 1: Giving a bath to a client will allow the nurse to assess the skin but this is not the most important purpose. Rationale 2: Giving a bath to a client will allow the nurse to develop a nurse–client relationship but this is not the most important purpose. Rationale 3: Giving a bath to a client will allow the nurse to moisturize the skin but this is not the most important purpose. Rationale 4: The three major reasons for a bath are to remove waste products such as perspiration, stimulate circulation, and refresh the client. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Identify the purposes of bathing. MNL Learning Outcome: 4.4.1. Describe the hygienic practices implemented in bathing a client. Page Number: 674 Question 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA The nurse is preparing to bath 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. Correct Answer: 3 Rationale 1: Applying lotion to the skin would be performed before or after, not during, the bath. Rationale 2: Changing the water needs to be done before it becomes cold, but it is not a priority. Rationale 3: 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. Rationale 4: A dressing change would be performed before or after, not during, the bath and only with a doctor's order. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Compare and contrast the task-centered approach and the person-centered approach to bathing. MNL Learning Outcome: 4.4.1. Describe the hygienic practices implemented in bathing a client. Page Number: 677

Question 3 Type: MCMA 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 linen? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Standard Text: Select all that apply. 1. Pulse 2. Respirations 3. Urine output 4. Blood pressure 5. Mobility status Correct Answer: 1, 2, 4, 5 Rationale 1: When changing the linen of an unoccupied bed the nurse should assess the client’s pulse. Rationale 2: When changing the linen of an unoccupied bed the nurse should assess the client’s respirations. Rationale 3: Urine output does not need to be assessed prior to assisting a client out of the bed to change the linen. Rationale 4: When changing the linen of an unoccupied bed the nurse should assess the client’s blood pressure. Rationale 5: When changing the linen of an unoccupied bed the nurse should assess the client’s mobility status. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15. Verbalize the steps used in: h. Changing an unoccupied bed. MNL Learning Outcome: 4.4.1. Describe the hygienic practices implemented in bathing a client. Page Number: 710 Question 4 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 3 Rationale 1: The hair should not be dry or thin. This could be a sign of alopecia. Darkness would depend on hair color through the gene pool. Rationale 2: Skin is assessed as being smooth, taut, or shiny, not hair. Rationale 3: The hair should be smooth in texture and neither oily nor dry. Rationale 4: A tender, warm scalp could indicate a problem, so this would not be normal. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify normal and abnormal assessment findings while providing hygiene care. MNL Learning Outcome: 4.4.4. Implement hygienic practices for the care of the feet, hair, mouth, eyes, and ears. Page Number: 700 Question 5 Type: MCSA 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 her teeth. 4. The nurse will stress the importance of adequate fluid intake. Correct Answer: 3 Rationale 1: Cognitive impairment limits the client's ability to understand and comprehend; therefore, naming the staff is not within the client’s realm of understanding. Rationale 2: Cognitive impairment limits the client's ability to understand and comprehend; therefore, eliminating safety hazards is not within the client’s realm of understanding. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: A client with cognitive impairment would be able to brush her teeth but only with supervision. The client would not voluntarily brush her teeth without prompting from the staff. Rationale 4: Cognitive impairment limits the client's ability to understand and comprehend; therefore, stressing adequate fluid intake is not within the client’s realm of understanding. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.4.4. Implement hygienic practices for the care of the feet, hair, mouth, eyes, and ears. Page Number: 672 Question 6 Type: MCSA 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 everyday. 4. The room temperature is set at 72°F. Correct Answer: 1 Rationale 1: 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 he will care for it or rely on others. This can pose a threat if the client chooses not to care for it. Rationale 2: Performing meticulous foot care does not pose a threat to one's hygiene. Rationale 3: Bathing every other day does not pose a threat to one's hygiene. Rationale 4: Room temperature of 72°F does not pose a threat to one's hygiene. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Identify factors influencing personal hygiene. MNL Learning Outcome: 4.4.2. Recognize factors that influence hygienic practices. Page Number: 699 Question 7 Type: MCSA 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 Correct Answer: 3 Rationale 1: Hygienic care does not include care of the client’s clothes. Rationale 2: Hygienic care does not include care to the client’s family. Rationale 3: Hygiene care consists of skin, hair, hands, feet, eyes, nose, mouth, back, and perineum. Rationale 4: Hygienic care does not include the client’s nutritional status. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe hygienic care that nurses provide to clients. MNL Learning Outcome: 4.4.4 Implement hygienic practices for the care of the feet, hair, mouth, eyes, and ears. Page Number: 669 Question 8 Type: MCSA A client needs to have soft contact lenses removed. What should the nurse do when removing the lenses? 1. Gently pinch the lens and lift it out. 2. Have the client look up. 3. Pull the lower eyelid upward. 4. Use the pad of the ring finger. Correct Answer: 1 Rationale 1: Gently pinching the lens and lifting it out is one of the correct steps for removing a client's soft contact lenses. Rationale 2: The nurse should have the client look straight ahead, not up. Rationale 3: The upper eyelid is pulled down gently. Rationale 4: The nurse would use the pad of the index finger, not the ring finger. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Identify the steps in removing contact lenses. MNL Learning Outcome: 4.4.4 Implement hygienic practices for the care of the feet, hair, mouth, eyes, and ears. Page Number: 703 Question 9 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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°F to 98.6°F. 4. Inspect feet thoroughly once a week. Correct Answer: 2 Rationale 1: Toenails should be cut straight across, and nurses do not cut diabetic clients' toenails. Only a podiatrist should handle this task. Rationale 2: Toes should be dried thoroughly after being washed to impede fungal growth and prevent maceration. Rationale 3: The water to wash the feet should be 100°F to 110°F. Rationale 4: Feet should be inspected each day, not once a week, for early detection of any problems. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15. Verbalize the steps used in: c. Providing foot care. MNL Learning Outcome: 4.4.4 Implement hygienic practices for the care of the feet, hair, mouth, eyes, and ears. Page Number: 686 Question 10 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Turn client every 3 hours. Correct Answer: 2 Rationale 1: For nutritional support to promote healthy tissue, clients should consume more than 40% of their meals. Rationale 2: Keeping linens dry and wrinkle-free will prevent pressure areas. Rationale 3: Fluids should not be restricted unless some other physical condition dictates. The skin should be kept hydrated. Rationale 4: To relieve pressure, the client should be turned every 2 hours, not every 3. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.4.4 Implement hygienic practices for the care of the feet, hair, mouth, eyes, and ears. Page Number: 686 Question 11 Type: MCSA Unlicensed 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 Correct Answer: 4 Rationale 1: Excess earwax is not an immediate problem. Rationale 2: Loud talking could be an indication the client is hard of hearing, which is not an immediate threat. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: The presence of a hearing aid should already be noted on the client's admission assessment. Rationale 4: The health care provider should report any drainage from the ears to the nurse. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify normal and abnormal assessment findings while providing hygiene care. 16. Recognize when it is appropriate to delegate hygiene skills for clients to unlicensed assistive personnel. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 704 Question 12 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: Clients are instructed not to remove their aids in common rooms like a sunroom. Rationale 3: The removal of the aid is necessary before bathing so that it is not damaged. Rationale 4: The aid should always be stored in the client's bedside table—not sent home with the family—so it is available for later use. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Describe the steps for removing, cleaning, and inserting hearing aids. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 704 Question 13 Type: MCSA 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. Correct Answer: 1 Rationale 1: It is recommended by the manufacturers to clean the aid with a dry, soft cloth to prevent any damage to the aid. Rationale 2: The aid should be turned off and the battery removed to preserve the life of the battery. Rationale 3: The aid should be stored in a safe place where it will not get damaged. It should not be stored in the bathroom cabinet. Rationale 4: Alcohol is not recommended to be used on an aid because it could damage the aid. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Describe the steps for removing, cleaning, and inserting hearing aids. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 705 Question 14 Type: MCSA 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 bottom linens. 2. Miter corners at the head of the bed. 3. Place the soiled sheet in a laundry bag. 4. Prepare the client. Correct Answer: 3 Rationale 1: Beginning at the head and moving toward the foot, loosening the bottom linens, provides maximum work space. Rationale 2: Mitering the corners at the head of the bed prevents linens from becoming easily loosened. Rationale 3: Placing the soiled sheet in the laundry bag reduces the spread of microorganisms, which is a safety measure for both the nurse and client. Rationale 4: Preparing the client readies the client for the procedure. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14. Identify safety and comfort measures underlying bed-making procedures. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 680

Question 15 Type: MCMA The nurse is preparing to remove ticks from a client’s scalp. Which actions should the nurse perform to safely remove these pathogens from the client? Standard Text: 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. Correct Answer: 1, 3, 4 Rationale 1: To remove a tick, grasp the tick as close to the skin as possible with blunt tweezers. Rationale 2: Applying heat to the tick with a match is a dangerous practice and should not be done. Rationale 3: After the tick is removed, wash the area with antibacterial soap. Rationale 4: Gently pull the tick away using a perpendicular motion. Rationale 5: Applying petroleum jelly to the surface of the tick is an ineffective approach to remove a tick. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 698 Question 16 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The nurse is making an occupied bed. Which step will provide comfort for the client during this linen change? 1. Allow for a toe pleat. 2. Place a bath blanket over the client. 3. Slide the mattress to the head of the bed. 4. Raise the side rail. Correct Answer: 1 Rationale 1: Allowing for a toe pleat provides for client comfort. Rationale 2: Placing the bath blanket over the client prevents unnecessary exposure. Rationale 3: Sliding the mattress to the head of the bed makes it easier to tuck in the linens. Rationale 4: Raising the side rail maintains client safety. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14. Identify safety and comfort measures underlying bed-making procedures. 15. Verbalize the steps used in: i. Changing an occupied bed. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 711 Question 17 Type: MCSA The nurse is preparing to shave a client. Which action step should the nurse consider when providing this care? 1. Assist the client to a prone position. 2. Pull the skin taut with the dominant hand. 3. Rinse the razor after each stroke. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Use long strokes. Correct Answer: 3 Rationale 1: Assist the client to a sitting position—not a prone position—because this is a more natural position. Rationale 2: The skin should be pulled taut with the nondominant hand—not the dominant hand—because this provides uniform shaving. Rationale 3: Rinsing the razor after each stroke keeps the cutting edge clean. Rationale 4: Short strokes should be used—not long strokes—because this provides for a closer shave without irritation. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 702 Question 18 Type: MCSA 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. Correct Answer: 2 Rationale 1: Cleansing biting surfaces prevents bacteria, odor, and stain formation. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Placing a washcloth in the bowl of the sink serves as a cushion for the dentures if accidentally dropped. Rationale 3: Replacing the upper dentures first promotes comfort. Rationale 4: Dentures should be rinsed thoroughly with tepid water, not hot water, because extreme temperatures will harm dentures. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15. Verbalize the steps used in: e. Providing special oral care. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 695

Question 19 Type: MCSA 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 Correct Answer: 2 Rationale 1: Hour-of-sleep care includes providing for elimination needs, washing the face and hands, oral care, and a back massage. Rationale 2: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Early morning care is provided to clients as they awaken in the morning and consists of aiding to void, washing the face and hands, and providing oral care. Rationale 4: Morning care is usually after breakfast and includes providing for elimination needs, a bath or shower, perineal care, back massage, and oral, nail, and hair care. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe hygienic care that nurses provide to clients. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 670 Question 20 Type: MCSA 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 Correct Answer: 4 Rationale 1: The client’s inability to lift the legs to get into the shower is not a religious practice. Rationale 2: The client’s inability to lift the legs to get into the shower is not a personal preference. Rationale 3: The client’s inability to lift the legs to get into the shower is not a cultural preference. Rationale 4: Ill people or those with neuromuscular disorders may not be able to perform hygienic care. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Identify factors influencing personal hygiene. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 670 Question 21 Type: MCSA 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. Correct Answer: 1 Rationale 1: For areas of erythema, the nurse should wash the area carefully to remove microorganisms. Rationale 2: Alcohol-free lotion would be applicable for excessively dry skin areas. Rationale 3: Washing without soap would be applicable for excessively dry skin areas. Rationale 4: Removing the hair would be applicable for hirsutism. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 671 Question 22 Type: MCSA 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. Correct Answer: 3 Rationale 1: Applying antiseptic spray would be applicable for areas of erythema but not for abrasions. Rationale 2: Avoiding soap would be applicable for excessively dry skin. Rationale 3: 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. Rationale 4: Applying alcohol-free lotion would be applicable for excessively dry skin but not for abrasions. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 671 Question 23 Type: MCMA The nurse wants to assess a client during the morning bath. What will the nurse be able to assess during this time? Standard Text: Select all that apply. 1. Skin status 2. Financial status 3. Psychosocial needs 4. Learning needs 5. Physical conditions Correct Answer: 1, 3, 4, 5 Rationale 1: Assessment of the skin can be done during the morning bath. Rationale 2: The client’s financial status is an area not usually assessed during the morning bath. Rationale 3: The client’s psychosocial needs can be assessed during the morning bath. Rationale 4: The client’s learning needs regarding hygienic care can be assessed during the morning bath. Rationale 5: Assessing the client’s physical conditions can be done during the morning bath. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify normal and abnormal assessment findings while providing hygiene care. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 672 Question 24 Type: MCMA A client is prescribed bed rest with bathroom privileges. Which types of bath would be appropriate for this client? Standard Text: Select all that apply. 1. Shower 2. Tub bath 3. Self-help bed bath 4. Therapeutic bath 5. Partial bath Correct Answer: 3, 5 Rationale 1: Getting into and out of a shower might be too strenuous for a client prescribed bed rest with bathroom privileges. Rationale 2: Getting into and out of a bathtub might be too strenuous for a client prescribed bed rest with bathroom privileges. Rationale 3: 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. Rationale 4: A therapeutic bath is for some physical effect and not used routinely for morning care. Rationale 5: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Describe various types of baths. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 671 Question 25 Type: MCSA 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 Correct Answer: 2 Rationale 1: A shower would not permit the medication to be in contact with the client’s skin long enough. Rationale 2: 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 to 30 minutes. If the client’s back, chest, and arms are to be treated, these areas need to be immersed in the solution. Rationale 3: A partial bath would not permit the medication to be in contact with the client’s skin long enough. Rationale 4: A complete bath would not permit the medication to be in contact with the client’s skin long enough. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 675 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 26 Type: MCSA A client tells the nurse that she does not want to get into the tub for a morning bath. The client has not been bathed for several days. What should the nurse do? 1. Assign UAP 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. Correct Answer: 3 Rationale 1: Assigning a UAP the task of giving the client a bath is following the task-centered approach. Rationale 2: Skipping the client’s bath and documenting “refused” is not following a client-centered approach. Rationale 3: To provide a person-centered approach to bathing, the nurse should ask the client to describe the usual way bathing occurs at home. Rationale 4: Telling the client that a bath is needed and ignoring the client’s comment is not following a clientcentered approach. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Compare and contrast the task-centered approach and the person-centered approach to bathing. MNL Learning Outcome: 4.4.2 Recognize factors that influence hygienic practices. Page Number: 674 Question 27 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 1 Rationale 1: 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. Rationale 2: The client did not refuse a morning bath but rather explained why showers are not used. Rationale 3: Shower shoes may not be sufficient to eliminate the client’s fear of falling when in the shower. Rationale 4: The nurse would not be able to hold the client during the shower. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Discuss factors that support a positive and safe environment for the client. MNL Learning Outcome: 4.4.2 Recognize factors that influence hygienic practices. Page Number: 675 Question 28 Type: MCMA 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? Standard Text: Select all that apply. 1. Move slowly. 2. Be flexible. 3. Help the client feel in control. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Avoid stopping once the bath is started. 5. Be prepared. Correct Answer: 1, 2, 3, 5 Rationale 1: When bathing a client with dementia, the nurse should move slowly. Rationale 2: When bathing a client with dementia, the nurse should be flexible to adapt the approach to meet the needs of the client. Rationale 3: When bathing a client with dementia, the nurse should offer the client choices in order for the client to feel in control. Rationale 4: When bathing a client with dementia, the nurse should stop if the client begins to feel distressed. Rationale 5: When bathing a client with dementia, the nurse should be prepared with all items prior to starting the bath. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe guidelines for bathing persons with dementia. MNL Learning Outcome: 4.4.2 Recognize factors that influence hygienic practices. Page Number: 681 Question 29 Type: MCSA 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. Correct Answer: 4 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Hard contact lenses are not removed by pinching. Rationale 2: The nurse should remove one lens at a time and store in the appropriate storage cup. Rationale 3: Hard contact lenses should be removed and cleaned every day, not every 2 weeks. Rationale 4: Hard contact lenses should only be worn for 12 to 14 hours. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Discuss the different types of contact lenses. MNL Learning Outcome: 4.4.2 Recognize factors that influence hygienic practices. Page Number: 703 Question 30 Type: MCSA 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 ophthalmology consult because the client will need help removing the lenses. Correct Answer: 3 Rationale 1: This type of lens should not be worn for more than 30 days. Rationale 2: The lenses should not be wrapped in tissue because this will cause the lenses to dry out and not be able to be worn or used. Rationale 3: 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. Rationale 4: The client does not need ophthalmology consult. The nurse can help the client remove the lenses. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Discuss the different types of contact lenses. 10. Identify the steps in removing contact lenses. MNL Learning Outcome: 4.4.2 Recognize factors that influence hygienic practices. Page Number: 703 Question 31 Type: SEQ The nurse is assisting a client in removing soft contact lenses. Place in order the steps the nurse should take to help this client. Standard Text: Click and drag the options below to move them up or down. Choice 1. Using the pad of the index finger of the other hand, move the lens down to the sclera. Choice 2. Have the client look forward. Choice 3. Apply gloves. Choice 4. Gently pinch the lens between the pads of the thumb and index finger. Choice 5. Retract the lower lid with one hand. Correct Answer: 3, 2, 5, 1, 4 Rationale 1: The nurse should use the pad of the index finger of the other hand to move the lens down to the sclera. Rationale 2: The nurse should ask the client to look forward. Rationale 3: The first step is for the nurse to apply gloves. Rationale 4: The nurse should gently pinch the lens between the pads of the thumb and index finger to remove the lens. Rationale 5: The nurse should retract the lower lid with one hand. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Identify the steps in removing contact lenses. MNL Learning Outcome: 4.4.2 Recognize factors that influence hygienic practices. Page Number: 703 Question 32 Type: MCSA The client has a hearing aid with an earpiece that is connected by a cord to a receiver that the client keeps in a shirt pocket. 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 Correct Answer: 1 Rationale 1: A body hearing aid is a pocket-sized aid that clips onto a shirt pocket. The case, containing the microphone and amplifier, is connected by a cord to the receiver, which snaps into the earpiece. Rationale 2: An in-the-canal aid is a hearing aid that fits directly into the client’s ear and is barely visible. It is not connected to a receiver worn by the client. Rationale 3: A completely-in-the-canal aid is a hearing aid that fits inside the client’s ear canal and is not visible. It is not connected to a receiver worn by the client. Rationale 4: An eyeglass aid has a hearing aid attached to the eyeglasses and is not connected to a receiver worn by the client. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11. Discuss the different types of hearing aids. MNL Learning Outcome: 4.4.2 Recognize factors that influence hygienic practices. Page Number: 705 Question 33 Type: MCSA The nurse has delegated the making of unoccupied beds to unlicensed 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 Correct Answer: 3 Rationale 1: The folding of the top sheet is not important for client safety. Rationale 2: The direction of the pillow is not important for client safety. Rationale 3: The nurse should assess for the call light being readily available while the client is out of the bed. Rationale 4: The presence of mitered corners is not important for client safety. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 14. Identify safety and comfort measures underlying bed-making procedures. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 712 Question 34 Type: MCMA A client recovering from acute illness has just received a tub bath. When documenting the bath, what should the nurse include? Standard Text: 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 Correct Answer: 2, 3, 4, 5 Rationale 1: It is not necessary for the nurse to document if the client was maintaining a conversation during the bath. Rationale 2: When evaluating the client’s bath, the nurse should include the client’s tolerance of the procedure. Rationale 3: When evaluating the client’s bath, the nurse should include the condition and integrity of the client’s skin. Rationale 4: When evaluating the client’s bath, the nurse should include the client’s strength. Rationale 5: When evaluating the client’s bath, the nurse should include the percentage of the bath done without assistance. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 17. Demonstrate appropriate documentation and reporting of hygiene skills. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 675 Question 35 Type: MCSA 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 Correct Answer: 2 Rationale 1: The nurse does not need to document the condition of the skin and nails unless a problem is noted. Rationale 2: Foot care is not generally recorded unless problems are noted. Rationale 3: The nurse does not need to document the amount of time taken on foot care. Rationale 4: The nurse does not need to document the client’s comments about the foot care. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 17. Demonstrate appropriate documentation and reporting of hygiene skills. MNL Learning Outcome: 4.4.3 Implement the nursing process in relation to all aspects of the client’s hygienic practices. Page Number: 686

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 34 Question 1 Type: MCSA 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. Correct Answer: 2 Rationale 1: Assessing the data occurs in the pretest phase. Rationale 2: Collecting the specimen comes during the intratest phase. Rationale 3: Observing the client occurs in the posttest phase as follow-up after the testing. Rationale 4: Preparing the client occurs in the pretest phase. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the nurse’s role for each of the phases involved in diagnostic testing. MNL Learning Outcome: 4.5.1. Explain the nurse's role related to diagnostic testing, specimen collection, and reporting results. Page Number: 719 Question 2 Type: MCSA The nurse is teaching a client with heart failure about diagnostic tests. Which test should the nurse emphasize in this teaching? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. BNP 2. CBC 3. LDH 4. PKU Correct Answer: 1 Rationale 1: 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. Rationale 2: A CBC is a complete blood count, which includes hemoglobin and hematocrit measurements, erythrocyte (red blood cells) count, leukocyte (white blood cell) count, red blood cell indices, and a differential white cell count. Rationale 3: This test measures the amount of the enzyme lactic dehydrogenase in the body. Rationale 4: This is a test to assess for phenylketonuria in the newborn. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. List common blood tests. MNL Learning Outcome: 4.5.2. Correlate the information related to specific serum laboratory studies to client care. Page Number: 723 Question 3 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Hemoglobin A1c 4. Serum electrolytes Correct Answer: 3 Rationale 1: A blood chemistry is a number of tests performed on blood serum. It can include LDH, CK, and AST. Rationale 2: The capillary blood glucose is used to determine or monitor blood glucose levels of clients at one point in time but not over time. Rationale 3: 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. Rationale 4: Serum electrolytes are often routinely ordered for any client admitted to a hospital as a screening test for electrolyte and acid–base imbalances. The most commonly ordered serum tests are for sodium, potassium, chloride, and bicarbonate ions. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. List common blood tests. MNL Learning Outcome: 4.5.2. Correlate the information related to specific serum laboratory studies to client care. Page Number: 723 Question 4 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 4 Rationale 1: Once the appropriate site is selected for puncture, the side of the finger is used where there are fewer nerve endings. Rationale 2: Because the client is performing self-blood glucose monitoring, applying gloves is not necessary. Rationale 3: Once the specimen is obtained, one holds the reagent strip under the puncture site until enough blood covers the indicator square. It is not smeared on the pad, which would cause an inaccurate reading. Rationale 4: One of the first steps the client would perform is hand washing for infection control. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 11. Verbalize the steps used in: a. Obtaining a capillary blood specimen to measure blood glucose. MNL Learning Outcome: 4.5.2. Correlate the information related to specific serum laboratory studies to client care. Page Number: 726 Question 5 Type: MCSA A client asks the nurse, "Why do I have to monitor my blood glucose levels?" What is an appropriate response from the nurse? 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." Correct Answer: 3 Rationale 1: "Because your doctor ordered it" is not a good enough reason. Rationale 2: The nurse should never tell a client what he or she would do; that is only an opinion. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Blood glucose monitoring improves diabetes management. By testing one's blood, one can change the insulin regimen to maintain a normal glycemic range. Rationale 4: Eating anything the client wants would give rise to too many episodes of hyperglycemia and make the diabetes harder to control. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Explain the rationale for the collection of each type of specimen. MNL Learning Outcome: 4.5.2. Correlate the information related to specific serum laboratory studies to client care. Page Number: 726 Question 6 Type: MCSA What is the responsibility of the nurse when collecting a specimen from a client? 1. Always 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. Correct Answer: 2 Rationale 1: The nurse should provide the client as much privacy as possible. Rationale 2: The nurse should handle the specimen discreetly to avoid embarrassing the client. Rationale 3: Aseptic technique is used to collect specimens to prevent contamination. Rationale 4: Specimens should be transported promptly to the lab. Fresh specimens provide the most accurate results. Global Rationale: Cognitive Level: Analyzing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Discuss the nursing responsibilities for specimen collection. MNL Learning Outcome: 4.5.1. Explain the nurse's role related to diagnostic testing, specimen collection, and reporting results. Page Number: 728 Question 7 Type: MCSA A client is prescribed a diagnostic test requiring a 24-hour stool specimen. What should this test indicate to the nurse? 1. Analyze the stool for dietary products and digestive secretions. 2. Detect the presence of bacteria or viruses. 3. Detect the presence of ova and parasites. 4. Determine the presence of occult blood. Correct Answer: 1 Rationale 1: 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. Rationale 2: To detect bacteria or viruses, only a small amount of stool is needed. Rationale 3: To detect ova or parasites, only a small amount of stool is needed. Rationale 4: To determine the presence of occult blood, only a small amount of stool is needed. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 4. Explain the rationale for the collection of each type of specimen. MNL Learning Outcome: 4.5.3. Correlate the information related to collection of stool and urine specimens to client care. Page Number: 729 Question 8 Type: MCSA A client is being treated for tuberculosis, and the doctor writes an order to collect a sputum specimen. What is the rationale behind this order? 1. To test for acid-fast bacillus 2. To assess the effectiveness of therapy 3. To identify origin, structure, function, and pathology of cells 4. To identify the specific organism Correct Answer: 2 Rationale 1: It is already known that TB is acid-fast. Rationale 2: The reason for this doctor's order is to assess if the therapy ordered is effective for this client. Rationale 3: TB does not require cytology for identification; therefore, there is no need for identifying origin, structure, and function. Rationale 4: Because it is known that the client has tuberculosis, the organism has already been identified. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain the rationale for the collection of each type of specimen. MNL Learning Outcome: 4.5.4. Correlate the information related to collection of sputum and throat specimens to client care. Page Number: 736 Question 9 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 2 Rationale 1: At least 1 to 2 teaspoons or 4 to 10 mL should be collected. Rationale 2: Offer mouth care so that the specimen will not be contaminated with microorganisms from the mouth. Rationale 3: The client should be instructed to breathe deeply and then cough, not take shallow breaths, as this would not raise the sputum. Rationale 4: A mask needs to be worn only if TB is suspected. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe how to collect sputum and throat specimens. MNL Learning Outcome: 4.5.4. Correlate the information related to collection of sputum and throat specimens to client care. Page Number: 736 Question 10 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Void before the specimen is collected. Correct Answer: 4 Rationale 1: The client should defecate in a clean bedpan or bedside commode, not the toilet. Rationale 2: Aseptic technique should be followed, not sterile, because the bowel contains microorganisms. Rationale 3: The usual amount needed for a specimen is 15 to 30 mL, not 60 mL. Rationale 4: To avoid contaminating the specimen, the client should void before the specimen is collected. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe how to collect and test stool specimens. MNL Learning Outcome: 4.5.3. Correlate the information related to collection of stool and urine specimens to client care. Page Number: 729 Question 11 Type: MCSA 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. Correct Answer: 2 Rationale 1: At least 10 mL of urine is generally sufficient for a routine urinalysis. Rationale 2: 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.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: A timed urine specimen should be refrigerated or kept on ice to prevent bacterial growth or decomposition of urine components. Rationale 4: A clean voided urine specimen does not need to be placed in a sterile container, but a clean-catch or midstream specimen does. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Collecting a urine specimen for culture and sensitivity by clean catch. MNL Learning Outcome: 4.5.3. Correlate the information related to collection of stool and urine specimens to client care. Page Number: 731 Question 12 Type: MCSA 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. Correct Answer: 3 Rationale 1: The client does not need to put on sterile gloves. The only thing that has to remain sterile is the inside of the collecting container. Rationale 2: Clearing the throat will not help produce the sputum; the client has to cough. Rationale 3: 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. Rationale 4: The client is allowed to use mouthwash after the collection but not before because the antiseptic could alter the results. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe how to collect sputum and throat specimens. MNL Learning Outcome: 4.5.4. Correlate the information related to collection of sputum and throat specimens to client care. Page Number: 736 Question 13 Type: MCSA 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 not been effective? 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." Correct Answer: 1 Rationale 1: The client should extend the tongue when a throat culture is to be taken, not hyperextend the neck. Rationale 2: Saying “ah” is done when collecting a throat specimen. Rationale 3: The client will need to sit up when having a throat culture done. Rationale 4: The nurse will use a light when obtaining a throat culture. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Describe how to collect sputum and throat specimens. MNL Learning Outcome: 4.5.4. Correlate the information related to collection of sputum and throat specimens to client care. Page Number: 737 Question 14 Type: MCSA 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. Correct Answer: 3 Rationale 1: Assessing bowel sounds is important, but if the bowel is not free of feces, the barium enema will not be accurate. Rationale 2: Assessing for allergies is important, but if the bowel is not free of feces, the barium enema will not be accurate. Rationale 3: 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. Rationale 4: Keeping the client NPO is important, but if the bowel is not free of feces, the barium enema will not be accurate. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 8. Describe visualization procedures that may be used for the client with gastrointestinal, urinary, and cardiopulmonary alterations. MNL Learning Outcome: 4.5.1. Explain the nurse's role related to diagnostic testing, specimen collection, and reporting results. Page Number: 738 Question 15 Type: MCSA 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." Correct Answer: 1 Rationale 1: An echocardiogram causes no discomfort, although conductive gel is used and it may be cold. Rationale 2: The client does not need to walk on a treadmill for this test. Rationale 3: The client does not need to be NPO for this test. Rationale 4: The client does not need to take his pulse before the test. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8. Describe visualization procedures that may be used for the client with gastrointestinal, urinary, and cardiopulmonary alterations. MNL Learning Outcome: 4.5.1. Explain the nurse's role related to diagnostic testing, specimen collection, and reporting results. Page Number: 738 Question 16 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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." Correct Answer: 4 Rationale 1: Because cystoscopy is direct visualization, x-rays are not needed nor taken. Rationale 2: Clients are either put to sleep or consciously sedated during this procedure; they are not awake. Rationale 3: Only the bladder, ureteral orifices, and urethra are directly visualized. Rationale 4: The cystoscope is a lighted instrument inserted through the urethra. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8. Describe visualization procedures that may be used for the client with gastrointestinal, urinary, and cardiopulmonary alterations. MNL Learning Outcome: 4.5.1. Explain the nurse's role related to diagnostic testing, specimen collection, and reporting results. Page Number: 738 Question 17 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Wear goggles. Correct Answer: 4 Rationale 1: Earplugs are offered to reduce the noise. Rationale 2: One does have to lie still, but the damage could still occur to the eyes if they are not covered. Rationale 3: Covering the eyes would prevent a complication of burning. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Compare and contrast CT, MRI, and nuclear imaging studies. MNL Learning Outcome: 4.5.1. Explain the nurse's role related to diagnostic testing, specimen collection, and reporting results. Page Number: 739 Question 18 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Lying prone with knees down toward the abdomen would position the client too high for the physician and could lead to increased intracranial pressure. Rationale 3: Sitting would not arch the back enough to increase the space between the vertebrae for puncture. Rationale 4: Supine with knees pulled toward the chest does not expose the vertebrae to be punctured. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Describe the nurse’s role in caring for clients undergoing aspiration/biopsy procedures. MNL Learning Outcome: 4.5.1. Explain the nurse's role related to diagnostic testing, specimen collection, and reporting results. Page Number: 740 Question 19 Type: MCSA 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. Correct Answer: 3 Rationale 1: Inserting a catheter into the bladder will only relieve urine, not the accumulation of fluid in the abdomen. Rationale 2: A liver biopsy is performed to obtain a sample of the liver, not to remove fluid. Rationale 3: An abdominal paracentesis is performed to remove ascites, which relieves pressure on the abdominal organs. Rationale 4: A thoracentesis is performed to remove excess fluid or air to ease breathing. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Describe the nurse’s role in caring for clients undergoing aspiration/biopsy procedures. MNL Learning Outcome: 4.5.1. Explain the nurse's role related to diagnostic testing, specimen collection, and reporting results. Page Number: 741 Question 20 Type: MCMA The nurse is providing care to a client during the posttest phase of diagnostic testing. What will the nurse do during this phase? Standard Text: 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. Correct Answer: 2, 4, 5 Rationale 1: Providing emotional and physical support to the client is done during the intratest phase of diagnostic testing. Rationale 2: During the posttest phase of diagnostic testing, the nurse will compare the previous and current test results. Rationale 3: Preparing the client for the test is done during the pretest phase. Rationale 4: During the posttest phase of diagnostic testing, the nurse will modify nursing interventions as necessary.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: During the posttest phase of diagnostic testing, the nurse will report the results to appropriate health team members. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Describe the nurse’s role in caring for clients undergoing aspiration/biopsy procedures. MNL Learning Outcome: 4.5.1. Explain the nurse's role related to diagnostic testing, specimen collection, and reporting results. Page Number: 719 Question 21 Type: MCSA The nurse needs to collect a specimen from a client; however, the nurse has never collected this type of specimen in the past. What should the nurse do? 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. Correct Answer: 3 Rationale 1: The nurse should not notify the physician. Rationale 2: The nurse should not ask another nurse to collect the specimen. Rationale 3: 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. Rationale 4: The nurse should not delegate the collection of the specimen to unlicensed assistive personnel. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Discuss the nursing responsibilities for specimen collection. MNL Learning Outcome: 4.5.1. Explain the nurse's role related to diagnostic testing, specimen collection, and reporting results. Page Number: 719 Question 22 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: The nurse should not document that the specimen could not be obtained. Rationale 3: The nurse needs a physician’s order to catheterize the client for the specimen. Rationale 4: Obtaining urine specimens is a nursing responsibility, and should not be delegated to the physician. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 11. Verbalize the steps used in: b. Collecting a urine specimen for culture and sensitivity by clean catch. MNL Learning Outcome: 4.5.3. Correlate the information related to collection of stool and urine specimens to client care. Page Number: 734 Question 23 Type: MCSA 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. Correct Answer: 2 Rationale 1: The MRI uses a magnetic field to produce an image of a body part or organ. Rationale 2: In nuclear imaging studies, a radioisotope is injected, and the body organ is determined as functioning as either hot or cold. Rationale 3: The CT scan produces a three-dimensional image of an organ. Rationale 4: The CT scan is more sensitive than an x-ray image. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Compare and contrast CT, MRI, and nuclear imaging studies. MNL Learning Outcome: 4.5.1. Explain the nurse's role related to diagnostic testing, specimen collection, and reporting results. Page Number: 739 Question 24 Type: MCMA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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? Standard Text: 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. Correct Answer: 2, 3, 5 Rationale 1: Cleaning the perineal area using a circular motion would be appropriate for a male client. Rationale 2: 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. Rationale 3: 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. Rationale 4: Cleaning the perineal area from back to front introduces bacteria from the anal region toward the perineum. Rationale 5: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Collecting a urine specimen for culture and sensitivity by clean catch. MNL Learning Outcome: 4.5.3. Correlate the information related to collection of stool and urine specimens to client care. Page Number: 733 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 25 Type: MCMA Unlicensed assistive personnel (UAP) will be conducting a test on a client’s urine. What should the nurse instruct the UAP about the test? Standard Text: Select all that apply. 1. Nothing, because the UAP can perform urine testing. 2. Remind the UAP 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. Correct Answer: 4, 5 Rationale 1: The nurse needs to instruct the UAP to report the results to the nurse and save the urine. Rationale 2: The UAP is not to tell the client the results of the test. Rationale 3: The nurse is to notify the physician with the results of the test. Rationale 4: The nurse should instruct the UAP to report the results of the test to the nurse. Rationale 5: The nurse should instruct the UAP to save the urine in case the nurse wants to repeat the test. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Recognize when it is appropriate to delegate diagnostic testing skills to unlicensed assistive personnel. MNL Learning Outcome: 4.5.1. Explain the nurse's role related to diagnostic testing, specimen collection, and reporting results. Page Number: 735 Question 26 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

A client is having a timed urine collection done. The unlicensed assistive personnel does not save one specimen. 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. Correct Answer: 4 Rationale 1: The test cannot be continued, and it should not be documented that one specimen is missing. Rationale 2: The test is not to be ended immediately, and the specimen should not be sent to the laboratory. The test is not complete. Rationale 3: The nurse should not document that the test cannot be completed. It needs to be restarted. Rationale 4: If the client or staff forgets and discards the client’s urine during a timed collection, the procedure must be restarted from the beginning. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Compare and contrast the different types of urine specimens. MNL Learning Outcome: 4.5.3. Correlate the information related to collection of stool and urine specimens to client care. Page Number: 735 Question 27 Type: MCMA The nurse is caring for a client who has just had a lumbar puncture. What should the nurse document about this client’s procedure? Standard Text: Select all that apply. 1. Date and time performed Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 1, 2, 4, 5 Rationale 1: When documenting after a lumbar procedure, the nurse should include the date and time the procedure was performed. Rationale 2: When documenting after a lumbar procedure, the nurse should include the physician’s name. Rationale 3: The nurse does not need to assess the client’s ability to void after the procedure, as the lumbar puncture is done through the spinal column and not the abdominal region. Rationale 4: When documenting after a lumbar procedure, the nurse should include the color, character, and amount of cerebrospinal fluid withdrawn. Rationale 5: When documenting after a lumbar procedure, the nurse should include the client’s status after the procedure. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Describe the nurse’s role in caring for clients undergoing aspiration/biopsy procedures. MNL Learning Outcome: 4.5.1. Explain the nurse's role related to diagnostic testing, specimen collection, and reporting results. Page Number: 744 Question 28 Type: MCMA A client has just completed a bone marrow biopsy. What should the nurse document about the client at this time? Standard Text: Select all that apply. 1. Client’s tolerance of the procedure Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Bowel sounds 3. The site for bleeding 4. Status of deep tendon reflexes 5. Presence of pain and any pain medication received Correct Answer: 1, 3, 5 Rationale 1: The nurse should document how well the client tolerated the procedure, as it can cause considerable discomfort. Rationale 2: Bowel sounds are not a part of the assessment after a bone marrow biopsy. Rationale 3: The nurse should document the bone marrow biopsy site for bleeding, as this can occur. Rationale 4: Deep tendon reflexes are not part of the assessment after a bone marrow biopsy. Rationale 5: The nurse should document whether the client is experiencing any pain, and whether any pain medication was provided. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Describe the nurse’s role in caring for clients undergoing aspiration/biopsy procedures. 13. Demonstrate appropriate documentation and reporting of diagnostic testing information. MNL Learning Outcome: 4.5.1. Explain the nurse's role related to diagnostic testing, specimen collection, and reporting results. Page Number: 745 Question 29 Type: MCMA A client is scheduled for a bronchoscopy. What should the nurse instruct the client about this procedure? Standard Text: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1, 3, 5 Rationale 1: A bronchoscopy is a sterile procedure. Tissue samples may also be taken for biopsy. Rationale 2: Eating can resume after the local anesthetic wears off. Rationale 3: A local anesthetic is sprayed on the client’s pharynx to prevent gagging. Rationale 4: Bed rest for 8 hours after the procedure is not necessary. Rationale 5: Informed consent is required for this procedure. Global Rationale: 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. Eating can resume after the local anesthetic wears off. Bed rest for 8 hours after the procedure is not necessary. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Describe the nurse’s role in caring for clients undergoing aspiration/biopsy procedures. MNL Learning Outcome: 4.5.1. Explain the nurse's role related to diagnostic testing, specimen collection, and reporting results. Page Number: 738 Question 30 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 4, 5 Rationale 1: When collecting a urine specimen from a client with an indwelling urinary catheter, the nurse should withdraw 30 mL of urine for a routine urinalysis. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Catheter care is not required before obtaining the specimen. Rationale 3: Sterile gloves are not required to obtain the urine specimen. Rationale 4: When collecting a urine specimen from a client with an indwelling urinary catheter, the nurse should send the specimen immediately or refrigerate it for later pickup. Rationale 5: When collecting a urine specimen from a client with an indwelling urinary catheter, the nurse should clamp the drainage tubing for 30 minutes if there is no urine in the catheter. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Compare and contrast the different types of urine specimens. MNL Learning Outcome: 4.5.3. Correlate the information related to collection of stool and urine specimens to client care. Page Number: 735

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 35 Question 1 Type: MCSA 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. Correct Answer: 1 Rationale 1: Most health care agencies maintain a list of high-alert medications, including controlled substances, which require the verification of two registered nurses. Rationale 2: Although the pharmacy is a valuable resource for nurses, the "high-alert" designation does not require pharmacy intervention. Rationale 3: High-alert medications do not require the presence of a physician for administration. Rationale 4: High-alert medications do not require the presence of a nursing supervisor for administration. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Ethical Comportment; Commit to a generative safety culture Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Define selected terms related to the administration of medications. MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 791 Question 2 Type: MCSA Why is the nurse writing out the name of the drug morphine sulfate instead of using the abbreviation MS? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. The hospital has placed MS on its list of do-not-use abbreviations. 2. The Joint Commission 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. Correct Answer: 3 Rationale 1: Although the hospital has probably placed MS on its list of do-not-use abbreviations, The Joint Commission does require that the abbreviation not be used. Rationale 2: The Joint Commission does require that the abbreviation not be used; however ,client safety is the primary reason. Rationale 3: The best answer is that using the abbreviation MS puts the client at risk of medication error. Rationale 4: Although some computerized charting systems will not accept the abbreviation MS, the best reason is for client safety. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Ethical Comportment; Commit to a generative safety culture Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe legal aspects of administering medications. MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 760 Question 3 Type: MCSA The hospitalized client has an order for Tylenol 325 mg 2 tablets every 4 hours prn temperature over 101°F. The client complains of a headache. Can the nurse legally administer Tylenol to treat the headache? 1. Yes, as Tylenol 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 2 Rationale 1: 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 Tylenol to treat the client's headache. Rationale 2: 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 Tylenol to treat the client's headache. Rationale 3: The nurse should never document false information in regard to medication administration. Rationale 4: The fact that this is an over-the-counter medication and is used both for fever and headache is not pertinent to the nurse's decision. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Ethical Comportment; Commit to a generative safety culture Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe legal aspects of administering medications. MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 773 Question 4 Type: MCSA 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. Correct Answer: 3 Rationale 1: Administering the dose as ordered may harm the client. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: The fact that previous nurses gave the medication as ordered does not make it the correct action. Rationale 3: 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. Rationale 4: The nurse cannot change the amount of medication to give without collaborating with the prescriber. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Ethical Comportment; Commit to a generative safety culture Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. State the “rights” to accurate medication administration. MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 769 Question 5 Type: FIB The client has required 2 sublingual nitroglycerine tablets that are gr 1/150 per tablet. How many mg of nitroglycerine did the client receive? Standard Text: Record your answer. Correct Answer: 0.8 mg or 800 mcg Rationale: The client received gr 2/150 of NTG. There are 60 mg in 1 grain. To convert, multiply 2/150 x 60 = 120/150 = 0.8 mg or 800 mcg. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9. Describe four formulas for calculating drug dosages. MNL Learning Outcome: 4.14.2. Utilize the four methods to calculate drug dosages accurately. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 763 Question 6 Type: MCSA 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. Correct Answer: 3 Rationale 1: This dose should be compared to the standard dose listed in a reputable drug reference book. Rationale 2: Although prescribers and pharmacists are also responsible to figure the correct dose, the nurse who administers the dose is the last possible person to prevent a medication error. The nurse has the final responsibility to ensure that the dose ordered and dose supplied are correct for the client. Rationale 3: 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. Rationale 4: This dose may be more or less than one-half the adult dosage. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe four formulas for calculating drug dosages. MNL Learning Outcome: 4.14.2. Utilize the four methods to calculate drug dosages accurately. Page Number: 764 Question 7 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: This nurse should employ a second method to verify the client's identification. Rationale 2: The MAR will be initialed after the medication has been given. Rationale 3: 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. Rationale 4: Once the nurse has verified client identification, the nurse should educate the client regarding the medication to be given. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Ethical Comportment; Commit to a generative safety culture Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. List six essential steps to follow when administering medication. MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 771 Question 8 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 3 Rationale 1: Medication should not be placed in essential foods such as orange juice or milk, as the child may develop an aversion to the food related to the taste of the medication. Rationale 2: Being untruthful about any interventions may cause the client to lose trust in the nurse. Rationale 3: 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. Rationale 4: Having a second nurse hold the client down to administer the medication is an unnecessary use of force and will frighten the child. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. List six essential steps to follow when administering medication. MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 774 Question 9 Type: MCSA The nurse is caring for a team of four clients who are seriously ill. One of the clients 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. Correct Answer: 4 Rationale 1: The UAP does not have the skills or legal responsibility to assess the client. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: It is the nurse's responsibility to teach the client or family about the medications. Rationale 3: The nurse should not expect that the UAP can determine from the drug reference book what drug actions and possible side effects are pertinent to this client. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Ethical Comportment; Commit to a generative safety culture Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21. Recognize when it is appropriate to delegate medication administration to unlicensed assistive personnel. MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 775 Question 10 Type: MCSA 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. Correct Answer: 4 Rationale 1: Mixing medications together may result in a chemical reaction that occludes the tube. Rationale 2: Mixing medications together may result in a chemical reaction that occludes the tube. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Mixing medications together may result in a chemical reaction that occludes the tube. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14. Outline the steps required for nasogastric and gastrostomy tube medication administration. MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 780 Question 11 Type: MCSA 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. Correct Answer: 2 Rationale 1: A filter needle is used to draw medication from an ampule. Rationale 2: The nurse uses a filter needle to draw medication up from an ampule to remove any possible shards of glass from the liquid. Rationale 3: If the filter needle was used to inject the client, the trapped shards of glass would be injected into the muscle. Rationale 4: The nurse uses a filter needle to draw medication up from an ampule to remove any possible shards of glass from the liquid. The filter needle is then changed to a regular needle prior to administering the liquid to the client. If the filter needle was used to inject the client, the trapped shards of glass would be injected into the muscle. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16. Verbalize the steps used in: a. Preparing medications from ampules. MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 785 Question 12 Type: MCSA 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. Correct Answer: 3 Rationale 1: Giving two separate injections, no matter how the medication is divided, should be avoided if possible. Rationale 2: There is no need for the nurse to consult the pharmacy for this standard technique. Rationale 3: 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. Rationale 4: Giving two separate injections, no matter how the medication is divided, should be avoided if possible. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16. Verbalize the steps used in: c. Mixing medications in one syringe. Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 791 Question 13 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: There is no need to withdraw the needle and start again. Rationale 3: Inserting the needle further into the skin and at a deeper angle would result in delivery of the fluid into the subcutaneous tissues. Rationale 4: The needle is inserted with the bevel up. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 18. Verbalize the steps used in administering parenteral medications by the following routes: a. Intradermal. Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 792 Question 14 Type: MCSA 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. Correct Answer: 2 Rationale 1: Massage is contraindicated for most medications because it alters the delivery rate from the tissues. Rationale 2: 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. Rationale 3: The needle should be removed slowly and smoothly to minimize pain for the client. Rationale 4: Bleeding rarely occurs after subcutaneous injection, but short application of manual pressure (1–3 minutes) should cause bleeding to stop. There is no need for a pressure dressing for 15 minutes. Subcutaneous injections do not result in bleb formation. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18. Verbalize the steps used in administering parenteral medications by the following routes: b. Subcutaneous. Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 796 Question 15 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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 Correct Answer: 3 Rationale 1: The same site should not be used because this is not enough time for tissue recovery. Rationale 2: The deltoid site will not accept 2.5 mL of medication. Rationale 3: 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. Rationale 4: The rectus femoris site is generally used only for self-injection of medication and is a painful site for medication administration. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17. Identify the sites used for: c. Intramuscular injection. Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 798 Question 16 Type: MCSA 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 1/4 inch and inject the medication. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Inject the medication as planned. 3. Notify the physician immediately. 4. Discard the medication and start over. Correct Answer: 4 Rationale 1: Simply pulling out the needle 1/4 inch does not guarantee that the needle point is not in a vessel, and the presence of blood in the syringe prevents checking the new site. Rationale 2: Blood return in the syringe barrel after aspiration indicates a strong probability that the needle tip is in a blood vessel. Injection of medication would then be intravenous, not intramuscular. Rationale 3: There is no need to notify the physician of this event. Rationale 4: The nurse should discard the medication and start over with new medication and a new syringe. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18. Verbalize the steps used in administering parenteral medications by the following routes: c. Intramuscular Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 801 Question 17 Type: MCSA The nurse is adding medication to an existing intravenous setup. Which nursing action is indicated? 1. Close the infusion clamp. 2. Ensure that the IV bag is full prior to adding medication. 3. Do not remove the IV bag from the pole. 4. Briskly shake the IV bag after injecting the medication. Correct Answer: 1 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: The nurse must close the infusion clamp prior to adding medication to an existing IV bag. Closing the clamp prevents the medication from inadvertently going directly down the tubing and into the client. Rationale 2: Medication is frequently added to IV bags that are less than completely full. The nurse must make a determination of whether the bag contains enough fluid to dilute the medication to the desired strength. Rationale 3: The bag can be taken from the IV pole for mixing. Rationale 4: The bag should receive a gentle rotation, not brisk shaking, to mix the medication and the fluid. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19. Verbalize the steps used in: a. Adding medications to intravenous fluid containers. Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 805 Question 18 Type: MCSA 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 1/8 inch and attempt aspiration. Correct Answer: 2 Rationale 1: Simple lack of blood upon aspiration does not indicate infiltration, so there is no need to discontinue the site. Rationale 2: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Often the reason for absence of blood return is that the vessel has collapsed around the catheter from the pressure of aspiration. Increasing the pressure will not increase the likelihood of blood return. Rationale 4: Pulling the intravenous catheter out 1/8 inch will not increase the likelihood of blood return and may make the site more unstable. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19. Verbalize the steps used in: b. Administering intravenous medications using IV push. Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 809 Question 19 Type: MCSA 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. Correct Answer: 1 Rationale 1: The nurse should administer the eye ointment as ordered, as the first bead of ointment is considered contaminated and should always be discarded. Rationale 2: There is no need to notify the pharmacy for a new tube of ointment. Rationale 3: There is no need to have the wastage witnessed by another nurse. Rationale 4: It is necessary to discard only the first bead of ointment, not an entire line. Global Rationale: Cognitive Level: Applying Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20. Verbalize the steps used in administering the following topical medications: b. Ophthalmic Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 814 Question 20 Type: MCSA 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. Correct Answer: 4 Rationale 1: After age 3, the pinna of the ear should be pulled up and back to straighten the ear canal. Rationale 2: The tip of the eardrop applicator should not be placed into the ear canal, but should be held just above the canal so that the drops can fall onto the side of the canal. Rationale 3: Eardrops should be warmed prior to administration, not cooled. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 20. Verbalize the steps used in administering the following topical medications: c. Otic Outcome: 4.14.4. Implement the nursing process in the administration of medications. Page Number: 816 Question 21 Type: MCSA 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. Correct Answer: 4 Rationale 1: If hair is a problem in keeping the patch on, choose a less hairy site for application or clip (do not shave) the hair. Rationale 2: Placement of a heating pad is contraindicated, as the heat could increase circulation and the rate of absorption. Rationale 3: Avoid touching the adhesive edges of the patch prior to placing it on the skin. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20. Verbalize the steps used in administering the following topical medications: a. Dermatologic Outcome: 4.14.4. Implement the nursing process in the administration of medications. Page Number: 812 Question 22 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: If a regular syringe is used to draw up the medication, the needle should be discarded. A syringe with a needle might also indicate that the medication is to be given parenterally and cause a medication route error. Rationale 2: If medications are measured in a cup, the correct measurement is at the bottom of the meniscus. Rationale 3: 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. Rationale 4: Medication might be diluted after measuring, but dilution before measuring would impact the dosage of the medication. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Verbalize the steps used in administering oral medications safely. Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 777 Question 23 Type: MCSA A client diagnosed with diabetes asks the nurse about reusing insulin syringes. Assessment reveals that the client has poor personal hygiene and difficulty with fine motor skills. The nurse also knows the client has financial difficulties. What instruction should the nurse give this client? 1. "The American Diabetes Association advises that syringes are for single use only." 2. "In order to save money, I advise you to reuse syringes up to three times or until the needle feels dull." Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. "Only people who practice good personal hygiene can reuse syringes." 4. "All clients are different, but I advise you to use a new syringe for each injection." Correct Answer: 4 Rationale 1: This is not true; the American Diabetes Association indicates that syringes can be reused. Rationale 2: This client does not meet the criteria for suggesting the reuse of syringes. Rationale 3: The nurse should not directly confront the client with the statement about personal hygiene, as that would damage the nurse–client relationship. Rationale 4: Although the American Diabetes Association does indicate that syringes can be reused, that suggestion is not made to people who have poor personal hygiene, acute concurrent illness, open wounds on the hands, or decreased resistance to infection. In this case, the nurse has assessed that this client has poor hygiene and has difficulty with fine motor skills. The best answer is to suggest that this client use a new syringe for each injection. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17. Identify the sites used for: b. Subcutaneous injection. Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 796 Question 24 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 2 Rationale 1: The old method of floating the canister in water is not accurate, as there may be propellant left in the canister after the medication is all dispensed. Rationale 2: 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. Rationale 3: Being able to smell the medication is not an indication of the amount left in the canister. Rationale 4: Waiting until there is lack of maximum effect from the medication may put the client at risk for respirator illness exacerbation. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20. Verbalize the steps used in administering the following topical medications: g. Respiratory inhalation Outcome: 4.14.4. Implement the nursing process in the administration of medications. Page Number: 822 Question 25 Type: MCSA The nurse is providing discharge teaching for a client who is being dismissed with prescriptions for 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. Correct Answer: 2 Rationale 1: The bronchodilator should be used first in order to open the airways so the corticosteroid medication can move deeply into the lungs. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: 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. Rationale 3: The bronchodilator should be used first in order to open the airways so the corticosteroid medication can move deeply into the lungs. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20. Verbalize the steps used in administering the following topical medications: g. Respiratory inhalation Outcome: 4.14.4. Implement the nursing process in the administration of medications. Page Number: 823 Question 26 Type: MCSA 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. Correct Answer: 2 Rationale 1: This is important but not the greatest priority. Rationale 2: 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. Rationale 3: This is important but not the greatest priority. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: This is important but not the greatest priority. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Describe actions of drugs on the body. Outcome: 4.14.1. Consider how drugs act on the body and how the body acts on drugs in the care of the client. Page Number: 752 Question 27 Type: MCSA A client who has been prescribed a narcotic for chronic back pain is demonstrating signs of withdrawal. The nurse identifies these symptoms as being 1. physical dependence. 2. psychological dependence. 3. plateau. 4. drug allergy. Correct Answer: 1 Rationale 1: 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. Rationale 2: Psychological dependence is emotional reliance on a drug to maintain a sense of well-being, accompanied by feelings of need or cravings for that drug. There are varying degrees of psychological dependence, ranging from mild desire to craving and compulsive use of the drug. Rationale 3: Plateau is a maintained concentration of a drug in the plasma during a series of scheduled doses. Rationale 4: A drug allergy is an immunologic reaction to a drug. When a client is first exposed to a foreign substance, the body might react by producing antibodies. A client can react to a drug in the same manner as an antigen and thus develop symptoms of an allergic reaction. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe actions of drugs on the body. Outcome: 4.14.1. Consider how drugs act on the body and how the body acts on drugs in the care of the client. Page Number: 754 Question 28 Type: MCSA 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 Correct Answer: 3 Rationale 1: Absorption is the process by which a drug passes into the bloodstream. Rationale 2: Distribution is the transportation of a drug from its site of absorption to its site of action. Rationale 3: 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. Rationale 4: Excretion is the process by which metabolites and drugs are eliminated from the body. Most drug metabolites are eliminated by the kidneys via the urine. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe actions of drugs on the body. 4. Identify factors affecting medication action. Outcome: 4.14.1. Consider how drugs act on the body and how the body acts on drugs in the care of the client. Page Number: 755 Question 29 Type: MCSA 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 Correct Answer: 4 Rationale 1: Peak plasma level is the highest plasma level achieved by a single dose when the elimination rate of the drug equals the absorption rate. Rationale 2: Drug half-life is the time required for the elimination process to reduce the concentration of the drug to one-half of what it was at initial administration. Rationale 3: Onset of action is the time after administration when the body initially responds to the drug. Rationale 4: Plateau is when a concentration of a drug is maintained in the client’s plasma through a series of scheduled doses. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe actions of drugs on the body. 4. Identify factors affecting medication action. Outcome: 4.14.1. Consider how drugs act on the body and how the body acts on drugs in the care of the client. Page Number: 755 Question 30 Type: MCMA 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? Standard Text: Select all that apply. 1. Occupation 2. Hormones 3. Fat amount 4. Physical activity status 5. Fluid level Correct Answer: 2, 3, 5 Rationale 1: Differences in the way men and women respond to drugs are not chiefly related to occupation. Rationale 2: Differences in the way men and women respond to drugs are chiefly related to hormone levels. Rationale 3: Differences in the way men and women respond to drugs are chiefly related to the distribution of body fat. Rationale 4: Differences in the way men and women respond to drugs are not chiefly related to physical activity status. Rationale 5: Differences in the way men and women respond to drugs are chiefly related to the distribution of body fluid. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify factors affecting medication action. Outcome: 4.14.1. Consider how drugs act on the body and how the body acts on drugs in the care of the client. Page Number: 757 Question 31 Type: MCMA 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 Standard Text: Select all that apply. 1. nausea. 2. anxiety. 3. vomiting. 4. pain from cuts and abrasions. 5. irritated gastric mucosa. Correct Answer: 1, 3, 5 Rationale 1: Oral medications are inappropriate for a client who is nauseated. Rationale 2: Oral medications are appropriate for the client experiencing anxiety. Rationale 3: Oral medications are inappropriate for a client who is vomiting Rationale 4: Oral medications are appropriate for the client experiencing pain from cuts and abrasions. Rationale 5: Oral medications are inappropriate for a client with irritated gastric mucosa. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe actions of drugs on the body. 5. Describe various routes of medication administration. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Outcome: 4.14.1. Consider how drugs act on the body and how the body acts on drugs in the care of the client. Page Number: 758 Question 32 Type: MCMA 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? Standard Text: Select all that apply. 1. Subcutaneous injection 2. Intramuscular injection 3. The oral route 4. Intradermal injection 5. Intravenous infusion Correct Answer: 1, 2, 4, 5 Rationale 1: Subcutaneous injection is considered a parenteral route of administration. Rationale 2: Intramuscular injection is considered a parenteral route of administration. Rationale 3: The oral route is not a parenteral route of administration. Rationale 4: Intradermal injection is considered a parenteral route of administration. Rationale 5: Intravenous injection is considered a parenteral route of administration. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15. Identify equipment required for parenteral medications.. Outcome: 4.14.4. Implement the nursing process in the administration of medications. Page Number: 759 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 33 Type: MCMA The nurse is reviewing a new medication order for a client, and determines that the order is incomplete when which element is missing? Standard Text: 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 Correct Answer: 3, 4, 5 Rationale 1: The client’s address is part of a prescription but not of a medication order. Rationale 2: Dispensing instructions for the pharmacist are a part of a prescription but not of a medication order. Rationale 3: The name of the medication is an essential part of the medication order. Rationale 4: The dosage is an essential part of the medication order. Rationale 5: The route of administration is an essential part of the medication order. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Identify essential parts of a medication order. Outcome: 4.14.4. Implement the nursing process in the administration of medications. Page Number: 761 Question 34 Type: MCMA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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? Standard Text: 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 Correct Answer: 1, 4, 5 Rationale 1: The Rx symbol is to be written on a prescription. Rationale 2: The client’s diagnosis is not part of a prescription. Rationale 3: The client’s Social Security number is not part of a prescription. Rationale 4: The dispensing instructions for the pharmacist are part of a prescription. Rationale 5: The number of refills must be provided on a prescription. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Identify essential parts of a medication order. Outcome: 4.14.4. Implement the nursing process in the administration of medications. Page Number: 761 Question 35 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Standing 2. PRN 3. STAT 4. Single Correct Answer: 1 Rationale 1: A standing order might not have a termination date. This medication may be provided to the client indefinitely. Rationale 2: A PRN order or an as-needed order permits the nurse to provide the client with the medication when, in the nurse’s judgment, the client needs it. Rationale 3: A STAT order indicates that the medication is to be provided immediately and only once. Rationale 4: A single order or a one-time order indicates that the medication is to be provided only once. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. List examples of various types of medication orders. Outcome: 4.14.4. Implement the nursing process in the administration of medications. Page Number: 760 Question 36 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 3 Rationale 1: A standing order might not have a termination date. This medication may be provided to the client indefinitely. Rationale 2: A PRN order or an as-needed order permits the nurse to provide the client with the medication when, in the nurse’s judgment, the client needs it. Rationale 3: A STAT order indicates that the medication is to be provided immediately and only once. Rationale 4: A single order or a one-time order indicates that the medication is to be provided only once. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. List examples of various types of medication orders. Outcome: 4.14.4. Implement the nursing process in the administration of medications. Page Number: 760 Question 37 Type: MCSA 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 at home? 1. 2 teaspoons 2. 1 teaspoon 3. 2 tablespoons 4. 1 tablespoon Correct Answer: 4 Rationale 1: In the household measurement system, 2 teaspoons is equivalent to 8–10 ml in the metric system. Rationale 2: In the household measurement system, 1 teaspoon is equivalent to 4–5 ml in the metric system. Rationale 3: In the household measurement system, 2 tablespoons is equivalent to 30 ml in the metric system. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: In the metric system, 15 ml is equal to 1 tablespoon in the household measurement system. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe four formulas for calculating drug dosages. Outcome: 4.14.2. Utilize the four methods to calculate drug dosages accurately. Page Number: 764 Question 38 Type: MCMA 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? Standard Text: Select all that apply. 1. Number of ounces 2. Number of drams of the solution 3. Number of milligrams of the medication 4. Number of grains of the medication 5. Number of milliliters of the solution Correct Answer: 3, 5 Rationale 1: Ounces are a measurement in the household system. Rationale 2: Drams are a measurement in the apothecaries’ system. Rationale 3: Milligrams are a measurement in the metric system. Rationale 4: Grains are a measurement in the apothecaries’ system. Rationale 5: Milliliters are a measurement in the metric system. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. State systems of measurement that are used in the administration of medications. Outcome: 4.14.4. Implement the nursing process in the administration of medications. Page Number: 762 Question 39 Type: MCSA 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. Correct Answer: 1 Rationale 1: After identifying the client, the nurse should next instruct the client as to the intended action of the medication. Rationale 2: The medication is administered after the client has been instructed about the medication. Rationale 3: Documentation occurs after the medication has been given. Rationale 4: The medication is evaluated for effectiveness after a period of time has elapsed after administering the medication. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. List six essential steps to follow when administering medication. 11. State the “rights” to accurate medication administration. Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 772 Question 40 Type: MCSA 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 Correct Answer: 2 Rationale 1: The nurse would not need to assess blood pressure, pulse, or laboratory values to determine the right medication. Rationale 2: 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. Rationale 3: The nurse would not need to assess blood pressure, pulse, or laboratory values to determine the right route. Rationale 4: The nurse would not need to assess blood pressure, pulse, or laboratory values to determine the right dose. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 10. List six essential steps to follow when administering medication. 11. State the “rights” to accurate medication administration. Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 773 Question 41 Type: MCMA The nurse is preparing medications for a client. What should the nurse do to ensure that the correct medication is provided to the client? Standard Text: 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. Correct Answer: 1, 2, 3, 4 Rationale 1: The right client is one of the rights of medication administration. Rationale 2: The right medication is one of the rights of medication administration. Rationale 3: The right dose is one of the rights of medication administration. Rationale 4: The right route is one of the rights of medication administration. Rationale 5: The right diagnosis is not one of the rights of medication administration. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. List six essential steps to follow when administering medication. 11. State the “rights” to accurate medication administration. Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 773 Question 42 Type: MCSA 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 Correct Answer: 2 Rationale 1: Altered memory will not cause an adverse drug effect. Rationale 2: 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. Rationale 3: Decreased manual dexterity will not cause an adverse drug effect. Rationale 4: Decreased visual acuity will not cause an adverse drug effect. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12. Describe the physiological changes in older adults that alter medication administration and effectiveness. Outcome: 4.14.1. Consider how drugs act on the body and how the body acts on drugs in the care of the client. Page Number: 774 Question 43 Type: MCMA The nurse is concerned that an older client will have difficulty self-administering medications. What did the nurse assess that caused this concern? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Standard Text: 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 Correct Answer: 2, 3, 4 Rationale 1: Eating several servings of fruits and vegetables each day will not influence the older client’s ability to self-administer medications. Rationale 2: Altered memory is one physiological change associated with aging that influences medication administration. Rationale 3: Decreased visual acuity is one physiological change associated with aging that influences medication administration. Rationale 4: Decreased manual dexterity is one physiological change associated with aging that influences medication administration. Rationale 5: Limiting red meat in the diet will not influence the older client’s ability to self-administer medications. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12. Describe the physiological changes in older adults that alter medication administration and effectiveness. Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 774 Question 44 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The nurse is preparing to administer a subcutaneous injection to a client. When selecting the needle, the nurse should choose one with a 1. small gauge number. 2. long shaft. 3. long bevel. 4. short bevel. Correct Answer: 3 Rationale 1: Needles with small gauge numbers are used for viscous medications. For subcutaneous injections, a larger gauge number should be used. Rationale 2: Long shafts are used for intramuscular injections. Rationale 3: Longer bevels provide the sharpest needles, and cause less discomfort. They are commonly used for subcutaneous and intramuscular injections. Rationale 4: Short bevels are used for intradermal and IV injections because a long bevel can become occluded if it rests against the side of a blood vessel. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. b. Subcutaneous Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 783 Question 45 Type: MCSA An adult client is prescribed the hepatitis B vaccination. The nurse will administer this medication through which site? 1. Dorsogluteal 2. Rectus femoris Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Vastus lateralis 4. Deltoid Correct Answer: 4 Rationale 1: Using the dorsogluteal site can lead to nerve damage, and is not recommended as a site for intramuscular injections. Rationale 2: The rectus femoris muscle is used only occasionally for intramuscular injections because it is painful. Rationale 3: The vastus lateralis muscle is recommended for infants younger than 1 year of age, although it can be used for clients of all ages. Rationale 4: 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 hepatitis B vaccine in adults. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17. Identify the sites used for: c. Intramuscular injection. Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 800 Question 46 Type: MCMA The nurse has provided an otic medication to a client. What should the nurse document about this medication’s administration? Standard Text: Select all that apply. 1. Name of the drug 2. The strength 3. The appetite of the client 4. The number of drops Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

5. The response of the client Correct Answer: 1, 2, 4, 5 Rationale 1: When documenting after providing an otic medication, the nurse should include the name of the drug. Rationale 2: When documenting after providing an otic medication, the nurse should include the strength. Rationale 3: When documenting after providing an otic medication, the nurse does not need to include the client’s appetite. Rationale 4: When documenting after providing an otic medication, the nurse should include the number of drops. Rationale 5: When documenting after providing an otic medication, the nurse should include the response of the client. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20. Verbalize the steps used in administering the following topical medications: c. Otic. 22. Demonstrate appropriate documentation and reporting of medication administration skills. Outcome: 4.14.4. Implement the nursing process in the administration of medications. Page Number: 817 Question 47 Type: MCSA 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. Correct Answer: 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: The nurse should not give the medication as prescribed, as the pharmacy has identified that the dose prescribed is outside of dosing limits. Rationale 2: If the primary care provider cannot be reached, document all attempts to contact the primary care provider and the reason for withholding the medication. Rationale 3: The nurse should not give the client one-half of the medication dose prescribed, as this is outside of the nurse’s licensure. Rationale 4: The nurse should not administer the medication through the oral route, as this might not be the best route for the medication and changing the route is outside of the nurse’s licensure. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe legal aspects of administering medications. Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 762 Question 48 Type: FIB A client weighing 220 lbs. is prescribed to receive 25 mg/kg of a medication, divided over 4 equal doses. How many mg of the medication should the nurse provide for each dose? Standard Text: Round to the nearest whole number. Correct Answer: 625 mg Global Rationale: 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 x 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. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe four formulas for calculating drug dosages. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Outcome: 4.14.2. Utilize the four methods to calculate drug dosages accurately. Page Number: 764, 765 Question 49 Type: MCMA 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? Standard Text: 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. Correct Answer: 2, 3, 4 Rationale 1: Never mix medications into foods that are essential, as the infant may associate the food with an unpleasant taste and refuse that food in the future. Never mix medications with formula. Rationale 2: Oral medications can be provided to a baby with the use of a nipple so that the baby sucks the medication. Rationale 3: Oral medications can be provided to a baby with a syringe or dropper. Rationale 4: 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. Rationale 5: The mother should never be instructed to provide the baby with twice the amount of medication that is prescribed. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe various routes of medication administration. Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients. Page Number: 779

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 36 Question 1 Type: MCSA The continuous quality improvement team is monitoring the nursing care of clean-contaminated wounds. Which operative wound would be excluded from this study? 1. Gastric resection 2. Uncomplicated abdominal hysterectomy 3. Breast biopsy 4. Lung resection Correct Answer: 3 Rationale 1: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered. These wounds show no evidence of infection. A gastric resection would be included in the study. Rationale 2: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered. These wounds show no evidence of infection. An uncomplicated abdominal hysterectomy would be included in the study. Rationale 3: 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. Rationale 4: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered. These wounds show no evidence of infection. A lung resection would be included in the study. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; apply health promotion/disease prevention strategies; apply health policy; Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify the main complications of and factors that affect wound healing. MNL Learning Outcome: 4.6.1. Recognize factors affecting skin integrity. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 829 Question 2 Type: MCSA 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 Correct Answer: 2 Rationale 1: Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered, but minimal to no spillage has occurred. Rationale 2: A surgical wound in which there is a large amount of spillage from the gastrointestinal tract is considered a contaminated wound. Rationale 3: A dirty wound is one that contains dead tissue or that has evidence of a clinical infection, such as purulent drainage. Rationale 4: An infected wound is one that contains dead tissue or that has evidence of a clinical infection, such as purulent drainage. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Identify the main complications of and factors that affect wound healing. MNL Learning Outcome: 4.6.1. Recognize factors affecting skin integrity. Page Number: 829 Question 3 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 1 Rationale 1: 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. Rationale 2: 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. Because these wounds are closed, there is no need for packing. Rationale 3: 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. Because these wounds are closed, there is no need for suturing. Rationale 4: 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. Because these wounds are closed, there is no need for surgery. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14. Identify physiological responses to and purposes of heat and cold. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 829 Question 4 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area? 1. Reactive hyperemia 2. Stage I pressure ulcer 3. Stage II pressure ulcer 4. Stage III pressure ulcer Correct Answer: 1 Rationale 1: 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. Rationale 2: Stage I pressure ulcers are reddened areas that do not blanch with thumb pressure and that do not clear in the allotted amount of time. Rationale 3: Stage II pressure ulcers show partial-thickness skin loss and have the appearance of abrasions, blisters, or shallow craters. Rationale 4: Stage III pressure ulcers demonstrate full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Describe the four stages of pressure ulcer development. MNL Learning Outcome: 4.6.2. Compare the stages of pressure ulcer development and types of wound healing. Page Number: 830 Question 5 Type: MCSA The nurse assesses an open area over a client's greater trochanter that is approximately 10 cm in diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the center. Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: Undermining of adjacent tissues can occur in either a stage III or stage IV pressure ulcer. Rationale 2: Extension into the subcutaneous tissue is a characteristic of a stage III pressure ulcer. Rationale 3: Stage IV ulcers demonstrate damage to muscle, bone, tendons, or the joint capsule. Rationale 4: If there is eschar present, the ulcer cannot be staged. Staging can occur only when the bottom of the ulcer can be seen and evaluated. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the four stages of pressure ulcer development. MNL Learning Outcome: 4.6.2. Compare the stages of pressure ulcer development and types of wound healing. Page Number: 831 Question 6 Type: MCSA The UAP 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 UAP 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 UAP to reevaluate the wound in 20 minutes. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 3 Rationale 1: The UAP is not educationally prepared to dress the wound. Rationale 2: At this point a consult with the wound care nurse is not required. Rationale 3: The nurse should go to the room, assess the wound, cleanse the wound, and apply a dressing. Rationale 4: The UAP is not educationally prepared to evaluate the wound. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Identify essential aspects of planning care to maintain skin integrity and promote wound healing. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 847 Question 7 Type: MCSA The newly hired nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to assess all new admissions. Before using this scale the nurse 1. should receive specific training. 2. must be certified. 3. is required to ask the client's permission. 4. has to obtain special assessment equipment. Correct Answer: 1 Rationale 1: The nurse should receive specific training in the use of the Braden scale in order for assessment to be accurate. Rationale 2: The nurse does not need to be certified in the use of the Braden Scale. Rationale 3: There is no specific permission required from the client. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: There is no special assessment equipment required. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Identify assessment data pertinent to skin integrity, pressure sites, and wounds. MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care. Page Number: 833 Question 8 Type: MCSA 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 ulcer development. 3. Trending would be more accurate if the same scale was used. 4. The scores indicate opposite risks for pressure ulcer development. Correct Answer: 3 Rationale 1: All of these scores indicate risk for development of a pressure ulcer, so some trending is possible, but it would be more accurate if the same scale was always used. Rationale 2: All of these scores indicate risk for development of a pressure ulcer, so some trending is possible, but it would be more accurate if the same scale was always used. Rationale 3: All of these scores indicate risk for development of a pressure ulcer, so some trending is possible, but it would be more accurate if the same scale was always used. Rationale 4: All of these scores indicate risk for development of a pressure ulcer, so some trending is possible, but it would be more accurate if the same scale was always used. Global Rationale: Cognitive Level: Analyzing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Identify assessment data pertinent to skin integrity, pressure sites, and wounds. MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care. Page Number: 832 Question 9 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Secondary healing involves wounds that cannot be approximated and that must "heal in." Rationale 3: Secondary healing involves wounds that cannot be approximated and that must "heal in." These wounds are at higher risk for infection, take longer to heal, and are more prone to scarring. Rationale 4: Wounds that are left open for 3 to 5 days allow edema or infection to resolve or exudate to drain and are then closed with sutures, staples, or adhesive skin closures heal by tertiary intention. This is also called delayed primary intention. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Differentiate primary and secondary wound healing. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 834 Question 10 Type: MCSA A client is prescribed steroid medication. When preparing discharge instructions, the nurse should include information about infection control because steroids cause 1. decreased oxygen supply to tissues. 2. suppression of the inflammatory process necessary for healing. 3. a decrease in the amount of nutrients such as glucose in the blood. 4. blood vessel constriction, which impairs waste product removal. Correct Answer: 2 Rationale 1: Steroids do not decrease oxygen supply to the tissues. Rationale 2: Steroids suppress the inflammatory process, which is a normal part of the healing process. Rationale 3: Steroids generally increase blood glucose. Rationale 4: Blood vessels are not constricted by steroids. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Describe nursing strategies to treat pressure ulcers, promote wound healing, and prevent complications of wound healing. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 835 Question 11 Type: MCSA On the fourth postoperative day, the client has a sudden coughing episode and tells the nurse 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. Correct Answer: 2 Rationale 1: Although notifying the surgeon is important, it is not the nurse’s first action. Rationale 2: Evisceration occurs when an abdominal wound opens and there is protrusion of the internal viscera through the incision. The nurse's first action should be to cover the area with a large saline-soaked dressing to keep the viscera moist. Rationale 3: Although positioning the client is important, it is not the nurse’s first action. Rationale 4: Nothing should be packed into this wound. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Describe nursing strategies to treat pressure ulcers, promote wound healing, and prevent complications of wound healing. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 836 Question 12 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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. Correct Answer: 2 Rationale 1: The stockings are worn day and night, so the client will not remove them for sleep. Rationale 2: The stockings should be removed to do this assessment. Rationale 3: The nurse is responsible for assessing the skin under the stockings and should not assume that the morning nurse's assessment is still accurate 12 hours later. Rationale 4: The stockings are worn day and night, so the client will not remove them for sleep. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify the main complications of and factors that affect wound healing. MNL Learning Outcome: 4.6.1. Recognize factors affecting skin integrity. Page Number: 837 Question 13 Type: MCSA Multiple severely injured clients have arrived in the emergency department. On rapid assessment, the nurse notes that a 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Add an additional dressing to the wound without removing the original. 4. Remove the dressing and replace it with a new sterile dressing. Correct Answer: 3 Rationale 1: A tourniquet should not be applied because of the risk of interrupting arterial flow to the tissues. Rationale 2: Removing the dressing and applying direct pressure would take too much time at this point. Rationale 3: In this scenario, where there are multiple clients in need of care and because this client is stable, the correct nursing action is to add an additional dressing to the wound without removing the original. Rationale 4: Removing the dressing and replacing the dressing with a new sterile dressing would take too much time at this point. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Identify essential aspects of planning care to maintain skin integrity and promote wound healing. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 847 Question 14 Type: MCSA 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 Correct Answer: 1 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Microorganisms that are most likely to be responsible for wound infections live in viable tissue such as granulation tissue. Rationale 2: Exudate contains a variety of components and will not give a good indication of what is causing the infection. Rationale 3: Pus contains a variety of components and will not give a good indication of what is causing the infection. Rationale 4: The skin at the edge of the wound contains skin organisms that may or may not be present in the wound itself. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Verbalize the steps used in: a. Obtaining wound specimens. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 841 Question 15 Type: MCSA The client has a documented stage III pressure ulcer on the right hip. What NANDA 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 Correct Answer: 3 Rationale 1:Although it is true that pressure ulcers result from altered tissue perfusion, the diagnosis problem statement Impaired Tissue Integrity is more specific. Rationale 2: Impaired Skin Integrity deals with the epidermal and dermal layers only and does not extend into the tissue. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Because a stage III pressure ulcer involves tissues, not just skin, this client has criteria for using the NANDA nursing diagnosis problem statement Impaired Tissue Integrity. Rationale 4: This client has already suffered injury, so this is not a Risk for Injury situation. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 9. Identify nursing diagnoses associated with impaired skin integrity. MNL Learning Outcome: 4.6.2. Compare the stages of pressure ulcer development and types of wound healing. Page Number: 842 Question 16 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: Air is drying to tissues and contains oxygen, so air circulation through the dressing is not desirable. Rationale 3: The dressings will not be changed that often. Rationale 4: Because the goal is to keep the wound bed moist, dressings should not wick exudates away. Global Rationale: Cognitive Level: Analyzing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12. Identify purposes of commonly used wound dressing materials and binders. MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care. Page Number: 846 Question 17 Type: MCSA The adult client is incontinent and wears incontinence briefs when using the wheelchair. An irritated rash has developed 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. Correct Answer: 3 Rationale 1: Cleansing should be done with a mild cleansing agent and warm water. Rationale 2: Petroleum-based creams are now thought to offer poor overall skin protection and to interfere with incontinence brief absorption. Rationale 3: The care should include wiping the skin with an alcohol-free barrier film agent after cleaning. Rationale 4: Keeping the client in bed to treat this area is not necessary and may lead to problems with immobility. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implement Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 2. Identify clients at risk for pressure ulcers. MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care. Page Number: 846 Question 18 Type: MCSA 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 degrees. 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. Correct Answer: 3 Rationale 1: The head of the client's bed should be kept at less than 30-degrees elevation as much as possible. Rationale 2: Baby powder should not be used because it causes abrasive grit damage to tissues. Rationale 3: The nurse should plan to use a turn sheet lifted by two staff members to move the client up in bed. Rationale 4: Cornstarch should not be used because it causes abrasive grit damage to tissues. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implement Learning Outcome: 10. Identify essential aspects of planning care to maintain skin integrity and promote wound healing. MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care. Page Number: 844 Question 19 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Upon assessing a pressure ulcer, 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 Correct Answer: 3 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8. Identify assessment data pertinent to skin integrity, pressure sites, and wounds.. MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care. Page Number: 846 Question 20 Type: MCSA The nurse has established an expected outcome that the client will demonstrate healing of a stage II pressure ulcer 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Unlicensed assistive personnel (UAP) followed a right side–back–left side–back turning schedule. Correct Answer: 4 Rationale 1: A rubber doughnut should not be used, so the fact that it was not delivered did not cause failure to meet the outcome. Rationale 2: An increase in serum albumin is a good finding and would increase wound healing, not decrease wound healing. Rationale 3: The use of alcohol interrupts healing, so it is good that nurses did not document its use. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 10. Identify essential aspects of planning care to maintain skin integrity and promote wound healing. MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care. Page Number: 861 Question 21 Type: MCSA The nurse has applied an aquathermia pad to a client's back. After 15 minutes of treatment, the client says that the pack no longer is warm and asks the nurse to increase the temperature. 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. The aquathermia pad should be replaced with a standard hot pack. Correct Answer: 3 Rationale 1: There is no evidence that this client has increased thermal tolerance. Rationale 2: There is no evidence that the rebound effect is occurring. Rationale 3: 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. Rationale 4: It is not necessary to replace the aquathermia pad with a hot pack. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 14. Identify physiological responses to and purposes of heat and cold. MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care. Page Number: 857 Question 22 Type: MCMA The nurse identifies an older client as being at risk for impaired skin integrity. What did the nurse assess in this client? Standard Text: Select all that apply. 1. Poor skin turgor. 2. Elevated body temperature. 3. Diminished pain sensation. 4. Thin epidermis. 5. Dry skin. Correct Answer: 1, 3, 4, 5 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: The older person is more prone to impaired skin integrity because of decreased strength and elasticity of the skin due to changes in the collagen fibers of the dermis. Rationale 2: Elevated body temperature does impact a person’s skin integrity, but this could occur at any age, and not just in an older client. Rationale 3: The older person is more prone to impaired skin integrity because of diminished pain perception due to a reduction in the number of cutaneous end organs responsible for the sensation of pressure and light touch. Rationale 4: The older person is more prone to impaired skin integrity because of generalized thinning of the epidermis. Rationale 5: The older person is more prone to impaired skin integrity because of increased dryness due to a decrease in the amount of oil produced by the sebaceous glands. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe factors affecting skin integrity. MNL Learning Outcome: 4.6.1. Recognize factors affecting skin integrity. Page Number: 837 Question 23 Type: MCMA 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? Standard Text: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 3, 4, 5 Rationale 1: In primary intention healing, there is minimal tissue loss. Rationale 2: In tertiary intention healing, the closure of the wound will occur within 5 days. Rationale 3: In secondary intention healing, the repair time is longer. Rationale 4: In secondary intention healing, the scarring is greater. Rationale 5: In secondary intention healing, the susceptibility to infection is greater. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Differentiate primary and secondary wound healing. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 834 Question 24 Type: MCSA A client sustained several wounds on the legs caused by a fall. On the day after the injuries, the wounds appear red and edematous. The nurse identifies the stage of healing of these wounds as being in which phase? 1. Inflammatory 2. Proliferative 3. Maturation 4. Remodeling Correct Answer: 1 Rationale 1: The inflammatory phase is initiated immediately after injury, and lasts 3–6 days. Rationale 2: The proliferative phase, the second phase in healing, extends from day 3 or 4 to about day 21 postinjury. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: The maturation phase begins on about day 21 and can extend 1 or 2 years after the injury. Rationale 4: Remodeling is another name for the maturation phase. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe the three phases of wound healing. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 835 Question 25 Type: MCSA 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 Correct Answer: 4 Rationale 1: Exudative is not a phase of wound healing. Rationale 2: Keloid formation does not occur during the proliferative phase of wound healing. Rationale 3: Keloid formation does not occur during the inflammatory phase of wound healing. Rationale 4: Dark, thick scars, or keloids, are caused by an abnormal amount of collagen during the maturation phase of healing. Global Rationale: Cognitive Level: Analyzing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe the three phases of wound healing. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 835 Question 26 Type: MCSA 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 Correct Answer: 1 Rationale 1: Purulent exudate is thick, and can vary in color, including green and yellow. Rationale 2: Serous drainage appears watery. Rationale 3: Sanguineous drainage is red because of the high number of red blood cells. Rationale 4: Serosanguinous drainage is watery with red blood cells. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Identify three major types of wound exudate; 16. Demonstrate appropriate documentation and reporting of skin integrity and wound care. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 836 Question 27 Type: MCSA 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 Correct Answer: 2 Rationale 1: Water and red blood cells would be considered serosanguinous drainage. Rationale 2: Purosanguinous drainage consists of purulent drainage and red blood cells. Rationale 3: Watery drainage would be considered serous drainage. Rationale 4: Pus would be considered purulent drainage. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Identify three major types of wound exudate. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 836 Question 28 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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. Correct Answer: 3 Rationale 1: Measuring the width of the wound does not provide the depth of the ulcer. Rationale 2: Measuring the length of the wound does not provide the depth of the ulcer. Rationale 3: 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. Rationale 4: Identifying locations on the face of a clock determines the presence of undermining or sinus tracts. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the four stages of pressure ulcer development. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 838 Question 29 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Risk for Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Risk for Infection Correct Answer: 2 Rationale 1: Impaired Skin Integrity is appropriate if the client has an alteration in the epidermis or dermis. Rationale 2: Because the client is experiencing episodes of incontinence without any current changes in skin integrity, the client is at Risk for Impaired Skin Integrity. Rationale 3: Impaired Tissue Integrity is appropriate if the client has damage to mucous membranes, integument, or subcutaneous tissues. Rationale 4: Risk for Infection would be appropriate if the client has severe skin impairment, the client is immunosuppressed, or the wound is caused by trauma. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 9. Identify nursing diagnoses associated with impaired skin integrity. MNL Learning Outcome: 4.6.4. Implement the nursing process in relation to all aspects of skin and wound care. Page Number: 842 Question 30 Type: MCMA A client has a yellow wound with purulent drainage. The nurse identifies what type of wound care as appropriate for this client’s wound? Standard Text: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Irrigate the wound. 5. Apply impregnated hydrogel. Correct Answer: 2, 4, 5 Rationale 1: Covering with a transparent film is not appropriate for a yellow wound. Rationale 2: A damp-to-damp normal saline dressing will remove nonviable tissue from the wound, and is appropriate for a yellow wound. Rationale 3: Covering with a dry dressing is not appropriate for a yellow wound. Rationale 4: Irrigating the wound is appropriate for a yellow wound. Rationale 5: Applying impregnated hydrogel is appropriate for a yellow wound. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12. Identify purposes of commonly used wound dressing materials and binders. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 846 Question 31 Type: SEQ The nurse is preparing to irrigate a client’s abdominal wound. In which order should the nurse perform this irrigation? Standard Text: Click and drag the options below to move them up or down. Choice 1. Dry the area around the wound. Choice 2. Insert the catheter into the wound until resistance is met. Choice 3. Remove and discard clean gloves. Choice 4. Apply clean gloves. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Choice 5. Irrigate until the solution flows clear. Choice 6. Select a syringe with a catheter attached or with an irrigating tip. Correct Answer: 4, 6, 2, 5, 1, 3 Rationale 1: After irrigating, the nurse should dry the area around the wound. Rationale 2: The nurse should then insert the catheter into the wound until resistance is met. Rationale 3: The nurse should then remove and discard the clean gloves. Rationale 4: The nurse first should apply clean gloves. Rationale 5: The nurse should then irrigate the wound until the solution flows clear. Rationale 6: The nurse should then select a syringe with a catheter attached or with an irrigating tip. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Verbalize the steps used in: b. Irrigating a wound. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 850 Question 32 Type: MCMA A client asks why a cold pack has been prescribed for an arm injury. What should the nurse explain to the client? Standard Text: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

5. The application of cold provides a calming, sedative effect. Correct Answer: 2, 3, 4 Rationale 1: The application of heat, not cold, dilates blood vessels. Rationale 2: The application of cold does constrict blood vessels. Rationale 3: The application of cold does decrease inflammation. Rationale 4: The application of cold does reduce localized pain. Rationale 5: The application of heat, not cold, provides a calming, sedative effect. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14. Identify physiological responses to and purposes of heat and cold. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 856 Question 33 Type: MCSA During morning care, unlicensed assistive personnel observe a client’s abdominal wound dressing become saturated with bright red blood. What should unlicensed assistive personnel 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. Correct Answer: 4 Rationale 1: UAP are not trained to reinforce dressings. This should not be done.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: UAP should not document that the bath was completed before communicating the dressing changes to the nurse. Rationale 3: UAP should not complete the bath first. Rationale 4: When delegating the care of the client to the UAP, the nurse should have provided direction to the UAP to report any changes to the nurse. UAP should report the dressing changes to the nurse immediately. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15. Recognize when it is appropriate to delegate aspects of skin and wound care to unlicensed assistive personnel. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 854 Question 34 Type: MCMA 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? Standard Text: Select all that apply. 1. Finger 2. Forearm 3. Upper leg 4. Lower leg 5. Upper arm Correct Answer: 2, 4 Rationale 1: Recurrent turns are used to cover distal parts of the body, for example, the end of a finger. Rationale 2: Spiral reverse turns are used to bandage cylindrical parts of the body that are not uniform in circumference, for example, the forearm. Rationale 3: Spiral turns are used to bandage parts of the body that are fairly uniform in circumference, for example, the upper leg. Rationale 4: Spiral reverse turns are used to bandage cylindrical parts of the body that are not uniform in circumference, for example, the lower leg. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: Spiral turns are used to bandage parts of the body that are fairly uniform in circumference, for example, the upper arm. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Verbalize the steps used in: c. Applying dressings. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 854 Question 35 Type: SEQ 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? Standard Text: Select all that apply. 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. Correct Answer: 4, 2, 5, 3, 1 Rationale 1: The last step is to apply tape or gauze to hold the pad in place. Rationale 2: Second, set the temperature according to the manufacturer’s instructions. Rationale 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. Rationale 4: First, the reservoir of the unit should be filled two-thirds full with water. Rationale 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. Global Rationale: Cognitive Level: Applying Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Verbalize the steps used in: d. Applying dry and moist heat and cold. MNL Learning Outcome: 4.6.3. Implement nursing strategies to treat wounds, promote wound healing, and prevent complications. Page Number: 858

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 37 Question 1 Type: MCSA 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 Correct Answer: 1 Rationale 1: The preoperative phase begins when the decision to have surgery is made and ends when the client is transferred to the operating table. Rationale 2: The intraoperative phase begins when the client is transferred to the operating table and ends when the client is admitted to the PACU. Rationale 3: The postoperative phase begins with the admission of the client to the postanesthesia area and ends when healing is complete. Rationale 4: There is not a specific perioperative phase of surgical care. Perioperative care consists of three phases: preoperative, intraoperative, and postoperative. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the phases of the perioperative period. MNL Learning Outcome: 4.7.1. Describe the surgical experience according to the perioperative phases. Page Number: 865 Question 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: The older client has decreased kidney function. Rationale 3: The older client has a decline in sensory functioning. Rationale 4: The older client may not be able to follow directions or understand instructions as well as a younger client. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify essential aspects of preoperative assessment. MNL Learning Outcome: 4.7.1. Describe the surgical experience according to the perioperative phases. Page Number: 866 Question 3 Type: MCMA The nurse is preparing to complete a physical assessment before surgery. Which assessments should the nurse obtain? Standard Text: Select all that apply. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Mini mental status 2. Assessment of hearing 3. Assessment of the respiratory system 4. Gastrointestinal assessment 5. Maintain NPO status Correct Answer: 1, 2, 3, 4 Rationale 1: 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. Rationale 2: Assessment of hearing helps guide the effectiveness of perioperative teaching. Rationale 3: 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. Rationale 4: The gastrointestinal status provides baseline data. Rationale 5: Maintaining NPO status is a nursing intervention. It is not included in the physical assessment. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify essential aspects of preoperative assessment. MNL Learning Outcome: 4.7.1. Describe the surgical experience according to the perioperative phases. Page Number: 868 Question 4 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. The role of the nurse during surgery 4. How to perform activities of daily living (ADLs) following surgery Correct Answer: 1 Rationale 1: The nurse should provide information related to what will happen to the client, when, and what the client will experience. Rationale 2: The nurse should clarify any misconceptions the client may have. Rationale 3: The nurse should also explain the roles of the client and support people in preoperative preparation, during the surgical procedure, and during the postoperative phase. Rationale 4: How to perform ADLs following surgery is not a part of preoperative teaching. Global Rationale: moving, leg exercises, and deep-breathing and coughing exercises. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.7.3. Implement appropriate nursing care during the preoperative and intraoperative phases. Page Number: 869 Question 5 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 2 Rationale 1: Although this diagnosis is appropriate for a client having surgery, the nurse should prioritize care according to the ABCs, or airway, breathing, and circulation, when planning care. Rationale 2: This is the priority nursing diagnosis for the client having surgery. The risk for aspiration would impact the client’s airway and breathing. Rationale 3: Although this diagnosis is appropriate for a client having surgery, the nurse should prioritize care according to the ABCs, or airway, breathing, and circulation, when planning care. Rationale 4: This nursing diagnosis is not appropriate during the intraoperative phase of care. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 4. Give examples of pertinent nursing diagnoses for surgical clients. MNL Learning Outcome: 4.7.3. Implement appropriate nursing care during the preoperative and intraoperative phases. Page Number: 879 Question 6 Type: MCSA The nurse is preparing the skin of a client for surgery. The nurse knows the purpose of the surgical skin preparation is to 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. Correct Answer: 3 Rationale 1: The preparation of the skin prior to surgery is not to sterilize the skin. Rationale 2: The purpose of a surgical skin preparation is not to assess the surgical site before surgery. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: The purpose of a surgical skin preparation is to reduce the risk of postoperative wound infection. Rationale 4: The purpose of a surgical skin preparation is not to clean any moles the client may have. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe essential aspects of preparing a client for surgery. MNL Learning Outcome: 4.7.3. Implement appropriate nursing care during the preoperative and intraoperative phases. Page Number: 880 Question 7 Type: MCSA 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 Correct Answer: 4 Rationale 1: Local anesthesia is used for minor surgical procedures such as suturing a small wound or performing a biopsy. Rationale 2: Spinal anesthesia is used for surgeries such as hernia repairs, rectal surgeries, or cesarean sections. Rationale 3: Epidural anesthesia is the introduction of an anesthetic into the epidural space. Rationale 4: Conscious sedation is often used for procedures such as endoscopies and incision and drainage of abscesses. Global Rationale: Cognitive Level: Applying Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Compare various types of anesthesia. MNL Learning Outcome: 4.7.2. Compare the types of anesthesia used for surgical procedures. Page Number: 879 Question 8 Type: MCSA 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 Correct Answer: 3 Rationale 1: In the supine position, the client could occlude the airway. Rationale 2: In the prone position, the client’s operative site may not be readily assessed. Rationale 3: The unconscious client should be positioned on the side, with the face slightly down. Rationale 4: A pillow under the head could cause the client’s airway to become obstructed. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Identify essential nursing assessments and interventions during the immediate postanesthetic phase. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 881 Question 9 Type: MCSA 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 Correct Answer: 1 Rationale 1: The nurse should assess the client's level of consciousness first. Rationale 2: The operative dressing is not assessed first. Rationale 3: Any operative drains are not assessed first. Rationale 4: The client’s skin color is not assessed first. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9. Identify essential nursing assessments and interventions during the immediate postanesthetic phase. MNL Learning Outcome: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 883 Question 10 Type: MCSA The nurse is caring for a client on the postoperative unit. Which nursing diagnosis is the priority for this client? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Self-Care Deficit 2. Disturbed Body Image 3. Ineffective Airway Clearance 4. Risk for Falls Correct Answer: 3 Rationale 1: After surgery, a client may have a self-care deficit; however, this is not the priority. Rationale 2: Depending upon the type of surgery, the client may have disturbed body image; however, this is not the priority. Rationale 3: When prioritizing, the nurse should remember the ABCs. Airway should always be the priority. Rationale 4: A client recovering from surgery may be at risk for falls; however, this is not the priority. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 4. Give examples of pertinent nursing diagnoses for surgical clients. MNL Learning Outcome: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 886 Question 11 Type: MCSA 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." Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1 Rationale 1: By increasing lung expansion and preventing accumulation of secretions, deep breathing helps prevent pneumonia and atelectasis. Rationale 2: These are nursing interventions and do not need to be prescribed by a physician. Rationale 3: Although this may be true, it does not instruct the client as to the purpose of the exercises. Rationale 4: Turning, deep breathing, and coughing exercises do not prevent thrombophlebitis. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 887 Question 12 Type: MCSA 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 Correct Answer: 2 Rationale 1: Absence of bleeding is an indication of healing. Rationale 2: If the wound becomes warm, red, and edematous, the nurse should suspect an infection and notify the physician. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Edges that are well approximated are an indication of healing. Rationale 4: Intact sutures are a sign of healing. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11. Identify potential postoperative complications and describe nursing interventions to prevent them. MNL Learning Outcome: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 891 Question 13 Type: MCSA 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 Correct Answer: 1 Rationale 1: A pregnancy test is done on all female clients of childbearing age. Rationale 2: An electroencephalogram is not considered a routine preoperative diagnostic test. Rationale 3: An electrocardiogram is done on all clients over 40 years of age and/or clients with preexisting cardiac conditions. Rationale 4: Pulmonary function tests are not routine preoperative diagnostic tests. Global Rationale: Cognitive Level: Analyzing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify nursing responsibilities in planning perioperative nursing care. MNL Learning Outcome: 4.7.3. Implement appropriate nursing care during the preoperative and intraoperative phases. Page Number: 869 Question 14 Type: MCSA 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. Correct Answer: 4 Rationale 1: Anticoagulant therapy must be prescribed by a physician. Rationale 2: Coughing every 2 hours will reduce the client’s risk of developing pneumonia or atelectasis. Rationale 3: Measuring intake and output every 2 hours assesses the client’s renal function. Rationale 4: Early ambulation, leg exercises, antiembolic stockings, SCDs, and adequate fluid intake are all interventions to reduce the risk for thrombophlebitis. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Identify potential postoperative complications and describe nursing interventions to prevent them. MNL Learning Outcome: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 884 Question 15 Type: MCSA A client is scheduled for a cholecystectomy. The nurse realizes that the purpose for this surgery is 1. diagnostic. 2. palliative. 3. ablative. 4. constructive. Correct Answer: 3 Rationale 1: A diagnostic surgery is done to confirm or establish a diagnosis. Rationale 2: Palliative surgery is done to relieve or reduce pain or symptoms of a disease. The surgery does not cure an illness. Rationale 3: When the purpose of surgery is ablative, the diseased body part is removed. Rationale 4: Constructive surgery restores function or appearance that has been lost or reduced. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Discuss various types of surgery according to the purpose, degree of urgency, and degree of risk. MNL Learning Outcome: 4.7.3. Implement appropriate nursing care during the preoperative and intraoperative phases. Page Number: 8669 Question 16 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCMA The nurse is obtaining preoperative assessment data. What should be included in this assessment? Standard Text: Select all that apply. 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Mother’s maiden name Correct Answer: 1, 2, 3, 4 Rationale 1: The client’s current health status should be obtained when completing a preoperative assessment. Rationale 2: The client’s allergies should be obtained when completing a preoperative assessment. Rationale 3: The client’s current medications should be obtained when completing a preoperative assessment. Rationale 4: The client’s mental status should be obtained when completing a preoperative assessment. Rationale 5: The mother’s maiden name is not a part of a preoperative assessment. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify essential aspects of preoperative assessment. MNL Learning Outcome: 4.7.3. Implement appropriate nursing care during the preoperative and intraoperative phases. Page Number: 868 Question 17 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 1 Rationale 1: Leg exercises may be implemented in the PACU to help prevent thrombophlebitis. Rationale 2: Coughing every 2 hours does not prevent thrombophlebitis. Rationale 3: Ambulation is not done in the postanesthesia care unit. Rationale 4: Oxygen does not prevent thrombophlebitis. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Identify potential postoperative complications and describe nursing interventions to prevent them. MNL Learning Outcome: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 871 Question 18 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Clean the stockings. Correct Answer: 2 Rationale 1: Measuring the calf is the first step of implementing antiembolic stockings. Rationale 2: Before applying antiembolic stockings, determine any potential or present circulatory problems and the surgeon’s orders involving the lower extremities. Rationale 3: Assessing the blood pressure is not done before applying antiembolic stockings. Rationale 4: The client should be given clean stockings, but the nurse should not have to wash stockings before using. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12. Verbalize the steps used in: b. Applying antiemboli stockings. MNL Learning Outcome: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 876 Question 19 Type: MCSA 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. Correct Answer: 3 Rationale 1: Water should not be inserted into the tube until placement is confirmed. Rationale 2: This is done to ensure placement; however, it is not the most reliable test. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Aspirating stomach contents and checking the acidity using a pH test strip is the most reliable test to confirm tube placement. Rationale 4: Connecting the tube to suction should not be done until tube placement has been confirmed. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12. Verbalize the steps used in: c. Managing gastrointestinal suction. MNL Learning Outcome: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 889 Question 20 Type: MCSA 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 Correct Answer: 2 Rationale 1: Pamphlets would be appropriate to supplement instruction to an adult or older client. Rationale 2: Play is an effective teaching tool with children. Rationale 3: Books would be more appropriate to supplement instruction to a school-age child. Rationale 4: Videotapes would be appropriate for adolescent or adult clients. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.7.3. Implement appropriate nursing care during the preoperative and intraoperative phases. Page Number: 873 Question 21 Type: MCSA 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. Correct Answer: 2 Rationale 1: Providing necessary preoperative teaching is an activity associated with the preoperative phase. Rationale 2: The goal of postoperative care is to assist the client to achieve the most optimal health status possible. Rationale 3: Ensuring client safety is a goal of the intraoperative phase. Rationale 4: Maintaining an aseptic environment is an action within the intraoperative phase. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10. Demonstrate ongoing nursing assessments and interventions for the postoperative client. MNL Learning Outcome: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 865 Question 22 Type: MCMA The nurse is planning a perioperative client’s needs upon discharge. What should be included when determining these needs? Standard Text: 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 health care services Correct Answer: 1, 4, 5 Rationale 1: Discharge planning incorporates an assessment of the client’s abilities for self-care. Rationale 2: Discharge planning does not include the client’s anticipated date of discharge. Rationale 3: Discharge planning does not include the name of the physician performing the surgery. Rationale 4: Discharge planning incorporates an assessment of the client’s financial resources. Rationale 5: Discharge planning incorporates an assessment of the client’s need for home health care. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Describe essential preoperative teaching, including pain assessment and management, moving, leg exercises, and deep-breathing and coughing exercises. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.7.3. Implement appropriate nursing care during the preoperative and intraoperative phases. Page Number: 869 Question 23 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 2, 4, 5 Rationale 1: Maintaining the sterile field will support the goals of maintaining client safety and homeostasis. Rationale 2: Performing instrument counts will support the goals of maintaining client safety and homeostasis. Rationale 3: Instructing in postoperative exercises will not support the goals of maintaining client safety and homeostasis. Rationale 4: Positioning the client appropriately for surgery will support the goals of maintaining client safety and homeostasis. Rationale 5: Performing preoperative skin preparation will support the goals of maintaining client safety and homeostasis. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Identify nursing responsibilities in planning perioperative nursing care. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.7.3. Implement appropriate nursing care during the preoperative and intraoperative phases. Page Number: 879 Question 24 Type: MCMA 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? Standard Text: 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. Correct Answer: 2, 4 Rationale 1: The client’s remaining conscious is an advantage of regional anesthesia. Rationale 2: An advantage of general anesthesia is that the respiratory rate can be regulated easily. Rationale 3: Regional anesthesia is used for minor surgical procedures. Rationale 4: An advantage of general anesthesia is that the anesthesia can be adjusted to the length of the procedure. Rationale 5: A nerve block focuses on a single nerve or nerve group. Global Rationale: Page Reference: 973 Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Compare various types of anesthesia. MNL Learning Outcome: 4.7.2. Compare the types of anesthesia used for surgical procedures. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 878 Question 25 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: Restricting fluids could cause the pulmonary secretions to thicken, making them more difficult for the client to cough and remove. Rationale 3: Leg exercises will not improve breath sounds. Rationale 4: Bed rest will not improve the client’s breath sounds. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Identify potential postoperative complications and describe nursing interventions to prevent them. MNL Learning Outcome: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 884 Question 26 Type: SEQ Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The nurse is preparing to change the dressing on a client’s postoperative wound. Place in order the steps the nurse should perform when removing the soiled dressing. Standard Text: Click and drag the options below to move them up or down. Choice 1. Assess the location, type, and odor of wound drainage. Choice 2. Remove the outer dressing. Choice 3. Discard the under dressing in a moisture-proof bag, and remove and discard gloves. Choice 4. Remove the under dressing. Choice 5. Apply clean gloves. Choice 6. Place the soiled dressing in a moisture-proof bag. Correct Answer: 5, 2, 6, 4, 1, 3 Rationale 1: Once the under dressing is removed, the nurse should assess the location, type, and odor of any wound drainage. Rationale 2: The nurse should then remove the outer dressing. Rationale 3: The nurse should then discard the under dressing in a moisture-proof bag and remove and discard the gloves. Rationale 4: The nurse should next remove the under dressing. Rationale 5: The nurse first should apply clean gloves. Rationale 6: The nurse should place the soiled outer dressing in a moisture-proof bag. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Verbalize the steps used in: d. Cleaning a sutured wound and changing a dressing on a wound with a drain. MNL Learning Outcome: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 893 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 27 Type: MCMA The nurse is planning to remove the sutures from a client’s surgical wound. What should the nurse do before removing the sutures? Standard Text: Select all that apply. 1. Apply clean gloves. 2. Verify the order for suture removal. 3. Ambulate the client to the bathroom. 4. Read the order to determine whether a dressing is to be applied after removal. 5. Remove the dressing and clean the incision. Correct Answer: 2, 4, 5 Rationale 1: The nurse is to apply sterile gloves for suture removal. Rationale 2: Before removing skin sutures, the nurse should verify that there is an order for suture removal. Rationale 3: The client is not to be ambulated to the bathroom for suture removal. Rationale 4: Before removing skin sutures, the nurse should verify whether a dressing is to be applied following the suture removal. Rationale 5: Before removing skin sutures, the nurse should remove the dressing and clean the incision. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Verbalize the steps used in: e. Removing sutures and staples. MNL Learning Outcome: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 896 Question 28 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: Lower extremity swelling and heat would indicate the presence of thrombophlebitis. Rationale 2: A hard vein would indicate the presence of thrombophlebitis, and that leg exercises were not effective. Rationale 3: The absence of cramping or pain with ambulation indicates that leg exercises instructed prior to surgery were effective to prevent the onset of thrombophlebitis. Rationale 4: Pain in the calf with dorsiflexion would indicate the presence of thrombophlebitis, and that leg exercises were not effective. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 13. Evaluate the effectiveness of perioperative nursing interventions. MNL Learning Outcome: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 884 Question 29 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Client vomiting. 4. Bowel movement occurred 24 hours after resuming a normal diet. Correct Answer: 4 Rationale 1: Abdominal distention is an indication of postoperative constipation. Rationale 2: Gas pain is an indication of postoperative constipation. Rationale 3: Vomiting is an indication of postoperative constipation. Rationale 4: A bowel movement that occurs within 48 hours after resuming a normal diet is evidence that postoperative constipation has been prevented. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 13. Evaluate the effectiveness of perioperative nursing interventions. MNL Learning Outcome: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 887 Question 30 Type: MCMA The nurse is caring for a postoperative client with an abdominal wound and a drain. What can the nurse delegate to unlicensed assistive personnel? Standard Text: 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. Correct Answer: 4, 5 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Cleaning a newly sutured wound, especially one with a drain, requires application of knowledge, problem solving, and aseptic technique. This procedure should not be delegated to UAP. Rationale 2: The nurse is responsible for assessment of the wound. Rationale 3: The nurse is responsible for evaluation of medication provided. Rationale 4: The nurse can ask the UAP to report soiled dressings that need to be changed. Rationale 5: The nurse can ask the UAP to report if the dressing is loose and needs to be reinforced. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14. Recognize when it is appropriate to delegate infection control and prevention skills to unlicensed assistive personnel. MNL Learning Outcome: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 893

Question 31 Type: MCMA 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? Standard Text: Select all that apply. 1. Type of surgery 2. Time of surgery 3. Postoperative diet 4. Preoperative orders 5. Name of the surgeon Correct Answer: 1, 2, 4, 5 Rationale 1: Before beginning to teach leg exercises, the nurse needs to determine the type of surgery. Rationale 2: Before beginning to teach leg exercises, the nurse needs to determine the time of the surgery. Rationale 3: The client’s postoperative diet is not a consideration prior to completing teaching on leg exercises. Rationale 4: Before beginning to teach leg exercises, the nurse needs to determine preoperative orders. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: Before beginning to teach leg exercises, the nurse needs to determine the name of the surgeon. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12. Verbalize the steps used in: a. Teaching moving, leg exercises, deep breathing, and coughing. MNL Learning Outcome: 4.7.3. Implement appropriate nursing care during the preoperative and intraoperative phases. Page Number: 871 Question 32 Type: MCMA The nurse has removed the sutures from a client’s surgical wound. What should the nurse document about this procedure? Standard Text: Select all that apply. 1. Number of sutures removed 2. Appearance of the incision 3. Client teaching 4. Client tolerance of the procedure 5. Name of the surgeon. Correct Answer: 1, 2, 3, 4 Rationale 1: The nurse should document the number of sutures removed. Rationale 2: The nurse should document the appearance of the incision. Rationale 3: The nurse should document any client teaching. Rationale 4: The nurse should document the client’s tolerance of the procedure. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: The nurse does not need to document the name of the surgeon. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15. Demonstrate appropriate documentation and reporting of perioperative skills. MNL Learning Outcome: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 897 Question 33 Type: MCMA A client in the postanesthesia care unit is to have suction applied through a nasogastric tube. When documenting, the nurse should include which information? Standard Text: 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 Correct Answer: 1, 3, 5 Rationale 1: For the nasogastric tube placed to suction, the nurse should document the time suction was started. Rationale 2: The characteristics of the wound drainage are not related to the nasogastric tube suction. Rationale 3: For the nasogastric tube placed to suction, the nurse should document the pressure on the suction. Rationale 4: The integrity of the surgical dressing is not related to the nasogastric tube suction. Rationale 5: For the nasogastric tube placed to suction, the nurse should document the color and consistency of the drainage. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Verbalize the steps used in: c. Managing gastrointestinal suction. 15. Demonstrate appropriate documentation and reporting of perioperative skills. MNL Learning Outcome: 4.7.4. Implement appropriate nursing care during the postoperative phase. Page Number: 891 Question 34 Type: MCMA The nurse is completing a preoperative assessment with a client. What should this assessment include? Standard Text: Select all that apply. 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Respiratory rate Correct Answer: 1, 2, 3, 4 Rationale 1: 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. Rationale 2: When documenting allergies, the nurse should include allergies to prescription and nonprescription drugs, food allergies, and allergies to tape, latex, soaps, or antiseptic agents. Rationale 3: All current medications should be listed. Herbal remedies and over-the-counter preparations are also a part of this assessment. Rationale 4: The client’s current mental status is a part of this assessment. Rationale 5: Respiratory rate is part of the physical assessment. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify essential aspects of preoperative assessment. MNL Learning Outcome: 4.7.3. Implement appropriate nursing care during the preoperative and intraoperative phases. Page Number: 868 Question 35 Type: MCMA 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? Standard Text: Select all that apply. 1. Age 2. Medications 3. General health 4. Blood pressure 5. Nutritional status Correct Answer: 1, 2, 3, 5 Rationale 1: The degree of risk involved in a surgical procedure is affected by the client’s age. Rationale 2: The degree of risk involved in a surgical procedure is affected by the client’s use of medications. Rationale 3: The degree of risk involved in a surgical procedure is affected by the client’s general health. Rationale 4: Blood pressure is not identified as specifically impacting the degree of risk when having a surgical procedure. Rationale 5: The degree of risk involved in a surgical procedure is affected by the client’s nutritional status. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Discuss various types of surgery according to the purpose, degree of urgency, and degree of risk. MNL Learning Outcome: 4.7.3. Implement appropriate nursing care during the preoperative and intraoperative phases. Page Number: 866

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 38 Question 1 Type: MCSA 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. Correct Answer: 3 Rationale 1: This would be appropriate for the client with an alteration in vision. Rationale 2: This would be appropriate for the client with an alteration in vision. Rationale 3: 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. Rationale 4: This intervention would be appropriate for a client having a tactile or skin disorder. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Discuss nursing interventions to promote and maintain sensory function. MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 904 Question 2 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Loss of ability to taste 2. Hearing loss 3. Vision loss 4. Loss of ability to smell Correct Answer: 2 Rationale 1: Furosemide (Lasix) does not affect the ability to taste. Rationale 2: Furosemide (Lasix) can be ototoxic if taken over long periods of time. The nurse would monitor for hearing loss. Rationale 3: Furosemide (Lasix) does not affect vision. Rationale 4: Furosemide (Lasix) does not affect the ability to smell. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Discuss factors that place a client at risk for sensory disturbances. MNL Learning Outcome: 4.14.1. Consider how drugs act on the body and how the body acts on drugs in the care of the client. Page Number: 906 Question 3 Type: MCSA A client has been treated for diabetes mellitus since childhood. Currently, the client’s blood glucose reading is 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 3 Rationale 1: Uncontrolled diabetes mellitus does not affect the ability to taste. Rationale 2: Uncontrolled diabetes mellitus does not affect hearing. Rationale 3: Uncontrolled diabetes mellitus is a leading cause of blindness in the United States. Rationale 4: Uncontrolled diabetes mellitus does not affect the ability to smell. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Discuss factors that place a client at risk for sensory disturbances. MNL Learning Outcome: 4.1.1. Recognize factors that affect client safety. Page Number: 906 Question 4 Type: MCSA 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. Schedule a Weber and Rinne test. 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. Correct Answer: 2 Rationale 1: The Weber and Rinne test may be a part of assessment, but will not yield as much information as the simple observation. Rationale 2: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Use of an otoscope may be a part of assessment, but will not yield as much information as the simple observation. Rationale 4: The client has already denied a hearing problem, so confronting the client with the nurse's suspicion will probably only serve to alienate the client from the nurse. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe essential components in assessing a client’s sensory-perception function. MNL Learning Outcome: 4.1.1. Recognize factors that affect client safety. Page Number: 914 Question 5 Type: MCSA The nurse is providing education for 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: The child should be stimulated with color, smells, body positions, and textures to develop compensatory mechanisms for the hearing loss. Rationale 3: 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. Rationale 4: Hearing loss is serious from birth. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Discuss nursing interventions to promote and maintain sensory function. MNL Learning Outcome: 4.1.1. Recognize factors that affect client safety. Page Number: 909 Question 6 Type: MCSA 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. Correct Answer: 3 Rationale 1: Spraying the room with a floral spray will add to the sensory overload. Rationale 2: Vinegar is not instilled into wounds. Rationale 3: The best way to keep odors controlled is to keep the wound dressing dry and clean. Rationale 4: Burning a candle will add to the sensory overload, and burning candles are not safe in the hospital environment. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Discuss nursing interventions to promote and maintain sensory function. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 914 Question 7 Type: MCSA The nurse is assisting a visually impaired client with ambulation. How 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. Correct Answer: 2 Rationale 1: Walking behind the client would be unsafe. Rationale 2: The nurse should walk about 1 foot in front of the client, offering the client an arm. Rationale 3: The side the nurse walks on will depend upon the preference of the client. Rationale 4: The side the nurse walks on will depend upon the preference of the client. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Discuss nursing interventions to promote and maintain sensory function. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 910 Question 8 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

An older client has become very confused since being hospitalized earlier in the week. Prior to this illness, the client exhibited clear thought processing and was able to maintain an independent lifestyle. How should the nurse document this mental state? 1. As reversible confusion 2. As sundown syndrome 3. As delirium 4. As dementia Correct Answer: 3 Rationale 1: The nurse has no way of knowing if this client’s confusion is reversible. Rationale 2: There is not enough information to determine if the client is experiencing sundown syndrome. Rationale 3: Delirium is acute confusion caused by illness, medication, or a change in environment and is the appropriate documentation for this client. Rationale 4: Dementia is chronic confusion with symptoms that are gradual in onset and are irreversible. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify clinical signs and symptoms of sensory deprivation and overload. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 915

Question 9 Type: MCMA 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? Standard Text: Select all that apply. 1. Speech 2. Stimuli Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Receptor 4. Perception 5. Impulse conduction Correct Answer: 2, 3, 4, 5 Rationale 1: Speech is not an aspect of the sensory process. Rationale 2: For an individual to be aware of the surroundings, four aspects of the sensory process must be present. One of these aspects is a stimulus, which is an agent or act that stimulates a nerve receptor. Rationale 3: For an individual to be aware of the surroundings, four aspects of the sensory process must be present. One of these is a receptor, which is the ability to convert the stimulus to a nerve impulse. Rationale 4: For an individual to be aware of the surroundings, four aspects of the sensory process must be present. One of these is perception, which is the awareness and interpretation of the stimuli in the brain. Rationale 5: For an individual to be aware of the surroundings, four aspects of the sensory process must be present. One of these is impulse conduction, which means the impulse travels along the nerve pathways to either the spinal cord or directly to the brain. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Discuss the components of the sensory-perception process. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 904 Question 10 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Semicomatose Correct Answer: 4 Rationale 1: The somnolent client is very drowsy, but will respond to stimuli. Rationale 2: A disoriented client is alert, but not oriented to time, place, or person. Rationale 3: The comatose client is not arousable. Rationale 4: Because this client can be aroused with extreme stimuli or repeated stimuli, the correct description is semicomatose. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Develop nursing diagnoses and outcome criteria for clients with impaired sensory function. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 905 Question 11 Type: MCSA 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. Correct Answer: 2 Rationale 1: The client typically is better oriented when it is quiet. Rationale 2: The client with dementia benefits from a routine schedule of activities. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Pain should be controlled. Rationale 4: Procedures should be explained in direct, clearly understandable terms, but the nurse should avoid "chatter." Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8. Identify strategies to promote a therapeutic environment for the client with acute confusion/delirium. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 915 Question 12 Type: MCSA The client who has the medical diagnosis of Alzheimer's disease is confused and has difficulty interpreting environmental stimuli. Which nursing diagnosis problem statement most accurately describes this client's situation? 1. Acute Confusion 2. Altered Role Performance 3. Disturbed Sensory Perception 4. Disturbed Thought Processes Correct Answer: 4 Rationale 1: Clients with Alzheimer's disease are more likely to exhibit chronic confusion. Rationale 2: There is no evidence to support Altered Role Performance. Rationale 3: Disturbed Sensory Perception is more useful with the client who has difficulty related to sensory input (perception). Rationale 4: Because this client has dementia, which interferes with the ability to interpret stimuli, the correct diagnosis problem statement is Disturbed Thought Processes. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 6. Develop nursing diagnoses and outcome criteria for clients with impaired sensory function. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 908 Question 13 Type: MCSA 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. Correct Answer: 4 Rationale 1: The nurse should use longer phrases that more completely explain concepts. Rationale 2: Overarticulation of words makes them difficult to lip-read. Rationale 3: The volume of the voice should be consistent. Rationale 4: The best intervention is to face the client during conversation so that the client can employ any lipreading skills. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Discuss nursing interventions to promote and maintain sensory function. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 915

Question 14 Type: MCMA A client is experiencing changes in taste. What can the nurse do to improve this client’s gustatory sense? Standard Text: 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. Correct Answer: 1, 2, 4, 5 Rationale 1: To improve the sense of taste, the nurse should encourage the client to eat each food separately. Rationale 2: To improve the sense of taste, the nurse should encourage the client to eat foods with a variety of flavors. Rationale 3: Eating cold foods will not improve the client’s sense of taste. Rationale 4: To improve the sense of taste, the nurse should encourage the client to take sips of water between eating different foods. Rationale 5: To improve the sense of taste, the nurse should encourage the client to consume foods of different textures. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Discuss nursing interventions to promote and maintain sensory function. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 911 Question 15 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The family of a client in the hospital is concerned about the constant noise in the care area. Which health care professionals have the greatest control over the level of sensory input in the hospital? 1. Physicians 2. Administrators 3. Nurses 4. Planners Correct Answer: 3 Rationale 1: Physicians are not at the bedside as much as nurses. Rationale 2: Administrators are not at the bedside as much as nurses. Rationale 3: 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. Rationale 4: Planners are not at the bedside as much as nurses. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe factors that influence sensory function. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 908 Question 16 Type: MCMA The nurse documents that a client is fully conscious. What did the nurse assess in this client? Standard Text: Select all that apply. 1. Client responded to verbal stimuli. 2. Client responded to written words. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Client oriented to time, place, and person. 4. Client demonstrated poor memory. 5. Client alert. Correct Answer: 1, 2, 3, 5 Rationale 1: A characteristic of being fully conscious is responding to verbal stimuli. Rationale 2: A characteristic of being fully conscious is responding to written words. Rationale 3: A characteristic of being fully conscious is being oriented to time, place, and person. Rationale 4: Demonstrating poor memory is a characteristic of being confused. Rationale 5: A characteristic of being fully conscious is being alert. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe essential components in assessing a client’s sensory-perception function. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 905 Question 17 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1 Rationale 1: 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. Rationale 2: There is no information to support that the client’s response to sensory stimuli is because of developmental stage. Rationale 3: There is no information to support that the client’s response to sensory stimuli is because of culture. Rationale 4: There is no information to support that the client’s response to sensory stimuli is because of illness. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe factors that influence sensory function.. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 906 Question 18 Type: MCMA The nurse is concerned that a client is experiencing sensory deprivation. What did the nurse assess to make this clinical decision? Standard Text: 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 Correct Answer: 1, 2, 3, 4 Rationale 1: A clinical manifestation of sensory deprivation is excessive sleeping. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: A clinical manifestation of sensory deprivation is nocturnal confusion. Rationale 3: A clinical manifestation of sensory deprivation is annoyance over small matters. Rationale 4: A clinical manifestation of sensory deprivation is a decreased attention span. Rationale 5: Sitting quietly reading a book is not a clinical manifestation of sensory deprivation. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify clinical signs and symptoms of sensory deprivation and overload. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 906 Question 19 Type: MCMA The nurse suspects a client will develop sensory overload. What characteristics did the nurse observe in the client? Standard Text: Select all that apply. 1. Ongoing pain 2. Confusion at night 3. Inability to sleep 4. Easily angered 5. Worrying about upcoming diagnostic tests Correct Answer: 1, 3, 5 Rationale 1: Pain can contribute to sensory overload. Rationale 2: Nocturnal confusion is a manifestation of sensory deprivation. Rationale 3: Sleeplessness can contribute to sensory overload. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Being easily annoyed is a manifestation of sensory deprivation. Rationale 5: Worry can contribute to sensory overload. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify clinical signs and symptoms of sensory deprivation and overload. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 906 Question 20 Type: MCSA A client is hospitalized for treatment of a new disorder. While admitted, the client 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 Correct Answer: 2 Rationale 1: The lack of telephone calls or visitors will not be assessed through assessing the client’s risk for sensory overload. Rationale 2: 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. Rationale 3: The lack of telephone calls or visitors will not be assessed through a mental status assessment. Rationale 4: The lack of telephone calls or visitors will not be assessed through an environmental assessment. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify clinical signs and symptoms of sensory deprivation and overload. 5. Discuss factors that place a client at risk for sensory disturbances. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 908 Question 21 Type: MCMA The nurse is assessing a client for possible sensory deprivation. What findings would indicate the client is at risk for developing this sensory disorder? Standard Text: 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. Correct Answer: 2, 3, 4, 5 Rationale 1: Severe pain increases a client’s risk for sensory overload. Rationale 2: Impaired vision increases a client’s risk for developing sensory deprivation. Rationale 3: Mobility restrictions increase a client’s risk for developing sensory deprivation. Rationale 4: Medications that affect the central nervous system increase a client’s risk for developing sensory deprivation. Rationale 5: Limited social contact with family and friends increases a client’s risk for developing sensory deprivation. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe factors that influence sensory function. 3. Identify clinical signs and symptoms of sensory deprivation and overload. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 908 Question 22 Type: MCSA 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 Correct Answer: 4 Rationale 1: Social Isolation would be appropriate for the client with long-term vision changes but not one with an acute change as in cataract surgery. Rationale 2: Risk for Impaired Skin Integrity is used to describe clients who have altered tactile sensation. Rationale 3: Disturbed Sensory Perception is used to describe clients whose perception has been altered by physiological factors such as pain, sleep deprivation, immobility, disease states such as CVA, or brain trauma. Rationale 4: Because the client lives alone and is recovering from cataract surgery, the client’s risk for injury is great. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 6. Develop nursing diagnoses and outcome criteria for clients with impaired sensory function. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 909 Question 23 Type: MCSA 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 beside 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. Correct Answer: 3 Rationale 1: The client’s placing the hearing aid on a bedside table when not in use would indicate that interventions were not successful. Rationale 2: The client’s responding inappropriately to questions would indicate that interventions were not successful. Rationale 3: 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. Rationale 4: The client’s demonstrating difficulty with problem solving is an indication of sensory overload. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 8. Identify strategies to promote a therapeutic environment for the client with acute confusion/delirium. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 911 Question 24 Type: MCMA A client is experiencing acute confusion. What nursing actions would be appropriate for this client? Standard Text: 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. Correct Answer: 1, 2, 3, 4 Rationale 1: Eliminating unnecessary noise would help the client who is experiencing acute confusion. Rationale 2: Keeping eyeglasses within reach would help the client who is experiencing acute confusion. Rationale 3: Placing a calendar in the room and identifying each day would help the client who is experiencing acute confusion. Rationale 4: Keeping the room well lit during waking hours would help the client who is experiencing acute confusion. Rationale 5: Providing dark glasses would help the client who is experiencing sensory overload. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Identify strategies to promote a therapeutic environment for the client with acute confusion/delirium. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 917 Question 25 Type: MCMA Which recent change, reported by a client’s family, would indicate that the client’s hearing ability is decreasing? Standard Text: Select all that apply. 1. Inability to follow directions 2. Mood swings 3. Decreased appetite 4. Complaints of dizziness 5. Answering questions incorrectly Correct Answer: 1, 2, 4, 5 Rationale 1: The client who has difficulty hearing might have an inability to follow directions because the directions were not heard. Rationale 2: The client who has difficulty hearing might have mood swings because of the stress of not hearing well. Rationale 3: Decrease in appetite is not generally associated with hearing loss. Rationale 4: The client who has difficulty hearing might have complaints of dizziness associated with inner ear disturbances. Rationale 5: The client who has difficulty hearing might answer questions incorrectly because a question was not heard or was misinterpreted. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Discuss factors that place a client at risk for sensory disturbances. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 907 Question 26 Type: MCMA The nurse is concerned that a hospitalized client is experiencing sensory overload. What did the nurse assess to come to this conclusion? Standard Text: Select all that apply. 1. Sleeplessness 2. Anxiety 3. Apathy 4. Racing thoughts 5. Somatic complaints Correct Answer: 1, 2, 4 Rationale 1: Sleeplessness is an indication of sensory overload. Rationale 2: Anxiety is an indication of sensory overload. Rationale 3: Apathy is associated with sensory deprivation. Rationale 4: Racing thoughts are an indication of sensory overload. Rationale 5: Somatic complaints are an indication of sensory deprivation. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify clinical signs and symptoms of sensory deprivation and overload. MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care. Page Number: 906 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 39 Question 1 Type: MCSA 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." Correct Answer: 3 Rationale 1: This statement reflects a high need for approval of others, which is not me-centered. Rationale 2: This statement reflects a comparison with others. Rationale 3: 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." Rationale 4: Other-centered persons compare themselves with others and often believe the world is against them. This outward focus results in a poorer self-concept. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Summarize the development of self-concept and self-esteem, including the framework described by Erikson. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 922 Question 2 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: The nurse's self-concept is not more important than the client's, but it is of equal importance in the nurse–client relationship. Rationale 2: There is no evidence that nurses with poor self-concept burn out earlier than nurses with good selfconcept. Rationale 3: Nurses who have positive self-concept are better prepared to assist clients with their own understanding of needs, desires, feelings, and conflicts. Rationale 4: There is no evidence that nurses with poor self-concept make more errors than nurses with good self-concept. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Describe the dimensions and components of self-concept. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 922 Question 3 Type: MCSA The newly graduated nurse is working with a mentor who has been a nurse for 25 years. The mentor tells the new graduate, "I learn something new about nursing every day." What does this indicate about the mentor's selfawareness? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. This nurse is not very self-aware. 2. The mentor's self-awareness is behind normal development. 3. Because this mentor 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. Correct Answer: 4 Rationale 1: The mentor’s comment about “learning something new about nursing everyday” demonstrates selfawareness. Rationale 2: Although this mentor has been a nurse for 25 years, there is still room for growth and development of self-awareness. Rationale 3: Although this mentor has been a nurse for 25 years, there is still room for growth and development of self-awareness. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe the dimensions and components of self-concept. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 922 Question 4 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Consider the feedback carefully but not change practice patterns. Correct Answer: 1 Rationale 1: 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. Rationale 2: Blaming the student–faculty relationship for the poor review reflects projection of the student's beliefs onto the situation. Rationale 3: Dismissing the feedback reflects projection of the student's beliefs onto the situation. Rationale 4: Considering the feedback but not using it to change personal practice reflects projection of the student's beliefs onto the situation. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Identify common stressors affecting self-concept and coping strategies. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 922 Question 5 Type: SEQ 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. Standard Text: Click and drag the options below to move them up or down. Choice 1. Expressing one's own opinion Choice 2. Guiding others Choice 3. Asserting independence Choice 4. Working well with others Correct Answer: 1, 4, 3, 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Expressing one’s own opinion is a behavior in the infancy stage of trust vs. mistrust. Rationale 2: Guiding others is a behavior in the middle-aged adult stage of generativity vs. stagnation. Rationale 3: Asserting independence is a behavior in the adolescence stage of identity vs. role confusion. Rationale 4: Working well with others is a behavior in the early school years stage of industry vs. inferiority. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Summarize the development of self-concept and self-esteem, including the framework described by Erikson. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 923 Question 6 Type: MCSA The adolescent male client who weighs 100 is considering taking "some herbal stuff" to increase muscle mass and strength. The nurse should interpret this statement as an indication that this client has 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. Correct Answer: 3 Rationale 1: This cannot be determined by the information provided. Rationale 2: This cannot be determined by the information provided. Rationale 3: The nurse can determine that there is incongruence between reality and this client's ideal self. Rationale 4: This cannot be determined by the information provided. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify common stressors affecting self-concept and coping strategies. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 924 Question 7 Type: MCSA During an assessment, the nurse notes that a client frequently refers to his Native American heritage. The nurse determines that this heritage is a strong part of the client’s 1. personal identity. 2. body image. 3. role performance. 4. self-esteem. Correct Answer: 1 Rationale 1: Self-concept consists of personal identity, body image, role performance, and self-esteem. Personal identity consists of name, sex, age, race, ethnic origin or culture, occupation or roles, talents, and other situational characteristics. Rationale 2: Body image is perception of size, appearance, and functioning of the body. Rationale 3: Role performance relates to how a person fulfills his or her own expectations of role. Rationale 4: Self-esteem is a judgment of one's own worth. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe the dimensions and components of self-concept. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 924 Question 8 Type: MCSA A client who has recently lost 75 pounds continues to dress in loose, baggy clothing and frequently talks about being fat. The nurse realizes this finding most likely indicates 1. role confusion. 2. body image disturbance. 3. fear of success. 4. lack of education. Correct Answer: 2 Rationale 1: Role confusion would be indicated if the client did not have a clear indication of what role to fulfill in life or how to fulfill a chosen role. Rationale 2: The most likely interpretation of this finding is that the client continues to see himself as fat, which is a body image disturbance. Rationale 3: The nurse would need more information to make this conclusion. Rationale 4: More information is needed to come to this conclusion. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify common stressors affecting self-concept and coping strategies. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 924 Question 9 Type: MCSA A rare malignancy will require the amputation of an adolescent client's leg. The client refuses the surgery, stating: "I would rather die than have my 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 Correct Answer: 1 Rationale 1: Adolescents are very concerned about body image and will make decisions based upon 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. Rationale 2: Although the client may need further education, the issues regarding the adolescent's focus on body image should be taken into consideration with every new intervention. Rationale 3: Even though the parents will make the ultimate decision, the issues regarding the adolescent's focus on body image should be taken into consideration with every new intervention. Rationale 4: Although there may be a problem with the client understanding medical terminology, the issues regarding the adolescent's focus on body image should be taken into consideration with every new intervention. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Describe the dimensions and components of self-concept. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 925 Question 10 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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." Correct Answer: 1 Rationale 1: 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." Rationale 2: Even though the husband staying at home while the mother works may not be the expected role assignment, there is no ambiguity in the arrangement. Rationale 3: Disappointment that the baby is not a girl is not specific to role ambiguity. Rationale 4: Not having the room finished is not specific to role ambiguity. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify common stressors affecting self-concept and coping strategies. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 925

Question 11 Type: MCMA The nurse suspects that a client is having difficulty with specific self-esteem. Which client statements caused the nurse to have this concern? Standard Text: Select all that apply. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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.” Correct Answer: 1, 3, 4 Rationale 1: Specific self-esteem is how much one approves of a certain part of oneself. The client hating her hair demonstrates an issue with specific self-esteem. Rationale 2: Stating that life is wonderful indicates healthy global self-esteem. Rationale 3: Specific self-esteem is how much one approves of a certain part of oneself. The client stating that her hips are too big demonstrates an issue with specific self-esteem. Rationale 4: Specific self-esteem is how much one approves of a certain part of oneself. The client wishing that a nose job was done 2 years ago demonstrates an issue with specific self-esteem. Rationale 5: Being successful at work indicates healthy specific and global self-esteem. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe the dimensions and components of self-concept. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 925 Question 12 Type: MCSA Which nursing intervention would be helpful when caring for a client who has negative self-esteem? 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 2 Rationale 1: Correcting the client when negativity arises puts the client in a childlike role and will not encourage positive self-esteem. Rationale 2: 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. Rationale 3: Correcting the client when negativity arises puts the client in a childlike role and will not encourage positive self-esteem. Rationale 4: The client likely already knows how much better life would be with positive self-esteem, so reiterating that fact would not be helpful. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 927 Question 13 Type: MCSA The nurse is conducting a thorough psychosocial assessment of a client who presents with complaints of 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. Correct Answer: 4 Rationale 1: Taking detailed notes to record client responses would not support an accurate assessment. Rationale 2: Asking many questions to explore all areas of concern does not support an accurate assessment. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Asking yes/no questions does not support an accurate assessment. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe the essential aspects of assessing role relationships. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 926 Question 14 Type: MCSA 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.” Correct Answer: 1 Rationale 1: The first information the nurse gathers when assessing self-concept should focus on the client's personal identity ("Describe yourself as a person"). Rationale 2: "Tell me about your family" assesses role performance. Rationale 3: "What do you do when you have free time" assesses social role. Rationale 4: “Tell me about the kind of work do you do" assesses work role. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 927 Question 15 Type: MCSA 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. Correct Answer: 2 Rationale 1: Documenting that the client is not cooperative labels the client for all other health care provider interactions. Rationale 2: The nurse should always consider that there could be a cultural implication of behavior. Rationale 3: Assuming that the client has something to hide labels the client for all other health care provider interactions. Rationale 4: Asking a second nurse to sit in on the next interview may make the client feel more intimidated. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 927 Question 16 Type: MCSA 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 Correct Answer: 2 Rationale 1: Motivation is not a characteristic of self-esteem. Rationale 2: Clients with low self-esteem often have difficulty identifying strengths and focus more on their limitations and problems. Rationale 3: Disinterest in working on improvement is not a characteristic of self-esteem. Rationale 4: Not being satisfied with a personal situation is not a characteristic of self-esteem. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 928 Question 17 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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. Correct Answer: 1 Rationale 1: When attempting to reinforce client strengths, it is important to help the client set attainable goals, even if the goals are small at first. Rationale 2: If the goal is too long range, the client may lose sight of the goal before it is attained. Rationale 3: Devising goals should be a team effort between the client, significant others, and the nurse. Rationale 4: The goal should not be so effortless that it is not important to the client. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 929 Question 18 Type: MCSA The nurse and client had set the following expected outcome: "At the next clinic visit, the client will report participation in three activities to increase self-esteem." At today's visit, the client is unable to meet the stated outcome. What should be the nurse's next action? 1. Explore the possible reasons for not meeting the outcome. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 1 Rationale 1: The nurse's first action should be to explore possible reasons the outcome was not met. Rationale 2: Reevaluating the accuracy of the outcome statement would be the second step. Rationale 3: Collaborating with the client to write a new expected outcome would not be the nurse’s next step. Rationale 4: Identifying new interventions to help the client achieve the outcome would not be the nurse’s first step. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 929 Question 19 Type: MCSA The spouse tells the nurse that the 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?" Correct Answer: 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: It is not appropriate to reinforce the spouse’s feelings by comparing the client to other clients. Rationale 2: It would be appropriate to respond that self-esteem work takes time and that improvement is sometimes not easy to evaluate. Rationale 3: It is not appropriate to blame the spouse for the slowness by asking what has been done to help the client. Rationale 4: It is not appropriate to instill doubt by asking if the client is really trying. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the dimensions and components of self-concept. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 931 Question 20 Type: MCSA 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. Correct Answer: 3 Rationale 1: In order to develop self-esteem in their baby, parents should be taught to respond to the baby's needs promptly and consistently. The baby should not be allowed to cry for extended periods of time at this age. Rationale 2: A 3-hour feeding schedule might work for some babies, but it should not be presented as the goal to a group of new parents because every baby is different. Rationale 3: In order to develop self-esteem in their baby, parents should be taught to respond to the baby's needs promptly and consistently. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Babies do not need or respond to discipline. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe ways to enhance client self-esteem. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 930 Question 21 Type: MCSA The parents tell the nurse that their preschooler demands to wear specific clothing. They are concerned that the day-care workers might think they are negligent because the preschooler often wears 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." Correct Answer: 2 Rationale 1: Even though day-care workers are accustomed to this stage, the option given discounts the parents' worry and does not give them any information that the preschooler is normal. Rationale 2: 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. Rationale 3: The only reason to notify the pediatrician would be to report this normal behavior. Rationale 4: Because this is a normal behavior, there are no issues about controlling the preschooler when older. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Summarize the development of self-concept and self-esteem, including the framework described by Erikson. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 930 Question 22 Type: MCSA The parents of an adolescent report that their child 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. They ask for the nurse's professional opinion about the suitability of the punishment. Which answer best supports self-esteem development in this adolescent? 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." Correct Answer: 4 Rationale 1: Because the nurse does not have all the information, it would be a mistake to agree that the punishment is excessive. Rationale 2: The nurse does need to respond to these parents, even though the nurse may not have enough information to form an opinion about the situation. Rationale 3: Because the nurse does not have all the information, it would be a mistake to agree that the punishment should be more extensive. Rationale 4: One of the most important tasks of adolescence and a prime way to develop self-esteem is to take responsibility and to live with the consequences of actions. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe ways to enhance client self-esteem. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 930 Question 23 Type: MCSA The nurse working in a long-term care facility notices that one of the residents has had a recent decline in selfesteem. 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. Correct Answer: 1 Rationale 1: Asking the client for advice in setting up an activity in the dayroom validates the client's usefulness and worth. Rationale 2: Reminiscence therapy is a standard therapy used with older clients. Rationale 3: The nurse and staff should listen carefully to client concerns. Rationale 4: Clients should be encouraged to be a part of the planning of their care. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe ways to enhance client self-esteem. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 931 Question 24 Type: MCMA The nurse is planning to assess a client’s family relationships. What questions should the nurse ask to obtain this information? Standard Text: 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?” Correct Answer: 2, 4 Rationale 1: The question “How do you spend your free time?” is a question to assess work and social roles. Rationale 2: The question “What is your home like?” is an appropriate question for the nurse to ask to assess a client’s family relationships. Rationale 3: The question “Who is most important to you?” is a question to assess work and social roles. Rationale 4: The question “How well do you feel you accomplish what is expected of you?” is an appropriate question for the nurse to ask to assess a client’s family relationships. Rationale 5: The question “Whom do you seek out for help?” is a question to assess work and social roles. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe the essential aspects of assessing role relationships. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 928 Question 25 Type: MCSA A client tells the nurse that her spouse expects the client to maintain the home and children as well as have a job to help with household expenses. The client is demonstrating fatigue and inadequacy. 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 Correct Answer: 2 Rationale 1: The client is experiencing fatigue and inadequacy with the current situation, and not long-term low self-esteem. Rationale 2: 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. Rationale 3: The client is not experiencing and alteration in perception of body image. Rationale 4: The client is not experiencing an issue with parenting. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 5. Identify nursing diagnoses related to altered self-concept. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 928 Question 26 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 3 Rationale 1: The client’s feelings of being ugly do not support the diagnosis of Powerlessness. Rationale 2: The client’s feelings of being ugly do not support the diagnosis of Social Isolation. Rationale 3: The diagnosis Grieving is appropriate, because the client is expressing a feeling related to a change in physical appearance. Rationale 4: The client’s feelings of being ugly do not support the diagnosis of Hopelessness. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 5. Identify nursing diagnoses related to altered self-concept. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 929 Question 27 Type: MCMA An adult client who has been a successful writer in the past has been experiencing low self-esteem over the last year. Which behaviors indicate that the client is attempting to make positive changes? Standard Text: Select all that apply. 1. The client joined a library book club. 2. The client counted the number of rejection letters she received from publishers. 3. The client states that she no longer reads Facebook to compare her life with her friends’ lives. 4. The client works with the local Wheels on Meals to deliver meals once a week to older community members. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

5. The client shared a letter from a magazine publisher that is going to print her short story in the next edition. Correct Answer: 1, 3, 4, 5 Rationale 1: Joining a book club demonstrates spending time with positive supportive people. Rationale 2: Counting the number of rejection letters is focusing on the negative and will not help improve selfesteem. Rationale 3: Avoiding comparisons with other people helps develop self-esteem. Rationale 4: Helping others will help develop the client’s self-esteem. Rationale 5: Having success will help develop the client’s self-esteem Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Describe ways to enhance client self-esteem. MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care. Page Number: 929

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 40 Question 1 Type: MCSA A client speaks about an adult son who is a practicing homosexual and expresses concern by stating: "I am so worried about him and I know he is going to hell." What is the most important fact for the nurse to consider in formulating a response to this client's concern? 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. Correct Answer: 3 Rationale 1: Even though many consider whatever activity gives pleasure and satisfaction to the involved adults to be normal, some cultures and religions do not hold that belief. Rationale 2: Although alternative lifestyles are well accepted in some cultures, apparently that is not true in this parent's belief patterns. Rationale 3: This nurse should remember that culture and religion have a big impact upon what a person believes to be normal sexual behavior. Rationale 4: Sexual development has both genetic and environmental components. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: Nursing Process: Planning Learning Outcome: 4. Give examples of how the family, culture, religion, and personal expectations and ethics influence one’s sexuality. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 934 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 2 Type: MCSA The parent of a 20-month-old is very 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 2 1/2 or 3. 4. Babies are sexual beings, but this activity should be discouraged. Correct Answer: 1 Rationale 1: 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. Rationale 2: Masturbation to orgasm can occur as early as age 3, although males do not ejaculate until after puberty. Rationale 3: At around age 21/2 or 3 the child begins to differentiate between genital differences and to identify as a male or female. Rationale 4: There is no need to discourage genital exploration at 20 months. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: Nursing Process: Planning Learning Outcome: 1. Describe sexual development and concerns across the life span. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 935 Question 3 Type: MCSA The nurse is teaching a class on body development to a group of middle school girls. One of the girls asks about using tampons for sanitary protection during menstruation. What advice should the nurse include? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Tampons should not be used until the menstrual cycle is well established, usually 2 to 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. Correct Answer: 3 Rationale 1: There is no evidence of need to delay tampon use. Rationale 2: Sanitary pads, not tampons, should be used at night. Rationale 3: The nurse should teach these girls to alternate tampons with sanitary pads to decrease risk for infection. Rationale 4: Tampons should be changed more frequently than every 8 hours to prevent infection and odor. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 936 Question 4 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1 Rationale 1: 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. Rationale 2: Increase of blood flow to the uterine muscle can decrease pain and cramping. There is no connection between the actual amount of flow and pain. Estrogen production should follow normal patterns and should not be altered. Rationale 3: There is no connection between the actual amount of flow and pain. Rationale 4: Estrogen production should follow normal patterns and should not be altered. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 936 Question 5 Type: MCSA 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. Correct Answer: 2 Rationale 1: An 11-year-old may feel uneasy about discussing sexual matters with parents, so this statement to the nurse may be the only opportunity to discuss concerns. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: 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. Rationale 3: This is not the time to tell the client about what is or is not appropriate; it is the time to make the client feel comfortable talking with the nurse. Rationale 4: Staying silent may make the client feel as if the nurse is disapproving and would adversely affect the client's comfort level. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 936 Question 6 Type: MCSA A young adult single mother of a second-grade child has to make a decision regarding the teacher her child will have in third grade and asks the nurse for advice. All other variables being equal, which choice is best? 1. A woman with 35 years of teaching experience 2. A man who is 40 years old 3. A newly graduated 22-year-old man 4. A 30-year-old woman Correct Answer: 2 Rationale 1: Because the child needs role modeling from both males and females, this teacher is not the best choice. Rationale 2: If all other variables are equal, the best choice is the 40-year-old male, as this child needs role modeling from both females (the mother) and males (this teacher). Rationale 3: Even though the child needs role modeling from both males and females, this teacher is not the best choice because of the teacher's age. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Because the child needs role modeling from both males and females, this teacher is not the best choice. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Give examples of how the family, culture, religion, and personal expectations and ethics influence one’s sexuality. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 940 Question 7 Type: MCSA 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." Correct Answer: 3 Rationale 1: This statement reflects normal changes associated with aging and healthy responses to those changes. Rationale 2: This statement reflects normal changes associated with aging and healthy responses to those changes. Rationale 3: 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? Rationale 4: This statement reflects normal changes associated with aging and healthy responses to those changes. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe sexual development and concerns across the life span. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 947 Question 8 Type: MCSA A research article the nurse is reading discusses the prevalence of androgyny in persons 20 to 30 years old. What should the nurse keep in mind when caring for clients who are androgynous? 1. They do not limit 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. Correct Answer: 1 Rationale 1: Androgyny means flexibility in gender roles. Androgynous individuals do not limit behaviors to one gender over another. Rationale 2: Androgyny has nothing to do with gender attraction. Rationale 3: Androgyny has nothing to do repression of sexual feelings. Rationale 4: Androgynous individuals do not hold rigid stereotyped gender role expectations; androgyny means flexibility in gender roles. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Discuss the varieties of sexuality. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 938 Question 9 Type: MCSA 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 Correct Answer: 3 Rationale 1: There is no indication that early menopause is a result of female circumcision. Rationale 2: There is no indication that increased menstrual flow is a result of female circumcision. Rationale 3: Female circumcision increases the possibility that the client will suffer chronic urinary tract infection. Rationale 4: There is no indication that female circumcision causes postpartum hemorrhage. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Give examples of how the family, culture, religion, and personal expectations and ethics influence one’s sexuality. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 941 Question 10 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The 45-year-old client reports that she has no interest in sex and that she and her husband have not had intercourse in 16 years. How should the nurse interpret this assessment data? 1. This couple is experiencing sexual dysfunction. 2. The woman's lack of sexual desire has resulted in impotence in her husband. 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. Correct Answer: 3 Rationale 1: This situation is unnatural in the predominant North American culture, but if both members of the couple are comfortable with the relationship, no dysfunction is present. Rationale 2: There is no evidence that the wife's lack of desire has resulted in sexual impotence in her husband, but further assessment might be in order. Rationale 3: 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. Rationale 4: This situation is unnatural in the predominant North American culture, but if both members of the couple are comfortable with the relationship, no dysfunction is present. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Identify the forms of altered sexual function. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 943 Question 11 Type: MCSA A client is concerned because he was unable to achieve an erection during his last sexual encounter with his wife. He tells the nurse that he has worried about becoming impotent because he had a sexually transmitted infection as a young adult. What is the nurse's best response to this client's concerns? 1. Sexually transmitted infections may result in sexual problems in adults. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: Although this can occur, it does not address the client's concerns about impotence. Rationale 2: Simply correcting the client's use of medical terminology does not address his concerns. Rationale 3: This client is concerned about his masculinity and sexual abilities. The correct answer at this point is to tell him that it is common and normal for men to experience occasional erectile difficulties. Rationale 4: Even though this is true, it is not the best response to address the client's concerns. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe sexual development and concerns across the life span. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 944 Question 12 Type: MCSA The nurse is preparing for pelvic physical examination of a woman who has been medically diagnosed 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 Correct Answer: 3 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: The client does not have an infection. Rationale 2: The client does not have thick external secretions. Rationale 3: 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. Rationale 4: This client does not need a preexamination douche. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8. Formulate nursing diagnoses and interventions for the client experiencing sexual problems. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 945 Question 13 Type: MCSA 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. Correct Answer: 4 Rationale 1: A complete sexual history is not necessary for every client. Rationale 2: This topic should be addressed only after rapport has been established. Rationale 3: Although the nurse should be sensitive about repeating questions that have already been asked, the client may be more forthcoming with information with the nurse.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 945 Question 14 Type: MCSA The mother of a 5-year-old tells the nurse that her daughter has always been closer to her than to her husband. The mother expresses concern that, over the last 2 months, the little girl wants to spend all of her time with her father instead of with the mother. The nurse recognizes that this behavior 1. may indicate sexual abuse by the father and should be further investigated. 2. is a normal expectation of a preschooler developing sexuality. 3. indicates that the girl is overidentifying with the male gender. 4. can be a sign of precocious puberty and should be monitored. Correct Answer: 2 Rationale 1: The nurse would be concerned if this attention to the father is accompanied by any manifestation of sexual abuse, but that is not indicated in this question. Rationale 2: A part of the normal sexual development of a preschooler is a time in which the child focuses love on the parent of the other gender. The same-gender parent may feel excluded during this time, but can be assured that the behavior is normal. Rationale 3: There is no indication of overidentification with the male gender. Rationale 4: There is no indication of precocious puberty. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe sexual development and concerns across the life span. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 935 Question 15 Type: MCSA A recently married couple is trying to conceive a child. The husband is a collegiate athlete and his coach forbids sexual activity for 2 days prior to a game. The wife asks the nurse if abstinence before the game is necessary. What is the best response? 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. Correct Answer: 3 Rationale 1: There is no evidence that avoiding intercourse is necessary. Rationale 2: The idea that sexual activity weakens the person physically is a common misconception among athletes, but there is no evidence to support that idea. Rationale 3: The idea that sexual activity weakens the person physically is a common misconception among athletes, but there is no evidence to support that idea. Rationale 4: There is no evidence that sexual activity before intense exercise affects stamina or endurance. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Give examples of how the family, culture, religion, and personal expectations and ethics influence one’s sexuality. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 936 Question 16 Type: MCSA The 15-year-old female tells the nurse that she makes her boyfriend stop intercourse before she has an orgasm so she will not get pregnant. What teaching is necessary for this client? 1. Even though she doesn't get pregnant, she might still get a sexually transmitted infection. 2. Intercourse until orgasm may actually reduce conception because the vaginal contractions help to expel sperm. 3. Conceiving is not related to whether or not the female partner experiences an orgasm. 4. As long as her boyfriend does not ejaculate in her vagina, conception is unlikely. Correct Answer: 3 Rationale 1: Conceiving is not related to experiencing orgasm. This client is very likely to conceive and is also at risk for getting any sexually transmitted infection her boyfriend might have. Rationale 2: Conceiving is not related to experiencing orgasm. Rationale 3: Conceiving is not related to experiencing orgasm. Rationale 4: The seminal fluid expelled prior to ejaculation also contains sperm and can result in pregnancy even if the male ejaculates outside the vagina. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 936 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 17 Type: MCSA The high school student tells the school nurse that during biology the class learned that alcohol is associated with erectile dysfunction. The student wonders why so many girls get pregnant during evenings when alcohol is consumed. The nurse should plan a response based upon 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 50. Correct Answer: 1 Rationale 1: Alcohol is implicated in behaviors leading to undesired pregnancy because it is a central nervous system depressant and affects judgment. Rationale 2: Situational erectile dysfunction often occurs when the male partner is drunk. Chronic erectile dysfunction is more common in older men, and alcohol abuse is associated with this problem. Rationale 3: Alcohol is implicated in behaviors leading to undesired pregnancy because it is a central nervous system depressant and affects judgment. It is not a sexual stimulant. Rationale 4: Situational erectile dysfunction often occurs when the male partner is drunk. Chronic erectile dysfunction is more common in older men, and alcohol abuse is associated with this problem. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 944 Question 18 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The female client has experienced recurrent candidiasis with intense vaginal itching and excoriation. After treatment the client is reexamined, and the nurse practitioner finds presence of 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 Correct Answer: 2 Rationale 1: There is no need for tissue excision. Rationale 2: Candidiasis is a sexually transmitted infection. It may be that this woman's sexual partner is also infected with candidiasis and that the couple is transmitting the infection between them. Rationale 3: Antibiotic therapy is not indicated and may, in fact, complicate treatment. Rationale 4: Antibiotic therapy is not indicated and may, in fact, complicate treatment. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Formulate nursing diagnoses and interventions for the client experiencing sexual problems. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 937 Question 19 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Ask the client if there are any sexual concerns that should be discussed. Correct Answer: 2 Rationale 1: Masturbation is not harmful to sexual well-being. Rationale 2: In this situation, the nurse should quickly and politely leave the room. Rationale 3: It is inappropriate to ask the client to stop so that care can be provided. Rationale 4: Masturbation does not indicate sexual concerns that should be discussed. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Define sexual health. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 937 Question 20 Type: MCSA 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. Correct Answer: 1 Rationale 1: Although all of these statements are true, the primary consideration is that early childhood education on sex should come primarily from parents. Rationale 2: Parents need to be the primary educators of children at an early age; however, peers, teachers, media, and toys also teach about sexual issues. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Parents need to be the primary educators of children at an early age; however, peers, teachers, media, and toys also teach about sexual issues. Rationale 4: Parents need to be the primary educators of children at an early age; however, peers, teachers, media, and toys also teach about sexual issues. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Give examples of how the family, culture, religion, and personal expectations and ethics influence one’s sexuality. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 947 Question 21 Type: MCSA In discussion with teenagers, 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. Correct Answer: 2 Rationale 1: Substituting the term infection for disease makes the diagnosis less threatening and makes it sound more treatable. Rationale 2: The term sexually transmitted disease can elicit guilt, shame, and fear in the client. Rationale 3: Third-party reimbursement is not a reason for choice of terms in this instance. Rationale 4: The preciseness of the term is not an issue. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 949 Question 22 Type: MCSA 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. Correct Answer: 3 Rationale 1: There is no need to ask permission from the physician prior to discussing sexual topics. Rationale 2: Obtaining signed informed consent from both the client and spouse or partner is not required. Rationale 3: 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. Rationale 4: Documentation of precertification for benefits from the client's insurance company would be an issue only if the nurse is acting in the role as a sexual therapist for which insurance would reimburse. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 949 Question 23 Type: MCSA 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. Correct Answer: 2 Rationale 1: Clients deserve information regarding sexual side effects, and the nurse is obligated to provide that information. Rationale 2: LI represents limited information. The nurse should give accurate but concise information regarding sexual matters. Rationale 3: Although the nurse should use terms the client understands, assuming that the client only understands slang terms could cause embarrassment for the client and the nurse. A better strategy is to use correct terms while assessing the client's understanding, changing to more common terms if necessary. Rationale 4: Although reviewing current literature is always a good idea, it does not relate to the LI section of the PLISSIT format. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 950 Question 24 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: Although some therapy may have somatic effects, the nurse should not focus solely on those effects. Rationale 3: Just giving the client a list of expected sexual side effects is not appropriate at this level of the format. Rationale 4: SS does not stand for “same sex.” Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 950 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 25 Type: MCSA 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. Correct Answer: 4 Rationale 1: Using information technology does not reflect this need for more intensive therapy. Rationale 2: Using informal therapeutic groups does not reflect this need for more intensive therapy. Rationale 3: Evaluation of previous interventions and treatments is not a part of the format. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 950 Question 26 Type: MCSA The daughters of an 80-year-old man who is aphasic after suffering a cerebrovascular accident (stroke) express concern that their father is "always exposing and playing with himself and his catheter" while they are in the room. Upon assessment, the nurse finds the client pulling on and rubbing his penis. What is the nurse's priority action? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Tell the client to keep his hands away from his penis. 2. Assess the client's penis for irritation from the catheter. 3. Ask the client to keep his linens at waist level when he has visitors. 4. Collaborate with the physician regarding medications to control this behavior. Correct Answer: 2 Rationale 1: Telling the client to keep his hands away from his penis is inappropriate and assumes the client is masturbating. Rationale 2: The nurse should assess whether this client has irritation of the penis that is causing his actions. The nurse needs to determine if there is a physical reason such as irritation that the client is trying to communicate. Rationale 3: Telling the client to keep his linens pulled up is inappropriate and assumes the client is masturbating. Rationale 4: Medicating the client to control the behavior is inappropriate and assumes that the client is doing something wrong. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Formulate nursing diagnoses and interventions for the client experiencing sexual problems. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 951 Question 27 Type: MCMA After an assessment, the nurse determines that a client has strong sexual health. What did the nurse assess in the client? Standard Text: Select all that apply. 1. Knowledge about sexual behavior 2. Reluctance to discuss sexual history Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 1, 3, 5 Rationale 1: Characteristics of sexual health include knowledge about sexuality and sexual behavior. Rationale 2: Reluctance to discuss sexual history is not a characteristic of sexual health. Rationale 3: Characteristics of sexual health include the right to make free and responsible reproductive choices. Rationale 4: Making a statement that there are no issues with sexuality is not a characteristic of sexual health. Rationale 5: Characteristics of sexual health include the ability to access sexual health care for sexual concerns, problems, and disorders. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Define sexual health. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 938 Question 28 Type: MCMA The nurse is preparing to assess a client’s sexual health. What will the nurse include in this assessment? Standard Text: Select all that apply. 1. Sexual self-concept 2. Body image 3. Gender identity 4. Contraceptive choices Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

5. Employment Correct Answer: 1, 2, 3 Rationale 1: Sexual self-concept is a component of sexual health. Rationale 2: Body image is a component of sexual health. Rationale 3: Gender identity is a component of sexual health. Rationale 4: Contraceptive choices are not a component of sexual health. Rationale 5: Employment is not a component of sexual health. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 938 Question 29 Type: MCSA 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 Correct Answer: 4 Rationale 1: Intersex is a condition in which there are contradictions among chromosomal sex, gonadal sex, internal organs, and external genital appearance. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Transgender individuals have a condition called gender dysphoria, or gender identity disorder: a strong and persistent feeling of discomfort with one’s assigned gender. For the transgendered person, sexual anatomy is not consistent with gender identity. Rationale 3: Homosexuality is not characterized by wearing clothing associated with the opposite sex. Rationale 4: Cross-dressing makes one’s outward appearance consistent with their inner identity and gender role, and increases their comfort with themselves. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Discuss the varieties of sexuality. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 939 Question 30 Type: MCSA 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 practices. 2. Explain the need to use contraception. 3. Explain the importance of having an annual HIV test. 4. Explain thy routine gynecologic examinations are not necessary. Correct Answer: 1 Rationale 1: Oral–genital sex is not completely free of the potential for sexually transmitted illness transmission, and safe sex practices must be used. Rationale 2: Contraception is not necessary for oral–genital sex. Rationale 3: An annual HIV test is not necessary for oral–genital sex. Rationale 4: The nurse should instruct the client on the importance of having routine gynecologic examinations. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Discuss the varieties of sexuality. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 940 Question 31 Type: MCMA 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? Standard Text: 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. Correct Answer: 3, 4, 5 Rationale 1: During the excitement phase of the sexual response cycle in females, there is vaginal lubrication. Rationale 2: During the excitement phase of the sexual response cycle in females, the inner two-thirds of the vagina widens and lengthens, and the outer third swells and narrows. Rationale 3: Physiological changes in females during the excitement phase of the sexual response cycle include erection of the clitoris. Rationale 4: Physiological changes in females during the excitement phase of the sexual response cycle include enlargement of the breasts. Rationale 5: Physiological changes in females during the excitement phase of the sexual response cycle include elevation of the uterus. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe physiological changes during the sexual response cycle. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 942 Question 32 Type: MCMA When discussing the orgasmic phase of the sexual response cycle, what should the nurse include as physiological changes that affect both sexes? Standard Text: 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. Correct Answer: 1, 2, 4 Rationale 1: 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. Rationale 2: Physiological changes that affect both sexes during the orgasmic phase of the sexual response cycle include involuntary muscle spasms throughout the body. Rationale 3: Physiological changes that affect both sexes during the orgasmic phase of the sexual response cycle include an increase in heart rate, not a decrease. Rationale 4: Physiological changes that affect both sexes during the orgasmic phase of the sexual response cycle include an increase of systolic blood pressure of 20–30 mm Hg above normal.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: Physiological changes that affect both sexes during the orgasmic phase of the sexual response cycle include an increase in diastolic blood pressure, not a decrease. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe physiological changes during the sexual response cycle. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 942 Question 33 Type: MCSA 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. Correct Answer: 2 Rationale 1: This is a physiological change that affects both sexes. Rationale 2: 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. Rationale 3: This is a physiological change that affects both sexes. Rationale 4: This is a physiological change that affects both sexes. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe physiological changes during the sexual response cycle. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 942 Question 34 Type: MCMA The nurse is conducting a sexual health history with a client. What questions should the nurse ask during this history? Standard Text: 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?” Correct Answer: 2, 3, 4 Rationale 1: Asking the client to describe erotic fantasies is not appropriate. Rationale 2: Asking whether the client is sexually active is appropriate for the nurse. Rationale 3: Asking whether the client has any pain with sexual interaction is appropriate. Rationale 4: Asking whether the client has any difficulty with sexual desire is appropriate. Rationale 5: Asking what the client likes the best about having sex is not appropriate. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 946 Question 35 Type: MCSA 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?” Correct Answer: 4 Rationale 1: This question is not necessarily appropriate for an older client. Rationale 2: This question is not appropriate for the nurse to ask any client. Rationale 3: This question is not appropriate for an older client. Rationale 4: 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?” Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 946 Question 36 Type: MCSA The nurse is preparing educational materials to be used when instructing clients on testicular and breast selfexamination. What would be applicable for both sets of instructions? 1. Perform palpation in the shower. 2. Perform the examination lying down. 3. Perform the examination once each week. 4. Perform the examination bimonthly. Correct Answer: 1 Rationale 1: One optional method to palpate the breasts is to perform the self-examination in the shower. For the testicular self-examination, the examination should be done in the bath or the shower. Rationale 2: The testicular examination is not performed lying down. Rationale 3: The testicular and breast self-examinations should be done monthly. Rationale 4: The testicular and breast self-examinations should be done monthly. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 948 Question 37 Type: MCMA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 health care provider? Standard Text: 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 Correct Answer: 1, 2, 5 Rationale 1: The client should be instructed to observe for puckering of the skin. Rationale 2: The client should be instructed to observe for changes in the size or shape of the breasts. Rationale 3: The breasts should have free movement over the chest wall. Rationale 4: Nipple symmetry is a normal assessment finding. Rationale 5: The client should be instructed to observe for changes in the size or shape of the breasts. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 948 Question 38 Type: MCMA The nurse is teaching a class of young adult men and women. What self-examination schedules should the nurse instruct these participants to follow? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Standard Text: Select all that apply. 1. Monthly breast self-exams for women 2. Yearly breast self-exams for men 3. Weekly testicular self-exams for men 4. Monthly breast self-exams for men 5. Yearly vulvar self-exams for women Correct Answer: 1, 4 Rationale 1: Women should be instructed to examine their breasts on a monthly schedule. Rationale 2: Men should be instructed to examine their breasts on a monthly schedule. Rationale 3: Men should be instructed to examine their testicles monthly. Rationale 4: Men should be instructed to examine their breasts on a monthly schedule. Rationale 5: There is no need for a yearly scheduled vulvar self-exam for women, as any abnormalities noticed should be examined by the woman or her health care provider immediately. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 948 Question 39 Type: MCMA While the nurse is measuring blood pressure, the client lifts his hand and fondles the nurse’s breast. What should the nurse do about this behavior? Standard Text: Select all that apply. 1. Ignore the fondling. 2. Move the client’s hand away. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Refocus the client on appropriate behavior. 4. Tell the client to stop performing the behavior. 5. Communicate that the behavior is not acceptable. Correct Answer: 2, 3, 4, 5 Rationale 1: The nurse needs to set limits with the client, and ignoring the behavior would communicate that it is acceptable. Rationale 2: The nurse needs to set firm limits and take the client’s hand and move it away. Rationale 3: The nurse needs to try to refocus the client from the inappropriate behavior to appropriate behavior. Rationale 4: The nurse needs to set firm limits and tell the client to stop the behavior. Rationale 5: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Formulate nursing diagnoses and interventions for the client experiencing sexual problems. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 951 Question 40 Type: MCMA 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? Standard Text: Select all that apply. 1. Antibiotics 2. Antipyretics 3. Cardiotonics 4. Beta-blockers 5. Anticoagulants Correct Answer: 3, 4 Rationale 1: Antibiotics are not identified as altering sexual response or desire. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Antipyretics are not identified as altering sexual response or desire. Rationale 3: Cardiotonics decrease sexual desire Rationale 4: Beta-blockers decrease sexual desire. Rationale 5: Anticoagulants are not identified as altering sexual response or desire. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Formulate nursing diagnoses and interventions for the client experiencing sexual problems. MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care. Page Number: 944

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 41 Question 1 Type: MCSA 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. Correct Answer: 2 Rationale 1: Nurses do provide holistic care, but so do many other health care professionals. Rationale 2: The nurse is concerned about the client's spiritual health because meeting spiritual needs can decrease suffering. Rationale 3: Physical needs can be addressed and healed without considering the spiritual side, but in order to provide holistic care both should be addressed. Rationale 4: Although the nurse must assess and understand the client's spirituality, it is not necessary for the nurse's ideas to match those of the client. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 954 Question 2 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 1 Rationale 1: The first step in successfully working with a client with spiritual distress is establishing a trusting nurse–client relationship. Rationale 2: This would not be the nurse’s primary intervention. Rationale 3: This would not be an effective intervention for the client experiencing spiritual distress. Rationale 4: This would not be an effective intervention for the nurse to make initially. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe methods to assess the spiritual and religious preferences, strengths, concerns, or distress of clients and plan appropriate nursing care. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 963 Question 3 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. The nurse should establish regular religious services in the facility. Correct Answer: 1 Rationale 1: 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. Rationale 2: Learning about diverse spiritual beliefs and practices would be appropriate after the nurse identifies awareness of spirituality within the self. Rationale 3: Going to church more often presupposes that spirituality and religion are the same which is not true. Rationale 4: Establishing regular religious services in the facility presupposes that spirituality and religion are the same, which is not true. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe strategies that can increase a nurse’s own spiritual awareness. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 965

Question 4 Type: MCMA A client who is facing a final surgery to save his life asks the nurse to stay and pray with him until the surgery begins. In which ways should the nurse demonstrate presencing with this client? Standard Text: 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 Correct Answer: 4, 5 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Adjusting the intravenous infusion demonstrates partial presence by being present; however, there is more to presencing than just attending to a task. Rationale 2: Talking with the client about the surgery does not demonstrating presencing because this does not fulfill the client’s request for the nurse to stay and pray. Rationale 3: Sitting next to the client in the holding area may demonstrate physical presence; however, the nurse is not fulfilling the client’s request. Rationale 4: Praying with the client for divine intervention demonstrates transcendent presence because the nurse is spiritually present for the client. Rationale 5: Focusing on the client and fulfilling his needs demonstrates full presence. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe methods to assess the spiritual and religious preferences, strengths, concerns, or distress of clients and plan appropriate nursing care. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 962 Question 5 Type: MCSA 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. Correct Answer: 4 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Polytheism is the belief in more than one God. Rationale 2: Atheists do not believe in a God. Rationale 3: Monotheism is the belief in one God. Rationale 4: Agnostics are persons who doubt the existence of God or a Supreme Being or believe the existence of God has not been proven. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe the influence of spiritual and religious beliefs and practices that can have an impact on a client’s health care: holy days, sacred texts, prayer and meditation, diet, healing, dress, birth, and death. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 955 Question 6 Type: MCSA 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." Correct Answer: 2 Rationale 1: If the nurse tells the client that it is too late to do anything about the problem, there is a possibility that distress will increase. Rationale 2: This client is in distress and is seeking forgiveness. The nurse should offer this forgiveness and a reason the forgiveness is valid. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Suggesting that the hospital chaplain be called for prayer reinforces that smoking cigarettes is a sin. Rationale 4: This option minimizes the client's concerns and does not offer forgiveness. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe the influence of spiritual and religious beliefs and practices that can have an impact on a client’s health care: holy days, sacred texts, prayer and meditation, diet, healing, dress, birth, and death. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 955 Question 7 Type: MCSA 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. Correct Answer: 3 Rationale 1: Offering to pray with the client is over the boundary of professional practice unless the client requests such intervention and the nurse is comfortable with the arrangement. Rationale 2: Offering to pray for the client is over the boundary of professional practice unless the client requests such intervention and the nurse is comfortable with the arrangement. Rationale 3: The client can be asked general questions to elicit information about what beliefs and practices are important to the present health care situation, and what, if anything, the client would like from the health care team to support spiritual health. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: At this point, there is no information that indicates the client is in need of referral for counseling. This would occur only if the client demonstrates spiritual distress at the level best handled by a specialist. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe nursing care/therapeutics to support religiosity and promote clients’ spiritual health. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 960 Question 8 Type: MCSA 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. Correct Answer: 3 Rationale 1: The fact that there is a policy to remove all jewelry is simply a policy, and an exception might be made and documented in this case. Rationale 2: The nurse should not tell the client that the medal will be allowed, as this decision belongs to those directly involved in the procedure. Rationale 3: 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. Rationale 4: Removing the medal and placing it on the head of the bed is not a good choice. There may be no reason to remove the medal. Placing the medal on the head of the bed might allow it to be lost. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale:

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe nursing care/therapeutics to support religiosity and promote clients’ spiritual health. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 957 Question 9 Type: MCSA The emergency department nurse contacts the admissions office to request a bed for a bed-bound 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. Correct Answer: 2 Rationale 1: There is no restriction that the room must be private. Rationale 2: 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. Rationale 3: There is no indication that the client will have hospital linens replaced by special sheets. Rationale 4: There is no restriction that the other client in a semi-private room must be Muslim. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe nursing care/therapeutics to support religiosity and promote clients’ spiritual health. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 959 Question 10 Type: MCSA A client who is devoutly Jewish is hospitalized during Yom Kippur, a time when many of the Jewish faith fast. The client expresses a desire to follow this religious pattern. 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. Correct Answer: 1 Rationale 1: The nurse should support the client's desires to the extent possible. Rationale 2: Because this client is a devout follower of Jewish tradition, it is not up to the nurse to instruct the client regarding Jewish law. Rationale 3: The nurse should not attempt to convince the client to ignore the tradition. Rationale 4: The physician also cannot ethically make this decision for the client. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe nursing care/therapeutics to support religiosity and promote clients’ spiritual health. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 958 Question 11 Type: MCSA The female client belongs to a religious community that requires women to dress conservatively in clothing that covers the arms and the knees. This client expresses concern that her 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, her body must be exposed. 4. Ask the cath lab charge nurse to come to the client's room to talk with her about the concerns. Correct Answer: 4 Rationale 1: Although medical personnel are often exposed to unclothed bodies, that information will not make this client more at ease. Rationale 2: Just making a note in the chart is not sufficient. Rationale 3: This is not sufficient to meet the client’s needs. Rationale 4: The best plan is to have the cath lab charge nurse talk to the client about her concerns. The charge nurse can then assure the client that even though a small part of her body must be exposed, her modesty will be protected. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe nursing care/therapeutics to support religiosity and promote clients’ spiritual health. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 959 Question 12 Type: MCSA 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. Correct Answer: 2 Rationale 1: The concern of this family will be baptism of the infant, not circumcision. Rationale 2: In this situation, the best choice is to have the hospital chaplain present in the delivery room. Rationale 3: This might be applicable if no other option, such as a Catholic chaplain, is available. Rationale 4: Transfer of a laboring woman to another facility is not possible. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Describe nursing care/therapeutics to support religiosity and promote clients’ spiritual health. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 959 Question 13 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The family of a dying client has informed the nurse that their religion requires that a ritual bath be given by members of the faith after death. Because the hospital unit is very busy and there is an acute need for every bed, how 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. Correct Answer: 2 Rationale 1: There is no need to notify the mortuary. Rationale 2: 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. Rationale 3: The nurse should not tell the family that they will have to delay the bath until the body is removed. Rationale 4: The nurse should not put a deadline on the bath. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe nursing care/therapeutics to support religiosity and promote clients’ spiritual health. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 959 Question 14 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. The assessment can now move on to physical assessment. 4. No further specific spiritual assessment is currently necessary. Correct Answer: 4 Rationale 1: If the client is satisfied and content with current levels of spirituality, there is no further specific spiritual assessment necessary. Rationale 2: There is no need to validate spiritual assessment with family unless there is a question of the client's reliability as a historian. Rationale 3: The spiritual assessment should take place at the end of the assessment, so physical assessment should already have been completed. Rationale 4: If the client is satisfied and content with current levels of spirituality, there is no further specific spiritual assessment necessary. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe methods to assess the spiritual and religious preferences, strengths, concerns, or distress of clients and plan appropriate nursing care. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 960 Question 15 Type: MCSA The client tells the nurse, "I don't know what to do. The treatment plan my physician has suggested is against some of my religious beliefs." What nursing diagnosis problem statement should the nurse identify as appropriate for this client? 1. Ineffective Coping 2. Decisional Conflict 3. Impaired Religiosity 4. Anxiety Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 2 Rationale 1: There is no evidence that this client is coping ineffectively. Rationale 2: 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. Rationale 3: Impaired Religiosity is impairment of the ability to exercise religious beliefs, which has not yet occurred in this situation. Rationale 4: Although there may be some anxiety, that nursing diagnosis is not specific to this situation. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 6. Describe nursing care/therapeutics to support religiosity and promote clients’ spiritual health. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 961 Question 16 Type: MCSA 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. Correct Answer: 2 Rationale 1: This may or may not be true. Rationale 2: Keeping in touch with nature is a form of spiritual care for these residents. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Although this might be true, this is not the rationale for this intervention. Rationale 4: Although this might be true, this is not the rationale for this intervention. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Describe nursing care/therapeutics to support religiosity and promote clients’ spiritual health. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 961 Question 17 Type: MCSA 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. Correct Answer: 4 Rationale 1: Standing inside the room is a violation of privacy and may also unduly influence the length of the prayer session. Rationale 2: Although it is perfectly acceptable for the nurse to pray with clients, joining the prayer without invitation is not acceptable. Rationale 3: The nurse should not interrupt the prayer to request to perform a task. Rationale 4: The nurse should wait in the hall until the prayer is over and the client or family give permission to enter the room. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe nursing care/therapeutics to support religiosity and promote clients’ spiritual health. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 963 Question 18 Type: MCSA The newly hired nurse notices that coworkers routinely pray with clients and their families. The nurse has never been particularly religious or spiritual and is unaccustomed to praying, but holds no strong feeling against prayer. What is the best strategy for the nurse to plan for such situations? 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. Correct Answer: 3 Rationale 1: It is impossible to be certain that the nurse will not be caring for a patient who will ask for prayer, especially because the practice of prayer is somewhat routine on this unit. Rationale 2: Having a coworker substitute for the nurse will be difficult to operationalize and may not always be an option, so the nurse would need some preparation anyway. Rationale 3: 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. Rationale 4: The second best option is to stand silently at the bedside while others pray. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Describe nursing care/therapeutics to support religiosity and promote clients’ spiritual health. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 963 Question 19 Type: MCSA The nurse has developed a strong rapport with a client whose medical care necessitates transfusion of multiple units of blood. The client has a religious objection to this treatment even though it is necessary to sustain life. What action should the nurse take? 1. Use the rapport established 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. Correct Answer: 3 Rationale 1: Using the rapport established to influence the decision is unethical. Rationale 2: Just explaining scientific reasons will not generally make a difference in the client's decision. Rationale 3: This is a delicate situation for a nurse who has developed a rapport and relationship with a client. 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. Rationale 4: This is unethical and should not be done by the nurse. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Recognize the importance of providing ethical spiritual care. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 964 Question 20 Type: MCSA 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. Correct Answer: 2 Rationale 1: Asking who God is assumes that the child's religion recognizes God. At this age, the child is a little young to articulate the identity of God. Rationale 2: 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. Rationale 3: If the child does not routinely pray before meals, the nurse should not introduce this activity. Rationale 4: Bringing in a Bible storybook to read to the child assumes that the child holds certain religious beliefs. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe nursing care/therapeutics to support religiosity and promote clients’ spiritual health. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 957 Question 21 Type: MCSA 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? Correct Answer: 3 Rationale 1: Although it is true that the nurse's personal life is private, the nurse might decide to self-disclose. Rationale 2: Some cultures do believe that religion and politics should not be discussed in polite interactions, but the client does deserve some answer to the question. Rationale 3: 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. Rationale 4: Although considering the culture of the unit is important, the nurse can make the clinical decision that what is generally done on the unit does not apply in this situation. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe methods to assess the spiritual and religious preferences, strengths, concerns, or distress of clients and plan appropriate nursing care. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 963 Question 22 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: This statement makes it appear as if the prayer was just one more task in the nurse's list of responsibilities and would not be appropriate. Rationale 2: The nurse should not pat the client and leave the room silently. This would not support the client's spiritual needs. Rationale 3: 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. Rationale 4: Asking if there is anything else the nurse can do makes the prayer look like just another task in a busy day. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe nursing care/therapeutics to support religiosity and promote clients’ spiritual health. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 965 Question 23 Type: MCSA The client diagnosed with diabetes mellitus develops diabetic ketoacidosis after a religious fast. The client tells the nurse, "I have fasted during this season every year since I became an adult. I am not going to stop now." The nurse is not knowledgeable about this particular religion. What is the best action for this nurse? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 4 Rationale 1: Telling the client that life is different now does not support religious beliefs. Rationale 2: Research into the meaning of fasting in this religion would be educative for the nurse, but the client requires more immediate intervention. Rationale 3: Asking the family to talk to the client might help, but the diabetes educator would be able to provide more direct and helpful information for the client. Rationale 4: The diabetes educator should be contacted to work with the client on strategies that might allow the fasting to occur in a safe manner. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe the influence of spiritual and religious beliefs and practices that can have an impact on a client’s health care: holy days, sacred texts, prayer and meditation, diet, healing, dress, birth, and death. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 958 Question 24 Type: MCSA The client states, "I don't know what all this fuss is about religion. God died years ago." The nurse does believe in God and has a strong inclination to share reasons for that belief with the client. What is the best question for the nurse to consider before responding to the client's remark? 1. "Will I get into trouble if I say anything?" 2. "How much longer will I be caring for this client?" Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. "Am I meeting my needs or the client's?" 4. "How can I best make this client understand?" Correct Answer: 3 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe nursing care/therapeutics to support religiosity and promote clients’ spiritual health. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 959

Question 25 Type: MCMA 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? Standard Text: Select all that apply. 1. Support the client to have hope for a cure. 2. Suggest the client view losses as liberations. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 2, 3, 4 Rationale 1: Supporting the client to have hope for a cure does not support the client’s spiritual development. Rationale 2: A nursing action to support the older client’s spiritual development includes supporting the client to reframe losses of aging as liberations. Rationale 3: A nursing action to support the older client’s spiritual development includes encouraging the client to conduct a life review or reminisce. Rationale 4: A nursing action to support the older client’s spiritual development includes asking open-ended questions to encourage open discussion about the client’s life. Rationale 5: Reminding the client that time is running out to make any life changes does not support the client’s spiritual development. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Appreciate spiritual development by describing spiritual developmental issues of childhood and aging in particular. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 957

Question 26 Type: MCMA 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? Standard Text: Select all that apply. 1. Expressing anger toward God Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 1, 5 Rationale 1: Defining characteristics of spiritual distress include expressing anger toward God. Rationale 2: Crying softly in the client’s room is not a defining characteristic of spiritual distress. Rationale 3: Hugging family members is not a defining characteristic of spiritual distress. Rationale 4: Talking with caregivers about the client’s personal items is not a defining characteristic of spiritual distress. Rationale 5: Defining characteristics of spiritual distress include refusing comfort from family. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe methods to assess the spiritual and religious preferences, strengths, concerns, or distress of clients and plan appropriate nursing care. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 955 Question 27 Type: MCSA The nurse determines that a middle-aged client has developed spiritually. What client statement caused the nurse 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.” Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. “I attend the same church as my parents and follow the customs of my culture.” Correct Answer: 1 Rationale 1: 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. Rationale 2: Stating that the tales in the Bible are real is a characteristic of a school-age client. Rationale 3: Attending services with friends on most Sundays is a characteristic of spiritual development of the adolescent. Rationale 4: Attending the same church and following cultural customs is a characteristic of a school-age client. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Describe methods to assess the spiritual and religious preferences, strengths, concerns, or distress of clients and plan appropriate nursing care. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 955

Question 28 Type: MCSA 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. Correct Answer: 1 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: 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. Rationale 2: The client statement that nothing can be done spiritually would not be evidence that interventions to address the diagnosis of Spiritual Distress have been effective. Rationale 3: The client’s planning to see a psychologist would not be evidence to support that interventions to address the diagnosis of Spiritual Distress have been effective. Rationale 4: The client’s thanking the nurse for trying to help improve feelings would not be evidence to support that interventions to address the diagnosis of Spiritual Distress have been effective. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Describe methods to assess the spiritual and religious preferences, strengths, concerns, or distress of clients and plan appropriate nursing care. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 965 Question 29 Type: MCSA 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. Correct Answer: 4 Rationale 1: There is not enough information to determine whether the client does not have family members to discuss spiritual issues. Rationale 2: The nurse has no way of knowing whether the client is searching for answers. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Requesting to talk with a spiritual counselor does not mean that the client does not want to talk with the nurse about spiritual concerns. Rationale 4: Requesting to talk with a spiritual counselor and desiring spiritual reading material indicate that interventions for the diagnosis of Spiritual Distress have been effective. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Compare and contrast spiritual needs, spiritual distress, and spiritual health. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 961 Question 30 Type: MCMA The nurse is planning to conduct a spiritual self-assessment. What questions would the nurse include in this assessment? Standard Text: 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?” Correct Answer: 1, 2, 4, 5 Rationale 1: “What makes me joyful?” is a question used for spiritual self-assessment. Rationale 2: “What causes me to feel despair?” is a question used for spiritual self-assessment. Rationale 3: “What possessions do I value the most?” is a question used for identifying significant values. Rationale 4: “What is my purpose in life?” is a question used for spiritual self-assessment. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: “What feeds my spirit?” is a question used for spiritual self-assessment. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 health care NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Describe strategies that can increase a nurse’s own spiritual awareness. MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care. Page Number: 965 Question 31 Type: MCMA The nurse is engaging in an activity to develop spiritual self-awareness. What activities can aid the nurse in achieving this goal? Standard Text: 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. Correct Answer: 3, 4, 5 Rationale 1: Writing a will is not a strategy to develop spiritual self-awareness. Rationale 2: Completing an advance directives form is not a strategy to develop spiritual self-awareness. Rationale 3: Exploring personal end-of-life issues is a strategy to develop spiritual self-awareness. Rationale 4: Creating a personal loss history is a strategy to develop spiritual self-awareness. Rationale 5: Listing significant values is a strategy to develop spiritual self-awareness. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 42 Question 1 Type: MCSA 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." Correct Answer: 4 Rationale 1: The scales take into consideration both positive and negative events. Rationale 2: Stress scales focus on recently occurring events. Rationale 3: The scales are only an idea of stress level because each individual reacts to stressful events differently. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify essential aspects of assessing a client’s stress and coping patterns. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 973 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 2 Type: MCSA The client has just received news of the death of a relative. Over the next few hours, what physiologic 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 Correct Answer: 2 Rationale 1: Blood pressure rises in response to angiotensin production. Rationale 2: 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. Rationale 3: Norepinephrine release decreases blood flow to the kidney, which could make urine output decrease. Rationale 4: The bronchial tree dilates, allowing more oxygen intake that would result in increased oxygen saturation. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify physiological, psychological, and cognitive indicators of stress. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 973 Question 3 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The nursing student admits to being mildly anxious about an upcoming examination. What is the likely result of this level of anxiety? 1. The student's perception and learning is enhanced. 2. The student's attention is focused solely on studying for the examination. 3. The student's only topic of conversation is the examination. 4. The student cannot talk about the examination without crying. Correct Answer: 1 Rationale 1: With mild anxiety, the student's perception and learning will be enhanced. Rationale 2: Focusing only on studying for the examination would indicate a moderate anxiety level. Rationale 3: Severe anxiety is the level at which the examination would consume all of the student's energy. Rationale 4: Panic is the state in which the student might lose control of emotions regarding the examination. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify physiological, psychological, and cognitive indicators of stress. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 975 Question 4 Type: MCSA 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 physiologic response, whereas anxiety is psychologic. 3. The source of fear is identifiable, but anxiety may be vague. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Anxiety is generally based in reality, fear is not. Correct Answer: 3 Rationale 1: Fear and anxiety are different, so anxiety is not just a milder form of fear. Rationale 2: Both fear and anxiety can have physiologic and psychologic components. Rationale 3: The source of fear is identifiable, but anxiety is vague. Rationale 4: Fear and anxiety can both be based in reality or may not be based in reality. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Identify physiological, psychological, and cognitive indicators of stress. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 976 Question 5 Type: MCSA 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. Correct Answer: 4 Rationale 1: The nurse should not try to eat lunch while working. This will not help reduce feeling overwhelmed at work.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Getting adequate sleep and rest is one way to reduce feeling overwhelmed and stressed. Getting up earlier may cause enhanced feelings of stress because of fatigue. Rationale 3: The nurse needs time to relax through spending time with family and in other activities. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss types of coping and coping strategies. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 981 Question 6 Type: MCSA The nurse is caring for a critically ill child. While the nurse is preparing to administer a treatment to the child, the child's mother 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 mother that she needs to control herself for the benefit of her child. 2. Distract the mother by having her straighten the linens on the bed. 3. Explain the procedure that will occur with the treatment. 4. Take the mother out of the room and comfort her. Correct Answer: 4 Rationale 1: Although the mother's expression of anxiety is understandable, the child should be protected from this strongly upsetting situation. Just telling the mother to control herself discounts the seriousness of her anxiety and may serve to alienate the mother from the nurse. Rationale 2: This mother is too upset to distract by smoothing linens. Rationale 3: Explaining the procedure may help, but the mother should be removed at least temporarily and be comforted so that she will be able to receive the information. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: In this situation, the nurse must analyze which of the available options would be best for this mother and child. At this level of emotion, the nurse should remove the mother from the room and comfort her. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Identify essential aspects of assessing a client’s stress and coping patterns. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 981 Question 7 Type: MCSA 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 until he is under control. 2. Apologize to the client for the unit rules, but tell him the rules must be followed. 3. Tell the client that it is understandable that he is upset, but the no-smoking rule is not negotiable. 4. Tell the client that he is acting like a child and that such behavior will not be tolerated. Correct Answer: 3 Rationale 1: The nurse cannot refuse to care for the client once the assignment has been accepted, as this may constitute client abandonment. Rationale 2: The nurse should not assume responsibility for the anger by apologizing. Rationale 3: Telling the client that it is understandable that he is upset serves to show that the nurse accepts his right to be angry, but that the anger is the client's. Rationale 4: Admonishing the client by saying that he is acting like a child is not professional and will most likely serve to destroy any hope of resolving this issue. Global Rationale: Cognitive Level: Applying Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe interventions to help clients minimize and manage stress. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 981 Question 8 Type: MCSA 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." Correct Answer: 2 Rationale 1: A crisis results in such a state of disequilibrium that it is generally self-limiting and not a long-term event. Rationale 2: In general, people are more successful in working through a crisis if they have someone to help them. Rationale 3: The need for help during a crisis is not dependent upon the client's gender. Rationale 4: Experiencing a crisis may actually offer the family or individual a potential for growth and change. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 7. Identify essential aspects of assessing a client’s stress and coping patterns. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 982 Question 9 Type: MCSA 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. Correct Answer: 2 Rationale 1: Asking physicians to assume nursing tasks is not appropriate. Rationale 2: 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. Rationale 3: Counseling cannot be made a requirement for the staff. Rationale 4: Exercise cannot be made a requirement by the organization's administration. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9. Describe interventions to help clients minimize and manage stress. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 983 Question 10 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The nurse identifies that a client has not met the expected outcome established for the 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. Correct Answer: 4 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9. Describe interventions to help clients minimize and manage stress. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 983 Question 11 Type: MCSA 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 has progressed to which anxiety level? 1. Mild Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Moderate 3. Severe 4. Panic Correct Answer: 3 Rationale 1: Mild anxiety causes an increase in questioning. Rationale 2: Moderate anxiety results in voice tremors and pitch changes. Rationale 3: At severe levels of anxiety, communication is difficult to understand. Rationale 4: Communication may not be understandable at all when the client reaches the panic stage. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe the three stages of Selye’s general adaptation syndrome. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 975 Question 12 Type: MCSA 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. Correct Answer: 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: There is no indication that the client doesn't understand the report. Rationale 2: Anxiety can be the result of both positive and negative stimuli. Rationale 3: There is no indication that the client discounts the need for teaching. Rationale 4: The amount of information retained may be drastically reduced by this level of anxiety, so the nurse should take extra pains to ascertain if the client understands the teaching. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Differentiate four levels of anxiety. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 975 Question 13 Type: MCSA 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 Correct Answer: 2 Rationale 1: Compensation is covering up weaknesses by emphasizing strength or by overachievement. Rationale 2: Denial is an attempt to ignore unacceptable realities by refusing to acknowledge them. Rationale 3: Displacement is transferring emotional reactions from one object or person to another object or person. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Identification is an attempt to manage anxiety by imitating the behavior of someone feared or respected. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify behaviors related to specific ego defense mechanisms. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 977 Question 14 Type: MCSA The victim of domestic abuse tells the nurse, "I know my spouse didn't mean to hurt me. The situation just got out of hand." The nurse recognizes that the client is exhibiting which defense mechanism? 1. Intellectualization 2. Introjection 3. Projection 4. Minimization Correct Answer: 4 Rationale 1: Intellectualization is a defense mechanism in which an uncomfortable or painful reality is evaded by using a rational explanation that removes personal significance from the event. Rationale 2: Introjection is a form of identification in which the person adopts another person's norms or values, even if those norms or values are contrary to what the person would have previously assumed. Rationale 3: Projection is blaming another person or the environment for one's own unacceptable thoughts, shortcomings, or failures. Rationale 4: Minimization is not acknowledging the significance of a behavior. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify behaviors related to specific ego defense mechanisms. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 981 Question 15 Type: MCSA 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 Correct Answer: 1 Rationale 1: Reaction formation is a mechanism that causes people to act exactly opposite to the way they feel. Rationale 2: Rationalization is justification of behaviors by faulty logic and by ascribing socially acceptable motives to the behavior. Rationale 3: Regression is resorting to an earlier, more comfortable level of functioning that is less demanding. Rationale 4: Reparation is not a recognized defense mechanism. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify behaviors related to specific ego defense mechanisms. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 977 Question 16 Type: MCSA 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 Correct Answer: 2 Rationale 1: Repression is an unconscious mechanism by which threatening thoughts and feelings are kept from becoming conscious. Rationale 2: Sublimation is displacement of sexual drives into more socially acceptable activities. Rationale 3: Substitution is a mechanism in which highly valued, unacceptable, or unavailable objects are replaced by less valuable, acceptable, or available objects. Rationale 4: Undoing is an action or words designed to cancel out some disapproved thoughts, impulses, or acts or in which the person acts to make reparation for a wrong. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify behaviors related to specific ego defense mechanisms. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 977 Question 17 Type: MCSA 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 Correct Answer: 4 Rationale 1: The normal response to anxiety is increased heart rate. Rationale 2: The normal response to anxiety is an increased rate and depth of respirations. Rationale 3: The normal response to anxiety is the retention of sodium and water, which might be reflected in a low-normal hematocrit due to increased blood volume. Rationale 4: The blood sugar generally increases because of the release of glucocorticoids and gluconeogenesis. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify physiological, psychological, and cognitive indicators of stress. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 976 Question 18 Type: MCSA 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. Correct Answer: 3 Rationale 1: Explaining all procedures in detail may overwhelm the client. Using short, clear sentences and explaining only enough to satisfy the client is a better plan. Rationale 2: A client who is ill cannot be expected to make the majority of decisions about the plan of care, but should be allowed as much autonomy and choice as can be arranged and tolerated. Rationale 3: 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. Rationale 4: Using multiple nurses for care can increase anxiety. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9. Describe interventions to help clients minimize and manage stress. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 981 Question 19 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 teenagers 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 teenagers and the increased risk of suicide. 4. Most of the SSRI antidepressant medications will deliver a marked improvement in depression within 3 to 4 days of the first dose. Correct Answer: 3 Rationale 1: Although the client may come to depend upon the medication relieving depression, the drugs are not addictive. Rationale 2: The medications must be taken with sufficient water, but a full meal is not necessary. Rationale 3: The major concern regarding use of antidepressants and teenagers is the increased risk for suicide. Rationale 4: Most of the SSRI antidepressant medications take at least 1 to 2 weeks to improve symptoms. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe interventions to help clients minimize and manage stress. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 983 Question 20 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: There is no evidence of parental abuse. Rationale 2: There is no evidence that the client is developmentally delayed. Rationale 3: Toddlers and preschool children often react to anxiety by either withdrawing or acting out. This child is behaving in a normal manner. Rationale 4: There is no evidence that the client is depressed. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify physiological, psychological, and cognitive indicators of stress. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 984 Question 21 Type: MCSA 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. The nurse identifies this client’s reaction to stress as being a 1. stimulus. 2. response. 3. transaction. 4. negotiation. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1 Rationale 1: 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. Rationale 2: Stress that is considered as a response is defined as the nonspecific response of the body to any kind of demand made upon it. Rationale 3: 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. Rationale 4: Negotiation is not a type of stress reaction. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Differentiate the concepts of stress as a stimulus, as a response, and as a transaction. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 973 Question 22 Type: MCSA 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 Correct Answer: 4 Rationale 1: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Stress that is considered a response is defined as the nonspecific response of the body to any kind of demand made upon it. Rationale 3: Combination is not a type of reaction to stress. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Differentiate the concepts of stress as a stimulus, as a response, and as a transaction. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 974 Question 23 Type: MCSA The nurse identifies that a client is experiencing the resistance stage of the 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. Correct Answer: 3 Rationale 1: The client’s inability to focus on activities and events is not a characteristic of the resistance stage of the general adaption syndrome. Rationale 2: The client’s being exhausted and sleeping are characteristics of the stage of exhaustion within the general adaption syndrome.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: In the second stage in the 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. Rationale 4: An elevated capillary blood glucose level is a finding associated with the alarm stage of the general adaption syndrome. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe the three stages of Selye’s general adaptation syndrome. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 973 Question 24 Type: MCMA A client is experiencing the shock phase within the general adaption syndrome. The nurse realizes that this phase affects which hormones? Standard Text: Select all that apply. 1. Epinephrine 2. Estrogen 3. Norepinephrine 4. Corticotropin-releasing 5. Progesterone Correct Answer: 1, 3, 4 Rationale 1: In the alarm phase of the general adaption syndrome, epinephrine secretion is increased, which affects heart rate, breathing, and blood-clotting mechanisms. Rationale 2: Estrogen is not affected in the alarm phase of the general adaption syndrome. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: In the alarm phase of the general adaption syndrome, norepinephrine secretion is increased, which decreases blood flow to the kidney and increases renin release. Rationale 4: 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. Rationale 5: Progesterone is not affected in the alarm phase of the general adaption syndrome. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe the three stages of Selye’s general adaptation syndrome. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 973 Question 25 Type: MCSA 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. Correct Answer: 2 Rationale 1: Problem solving involves thinking through the threatening situation, using specific steps to arrive at a solution. The person assesses the situation or problem, analyzes or defines it, chooses alternatives, carries out the selected alternative, and evaluates whether the solution was successful. Rationale 2: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Rationale 3: Structuring is the arrangement or manipulation of a situation so that the threatening events do not occur. Rationale 4: Daydreaming is likened to make-believe. Unfulfilled wishes and desires are imagined as fulfilled, or a threatening experience is reworked or replayed so that it ends differently from reality. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify physiological, psychological, and cognitive indicators of stress. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 977 Question 26 Type: MCMA 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? Standard Text: Select all that apply. 1. Dilated pupils 2. Diaphoretic 3. Tachycardia 4. Flaccid muscle tone 5. Excessive oral secretions Correct Answer: 1, 2, 3 Rationale 1: Pupils dilate to increase visual perception when serious threats to the body arise. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Sweat production or diaphoresis increases to control elevated body heat due to increased metabolism. Rationale 3: The heart rate increases to transport nutrients and by-products of metabolism more efficiently. Rationale 4: Muscle tension increases to prepare for rapid motor activity or defense. Rationale 5: The mouth might be dry, and would not have an increase in oral secretions. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify physiological, psychological, and cognitive indicators of stress. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 976 Question 27 Type: MCMA The nurse is concerned that a client diagnosed with a chronic illness is experiencing depression. What did the nurse assess in this client? Standard Text: Select all that apply. 1. Weight gain 2. Irritability 3. No appetite 4. Constipation 5. Complaints of headache and dizziness Correct Answer: 2, 3, 4, 5 Rationale 1: Physical signs of depression include weight loss, not weight gain. Rationale 2: Behavioral signs of depression include irritability. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Physical signs of depression include loss of appetite. Rationale 4: Physical signs of depression include constipation. Rationale 5: Physical signs of depression include headache and dizziness. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify physiological, psychological, and cognitive indicators of stress. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 977 Question 28 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Long-term coping strategies can be constructive and practical, and include talking with others, eating a healthy diet, exercising regularly, balancing leisure time with working, and using problem solving in decision making instead of anger or other nonconstructive responses. Rationale 3: Adaptive coping helps the person to deal effectively with stressful events and minimizes the distress associated with them. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Effective coping results in adaptation. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Discuss types of coping and coping strategies. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 978 Question 29 Type: MCSA 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 Correct Answer: 4 Rationale 1: The effects of stress on the basic need of love and belonging include becoming isolated and withdrawn, becoming overly dependent, and blaming others for problems. Rationale 2: The effects of stress on the basic need of self-actualization include being preoccupied with one’s own problems. Rationale 3: The effects of stress on basic physiological needs include an altered elimination pattern, a change in appetite, and an altered sleep pattern. Rationale 4: The effects of stress on the basic need of self-esteem include becoming a workaholic. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify essential aspects of assessing a client’s stress and coping patterns. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 978 Question 30 Type: MCMA The nurse asks a client what strategies he uses to cope with stress. The client does not respond. What should the nurse do? Standard Text: 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. Correct Answer: 3, 4, 5 Rationale 1: The nurse should not document that the client has no stress. Rationale 2: The nurse should not move on with the assessment. Rationale 3: If the client does not adequately describe how stressful situations are handled, the nurse should prompt by asking the client whether crying occurs. Rationale 4: If the client does not adequately describe how stressful situations are handled, the nurse should prompt by suggesting the client use humor or exercise. Rationale 5: If the client does not adequately describe how stressful situations are handled, the nurse should ask the client about using anger or being angry. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Discuss types of coping and coping strategies. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 979 Question 31 Type: MCMA During a health interview, the nurse decides to focus the assessment questions on the middle-aged client’s amount of stress. What information did the nurse use to make this clinical decision? Standard Text: 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 Correct Answer: 1, 2, 5 Rationale 1: Stressors common in middle adulthood include caring for aging parents. Rationale 2: Stressors common in middle adulthood include physical changes of aging, including having to wear glasses to read. Rationale 3: Stressors in young adulthood include being newly married. Rationale 4: Stressors common in adolescence include choosing a career. Rationale 5: Stressors common in middle adulthood include physical changes of aging, including not having stamina and energy. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify essential aspects of assessing a client’s stress and coping patterns. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 984 Question 32 Type: MCMA The nurse is preparing to assess a client’s stress and coping patterns. What will be included in this assessment? Standard Text: Select all that apply. 1. Client’s perception of stressors 2. Manifestations of stress 3. Employment status 4. Coping strategies 5. Weight changes Correct Answer: 1, 2, 4, 5 Rationale 1: When obtaining the nursing history, the nurse should pose questions about the client’s perception of stressors. Rationale 2: When obtaining the nursing history, the nurse should pose questions about manifestations of stress. Rationale 3: Employment status is not a part of either the nursing history or physical examination when assessing a client’s stress and coping patterns. Rationale 4: When obtaining the nursing history, the nurse should pose questions about past and present coping strategies. Rationale 5: When obtaining the nursing history, the nurse should assess for indicators of stress, including weight changes. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify essential aspects of assessing a client’s stress and coping patterns. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 979 Question 33 Type: MCSA 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 Correct Answer: 3 Rationale 1: Defensive coping is the repeated projection of falsely positive self-evaluation based on a selfprotective pattern that defends against underlying perceived threats to positive self-regard. Rationale 2: Disabled Family Coping is an appropriate diagnosis when the behavior of a significant person disables his or her capacities and the client’s capacities to effectively address tasks essential to either person’s adaption to the health challenge. Rationale 3: 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. Rationale 4: Ineffective coping is the inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use resources. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 8. Identify nursing diagnoses related to stress. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 979 Question 34 Type: MCSA 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 Correct Answer: 4 Rationale 1: 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. Rationale 2: Ineffective coping is the inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use resources. Rationale 3: Disabled Family Coping is applicable when the behavior of a significant person disables his or her capacities and the client’s capacities to effectively address tasks essential to either person’s adaption to the health challenge. Rationale 4: Defensive coping is the repeated projection of falsely positive self-evaluation based on a selfprotective pattern that defends against underlying perceived threats to positive self-regard. Global Rationale: Cognitive Level: Analyzing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 8. Identify nursing diagnoses related to stress. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 979 Question 35 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 2, 3, 5 Rationale 1: Optimal nutrition is essential for health and in increasing the body’s resistance to stress. To minimize the negative effects of stress, people need to avoid excesses of sugar. Rationale 2: Optimal nutrition is essential for health and in increasing the body’s resistance to stress. To minimize the negative effects of stress, people need to avoid excesses of salt. Rationale 3: Optimal nutrition is essential for health and in increasing the body’s resistance to stress. To minimize the negative effects of stress, people need to avoid excesses of caffeine. Rationale 4: Optimal nutrition is essential for health and in increasing the body’s resistance to stress. To minimize the negative effects of stress, people need to address deficiencies in vitamins and minerals. Rationale 5: Optimal nutrition is essential for health and in increasing the body’s resistance to stress. To minimize the negative effects of stress, people need to avoid excesses of fat. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe interventions to help clients minimize and manage stress. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Page Number: 980 Question 36 Type: MCMA 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 upon which factors? Standard Text: 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 Correct Answer: 2, 4, 5 Rationale 1: Release of hormones occurs in the shock phase of stress. Rationale 2: The end of this stage depends largely on the severity of the stressor. Rationale 3: Reversal of body changes occurs in the countershock phase of stress. Rationale 4: The end of this stage depends largely on the external adaptive resources provided. Rationale 5: The end of this stage depends largely on the adaptive energy resources of the individual. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Describe the three stages of Selye’s general adaptation syndrome. MNL Learning Outcome: 2.2.4. Examine the components of stress and coping strategies and the associated nursing care. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 974

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 43 Question 1 Type: MCSA 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. Correct Answer: 4 Rationale 1: Showing photographs of the deceased is a normal response to grief. Rationale 2: Talking about good and bad points of the deceased is a normal response to grief. Rationale 3: Sending out the laundry to be done is a healthy response to a problem that this client identified. Rationale 4: Leaving the deceased wife's craft room and belongings intact for over 3 years is considered outside the normal limits of the grief process. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe types and sources of losses. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 990 Question 2 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 1 Rationale 1: Grieving prior to the actual loss is termed anticipatory grieving. Rationale 2: There are no assessment findings in the question that indicate dysfunctional grieving. Rationale 3: There are no assessment findings in the question that indicate hopelessness. Rationale 4: This reaction is typical of family members, so there is no indication that the family is exhibiting caregiver role strain. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1. Describe types and sources of losses. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 990 Question 3 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: Toddlers fear abandonment. Rationale 2: Preschoolers view death as reversible. Rationale 3: At about age 9, children's concept of death matures and most understand that death is an inevitable part of life. Rationale 4: Adults generally have better outcomes than adolescents when confronted with death. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Discuss factors affecting a grief response. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 996 Question 4 Type: MCSA 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. Which family would the nurse screen as at highest risk for complicated grief? The family of a client who 1. died after a long battle against cancer. 2. died after developing diabetes-induced renal failure. 3. was killed in the robbery of a bank. 4. died from chronic heart disease. Correct Answer: 3 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: The client who died of cancer does not meet the criteria as well as the murdered client. Rationale 2: The client who died of renal failure does not meet the criteria as well as the murdered client. Rationale 3: 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. Rationale 4: The client who died of heart disease had been ill for some time and does not meet the criteria as well as the murdered client. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Discuss factors affecting a grief response. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 990 Question 5 Type: MCSA 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. Correct Answer: 2 Rationale 1: Kübler-Ross describes all stages of grief and grieving. Rationale 2: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: None of the models are clear or definitive predictors of grief behaviors. Rationale 4: These models are useful for many dying clients. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify measures that facilitate the grieving process. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 992

Question 6 Type: MCMA A client hospitalized for injuries from a motor vehicle crash is diagnosed with higher brain death. What findings support this client’s diagnosis? Standard Text: 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 Correct Answer: 2, 3, 5 Rationale 1: Episodic coughing might be a reflex or an attempt to clear the airway. This is not a manifestation of higher brain death. Rationale 2: Evidence of higher brain death includes absence of cephalic reflexes. Rationale 3: Evidence of higher brain death includes apnea. Rationale 4: Inconsistent cardiac function on the heart monitor indicates the client is still alive. Rationale 5: Evidence of higher brain death includes absence of cephalic reflexes, apnea, and an isoelectric electroencephalogram for at least 30 minutes.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Evidence of higher brain death includes an isoelectric electroencephalogram for at least 30 minutes. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. List clinical signs of impending and actual death. MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care. Page Number: 997 Question 7 Type: MCSA 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-toknow basis. 4. Encourage early pharmaceutical intervention with antianxiety and sedative medications. Correct Answer: 1 Rationale 1: 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. Rationale 2: The need for discussion and the amount of time needed will vary from client to client, so "dwelling" is an inappropriate descriptor. Rationale 3: The client must be given facts about the disease process and projected trajectory so that final business and relationships can be addressed. Rationale 4: Early use of antianxiety and sedative medications is not appropriate because these medications can adversely affect the client's ability to think clearly about the future. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Identify measures that facilitate the grieving process. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 1000 Question 8 Type: MCSA 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." The nurse recognizes this statement as being 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: This is not a simple statement of the facts regarding AIDS. Rationale 3: Feelings of hopelessness are not common and expected in those facing the end of life. Rationale 4: Even though death is inevitable, the client should continue to express hope of some nature. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Identify clinical symptoms of grief. MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care. Page Number: 997 Question 9 Type: MCSA The client tells the nurse that she has been having problems sleeping since her boss died unexpectedly 3 weeks ago. She confides that she and the boss had been having a secret extramarital affair for years. 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 Correct Answer: 3 Rationale 1: Abbreviated grieving is grieving that is brief, but genuinely felt. Rationale 2: This client's grief is not yet chronic, as only 3 weeks have passed. Rationale 3: This client is unable to grieve openly for her lost relationship, as extramarital affairs are not socially sanctioned. Rationale 4: External grieving is not a recognized type of grief response. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 1. Describe types and sources of losses. 3. Identify clinical symptoms of grief. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 990 Question 10 Type: MCMA The nurse is working with a father and his three children, ages 10, 14, and 17. The mother recently died after a long illness. The children are doing poorly in school, and the father is having a difficult time keeping up with household chores. He has recently taken on a second job to help pay his late wife's hospital bills. Which nursing diagnoses should the nurse consider in planning care for this family? Standard Text: Select all that apply. 1. Anticipatory Grieving 2. Impaired Family Processes 3. Impaired Adjustment 4. Caregiver Role Strain 5. Hopelessness Correct Answer: 2, 3, 4, 5 Rationale 1: Anticipatory grief is experienced in advance of the event, such as the wife who grieves before her ailing husband dies. Rationale 2: There may be numerous nursing diagnoses that should be investigated in planning care for this grieving family. This list may not be all inclusive, as problems with sleep, nutrition, self-concept, and role adjustment are common following the long illness and death of a loved one. Rationale 3: There may be numerous nursing diagnoses that should be investigated in planning care for this grieving family. This list may not be all inclusive, as problems with sleep, nutrition, self-concept, and role adjustment are common following the long illness and death of a loved one. Rationale 4: There may be numerous nursing diagnoses that should be investigated in planning care for this grieving family. This list may not be all inclusive, as problems with sleep, nutrition, self-concept, and role adjustment are common following the long illness and death of a loved one. Rationale 5: There may be numerous nursing diagnoses that should be investigated in planning care for this grieving family. This list may not be all inclusive, as problems with sleep, nutrition, self-concept, and role adjustment are common following the long illness and death of a loved one. Global Rationale: Cognitive Level: Analyzing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1. Describe types and sources of losses. 3. Identify clinical symptoms of grief. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 995 Question 11 Type: MCSA During the 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." Correct Answer: 3 Rationale 1: "Let's think of something more cheerful" is changing the subject. Rationale 2: "You are doing so well, don't talk like that" is offering false reassurance and devaluing the client's concern. Rationale 3: 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. Rationale 4: "Whatever is meant to be will happen" is being fatalistic and devaluing the client's concerns. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe the process of helping clients die with dignity. MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care. Page Number: 997 Question 12 Type: MCSA The client has a documented advance health care directive that indicates that no resuscitative measures should be employed in the event of a respiratory or cardiac arrest. The client begins to exhibit severe dyspnea and air hunger and says, "Please do something, I can't breathe." 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. Correct Answer: 3 Rationale 1: Just offering comfort measures until the client dies is ignoring the client's wishes. Rationale 2: There is no need to call the physician for direction, as the client has clearly given the nurse direction. Rationale 3: This client has the right to change decisions about resuscitation, and has asked for help. The nurse should initiate resuscitative measures. Rationale 4: The nurse should have already known the terms of the directive and would not have time to seek clarification at this point. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. List clinical signs of impending and actual death. MNL Learning Outcome: 2.3.1. Implement advance directives in the care of the client at end-of-life. Page Number: 1000 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 13 Type: MCMA A client with end-stage renal disease knows that he is dying but refuses to talk about it with his spouse. At times the spouse talks with the nursing staff about the client’s condition but adamantly refuses to discuss death with the client. What will be the outcomes of this situation? Standard Text: 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 Correct Answer: 1, 2, 5 Rationale 1: With mutual pretense, the client, family, and health care personnel know that the prognosis is terminal but do not talk about it and make an effort not to raise the subject. Mutual pretense permits the client a degree of dignity. Rationale 2: With mutual pretense, the client, family, and health care personnel know that the prognosis is terminal but do not talk about it and make an effort not to raise the subject. Mutual pretense permits the client a degree of privacy. Rationale 3: With open awareness the client will have the ability to finalize affairs. Rationale 4: With open awareness the client can participate in the planning of his own funeral. Rationale 5: With mutual pretense, the client, family, and health care personnel know that the prognosis is terminal but do not talk about it and make an effort not to raise the subject. Mutual pretense places a heavy burden on the dying person, who then has no one in whom to confide. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Describe the process of helping clients die with dignity. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 998

Question 14 Type: MCSA The family of a young adult client who has recently been diagnosed with a rapidly progressing terminal illness tells the nurse, "This cannot be happening. There must be some mistake in the 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. Correct Answer: 2 Rationale 1: This would be appropriate to do after the nurse first addresses the potential issue of self-denial of the situation. Rationale 2: The nurse must first self-examine feelings to ensure that the nurse's behaviors do not demonstrate denial of the situation. Rationale 3: This would be appropriate to do after the nurse first addresses the potential issue of self-denial of the situation. Rationale 4: This would be appropriate to do after the nurse first addresses the potential issue of self-denial of the situation. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe the role of the nurse in working with families or caregivers of dying clients. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 991 Question 15 Type: MCSA 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. Correct Answer: 2 Rationale 1: Clients are not automatically assigned to hospice. Rationale 2: 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. Rationale 3: Medicare does provide hospice benefits. Rationale 4: The client may receive both hospice and other palliative care treatments. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe the process of helping clients die with dignity. MNL Learning Outcome: 2.3.2. Differentiate between hospice and palliative care. Page Number: 1001 Question 16 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 1 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Identify measures that facilitate the grieving process. MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care. Page Number: 1003 Question 17 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 4 Rationale 1: The nurse should not talk with the client before discussing the situation with the family. Rationale 2: The nurse should not change the subject if the client asks about impending death, but should not encourage such an encounter before discussing the situation with the family. Rationale 3: The nurse should discuss the reasons why the family does not want the client to be aware of impending death before offering advice. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe the role of the nurse in working with families or caregivers of dying clients. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 998 Question 18 Type: MCSA The nurse who is providing postmortem care for a client 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 4 Rationale 1: The ring should not be removed. The nurse should let the family know that the ring is on the client. Rationale 2: The nurse could do this if the funeral director arrives and the nurse is still in attendance caring for the client. Rationale 3: Theoretically, all jewelry should be removed; in some instances, a ring may be taped to the finger. This may or may not be done, depending upon the circumstances. Rationale 4: Depending upon 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. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe nursing measures for care of the body after death. MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care. Page Number: 1003 Question 19 Type: MCSA A client recovering from back surgery is seen crying softly in bed. Upon assessment, the nurse learns that the client has been told 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Developmental loss Correct Answer: 1 Rationale 1: The loss of functional ability because of acute illness or injury is a situational loss. Rationale 2: An anticipatory loss is experienced before the loss actually occurs. Rationale 3: Psychological losses are often perceived losses in that they are not directly verified, such as the loss of independence or freedom. Rationale 4: Losses that occur in the process of normal development, such as retirement from a career or the death of aged parents, are developmental losses. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe types and sources of losses. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 989 Question 20 Type: MCSA An older client has just relocated from home to an assisted living facility. The nurse is concerned because the client has been 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 Correct Answer: 2

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Loss of external objects includes the loss of inanimate objects that have importance to the person. The client might be experiencing this type of loss; however, there is not enough information to determine whether personal belongings were not also relocated to the assisted living facility with the client. Rationale 2: 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. Rationale 3: The client was relocated to an assisted living facility. There is no information to suggest that the client is experiencing a loss of a loved one. Rationale 4: Psychological losses are often perceived losses in that they are not directly verified, such as with the loss of independence or freedom. The client who has moved from home to an assisted living facility might have this type of loss; however, it is not the primary loss in this case. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe types and sources of losses. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 989 Question 21 Type: MCMA A client with terminal cancer of the lung 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? Standard Text: 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 non-rebreathing mask. 5. Elevate the head of the client’s bed to a Fowler’s position. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

6. Consider use of a p.r.n. morphine sulfate order. Correct Answer: 3, 5, 6 Rationale 1: The client does not need to be moved to a room closer to the nurse’s station. Rationale 2: Lateral positions are appropriate for unconscious clients but not for those who are conscious. Rationale 3: Placement of a fan to circulate air might relieve shortness of breath. Rationale 4: Conscious clients who are short of breath do not tolerate oxygen therapy by mask. Rationale 5: Elevating the head of the bed might relieve shortness of breath. Rationale 6: Use of morphine sulfate might relieve shortness of breath. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe the process of helping clients die with dignity. MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care. Page Number: 1002 Question 22 Type: MCMA 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? Standard Text: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

5. Place a pillow under the head. 6. Tape the eyelids closed. Correct Answer: 2, 5 Rationale 1: A total bed bath is not necessary. Rationale 2: The nurse should place absorbent pads beneath the body. Rationale 3: Dentures should be inserted. Rationale 4: The client should be dressed in a clean gown. Rationale 5: The nurse should place a pillow under the head. Rationale 6: The eyelids should be held in place until they stay closed, and should not be taped. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe nursing measures for care of the body after death. MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care. Page Number: 1003 Question 23 Type: SEQ The spouse of a deceased client is working through the stages of grief. If the nurse applies Martocchio’s five clusters of grief to this situation, the spouse would progress through the clusters in which order? Standard Text: Click and drag the options below to move them up or down. Choice 1. Reorganization and restitution Choice 2. Yearning and protest Choice 3. Identification in bereavement Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Choice 4. Shock and disbelief Choice 5. Anguish, disorganization, and despair Correct Answer: 4, 2, 5, 3, 1 Rationale 1: Martocchio’s five clusters of grief are: (1) shock and disbelief; (2) yearning and protest; (3) anguish, disorganization, and despair; (4) identification in bereavement; and (5) reorganization and restitution. Rationale 2: Martocchio’s five clusters of grief are: (1) shock and disbelief; (2) yearning and protest; (3) anguish, disorganization, and despair; (4) identification in bereavement; and (5) reorganization and restitution. Rationale 3: Martocchio’s five clusters of grief are: (1) shock and disbelief; (2) yearning and protest; (3) anguish, disorganization, and despair; (4) identification in bereavement; and (5) reorganization and restitution. Rationale 4: Martocchio’s five clusters of grief are: (1) shock and disbelief; (2) yearning and protest; (3) anguish, disorganization, and despair; (4) identification in bereavement; and (5) reorganization and restitution. Rationale 5: Martocchio’s five clusters of grief are: (1) shock and disbelief; (2) yearning and protest; (3) anguish, disorganization, and despair; (4) identification in bereavement; and (5) reorganization and restitution. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Discuss selected frameworks for identifying stages of grieving. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 992 Question 24 Type: MCMA 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? Standard Text: Select all that apply. 1. Crying 2. Weakness Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Inability to sleep 4. No appetite 5. Inability to concentrate on conversations Correct Answer: 1, 3, 4, 5 Rationale 1: Crying is considered a normal manifestation of grief. Rationale 2: Weakness is not a normal manifestation of grief. Rationale 3: Inability to sleep is considered a normal manifestation of grief. Rationale 4: Loss of appetite is considered a normal manifestation of grief. Rationale 5: Difficulty concentrating is considered a normal manifestation of grief. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify clinical symptoms of grief. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 992 Question 25 Type: MCMA The nurse is concerned that a client is experiencing complicated grieving after the unexpected death of a son. The nurse most likely assessed Standard Text: Select all that apply. 1. the client’s denying the son’s death. 2. depression. 3. sudden weight loss because of not eating. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. crying. 5. verbalizing the desire to not live anymore. Correct Answer: 1, 2, 3, 5 Rationale 1: Complicated grieving might be characterized by extended time of denial. Rationale 2: Complicated grieving might be characterized by depression. Rationale 3: Complicated grieving might be characterized by severe physiological symptoms such as sudden weight loss because of not eating. Rationale 4: Crying is considered a normal manifestation of grief. Rationale 5: Complicated grieving might be characterized by suicidal thoughts such as verbalizing the desire not to live anymore. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify clinical symptoms of grief. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 990 Question 26 Type: MCMA 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 Standard Text: 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. The client’s values 5. The client’s socioeconomic status Correct Answer: 1, 2, 3, 4 Rationale 1: The importance of the lost person to the client affects the significance of the loss. Rationale 2: The degree of change required because of the loss affects the significance of the loss. Rationale 3: The client’s beliefs affect the significance of the loss. Rationale 4: The client’s values affect the significance of the loss. Rationale 5: The client’s socioeconomic status does not affect the significance of the loss. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Discuss factors affecting a grief response. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 993 Question 27 Type: MCMA 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? Standard Text: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

5. Provide advice to the client. Correct Answer: 1, 2, 4 Rationale 1: The skills most relevant to situations of loss and grief are those of effective communication, such as active listening. Rationale 2: The skills most relevant to situations of loss and grief are those of effective communication, such as clarifying and reflecting the client’s feelings. Rationale 3: Actions that are less helpful to clients experiencing loss and grief include those that give unwarranted reassurance. Rationale 4: The skills most relevant to situations of loss and grief are those of effective communication, such as using silence. Rationale 5: Actions that are less helpful to clients experiencing loss and grief include giving advice. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Identify measures that facilitate the grieving process. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 995 Question 28 Type: MCMA 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? Standard Text: Select all that apply. 1. Encourage the client to resume normal activities on a schedule that promotes physical and psychological health. 2. Use therapeutic communication techniques. 3. Offer choices that promote client autonomy. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Provide information about community resources or support groups. 5. Acknowledge the grief of the client. Correct Answer: 2, 3, 4, 5 Rationale 1: Encouraging the client to resume normal activities on a schedule that promotes physical and psychological health would be appropriate to facilitate grief work, but would not provide emotional support. Rationale 2: Therapeutic communication techniques let the client know that the nurse acknowledges the client’s feelings. Rationale 3: Offering choices that promote autonomy helps the client have a sense of some control at a time when much control might not be possible. Rationale 4: Providing information about community resources or support groups provides the client with sources of additional information. Rationale 5: Acknowledging the grief of the client is helpful when providing emotional support. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Identify measures that facilitate the grieving process. MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care. Page Number: 995 Question 29 Type: MCSA A terminally ill client is demonstrating gurgling respirations. The nurse realizes that this client is 1. improving. 2. experiencing pain. 3. trying to talk. 4. nearing death. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 4 Rationale 1: The death rattle does not mean the client is improving. Rationale 2: The death rattle does not mean that the client is experiencing pain. Rationale 3: The death rattle does not mean that the client is trying to talk. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. List clinical signs of impending and actual death. MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care. Page Number: 999 Question 30 Type: MCMA The nurse determines that a terminally ill client is nearing death. What did the nurse assess to make this clinical decision? Standard Text: Select all that apply. 1. Diarrhea 2. Muscle spasms 3. Slow, weak pulse 4. Decreased blood pressure 5. Cyanosis of the extremities Correct Answer: 3, 4, 5 Rationale 1: Diarrhea is not a clinical manifestation of impending death. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Muscle spasms are not a clinical manifestation of impending death. Rationale 3: A slow, weak pulse is a clinical manifestation of impending death. Rationale 4: Decreased blood pressure is a clinical manifestation of impending death. Rationale 5: Cyanosis of the extremities is a clinical manifestation of impending death. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. List clinical signs of impending and actual death. MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care. Page Number: 999 Question 31 Type: MCSA 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. Correct Answer: 3 Rationale 1: Leaving the client alone does not acknowledge the client’s feelings or support the client’s emotional needs at this time. Rationale 2: Providing physical care to increase comfort might not be what the client needs at this time. Rationale 3: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Offering to provide pain medication assumes the client is in pain. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Identify measures that facilitate the grieving process. MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care. Page Number: 1000 Question 32 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 3, 5 Rationale 1: 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. Rationale 2: The nurse should not ignore the spouse. Rationale 3: 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. Rationale 4: The nurse should not recommend that the spouse return home to get rest. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: 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. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Identify measures that facilitate the grieving process. MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care. Page Number: 1002 Question 33 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 2, 4, 5 Rationale 1: 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. Rationale 2: It is important to make the environment as clean and pleasant as possible, so equipment should be removed from the room. Rationale 3: The nurse should not permit the family to view the client before cleaning and care are provided. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: It is important to make the environment as clean and pleasant as possible, so the linens should be changed. Rationale 5: It is important to make the environment as clean and pleasant as possible, so the client’s position should appear natural and comfortable. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe the role of the nurse in working with families or caregivers of dying clients. MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care. Page Number: 1002

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 44 Question 1 Type: MCMA 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? Standard Text: 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 Correct Answer: 3, 4, 5 Rationale 1: A pillow between the legs when logrolling does not stabilize the spine. Rationale 2: A pillow between the legs when logrolling does not prevent hip contractures. Rationale 3: A pillow between the client’s legs when logrolling supports the upper leg when the client is turned. Rationale 4: A pillow between the client’s legs when logrolling keeps the legs parallel and aligned. Rationale 5: A pillow between the client’s legs when logrolling prevents adduction of the upper leg. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: c. Logrolling a client. MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 1042 Question 2 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: Pregnant clients should be encouraged to exercise, regardless if exercise was a part of life prior to being pregnant. Rationale 2: Exercise should be done 30 minutes on most days. Rationale 3: 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. Rationale 4: There is no indication that the pregnant woman needs more exercise than the general population. Global Rationale:

3. Protect the client's bones with strict bed rest. 4. Provide the client with assisted range-of-motion exercising twice daily. Correct Answer: 1 Rationale 1: 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 weight-bearing activities. Rationale 2: Additional calcium in the diet after osteoporosis has begun is not thought to be effective. Rationale 3: Strict bed rest may well make the osteoporosis worse because there is no weight-bearing activity. Rationale 4: Assisted range-of-motion exercises are not weight-bearing activities and do not help delay or reverse osteoporosis. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Differentiate isotonic, isometric, isokinetic, aerobic, and anaerobic exercise. MNL Learning Outcome: 4.3.2. Recognize factors that affect movement and immobility. Page Number: 1020 Question 4 Type: MCSA 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 Correct Answer: 3 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Frequent position changes will not reverse contractures. Rationale 2: The contracture occurs because the flexor muscles are stronger than the extensor muscles. This imbalance in strength pulls the inactive joint into a flexed position, and a permanent shortening of the muscle occurs. Rationale 3: 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. Rationale 4: Weight-bearing activities will not reverse contractures. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.3.2. Recognize factors that affect movement and immobility. Page Number: 1051 Question 5 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Orthostatic hypotension is a drop in blood pressure not a drop in heart rate. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Paleness of the legs is not significant. Rationale 4: The blood pressure drops, the heart rate increases, and the client may complain of dizziness or may faint upon arising. Global Rationale: Page Reference: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.3.2. Recognize factors that affect movement and immobility. Page Number: 1054 Question 6 Type: MCSA The client's chief complaint is, "I just can't get around like I used to. I have to stop halfway up the stairs to the bedroom, and just walking to the bathroom makes me so tired." Which nursing diagnosis is most likely appropriate for this client? Activity Intolerance: 1. Level 1. 2. Level 2. 3. Level 3. 4. Level 4. Correct Answer: 3 Rationale 1: The NANDA diagnosis Activity Intolerance is further individualized to the client's level of intolerance. Level 1 indicates normal activity with slightly more shortness of breath. Rationale 2: The NANDA diagnosis Activity Intolerance is further individualized to the client's level of intolerance. Level 2 indicates ability to walk about one level city block without difficulty or to climb one flight of stairs without stopping.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: The NANDA diagnosis Activity Intolerance is further individualized to the client's level of intolerance. Level 3 (this client's level) indicates ability to walk no more than 50 feet on level ground without stopping and inability to climb one flight of stairs without stopping. Rationale 4: The NANDA diagnosis Activity Intolerance is further individualized to the client's level of intolerance. Level 4 indicates dyspnea and fatigue at rest. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 6. Develop nursing diagnoses and outcomes related to activity, exercise, and mobility problems. MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 1030 Question 7 Type: MCSA 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. Use Level 1, 2, 3, or 4 to describe immobility. 3. Describe what happens when the client attempts mobility. 4. Add strength assessment data. Correct Answer: 1 Rationale 1: 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. Rationale 2: There are NANDA levels of activity intolerance, but not of immobility. Rationale 3: Describing what happens when the client attempts mobility might be used in the "as manifested by" section of the nursing diagnosis, but not in the problem statement section. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Strength assessment data might be used in the "as manifested by" section of the nursing diagnosis, but not in the problem statement section. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 6. Develop nursing diagnoses and outcomes related to activity, exercise, and mobility problems. MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 1030 Question 8 Type: MCSA 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. Correct Answer: 4 Rationale 1: Wearing a back belt does not prevent injury. Rationale 2: Body mechanics training does not prevent injuries. Rationale 3: Physical fitness does not prevent back injury. Rationale 4: The only option that has any influence on frequency of back injury is a practice prohibiting solo lifting. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Use safe practices when positioning, moving, transferring, and ambulating clients. MNL Learning Outcome: 4.3.1. Recognize aspects of normal movement and associated physiology. Page Number: 1033 Question 9 Type: MCSA 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. Correct Answer: 4 Rationale 1: Placing the feet together makes the body more unstable and more likely to fall. Rationale 2: In order to pick up this box as safely as possible, the nurse should flex the knees to lower the center of gravity. Rationale 3: After picking up the weight, the body should not be rotated, but should be turned to face the table. Rationale 4: In order to pick up this box as safely as possible, the nurse should hold the box as close to the body as possible.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Use safe practices when positioning, moving, transferring, and ambulating clients. MNL Learning Outcome: 4.3.1. Recognize aspects of normal movement and associated physiology. Page Number: 1033 Question 10 Type: MCSA The nurse is caring for a client experiencing dyspnea. In which position should the nurse place this client? 1. High Fowler's 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 Correct Answer: 2 Rationale 1: The high Fowler's position should not be used with more than one pillow or with overly large pillows. Rationale 2: The orthopneic position across the overbed table facilitates respiration by allowing maximum chest expansion. Rationale 3: The prone position places the client on the abdomen and makes chest expansion difficult. Rationale 4: The Sims position is a side-lying position and does not support full chest expansion as much as the orthopneic position. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.3.2. Recognize factors that affect movement and immobility. Page Number: 1037 Question 11 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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. Correct Answer: 3 Rationale 1: This activity does not utilize all of the major joints in the hands and arms. Rationale 2: The wash basin should be close to the client to prevent overreaching and possible falls. Rationale 3: Brushing the hair and teeth includes more of the joints of the hands and the arms than does washing the face. Rationale 4: Passive range of motion is a second best choice after normal use of the joints. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Compare and contrast active, passive, and active-assistive range-of-motion (ROM) exercises. MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 1050 Question 12 Type: MCSA The bed-bound client 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Measure the calf and compare to the opposite calf. 4. Medicate the client for pain and reassess in 30 minutes. Correct Answer: 3 Rationale 1: Palpating the area is contraindicated because injury to the vein may induce a thrombus. Rationale 2: Percussing the area is contraindicated because injury to the vein may induce a thrombus. Rationale 3: The nurse should measure the calf and compare it to the opposite calf. The client may be developing a deep vein thrombosis or thrombophlebitis. Rationale 4: Medicating the client and reassessing in 30 minutes might allow a worsening of the client's condition. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 1029 Question 13 Type: MCSA 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. Correct Answer: 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Flatness is the normal percussion sound over the liver. Rationale 2: The nurse should palpate for bladder fullness that could cause this discomfort. Rationale 3: The nurse should not medicate the client until assessment is complete. Rationale 4: Sacral edema may occur with the bed-bound client, but should not be a contributor to abdominal pain. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 1029 Question 14 Type: MCSA 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. Correct Answer: 1 Rationale 1: High-topped shoes will place the client's feet in the anatomical position of dorsal flexion. Rationale 2: Turning the linens back will keep the weight of the linens off of the feet but will not prevent foot drop. Rationale 3: The prone and Sims positions are implicated in the development of foot drop. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: A device to elevate the linens off of the feet will not prevent foot drop. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 1035 Question 15 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 2, 5 Rationale 1: Placing a turn sheet on the bed will help overcome inertia and friction during moving. Rationale 2: Using two personnel will allow a "lift and move" rather than pulling or sliding the client over linens. Rationale 3: The personnel should stand on either side of the bed and use the turn sheet to move the client. Rationale 4: Sliding the client causes friction. The client should be moved using the turn sheet. Rationale 5: Encouraging the client to assist as much as possible will lighten the workload. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Use safe practices when positioning, moving, transferring, and ambulating clients. MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 1035 Question 16 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: This action is done later in the procedure. Rationale 3: This action is done later in the procedure. Rationale 4: This action is done later in the procedure. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Use safe practices when positioning, moving, transferring, and ambulating clients. MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 1041 Question 17 Type: MCSA 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 a fractured tibia 4. A client who has a severe headache from hypertensive crisis Correct Answer: 3 Rationale 1: There is no physiological reason why a client with pneumonia would need to be logrolled. Rationale 2: There is no physiological reason why a client recovering from abdominal surgery would need to be logrolled. Rationale 3: 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. Rationale 4: There is no physiological reason why the client with a headache would need to be logrolled. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Use safe practices when positioning, moving, transferring, and ambulating clients. MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 1042 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 18 Type: MCSA 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 Correct Answer: 3 Rationale 1: This position could cause the nurse's trunk to twist. Rationale 2: This position could cause the nurse's trunk to twist. Rationale 3: The nurse should face the far corner of the foot of the bed because this is the direction in which movement will occur. Rationale 4: This position could cause the nurse's trunk to twist. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: d. Assisting a client to sit on the side of the bed. MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 1054 Question 19 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Place the wheelchair parallel to the bed. 3. Lock the brakes on the bed. 4. Place a transfer belt on the client. Correct Answer: 3 Rationale 1: This is not the most important action of the nurse. Rationale 2: This is not the most important action of the nurse. Rationale 3: 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. Rationale 4: This is not the most important action. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: e. Transferring between bed and chair. MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 1047 Question 20 Type: MCSA The nurse is preparing to transfer a client from the bed to a stretcher. The correct position for the bed to be placed is parallel to the stretcher and 1. slightly higher. 2. slightly lower. 3. at the same height. 4. at least 2 inches lower. Correct Answer: 1 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: 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. Rationale 2: It is easier for the client to move down a slant to the new surface than to move up to a higher surface. Rationale 3: It is easier for the client to move down a slant to the new surface than to move up to an even surface. Rationale 4: It is easier for the client to move down a slant to the new surface than to move up to a higher surface. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: f. Transferring between bed and stretcher. MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 1049 Question 21 Type: MCSA The postoperative client is ambulating for the first time since surgery. The client has been able to tolerate sitting up on the side of the bed and has stood at the bedside without difficulty on two occasions. Which staff member should ambulate this client? 1. The UAP 2. A licensed practical (vocational) nurse 3. A registered nurse 4. It makes no difference Correct Answer: 3 Rationale 1: Because this is the first time this client has ambulated, the best choice is for the registered nurse to ambulate the client. Rationale 2: Because this is the first time this client has ambulated, the best choice is for the registered nurse to ambulate the client.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: 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. Rationale 4: Because this is the first time this client has ambulated, the best choice is for the registered nurse to ambulate the client. Once the client has successfully ambulated, any nursing staff member can assist. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11. Recognize when it is appropriate to delegate aspects of moving, transferring, and ambulating a client to unlicensed assistive personnel. MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 1053 Question 22 Type: MCSA The nurse is assisting a newly delivered mother in ambulating to the nursery to see the baby. The client complains of light-headedness and begins to faint. What is the nurse's most important action? 1. Ensure the client's modesty as she falls. 2. Be certain the client does not hit the head on anything. 3. Call for immediate assistance. 4. Check the vital signs and for excessive vaginal bleeding. Correct Answer: 2 Rationale 1: This is not the priority for the nurse at this time. Rationale 2: All of these actions are important, but the priority is ensuring the client does not strike her head on anything when falling. The nurse should ease the client down while supporting her body against the nurse, protecting the head and laying it gently on the floor. Rationale 3: This is important; however, it does not address that the client is falling. Rationale 4: This is important to do after the client has been assisted to the floor. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: g. Assisting a client to ambulate. MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 1054 Question 23 Type: MCSA 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. Correct Answer: 3 Rationale 1: Stopping the treatment is not justified until an assessment occurs. Rationale 2: Stopping the exercises is not justified until an assessment occurs. Rationale 3: 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. Rationale 4: Continuing at the same level of intensity may cause damage to the joint as well as cause the client pain. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Compare and contrast active, passive, and active-assistive range-of-motion (ROM) exercises. MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 1050 Question 24 Type: MCMA The client has a history of postural hypotension. Which activities should the nurse advise this client as likely to cause postural hypotension? Standard Text: 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 Correct Answer: 1, 2, 5 Rationale 1: Hot baths can cause venous pooling in the lower extremities. Rationale 2: Heavy meals divert blood to the gastrointestinal organs. Rationale 3: Use of a rocking chair can be good for the client, as the rocking action exercises the legs. Rationale 4: Moving in bed is not likely to cause postural hypotension. Rationale 5: Bending to the floor can cause rapid changes in blood pressure upon standing up again. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.3.3. Implement the nursing process in the care of the client with diminished mobility. Page Number: 1053 Question 25 Type: MCMA The nurse is teaching a client on the use of a cane. What should the nurse include in this teaching? Standard Text: 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. Correct Answer: 2, 4, 5 Rationale 1: The can should be held on the stronger side of the body to provide maximum support and appropriate body alignment while walking. Rationale 2: The cane should be moved forward while the body weight is borne by both legs. Rationale 3: The length should permit the elbow to be slightly flexed. Rationale 4: The weaker leg is moved forward while the weight is borne by the cane and stronger leg. Rationale 5: The stronger leg is moved forward while the weight is borne by the cane and weak leg. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe client teaching for clients who use mechanical aids for walking. MNL Learning Outcome: 4.3.4. Implement strategies to promote mobility through the use of assistive devices. Page Number: 1056 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 45 Question 1 Type: MCSA The mother of a newborn tells the nurse, "I am concerned about my baby. When she first goes to sleep, her eyes dart around under her eyelids, she doesn't breathe regularly, and she sometimes twitches." 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. Correct Answer: 2 Rationale 1: There is no need for the mother to bring the baby in for an immediate checkup. Rationale 2: These are indications of normal REM sleep in the newborn. The mother should be reassured that this is normal. Rationale 3: Having the mother wait until the next checkup unnecessarily delays reassurance that this is normal sleep behavior for a newborn. Rationale 4: This is normal sleep behavior for a newborn. The baby does not need to be seen in the emergency department. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Identify the characteristics of the NREM and REM sleep states. MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a client’s state of rest. Page Number: 1068 Question 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA The parents of a 6-month-old tell the nurse that they are exhausted because their 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 picking him up for feeding. 2. Let the baby "cry it out" for a few nights until he can sleep through the night. 3. Continue to respond to the baby whenever he is restless during the night. 4. Bring the baby in for a possible sleep study to check for sleeping disorders. Correct Answer: 1 Rationale 1: Babies often move and make noises while sleeping that do not indicate wakefulness. The parents should be certain the baby is awake before picking him up to feed, change, or comfort. Rationale 2: Letting the baby "cry it out" is not appropriate if he really needs care. Rationale 3: Continuing to respond to the baby whenever he is restless during the night is not necessary and may result in parental exhaustion. Rationale 4: There is no indication for need of a sleep study for this baby. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe interventions that promote sleep. MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a client’s state of rest. Page Number: 1069 Question 3 Type: MCSA The 70-year-old client tells the nurse, "I can go to sleep without a problem, but then I wake up in a couple of hours and can't 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: Alcohol can interfere with sleep. Rationale 2: If the client has pain, the nurse should not encourage avoidance of medication. Rationale 3: 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. Rationale 4: Exercise can interfere with sleep. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Describe interventions that promote sleep. MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a client’s state of rest. Page Number: 1071 Question 4 Type: MCSA 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. Correct Answer: 1 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: 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. Rationale 2: Daytime hypersomnia is rarely caused by psychologic issues. Rationale 3: An over-the-counter sleep aid is not a good choice, as the client already sleeps well at night and sleep aids can sometimes cause future sleep disturbances. Rationale 4: Caffeinated beverages may increase daytime wakefulness, but will not help any underlying problem that may be present. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe common sleep disorders. MNL Learning Outcome: 4.12.3. Relate common sleep disorders to their associated clinical manifestations. Page Number: 1073 Question 5 Type: MCSA 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. Correct Answer: 2 Rationale 1: In narcolepsy, nighttime sleep is not affected. Rationale 2: The medication modafinil (Provigil) is prescribed to control the daytime drowsiness associated with narcolepsy. Rationale 3: Sodium oxybate (Xyrem) is a prescription medication that has very limited availability. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The client should avoid antihistamines, as they can cause daytime drowsiness to increase. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Describe common sleep disorders. MNL Learning Outcome: 4.12.3. Relate common sleep disorders to their associated clinical manifestations. Page Number: 1074 Question 6 Type: MCSA The 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. Correct Answer: 4 Rationale 1: Weight loss is not a direct result of CPAP therapy. Rationale 2: Snoring is a sign of apnea, not sound sleeping. Rationale 3: Successful treatment for sleep apnea will not help control diabetes. Rationale 4: The fact that the client experiences a decrease in morning headache indicates the client is sleeping better. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4.12.3. Relate common sleep disorders to their associated clinical manifestations. Page Number: 1074 Question 7 Type: MCSA 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?” Correct Answer: 1 Rationale 1: When the client is critically ill or being admitted for an outpatient procedure, sleep history can be omitted or deferred. Rationale 2: Because the client is critically ill, the sleep assessment can be done at a later time. Rationale 3: Because the client is critically ill, the sleep assessment can be done at a later time. Rationale 4: Because the client is critically ill, the sleep assessment can be done at a later time. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Identify the components of a sleep pattern assessment. MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep. Page Number: 1075 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 8 Type: MCSA The client who has 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 Correct Answer: 4 Rationale 1: Although this diagnosis may be applicable for the client, it is not the priority. Rationale 2: Although this diagnosis may be applicable for the client, it is not the priority. Rationale 3: Although this diagnosis may be applicable for the client, it is not the priority. Rationale 4: The priority is Risk for Injury related to somnambulism because it reflects the most dangerous situation for the client. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep. Page Number: 1077 Question 9 Type: MCSA The nurse is working with a client to develop an expected outcome for 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: The client may require more than 8 hours of sleep to feel rested and have sufficient energy. Rationale 2: Simply listing coping mechanisms for anxiety relief is not as helpful as actually getting sleep. Rationale 3: The best outcome statement for this client is to report getting sufficient sleep to provide energy for daily activities. Rationale 4: Antianxiety medications are probably not the most important factor for this client. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep. Page Number: 1077 Question 10 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1 Rationale 1: The best intervention is to have the client establish and maintain a regular bedtime and wake-up time for all days of the week. Rationale 2: Moving bedtime according to previous delays does not promote a sleep routine. Rationale 3: Moving bedtime according to drowsiness does not promote a sleep routine. Rationale 4: Changing awake times according to work schedules does not promote a sleep routine. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep. Page Number: 1077 Question 11 Type: MCSA The 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. Correct Answer: 3 Rationale 1: Music can promote wakefulness. Rationale 2: Television can promote wakefulness. Rationale 3: Noise should be kept to a minimum. Extraneous noise can be blocked by white noise from a fan, air conditioner, or white noise machine. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Talk radio can promote wakefulness. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep. Page Number: 1077 Question 12 Type: MCSA The 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: Exercise within 2 hours of attempting to sleep may cause wakefulness. Rationale 3: Sitting in the bed while watching television will strengthen the association between wakefulness and bed. Rationale 4: Lying awake in bed will strengthen the association between wakefulness and bed. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep. Page Number: 1077 Question 13 Type: MCSA The 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 Correct Answer: 3 Rationale 1: Hot chocolate contains caffeine, which can cause wakefulness and nocturia. Rationale 2: Tea contains caffeine, which can cause wakefulness and nocturia. Rationale 3: The nurse should offer the client a light carbohydrate (cereal) and milk. Rationale 4: Chips and salsa is a spicy snack, and may cause gastrointestinal upsets that disturb sleep. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe interventions that promote sleep. MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep. Page Number: 1077 Question 14 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: The client should not take the medication at dinnertime, which is probably some hours before bedtime. Rationale 3: There is no reason to avoid calcium when taking this medication. Rationale 4: There is no need for extra water when taking this medication. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep. Page Number: 1080 Question 15 Type: MCSA The 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." Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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." Correct Answer: 3 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep. Page Number: 1080 Question 16 Type: MCSA A client questions why a medication that is used to treat Parkinson's 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's 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 Correct Answer: 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: The nurse does not need to contact the physician. The nurse can discuss the prescribed medication with the client. Rationale 2: Medications that are commonly prescribed for the treatment of Parkinson's disease are also prescribed for the treatment of PLMD. Rationale 3: This is not an error. Medications used to treat Parkinson's disease are also prescribed for PLMD. Rationale 4: This action is not necessary. Medications used to treat Parkinson's disease are also prescribed to treat PLMD. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep. Page Number: 1075 Question 17 Type: MCSA The client has complained of stiffness and muscle tension in his back. The nurse suggests a back rub, but the client declines the offer. 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 he changes his mind. 4. Instruct the UAP to rub the client's back while assisting him to change into a clean gown. Correct Answer: 3 Rationale 1: The nurse should not force the client to have a back rub if one is not desired. Rationale 2: The client is not noncompliant; he is simply stating his preference. Rationale 3: 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 he changes his mind. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The UAP should not attempt to rub the client's back without permission. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe interventions that promote sleep. MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep. Page Number: 1078 Question 18 Type: MCSA 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. Correct Answer: 3 Rationale 1: Because this is a partial awakening, walking the child around the room will not help and the child will probably not awaken. Rationale 2: The child will have no memory of the event the next morning. Rationale 3: 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. Rationale 4: There is no reason to add an additional pillow behind the child's head. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep. Page Number: 1071 Question 19 Type: MCMA The nurse is completing the admission assessment on a client who has obstructive sleep apnea. Which findings should the nurse expect when assessing this client? Standard Text: Select all that apply. 1. Reddened uvula 2. Large soft palate 3. Obesity 4. Short neck 5. Deviated septum Correct Answer: 1, 2, 3 Rationale 1: Clients with obstructive sleep apnea are likely to have a reddened uvula. Rationale 2: Clients with obstructive sleep apnea are likely to have an enlarged soft palate. Rationale 3: Clients with obstructive sleep apnea are likely to be obese. Rationale 4: A large, thick neck (over 17.5 inches) is more likely to be problematic than is a short neck. Rationale 5: Deviated septum is an unlikely cause of obstructive sleep apnea. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe common sleep disorders. MNL Learning Outcome: 4.12.3. Relate common sleep disorders to their associated clinical manifestations. Page Number: 1076 Question 20 Type: MCMA The nurse is working on a hospital committee tasked with reducing environmental distractions to sleep within the hospital. Which recommendations by the committee would be helpful? Standard Text: Select all that apply. 1. Turn off all overhead lights on the unit and use night-lights 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. Correct Answer: 2, 3 Rationale 1: It is not possible to turn off all overhead lights and use only night-lights and flashlights, but those lights that can be eliminated should be. Rationale 2: Establishing a time at which radios and televisions should be turned off or down will reduce the amount of disturbance to clients. Rationale 3: Discontinuing use of the paging system at 2100 will also reduce noise. Rationale 4: Nursing reports should be conducted in an area away from the client beds. Rationale 5: Closing the curtains, not opening the curtains, between beds in semiprivate rooms will decrease disturbance. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8. Describe interventions that promote sleep. MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep. Page Number: 1078 Question 21 Type: MCSA 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 to in order to function.” 4. “You must be very productive.” Correct Answer: 2 Rationale 1: This statement implies that the client is not getting sufficient sleep. It would be more appropriate for the nurse to suggest that the client obtain more sleep on a routine basis and not just when able. Rationale 2: 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. Rationale 3: Although this might be true, everyone needs sleep. The client’s statement of sleep becoming optional indicates that the client is not getting sufficient sleep. Rationale 4: There are studies indicating that errors occur and changes in response times are altered with a lack of sleep. The client might not be productive with a lack of sleep. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain the physiology and the functions of sleep. MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a client’s state of rest. Page Number: 1070 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 22 Type: MCMA The nurse is assessing a client in the intensive care unit who is asleep. What physiological changes will the nurse observe in this client? Standard Text: 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 Correct Answer: 4, 5 Rationale 1: A change in respirations is not associated with sleep. Rationale 2: Skeletal muscles relax during sleep. Rationale 3: Peripheral blood vessels dilate during sleep, which will reduce lower extremity edema. Rationale 4: One physiological change that occurs during sleep is a drop in arterial blood pressure. Rationale 5: One physiological change that occurs during sleep is a decrease in heart rate. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Identify the characteristics of the NREM and REM sleep states. MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a client’s state of rest. Page Number: 1068 Question 23 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

A client with diabetes asks the nurse why his blood glucose level is higher on days when he sleeps less. 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: The nurse has no way of knowing what the client is ingesting that would impact blood glucose level and sleep. Rationale 3: There is a relationship between sleep and blood glucose levels. Rationale 4: The body does not use cortisol for energy. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain the physiology and the functions of sleep. MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a client’s state of rest. Page Number: 1066 Question 24 Type: MCSA A hospitalized client is being woken up 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Increase thirst 3. Increase susceptibility to infection 4. Decrease heart rate Correct Answer: 3 Rationale 1: The loss of NREM sleep does not impact urine output. Rationale 2: The loss of NREM sleep does not impact thirst. Rationale 3: The loss of NREM sleep causes immunosuppression, slows tissue repair, lowers pain tolerance, triggers profound fatigue, and increases susceptibility to infection. Rationale 4: In NREM sleep, the heart rate decreases. With the loss of NREM sleep, this decrease would not occur. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the physiology and the functions of sleep. MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a client’s state of rest. Page Number: 1068 Question 25 Type: MCMA 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? Standard Text: Select all that apply. 1. Depression 2. Confusion 3. Disorientation 4. Impaired memory Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

5. Muscle weakness Correct Answer: 1, 2, 3, 4 Rationale 1: In a sleep-deprived client, the loss of REM sleep causes psychological disturbances such as depression. Rationale 2: In a sleep-deprived client, the loss of REM sleep causes psychological disturbances such as confusion. Rationale 3: In a sleep-deprived client, the loss of REM sleep causes psychological disturbances such as disorientation. Rationale 4: In a sleep-deprived client, the loss of REM sleep causes psychological disturbances such as impaired memory. Rationale 5: Muscle weakness is not associated with a loss of REM sleep. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the physiology and the functions of sleep. MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a client’s state of rest. Page Number: 1070 Question 26 Type: MCSA The nurse, seeing a client asleep, turns off the television in the room. The client opens her eyes and says “I was watching that. I wasn’t sleeping.” The nurse realizes that the client was demonstrating which stage of NREM sleep? 1. IV 2. III 3. II 4. I Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 4 Rationale 1: Stage IV is not a stage of NREM sleep. Rationale 2: Stage III is the deepest stage of sleep, differing only in the percentage of delta waves recorded during a 30-second period. During deep sleep or delta sleep, the sleeper’s heart and respiratory rates drop 20% to 30% below those exhibited during waking hours. The sleeper is difficult to arouse. The person is not disturbed by sensory stimuli, the skeletal muscles are very relaxed, reflexes are diminished, and snoring is most likely to occur. Rationale 3: Stage II is the stage of light sleep during which body processes continue to slow down. The eyes are generally still, the heart and respiratory rates decrease slightly, and body temperature falls. An individual in stage II requires more intense stimuli than in stage I to awaken, such as touching or shaking. Rationale 4: Stage I 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. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Identify the characteristics of the NREM and REM sleep states. MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a client’s state of rest. Page Number: 1067 Question 27 Type: MCSA 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. Correct Answer: 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Chocolate is a stimulant, and could reduce the child’s ability to fall asleep. Rationale 2: 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. Rationale 3: Physical activity is a stimulant, and could reduce the child’s ability to fall asleep. Rationale 4: Playing a computer game is a stimulant, and could reduce the child’s ability to fall asleep or cause an increase in nightmares. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep. Page Number: 1069 Question 28 Type: MCSA 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 Correct Answer: 1 Rationale 1: The need to urinate during the night disrupts sleep, and people who awaken at night to urinate sometimes have difficulty getting back to sleep. Rationale 2: Caffeinated beverages and alcohol are stimulants that influence sleep. Rationale 3: Body weight and the use of beverages that contain l-tryptophan are dietary influences of sleep. Rationale 4: Hours of work, activity, and exercise are lifestyle influences of sleep. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4.12.2. Recognize how factors that impact sleep affect the client’s state of rest. Page Number: 1071 Question 29 Type: MCSA 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 Correct Answer: 4 Rationale 1: Chemical changes result in less REM sleep. Rationale 2: Chemical changes result in less NREM sleep in Stages III and IV. Rationale 3: Chemical changes affect deep and REM sleep. Rationale 4: Stress is considered by most sleep experts to be the number one cause of short-term 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. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify factors that affect sleep. MNL Learning Outcome: 4.12.2. Recognize how factors that impact sleep affect the client’s state of rest. Page Number: 1072 Question 30 Type: MCSA A client who smokes cigarettes tells the nurse that sleep is light, and that he awakens easily. What should the nurse suggest to help this client with 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. Correct Answer: 2 Rationale 1: Smoking up to 1 hour before sleep will be too much stimulation before sleep. Rationale 2: 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. Rationale 3: Limiting the number of cigarettes smoked during the day will not impact the client’s ability to sleep at night. Rationale 4: The client can be instructed not to smoke after the evening meal, and should not be told to adjust to the lack of sleep, because those who smoke do not get sufficient sleep. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4.12.2. Recognize how factors that impact sleep affect the client’s state of rest. Page Number: 1072 Question 31 Type: MCMA A client tells the nurse about having problems falling and staying asleep. What should the nurse ask the client to gain more information about this client problem? Standard Text: 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?” Correct Answer: 1, 2, 3, 5 Rationale 1: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include “How often does this happen?” Rationale 2: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include “How much coffee do you drink each day?” Rationale 3: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include “How do you feel when you wake up in the morning?” Rationale 4: Asking when the client ingests the evening meal might not be appropriate with the client who is experiencing a sleep disturbance. Rationale 5: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include “What have you done to deal with this sleeping problem?” Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Identify the components of a sleep pattern assessment. MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep. Page Number: 1075 Question 32 Type: MCMA 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? Standard Text: Select all that apply. 1. Is wide awake around 3 AM 2. Takes a nap after lunch every day 3. Returns to sleep after using the bathroom 4. Goes to sleep before 9 PM most evenings 5. Wakes up and looks at the clock every hour Correct Answer: 1, 2, 4, 5 Rationale 1: A hallmark change with age is a tendency toward earlier wake times. Rationale 2: Many older adults report daytime napping, which may contribute to reduced nocturnal sleep. Rationale 3: Older adults have difficulty falling back to sleep after awakening. Rationale 4: A hallmark change with age is a tendency toward earlier bedtime. Rationale 5: Older adults may awaken an average of six times during the night. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe variations in sleep patterns throughout the life span. MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep. Page Number: 1070 Question 33 Type: MCMA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The nurse suspects that an adult is not getting an adequate amount of nightly sleep. What information caused the nurse to have this suspicion? Standard Text: 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 job steady night turn and another part-time late afternoon Correct Answer: 1, 2, 3, 5 Rationale 1: The National Sleep Foundation reports that certain adults, such as students, are vulnerable for not getting enough sleep. Rationale 2: 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. Rationale 3: The National Sleep Foundation reports that certain adults, such as those experiencing chronic pain, are vulnerable for not getting enough sleep. Rationale 4: Attending religious services is not identified as contributing to vulnerability for not getting enough sleep. Rationale 5: The National Sleep Foundation reports that 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. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify factors that affect sleep. MNL Learning Outcome: 4.12.2. Recognize how factors that impact sleep affect the client’s state of rest. Page Number: 1070

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 9/E Chapter 46 Question 1 Type: MCSA 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 Correct Answer: 1 Rationale 1: The FLACC scale has been validated in children from 2 months to 7 years old. Rationale 2: This pain scale would not be appropriate for a client of this age. Rationale 3: This pain scale would not be appropriate for a client of this age. Rationale 4: This pain scale would not be appropriate for a client of this age. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify subjective and objective data to collect and analyze when assessing pain. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1097 Question 2 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Gastrointestinal (GI) distress 2. Shakiness 3. Tremors 4. Rash Correct Answer: 1 Rationale 1: The most common side effect of NSAIDs, including ibuprofen, is gastrointestinal distress, such as heartburn or indigestion. Rationale 2: Shakiness is not a common side effect of NSAIDs. Rationale 3: Tremors are not a common side effect of NSAIDs. Rationale 4: A rash is not a common side effect of NSAIDs. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Describe pharmacologic interventions for pain. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1107 Question 3 Type: MCSA Which of the following objective assessment data will 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 3 Rationale 1: This is an example of subjective data. Rationale 2: This is an example of subjective data. Rationale 3: Opioids may depress the respiratory system, so the nurse should assess the respiratory rate before administering opioids. Rationale 4: This is not applicable to assess prior to administering an opioid medication to a client. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify subjective and objective data to collect and analyze when assessing pain. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1110 Question 4 Type: MCSA The nurse provides an oral opiate to a client with pain. In how many hours should the nurse expect the client to need another dose of the medication? 1. 2 hours 2. 4 hours 3. 6 hours 4. 8 hours Correct Answer: 2 Rationale 1: The duration of action for most opiates is 4 hours. Rationale 2: The duration of action for most opiates is 4 hours. Rationale 3: The duration of action for most opiates is 4 hours. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The duration of action for most opiates is 4 hours. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10. Describe pharmacologic interventions for pain. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1111 Question 5 Type: MCSA 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 the nurse use to administer the medication? 1. Oral 2. Vaginal 3. Rectal 4. Intravenous Correct Answer: 3 Rationale 1: The rectal route is often used if the client has nausea or vomiting. The nurse should administer an acetaminophen suppository to the client. Rationale 2: This medication is not available as a vaginal suppository. Rationale 3: The rectal route is often used if the client has nausea or vomiting. The nurse should administer an acetaminophen suppository to the client. Rationale 4: There is not an intravenous form of this medication. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Identify risks and benefits of various analgesic delivery routes and analgesic delivery technologies. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1112 Question 6 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Acute pain is directly related to tissue injury and resolves when tissue heals. Rationale 3: Chronic pain persists beyond 3 to 6 months secondary to chronic disorders or nerve malfunctions that produce ongoing pain after healing is complete. Rationale 4: There is no such type of pain. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 4. Describe factors that can affect a person’s perception of and reaction to pain. MNL Learning Outcome: 4.11.2. Distinguish factors that affect the pain response. Page Number: 1118 Question 7 Type: MCSA 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 6 to 8 glasses of water per day. 3. Assess respiratory rate before taking medication. 4. Assess heart rate before taking medication. Correct Answer: 2 Rationale 1: Antihistamines do not prevent constipation. Rationale 2: Increasing fluid intake can help prevent constipation. Rationale 3: Assessing respiratory rate will not help prevent constipation. Rationale 4: Assessing heart rate will not impact the development of constipation. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. 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: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1109 Question 8 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The nurse is caring for a client who is using morphine through patient-controlled analgesia (PCA). What medication should the nurse have readily available? 1. Naloxone hydrochloride (Narcan) 2. Acetaminophen (Tylenol) 3. Diphenhydramine hydrochloride (Benadryl) 4. Normal saline Correct Answer: 1 Rationale 1: Narcan is an opioid antagonist and should be readily available when a client is receiving an opioid. Rationale 2: Tylenol would not be helpful to have available for a client who is receiving morphine through PCA administration. Rationale 3: Benadryl would not be helpful to have available for a client who is receiving morphine through PCA administration. Rationale 4: Normal saline would not be helpful to have available for a client who is receiving morphine through PCA administration. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10. Describe pharmacologic interventions for pain. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1110 Question 9 Type: MCSA The client is taking meperidine (Demerol) and experiencing pruritus. Which medication should the nurse expect the physician to order? 1. Naloxone hydrochloride (Narcan) 2. Acetaminophen (Tylenol) Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Diphenhydramine hydrochloride (Benadryl) 4. Normal saline Correct Answer: 3 Rationale 1: Naloxone hydrochloride (Narcan) will not help with pruritus. Rationale 2: Acetaminophen (Tylenol) will not help with pruritus. Rationale 3: When clients experience pruritus, an antihistamine, such as Benadryl, is ordered. Rationale 4: Normal saline will not help with pruritus. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Describe pharmacologic interventions for pain. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1110 Question 10 Type: MCSA The nurse is admitting a client to the emergency department with complaints of 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. Correct Answer: 3 Rationale 1: This would occur after the client was assessed. Rationale 2: This would occur after the client was assessed. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Assessment should always occur before implementation. Rationale 4: This may or may not be appropriate for the client. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. 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: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1110 Question 11 Type: MCSA 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 Correct Answer: 2 Rationale 1: Phantom pain is that which is experienced in a limb after an amputation. Rationale 2: Referred pain appears to arise in different areas of the body, as may occur with cardiac pain. Rationale 3: Visceral pain originates in an organ. Rationale 4: Chronic pain is that which is felt for months after the pain experience should have ended. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Discriminate between nociceptive and neuropathic pain categories. MNL Learning Outcome: 4.11.1. Explain the pain experience and the pain response. Page Number: 1087 Question 12 Type: MCSA 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 Correct Answer: 3 Rationale 1: Mild pain is rated as being from 1 to 3 on a 0-to-10 rating scale. Rationale 2: Moderate pain is rated as being from 4 to 6 on a 0-to-10 rating scale. Rationale 3: Severe pain is rated as being from 7 to 10 on a scale of 0 to 10. Rationale 4: Physiological pain does not describe the intensity of the client's pain. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify subjective and objective data to collect and analyze when assessing pain. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 1088 Question 13 Type: MCSA 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 Correct Answer: 3 Rationale 1: Mild is not a type of pain. Rationale 2: Severe is not a type of pain. Rationale 3: 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. Rationale 4: Visceral pain is that which originates within an organ. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Discriminate between nociceptive and neuropathic pain categories. MNL Learning Outcome: 4.11.1. Explain the pain experience and the pain response. Page Number: 1088 Question 14 Type: MCSA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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." Correct Answer: 1 Rationale 1: Clients can experience intense pain after minor surgery, so pain medication may be ordered. Rationale 2: This is not true. The client can have pain after minor surgery and can receive pain medication. Rationale 3: Nonpharmacologic pain relief measures may not be enough for the pain after surgery. Rationale 4: The nurse has no way of knowing the dose the physician will prescribe for the client. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. 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: 4.11.3. Consider the differences between the types of pain and how each affects the client. Page Number: 1105 Question 15 Type: MCSA The nurse is performing discharge teaching for a client taking an NSAID. The client states he has heard that taking an antacid with this medication will help decrease the incidence of upset stomach. What is the nurse's best response? 1. "Antacids reduce the absorption and therefore the effectiveness of the NSAID." 2. "Antacids help to reduce the incidence of gastric bleeding that could occur with the use of NSAIDs." 3. "Antacids should never be taken with an NSAID." 4. "Antacids help to reduce the incidence of pain." Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1 Rationale 1: It is documented that the use of antacids can reduce the risk of gastric distress, but can also reduce the absorption and the effectiveness of the medication. Rationale 2: Antacids can reduce the likelihood of gastric bleeding; however, antacids will interfere with the absorption of the medication in the client. Rationale 3: This statement is not correct. Rationale 4: Antacids may reduce the pain associated with gastric distress; however, antacids are not a category of pain medication. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Compare and contrast barriers to effective pain management affecting nurses and clients. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1108 Question 16 Type: MCSA 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 Correct Answer: 2 Rationale 1: This is a normal pulse rate. Rationale 2: A respiratory rate below 8 should be reported immediately. Rationale 3: This is a blood pressure that is within normal limits. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The nurse does not need to report the client's pain rating to the physician. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13. Identify risks and benefits of various analgesic delivery routes and analgesic delivery technologies. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1111 Question 17 Type: MCSA 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 Correct Answer: 4 Rationale 1: Chronic pain, also known as persistent pain, is prolonged, usually recurring or lasting 3 months or longer, and interferes with functioning. Rationale 2: Phantom pain is the feeling that a lost body part is present. It occurs in most people after amputation. Rationale 3: Visceral pain tends to be characterized by cramping, throbbing, pressing, or aching qualities. Often visceral pain is associated with feeling sick. Rationale 4: Acute pain is pain that is directly related to tissue injury and resolves when tissue heals. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Discriminate between nociceptive and neuropathic pain categories.. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1088 Question 18 Type: MCMA The nurse is preparing to conduct a pain assessment. What should the nurse include in this assessment? Standard Text: Select all that apply. 1. Duration 2. Location 3. Intensity 4. Etiology 5. Neurology Correct Answer: 1, 2, 3, 4 Rationale 1: Pain may be described in terms of duration. Rationale 2: Pain may be described in terms of location. Rationale 3: Pain may be described in terms of intensity. Rationale 4: Pain may be described in terms of etiology. Rationale 5: Pain is not described in terms of neurology. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify subjective and objective data to collect and analyze when assessing pain. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1097-1098 Question 19 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: The transmission of pain includes three segments. During the first segment, the pain impulses travel from the peripheral nerve fibers to the spinal cord. The second segment is transmission from the spinal cord, and ascension, via spinothalamic tracts, to the brainstem and thalamus. The third segment involves transmission of signals between the thalamus to the somatic sensory cortex, where pain perception occurs. Pain control can take place during this second process of transmission. Opioids block the release of neurotransmitters, which stops the pain at the spinal level. Rationale 3: 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. Rationale 4: Modulation is often described as the “descending system,” and occurs when neurons in the thalamus and brainstem send signals back down to the dorsal horn of the spinal cord. These descending fibers release substances such as endogenous opioids, serotonin, and norepinephrine, which can inhibit the ascending painful impulses in the dorsal horn. In contrast, excitatory amino acids and the upregulation of excitatory glial cells can amplify these pain signals. The effects of excitatory amino acids and glial cells tend to persist, whereas the effects Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

of the inhibitory neurotransmitters tend to be short-lived because they are reabsorbed into the nerves. Tricyclic antidepressants block the reuptake of norepinephrine and serotonin, and may be used to help diminish the pain signals. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Describe the four processes involved in nociception and how pain interventions can work during each process. MNL Learning Outcome: 4.11.2. Distinguish factors that affect the pain response. Page Number: 1090 Question 20 Type: MCSA A client is complaining of having the same type of pain that he experienced 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 Correct Answer: 3 Rationale 1: Transmission is a process by which the pain signals are transmitted to the brain. Rationale 2: Modulation is the process where signals are sent back down the spinal tracts in response to the pain. Rationale 3: 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. Rationale 4: Transduction is a process whereby chemicals are released in response to noxious stimuli. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe the four processes involved in nociception and how pain interventions can work during each process. MNL Learning Outcome: 4.11.2. Distinguish factors that affect the pain response. Page Number: 1090 Question 21 Type: MCSA A client tells the nurse that an ice pack works well to reduce the intensity of back pain. The nurse realizes that the client is implementing 1. a placebo. 2. distraction. 3. guided imagery. 4. the gate control theory of pain. Correct Answer: 4 Rationale 1: The application of ice is not a placebo. Rationale 2: The application of ice is not a distraction. Rationale 3: The application of ice is not a use of guided imagery. Rationale 4: In the gate control theory, signals of noxious stimuli are carried to the dorsal horn, where they are modified according to the balance of the substantia gelatinosa. By using ice, the substantia gelatinosa is calmed, reducing the pain. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the gate control theory and its application to nursing care. MNL Learning Outcome: 4.11.1. Explain the pain experience and the pain response. Page Number: 1091 Question 22 Type: MCSA A client recovering from hip surgery is reluctant to ambulate because of the amount of pain that occurred with walking prior to the surgery. What can the nurse do to help this client with pain control? 1. Provide pain medication before every ambulation session. 2. Address the client’s fear of pain with walking. 3. Tell the client that the pain is now gone. 4. Explain that the client is confusing postoperative pain with the pain before the surgery. Correct Answer: 2 Rationale 1: The client may not be prescribed pain medication before every ambulation session. Rationale 2: Nurses can use the gate control theory to stop nociceptor firing by applying topical therapies and addressing the client’s mood to reduce fear and anxiety. Rationale 3: The nurse needs to do more than tell the client that the pain is gone. Rationale 4: The client does not appear to be confused between the postoperative pain and the pain before the surgery. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe the gate control theory and its application to nursing care. MNL Learning Outcome: 4.11.1. Explain the pain experience and the pain response. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 1092 Question 23 Type: MCMA The nurse is caring for an adolescent client who is experiencing postoperative pain. What interventions should the nurse use to help this client? Standard Text: 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. Correct Answer: 1, 2, 3, 4 Rationale 1: Nursing interventions to assist with pain management for an adolescent client include talking with the client about the pain. Rationale 2: Nursing interventions to assist with pain management for an adolescent client include providing privacy. Rationale 3: Nursing interventions to assist with pain management for an adolescent client include presenting choices for dealing with the pain. Rationale 4: Nursing interventions to assist with pain management for an adolescent client include encouraging distraction with music or television. Rationale 5: Allaying fears and anxiety would be a nursing intervention to assist with pain management for an adult. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe factors that can affect a person’s perception of and reaction to pain. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.11.1. Explain the pain experience and the pain response. Page Number: 1094 Question 24 Type: MCMA 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? Standard Text: 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. Correct Answer: 2, 3, 5 Rationale 1: When planning pharmacologic intervention for an older client, the approach should be to start low and go slow because of the effects on renal and liver function. Rationale 2: If pain is not effectively controlled in the older client, the ability to sleep will be affected. Rationale 3: If pain is not effectively controlled in the older client, irritability can occur. Rationale 4: When planning pharmacologic intervention for an older client, the nurse must assess the client for potential risks because of changes in organ and system functioning. Rationale 5: If pain is not effectively controlled in the older client, mobility and activity tolerance will be affected. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe factors that can affect a person’s perception of and reaction to pain. MNL Learning Outcome: 4.11.1. Explain the pain experience and the pain response. Page Number: 1095 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 25 Type: MCSA 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 Correct Answer: 1 Rationale 1: The diagnosis of Anxiety would be appropriate for the client, as the client has past experiences of poor pain control and is anticipating pain. Rationale 2: The diagnosis of Ineffective Coping would be applicable if the client were experiencing prolonged pain because of ineffective pain management. Rationale 3: The diagnosis of Deficient Knowledge would be applicable if the client had a lack of exposure to information regarding pain management. Rationale 4: The diagnosis of Hopelessness would be appropriate if the client were experiencing continuous pain. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 6. Identify examples of nursing diagnoses for clients with pain. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1102 Question 26 Type: MCMA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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? Standard Text: Select all that apply. 1. Anxiety 2. Hopelessness 3. Ineffective Health Maintenance 4. Insomnia 5. Impaired Physical Mobility Correct Answer: 3, 4, 5 Rationale 1: The diagnosis of Anxiety would not be applicable, as the client did not express past experiences of poor control of pain or anticipation of future pain events. Rationale 2: The diagnosis of Hopelessness would not be applicable, as the client did not state that the pain is continuous. Rationale 3: The diagnosis of Ineffective Health Maintenance would be applicable, as the client is experiencing chronic arthritic pain and is fatigued. Rationale 4: The diagnosis of Insomnia would be applicable, as the client is experiencing increased pain perception at night, affecting sleep. Rationale 5: The diagnosis of Impaired Physical Mobility would be applicable, as the client is experiencing arthritic pain in the hips and knees. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 6. Identify examples of nursing diagnoses for clients with pain. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1102 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 27 Type: MCSA 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. Correct Answer: 2 Rationale 1: If a pain relief measure is ineffective, encourage the client to try it again before abandoning it. Medications might need repeated doses to saturate plasma proteins before sufficient “free drug” is available to work on the intended target. Rationale 2: 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. Rationale 3: The nurse should not ignore the client. Rationale 4: Many nonpharmacologic measures require practice before they are effective. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. 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: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1104 Question 28 Type: MCSA A client’s pain level is assessed as being severe. Which intervention would be the most applicable for the client at this time? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 4 Rationale 1: The selection of pain relief measures should be aligned with the client’s report of the severity of the pain. If the client reports mild pain, an analgesic such as acetaminophen might be indicated. Rationale 2: Using a technique such as guided imagery is essentially telling the client to ignore the pain, which is a misalignment of the pain severity and the intervention selected. Rationale 3: Using a technique such as watching television is essentially telling the client to ignore the pain, which is a misalignment of the pain severity and the intervention selected. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. 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: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1107 Question 29 Type: MCSA 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.” Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. “All pain medication causes addiction. There is nothing that can be done to prevent it.” Correct Answer: 3 Rationale 1: Stating that the nurse understands the client’s concern is not sufficient. The nurse needs to explain how the pain medication will not likely lead to addiction. Rationale 2: This response supports the client’s fears of becoming addicted to pain medication. Rationale 3: Clients are unlikely to become addicted to an analgesic provided to treat pain. Rationale 4: Not all pain medication causes addiction. Clients are unlikely to become addicted to an analgesic that is provided to treat pain. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Differentiate tolerance, physical dependence, pseudoaddiction, and addiction. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1103 Question 30 Type: MCSA A client experiencing pain after surgery says “Something must be 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?” Correct Answer: 1 Rationale 1: 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. Rationale 2: This is not true. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: This statement assumes the client was taking pain medication for years, and would be incorrect and inappropriate for the nurse to make. Rationale 4: This response is questioning the client’s experience of pain, and would be incorrect and inappropriate for the nurse to make. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the four processes involved in nociception and how pain interventions can work during each process. MNL Learning Outcome: 4.11.2. Distinguish factors that affect the pain response. Page Number: 1086 Question 31 Type: MCSA A client has been taking medication for back pain for several months, and has seen several different health care providers in efforts to receive pain medication. The nurse is concerned that the client is exhibiting 1. tolerance. 2. addiction. 3. physical dependence. 4. pseudoaddiction. Correct Answer: 2 Rationale 1: Tolerance is a state in which continued exposure to the medication causes changes that result in a reduction in the effectiveness of the medication over time. Rationale 2: Addiction is characterized by the behaviors of compulsive use of pain medication, continued use despite harm, and craving. Rationale 3: Physical dependence is a state of adaptation that manifests with withdrawal symptoms when the drug is stopped or drastically reduced.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Pseudoaddiction is a condition that results from the under-treatment of pain where the client can become so focused on obtaining medications for pain relief that the client becomes angry and demanding, might “clock watch,” and might seem to display other inappropriate “drug-seeking” behaviors. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9. Differentiate tolerance, physical dependence, pseudoaddiction, and addiction. MNL Learning Outcome: 4.11.2. Distinguish factors that affect the pain response. Page Number: 1103 Question 32 Type: MCSA A client repeatedly asks the nurse “How much longer until I can get more pain medication?” Once the medication is provided, the client stops asking for it. The nurse identifies the client’s behavior as being 1. addiction. 2. tolerance. 3. pseudoaddiction. 4. physical dependence. Correct Answer: 3 Rationale 1: Addiction is characterized by the behaviors of compulsive use of pain medication, continued use despite harm, and craving. Rationale 2: Tolerance is a state in which continued exposure to the medication causes changes that result in a reduction in the effectiveness of the medication over time. Rationale 3: Pseudoaddiction is a condition that results from the under-treatment of pain where the client can become so focused on obtaining medications for pain relief that the client becomes angry and demanding, might “clock watch,” and might display other inappropriate “drug-seeking” behaviors. To differentiate between pseudoaddiction and addiction, if the client’s negative behavior resolves when the pain is treated effectively, the client is exhibiting pseudoaddiction.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Physical dependence is a state of adaptation that manifests with withdrawal symptoms when the drug is stopped or drastically reduced. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9. Differentiate tolerance, physical dependence, pseudoaddiction, and addiction. MNL Learning Outcome: 4.11.2. Distinguish factors that affect the pain response. Page Number: 1105 Question 33 Type: MCMA A client experiencing pain has been prescribed a coanalgesic. The nurse should prepare to administer what medications to the client? Standard Text: Select all that apply. 1. Nortriptyline 2. Amitriptyline 3. Tramadol 4. Meloxicam 5. Gabapentin Correct Answer: 1, 2, 5 Rationale 1: Nortriptyline is a tricyclic antidepressant used as a coanalgesic to treat pain. Rationale 2: Amitriptyline a tricyclic antidepressant used as a coanalgesic to treat pain. Rationale 3: Tramadol is an opioid analgesic used for moderate pain. Rationale 4: Meloxicam is a nonopioid analgesic used for mild pain. Rationale 5: Gabapentin is an anticonvulsant used as a coanalgesic to treat pain. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10. Describe pharmacologic interventions for pain. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1107 Question 34 Type: MCMA 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? Standard Text: Select all that apply. 1. Acetaminophen (Tylenol) 2. Ibuprofen (Motrin) 3. Naproxen (Naprosyn) 4. Hydrocodone (Vicodin) 5. Methadone (Dolophine) Correct Answer: 1, 2, 3 Rationale 1: Reporting pain as a 2 on a scale from 0 to 10 means the client is experiencing mild pain. According to the WHO approach to pain management, the client should be provided with a nonopioid analgesic such as acetaminophen (Tylenol). Rationale 2: Reporting pain as a 2 on a scale from 0 to 10 means the client is experiencing mild pain. According to the WHO approach to pain management, the client should be provided with a nonopioid analgesic such as ibuprofen (Motrin). Rationale 3: Reporting pain as a 2 on a scale from 0 to 10 means the client is experiencing mild pain. According to the WHO approach to pain management, the client should be provided with a nonopioid analgesic such as naproxen (Naprosyn). Rationale 4: Hydrocodone (Vicodin) would be provided if the client were experiencing moderate pain. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: Methadone (Dolophine) would be provided if the client were experiencing severe pain. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11. Describe the World Health Organization’s ladder step approach developed for cancer pain control. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1107 Question 35 Type: MCSA 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. Correct Answer: 3 Rationale 1: Because the client’s pain is persisting, the next step of the WHO ladder for pain control must be applied. Rationale 2: The next step of the WHO ladder for pain indicates that an opioid for moderate pain be provided, not an opioid for severe pain. Rationale 3: 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 coanalgesic medications. Rationale 4: The client should not receive two doses of an opioid for moderate pain at one time. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Describe the World Health Organization’s ladder step approach developed for cancer pain control. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1107 Question 36 Type: MCMA A client is prescribed a medication that is a blend of an opioid analgesic with an NSAID. The nurse realizes that this medication will have which effects on the client? Standard Text: Select all that apply. 1. Encourage the development of tolerance. 2. Encourage the development of addiction. 3. Maximize pain control while minimizing toxicity. 4. Maximize pain control while minimizing side effects. 5. Reduce the onset of pseudoaddiction. Correct Answer: 3, 4 Rationale 1: Blended medications do not encourage the development of tolerance. Rationale 2: Blended medications do not encourage the development of addiction. Rationale 3: Rational pharmacy is a concept whereby health professionals should be aware of all ingredients of medication that alleviate pain. Combinations reduce the need for high doses of any one medication, maximizing pain control while minimizing toxicity. Rationale 4: Rational pharmacy is a concept whereby health professionals should be aware of all ingredients of medication that alleviate pain. Combinations reduce the need for high doses of any one medication, maximizing pain control while minimizing side effects. Rationale 5: Blended medications do not reduce the onset of pseudoaddiction. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12. Describe rational polypharmacy. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1107 Question 37 Type: MCSA A client is diagnosed with chronic low back pain syndrome. The nurse realizes that which analgesic delivery route might be beneficial for this client? 1. Topical 2. Rectal 3. Transmucosal 4. Transdermal Correct Answer: 1 Rationale 1: Topical medications work directly at the point of application on the body. They are useful for painful procedures such as lumbar punctures or bone marrow biopsies, or for injections. These products can also offer effective pain relief for chronic pain syndromes such as low back pain. Rationale 2: The rectal route is useful for clients who have difficulty swallowing, or nausea and vomiting. Rationale 3: The transmucosal route is helpful for breakthrough pain because the oral mucosa is well vascularized, which facilitates rapid absorption. Rationale 4: The transdermal approach delivers a relatively stable plasma drug level, and is noninvasive. The medication, however, is systemic, which might not be what is necessary for the client with chronic low back pain syndrome. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13. Identify risks and benefits of various analgesic delivery routes and analgesic delivery technologies. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1112 Question 38 Type: MCSA 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 Correct Answer: 3 Rationale 1: Interventions that target the body for pain control include massage, heat, and exercise. Rationale 2: Interventions that target the mind for pain control include relaxation and imagery. Rationale 3: Social interactions that are used as nonpharmacologic pain control methods include pet therapy. Rationale 4: Interventions that target the spirit for pain control include prayer, meditation, and energy work. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 18. List three nonpharmacologic interventions directed at each of the following: the body, the mind, the spirit, and social interactions. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1116 Question 39 Type: MCMA 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? Standard Text: Select all that apply. 1. Massage 2. Acupressure 3. Self-hypnosis 4. Exercise 5. Nutritional supplements Correct Answer: 1, 2, 4, 5 Rationale 1: Massage is a nonpharmacologic intervention that targets the body for pain control. Rationale 2: Acupressure is a nonpharmacologic intervention that targets the body for pain control. Rationale 3: Self-hypnosis is a nonpharmacologic intervention that targets the mind for pain control. Rationale 4: Exercise is a nonpharmacologic intervention that targets the body for pain control. Rationale 5: Nutritional supplements are a nonpharmacologic intervention that target the body for pain control. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 18. List three nonpharmacologic interventions directed at each of the following: the body, the mind, the spirit, and social interactions. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1116 Question 40 Type: SEQ 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. Standard Text: Click and drag the options below to move them up or down. Choice 1. Move the hands down the sides of the back. Choice 2. Pour lotion into the palms of the hands to warm the lotion. Choice 3. Massage the areas over the right and left iliac crests. Choice 4. Move the hands up the center of the back. Choice 5. With the palms, massage the sacral area with smooth, circular strokes. Choice 6. Move the hands to the scapulae and massage this region using circular strokes. Correct Answer: 2, 5, 4, 6,1, 3 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: 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. Rationale 6: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15. Verbalize the steps used in performing a back massage. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1117 Question 41 Type: MCMA The nurse is preparing a client for a back massage. Which positions would be the best for the client to receive this massage? Standard Text: Select all that apply. 1. Supine 2. Fowler’s 3. Trendelenburg 4. Prone 5. Side-lying Correct Answer: 4, 5 Rationale 1: The supine position does not expose the client’s back. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: The Fowler’s position does not expose the client’s back. Rationale 3: The Trendelenburg position does not expose the client’s back. Rationale 4: The prone position is recommended for a back rub. Rationale 5: The side-lying position can be used if a client cannot assume the prone position for a back rub. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15. Verbalize the steps used in performing a back massage. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1117 Question 42 Type: MCSA A client who is on postoperative day 1 after abdominal surgery is requesting a back rub. The nurse realizes this care should be provided by 1. the registered nurse. 2. unlicensed assistive personnel. 3. no one, because the client cannot assume the prone position. 4. the physician. Correct Answer: 1 Rationale 1: Because the client is on day 1 in recovery from abdominal surgery, the client’s condition might not be stable enough to have unlicensed assistive personnel perform the skill. Rationale 2: Although unlicensed assistive personnel might be able to perform the skill, the client’s condition might warrant that the nurse provide the back rub. Rationale 3: The client can assume a side-lying position for the back rub. Rationale 4: The nurse can provide the back rub. The physician does not need to be contacted to do this. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 16. Recognize when it is appropriate to delegate aspects of back massage to unlicensed assistive personnel. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1117 Question 43 Type: MCMA The nurse wants to assign back rubs to unlicensed assistive personnel (UAP). Before doing so, the nurse should first determine whether Standard Text: Select all that apply. 1. unlicensed assistive personnel know how to perform a back rub. 2. there any clients who have intravenous fluids infusing. 3. there any clients who should not have a back rub performed. 4. there any clients who are prescribed to take nothing by mouth. 5. there any clients who do not want a back rub done by unlicensed assistive personnel. Correct Answer: 1, 3, 5 Rationale 1: The nurse can delegate this skill to UAP; however, the nurse first should assess for the UAP’s comfort and ability. Rationale 2: An intravenous infusion is not a contraindication for a back rub. Rationale 3: The nurse can delegate this skill to UAP; however, the nurse first should assess for client contraindications. Rationale 4: Being prescribed nothing by mouth is not a contraindication for a back rub. Rationale 5: The nurse can delegate this skill to UAP; however, the nurse first should assess for client willingness to participate. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16. Recognize when it is appropriate to delegate aspects of back massage to unlicensed assistive personnel. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1117 Question 44 Type: MCMA The nurse has completed a back massage for a client. What should the nurse document about this procedure? Standard Text: 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 Correct Answer: 2, 5 Rationale 1: Effectiveness of pain medication is not a part of the documentation of a back massage. Rationale 2: The nurse should document the position in which the massage was performed on the client. Rationale 3: The content of communication that occurred during the back massage is not necessary to document. Rationale 4: The amount of lotion used during the back massage is not necessary to document. Rationale 5: The nurse should document the client’s response to the massage. Global Rationale: Cognitive Level: Applying Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17. Demonstrate appropriate documentation and reporting of back massage. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1118 Question 45 Type: MCSA 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 non-casted leg. 3. Apply heat to the knee over the cast. 4. Rub the foot of the casted extremity. Correct Answer: 2 Rationale 1: Ice will not penetrate the cast. Rationale 2: 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. Rationale 3: Heat will not penetrate the cast. Rationale 4: Rubbing the foot might not be effective to reduce pain in the knee. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14. Describe nonpharmacologic pain control interventions. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1118 Question 46 Type: MCSA 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 Correct Answer: 1 Rationale 1: Visual distraction includes watching television. Rationale 2: Tactile distraction includes slow, rhythmic breathing or a massage. Rationale 3: Intellectual distraction includes crossword puzzles or engaging in hobby. Rationale 4: Behavioral is not a type of distraction. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14. Describe nonpharmacologic pain control interventions. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1119 Question 47 Type: MCMA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The health care 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? Standard Text: Select all that apply. 1. Oxymorphone (Opana) 2. Hydrocodone (Vicodin) 3. Oxycodone (OxyContin) 4. Morphine sulfate (morphine) 5. Hydromorphone hydrochloride (Dilaudid) Correct Answer: 1, 3, 4, 5 Rationale 1: Oxymorphone (Opana) is an opioid analgesic for severe pain. Because the client rated the pain as 9, which is severe, this medication is appropriate. Rationale 2: Hydrocodone (Vicodin) is an opioid analgesic for moderate pain. Considering that the client rates pain as being severe, this medication would not sufficiently control the client’s pain. Rationale 3: Oxymorphone (Opana) is an opioid analgesic for severe pain. Because the client rated the pain as 9, which is severe, this medication is appropriate. Rationale 4: Morphine sulfate (morphine) is an opioid analgesic for severe pain. Because the client rated the pain as 9, which is severe, this medication is appropriate. Rationale 5: Hydromorphone hydrochloride (Dilaudid) is an opioid analgesic for severe pain. Because the client rated the pain as 9, which is severe, this medication is appropriate. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10. Describe pharmacologic interventions for pain. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1107 Question 48 Type: MCMA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Standard Text: 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. Correct Answer: 2, 4, 5 Rationale 1: Tubing connections should be secured with tape. Rationale 2: Apply tape over all injection ports on the epidural line to avoid the injection of substances intended for IV administration into the epidural catheter. Rationale 3: Do not use alcohol in any care of the catheter or insertion site because it can be neurotoxic. Rationale 4: Label the tubing, the infusion bag, and the front of the pump with tape marked “epidural” to prevent confusion with similar-looking IV lines. Rationale 5: Post a sign above the client’s bed indicating that an epidural is in place. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Identify risks and benefits of various analgesic delivery routes and analgesic delivery technologies. MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain. Page Number: 1114

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 47 Question 1 Type: MCSA 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. Correct Answer: 2 Rationale 1: Making the baby wait longer between feedings may result in feeding difficulties later in childhood. Rationale 2: Newborns are often fed following an on-demand schedule. This might include feedings every 2 hours at first. Rationale 3: Trying to keep the baby awake to feed may result in feeding difficulties later in childhood. Rationale 4: Offering less formula may result in feeding difficulties later in childhood. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify nutritional variations throughout the life cycle. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1135 Question 2 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 3 Rationale 1: Many babies spit up after every meal and some seem to spit up a great deal. Rationale 2: How much the baby spits up at a time is not included in criteria to evaluate if the regurgitation should be further investigated. Rationale 3: As long as the baby is gaining weight adequately, it is not abnormal for regurgitation or spitting up to occur. Rationale 4: The consistency of the regurgitated material may be thin (just consumed) or curdled (has been partially digested) and either case is normal. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify nutritional variations throughout the life cycle. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1135 Question 3 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Green beans 3. Squash 4. Strained chicken Correct Answer: 3 Rationale 1: Meat should be introduced last. Rationale 2: Yellow vegetables should be offered before green vegetables. Rationale 3: 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. Rationale 4: Meat products should be introduced last. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify nutritional variations throughout the life cycle. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1135 Question 4 Type: MCSA The nurse has advised the client to consume alcohol only in moderation. What guideline should the nurse provide as a "moderate" alcohol intake? 1. Two drinks per week for women, three for men 2. Two drinks per day for women, three for men 3. One drink per day for women, two for men 4. One drink per week for women, two for men Correct Answer: 3 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Moderate alcohol consumption is considered one drink per day for women, two drinks per day for men. Rationale 2: Moderate alcohol consumption is considered one drink per day for women, two drinks per day for men. Rationale 3: Moderate alcohol consumption is considered one drink per day for women, two drinks per day for men. Rationale 4: Moderate alcohol consumption is considered one drink per day for women, two drinks per day for men. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe nursing interventions to promote optimal nutrition. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1141 Question 5 Type: MCSA 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 Correct Answer: 4 Rationale 1: The changes in this measurement occur so slowly that remeasuring in 2 days would not provide significant data.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: The changes in this measurement occur so slowly that remeasuring in 10 days to 2 weeks would not provide significant data. Rationale 3: The changes in this measurement occur so slowly that remeasuring in 1 month would not provide significant data. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9. Discuss nursing interventions to treat clients with nutritional problems. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1146 Question 6 Type: MCSA 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 to 8 months ago. 3. The client is at risk for development of malabsorption syndromes. 4. Carbohydrate malnutrition has occurred over the last 6 months. Correct Answer: 1 Rationale 1: Prealbumin is the most responsive serum protein to rapid changes in nutritional status. A level below 11 indicates that aggressive nutritional intervention is necessary. Rationale 2: Serum albumin is the slowest of the serum proteins to reflect changes, so abnormalities indicate prolonged protein malnutrition. Rationale 3: There is no specific link to malabsorption syndromes. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: These tests are indicators of protein malnutrition, not carbohydrate malnutrition. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9. Discuss nursing interventions to treat clients with nutritional problems. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1149 Question 7 Type: MCSA 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. Following the appropriate food pyramid is helpful, but there are additional factors to consider in a balanced diet. Correct Answer: 4 Rationale 1: Overall, the food pyramid is a good guide, but unless the client eats a variety of foods from each group, some recommended nutrient levels may be missed. Rationale 2: Food pyramids are available for different age groups, including children, middle adults, and older adults. Rationale 3: The food pyramid does not take fluid intake and activity level into consideration. Rationale 4: Because there are numerous food pyramids, the client should be following the appropriate one, and other factors such as fluid intake and activity level should be considered in planning a balanced diet. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Evaluate a diet using a food guide pyramid. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1141 Question 8 Type: MCSA 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 low 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 less than 40 calories per serving. 4. The product will contain no more than 11% fat. Correct Answer: 3 Rationale 1: The words "lighter" or "reduced calories" only mean that this version of the food is lower in calories than a previous version, but the food can still be very high in calories. Rationale 2: There is no special label letter that indicates foods lighter in calories. Rationale 3: In order to qualify as a low-calorie food in a 2,000-calorie diet, the food must have less than 40 calories per serving. Rationale 4: Foods that are lower in fat also contain fewer calories, but low fat is considered less than 5%. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9. Discuss nursing interventions to treat clients with nutritional problems. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1144 Question 9 Type: MCSA 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. Correct Answer: 2 Rationale 1: The presence of an oxygen cannula is not associated with preparation for the test. Rationale 2: 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. Rationale 3: Urine output is not collected for 48 hours for this test. Rationale 4: The client must have protein intake during the testing time. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9. Discuss nursing interventions to treat clients with nutritional problems. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1149 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 10 Type: MCSA A client who has undergone a 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 Correct Answer: 3 Rationale 1: Apricot nectar is thick with pulp. Rationale 2: Cranberry juice is red. Clients who have undergone gastrointestinal surgery are often not allowed to have red liquids because the color can be confused with blood if the client vomits. Rationale 3: Chicken broth is the only liquid listed that is clear and not red. Rationale 4: A cherry ice pop is red. Clients who have undergone gastrointestinal surgery are often not allowed to have red liquids because the color can be confused with blood if the client vomits. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Discuss nursing interventions to treat clients with nutritional problems. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1154 Question 11 Type: MCSA Unlicensed 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 4 Rationale 1: It may well take over 45 minutes to feed these clients in an unhurried manner. Rationale 2: Fluids should be offered when the client requests fluids, or after three to four bites of food. Rationale 3: The personnel should sit while feeding the client to convey a relaxed and unhurried atmosphere. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Discuss nursing interventions to treat clients with nutritional problems. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1155 Question 12 Type: SEQ The nurse is preparing to insert a nasogastric tube into a client. In what order will the nurse conduct the following steps? Standard Text: Click and drag the options below to move them up or down. Choice 1. Ask the client to tilt the head forward. Choice 2. Insert the tube with its natural curve toward the client. Choice 3. Ask the client to hyperextend the neck. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Choice 4. Have the client swallow a small amount of liquid. Choice 5. Employ a slight twisting motion on the tube. Correct Answer: 2, 3, 5, 1, 4 Rationale 1: At this time, have the client tilt the head forward to facilitate passage of the tube into the posterior pharynx and esophagus. Rationale 2: The tube should first be inserted with its natural curve toward the client. Rationale 3: At this time, having the client hyperextend the neck will reduce the curvature of the nasopharyngeal junction. Rationale 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. Rationale 5: A slight twisting motion may help pass the tube into the nasopharynx. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: a. Inserting a nasogastric tube. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1157 Question 13 Type: MCSA The nurse has delegated administration of tube feeding to a specially trained UAP. 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 2 Rationale 1: The nurse is responsible to assess tube placement and to determine that the tube is patent. The UAP can order equipment. Rationale 2: The nurse is responsible to assess tube placement and to determine that the tube is patent. Rationale 3: The UAP can set up equipment and mix the feeding. Rationale 4: The UAP can order equipment and regulate the rate of feeding. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Recognize when it is appropriate to delegate aspects of feeding clients to unlicensed assistive personnel. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1163 Question 14 Type: MCSA 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. Correct Answer: 3 Rationale 1: Feeding is not added to that which has already been hanging. Rationale 2: There is no indication to change the type of feeding to a closed system. Rationale 3: The open set should be taken down, washed well, and rehung with new feeding. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Carbonated soda should not be used to irrigate the tube, as it can lead to occlusion. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: c. Administering a tube feeding. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1164 Question 15 Type: MCSA 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. Correct Answer: 2 Rationale 1: This is a common response to the presence of a tube in the oropharynx, so removal of the tube is not necessary. Rationale 2: Swallowing ice or water may help calm the gag reflex and also facilitate the "swallowing" of the tube. Rationale 3: The nurse should not use pressure to pass the tube. Rationale 4: The client's head should be tilted forward at this point. Tilting the head back will open the airway, not the esophagus. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: a. Inserting a nasogastric tube. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1159 Question 16 Type: MCSA 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's position. 2. Turn off the tube feeding. 3. Assess the client's lung sounds. 4. Assess the client's bowel sounds. Correct Answer: 2 Rationale 1: This action is not the priority. Rationale 2: 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. Rationale 3: This is not the priority action. Rationale 4: This is not the priority action. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Plan, implement, and evaluate nursing care associated with nursing diagnoses related to nutritional problems. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1167 Question 17 Type: MCSA 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. Correct Answer: 2 Rationale 1: Clients who have a BMI of less than 16 are considered malnourished. Rationale 2: A BMI of 18 falls within the category of being underweight (16–19). Rationale 3: Clients with a BMI of 20–25 are considered normal. Rationale 4: A BMI of 26–30 is considered overweight. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12. Plan, implement, and evaluate nursing care associated with nursing diagnoses related to nutritional problems. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1131 Question 18 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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% Correct Answer: 3 Rationale 1: 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%. Rationale 2: 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%. Rationale 3: 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%. Rationale 4: 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%. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Discuss essential components and purposes of nutritional assessment and nutritional screening. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1151 Question 19 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 2 Rationale 1: 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% to 90%, moderate malnutrition is 75% to 84%, and severe malnutrition is less than 74%. This calculation is particularly important in an unintentional weight loss. Rationale 2: 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% to 90%, moderate malnutrition is 75% to 84%, and severe malnutrition is less than 74%. This calculation is particularly important in an unintentional weight loss. Rationale 3: 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% to 90%, moderate malnutrition is 75% to 84%, and severe malnutrition is less than 74%. This calculation is particularly important in an unintentional weight loss. Rationale 4: 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% to 90%, moderate malnutrition is 75% to 84%, and severe malnutrition is less than 74%. This calculation is particularly important in an unintentional weight loss. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12. Plan, implement, and evaluate nursing care associated with nursing diagnoses related to nutritional problems. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1151 Question 20 Type: MCSA The nurse is reviewing laboratory data for a client who is receiving total parenteral nutrition. Which laboratory value should be immediately brought to the physician's attention? 1. BUN of 60 2. Prealbumin of 15 3. Serum glucose of 328 4. Potassium of 3.5 Correct Answer: 3 Rationale 1: This laboratory value does not need to be immediately brought to the physician's attention. Rationale 2: This laboratory value does not need to be immediately brought to the physician's attention. Rationale 3: The most important concern in this set of laboratory data is the increased serum glucose. Rationale 4: The potassium reading is normal. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify risk factors for and clinical signs of malnutrition. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1169 Question 21 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA What nursing diagnosis is the most important for the nurse to include in the care plan of a client who has just been started on total parenteral nutrition (TPN) therapy? 1. Risk for Infection 2. Imbalanced Nutrition: Less Than Body Requirements 3. Activity Intolerance 4. Fluid Volume Deficit Correct Answer: 1 Rationale 1: TPN is delivered via a venous catheter and is very high in glucose. There is a very high risk for infection. Rationale 2: The client already has imbalanced nutrition, so although that nursing diagnosis would be included, it is not as important as the risk for infection. The TPN therapy is already addressing the imbalanced nutrition. Rationale 3: The client may have activity intolerance, but the risk for infection takes priority, as it can cause greater physical harm to the client. Rationale 4: The client is now at more risk of fluid volume overload from the additional TPN fluid. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 12. Plan, implement, and evaluate nursing care associated with nursing diagnoses related to nutritional problems. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1169 Question 22 Type: MCMA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Standard Text: Select all that apply. 1. Tofu 2. Soybeans 3. Brewer’s yeast 4. Raisins 5. Okra Correct Answer: 1, 2, 4 Rationale 1: Calcium deficiency is a concern for strict vegetarians. It can be prevented by including in the diet tofu (soybean curd) fortified with calcium. Rationale 2: Calcium deficiency is a concern for strict vegetarians. It can be prevented by including in the diet soybean milk. Rationale 3: Brewer’s yeast is a good source of vitamin B12. Rationale 4: Raisins are a good source of iron. Rationale 5: Okra does not have an appreciable amount of calcium. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe nursing interventions to promote optimal nutrition. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1144 Question 23 Type: MCSA During diet teaching with a client diagnosed with diabetes, the nurse should instruct that the most prevalent monosaccharide is Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. fructose. 2. galactose. 3. corn syrup. 4. glucose. Correct Answer: 4 Rationale 1: Fructose is not as abundant as is glucose. Rationale 2: Galactose is not as abundant as is glucose. Rationale 3: Corn syrup is considered a processed sugar. Rationale 4: Of the three monosaccharides—glucose, fructose, and galactose—glucose is by far the most abundant simple sugar. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Identify essential nutrients and their dietary sources. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1128 Question 24 Type: MCMA The nurse is instructing a client on foods that are considered complete proteins. What will the nurse include in these instructions? Standard Text: Select all that apply. 1. Meat 2. Gelatin 3. Eggs Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Chicken 5. Fish Correct Answer: 1, 3, 4, 5 Rationale 1: Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including meats, are complete proteins. Rationale 2: Some animal proteins contain less than the required amount of one or more essential amino acids, and therefore cannot support continued growth alone. These proteins are sometimes referred to as partially complete proteins. Gelatin is an incomplete protein. Rationale 3: Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including eggs, are complete proteins. Rationale 4: Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including poultry, are complete proteins. Rationale 5: Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including fish, are complete proteins. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Identify essential nutrients and their dietary sources. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1128 Question 25 Type: MCMA A client is diagnosed with an elevated cholesterol level. What should the nurse instruct the client regarding foods to avoid? Standard Text: Select all that apply. 1. Fish Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Milk 3. Liver 4. Chicken 5. Egg yolk Correct Answer: 2, 3, 5 Rationale 1: Cholesterol is not as prevalent in fish. Rationale 2: Cholesterol is found in milk. Rationale 3: Cholesterol is found in organ meats, such as liver. Rationale 4: Cholesterol is not as prevalent in chicken. Rationale 5: Cholesterol is found in egg yolks. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Identify essential nutrients and their dietary sources. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1130 Question 26 Type: MCMA 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? Standard Text: Select all that apply. 1. Enzymes are needed to digest carbohydrates. 2. The breakdown of carbohydrates results in simple sugars. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 1, 2, 3, 4 Rationale 1: Major enzymes of carbohydrate digestion speed up chemical reactions. Rationale 2: The desired end products of carbohydrate digestion are monosaccharides. Some simple sugars are already monosaccharides, and require no digestion. Rationale 3: Carbohydrate metabolism is a major source of body energy. Rationale 4: 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. Rationale 5: Insulin, a hormone secreted by the pancreas, enhances the transport of glucose into cells. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Describe normal digestion, absorption, and metabolism of carbohydrates, proteins, and lipids. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1128 Question 27 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Analyze reasons why fats should be limited in the diet. Correct Answer: 3 Rationale 1: This would further decrease the client’s protein stores, worsening the nitrogen balance. Rationale 2: Nitrogen balance does not measure carbohydrate intake in the diet. Rationale 3: 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. Rationale 4: Fat intake does not influence nitrogen balance. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Discuss nursing interventions to treat clients with nutritional problems. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1149 Question 28 Type: MCSA A client diagnosed with negative nitrogen balance tells the nurse about participating in ritualistic fasts as a part of his culture. The client 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 Correct Answer: 2

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: The client’s weight loss is not as important as is the harm the fast is doing to the client’s protein stores and nitrogen balance. Rationale 2: A person who fasts will obtain most of his or her 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 during the ritualistic fasts. Rationale 3: The client’s need for increased caloric intake after the fast is not as important as is the harm the fast is doing to the client’s protein stores and nitrogen balance. Rationale 4: The importance of the practice to the client is not as important as is the harm the fast is doing to the client’s protein stores and nitrogen balance. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Discuss nursing interventions to treat clients with nutritional problems. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1129 Question 29 Type: MCMA 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? Standard Text: 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.” Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1, 5 Rationale 1: 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. Rationale 2: The nurse should not support the client’s belief about foods being either “good” or bad.” Rationale 3: The nurse should not support the client’s belief about foods being either “good” or bad.” Rationale 4: This might not be enough to sustain the client’s calorie needs. Rationale 5: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Identify essential nutrients and their dietary sources. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1132 Question 30 Type: MCSA 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. The nurse realizes this client’s nutritional status is influenced by 1. lifestyle. 2. culture. 3. beliefs about food. 4. religious practices. Correct Answer: 3

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Certain lifestyles are linked to food-related behaviors. People who are always in a hurry probably buy convenience grocery items or eat restaurant meals. People who spend many hours at home might take time to prepare more meals “from scratch.” Rationale 2: Ethnicity often determines food preferences. Traditional foods are still eaten long after other customs are abandoned. Rationale 3: 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 practices are relatively common. Rationale 4: Religious practice also affects diet. In some religions, meat is avoided on certain days. In some faiths, meat, tea, coffee, and/or alcohol are prohibited. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify factors influencing nutrition. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1132 Question 31 Type: MCMA The nurse is planning instruction for a client who is underweight. What should be included in this teaching? Standard Text: 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. Correct Answer: 1, 2, 4, 5 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Client teaching for underweight clients should include a discussion of the factors contributing to inadequate nutrition and weight loss. Rationale 2: Client teaching for underweight clients should include a discussion of ways to manage, minimize, or alter the factors contributing to malnourishment. Rationale 3: Client teaching for overweight clients should include the principles of a well-balanced diet. Highand low-calorie foods are not necessary to review with the client in this scenario. Rationale 4: Client teaching for underweight clients should include information about community agencies that can assist in providing food. Rationale 5: Client teaching for underweight clients should include information about ways to increase caloric intake. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe nursing interventions to promote optimal nutrition. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1153 Question 32 Type: MCMA The nurse is planning interventions for a client to improve the appetite. What actions would be appropriate for this client? Standard Text: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 1, 2, 3, 4 Rationale 1: Interventions to improve a client’s appetite include selecting small portions. Rationale 2: Interventions to improve a client’s appetite include avoiding unpleasant treatments immediately before or after a meal. Rationale 3: Interventions to improve a client’s appetite include ensuring a clean environment that is free of unpleasant sights and odors. Rationale 4: Interventions to improve a client’s appetite include encouraging oral hygiene before a meal. Rationale 5: Interventions to improve a client’s appetite include providing medication for pain or other symptoms before a meal, not after a meal. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Discuss nursing interventions to treat clients with nutritional problems. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1155 Question 33 Type: SEQ 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. Standard Text: Click and drag the options below to move them up or down. Choice 1. Place the tube in a plastic bag. Choice 2. Ask the client to take a deep breath and to hold it. Choice 3. Smoothly withdraw the tube. Choice 4. Pinch the tube with the gloved hand. Choice 5. Observe the intactness of the tube. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Choice 6. Apply clean gloves. Correct Answer: 6, 2, 4, 3, 1, 5 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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. Rationale 5: 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. Rationale 6: 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. Global Rationale:

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: b. Removing a nasogastric tube. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1169 Question 34 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 1 Rationale 1: Prior to administering a feeding through a gastrostomy tube, the nurse should assess for tube placement. Rationale 2: The client’s vital signs do not need to be assessed prior to receiving a feeding through a gastrostomy tube. Rationale 3: The client should be in the sitting position or the Fowler’s position. Rationale 4: The head of the bed should be elevated at least 30 degrees. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: d. Administering a gastrostomy or jejunostomy tube feeding. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1166 Question 35 Type: MCMA The nurse has finished providing a tube feeding to a client. What should the nurse document about this procedure? Standard Text: Select all that apply. 1. Name of physician prescribing the feedings 2. Solution provided Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Amount of fluid 4. Duration of the feeding 5. Client tolerance of the feeding Correct Answer: 2, 3, 4, 5 Rationale 1: The nurse does not need to document the name of the physician who prescribed the feedings. Rationale 2: When documenting after a tube feeding, the nurse should document the solution provided. Rationale 3: When documenting after a tube feeding, the nurse should document the amount of fluid provided. Rationale 4: When documenting after a tube feeding, the nurse should document the duration of the feeding. Rationale 5: When documenting after a tube feeding, the nurse should document the client’s tolerance of the feeding. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Demonstrate appropriate documentation and reporting of nutritional therapy. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1165 Question 36 Type: MCSA A client receives several tube feedings each day. After documenting the client’s tolerance of the feedings and assessments in the medical record, the nurse should also document the amount of feeding provided on the 1. graphic sheet. 2. dietary consultation notes. 3. vital signs record. 4. intake and output record. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 4 Rationale 1: Fluid intake for each feeding is not entered on the graphic sheet. The amount of fluid for a 24-hour period would be documented on this sheet. Rationale 2: Fluid intake for tube feedings is not documented in the dietary consultation notes. Rationale 3: Fluid intake for tube feedings is not documented on the vital signs record. Rationale 4: The amount of fluid as feeding provided to the client should be recorded on the intake and output record. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Demonstrate appropriate documentation and reporting of nutritional therapy. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1165 Question 37 Type: FIB A client is prescribed a 1600-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? Standard Text: Calculate to the nearest whole number. Correct Answer: 200 grams Rationale: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss essential components and purposes of nutritional assessment and nutritional screening. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1130 Question 38 Type: MCMA The nurse is concerned that an older client is at risk for aspiration. What feeding techniques should the nurse instruct the family to use once the client is discharged? Standard Text: 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. Correct Answer: 1, 2, 3, 4 Rationale 1: 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. Rationale 2: 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. Rationale 3: Safety should always be a priority concern, with attention paid to preventing aspiration. Techniques to reduce this risk include eating in a seated position. Rationale 4: Safety should always be a priority concern, with attention paid to preventing aspiration. Techniques to reduce this risk include focusing on food preferences. Rationale 5: Safety should always be a priority concern, with attention paid to preventing aspiration. Keeping the head of the bed at a 30-degree angle would encourage aspiration. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify nutritional variations throughout the life cycle. MNL Learning Outcome: 4.9.1. Implement interventions to support nutritional intake in clients who are unable to eat. Page Number: 1141

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 48 Question 1 Type: MCSA 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 Correct Answer: 1 Rationale 1: Development factors such as how old the client is influence urinary elimination. Rationale 2: Body image does not influence urinary elimination. Rationale 3: Knowledge does not influence urinary elimination. Rationale 4: Socioeconomic status does not influence urinary elimination. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Identify factors that influence urinary elimination. MNL Learning Outcome: 4.8.2. Recognize factors affecting urinary elimination. Page Number: 1178 Question 2 Type: MCSA The nurse realizes that which client is at risk for difficulty in urinary elimination? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 3 Rationale 1: The client who had bladder cancer and now has an ileal conduit doesn't have kidney damage, only the bladder removed. Continued urine production through the ileal conduit will need to be observed and assessed frequently by the staff. Rationale 2: The 25-year-old experiencing low self-esteem has a psychological problem and will need therapy to find the root of the problem. Rationale 3: 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. Rationale 4: The client with high blood pressure takes her medication to remove excess fluid from the body, and as long as urine elimination increases, there should be no problems. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify common causes of selected urinary problems. MNL Learning Outcome: 4.8.2. Recognize factors affecting urinary elimination. Page Number: 1180 Question 3 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Decrease in number of nephrons 4. Decrease in cardiac output Correct Answer: 1 Rationale 1: 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 (UTI), stress, and pregnancy can cause frequent voiding of small quantities of urine. Total fluid intake and output may be normal. Rationale 2: A decrease in blood supply causes an increase in urine concentration. Rationale 3: A decrease in the number of nephrons decreases the filtration rate. Rationale 4: A decrease in cardiac output decreases peripheral circulation, which would decrease urinary output during both the day and the night. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify common causes of selected urinary problems. MNL Learning Outcome: 4.8.2. Recognize factors affecting urinary elimination. Page Number: 1180 Question 4 Type: MCSA 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. Correct Answer: 3 Rationale 1: Irritating soaps and bubble baths can contribute to infections and should be avoided. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: The client should decrease the amount of sugar in the diet because sugar promotes bacterial growth. Rationale 3: Completely emptying the bladder prevents stasis of urine, which would contribute to a urinary tract infection. Rationale 4: The client should wipe from front to back because wiping from back to front would contaminate the urinary meatus. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe nursing interventions to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence. MNL Learning Outcome: 4.8.2. Recognize factors affecting urinary elimination. Page Number: 1188 Question 5 Type: MCSA 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. Correct Answer: 2 Rationale 1: The appliance should be changed as necessary. Changing the appliance too frequently can cause skin breakdown. Rationale 2: Increasing the fluid intake helps to flush out sediment and mucus and prevents clogging of the stoma. Rationale 3: A deep pink, shiny stoma is normal, and there's no need to notify the physician. Rationale 4: Strands of mucus, not blood, may appear in urine because of the mucus-producing cells of the ileum. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9. Explain the care of clients with retention catheters or urinary diversions.. MNL Learning Outcome: 4.8.2. Recognize factors affecting urinary elimination. Page Number: 1189 Question 6 Type: MCSA Which nursing intervention is appropriate when caring for a client with a retention 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. Correct Answer: 4 Rationale 1: Gloves are to be worn for cleaning but not sterile gloves. Rationale 2: When giving catheter care to a female, the labia minora is gently retracted away from the urinary meatus, not the labia majora. Rationale 3: The urine in the tubing should be observed, not the urine in the bag. Observing the urine in the tubing promotes accurate assessment of urine. Rationale 4: Retaping the catheter to the thigh after care is given prevents trauma and pain from tension and pulling. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Explain the care of clients with retention catheters or urinary diversions. MNL Learning Outcome: 4.8.2. Recognize factors affecting urinary elimination. Page Number: 1204 Question 7 Type: MCSA 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 Correct Answer: 2 Rationale 1: There is a possibility of skin impairment with a catheter, but the emphasis here is on where the drainage bag was found. Rationale 2: The floor is the dirtiest place, so the drainage device should never be placed on the floor. Rationale 3: Even though a client has a catheter in place, it does not restrict one from providing self-care. The client may need some assistance. Rationale 4: The placement of a catheter prevents incontinence; it does not add to it. Patency of the catheter ensures flow, not obstruction. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 6. Develop nursing diagnoses and desired outcomes related to urinary elimination. MNL Learning Outcome: 4.8.2. Recognize factors affecting urinary elimination. Page Number: 1187 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 8 Type: MCSA 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 her bladder every time she voids. 2. The client will improve her incontinence within 1 month. 3. The client will perform four to five squeezes for 5 to 10 seconds. 4. The client will stop the flow of urine when voiding. Correct Answer: 3 Rationale 1: Emptying the bladder completely every time she voids would not be realistic in the beginning. This will take time. Rationale 2: Improved continence takes 3 to 6 months, so 1 month is not a realistic goal. Rationale 3: Performing four to five squeezes for 5 to 10 seconds is the goal to start with when teaching a client Kegel exercises, which are used for stress and urge incontinence. Rationale 4: Clients are not instructed to stop the flow of urine when voiding because this could lead to retention. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Develop nursing diagnoses and desired outcomes related to urinary elimination. MNL Learning Outcome: 4.8.2. Recognize factors affecting urinary elimination. Page Number: 1187 Question 9 Type: MCSA Which goals should the nurse identify as appropriate for a client with the nursing diagnosis Urinary Pattern Alteration related to an enlarged prostate? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 1 Rationale 1: 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. Rationale 2: One would want to maintain fluid balance, not imbalance, with a client with urinary obstruction and enlarged prostate. Keeping up with the client's intake and output would be a better goal. Rationale 3: It is important to keep urine off the skin to prevent breakdown, but with an enlarged prostate the problem will be more of the client retaining urine instead of it being on the skin. Rationale 4: One would hope that if the retention subsides, the client would voice less discomfort, not more. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Develop nursing diagnoses and desired outcomes related to urinary elimination. MNL Learning Outcome: 4.8.2. Recognize factors affecting urinary elimination. Page Number: 1193 Question 10 Type: MCSA The RN is admitting a client to the medical unit for 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 observation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 4 Rationale 1: The nurse will not use auscultation when assessing the client's urinary system. Rationale 2: The percussion technique is the least frequently used by nurses, and it would cause discomfort if this client is already uncomfortable with a kidney condition. The nurse should not make matters worse. Rationale 3: The nurse will not use auscultation when assessing the client's urinary system. Rationale 4: The hands and sense of touch are used with palpation to gather data along with observation or inspection, which visually allows the nurse to observe all responses and nonverbal behavior. It is also the most frequently used technique and the most convenient. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe nursing assessment of urinary function, including subjective and objective data. MNL Learning Outcome: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1184 Question 11 Type: MCSA 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. Correct Answer: 2 Rationale 1: A client with incontinence would wear some kind of undergarment pad. Cotton undergarments alone would not provide protection for catching the urine. Rationale 2: Incontinence involves a small leakage of urine when a client laughs. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Incontinence does not occur if a client just carries on a conversation. Rationale 4: If the client has been experiencing incontinence, the nurse might expect to see the skin inflamed and irritated because urine is very irritating to the skin. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe nursing assessment of urinary function, including subjective and objective data. MNL Learning Outcome: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1187 Question 12 Type: MCSA 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 Correct Answer: 1 Rationale 1: Black color to the stoma and sloughing are signs of necrosis of the stoma. Rationale 2: A healthy stoma should appear moist. Rationale 3: A healthy stoma should appear pink and shiny. Slight bleeding might occur because the intestinal mucosa is very fragile. Rationale 4: Slight bleeding might occur because the intestinal mucosa is very fragile. Global Rationale: Cognitive Level: Analyzing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe nursing assessment of urinary function, including subjective and objective data. MNL Learning Outcome: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1204 Question 13 Type: MCSA 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 Correct Answer: 4 Rationale 1: An elevated specific gravity is seen in dehydration. Rationale 2: The glucose would be elevated in diabetic ketoacidosis. Rationale 3: Blood would be present in trauma. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify normal and abnormal characteristics and constituents of urine. MNL Learning Outcome: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1185 Question 14 Type: MCSA 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 Correct Answer: 3 Rationale 1: There should be no blood present as well as no ketones. Rationale 2: The urine should be an amber color, not dark amber. For an adult, normal output range is 1,200 to 1,500 mL in 24 hours. Rationale 3: Normal pH is 4.5 to 8, so a pH of 6 and no glucose present are two normal characteristics of urine. Rationale 4: A specific gravity of 1.035 does not fall within the normal range of 1.010 to 1.025, but a faint aromatic odor is normal. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify normal and abnormal characteristics and constituents of urine. MNL Learning Outcome: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1185 Question 15 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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. Correct Answer: 2 Rationale 1: Clients should always check with their physician before stopping any medication because there could be some major complications. Rationale 2: A beta-adrenergic blocker such as propranolol can cause urinary retention; therefore, it would be of the utmost importance to notify the physician. Rationale 3: Constipation has been reported from clients taking propranolol, but a laxative should not be taken every day, as one can become dependent. Rationale 4: This medicine should be taken with food, not on an empty stomach, in order to enhance absorption. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe nursing interventions to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence. MNL Learning Outcome: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1181 Question 16 Type: MCSA A client is having issues with urinary elimination. What should the nurse instruct this client to promote urinary elimination? 1. Don't interrupt your day by going to the bathroom; wait until you're at a good stopping place. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Drink 8 to 10 glasses of water daily. 3. Urine color changes are not important. 4. Wash with soap and water every other day. Correct Answer: 2 Rationale 1: The client should respond to the urge to void as soon as possible to avoid urinary retention. Rationale 2: Drinking 8 to 10 glasses of water daily will encourage the need for bladder emptying, keeping the system flushed. Rationale 3: The client should report any changes in urine color, which could be indicative of a problem. Rationale 4: To maintain asepsis, the client should wash with soap and water every day, not every other day. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe nursing interventions to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence. MNL Learning Outcome: 4.8.2. Recognize factors affecting urinary elimination. Page Number: 1188 Question 17 Type: MCSA A client is instructed on the care of an indwelling urinary catheter. Which returned demonstration by the client indicates that teaching has been effective? 1. The client empties the drainage bag once a day. 2. The client hangs the drainage bag on the towel rod. 3. The client refuses drinks one to two 8-ounce glasses of fluid each day. 4. The client takes a shower each day. Correct Answer: 4 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: The drainage bag should be emptied regularly, not just once a day but at least three times a day. Rationale 2: Hanging the drainage bag on the towel rod is too high. The drainage bag should be hung below the bladder. Rationale 3: Adequate amounts of fluids should be consumed to help prevent sediments and infections. Rationale 4: The client should take a shower rather than a tub bath because sitting in a tub allows bacteria to easily access the urinary tract. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Develop nursing diagnoses and desired outcomes related to urinary elimination. MNL Learning Outcome: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1188 Question 18 Type: MCSA A client recovering from a transurethral resection of the prostate (TURP) 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. Correct Answer: 2 Rationale 1: Deflating and reinflating the balloon is not an option. The surgeon knows how much pressure is needed to control bleeding after surgery. Rationale 2: Blood clots give the client the sensation to urinate when they obstruct the urine outflow; therefore, irrigation will have to remedy the problem. Rationale 3: Repositioning the catheter would not be an option right after surgery. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The catheter is usually taped to the client's leg after a TURP and is not to be manipulated. This also controls bleeding after surgery. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe nursing interventions to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence. MNL Learning Outcome: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1202 Question 19 Type: HOTSPOT The nurse is reviewing kidney function with a client experiencing renal failure. Identify the area in the nephron where solutes such as glucose are reabsorbed.

Standard Text: Click on the correct area on the image.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: Rationale: Solutes such as glucose are reabsorbed in the loop of Henle. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe the process of urination, from urine formation through micturition. MNL Learning Outcome: 4.8.1. Explain the physiological process of urinary elimination from the formation of urine to micturition. Page Number: 1177 Question 20 Type: MCSA The nurse is caring for a client with a urinary diversion. For which type of diversion should the nurse plan care for this client?

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Incontinent urinary diversion 2. The kock pouch. 3. Neobladder 4. Nephrostomy Correct Answer: 1 Rationale 1: This is an incontinent urinary diversion (ileal conduit). Rationale 2: This is not a continent urinary diversion. Rationale 3: This is not a neobladder. Rationale 4: This is not a nephrostomy. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Identify factors that influence urinary elimination. MNL Learning Outcome: 4.8.2. Recognize factors affecting urinary elimination. Page Number: 1205 Question 21 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

A client is diagnosed with an elevated aldosterone level. The nurse realizes that this finding will affect what aspect of urinary elimination? 1. Increased urine output 2. Urinary incontinence 3. Decreased urine output 4. Urinary retention Correct Answer: 3 Rationale 1: Elevated aldosterone levels will not increase the urine output. Rationale 2: Elevated aldosterone levels do not cause urinary incontinence. Rationale 3: When aldosterone is released from the adrenal cortex, sodium and water are reabsorbed in greater quantities, increasing the blood volume and decreasing urinary output. Rationale 4: Elevated aldosterone levels do not cause urinary retention. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Identify factors that influence urinary elimination. MNL Learning Outcome: 4.8.2. Recognize factors affecting urinary elimination. Page Number: 1177 Question 22 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Urethra function Correct Answer: 1 Rationale 1: 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. Rationale 2: A cervical spine injury does not typically affect kidney function. Rationale 3: A cervical spine injury does not typically affect ureteral function. Rationale 4: A cervical spine injury does not typically affect urethra functioning. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Identify factors that influence urinary elimination. MNL Learning Outcome: 4.8.2. Recognize factors affecting urinary elimination. Page Number: 1178 Question 23 Type: MCMA A client is complaining of pain with urination. The nurse realizes that the client needs to be assessed for which health problems? Standard Text: Select all that apply. 1. Urethral stricture 2. Renal failure 3. Urethral injury 4. Bladder injury 5. Urinary infection Correct Answer: 1, 3, 4, 5 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Dysuria means voiding that is either painful or difficult. It can occur with a urethral stricture. Rationale 2: Dysuria means voiding that is either painful or difficult. It is not typically associated with renal failure. Rationale 3: Dysuria means voiding that is either painful or difficult. It can occur with a urethral injury. Rationale 4: Dysuria means voiding that is either painful or difficult. It can occur with a bladder injury. Rationale 5: Dysuria means voiding that is either painful or difficult. It can occur with a urinary infection. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify common causes of selected urinary problems. MNL Learning Outcome: 4.8.2. Recognize factors affecting urinary elimination. Page Number: 1182 Question 24 Type: MCMA A client needs a test to determine the amount of residual urine. The nurse realizes that this assessment is used for which reason(s)? Standard Text: Select all that apply. 1. To evaluate the glomerular filtration rate 2. To determine the extent of renal failure 3. To determine the amount of retained urine after voiding 4. To determine the need for medications 5. To evaluate fluid volume status Correct Answer: 3, 4 Rationale 1: Residual urine is not measured to evaluate the glomerular filtration rate. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Residual urine is not measured to determine the extent of renal failure. Rationale 3: Residual urine is measured to assess the amount of retained urine after voiding. Rationale 4: Residual urine is measured to determine the need for interventions such as medications. Rationale 5: Residual urine is not measured to evaluate fluid volume status. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe nursing assessment of urinary function, including subjective and objective data. MNL Learning Outcome: 4.8.2. Recognize factors affecting urinary elimination. Page Number: 1185 Question 25 Type: MCMA A client’s urine pH is 8.0. What further assessments would be indicated for this client? Standard Text: 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 Correct Answer: 1, 5 Rationale 1: Alkaline urine might indicate a diet high in fruits and vegetables. Rationale 2: Acidic urine is found in an intake high in cranberries. Rationale 3: Acidic urine is found in a diet high in proteins. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Acidic urine is found with diarrhea. Rationale 5: Alkaline urine might indicate a urinary tract infection. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe nursing assessment of urinary function, including subjective and objective data. MNL Learning Outcome: 4.8.2. Recognize factors affecting urinary elimination. Page Number: 1185 Question 26 Type: MCMA The nurse is instructing a client on ways to manage stress urinary incontinence. What should be included in this client’s teaching? Standard Text: 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. Correct Answer: 1, 2, 4 Rationale 1: Clients with stress incontinence should be instructed to limit the intake of caffeine. Rationale 2: Clients with stress incontinence should be instructed to limit the intake of alcohol. Rationale 3: Clients with stress incontinence should be instructed to limit, not increase, the intake of citrus juices. Rationale 4: Clients with stress incontinence should be instructed to limit evening fluid intake.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 5: Clients with stress incontinence should be instructed to limit, not increase, the intake of beverages with artificial sweeteners. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe nursing interventions to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence. MNL Learning Outcome: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1191 Question 27 Type: MCSA 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 8–10 8-ounce glasses of water and low-calorie beverages each day. 4. The client exercises for 30–60 minutes most days of the week. Correct Answer: 1 Rationale 1: Tight-fitting pants or other clothing can cause irritation to the urethra and prevent ventilation of the perineal area, leading to an infection. Rationale 2: Employment is not usually a risk factor for the development of a urinary tract infection. Rationale 3: This fluid intake would be sufficient to flush the urinary system and prevent the accumulation of bacteria and waste products. Rationale 4: Exercise is not a risk factor for the development of a urinary tract infection. Global Rationale: Cognitive Level: Analyzing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify common causes of selected urinary problems. MNL Learning Outcome: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1188 Question 28 Type: MCSA The nurse is concerned that an older client with a retention 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 Correct Answer: 3 Rationale 1: Elevated blood pressure is not a sign of urinary tract infection. Rationale 2: Elevated heart rate is not a sign of urinary tract infection. Rationale 3: In the older client, confusion can be an early sign of urinary tract infection. Rationale 4: Leg pain is not a sign of urinary tract infection. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 4. Describe nursing assessment of urinary function, including subjective and objective data. MNL Learning Outcome: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1189 Question 29 Type: MCSA 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. Wash his or her hands. 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. Correct Answer: 4 Rationale 1: The nurse should wash his or her hands before and after the procedure. Rationale 2: The nurse should document after the procedure is completed. Rationale 3: The nurse should instruct the client about the drainage system after attaching the bag to the device. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: a. Applying an external urinary device. MNL Learning Outcome: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1192 Question 30 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The nurse is performing urinary catheterization for a client. After using the nondominant hand to separate the client’s labia for cleansing, the nurse will maintain this hand as being 1. sterile. 2. contaminated. 3. able to evaluate the effectiveness of the catheter balloon. 4. clean. Correct Answer: 2 Rationale 1: The hand is contaminated after touching the client’s skin. Rationale 2: When performing urinary catheterization, the nondominant hand is considered contaminated once it touches the client’s skin. Rationale 3: The hand should not be used to touch any equipment once it touches the client’s skin. Rationale 4: The hand is contaminated, not clean, after touching the client’s skin. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: b. Performing urinary catheterization. MNL Learning Outcome: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1197 Question 31 Type: MCSA The nurse wants to delegate the application of a condom catheter to unlicensed assistive personnel (UAP). 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Assess changes in the client’s mobility status. Correct Answer: 1 Rationale 1: Applying a condom catheter may be delegated to UAP. 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 UAP in the use of the condom catheter. Rationale 2: The nurse does not need to measure the client’s intake before delegating the application of a condom catheter to UAP. Rationale 3: The nurse does not need to assist the client out of bed to a chair before delegating the application of a condom catheter to UAP. Rationale 4: The nurse does not need to assess changes in the client’s mobility status before delegating the application of a condom catheter to UAP. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11. Recognize when it is appropriate to delegate aspects of urinary elimination to unlicensed assistive personnel. MNL Learning Outcome: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1191 Question 32 Type: MCSA The nurse is determining tasks to delegate to unlicensed assistive personnel (UAP). Which task should the nurse question before delegating to this level of health care 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 Correct Answer: 4 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: This skill can be delegated to UAP. Rationale 2: This skill can be delegated to UAP. Rationale 3: This activity can be delegated to UAP. Rationale 4: Due to the need for sterile technique and detailed knowledge of anatomy, insertion of a urinary catheter is not delegated to UAP. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11. Recognize when it is appropriate to delegate aspects of urinary elimination to unlicensed assistive personnel. MNL Learning Outcome: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1196 Question 33 Type: MCMA The nurse is documenting the insertion of a retention catheter for a client. What should be included in this documentation? Standard Text: 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 Correct Answer: 1, 3, 5 Rationale 1: The nurse should document the catheterization procedure, including the catheter size. Rationale 2: The nurse does not need to document the location of the drainage bag. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: The nurse should document the amount of urine that drained after insertion. Rationale 4: The nurse does not need to document the name of the physician who prescribed the insertion of the catheter. Rationale 5: The nurse should document the client’s tolerance of the procedure. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1199 Question 34 Type: MCMA A UAP has applied a condom catheter to a client. The nurse should document what information about this procedure? Standard Text: 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 UAP who applied the device 4. Time and date that the condom catheter was applied 5. Integrity of the penis Correct Answer: 4, 5 Rationale 1: A condom catheter does not have a balloon that needs to be inflated. Rationale 2: The nurse does not need to document the location of the drainage bag. Rationale 3: The nurse does not need to document the name of the UAP who applied the device. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The nurse should document the application of the condom, including the time. Rationale 5: The nurse should document any pertinent observations, such as the integrity of the penis. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1193 Question 35 Type: MCSA 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 Correct Answer: 2 Rationale 1: The nurse does not need to document the number of ml of solution used to inflate the balloon of the catheter, as the catheter already was in place. Rationale 2: The nurse should note any abnormal constituents, such as blood clots, pus, or mucous shreds. Rationale 3: The nurse does not need to document the location of the drainage bag. Rationale 4: The nurse does not need to document the technique used to conduct the irrigation. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1203 Question 36 Type: FIB 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? Standard Text: Calculate to the nearest whole number. Correct Answer: 625 mL Rationale: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10. Verbalize the steps used in: c. Performing bladder irrigation. MNL Learning Outcome: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1202 Question 37 Type: MCMA 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? Standard Text: Select all that apply. 1. Maintain a sterile closed drainage system. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Clean the peri-urethral area with antiseptics. 3. Ensure the catheter and tubing are not kinked. 4. Wash his or her hands before manipulating the catheter. 5. Keep the collection bag below the level of the bladder. Correct Answer: 1, 3, 4, 5 Rationale 1: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should maintain a sterile closed drainage system. Rationale 2: Cleaning the peri-urethral area with antiseptics is an action that should be avoided. Rationale 3: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should maintain unobstructed urine flow by making sure the catheter and tubing are not kinked. Rationale 4: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should wash his or her hands before any manipulation of the catheter or collection system. Rationale 5: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should keep the collection bag below the level of the bladder at all times. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Delineate ways to prevent urinary infection. MNL Learning Outcome: 4.8.4. Implement the nursing process in relation to all aspects of urinary elimination. Page Number: 1200

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 49 Question 1 Type: MCSA A client asks the RN 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. Correct Answer: 2 Rationale 1: Expulsion of the feces is assisted by contraction of the abdominal muscles and the diaphragm, which increases abdominal pressure, and by contraction of the muscles of the pelvic floor, which moves the feces through the anal canal. Rationale 2: 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. Rationale 3: Thigh flexion increases the pressure within the abdomen. Rationale 4: The sitting position increases the downward pressure on the rectum. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the physiology of defecation. MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination. Page Number: 1212 Question 2 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

A client asks the nurse 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. Correct Answer: 1 Rationale 1: The actions of the microorganisms are responsible for the odor produced and also the color of the feces. Rationale 2: Extreme stimulation of the client's emotions would result in large amounts of mucus being secreted. Rationale 3: The sensory nerves, when stimulated, give one the desire to defecate, not form gas. Rationale 4: Eating too fast or talking while eating does cause the formation of gas but does not contribute to the odor. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the physiology of defecation. MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination. Page Number: 1212 Question 3 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. A toddler who is now walking Correct Answer: 1 Rationale 1: Adults who are on bed rest are at greatest risk for developing constipation. Rationale 2: Infants who are breast-fed pass stools frequently, usually after each feeding, because the intestine is immature and water is not well absorbed. Rationale 3: School-age children may delay defecation because of play, but their activity still promotes regular bowel movements. Rationale 4: A toddler who is now walking has some control of defecation, and the nervous and muscular systems are sufficiently well developed to permit bowel control. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems. MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination. Page Number: 1215 Question 4 Type: MCSA The nurse is taking care of a client who states that he ignores the urge to defecate when he is 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." Correct Answer: 1 Rationale 1: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: This response does not explain why the client should change the practice. Rationale 3: Ignoring the urge will not strengthen the reflex later. Eventually the urge will be lost. Rationale 4: The urge can be lost. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems. MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination. Page Number: 1215 Question 5 Type: MCSA 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. Correct Answer: 1 Rationale 1: Assessment of fecal elimination includes a nursing history and also a review of any data from the client's records. Rationale 2: Interpretation of diagnostic test results would demonstrate evaluation of the nursing process. Rationale 3: Performing a physical examination would demonstrate implementation of the nursing process. Rationale 4: Setting goals for the client demonstrates the planning step of the nursing process. Global Rationale: Cognitive Level: Applying Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe methods used to assess fecal elimination. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1220 Question 6 Type: MCSA 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 Correct Answer: 2 Rationale 1: Black is abnormal. Rationale 2: Cylindrical in contour is a normal characteristic of feces because it takes the shape of the rectum. Rationale 3: Pungent is abnormal, but aromatic odor is normal. Rationale 4: Yellow is the color of an infant's feces, not an adult's. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 2. Distinguish normal from abnormal characteristics and constituents of feces. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1213 Question 7 Type: MCSA 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. Correct Answer: 4 Rationale 1: Changing one's daily routine can cause or contribute to diarrhea. Rationale 2: Decreasing fluid consumption may cause constipation. If a client has diarrhea and still decreases fluid intake, this can contribute to dehydration. Rationale 3: Increasing fiber in the diet when one already has diarrhea would just make matters worse. Rationale 4: Psychological stress such as anxiety, medications, food allergies, and certain diseases can cause diarrhea. Noting the event can help identify and stop the cause. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Identify factors that influence fecal elimination and patterns of defecation. MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination. Page Number: 1221 Question 8 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 4 Rationale 1: Pain medication contributes to constipation, especially those that are opiates. Rationale 2: Decreasing fluid intake further contributes to constipation. Rationale 3: Refusing to eat bran flakes would also promote constipation. Rationale 4: Increased activity such as walking promotes gastric motility, which increases bowel function. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Identify examples of nursing diagnoses, outcomes, and interventions for clients with elimination problems. MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination. Page Number: 1223 Question 9 Type: MCSA A client has a bowel movement of hard, dry, but formed stool. The nurse associates these characteristics with 1. bowel incontinence. 2. constipation. 3. diarrhea. 4. fecal impaction. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 2 Rationale 1: Bowel incontinence is the loss of voluntary ability to control feces. Rationale 2: Hard, dry, formed stool is characteristic of constipation. Rationale 3: Diarrhea is the passage of liquid feces. Rationale 4: Fecal impaction is a mass of hardened feces in the folds of the rectum. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems. MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination. Page Number: 1215 Question 10 Type: MCSA 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 Correct Answer: 2 Rationale 1: Lack of sphincter control contributes to bowel incontinence, not bed rest. Rationale 2: Lack of activity, as in bed rest, is a major contributor to constipation. Lack of movement slows bowel movements. Rationale 3: Diarrhea would come from a GI upset triggered by diseases, medication, or diet. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Disturbed body image would affect a client who has undergone a bowel diversion. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 6. Identify examples of nursing diagnoses, outcomes, and interventions for clients with elimination problems. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1221 Question 11 Type: MCSA 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. Correct Answer: 4 Rationale 1: Defecating regularly once the diarrhea has subsided can be a goal, but it is too soon for this goal. The problem needs to be corrected first. Rationale 2: Increasing the amount of sugar in the diet will just add to the diarrhea. Rationale 3: Because the client is experiencing diarrhea, which can dehydrate the client and promote electrolyte loss, limiting fluid would not be appropriate. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Identify examples of nursing diagnoses, outcomes, and interventions for clients with elimination problems. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1221 Question 12 Type: MCSA 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. Correct Answer: 4 Rationale 1: The drainage pouches are expensive, and they can be used for up to a week before being changed. Just daily rinsing and cleaning is necessary. Rationale 2: No special clothing has to be worn with a colostomy pouch. The client can wear the same clothes he or she wore prior to the surgery. Rationale 3: If a pin is stuck into the pouch, a hole will be left and it will cause leakage, which is not recommended. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Changing a bowel diversion ostomy appliance. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1235 Question 13 Type: MCSA 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 Correct Answer: 2 Rationale 1: After inspection, the nurse should then auscultate for bowel sounds. Rationale 2: The nurse will first inspect the client's abdominal region. Rationale 3: This technique would be used last in the assessment of a client with a fecal elimination problem. Rationale 4: This technique would be used after inspection and auscultation. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe methods used to assess fecal elimination. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 1220 Question 14 Type: MCSA 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 Correct Answer: 2 Rationale 1: Bowel sounds active in all four quadrants is indicative of normal bowel activity. Rationale 2: 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). Rationale 3: If the GI tract were compromised, the client would have a decrease in appetite, not an increase. Rationale 4: A semisolid and moist stool indicates normal bowel function. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems. MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination. Page Number: 1213 Question 15 Type: MCSA A client has a history of an inconsistent fecal elimination pattern. What should the nurse instruct this client to improve this health problem? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: For regular elimination, six to eight glasses of water should be consumed daily. Rationale 2: Increasing the consumption of spicy foods and sugar will cause diarrhea, which is not a normal fecal pattern. Rationale 3: Eating more whole grains will increase fiber in the diet, which increases bulk and volume. Rationale 4: The constant use of enemas and laxatives will promote dependence. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Identify measures that maintain normal fecal elimination patterns. MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination. Page Number: 1222 Question 16 Type: MCSA 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. Correct Answer: 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Applying pressure over the stoma may damage the stoma. Rationale 2: Stoma care includes cleaning the area and patting dry. Rationale 3: A physician's order is needed if the stoma is to be dilated. Dilating is not routine. Rationale 4: Scrubbing would cause the stoma to bleed because the area is very vascular. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe essentials of fecal stoma care for clients with an ostomy. MNL Learning Outcome: 4.9.3. Correlate alterations in bowel elimination to client care. Page Number: 1234 Question 17 Type: MCSA 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. Correct Answer: 2 Rationale 1: Once the enema is given, the client should hold the solution as long as possible for the best results. Rationale 2: The client lies in the left lateral position in order to clean the rectum and sigmoid. Rationale 3: The client lies in the left lateral position, not the right, in order to clean the rectum and sigmoid. Rationale 4: The client should take slow deep breaths through the mouth. This will enable the client to hold the solution being given. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe the purpose and action of commonly used enema solutions. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1228 Question 18 Type: MCSA 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 Correct Answer: 1 Rationale 1: A hypertonic solution exerts osmotic pressure and draws fluid from the interstitial space into the colon. Rationale 2: A hypotonic solution exerts a lower osmotic pressure than the surrounding interstitial fluid. Rationale 3: An isotonic solution is the safest enema solution to use. It exerts the same osmotic pressure as the interstitial fluid surrounding the colon. Rationale 4: Soapsuds stimulate peristalsis by increasing the volume in the colon and irritating the colon. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8. Describe the purpose and action of commonly used enema solutions. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1226 Question 19 Type: MCSA 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. Mass peristalsis 3. Haustral churning 4. Peristalsis Correct Answer: 2 Rationale 1: Flatus is largely air and the by-products of the digestion of carbohydrates. Rationale 2: Mass peristalsis involves a wave of powerful muscular contraction that moves over large areas of the colon. Mass peristalsis most commonly occurs after eating, stimulated by the presence of food in the stomach and small intestine. In adults, mass peristaltic waves occur only a few times a day. Rationale 3: Haustral churning involves movement of the chyme back and forth within the haustra. This action aids in the absorption of water and moves the contents forward to the next haustra. Rationale 4: Peristalsis is wavelike movement produced by the circular and longitudinal muscle fibers of the intestinal walls; it propels the intestinal contents forward. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify factors that influence fecal elimination and patterns of defecation. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination. Page Number: 1211 Question 20 Type: MCSA 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. Correct Answer: 1 Rationale 1: Stool that is pale in color is seen in those who ingest a diet high in milk and milk products and low in meat. Rationale 2: Eating a diet low in fruits and vegetables will not produce pale stool. Rationale 3: Using laxatives routinely will not produce pale stool. Rationale 4: Drinking 8 to 10 8-ounce glasses of water each day will not produce pale stool. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Distinguish normal from abnormal characteristics and constituents of feces. MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination. Page Number: 1213 Question 21 Type: MCMA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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? Standard Text: 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. Correct Answer: 1, 2, 3, 5 Rationale 1: 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. Rationale 2: Constipation can be relieved by increasing the fiber intake to 20–35 grams per day. Rationale 3: Adequate exercise is a preventative measure for constipation. Rationale 4: Responding to the gastrocolic reflex, and not ignoring it, also helps with constipation. Rationale 5: Daily fluid intake of six to eight glasses is an essential preventive measure for constipation. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Identify factors that influence fecal elimination and patterns of defecation. MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination. Page Number: 1213 Question 22 Type: MCSA A client recovering from abdominal surgery is demonstrating abdominal distention from trapped flatus. What can the nurse do to help this client? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: Activity does help with the expulsion of flatus; however, the client is recovering from abdominal surgery, and will not be able to participate in sufficient movement and exercise to pass the accumulated gas. Rationale 2: Restricting fluids will not help with the expulsion of flatus. Rationale 3: If excessive gas cannot be expelled through the anus, it might be necessary to insert a rectal tube to remove it. Rationale 4: Providing a diet rich in foods that create flatulence will cause the problem to be worse. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems. MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination. Page Number: 1217 Question 23 Type: MCSA A client with an upper gastrointestinal disorder is experiencing seeping of liquid stool, anorexia, abdominal distention, nausea, and vomiting. The nurse suspects the client is experiencing 1. constipation. 2. diarrhea. 3. trapped flatus. 4. fecal impaction. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 4 Rationale 1: Liquid stool is not an indication of constipation. Rationale 2: The liquid stool associated with abdominal distention, anorexia, nausea, and vomiting is not an indication of diarrhea. Rationale 3: Trapped flatus does not cause the seeping of liquid stool. Rationale 4: 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, nausea, and vomiting. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems. MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination. Page Number: 1215 Question 24 Type: MCMA 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? Standard Text: 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 to 3000 mL a day. 4. Do not ignore the urge to defecate. 5. Use over-the-counter medications to treat constipation. Correct Answer: 1, 2, 3, 4 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Measures to promote healthy defecation include establishing a regular exercise regimen. Rationale 2: Measures to promote healthy defecation include the intake of high-fiber foods such as vegetables, fruits, and whole grains. Rationale 3: Measures to promote healthy defecation include maintaining a fluid intake of 2000 to 3000 mL per day. Rationale 4: Measures to promote healthy defecation include not ignoring the urge to defecate. Rationale 5: Measures to promote healthy defecation include avoiding the use of over-the-counter medications to treat constipation. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Identify measures that maintain normal fecal elimination patterns. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1221 Question 25 Type: MCSA 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. Correct Answer: 2 Rationale 1: Providing a laxative does not address the issue that there are “too many people around” for the client to feel comfortable with bowel evacuation. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: 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. Rationale 3: Restricting fluids would encourage constipation. Rationale 4: Assisting the client with ambulation does not address the issue of too many people being around for the client to feel comfortable with defecation. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Identify measures that maintain normal fecal elimination patterns. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1221 Question 26 Type: MCSA A client has received an oil retention enema. The nurse should instruct the client that the enema will take effect within 1. 1 to 3 hours. 2. 10 to 20 minutes. 3. 5 to 10 minutes. 4. 10 to 15 minutes. Correct Answer: 1 Rationale 1: Oil retention enemas take effect within 1 to 3 hours. Rationale 2: Enemas using a hypertonic solution take effect in 5 to 10 minutes. Rationale 3: Soapsuds enemas take effect in 10 to 15 minutes. Rationale 4: Enemas using hypotonic or isotonic solutions take effect in 10 to 20 minutes. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe the purpose and action of commonly used enema solutions. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1227 Question 27 Type: MCMA 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? Standard Text: Select all that apply. 1. Hypertonic 2. Hypotonic 3. Soapsuds 4. Oil retention 5. Isotonic Correct Answer: 2, 5 Rationale 1: Hypertonic enema solutions draw water into the colon. Rationale 2: Hypotonic enema solutions soften the feces. Rationale 3: Soapsuds enema solutions irritate the mucosa. Rationale 4: Oil retention enema solutions lubricate the feces. Rationale 5: Isotonic enema solutions soften the feces. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8. Describe the purpose and action of commonly used enema solutions. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1226 Question 28 Type: MCMA 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 Standard Text: 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. Correct Answer: 2, 3, 4 Rationale 1: An ostomy appliance does not need to be changed daily. Rationale 2: An ostomy appliance should protect the skin. Rationale 3: An ostomy appliance should collect stool. Rationale 4: An ostomy appliance should control odor. Rationale 5: An ostomy appliance can be either open or closed. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe essentials of fecal stoma care for clients with an ostomy. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1232 Question 29 Type: MCSA The nurse is delegating activities regarding fecal elimination to unlicensed assistive personnel (UAP). Which activity can UAP 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. Correct Answer: 1 Rationale 1: Providing a client who is on bed rest with a fracture pan is within the skill level of UAP. Rationale 2: The client has a prolapsed rectum. The nurse should be providing the enema. Rationale 3: The client has an ostomy. The nurse should be providing ostomy care. Rationale 4: Irrigation of an ostomy should be done by the nurse. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10. Recognize when it is appropriate to delegate assistance with fecal elimination to unlicensed assistive personnel. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1224 Question 30 Type: MCSA During morning care, a UAP notes that thick green drainage is seeping around the appliance of a client’s new ostomy. What should the UAP 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. Correct Answer: 4 Rationale 1: UAP should have been instructed to clean drainage off of the skin. Rationale 2: UAP should not be instructed to remove the appliance and cover the stoma with toilet tissue. Rationale 3: UAP should not be instructed to perform care to a new ostomy. Rationale 4: Care of a new ostomy is not delegated to UAP. 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. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 10. Recognize when it is appropriate to delegate assistance with fecal elimination to unlicensed assistive personnel. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1233 Question 31 Type: SEQ Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The nurse is performing ostomy care for a client. Place in order the steps the nurse will perform to do this care. Standard Text: Click and drag the options below to move them up or down. Choice 1. Clean and dry the peristomal skin and stoma. Choice 2. Prepare and apply the skin barrier. Choice 3. Empty the pouch and remove the ostomy barrier. Choice 4. Assess the stoma and peristomal skin. Choice 5. Apply the pouch. Choice 6. Place a piece of tissue or gauze over the stoma and change it as needed. Correct Answer: 3, 1, 4, 6, 2, 5 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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. Rationale 5: 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. Rationale 6: 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. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Changing a bowel diversion ostomy appliance. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1234 Question 32 Type: MCSA 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. Correct Answer: 2 Rationale 1: Raising the height of the enema solution container will cause the solution to infuse faster, leading to more abdominal cramping. Rationale 2: 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. Rationale 3: The enema should not be discontinued. Rationale 4: The supine position will not reduce the client’s abdominal cramping. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: a. Administering an enema. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1229 Question 33 Type: MCMA A client has received a return-flow enema. What should the nurse document about this procedure? Standard Text: 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. Correct Answer: 2, 3, 4, 5 Rationale 1: The nurse does not need to document the number of times the solution was changed. Rationale 2: For a return-flow enema, the nurse should document the type of solution used. Rationale 3: For a return-flow enema, the nurse should document the length of time the solution was retained. Rationale 4: For a return-flow enema, the nurse should document the amount, color, and consistency of the return. Rationale 5: For a return-flow enema, the nurse should document the client’s relief of flatus and abdominal distention. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 12. Demonstrate appropriate documentation and reporting related to fecal elimination. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1229 Question 34 Type: MCMA The nurse has completed care with a client who has a new ostomy. What should the nurse document about the care provided? Standard Text: 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 Correct Answer: 1, 2, 3, 4 Rationale 1: After ostomy care, the nurse should document any changes in stoma size. Rationale 2: After ostomy care, the nurse should document the condition of the skin around the stoma. Rationale 3: After ostomy care, the nurse should document the amount and type of drainage. Rationale 4: After ostomy care, the nurse should document the client’s response to the procedure. Rationale 5: The nurse should assess the client’s bowel sounds before ostomy care. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Demonstrate appropriate documentation and reporting related to fecal elimination. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 1235 Question 35 Type: MCMA 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? Standard Text: Select all that apply. 1. Iron 2. Aspirin 3. Antacids 4. Antibiotics 5. Pepto-Bismol Correct Answer: 1, 2, 5 Rationale 1: Iron salts lead to black stool because of the oxidation of the iron. Rationale 2: Any drug that causes gastrointestinal bleeding, such as aspirin, can cause the stool to be black. Rationale 3: Antacids can cause a whitish discoloration or white specks in the stool. Rationale 4: Antibiotics may cause a gray-green discoloration of the stool. Rationale 5: Pepto-Bismol causes stools to be black. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify factors that influence fecal elimination and patterns of defecation. MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination. Page Number: 1213 Question 36 Type: MCMA The nurse is caring for a client with a fecal incontinence pouch. What should the nurse do when caring for this client? Standard Text: Select all that apply. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 1, 3, 4, 5 Rationale 1: For the client with a fecal incontinence pouch, the nurse should regularly assess the perianal skin area. Rationale 2: Fecal incontinence pouches are not irrigated. Rationale 3: For the client with a fecal incontinence pouch, the nurse should maintain the drainage system. Rationale 4: For the client with a fecal incontinence pouch, the nurse should change the bag every 72 hours or sooner if there is leakage. Rationale 5: For the client with a fecal incontinence pouch, the nurse should explain the purpose of the pouch to the client. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the life span NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Identify examples of nursing diagnoses, outcomes, and interventions for clients with elimination problems. MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function. Page Number: 1231

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 50 Question 1 Type: MCSA 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 Correct Answer: 2 Rationale 1: The client is able to cough. Rationale 2: 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. Rationale 3: The client can sneeze. Rationale 4: There is no decrease in the oxygen-carrying capacity of the trachea. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe the mechanisms for respiratory regulation. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1242 Question 2 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

When planning care, for which client should the nurse include close observation for a decreased or absent cough reflex? 1. The client with a nasal fracture 2. The client with impairment of vagus nerve conduction 3. The client with a sinus infection 4. The client with reduction in respiratory membrane conduction Correct Answer: 2 Rationale 1: Nasal fracture does not depress the cough reflex. Rationale 2: The cough reflex depends upon nerve impulse transmission via the vagus nerve to the medulla. The nurse must monitor clients with vagus nerve impairment (through spinal cord injury, trauma, CNS depression, or other means) for a decreased or absent cough reflex. This decreased or absent reflex places the client at high risk for aspiration or development of pneumonia or other respiratory infections. Rationale 3: A sinus infection will not depress the cough reflex. Rationale 4: The respiratory membrane is the alveolar/capillary membrane and is not implicated in decreased or absent cough reflex. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Identify factors influencing respiratory function. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1243 Question 3 Type: MCSA The client complains of difficulty breathing. Which assessment findings should the nurse associate with that complaint? 1. Use of accessory muscles Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Increased respiratory depth 3. Increased respiratory rate 4. Decreased respiratory depth 5. Decreased respiratory rate Correct Answer: 1, 2, 3, 4 Rationale 1: Use of accessory muscles often is an assessment finding indicating difficulty breathing. Rationale 2: Depth is often assessed when determining difficulty breathing. The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or more shallow if partial obstruction is present. Rationale 3: Rate is assessed when determining difficulty breathing. Rate is generally increased. Rationale 4: The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or more shallow if partial obstruction is present. Rationale 5: Rate is generally increased. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Describe nursing assessments for oxygenation status. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1247 Question 4 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Increased blood sugar 4. Increased sedimentation rate Correct Answer: 1 Rationale 1: 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. Rationale 2: BUN is a measure of blood urea nitrogen, not oxygen-carrying capacity. Rationale 3: The blood glucose level is not used to measure oxygenation. Rationale 4: The sedimentation rate is not a direct measure of oxygenation. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Identify four major types of conditions that can alter respiratory function. MNL Learning Outcome: 4.10.1. Examine the factors that affect oxygenation. Page Number: 1245 Question 5 Type: MCSA 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's position. 3. Have the client breathe through pursed lips. 4. Encourage the client to breathe more rapidly. Correct Answer: 3

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: In the client with chronic obstructive lung disease, the drive to breathe is often dependent upon low oxygen concentration. Increasing oxygen delivery by increasing the oxygen from 1.5 Lpm to 3 Lpm may be dangerous to this client. Rationale 2: Lowering the head of the bed makes it more difficult to breathe. This client should have the head of the bed elevated to the Fowler's position or should be assisted to lean over the overbed table to increase chest excursion. Rationale 3: 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. Rationale 4: Chronic obstructive lung disease makes it difficult for the client to breathe out, so increasing the rate of respiration will not be helpful. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe nursing measures to promote respiratory function and oxygenation. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1252 Question 6 Type: MCSA 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's position and ask him to cough forcefully. 4. Administer 25 mg of meperidine (Demerol) according to the prn pain order. Correct Answer: 2 Rationale 1: There is no indication that this client needs resuscitation. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: 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. Rationale 3: There is no need to place the client in Trendelenburg's position for coughing. Rationale 4: Demerol may slow breathing, but is not necessary at this time. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe nursing measures to promote respiratory function and oxygenation. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1247 Question 7 Type: MCSA The client is experiencing severe shortness of breath, but is not cyanotic. What laboratory value should the nurse review in an attempt to understand this phenomenon? 1. Blood sugar 2. Hemoglobin and hematocrit 3. Cardiac enzymes 4. Serum electrolytes Correct Answer: 2 Rationale 1: Blood sugar is not used to evaluate respiratory function. Rationale 2: In order to exhibit cyanosis, the client's blood must contain about 5 g or more of unoxygenated hemoglobin per 100 mL of blood and the surface blood capillaries must be dilated. Severe anemia will interfere with the development of cyanosis, so the nurse should review the hemoglobin and hematocrit. Rationale 3: Cardiac enzymes are not used to evaluate respiratory function. Rationale 4: Serum electrolytes are not used to evaluate respiratory function. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Identify four major types of conditions that can alter respiratory function. MNL Learning Outcome: 4.10.1. Examine the factors that affect oxygenation. Page Number: 1248 Question 8 Type: MCSA A client has a medical condition that often results in the development of metabolic acidosis. The nurse should observe this client for the development of which breathing pattern as a result of this condition? 1. Cheyne-Stokes 2. Biot's 3. Cluster 4. Kussmaul's Correct Answer: 4 Rationale 1: Cheyne-Stokes respirations are commonly a result of chronic diseases, increased intracranial pressure, or drug overdose. Rationale 2: Biot's respirations are often the result of central nervous system disorders. Rationale 3: Cluster respirations are often the result of central nervous system disorders. Rationale 4: Kussmaul's respirations are a type of hyperventilation that accompanies metabolic acidosis. They represent the body's attempt to compensate for the acidosis by "blowing off" carbon dioxide. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Describe nursing assessments for oxygenation status. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1247 Question 9 Type: MCSA 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 Correct Answer: 3 Rationale 1: There are no data that support Ineffective Breathing Pattern as a diagnosis. Rationale 2: There are no data that support Anxiety as a diagnosis. Rationale 3: 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. Rationale 4: There are no data that support Impaired Gas Exchange as a diagnosis. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 6. Identify four major types of conditions that can alter respiratory function. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1249 Question 10 Type: MCSA 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. Correct Answer: 3 Rationale 1: Sputum does contain bacteria, but they are killed by the acid environment of the gastrointestinal tract. Rationale 2: There is no danger to swallowing sputum. Rationale 3: There is no good rationale for having the client expectorate the sputum except for the nurse to view it for quality and quantity. Rationale 4: The client is no more likely to aspirate sputum than any other fluid. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe nursing measures to promote respiratory function and oxygenation. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1249 Question 11 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 3 Rationale 1: 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. Because this client is getting the treatments only twice each day, the sessions should be separated as far as possible to allow for benefits across a longer time span. Rationale 2: Because this client is getting the treatments only twice each day, the sessions should be separated as far as possible to allow for benefits across a longer time span. Rationale 3: 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 the meal schedule and is most widely distributed is 0700 and 2000. Rationale 4: 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. Because this client is getting the treatments only twice each day, the sessions should be separated as far as possible to allow for benefits across a longer time span. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8. Describe nursing measures to promote respiratory function and oxygenation. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1257 Question 12 Type: MCSA A client is receiving oxygen by nonrebreather mask, but the bag is deflating on inspiration. What action should be taken by the nurse? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 4 Rationale 1: There is no need to turn the client to either side. Rationale 2: All oxygen is delivered at 100%, so there is no method to increase the percentage of oxygen being delivered. Rationale 3: The seal between the client's face and the mask should be snug, but will not be airtight. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1260 Question 13 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 3 Rationale 1: The airway should not be taped in place, as it would then act as an airway obstruction if dislodged. Rationale 2: Although suctioning the client is possible with the airway in place, the client should be suctioned only when it is necessary. Rationale 3: The nurse should turn the client's head to the side to allow drainage of oral secretions. Rationale 4: Insertion of a nasal trumpet or nasopharyngeal airway is not necessary when the oropharyngeal airway is in place. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1265 Question 14 Type: MCSA 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. Correct Answer: 4 Rationale 1: The cuff should not be deflated if the client is being mechanically ventilated. Rationale 2: The tracheostomy ties are only removed when they are soiled and need to be changed. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: The tracheostomy inner cannula is only removed for cleaning. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1266 Question 15 Type: MCSA 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 2 to 3 breaths at 1.5 times the tidal volume prior to suction. 4. Instruct the client to cough forcefully from the abdomen prior to suction. Correct Answer: 3 Rationale 1: Turning up the suction level will not hyperinflate the client's lungs. Rationale 2: Increasing the oxygen flow rate will not hyperinflate the client's lungs. Rationale 3: The nurse should provide 2 to 3 breaths at 1.5 times the client's normal tidal volume prior to and after insertion of the suction catheter. Rationale 4: Coughing will not hyperinflate the client's lungs. Global Rationale: Cognitive Level: Applying Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1272 Question 16 Type: MCSA 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. Correct Answer: 2 Rationale 1: Chest tube suction should not be discontinued. Rationale 2: 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. Rationale 3: The tube should not be removed. Rationale 4: Simply reinforcing the chest tube dressing will not prevent further air loss and does not allow for physician input. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1280 Question 17 Type: MCSA 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 non-adherent gauze dressing Correct Answer: 1 Rationale 1: 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. Rationale 2: This is not an occlusive dressing. Rationale 3: This is not an occlusive dressing. Rationale 4: This is not an occlusive dressing. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1281 Question 18 Type: MCSA 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." Correct Answer: 1 Rationale 1: Polyester blankets and fabrics tend to produce static electricity, which can cause sparks and can cause oxygen-saturated fabrics to burn more readily. Rationale 2: The client understands the hazards associated with home oxygen therapy. Rationale 3: This statement reflects understanding of home oxygen therapy. Rationale 4: This statement reflects understanding of home oxygen therapy. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation 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: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1259 Question 19 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: Counting the respirations does not assess tube placement. Rationale 2: This will not determine tube placement. Rationale 3: 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. Rationale 4: Deflating the cuff and listening for minimal leak is a way to prevent damage to the trachea, not a way to assess placement. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1266 Question 20 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 2 Rationale 1: The humidifier should be filled with water prior to initiating therapy. Rationale 2: It is necessary to pad the cannula where it contacts the client's ears, as pressure irritation may occur. Rationale 3: Because this client has chronic obstructive pulmonary disease, the oxygen should be set at a lower delivery rate (generally no more than 1.5 to 2 Lpm). Rationale 4: The cannula does not require ties to secure. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: a. Administering oxygen by cannula, face mask, or face tent. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1263 Question 21 Type: MCSA 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. Correct Answer: 3 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Removing the ties without an assistant could allow the tracheostomy tube to become dislodged. Rationale 2: The knot for securing the tracheostomy tube should be tied at the side of the neck to prevent an area of pressure development. Rationale 3: 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. Rationale 4: The outer cannula is not removed in a new tracheostomy. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: d. Providing tracheostomy care. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1278 Question 22 Type: MCSA The nurse is planning the care of a client who has need for frequent suctioning. What should the nurse delegate to the UAP? 1. Both oral and tracheal suctioning 2. Only oral suctioning 3. Only tracheal suctioning 4. Neither oral nor tracheal suctioning Correct Answer: 2 Rationale 1: The suctioning of the oral cavity is a nonsterile procedure and can be delegated to the UAP. Tracheal suctioning is a sterile procedure that requires client assessment and should not be delegated to the UAP. Rationale 2: The suctioning of the oral cavity is a nonsterile procedure and can be delegated to the UAP.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Tracheal suctioning is a sterile procedure that requires client assessment and should not be delegated to the UAP. Rationale 4: The suctioning of the oral cavity is a nonsterile procedure and can be delegated to the UAP. Tracheal suctioning is a sterile procedure that requires client assessment and should not be delegated to the UAP. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Recognize when it is appropriate to delegate aspects of oxygen therapy, suctioning, and tracheostomy care. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1269 Question 23 Type: MCSA During tracheal suctioning, the nurse notes that the client' heart rate has increased from 80 to 100 bpm. Based upon 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. Correct Answer: 4 Rationale 1: There is no need to immediately discontinue suctioning. Rationale 2: There is no need to prepare to resuscitate the client. Rationale 3: The client will likely not tolerate continuing the suction episode until the airway is clear. Rationale 4: 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. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: c. Suctioning a tracheostomy or endotracheal tube. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1271 Question 24 Type: MCSA 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. Correct Answer: 4 Rationale 1: Hyperventilating the client will likely serve to force secretions back into the respiratory tract. Rationale 2: Hyperventilating the client will likely serve to force secretions back into the respiratory tract. Rationale 3: There is no need to instill normal saline into the tube of a client with copious frothy secretions. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: c. Suctioning a tracheostomy or endotracheal tube. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1274 Question 25 Type: MCSA 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. Correct Answer: 4 Rationale 1: The medications can be used on the same day. Rationale 2: It is imperative for the client to understand that the steroid inhaler is not a "rescue" inhaler and should not be used for immediate relief. Rationale 3: Although the client should be taught to use both inhalers as infrequently as possible, the client should be taught to use the inhaler when necessary. When the inhalers are used together, the bronchodilator is used first, followed by the steroid. Rationale 4: Both of these medications have the possible side effect of increased heart rate. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1253 Question 26 Type: MCMA A client complains of difficulty breathing. What will the nurse most likely assess in this client? Standard Text: 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 Correct Answer: 1, 2, 3, 4 Rationale 1: Use of accessory muscles is an assessment finding associated with difficulty breathing. Rationale 2: Increased respiratory depth is an assessment finding associated with difficulty breathing. Rationale 3: Increased respiratory rate is an assessment finding associated with difficulty breathing. Rationale 4: The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or more shallow if partial obstruction is present in conditions such as asthma. Respiratory rate is generally increased. Rationale 5: Respiratory rate is generally increased. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Describe nursing assessments for oxygenation status. MNL Learning Outcome: 4.10.1. Examine the factors that affect oxygenation. Page Number: 1245 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 27 Type: MCSA A client who was a victim of a house fire is coughing. The nurse realizes that the purpose of the cough is to 1. improve oxygenation. 2. remove irritants from the nasal passages. 3. remove irritants from the trachea or bronchi. 4. close the glottis. Correct Answer: 3 Rationale 1: Coughing does not improve oxygenation. Rationale 2: Sneezing removes irritants from the nasal passages. Rationale 3: 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. Rationale 4: Swallowing closes the glottis. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.10.1. Examine the factors that affect oxygenation. Page Number: 1243 Question 28 Type: MCSA A client is experiencing atelectasis. The nurse anticipates that this client will have an alteration in 1. Ventilation. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Alveolar gas exchange. 3. Transportation of oxygen and carbon dioxide. 4. Systemic diffusion. Correct Answer: 1 Rationale 1: Atelectasis affects lung compliance, which is a condition that needs to be present for adequate ventilation. Rationale 2: Alveolar gas exchange is the diffusion of oxygen from the alveoli and into the pulmonary blood vessels, and occurs after ventilation. Rationale 3: Transportation of oxygen and carbon dioxide occurs in the blood. Rationale 4: Systemic diffusion of oxygen and carbon dioxide occurs between the capillaries and the tissues and cells. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe the processes of breathing (ventilation) and gas exchange (respiration). MNL Learning Outcome: 4.10.1. Examine the factors that affect oxygenation. Page Number: 1245 Question 29 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 4 Rationale 1: The blood glucose level is not used to determine a client’s degree of effective gas exchange. Rationale 2: The serum potassium level is not used to determine a client’s degree of effective gas exchange. Rationale 3: The serum sodium level is not used to determine a client’s degree of effective gas exchange. Rationale 4: Blood for partial pressures or blood gases is usually obtained from arterial blood. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Describe nursing assessments for oxygenation status. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1245 Question 30 Type: MCMA The nurse is determining a client’s ability to transport oxygen from the lungs to body tissues. What factors will influence this ability? Standard Text: Select all that apply. 1. Cardiac output 2. Exercise 3. Diet 4. Erythrocyte count 5. Hematocrit Correct Answer: 1, 2, 4, 5 Rationale 1: Cardiac output is a factor that affects the rate of oxygen transport from the lungs to the tissues. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Exercise is a factor that affects the rate of oxygen transport from the lungs to the tissues. Rationale 3: Diet is not a factor that affects the rate of oxygen transport from the lungs to the tissues. Rationale 4: Erythrocyte count is a factor that affects the rate of oxygen transport from the lungs to the tissues. Rationale 5: Hematocrit level is a factor that affects the rate of oxygen transport from the lungs to the tissues. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify factors influencing respiratory function. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1245 Question 31 Type: MCSA 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 Correct Answer: 2 Rationale 1: An increase in carbon dioxide level will increase, not decrease, respirations. Rationale 2: 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. Rationale 3: An increase in carbon dioxide level might not increase the client’s blood pressure. Rationale 4: An increase in carbon dioxide level has no effect on the client’s bowel sounds. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Describe nursing assessments for oxygenation status. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1246 Question 32 Type: MCSA 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 Correct Answer: 4 Rationale 1: The alveoli do not respond to a low oxygen level. Rationale 2: The trachea does not respond to a low oxygen level. Rationale 3: The bronchioles do not respond to a low oxygen level. Rationale 4: Special neural receptors sensitive to decreases in O2 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. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe the processes of breathing (ventilation) and gas exchange (respiration). MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1246 Question 33 Type: MCSA 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 Correct Answer: 1 Rationale 1: 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. Rationale 2: Diazepam (Valium) does not affect urine output. Rationale 3: Diazepam (Valium) does not affect muscle tone. Rationale 4: Diazepam (Valium) does not affect appetite. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1247 Question 34 Type: MCMA The nurse is assessing an older client. What effects of aging should the nurse keep in mind during this assessment? Standard Text: 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 Correct Answer: 1, 4, 5 Rationale 1: The cough reflex decreases during aging. Rationale 2: Stiffening of blood vessels is an effect of aging on the cardiovascular system. Rationale 3: Alteration in protein synthesis is an effect of aging on the metabolic system. Rationale 4: Mucous membranes are drier with aging. Rationale 5: Increased risk of aspiration occurs in aging because of gastroesophageal reflux disease. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify factors influencing respiratory function. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1246 Question 35 Type: MCSA 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. Correct Answer: 2 Rationale 1: Conditions that affect the airway are those that partially or totally occlude the respiratory passages. Rationale 2: 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. Rationale 3: Conditions that affect the movement of air would alter the client’s breathing pattern. Rationale 4: Impaired diffusion can affect levels of gases in the blood, particularly oxygen, which does not diffuse as readily as does carbon dioxide. Hypoxemia, or reduced oxygen levels in the blood, can be caused by conditions that impair diffusion at the alveolar–capillary level, such as pulmonary edema or atelectasis, or by low hemoglobin levels. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify factors influencing respiratory function. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 1245 Question 36 Type: MCMA The nurse is conducting a health history for a client with a respiratory disorder. What should the nurse include in this assessment? Standard Text: Select all that apply. 1. Lifestyle 2. Presence of cough 3. Sputum production 4. Pain 5. Diet Correct Answer: 1, 2, 3, 4 Rationale 1: A comprehensive nursing history relevant to oxygenation status should include data about lifestyle. Rationale 2: A comprehensive nursing history relevant to oxygenation status should include data about the presence of a cough. Rationale 3: A comprehensive nursing history relevant to oxygenation status should include data about sputum production. Rationale 4: A comprehensive nursing history relevant to oxygenation status should include data about pain. Rationale 5: A comprehensive nursing history relevant to oxygenation status does not include data about diet. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Describe nursing assessments for oxygenation status. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 1246 Question 37 Type: MCMA 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? Standard Text: 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. Correct Answer: 2, 3, 4 Rationale 1: Client teaching to promote healthy breathing does not include the use of pursed-lip breathing. This technique is for a client with a lung disorder such as chronic obstructive lung disease or emphysema. Rationale 2: Client teaching to promote healthy breathing includes regular exercise. Rationale 3: Client teaching to promote healthy breathing includes not smoking. Rationale 4: Client teaching to promote healthy breathing includes breathing through the nose. Rationale 5: Client teaching to promote healthy breathing does not include breathing through the mouth. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe nursing measures to promote respiratory function and oxygenation. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1252 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 38 Type: MCSA 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.” Correct Answer: 3 Rationale 1: A humidifier adds moisture to the air. Rationale 2: A humidifier loosens secretions. Rationale 3: The purposes of humidifiers are to prevent mucous membranes from drying and becoming irritated and to loosen secretions for easier expectoration. Rationale 4: A humidifier does not replace the use of oxygen but is used with oxygen. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 10. State outcome criteria for evaluating client responses to measures that promote adequate oxygenation. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1252 Question 39 Type: MCSA The nurse documents that a prescribed expectorant has been effective for a client. What did the nurse evaluate in this client?

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

1. Respiratory rate 24 and labored 2. Audible wheeze upon auscultation 3. High-pitched cough present 4. Presence of a productive cough Correct Answer: 4 Rationale 1: Expectorants do not affect the respiratory rate. Rationale 2: Expectorants should improve lung sounds. Rationale 3: Expectorants should cause a more productive cough. Rationale 4: Expectorants break up mucus, making it more liquid and easier to cough out. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 10. State outcome criteria for evaluating client responses to measures that promote adequate oxygenation. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1253 Question 40 Type: MCSA 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. Correct Answer: 1 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: When conducting nasotracheal suctioning, the nurse should apply suction for 5–10 seconds. Rationale 2: Suctioning should be done for no longer than 5 minutes. Rationale 3: Suction should never be applied while inserting the catheter. Rationale 4: Suction should only be applied for 5–10 seconds. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1270 Question 41 Type: MCSA The nurse wants to delegate the Yankauer suctioning of a client to UAP. What will the nurse ensure that UAP 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 Correct Answer: 2 Rationale 1: The nurse would instruct not to apply suction during the insertion of the catheter. Rationale 2: Oral suctioning using a Yankauer suction tube can be delegated to UAP, 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. Rationale 3: Oral suctioning uses clean, not sterile, technique. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: The nurse should not delegate the auscultation of lung sounds to UAP. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11. Verbalize the steps used in: b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning; 12. Recognize when it is appropriate to delegate aspects of oxygen therapy, suctioning, and tracheostomy care. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1269 Question 42 Type: MCMA The nurse has completed nasopharyngeal suctioning of a client. What should the nurse document about this procedure? Standard Text: 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 Correct Answer: 1, 3, 4, 5 Rationale 1: The nurse should document the amount, consistency, color, and odor of suctioned sputum. Rationale 2: The nurse does not need to document the amount of sterile solution used to flush the catheter. Rationale 3: The nurse should document the client’s lung sounds before the procedure. Rationale 4: The nurse should document the client’s lung sounds after the procedure. Rationale 5: The nurse should document the client’s oxygen saturation after the procedure. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning; 13. Demonstrate appropriate documentation and reporting of oxygen therapy, suctioning, and tracheostomy care. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1271 Question 43 Type: MCMA The nurse is documenting the completion of tracheostomy suctioning and tracheostomy care in a client’s medical record. What should this documentation include? Standard Text: 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 Correct Answer: 1, 2, 3, 5 Rationale 1: The nurse should document lung sounds before and after suctioning. Rationale 2: The nurse should document the characteristics of the suctioned sputum. Rationale 3: The nurse should document the integrity of the skin around the stoma. Rationale 4: The nurse does not need to document the side on which the tracheostomy tie knot is located. Rationale 5: The flow rate of the oxygen is not a part of documentation after tracheostomy suctioning or tracheostomy care. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Verbalize the steps used in: c. Suctioning a tracheostomy or endotracheal tube. d. Providing tracheostomy care. 13. Demonstrate appropriate documentation and reporting of oxygen therapy, suctioning, and tracheostomy care. MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1275 Question 44 Type: MCSA The nurse is planning care for a client who was admitted after having a myocardial infarction. Based upon 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 Correct Answer: 3 Rationale 1: Injury to the heart muscle might affect renal function, but this is not the nurse's greatest concern. Rationale 2: Although an injury to the heart muscle can cause stress to the client and lead to a gastric ulcer, this is not the nurse's greatest concern. Rationale 3: 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. Rationale 4: Injury to the heart muscle may or may not cause a cerebral vascular accident. This is not the area of greatest concern to the nurse at this time. Global Rationale: Cognitive Level: Analyzing Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Outline the structure and function of the respiratory system. MNL Learning Outcome: 4.10.1. Examine the factors that affect oxygenation. Page Number: 1248 Question 45 Type: MCMA Before administering the prescribed medication propranolol (Inderal) to a client, the nurse contacts the health care provider to question the order. What health problems did the client have that caused the nurse to question the medication order? Standard Text: Select all that apply. 1. COPD 2. Asthma 3. Arthritis 4. Gastritis 5. Heart failure Correct Answer: 1, 2 Rationale 1: 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. Rationale 2: 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. Rationale 3: Beta-adrenergic blocking agents such as propranolol affect the sympathetic nervous system to reduce the workload of the heart. These drugs are not contraindicated in clients with arthritis. Rationale 4: Beta-adrenergic blocking agents such as propranolol affect the sympathetic nervous system to reduce the workload of the heart. These drugs are not contraindicated in clients with gastritis. Rationale 5: Beta-adrenergic blocking agents such as propranolol affect the sympathetic nervous system to reduce the workload of the heart. These drugs are not contraindicated in clients with heart failure. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment. Page Number: 1254 Question 46 Type: MCMA 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? Standard Text: Select all that apply. 1. Insert an oropharyngeal airway. 2. Provide nasal care every 2 to 4 hours. 3. Provide oral hygiene every 2 to 4 hours. 4. Adjust non-humidified airflow as prescribed. 5. Move the tube to opposite sides of the mouth every 8 hours. Correct Answer: 1, 2, 3, 5 Rationale 1: For an oral endotracheal tube, use an oropharyngeal airway to prevent the client from biting down on the oral endotracheal tube. Rationale 2: For an oral endotracheal tube, provide nasal care every 2 to 4 hours. Rationale 3: For an oral endotracheal tube, provide oral hygiene every 2 to 4 hours. Rationale 4: Provide humidified air or oxygen because the endotracheal tube bypasses the upper airways, which normally moisten the air. Rationale 5: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 51 Question 1 Type: MCSA After a cardiac catheterization, an infant is diagnosed with a malformation of the mitral valve. The nurse will monitor the client for the development of a problem associated with the delivery of 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. Correct Answer: 1 Rationale 1: 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. Rationale 2: The pulmonic valve separates the right ventricle from the pulmonary artery. Problems with this valve would impede the delivery of deoxygenated blood back to the lung. Rationale 3: The blood that returns to the right atrium is deoxygenated. Rationale 4: The blood delivered to the left ventricle is oxygenated. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe three major alterations in cardiovascular function. MNL Learning Outcome: 4.10.3. Relate the factors that alter cardiac function to clinical manifestations and treatment. Page Number: 1287 Question 2 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

During assessment, the nurse notes a cardiac murmur that occurs between S1 and S2. The nurse documents this murmur as being 1. diastolic. 2. holosystolic. 3. systolic. 4. pansystolic. Correct Answer: 3 Rationale 1: 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. Rationale 2: 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. Holosystolic is not a type of murmur. Rationale 3: 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. Rationale 4: 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. Pansystolic is not a type of murmur. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Outline the structure and physiology of the cardiovascular system. MNL Learning Outcome: 4.10.3. Relate the factors that alter cardiac function to clinical manifestations and treatment. Page Number: 1289

Question 3 Type: MCMA 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? Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Standard Text: Select all that apply. 1. Age 2. Gender 3. Obesity 4. Smoking 5. Hypertension Correct Answer: 3, 4, 5 Rationale 1: Age is a nonmodifiable risk factor. Rationale 2: Gender is a nonmodifiable risk factor. Rationale 3: Many of the Healthy People 2020 objectives for cardiovascular health relate to modifiable risk factors. Modifiable risk factors include obesity. Rationale 4: Many of the Healthy People 2020 objectives for cardiovascular health relate to modifiable risk factors. Modifiable risk factors include smoking. Rationale 5: Many of the Healthy People 2020 objectives for cardiovascular health relate to modifiable risk factors. Modifiable risk factors include hypertension. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Identify major risk factors for the development of cardiovascular disease and related healthpromotion objectives from Healthy People 2020. MNL Learning Outcome: 4.10.3. Relate the factors that alter cardiac function to clinical manifestations and treatment. Page Number: 1294 Question 4 Type: MCSA

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

The 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 upon 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 Correct Answer: 3 Rationale 1: 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. Although extreme changes in blood sugar can result in cardiac disturbances, the most likely cause of rhythm disturbance following myocardial infarction is insult to the cells causing them to be irritable. Rationale 2: 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. Although electrolyte disturbances can result in cardiac disturbances, the most likely cause of rhythm disturbance following myocardial infarction is insult to the cells causing them to be irritable. Rationale 3: 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. Rationale 4: 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. Although extreme changes in blood flow to the liver can result in cardiac disturbances, the most likely cause of rhythm disturbance following myocardial infarction is insult to the cells causing them to be irritable. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 3. Describe three major alterations in cardiovascular function. MNL Learning Outcome: 4.10.3. Relate the factors that alter cardiac function to clinical manifestations and treatment. Page Number: 1290 Question 5 Type: MCSA 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 Correct Answer: 4 Rationale 1: Cardiac output equals stroke volume x 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. Rationale 2: Preload refers to the degree to which muscle fibers in the ventricle are stretched at the end of the relaxation period. Rationale 3: Afterload is reflective of systemic vascular resistance. Rationale 4: Cardiac output equals stroke volume x 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Page Number: 1290 Question 6 Type: MCSA 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 Correct Answer: 2 Rationale 1: The client's symptoms may or may not be associated with the blood urea nitrogen level. Rationale 2: 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. Rationale 3: These symptoms may or may not be seen in a client with an alteration in the blood sugar level. Rationale 4: These symptoms may or may not be seen in a client with an altered serum potassium level. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1293 Question 7 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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. Correct Answer: 3 Rationale 1: There is no need to contact the infant's physician. Rationale 2: This infant does not need resuscitation. Rationale 3: 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. Rationale 4: This infant does not need stimulation. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1293 Question 8 Type: MCSA The 50-year-old who is postmenopausal asks the nurse about the use of estrogen replacement therapy to protect the heart. How 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." Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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." Correct Answer: 4 Rationale 1: Research on estrogen replacement therapy is ongoing. Currently, it is thought that there may be some benefit in reducing cardiac risk. Rationale 2: Research on estrogen replacement therapy is ongoing. Currently, it is thought that there may be some benefit in reducing cardiac risk. Rationale 3: Research on estrogen replacement therapy is ongoing. Currently, it is thought that there may be some benefit in reducing cardiac risk. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1301 Question 9 Type: MCSA The post–myocardial infarction client asks the nurse about return 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Hot temperatures increase peripheral blood vessel contraction. Correct Answer: 3 Rationale 1: Cold temperatures increase peripheral blood vessel contraction and therefore peripheral vascular resistance, making it more difficult for the heart to circulate blood. Rationale 2: 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. Rationale 3: 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. Rationale 4: Hot temperatures decrease systemic vascular resistance by dilating peripheral vessels. This decrease makes the heart rate increase, thereby increasing the heart's workload. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1301 Question 10 Type: MCSA 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. Correct Answer: 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: Although reduction of salt intake may help to prevent hypertension, there is no connection to homocysteine levels. Rationale 2: Supplementation with a vitamin that provides folate, vitamin B6, vitamin B12, and riboflavin can reduce homocysteine levels, although results can vary. Rationale 3: An increase in fluid intake is not associated with decreased homocysteine levels. Rationale 4: Alcohol in moderation can reduce the risk of heart disease. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1296 Question 11 Type: MCSA The client has a history of recurrent transient ischemic attack (TIA). Based upon this history the nurse should be most concerned about the client's potential to develop 1. renal failure. 2. gangrene. 3. myocardial infarction. 4. stroke. Correct Answer: 4 Rationale 1: Renal failure would result from atherosclerotic changes in the renal artery. Rationale 2: Gangrene may occur if atherosclerosis reduces blood flow to the extremities. Rationale 3: Myocardial infarction results from atherosclerosis of the coronary arteries.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Transient ischemic attacks may result from atherosclerosis of the cerebral vessels. Continued development of this atherosclerosis may result in stroke. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe three major alterations in cardiovascular function. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1298 Question 12 Type: MCSA The nurse is assessing a newly admitted client for the presence of impaired peripheral arterial circulation. Which finding would be significant to this condition? 1. Ruddy skin color over legs 2. Bounding pedal pulses 3. Hot spots on the feet and legs 4. Decreased hair on the legs Correct Answer: 4 Rationale 1: The skin color of the legs is more likely to be pale. Rationale 2: The pulses will be weak. Rationale 3: The feet and legs will be cool to the touch. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1298 Question 13 Type: MCSA 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 Correct Answer: 3 Rationale 1: The thrombus is less likely to cause a myocardial infarction. Rationale 2: The thrombus is not going to cause renal failure. Rationale 3: 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. Rationale 4: The thrombus is not going to cause pneumonia. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1298 Question 14 Type: MCSA The nurse is collecting equipment to assess a client's ankle/brachial index (ABI). 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 Correct Answer: 1 Rationale 1: The nurse should take a blood pressure cuff and a Doppler ultrasound device to the bedside for this measurement. Rationale 2: The nurse should take a blood pressure cuff and a Doppler ultrasound device to the bedside for this measurement. Rationale 3: No other equipment is used in this assessment. Rationale 4: No other equipment is used in this assessment. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1299 Question 15 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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. Correct Answer: 2 Rationale 1: This is not the first thing that the nurse should do. Rationale 2: 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. Rationale 3: The nurse should not immediately defibrillate the client. Rationale 4: The nurse should not check the rhythm in a different lead first. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1300 Question 16 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Decreased creatine kinase 3. Increased troponin 4. High normal potassium Correct Answer: 3 Rationale 1: An increased hemoglobin level is significant; however, it is not the most important result for the nurse to discuss with the physician. Rationale 2: A decreased creatine kinase level is significant; however, it is not the most important result for the nurse to discuss with the physician. Rationale 3: Of these options, the most important finding to discuss with the physician is the increase in troponin, which may help diagnose myocardial infarction. Rationale 4: A high normal potassium level is significant; however, it is not the most important result for the nurse to discuss with the physician. Global Rationale: Page reference: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1300 Question 17 Type: MCSA A client exhibits confusion, decreased capillary refill time, low oxygen saturation readings, and decreased renal output. What NANDA nursing diagnosis problem statement should the nurse choose for this client? 1. Ineffective Tissue Perfusion 2. Decreased Cardiac Output 3. Activity Intolerance Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. Risk for Injury Correct Answer: 1 Rationale 1: Ineffective Tissue Perfusion is the diagnosis assigned when there is a decrease in oxygenation from failure to nourish tissues at the capillary level. Rationale 2: Decreased Cardiac Output is the diagnosis assigned when there is inadequate blood pumped by the heart to meet the demands of the body. Rationale 3: Activity Intolerance is the diagnosis assigned when the client does not have the energy for daily activities. Rationale 4: Risk for Injury is the diagnosis assigned when the client has an increased chance of being injured. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1300 Question 18 Type: MCSA 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. Correct Answer: 3 Rationale 1: Placing pillows under the knees supports the development of clotting. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Positioning the bed so that the knees are in more than 15 degrees of flexion supports the development of clotting. Rationale 3: 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. Rationale 4: The client would not be placed in the prone (on abdomen) position. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1301 Question 19 Type: MCSA 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. Correct Answer: 2 Rationale 1: In the absence of cyanosis, the logical sequence of events would be cardiac arrest followed by respiratory arrest. Rationale 2: In the absence of cyanosis, the logical sequence of events would be cardiac arrest followed by respiratory arrest. Rationale 3: Unless the client has do-not-resuscitate orders, a code should be called.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: There is no indication that the arrest was caused by airway obstruction or that the client cannot be resuscitated. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe the critical nature of cardiopulmonary resuscitation. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1304 Question 20 Type: MCSA A client has a long history of hypertension and has developed heart failure. The nurse should anticipate giving medications for which purpose? 1. To increase preload 2. To decrease afterload 3. To decrease contractility 4. To decrease cardiac output Correct Answer: 2 Rationale 1: There is no reason to provide medication to increase preload. Rationale 2: 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. Rationale 3: There is no reason to decrease this client's contractility. Rationale 4: There is no reason to provide medications to decrease this client's cardiac output. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 21 Type: SEQ The nurse is preparing to apply sequential compression devices to a client. In which order should the nurse apply these devices? Standard Text: Click and drag the options below to move them up or down. 1. Place in the dorsal recumbent or semi-Fowler’s 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. Correct Answer: 1, 2, 3, 5, 4 Rationale 1: When applying sequential compression devices, the nurse should first place the client in the dorsal recumbent or semi-Fowler’s position. Rationale 2: The second step is to place a sleeve under each leg with the opening at the knee. Rationale 3: The third step is to wrap the sleeve securely around the leg, securing the Velcro tabs. Rationale 4: The fifth step is to turn on the control unit and adjust the alarms and pressures as needed. Rationale 5: The fourth step is to connect the sleeves to the control unit and adjust the pressure as needed. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 6. Verbalize the steps used in: A. Applying a sequential compression device. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1303

Question 22 Type: MCSA The nurse is planning morning care for a client who has sequential compression devices in place. How should the nurse instruct the UAP 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." Correct Answer: 4 Rationale 1: The UAP is able to perform this activity. Rationale 2: The UAP can reapply the devices. Rationale 3: The UAP should dry the client's legs and reapply the devices. Rationale 4: The nurse should remind the UAP 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 UAP who knows the correct removal and application process may remove and apply these devices. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Recognize when it is appropriate to delegate aspects of applying a sequential compression device to unlicensed assistive personnel. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1303 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Question 23 Type: MCSA 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. Correct Answer: 1 Rationale 1: Blood pressure measurements should be included for all children over the age of 3 years. Rationale 2: Blood pressure measurements should be included for all children over the age of 3 years. Rationale 3: Blood pressure measurements should be included for all children over the age of 3 years. Rationale 4: The blood pressure is measured with a child-size cuff and can be taken in any extremity. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1294 Question 24 Type: MCMA A client is diagnosed with anemia. What will the nurse most likely assess in this client as evidence of an alteration in cardiovascular functioning? Standard Text: Select all that apply. 1. Chronic fatigue Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Lower-extremity edema 3. Pallor 4. Shortness of breath 5. Hypotension Correct Answer: 1, 3, 4, 5 Rationale 1: A lack of red blood cells to transport oxygen to tissues can lead to chronic fatigue. Rationale 2: A lack of red blood cells does not cause lower-extremity edema. Rationale 3: A lack of red blood cells within tissues can cause skin pallor. Rationale 4: A lack of red blood cells to transport oxygen to tissues can cause shortness of breath. Rationale 5: A lack of red blood cells to transport oxygen to tissues can cause hypotension. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1298 Question 25 Type: MCSA 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 to 6 minutes Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

4. 20 to 40 minutes Correct Answer: 3 Rationale 1: Extensive damage occurs after 4 to 6 minutes. Rationale 2: Extensive damage occurs after 4 to 6 minutes. Rationale 3: After 4 to 6 minutes, the lack of oxygen supply to the brain causes permanent and extensive damage. Rationale 4: The person is clinically dead 20 to 40 minutes after the heart stops beating. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Describe the critical nature of cardiopulmonary resuscitation. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1304 Question 26 Type: MCSA 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. Correct Answer: 4 Rationale 1: Both legally and ethically, there is no such thing as a “slow code.” Rationale 2: Both legally and ethically, there is no such thing as a partial code. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: The nurse should start CPR, and not stop to phone the physician. Rationale 4: If there is no do-not-resuscitate order, all clients who arrest will have resuscitation efforts begun. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe the critical nature of cardiopulmonary resuscitation. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1304 Question 27 Type: MCSA 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 walking out of bed.” Correct Answer: 1 Rationale 1: Sequential compression devices simulate the blood flow that results from walking. Rationale 2: Sequential compression devices do not prevent lymph drainage buildup in the tissues. Rationale 3: Sequential compression devices do not exercise the muscles of the leg. Rationale 4: Sequential compression devices are not used instead of walking out of bed. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1302 Question 28 Type: MCSA The nurse determines that UAP 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. Correct Answer: 3 Rationale 1: The client should wear the devices as much as possible. Rationale 2: The alarm should be activated. Rationale 3: The tubing should not be kinked. Rationale 4: Ankle pressure should be set at 35 to 55 mm Hg. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Recognize when it is appropriate to delegate aspects of applying a sequential compression device to unlicensed assistive personnel. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1303 Question 29 Type: MCMA The nurse is documenting the use of sequential compression devices in a client’s medical record. What should be included in this documentation? Standard Text: Select all that apply. 1. Calf circumference 2. Skin integrity 3. Peripheral vascular status 4. Neurovascular status 5. Control unit settings Correct Answer: 2, 3, 4, 5 Rationale 1: The nurse does not need to document the client’s calf circumference unless it is warranted for another health problem. Rationale 2: The nurse should document the client’s skin integrity. Rationale 3: The nurse should document the client’s peripheral vascular status. Rationale 4: The nurse should document the client’s neurovascular status. Rationale 5: The nurse should document the control unit’s settings. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Demonstrate appropriate documentation and reporting when applying a sequential compression device. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1303 Question 30 Type: MCSA 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. Correct Answer: 2 Rationale 1: The devices should be worn as prescribed. Rationale 2: The nurse should remove the devices if the client complains of numbness, tingling, or leg pain. Rationale 3: The devices should be worn as prescribed. Rationale 4: The devices should be worn as prescribed. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Demonstrate appropriate documentation and reporting when applying a sequential compression device. MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function. Page Number: 1303

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 52 Question 1 Type: MCSA 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 not yet been successful and should continue? 1. 35 mL per hour 2. 80 mL per hour 3. 50 mL per hour 4. 30 mL per hour Correct Answer: 4 Rationale 1: This is the expected urine output and would be considered successful. Rationale 2: This volume of urine output means efforts to rehydrate the client have been successful. Rationale 3: This volume of urine output indicates efforts to rehydrate the client have been successful. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1. Discuss the function, distribution, composition, movement, and regulation of fluids and electrolytes in the body. MNL Learning Outcome: 4.13.2. Explain the factors that regulate body fluids and electrolytes. Page Number: 1313 Question 2 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCSA 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. Correct Answer: 3 Rationale 1: Respiratory regulation is rapid, but temporary. Rationale 2: The gastrointestinal system is not involved in the regulation of acid–base balance. Rationale 3: Renal regulation is slower, but powerfully effective. Rationale 4: The cardiovascular system is not involved in the regulation of acid–base balance. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.13.3. Examine the processes and components that maintain acid–base balance. Page Number: 1317 Question 3 Type: MCSA 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

3. Assist the client to ambulate around the room at least three times daily. 4. Irrigate the client's nasogastric tube every 2 hours. Correct Answer: 3 Rationale 1: Measuring vital signs will not decrease the possibility of developing hypercalcemia. Rationale 2: Turning, coughing, and deep breathing every 2 hours will not prevent the development of hypercalcemia. Rationale 3: Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching of calcium from the bones into the serum. Rationale 4: Irrigating the nasogastric tube every 2 hours is not going to prevent the development of hypercalcemia. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1323 Question 4 Type: MCSA 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. Correct Answer: 1 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: 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. Rationale 2: There is no indication of the need to place this client in strict isolation. Rationale 3: A high-carbohydrate diet is not going to improve this client's phosphorus level. Rationale 4: Straining all urine is not going to improve this client's phosphorus level. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1324 Question 5 Type: MCSA 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. Correct Answer: 1 Rationale 1: 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 health care providers for evaluation. Rationale 2: Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, nor is juice the best choice of fluid. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 3: Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated. Rationale 4: Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, nor is glucose water the best choice of fluid. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1317 Question 6 Type: MCSA 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 Correct Answer: 2 Rationale 1: Bibasilar crackles may develop secondary to fluid overload or to the disease process, but would not be particularly evident just after placement of the subclavian catheter. Rationale 2: 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. Rationale 3: A decrease in pedal pulses would not be associated with the placement of a subclavian catheter. Rationale 4: A headache would not be associated with the placement of a subclavian catheter. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Collect assessment data related to clients’ fluid, electrolyte, and acid–base balances. MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1339 Question 7 Type: MCSA 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 Correct Answer: 1 Rationale 1: The drop factor (number of drops per milliliter of fluid) of tubing is located on the packaging. Rationale 2: The nurse would not document the drop factor of the intravenous tubing. Rationale 3: The drop factor would not be in a drug reference book. Rationale 4: The drop factor would not be on the roller clamp of the intravenous tubing. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: b. Monitoring an intravenous infusion. MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1348 Question 8 Type: FIB 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? Standard Text: Record your answer, rounding to the nearest whole number. Correct Answer: 150 mL/hr Rationale: 50 mL/20 minutes = x mL/60 minutes. 3000/20 = 150 mL/hr Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: b. Monitoring an intravenous infusion. MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1349 Question 9 Type: FIB 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? Standard Text: Record your answer, rounding to the nearest whole number. Correct Answer: 50 drops per minute Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale: 75 mL/1 hour 20 drops/30 minutes = 50 drops per minute. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: b. Monitoring an intravenous infusion. MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1349 Question 10 Type: MCSA The nurse is caring for a client who is receiving IV therapy at a rate of 10 mL/hour. The 500-mL 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. Correct Answer: 3 Rationale 1: There is no need to refigure the rate of the IV. Rationale 2: The nurse should not infuse the remaining IV fluid before hanging a new bag. Rationale 3: 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. Rationale 4: There is no need to restart the IV in the opposite hand. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: c. Changing an intravenous container, tubing, and dressing. MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1352 Question 11 Type: MCSA 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 Correct Answer: 3 Rationale 1: Starvation would not result in respiratory acidosis. Rationale 2: Starvation would not result in respiratory alkalosis. Rationale 3: 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. Rationale 4: Starvation would not result in metabolic alkalosis. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 4. Discuss risk factors for, and causes and effects of, fluid, electrolyte, and acid–base imbalances. MNL Learning Outcome: 4.13.3. Examine the processes and components that maintain acid–base balance. Page Number: 1325 Question 12 Type: MCSA 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 Correct Answer: 2 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 3. Identify factors affecting normal body fluid, electrolyte, and acid–base balance. MNL Learning Outcome: 4.13.3. Examine the processes and components that maintain acid–base balance. Page Number: 1326 Question 13 Type: MCSA The client's arterial blood gas report reveals a pH of 6.58. How does 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. Correct Answer: 2 Rationale 1: The body's pH range is normally 7.35 to 7.45. This is not an elevation. Rationale 2: 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. Rationale 3: 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. Rationale 4: The body's pH range is normally 7.35 to 7.45. This value is not extremely elevated. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Identify factors affecting normal body fluid, electrolyte, and acid–base balance. MNL Learning Outcome: 4.13.3. Examine the processes and components that maintain acid–base balance. Page Number: 1325 Question 14 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 1 Rationale 1: Because narcotics generally act to decrease or suppress respirations, this client is probably hypoventilating. The expected acid–base imbalance would be respiratory acidosis. Rationale 2: Respiratory alkalosis is associated with hyperventilation. Rationale 3: This imbalance occurs with too much acid in the body. The respirations will increase. It is not typically seen in a client experiencing a narcotic overdose. Rationale 4: This imbalance is seen in those with prolonged periods of vomiting or other conditions where the body loses acid. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify factors affecting normal body fluid, electrolyte, and acid–base balance. MNL Learning Outcome: 4.13.3. Examine the processes and components that maintain acid–base balance. Page Number: 1325 Question 15 Type: MCSA Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client complains of a headache. The nurse assesses that the client has slight shortness of breath and feels warm to the touch. What action by the nurse is priority? 1. Notify the client's physician. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

2. Discontinue the transfusion. 3. Slow the rate of the transfusion. 4. Prepare to resuscitate the client. Correct Answer: 2 Rationale 1: This would not be the nurse's first action. Rationale 2: 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. Rationale 3: Slowing the rate of the transfusion allows additional blood to be infused. Rationale 4: At this point, there is no need to prepare for resuscitation. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1359 Question 16 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Correct Answer: 3 Rationale 1: 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. Rationale 2: 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. Rationale 3: 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. Rationale 4: 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. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Teach clients measures to maintain fluid and electrolyte balance. MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1315 Question 17 Type: MCSA A client has orders for the administration of IV fluid at a "keep vein open" rate in preparation for administration of IV antibiotics starting at noon. When the nurse goes to the room to start the IV, the UAP is preparing to bathe the client. What should the nurse do? 1. Instruct the UAP to wait until the IV is started to bathe the client. 2. Let the UAP start the bath on the opposite side of where the nurse will be starting the IV. 3. Tell the UAP to notify the nurse as soon as the bath is completed. 4. Give the UAP permission to skip the client's bath for today. Correct Answer: 3

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: 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 UAP give the bath and then start the IV. Rationale 2: Having the UAP bathing one side of the client while the nurse starts the IV on the opposite side would be uncomfortable and stressful for the client and could potentially compromise client modesty. This action would also not protect the IV site from movement while the UAP completes the bath. Rationale 3: 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 UAP give the bath and then start the IV. This will protect the IV site from movement during the bath. Rationale 4: There is no reason to skip the bath. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: a. Starting an intravenous infusion. MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1344 Question 18 Type: MCSA 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? 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. Correct Answer: 2, 3, 5 Rationale 1: The hand should be lower than the heart to dilate the vein. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 2: Stroking the vein helps to dilate the vein. Rationale 3: Having the client clench and unclench the fist is a strategy used to help dilate a vein. Rationale 4: Slapping the vein is contraindicated and may actually reduce venous filling. Rationale 5: Massaging the vein helps with vein dilation. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: a. Starting an intravenous infusion. MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1345 Question 19 Type: MCSA 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. Correct Answer: 3 Rationale 1: Simply slowing the IV will not prevent further damage to the vein and will also alter the amount of IV fluid and medication the client is receiving. Rationale 2: Ice is not indicated in the treatment of phlebitis. Rationale 3: 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. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: This assessment and evaluation are within the scope of nursing practice, so at this point, collaboration with the physician is not necessary. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: b. Monitoring an intravenous infusion. MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1352 Question 20 Type: MCSA 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 UAP 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. Correct Answer: 2 Rationale 1: UAP cannot discontinue the lock. Rationale 2: The client can shower if the lock is covered with an occlusive dressing. Rationale 3: Cloth tape will not protect the lock. Rationale 4: The client can shower if the lock is covered with an occlusive dressing. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: e. Changing an intravenous catheter to an intermittent infusion lock. MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1341 Question 21 Type: MCSA 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 Correct Answer: 2 Rationale 1: Blood and blood products should only be administered with normal saline. Other IV fluids may cause damage to the cells being administered. Rationale 2: Blood and blood products should only be administered with normal saline. Other IV fluids may cause damage to the cells being administered. Rationale 3: Blood and blood products should only be administered with normal saline. Other IV fluids may cause damage to the cells being administered. Rationale 4: Blood and blood products should only be administered with normal saline. Other IV fluids may cause damage to the cells being administered. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: f. Initiating, maintaining, and terminating a blood transfusion using a Y-set. MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1359 Question 22 Type: MCSA 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. Correct Answer: 3 Rationale 1: Blood should not be held at room temperature for more than 30 minutes before the transfusion is initiated. Rationale 2: The unit refrigerator is not climate controlled for blood storage. Rationale 3: 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. Rationale 4: Blood should not be held at room temperature for more than 30 minutes before the transfusion is initiated. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: f. Initiating, maintaining, and terminating a blood transfusion using a Y-set. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1362 Question 23 Type: MCSA 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 to 10 minutes of the transfusion. 2. Assign the UAP 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. Correct Answer: 1 Rationale 1: The nurse should stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion. Rationale 2: The nurse cannot delegate this assessment to the UAP. Rationale 3: The client should be advised of reactions to report, but this self-reporting is more indicated after the nurse is no longer in constant attendance. Rationale 4: The nurse should stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion. The nurse cannot delegate this assessment to the UAP. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: f. Initiating, maintaining, and terminating a blood transfusion using a Y-set. MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1362 Question 24 Type: MCSA Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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). Correct Answer: 3 Rationale 1: The medication should be taken in the morning to prevent awakening at night to void. Rationale 2: The client should be encouraged to eat potassium-rich foods and will probably be prescribed a potassium supplement. Rationale 3: Clients who are taking diuretics must make position changes slowly in order to minimize dizziness from orthostatic hypotension. Rationale 4: Although clients who take digitalis (Lanoxin) and furosemide (Lasix) are at higher risk for the development of digitalis toxicity, the medications are often taken concurrently. The client and health care provider must monitor these clients closely for the development of digitalis toxicity. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Teach clients measures to maintain fluid and electrolyte balance. MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1321 Question 25 Type: MCSA 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 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

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 Correct Answer: 1 Rationale 1: Parenteral potassium should be well diluted and given IV. Rationale 2: If given in concentrated form, parenteral potassium is lethal to the client. Rationale 3: Parenteral potassium should be well diluted and given IV. It is not given SQ, by IV push, or in limited dilution (such as 20 mEq in 25 mL of fluid). Rationale 4: Parenteral potassium should be well diluted and given IV. It is not given SQ, by IV push, or in limited dilution (such as 20 mEq in 25 mL of fluid). Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1321 Question 26 Type: MCSA The client has been placed on a 1200-mL oral fluid restriction. How should the nurse plan for this restriction? 1. Allow 600 mL from 7–3, 400 mL from 3–11, and 200 mL from 11–7. 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. Correct Answer: 1 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 1: The amount of fluid allowed should be divided between the three major times of the day (7–3, 3–11, 11–7). This helps by taking into consideration meals and medication administration. Rationale 2: The client should be given a choice regarding consumption of fluids at mealtime. Rationale 3: Sherbet and custard are counted as liquids and should be avoided. Rationale 4: The client should be given a choice regarding consumption of fluids at mealtime. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1334 Question 27 Type: MCSA The nurse is caring for an 80-year-old client with the medical diagnosis of heart failure. The client 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 Correct Answer: 3 Rationale 1: Heart failure is a medical diagnosis, not a nursing diagnosis. Rationale 2: This client does not exhibit fluid volume deficit. Rationale 3: Edema and orthopnea are assessment findings associated with excess fluid volume.

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Rationale 4: Congestive heart failure is a medical diagnosis and cannot be used as the "related to" factor in a nursing diagnosis. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: 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: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1319 Question 28 Type: MCSA 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. Correct Answer: 2 Rationale 1: Assessment of edema is not a part of the assessment of orthostatic hypotension. Rationale 2: The nurse should measure the client's blood pressure and heart rate in the sitting position and then again in the standing position. Rationale 3: Normal saline challenges are often administered to clients who are dehydrated, but they are not part of assessment of orthostatic hypotension. Rationale 4: The nurse should measure the client's blood pressure and heart rate in the sitting position and then again in the standing position. Global Rationale: Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Collect assessment data related to clients’ fluid, electrolyte, and acid–base balances. MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1329 Question 29 Type: MCSA The nurse is caring for a client who is being mechanically ventilated. Arterial blood gas analysis reveals 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 Correct Answer: 3 Rationale 1: Decreasing oxygen will not decrease CO2 levels. Rationale 2: Decreasing the tidal volume will not decrease CO2 levels. Rationale 3: This client needs to "blow off" more CO2; therefore the respiratory rate would be increased. Rationale 4: Increasing the humidification will not decrease CO2 levels. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Nursing/Integrated Concepts: Nursing Process: 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: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1325 Question 30 Type: MCSA An older client receiving intravenous fluids at 175 ml/hr is demonstrating crackles, shortness of breath, and distended neck veins. The nurse recognizes these findings as being which complication of intravenous fluid therapy? 1. An allergic reaction to the antibiotics in the fluid 2. Fluid volume excess 3. Pulmonary embolism 4. Speed shock Correct Answer: 2 Rationale 1: The information provided does not support that the client is receiving an antibiotic. Rationale 2: Fluid volume excess may occur if clients, especially the very young or elderly, receive IV fluid rapidly. Rationale 3: The information provided does not support the development of a pulmonary embolism. Rationale 4: The client has been receiving fluids at the established rate and would not be experiencing symptoms of speed shock. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9. Evaluate the effect of nursing and collaborative interventions on clients’ fluid, electrolyte, or acid–base balance. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1319 Question 31 Type: MCMA A client sustained a significant loss of blood after a motor vehicle accident. The nurse notes that the client’s urine output has decreased and suspects that which hormones have influenced this client’s fluid balance? Standard Text: Select all that apply. 1. Aldosterone 2. Angiotensin 3. Antidiuretic hormone 4. Estrogen 5. Progesterone Correct Answer: 1, 2, 3 Rationale 1: Aldosterone promotes sodium retention in the distal nephron, reducing urine output. Rationale 2: Angiotensin acts directly on the nephrons to promote sodium and water retention. Rationale 3: 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. Rationale 4: Estrogen is not a hormone that participates in fluid balance in the body. Rationale 5: Progesterone is not a hormone that participates in fluid balance in the body. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Learning Outcome: 1. Discuss the function, distribution, composition, movement, and regulation of fluids and electrolytes in the body. MNL Learning Outcome: 4.13.1. Examine the processes involved in the body’s maintenance of fluid and electrolyte balance. Page Number: 1313 Question 32 Type: MCMA A client tells the nurse about rarely feeling thirsty. The nurse realizes that further assessment is needed to evaluate Standard Text: Select all that apply. 1. status of osmotic pressure. 2. vascular volume. 3. presence of angiotensin. 4. urine output. 5. body weight. Correct Answer: 1, 2, 3 Rationale 1: A number of stimuli trigger the thirst center, including the osmotic pressure of body fluids. Rationale 2: A number of stimuli trigger the thirst center, including vascular volume. Rationale 3: A number of stimuli trigger the thirst center, including angiotensin. Rationale 4: Urine output does not trigger the thirst center. Rationale 5: Body weight does not trigger the thirst center. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Discuss the function, distribution, composition, movement, and regulation of fluids and electrolytes in the body. Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

MNL Learning Outcome: 4.13.1. Examine the processes involved in the body’s maintenance of fluid and electrolyte balance. Page Number: 1312 Question 33 Type: MCMA The nurse is preparing to discontinue a client’s intravenous infusion. Which actions should the nurse take when removing the catheter from the vein? Standard Text: 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 2 to 3 minutes. Correct Answer: 1, 5 Rationale 1: When removing an intravenous catheter, the nurse should pull the catheter out in line with the vein. This avoids injury to the vein. Rationale 2: Pressure should not be applied to the site while removing the catheter. Rationale 3: When removing an intravenous catheter, the nurse should pull the catheter out in line with the vein. An angle perpendicular to the vein will injure the vein. Rationale 4: Hold the client’s arm above heart level, not bending at the elbow, if any bleeding persists. Raising the limb decreases blood flow to the area. Rationale 5: After removing the catheter, immediately apply firm pressure to the site, using sterile gauze, for 2 to 3 minutes. Pressure helps stop the bleeding and prevents hematoma formation. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Verbalize the steps used in: d. Discontinuing an intravenous infusion. MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1354 Question 34 Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..

Type: MCMA A client is receiving a continuous intravenous infusion. What should the nurse document in the medical record about this infusion? Standard Text: 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 Correct Answer: 2, 3, 4 Rationale 1: Body temperature may help determine fluid status; however, this is not documented in the medical record related to the client’s continuous intravenous fluid infusion. Rationale 2: The type of solution and flow rate should be documented. Rationale 3: Total intravenous intake for the shift should be documented according to agency policy. Rationale 4: The status of the intravenous insertion site should be documented. Rationale 5: Blood pressure may help determine fluid status; however, this is not documented in the medical record related to the client’s continuous intravenous fluid infusion. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Demonstrate appropriate documentation and reporting of fluid, electrolyte and acid–base balance activities. MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance. Page Number: 1352

Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank ..