Module 4

11.The nurse is completing an assessment on an older-adult patient who is having difficulty falling asleep. Which condition will the nurse further assess for in this patient? a. Depression b. Mild fatigue c. Hypertension d. Hypothyroidism

A

45. The nurse is administering medications to several patients. Which action should the nurse take? a. Advise a patient after a corticosteroid inhaler treatment to rinse mouth with water. b. Administer an intravenous medication through tubing that is infusing blood. c. Pinch up the deltoid muscle of an adult patient receiving a vaccination. d. Aspirate before administering a subcutaneous injection in the abdomen.

A

26. A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement? a. Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order. b. Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, "felt better." Finally, patient had no complaints. c. Breathing without difficulty. Sitting up in bed watching TV. Had a good day. d. Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours.

ANS: A Accurately documenting services provided, including the supplies and equipment used in a patient's care, clarifies the type of treatment a patient received. This documentation also supports accurate and timely reimbursement to a health care agency and/or patient. None of the other options had equipment or supplies listed. Avoid using generalized, empty phrases such as "status unchanged" or "had good day." Do not enter personal opinions—stating that the patient is cooperative is a personal opinion and should be avoided. "Finally, patient had no complaints" is a critical comment about the patient and if charted can be used as evidence of nonprofessional behavior or poor quality of care.

18. While preparing medications, the nurse knows one of the drug is an acidic medication. In which area does the nurse anticipate the drug will be absorbed? a. Stomach b. Mouth c. Small intestine d. Large intestine

ANS: A Acidic medications pass through the gastric mucosa rapidly. Medications that are basic are not absorbed before reaching the small intestine.

19. The nurse administers a central nervous system stimulant to a patient. Which assessment finding indicates to the nurse that an idiosyncratic event is occurring? a. Falls asleep during daily activities b. Presents with a pruritic rash c. Develops restlessness d. Experiences alertness

ANS: A An idiosyncratic event is a reaction opposite to what the effects of the medication normally are, or the patient overreacts or underreacts to the medication. Falls asleep is an opposite effect of what a central nervous system stimulant should do. A stimulant should make a patient restless and alert. A pruritic (itch) rash could indicate an allergic reaction.

44. A nurse is preparing to administer an antibiotic medication at 1000 to a patient but gets busy in another room. When should the nurse give the antibiotic medication? a. By 1030 b. By 1100 c. By 1130 d. By 1200

ANS: A Give time-critical scheduled medications (e.g., antibiotics, anticoagulants, insulin, anticonvulsants, and immunosuppressive agents) at the exact time ordered (within 30 minutes before or after scheduled dose). Give non-time critical scheduled medications within a range of either 1 or 2 hours of scheduled dose. 1100, 1130, and 1200 are too late.

7. A nurse is assessing internal variables that are affecting the patient's health status. Which area should the nurse assess? a. Perception of functioning b. Socioeconomic factors c. Cultural background d. Family practices

ANS: A Internal variables include a person's developmental stage, intellectual background, perception of functioning, and emotional and spiritual factors. External variables influencing a person's health beliefs and practices include family practices, socioeconomic factors, and cultural background.

4. The nurse is preparing a smoking cessation class for family members of patients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the benefits of not smoking. Which health care model is the nurse following? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs

ANS: A The health belief model addresses the relationship between a person's beliefs and behaviors. The holistic health model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. The health promotion model focuses on the following three areas: (1) individual characteristics and experiences, (2) behaviorspecific knowledge and affect, and (3) behavioral outcomes, in which the patient commits to or changes a behavior. Maslow's' hierarchy of needs is based on the theory that all people share basic human needs, and the extent to which basic needs are met is a major factor in determining a person's level of health.

13.The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel? a. Measuring capillary blood glucose level b. Measuring nasoenteric tube for insertion c. Measuring pH in gastrointestinal aspirate d. Measuring the patient's risk for aspiration

ANS: A The skill of measuring blood glucose level after skin puncture (capillary puncture) can be delegated to nursing assistive personnel. The other skills cannot be delegated. A nurse must measure a nasoenteric tube for insertion, pH in gastrointestinal aspirate, and patient's risk for aspiration.

35. The nurse is preparing to administer medications to two patients with the same last name. After the administration, the nurse realizes that did not check the identification of the patient before administering medication. Which action should the nurse complete first? a. Return to the room to check and assess the patient. b. Administer the antidote to the patient immediately. c. Alert the charge nurse that a medication error has occurred. d. Complete proper documentation of the medication error in the patient's chart

ANS: A When an error occurs, the patient's safety and well-being are the top priorities. You first assess and examine the patient's condition and notify the health care provider of the incident as soon as possible. The nurse's first priority is to establish the safety of the patient by assessing the patient. Second, notify the charge nurse and the health care provider. Administer antidote if required. Finally, the nurse needs to complete proper documentation.

24.The nurse is evaluating outcomes for the patient with insomnia. Which key principle will the nurse consider during this process? a. The patient is the best evaluator of sleep. b. The nurse is the best evaluator of sleep. c. Effective interventions are the best evaluators of sleep. d. Observations of the patient are the best evaluators of sleep.

ANS: A With regard to problems with sleep, the patient is the source for evaluating outcomes. The patient is the only one who knows whether sleep problems have improved and what has been successful. Interventions are not the best indicator; achievement of goals according to the patient is the best. Observations do provide needed data, but in the case of insomnia, the patient is the source for evaluating the restfulness of sleep

1. A nurse is assessing threats concerning the family. Which areas will the nurse include in the assessment? (Select all that apply.) a. Homelessness b. Domestic violence c. Presence of illness d. Changing economic status e. Rise of homosexual families

ANS: A, B, C, D Social scientists have identified five trends as threats facing the family. These include (1) Changing economic status, (2) homelessness, (3) domestic violence, (4) the presence of acute or chronic illness or trauma, and (5) end-of-life care. Homosexual families are not a threat facing the family; in fact, many homosexual couples now define their relationship in family terms.

17. Upon completion of the assessment, the nurse finds that the patient has quit drinking and has been alcohol free for the past 2 years. Which stage best describes the nurse's assessment finding? a. Contemplation b. Maintenance c. Preparation d. Actio

ANS: B Because the patient has been alcohol free for 2 years, the patient is in the maintenance stage. These stages range from no intention to change (precontemplation), to considering a change within the next 6 months (contemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance).

43. A nurse is performing the three accuracy checks before administering an oral liquid medication to a patient. When will the nurse perform the second accuracy check? a. At the patient's bedside b. Before going to the patient's room c. When checking the medication order d. When selecting medication from the unit-dose drawer

ANS: B Before going to the patient's room, compare the patient's name and name of medication on the label of prepared drugs with MAR for the second accuracy check. Selecting the correct medication from the stock supply, unit-dose drawer, or automated dispensing system (ADS) is the first check. The third accuracy check is comparing names of medications on labels with MAR at the patient's bedside. Checking the orders is not one of the three accuracy checks but should be done if there is any confusion about an order

39. A nurse is attempting to administer an oral medication to a child, but the child refuses to take the medication. A parent is in the room. Which statement by the nurse to the parent is best? a. "Please hold your child's arms down, so I can give the full dose." b. "I will prepare the medication for you and observe if you would like to try to administer the medication." c. "Let's turn the lights off and give your child a moment to fall asleep before administering the medication." d. "Since your child loves applesauce, let's add the medication to it, so your child doesn't resist."

ANS: B Children often have difficulties taking medication, but it can be less traumatic for the child if the parent administers the medication and the nurse supervises. Another nurse should help restrain a child if needed; the parent acts as a comforter, not a restrainer. Holding down the child is not the best option because it may further upset the child. Never administer an oral medication to a sleeping child. Don't mix medications into the child's favorite foods, because the child might start to refuse the food.

14. The nurse is providing discharge teaching for an older-adult patient who will need tube feedings at home. The spouse is the only source of care and states "I will not be able to perform the feedings due to arthritis." Which action should the nurse take? a. Obtain extra feeding supplies. b. Arrange for home care. c. Cancel the discharge. d. Teach the spouse.

ANS: B Discharge planning with a family involves an accurate assessment of what will be needed for care at the time of discharge, along with any shortcomings in the home setting. If no one can do the feedings properly, the nurse will need to arrange for a home care service referral. Extra feeding supplies will not help the situation if the spouse cannot use them. Canceling the discharge is not an option. Teaching the spouse will not be effective since the spouse is unable to perform the feeding.

37. A patient prefers not to take the daily allergy pill this morning because it causes drowsiness throughout the day. Which response by the nurse is best? a. "The physician ordered it; therefore, you must take your medication every morning at the same time whether you're drowsy or not." b. "Let's see if we can change the time you take your pill to 9 PM, so the drowsiness occurs when you would normally be sleeping." c. "You can skip this medication on days when you need to be awake and alert." d. "Try to get as much done as you can before you take your pill, so you can sleep in the afternoon."

ANS: B The nurse should use knowledge about the medication to educate the patient about potential response to medications. Then the medication schedule can be altered based on that knowledge. It is the patient's right to refuse medication; however, the nurse should educate the patient on the importance and effects of the medication. Asking a patient to fit a schedule around a medication is unreasonable and will decrease compliance. The nurse should be supportive and should offer solutions to manage medication effects.

7.The nurse is teaching a new mother about the sleep requirements of a neonate. Which comment by the patient indicates a correct understanding of the teaching? a. "I can't wait to get the baby home to play with the brothers and sisters." b. "I will ask my mom to come after the first week, when the baby is more alert." c. "I can get the baby on a sleeping schedule the first week while my mom is here." d. "I won't be able to nap during the day because the baby will be awake."

ANS: B The patient indicates an understanding when asking the mother to come after the first week. The neonate up to the age of 3 months averages about 16 hours of sleep a day, sleeping almost constantly during the first week. The baby will sleep rather than play. The baby will not be on a sleeping schedule the first week home. The mother will be able to nap since the baby sleeps 16 hours a day.

34.The patient is having at least 75% of nutritional needs met by enteral feeding, so the health care provider has ordered the parenteral nutrition (PN) to be discontinued. However, the nurse notices that the PN infusion has fallen behind. What should the nurse do? a. Increase the rate to get the volume caught up before discontinuing. b. Stop the infusion as ordered. c. Taper infusion gradually. d. Hang 5% dextrose.

ANS: C Sudden discontinuation of PN can cause hypoglycemia. PN must be tapered off. Usually, 10% dextrose is infused when PN solution is suddenly discontinued. Too rapid administration of hypertonic dextrose (PN) can result in an osmotic diuresis and dehydration. If an infusion falls behind schedule, the nurse should not increase the rate in an attempt to catch up.

31. Which patient using an inhaler would benefit most from using a spacer? a. A 15 year old with a repaired cleft palate who is alert b. A 25 year old with limited coordination of the extremities c. A 50 year old with hearing impairment who uses a hearing aid d. A 72 year old with left-sided hemiparesis using a dry powder inhaler

B

12. A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. Which level of preventive care is the patient receiving? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion

C

11.The nurse is providing nutrition education to a Korean patient using the five food groups. In doing so, what should be the focus of the teaching? a. Discouraging the patient's ethnic food choices b. Changing the patient's diet to a more conventional American diet c. Including racial and ethnic practices with food preferences of the patient d. Comparing the patient's ethnic preferences with American dietary choices

C As a nurse, consider the food preferences of patients from different racial and ethnic groups, vegetarians, and others when planning diets. Initiation of a balanced diet is more important than conversion to what may be considered an American diet. Ethnic food choices may be just as nutritious as American choices. Foods should be chosen for their nutritive value and should not be compared with the American diet.

10.The nurse is teaching a health class about the ChooseMyPlate program. Which guidelines will the nurse include in the teaching session? a. Balancing sodium and potassium b. Decreasing water consumption c. Increasing portion size d. Balancing calories

D

27. A patient refuses medication. Which is the nurse's first action? a. Educate the patient about the importance of the medication. b. Discreetly hide the medication in the patient's favorite gelatin. c. Agree with the patient's decision and document it in the chart. d. Explore with the patient reasons for not wanting to take the medication.

D

9.A single parent is discussing the sleep needs of a preschooler with the nurse. Which information will the nurse share with the parent? a. "Most preschoolers sleep soundly all night long." b. "It is important that the 5-year-old get a nap every day." c. "On average, the preschooler needs to sleep 10 hours a night." d. "Preschoolers may have trouble settling down after a busy day."

D

19.The nurse is caring for a postpartum patient. The patient's labor has lasted over 28 hours within the hospital; the patient has not slept and is disoriented to date and time. Which nursing diagnosis will the nurse document in the patient's care plan? a. Insomnia b. Impaired parenting c. Ineffective coping d. Sleep deprivation

D This patient has been deprived of sleep by staying awake during a 28-hour labor. Disorientation is one potential sign of sleep deprivation. In this scenario, there is a clear cause for the patient's lack of sleep, and it is a one-time episode. Insomnia, on the other hand, is a chronic disorder whereby patients have difficulty falling asleep, awaken frequently, or sleep only for a short time. This scenario does not indicate that this has been a chronic problem for this patient. Although ineffective coping can manifest as a sleep disturbance, clear evidence shows that it was labor that deprived this patient of sleep, not an inability to cope. It could be difficult to care for an infant when sleep deprived; however, this scenario gives no evidence that this mother displays impaired parenting and is not caring adequately for her child or lacks the skills to do so.

22.In determining malnourishment in a patient, which assessment finding is consistent with this disorder? a. Moist lips b. Pink conjunctivae c. Spoon-shaped nails d. Not easily plucked hair

C

23. A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using? a. Clinical decision support system b. Nursing process design c. Critical pathway design d. Computerized provider order entry system

C

26.An older-adult patient is visiting the clinic after a fall during the night. The nurse obtains information on what medications the patient takes. Which medication most likely contributed to the patient's fall? a. Melatonin b. L-tryptophan c. Benzodiazepine d. Iron supplement

C

26.Before giving the patient an intermittent gastric tube feeding, what should the nurse do? a. Make sure that the tube is secured to the gown with a safety pin. b. Inject air into the stomach via the tube and auscultate. c. Have the tube feeding at room temperature. d. Check to make sure pH is at least 5.

C

3.The nurse is caring for a patient who is having trouble sleeping. Which action will the nurse take? a. Suggest snug-fitting nightwear. b. Provide a favorite beverage. c. Encourage deep breathing. d. Walk with the patient.

C

14.In teaching mothers-to-be about infant nutrition, which instruction should the nurse provide? a. Supplement breast milk with corn syrup. b. Give cow's milk during the first year of life. c. Add honey to infant formulas for increased energy. d. Provide breast milk or formula for the first 4 to 6 months.

D

18.The nurse is assessing a patient for nutritional status. Which action will the nurse take? a. Forego the assessment in the presence of chronic disease. b. Use the Mini Nutritional Assessment for pediatric patients. c. Choose a single objective tool that fits the patient's condition. d. Combine multiple objective measures with subjective measures.

D

20.A nurse is caring for patients with dysphagia. Which patient has neurogenic dysphagia? a. A patient with benign peptic stricture b. A patient with muscular dystrophy c. A patient with myasthenia gravis d. A patient with stroke

D

29.The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. Which action is best for the nurse to take? a. Instill nonliquid medications without diluting. b. Irrigate the tube with 60 mL of water after all medications are given. c. Mix all medications together to decrease the number of administrations. d. Check with the pharmacy for availability of the liquid forms of medications

D

15.When planning care for an adolescent who plays sports, which modification should the nurse include in the care plan? a. Increasing carbohydrates to 55% to 60% of total intake b. Providing vitamin and mineral supplements c. Decreasing protein intake to 0.75 g/kg/day d. Limiting water before and after exercise

A

17.The patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient's skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide? a. Drink more water to prevent further dehydration. b. Drink more calorie-dense fluids to increase caloric intake. c. Drink more milk and dairy products to decrease the risk of osteoporosis. d. Drink more grapefruit juice to enhance vitamin C intake and medication absorption.

A

2.The nurse is providing an educational session on sleep regulation for new nurses in the Sleep Disorder Treatment Center. Which statement by the nurses will best indicate that the teaching is effective? a. "If the patient has a disease process in the central nervous system, it can influence the functions of sleep." b. "If the patient has a disease process in the cranial nerves, it can influence the functions of sleep." c. "If the patient has an interruption in the urinary pathways, it can influence the functions of sleep." d. "If the patient has an interruption in the spinal reflexes, it can influence the functions of sleep."

A

22. A nurse has withdrawn a narcotic from the medication dispenser and must waste a portion of the medication. What should the nurse do? a. Have another nurse witness the wasted medication. b. Return the wasted medication to the medication dispenser. c. Place the wasted portion of the medication in the sharps container. d. Exit the medication room to call the health care provider to request an order that matches the dosages.

A

23. A nurse teaches the patient about the prescribed buccal medication. Which statement by the patient indicates teaching by the nurse is successful? a. "I should let the medication dissolve completely." b. "I will place the medication in the same location." c. "I can only drink water, not juice, with this medication." d. "I better chew my medication first for faster distribution."

A

24. What is the nurse's priority action to protect a patient from medication error? a. Reading medication labels at least 3 times before administering b. Administering as many of the medications as possible at one time c. Asking anxious family members to leave the room before giving a medication d. Checking the patient's room number against the medication administration record

A

25. The nurse prepares a pain injection for a patient but had to check on another patient and asks a new nurse to give the medication. Which action by the new nurse is best? a. Do not give the medication. b. Administer the medication just this once. c. Give the medication for any pain score greater than 8. d. Avoid the issue and pretend to not hear the request

A

27. A nurse is teaching the staff about health care reimbursement. Which information should the nurse include in the teaching session? a. Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care. b. A clinical information system must be installed by 2014 to obtain health care reimbursement. c. A "near miss" helps determine reimbursement issues for health care. d. HIPAA is the basis for establishing reimbursement for health care.

A

12. The nurse is planning to administer a tuberculin test with a 27-gauge, -inch needle. At which angle will the nurse insert the needle? a. 15 degree b. 30 degree c. 45 degree d. 90 degree

A A 27-gauge, -inch needle is used for intradermal injections such as a tuberculin test, which should be inserted at a 5- to 15-degree angle, just under the dermis of the skin. Placing the needle at 30 degrees, 45 degrees, or 90 degrees will place the medication too deep.

30.The patient has just started on enteral feedings, and the patient is reporting abdominal cramping. Which action will the nurse take next? a. Slow the rate of tube feeding. b. Instill cold formula to "numb" the stomach. c. Change the tube feeding to a high-fat formula. d. Consult with the health care provider about prokinetic medication

A One possible cause of abdominal cramping is a rapid increase in rate or volume. Lowering the rate of delivery may increase tolerance. Another possible cause of abdominal cramping is the use of cold formula. The nurse should warm the formula to room temperature. High-fat formulas are also a cause of abdominal cramping. Consult with the health care provider regarding prokinetic medication for increasing gastric motility for delayed gastric emptying.

16.The nurse is completing a sleep assessment on a patient. Which tool will the nurse use to complete the assessment? a. Visual analog scale b. Cataplexy scale c. Polysomnogram d. RAS scale

A The visual analog scale is utilized for assessing sleep quality. Cataplexy, or sudden muscle weakness during intense emotions such as anger, sadness, or laughter, occurs at any time during the day; there is no cataplexy scale for sleep assessment. A polysomnogram involves the use of EEG, EMG, and EOG to monitor stages of sleep and wakefulness during nighttime sleep; this is used in a sleep laboratory study. Researchers believe that the ascending reticular activating system (RAS) located in the upper brainstem contains special cells that maintain alertness and wakefulness; however, there is no assessment tool called the RAS scale

19. A patient has had emphysema (lung disease) for many years. When approached by the nurse, the patient states "I would be better off dead." The patient supports the family, and now because of oxygen dependency the patient must quit work. The patient's spouse will have to go to work. Which action should the nurse take? a. Develop a plan of care for the family. b. Contact psychiatric services for a referral. c. Assure the patient that things will work out. d. Focus the plan of care solely on maximizing patient function.

ANS: A Because of the effects of chronic illness, family dynamics often change. The nurse must view the whole family as a patient under stress, planning care to help the family regain its maximal level of functioning and well-being. Psychiatric services may be a part of that plan but do not represent the entire plan. Offering false assurance is never acceptable. Focusing only on the patient will not help the family adjust.

7. A nurse is assessing a child that lives in a car with family members who presents to the emergency department. Which area should the nurse assess closely? a. Ears b. Eyes c. Head d. Hands

ANS: A Children of homeless families are often in fair or poor health and have higher rates of asthma, ear infections, stomach problems, and mental illness. Eyes, head, and hands are not as important as the ears.

3. A 2-year-old child is ordered to have eardrops daily. Which action will the nurse take? a. Pull the auricle down and back to straighten the ear canal. b. Pull the auricle upward and outward to straighten the ear canal. c. Sit the child up for 2 to 3 minutes after instilling drops in ear canal. d. Sit the child up to insert the cotton ball into the innermost ear canal.

ANS: A Children up to 3 years of age should have the auricle pulled down and back, children 3 years of age to adults should have the auricle pulled upward and outward. Solution should be instilled 1 cm (1/2 in) above the opening of the ear canal. The patient should remain in the side-lying position 2 to 3 minutes. If a cotton ball is needed, place it into the outermost part of the ear canal.

9.The nurse is describing the ChooseMyPlate program to a patient. Which statement from the patient indicates successful learning? a. "I can use this to make healthy lifestyle food choices." b. "I can use this to count specific calories of food." c. "I can use this for my baby girl." d. "I can use this when I am sick."

ANS: A ChooseMyPlate serves as a basic guide for making food choices for a healthy lifestyle. The ChooseMyPlate program was developed by the U.S. Department of Agriculture to replace the MyFoodPyramid program. It helps balance calories but does not provide specific calories of food. These guidelines are for Americans over the age of 2 years. These guidelines are provided for health, not sickness.

6.Which nursing observation of the patient in intensive care indicates the patient is sleeping comfortably during NREM sleep? a. Eyes closed, lying quietly, respirations 12, heart rate 60 b. Eyes closed, tossing in bed, respirations 18, heart rate 80 c. Eyes closed, mumbling to self, respirations 16, heart rate 68 d. Eyes closed, lying supine in bed, respirations 22, heart rate 66

ANS: A During NREM sleep, biological functions slow. During sleep, the heart rate decreases to 60 beats/min or less. The patient experiences decreased respirations, blood pressure, and muscle tone. Heart rates above 60 are too high and respirations of 22 are too high to indicate comfortable NREM sleep.

8.The nurse is discussing lack of sleep with a middle-aged adult. Which area should the nurse most likely assess to determine a possible cause of the lack of sleep? a. Anxiety b. Loud teenagers c. Caring for pets d. Late night television

ANS: A During middle adulthood, the total time spent sleeping at night begins to decline. Anxiety, depression, and certain physical illnesses can affect sleep, and women can experience menopausal symptoms. Insomnia is common because of the changes and stresses associated with middle age. Teenagers, caring for pets, and late night television can influence the amount of sleep; however, these are not the most common causes of insomnia in this age group.

12. The nurse is caring for an older adult patient who has no apparent family. When questioned about family and the definition of family, the patient states, "I have no family. They're all gone." When asked, "Who prepares your meals?" the patient states, "I do, or I go out." Which approach should the nurse use for this patient? a. Family as context b. Family as patient c. Family as system d. Family as caregiver

ANS: A If only one family member receives nursing care, it is realistic and practical to use the approach "family as context." Although family nursing is based on the assumption that all people regardless of age are a member of some type of family form, the patient insists that there is no family. The nurse should investigate further. However, at this time, family as patient or as system is not appropriate. Family as caregiver is not an approach but rather is a term to describe a family member caring for another family member.

10. The nurse is working in a clinic that is designed to provide health education and immunizations. Which type of preventive care is the nurse providing? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Risk factor prevention

ANS: A Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Primary prevention includes health education programs, immunizations, and physical and nutritional fitness activities. Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration. While risk factor modification is an integral component of health promotion, it is not a type of preventive care.

35.The patient is on parenteral nutrition and is lethargic. The patient reports thirst and headache and has had increased urination. Which problem does the nurse prepare to address? a. Hyperglycemia b. Hypoglycemia c. Hypercapnia d. Hypocapnia

ANS: A Signs and symptoms of hyperglycemia are thirst, headache, lethargy, and increased urination. Hypocapnia is not associated with parenteral nutrition. Hypercapnia increases oxygen consumption and increases CO2 levels. Ventilator-dependent patients are at greatest risk for this. Hypoglycemia is characterized by diaphoresis, shakiness, confusion, and loss of consciousness.

9. A nurse is caring for a patient from a motor vehicle accident. Which action by the unlicensed assistive personnel will cause the nurse to intervene? a. Tells the family not to leave the bedside b. Offers the family a sandwich c. Gives the family a blanket d. Sits with the family

ANS: A The action of telling the family not to leave is inappropriate and should be corrected. Sometimes telling the family that you will stay with their loved one while they are gone is all they need to feel comfortable in leaving. Offering a sandwich, giving a blanket, and sitting with the family are appropriate and do not require the nurse to intervene. When the victim of trauma is hospitalized, take time to make sure that the family is comfortable. You can bring them something to eat or drink, give them a blanket, or encourage them to get a meal.

15. The nurse is working in a drug rehabilitation clinic and is in the process of admitting a patient for "detox." What should the nurse do next? a. Identify the patient's stage of change. b. Realize that the patient is ready to change. c. Teach the patient that choices will have to change. d. Instruct the patient that relapses will not be tolerated.

ANS: A The nurse should identify the stage of change and assess where the patient is currently in this situation. To be most effective, nursing interventions should match the stage of change. The nurse cannot realize the patient is ready for change because only a minority of people are actually in the action stage of changing. While teaching that choices will have to change, it will follow later after the nurse has determined which stage the person is in. As individuals attempt a change in behavior, relapse followed by recycling through the stages occurs frequently.

1. A nurse is teaching about the goals of Healthy People 2020. Which information should the nurse include in the teaching session? a. Eliminate health disparities in America. b. Eliminate health behaviors in America. c. Eliminate quality of life in America. d. Eliminate healthy life in America.

ANS: A The nurse should include eliminating health disparities in America. Healthy People 2020 promotes a society in which all people live long, healthy lives. There are four overarching goals: (1) attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; (2) achieve health equity, eliminate disparities, and improve the health of all groups; (3) create social and physical environments that promote good health for all; and (4) promote quality of life, healthy development, and healthy behaviors across all life stages.

8. The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about employment status and displays a nonjudgmental attitude. What is the rationale for the nurse's actions? a. External variables have little effect on compliance. b. A person's compliance is affected by economic status. c. Employment status is an internal variable that impacts compliance. d. Noncompliant patients thrive on the disapproval of authority figures.

ANS: B A person's compliance with treatment is affected by economic status. A person tends to give a higher priority to food and shelter than to costly drugs or treatments. External variables can have a major impact on compliance. Employment status is an external variable, not an internal variable. A person generally seeks approval and support from social networks, and this desire for approval affects health beliefs and practices; noncompliance does not occur from thriving on disapproval of authority figures.

5. A nurse is using Maslow's hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first? a. Anxiety b. Not eating c. Mental health d. Not seeing family members

ANS: B According to Maslow, in all cases an emergent physiological need takes precedence over a higher-level need. Nutrition is a physiological need and should be addressed first. Anxiety, mental health, and not seeing family members are all higher-level needs.

28. A nurse is discussing the advantages of a nursing clinical information system. Which advantage should the nurse describe? a. Varied clinical databases b. Reduced errors of omission c. Increased hospital costs d. More time to read charts

ANS: B Advantages associated with the nursing information system include reduced errors of omission; better access to information (not more time to read charts); enhanced quality of documentation; reduced, not increased, hospital costs; increased nurse job satisfaction; compliance with requirements of accrediting agencies (e.g., TJC); and development of a common, not varied, clinical database.

18. The patient had a colostomy placed 1 week ago. When approached by the nurse, the patient and spouse refuse to talk about it and refuse to be taught about how to care for it. How will the nurse evaluate this couple's stage of adjustment? a. Shock b. Withdrawal c. Acceptance d. Rehabilitation

ANS: B As the patient and family recognize the reality of a change, they become anxious and may withdraw, refusing to discuss it. This is an adaptive coping mechanism that assists the patient in making the adjustment. Initially, the patient may be shocked by the change. This is followed by withdrawal, acknowledgment, acceptance, and rehabilitation (ready to adapt to the change through use of colostomy bag).

10.The nurse is having a conversation with an adolescent regarding the need for sleep. The adolescent states that it is common to stay up with friends several nights a week. Which action should the nurse take next? a. Talk with the adolescent's parent about staying up with friends and the need for sleep. b. Discuss with the adolescent sleep needs and the effects of excessive daytime sleepiness. c. Refer the adolescent for counseling about alcohol abuse problems. d. Take no action for this normal occurrence.

ANS: B Discussion regarding adolescent sleep needs should first occur with the adolescent. Although it may be common for this adolescent to want to visit with friends and experience activities that go late into the night, these activities can and do impact the hours of sleep and the physical needs of the adolescent, no matter the reason for the late nights, and they do need to be addressed. The nurse will address the adolescent, not the parents. Addressing alcohol abuse problems is not the next step but may be required later. While staying up late may be a normal occurrence for this adolescent, action is required.

1. A nurse is assessing the family unit to determine the family's ability to adapt to the change of a member having surgery. Which area is the nurse monitoring? a. Family durability b. Family resiliency c. Family diversity d. Family forms

ANS: B Family resiliency is the ability of the family to cope with expected and unexpected stressors; it's the families' ability to adapt to changes. Family diversity is the uniqueness of each family unit. Every person within a family unit has specific needs, strengths, and important developmental considerations. Family durability is a system of support and structure within a family that extends beyond the walls of the household. Family forms are patterns of people considered by family members to be included in the family.

1. A nurse is teaching a patient about medications. Which statement from the patient indicates teaching is effective? a. "My parenteral medication must be taken with food." b. "I will rotate the sites in my left leg when I give my insulin." c. "Once I start feeling better, I will stop taking my antibiotic." d. "If I am 30 minutes late taking my medication, I should skip that dose."

ANS: B For daily insulin, rotate site within anatomical area. Rotating injections within the same body part (instrasite rotation) provides greater consistency in absorption of medication. Parenteral medication absorption is not affected by the timing of meals. Taking a medication 30 minutes late is within the 60-minute window of the time medications should be taken. Medications are usually stopped based on the provider's orders except in extenuating circumstances. With some medications, such as antibiotics, it is crucial that the full course of medication is taken to avoid relapse of infection.

7.A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the nurse take when feeding this patient? a. Position in semi-Fowler's. b. Flex head with chin tuck. c. Place food on left side. d. Offer fruit juice.

ANS: B Have the patient flex the head slightly to a chin-down position to help prevent aspiration. If the patient has unilateral weakness, teach him or her and the caregiver to place food in the stronger side of the mouth. Provide a 30-minute rest period before eating and position the patient in an upright, seated position in a chair or raise the head of the bed to 90 degrees. Thin liquids such as water and fruit juice are difficult to control in the mouth and are more easily aspirated

24.The patient is admitted with facial trauma, including a broken nose, and has a history of esophageal reflux and of aspiration pneumonia. With which tube will the nurse most likely administer the feeding? a. Nasogastric tube b. Jejunostomy tube c. Nasointestinal tube d. Percutaneous endoscopic gastrostomy (PEG) tube

ANS: B Patients with gastroparesis or esophageal reflux or with a history of aspiration pneumonia may require placement of tubes beyond the stomach into the intestine. The jejunostomy tube is the only tube in the list that is beyond the stomach and is not contraindicated by facial trauma. The nasogastric tube and the PEG tube are placed in the stomach, and placement could lead to aspiration. The nasointestinal tube and the nasogastric tube may be contraindicated by facial trauma and the broken nose.

11. The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. The patient is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. Which level of preventive care is this patient receiving? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion

ANS: B Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities for healthy people. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration.

20. A nurse is providing care to a group of patients. Which situation will require the nurse to obtain a telephone order? a. As the nurse and health care provider leave a patient's room, the primary care provider gives the nurse an order. b. At 0100, a patient's blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood. c. At 0800, the nurse and health care provider make rounds, and the primary care provider tells the nurse a diet order. d. A nurse reads an order correctly as written by the health care provider in the patient's medical record.

ANS: B Telephone orders and verbal orders (VO) usually occur at night or during emergencies (blood pressure dropping); they should be used only when absolutely necessary and not for the sake of convenience. Because the time is 1 AM (0100 military time) and the health care provider is not present, the nurse will need to call the health care provider for a telephone order. A VO involves the health care provider giving orders to a nurse while they are standing in proximity to one another. Just reading an order that is correctly written in the chart does not require a telephone order.

3. A nurse is using the World Health Organization definition of health to provide care. Which area will the nurse focus on while providing care? a. Making sure the patients are disease free b. Making sure to involve the whole person c. Making sure care is strictly personal in nature d. Making sure to focus only on the pathological state

ANS: B The World Health Organization (WHO) defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." Therefore, nurses' attitudes toward health and illness should consider the total person, as well as the environment in which the person lives. All people free of disease are not necessarily healthy. Strictly personal and a focus only on pathological states do not correlate to WHO's definition.

1.A nurse is teaching about the energy needed at rest to maintain life-sustaining activities for a specific period of time. What is the nurse discussing? a. Resting energy expenditure (REE) b. Basal metabolic rate (BMR) c. Nutrient density d. Nutrients

ANS: B The basal metabolic rate (BMR) is the energy needed at rest to maintain life-sustaining activities for a specific period of time. The resting energy expenditure (REE), or resting metabolic rate, is the amount of energy an individual needs to consume over a 24-hour period for the body to maintain all of its internal working activities while at rest. Nutrients are the elements necessary for body processes and function. Nutrient density is the proportion of essential nutrients to the number of kilocalories. High-nutrient density foods provide a large number of nutrients in relation to kilocalories.

10. A nurse is using the family as context approach to provide care to a patient. What should the nurse do next? a. Assess family patterns versus individual characteristics. b. Assess how much the family provides the patient's basic needs. c. Use "family as patient" and "family as context" approaches simultaneously. d. Plan care to meet not only the patient's needs but those of the family as well.

ANS: B When the nurse views the family as context, the primary focus is on the health and development of an individual member existing within a specific environment (i.e., the patient's family). Although the focus is on the individual's health status, the nurse assesses how much the family provides the individual's basic needs. Family patterns are in the realm of "family as patient" approach. Often, the nurse will use the two simultaneously (family as context and family as patient) with the approach of "family as system." "Family as patient" involves planning to meet the needs of the patient and those of the family as well.

6. The patient is reporting moderate incisional pain that was not relieved by the last dose of pain medication. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music the patient likes, and sets the television to the channel playing that type of music. Which health care model is the nurse using? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs

ANS: B The holistic health model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. The health belief model addresses the relationship between a person's beliefs and behaviors. The health promotion model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The basic human needs model believes that the extent to which basic needs are met is a major factor in determining a person's level of health. Maslow's hierarchy of needs is a model that nurses use to understand the interrelationships of basic human needs.

13. Upon completing a history, the nurse finds that a patient has risk factors for lung disease. How should the nurse interpret this finding? a. A person with the risk factor will get the disease. b. The chances of getting the disease are increased. c. Risk modification will have no effect on disease prevention. d. The disease is guaranteed not to develop if the risk factor is controlled.

ANS: B The presence of risk factors does not mean that a disease will develop, but risk factors increase the chances that the individual will experience a particular disease or dysfunction. Control of risk factors does not guarantee that a disease will not develop. However, risk factor modification can assist patients in adopting activities to promote health and decrease risks of illness.

16. A female patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. The patient is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. Which stage is the patient displaying? a. Precontemplation b. Contemplation c. Preparation d. Action

ANS: B This patient is planning to make the change within the next 6 months and is in the contemplation stage. These stages range from no intention to change (precontemplation), to considering a change within the next 6 months (contemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance).

2. A nurse is following the goals of Healthy People 2020 to provide care. Which action should the nurse take? a. Allow people to continue current behaviors to reduce the stress of change. b. Focus only on health changes that will lead to better local communities. c. Create social and physical environments that promote good health. d. Focus on illness treatment to provide fast recuperation.

ANS: C Healthy People 2020 includes four goals, one of which is to create social and physical environments that promote good health for all. The goals do not include continuing current behaviors to reduce stress, focusing only on health changes for communities, or focusing on fast recuperation.

15. A patient is to receive a proton pump inhibitor through a nasogastric (NG) feeding tube. Which is the most important nursing action to ensure effective absorption? a. Thoroughly shake the medication before administering. b. Position patient in the supine position for 30 minutes to 1 hour. c. Hold feeding for at least 30 minutes after medication administration. d. Flush tube with 10 to 15 mL of water, after all medications are administered

ANS: C If a medication needs to be given on an empty stomach or is not compatible with the feeding (e.g., phenytoin, carbamazepine [Tegretol], warfarin [Coumadin], fluoroquinolones, proton pump inhibitors), hold the feeding for at least 30 minutes before or 30 minutes after medication administration. Thoroughly shaking the medication mixes the medication before administration but does not affect absorption. Flushing the tube after all medications should be 30 to 60 mL of water; 15 to 30 mL of water is used for flushing between medications. Patients with NG tubes should never be positioned supine but instead should be positioned at least to a 30-degree angle to prevent aspiration, provided no contraindication condition is known

2.In general, when a patient's energy requirements are completely met by kilocalorie (kcal) intake in food, which assessment finding will the nurse observe? a. Weight increases. b. Weight decreases. c. Weight does not change. d. Weight fluctuates daily.

ANS: C In general, when energy requirements are completely met by kilocalorie (kcal) intake in food, weight does not change. When kilocalories ingested exceed a person's energy demands, the individual gains weight. If kilocalories ingested fail to meet a person's energy requirement, the individual loses weight. Fluid, not kilocalories, causes daily weight fluctuations.

13.A patient has obstructive sleep apnea. Which assessment is the priority? a. Gastrointestinal function b. Neurological function c. Respiratory status d. Circulatory status

ANS: C In obstructive sleep apnea, the upper airway becomes partially or completely blocked, diminishing nasal airflow or stopping it. The person still attempts to breathe because the chest and abdominal movement continue, which results in loud snoring and snorting sounds. According to the ABCs of prioritizing care, airway and respiratory status takes priority over gastrointestinal, circulatory, and neurologic functioning.

2. A nurse reviews the current trends affecting the family. Which trend will the nurse find? a. Mothers are staying at home. b. Adolescent mothers usually live on their own. c. More grandparents are raising their grandchildren. d. Teenage fathers usually have stronger support systems.

ANS: C More grandparents are raising their grandchildren. The majority of women work outside the home, and about 60% of mothers are in the workforce. The majority of adolescent mothers continue to live with their families. Teenage fathers usually have poorer support systems and fewer resources to teach them how to parent.

6. A nurse is working with a patient. When the nurse asks about family members, the patient states that it includes my spouse, children, and aunt and uncle. How will the nurse describe this type of family? a. Nuclear b. Blended c. Extended d. Alternative

ANS: C The extended family includes relatives (aunts, uncles, grandparents, and cousins) in addition to the nuclear family. The nuclear family consists of husband and wife (and perhaps one or more children). The blended family is formed when parents bring unrelated children from prior adoptive or foster parenting relationships into a new, joint living situation. Relationships include multi-adult households, "skip-generation" families (grandparents caring for grandchildren), communal groups with children, "nonfamilies" (adults living alone), cohabitating partners, and homosexual couples.

14.The patient has just been diagnosed with narcolepsy. The nurse teaches the patient about management of the condition. Which information from the patient will cause the nurse to intervene? a. Takes antidepressant medications b. Naps shorter than 20 minutes c. Sits in hot, stuffy rooms d. Chews gum

ANS: C The nurse will intervene about sitting in a hot, stuffy room as this will make the narcolepsy worse so this needs to be corrected. Patients with narcolepsy need to avoid factors that increase drowsiness (e.g., alcohol, heavy meals, exhausting activities, long-distance driving, and long periods of sitting in hot, stuffy rooms). Patients are treated with antidepressants, and management techniques involve scheduling naps no longer than 20 minutes and chewing gum. Additional management techniques include exercise, light high-protein meals, deep breathing, and taking vitamins.

4.The nurse is caring for a patient in the sleep lab. Which assessment finding indicates to the nurse that the patient is in stage 4 NREM? a. The patient awakens easily. b. The patient's eyes rapidly move. c. The patient is difficult to awaken. d. The patient's vital signs are elevated.

ANS: C The patient is difficult to arouse, vital signs are significantly lower, and this stage lasts about 15 to 30 minutes. Stage 4 NREM is the deepest stage of sleep. Lighter sleep is seen in stages 1 and 2, where the patient awakens easily. REM sleep is characterized by rapid eye movement.

10. When the nurse administers an IM corticosteroid injection, the nurse aspirates. What is the rationale for the nurse aspirating? a. Prevent the patient from choking. b. Increase the force of the injection. c. Ensure proper placement of the needle. d. Reduce the discomfort of the injection.

ANS: C The purpose of aspiration is to ensure that the needle is in the muscle and not in the vascular system. Blood return upon aspiration indicates improper placement, and the injection should not be given. While a patient can aspirate fluid and food into the lungs, this is not related to the reason for why a nurse pulls back the syringe plunger after inserting the needle (aspirates) before injecting the medication. Reducing discomfort and prolonging absorption time are not reasons for aspirating medications.

8. The nurse is interviewing a patient who is being admitted to the hospital. The patient's family went home before the nurse's interview. The nurse asks the patient, "Who decides when to come to the hospital?" What is the rationale for the nurse's action? a. To assess the family form b. To assess the family function c. To assess the family structure d. To assess the family generalization

ANS: C To assess the family structure, the nurse asks questions that determine the power structure and patterning of roles and tasks (e.g., "Who decides where to go on vacation?"). When focusing on family form, the nurse should begin the family assessment by determining the patient's definition of family. Family function is the ability of the family to provide emotional support and to cope with health problems or situations. The question asked by the nurse will not assess that. Nurses do not assess family generalization.

5.A nurse is caring for a patient with a postsurgical wound. When planning care, which goal will be the priority? a. Reduce dependent nitrogen balance. b. Maintain negative nitrogen balance. c. Promote positive nitrogen balance. d. Facilitate neutral nitrogen balance.

ANS: C When intake of nitrogen is greater than output, the body is in positive nitrogen balance. Positive nitrogen balance is required for growth, normal pregnancy, maintenance of lean muscle mass and vital organs, and wound healing. Negative nitrogen balance occurs when the body loses more nitrogen than the body gains. Neutral nitrogen balance occurs when gain equals loss and is not optimal for tissue healing. There is no such term as dependent nitrogen balance.

14. The nurse is caring for a patient who has been trying to quit smoking. The patient has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate? a. The patient does not want to and will never quit smoking. b. The patient must pick up the attempt right where the patient left off. c. The patient will return to the contemplation or precontemplation phase. d. The patient will need to adopt a new lifestyle for change to be effective.

ANS: C When relapse occurs, the person will return to the contemplation or precontemplation stage before attempting the change again. The patient cannot pick up the attempt where left off. It is believed that change involves movement through a series of stages (precontemplation, contemplation, preparation, action, and maintenance). Anticipating that the patient does not want to and will never quit is premature. While the patient will need to adopt a new lifestyle for change to be effective, it does not correlate to this scenario since the patient relapsed.

13. The nurse is caring for an older adult patient at home who requires teaching for dressing changes. The spouse and adult child are also involved in changing the dressing. Which statement by the nurse will most likely elicit a positive response from the patient and family? a. "You're doing that all wrong. Let me show you how to do it." b. "I don't know who showed you how to change a dressing, but you're not doing it right. Let me show you again." c. "You're hesitant about changing the dressing like I was before I was shown an easier way; would you like to see?" d. "I used to change the dressing the same way you are doing it: the wrong way. I'll show you the right way to do it."

ANS: C When the nurse is confident and skillful instead of coming across as an authority on the subject, the patient's/family's defenses will be down, making the patient/family more willing to listen without feeling embarrassed. Respectful communication is necessary. Saying that you're doing it wrong, you're not doing it right, or the wrong way is not respectful or necessary.

22. A nurse is teaching the staff about informatics. Which information from the staff indicates the nurse needs to follow up? a. To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice. b. A nurse needs to know how to find, evaluate, and use information effectively. c. If a nurse has computer competency, the nurse is competent in informatics. d. Nursing informatics is a recognized specialty area of nursing practice.

ANS: C When the staff make an incorrect statement, then the nurse needs to follow up. Competence in informatics is not the same as computer competency. All the rest are correct information so the nurse does not need to follow up. To become competent in informatics, you need to be able to use evolving methods of discovering, retrieving, and using information in practice. This means that you learn to recognize when information is needed and have the skills to find, evaluate, and use that information effectively. Nursing informatics is a specialty that integrates the use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research.

11. The nurse is caring for a patient in hospice. The nurse notes that the patient is getting adequate care, but the spouse is not sleeping well. The nurse also assesses the need for better family nutrition and meals assistance. The nurse discusses these needs with the patient and family and develops a plan of care with them using community resources. Which approach is the nurse using? a. Family as context b. Family as patient c. Family as system d. Family as caregiver

ANS: C When you care for the family as a system, you are caring for each family member (family as context) and the family unit (family as patient), using all available environmental, social, psychological, and community resources. In family as context, the primary focus is on the health of an individual member. In family as patient, family processes and relationships are the primary focus. Family as caregiver is not an approach to family-focused nursing but is a term used to describe a family member caring for another family member

4. A nurse cares for the family's as well as the patient's needs using available resources. Which approach is the nurse using? a. Family as context b. Family as patient c. Family as system d. Family as caregivers

ANS: C When you care for the family as a system, you are caring for each family member (family as context) and the family unit (family as patient), using all available environmental, social, psychological, and community resources. When you view the family as context, the primary focus is on the health and development of an individual member existing within a specific environment (i.e., the patient's family). When you view the family as patient, the family processes and relationships (e.g., parenting or family caregiving) are the primary focuses of nursing care. There is no approach for family as caregivers; rather it is a term to describe family members caring for other family members usually at home.

3. A spouse brings the children in to visit their mother in the hospital. The nurse asks how the family is doing. The husband states, "None of her jobs are getting done, and I don't do those jobs, so the house and the kids are falling apart." How will the nurse interpret this finding? a. The family structure is resilient. b. The family structure is flexible. c. The family structure is hardy. d. The family structure is rigid.

ANS: D A rigid structure specifically dictates who is able to accomplish different tasks and also limits the number of persons outside the immediate family allowed to assume these tasks. Resiliency helps to evaluate healthy responses when individuals and families are experiencing stressful events. An extremely flexible structure also presents problems for the family. There is sometimes an absence of stability that would otherwise lead to automatic action during a crisis or rapid change. Hardiness is the internal strength and durability of the family unit characterized by a sense of control over the outcome of life and an active, rather than passive, orientation in adapting to stressful events.

4. A patient has an order to receive 0.3 mL of U-500 insulin. Which syringe will the nurse obtain to administer the medication? a. 3-mL syringe b. U-100 syringe c. Needleless syringe d. Tuberculin syringe

ANS: D Because there is no syringe currently designed to prepare U-500 insulin, many medication errors result with this kind of insulin. To prevent errors, ensure that the order for U-500 specifies units and volume (e.g., 150 units, 0.3 mL of U-500 insulin), and use tuberculin syringes to draw up the doses. A 3 mL and U-100 can result in inaccurate dosing. A needleless syringe will not be acceptable in this situation.

12.The nurse is caring for an adolescent with an appendectomy who is reporting difficulty falling asleep. Which intervention will be most appropriate? a. Close the door to decrease noise from unit activities. b. Adjust temperature in the patient's room to 21° C (70° F). c. Ensure that the night-light in the patient's room is working. d. Encourage the discontinuation of a soda and chocolate nightly snack.

ANS: D Discontinuing the soda and chocolate nightly snack will be most beneficial for this patient since it has two factors that will cause difficulty falling asleep. Coffee, tea, colas, and chocolate act as stimulants, causing a person to stay awake or to awaken throughout the night. Personal preference influences the temperature of the room, as well as the lighting of the room. Noise can be a factor in the unit and can awaken the patient, but caffeine can make it difficult to fall asleep.

9. The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. Which concept is the nurse fostering? a. Illness prevention b. Wellness education c. Active health promotion d. Passive health promotion

ANS: D Fluoridation of municipal drinking water and fortification of homogenized milk with vitamin D are examples of passive health promotion strategies. With active strategies of health promotion, individuals are motivated to adopt specific health programs such as weight reduction and smoking cessation programs. Illness prevention activities such as immunization programs protect patients from actual or potential threats to health. Wellness education teaches people how to care for themselves in a healthy way.

18.The nurse adds a nursing diagnosis of ineffective breathing pattern to a patient's care plan. Which sleep condition caused the nurse to assign this nursing diagnosis? a. Insomnia b. Narcolepsy c. Sleep deprivation d. Obstructive sleep apnea

ANS: D Obstructive sleep apnea (OSA) occurs when the muscles or structures of the oral cavity or throat relax during sleep. The upper airway becomes partially or completely blocked, diminishing airflow or stopping it for as long as 30 seconds. The person still attempts to breathe because chest and abdominal movements continue, resulting in snoring or snorting sounds. With narcolepsy, the person feels an overwhelming wave of sleepiness and falls asleep. Insomnia is characterized by chronic difficulty falling asleep. Sleep deprivation is a condition caused by dyssomnia. OSA is the only one of these conditions that results in blockage of the airway and impacts the ability to breathe.

5. A nurse is caring for a patient who needs constant care in the home setting and for whom most of the care is provided by the patient's family. Which action should the nurse take to help relieve stress? a. Encourage caregiver to do as much as possible. b. Focus primarily on the patient. c. Point out weaknesses. d. Provide education.

ANS: D Providing education to the family and caregiver helps relieve some of the stress of caregiving. Help the family focus on their strengths instead of on problems and weaknesses. While caregivers desire to care for the loved one, they often feel extreme pressure to do everything; therefore, encouraging the caregiver to do more will add stress. Focusing primarily on the patient will not be beneficial; the entire family is the patient.

5.A nurse is teaching the staff about the sleep cycle. Which sequence will the nurse include in the teaching session? a. NREM Stage 1, 2, 3, 4, REM b. NREM Stage 1, 2, 3, 4, 3, 2, 1, REM c. NREM Stage 1, 2, 3, 4, REM, 4, 3, 2 REM d. NREM Stage 1, 2, 3, 4, 3, 2, REM

ANS: D The cyclical pattern usually progresses from stage 1 through stage 4 of NREM, followed by a reversal from stages 4 to 3 to 2, ending with a period of REM sleep. The others are incorrect sequences.

1.The nurse is caring for a young-adult patient on the medical-surgical unit. When doing midnight checks, the nurse observes the patient awake, putting a puzzle together. Which information will the nurse consider to best explain this finding? a. The patient misses family and is lonely. b. The patient was waiting to talk with the nurse. c. The patient has been kept up with the noise on the unit. d. The patient's sleep-wake cycle preference is late evening.

ANS: D This patient is awake and alert enough to do a puzzle. The individual's sleep-wake preference is probably late evening. All persons have biological clocks that synchronize their sleep-wake cycle. This explains why some individuals fall asleep in the early evening, whereas others go to bed at midnight or early morning. Waiting to talk with the nurse, being lonely, and noise on the unit may contribute to lack of sleep, but the best explanation for the patient being awake is the biological clock.

24. A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take? a. Use the same password all the time. b. Share password with only one other staff member. c. Print out and review computer nursing notes at home. d. Chart on the computer immediately after care is provided.

ANS: D To increase accuracy and decrease unnecessary duplication, many health care agencies keep records or computers near a patient's bedside to facilitate immediate documentation of information as it is collected. A good system requires frequent, random changes in personal passwords to prevent unauthorized persons from tampering with records. When using a health care agency computer system, it is essential that you do not share your computer password with anyone under any circumstances. You destroy all papers containing personal information immediately after you use them. Taking nursing notes home is a violation of

8.The patient has been diagnosed with cardiovascular disease and placed on a low-fat diet. The patient asks the nurse, "How much fat should I have? I guess the less fat, the better." Which information will the nurse include in the teaching session? a. Cholesterol intake needs to be less than 300 mg/day. b. Fats have no significance in health and the incidence of disease. c. All fats come from external sources so this can be easily controlled. d. Deficiencies occur when fat intake falls below 10% of daily nutrition.

D

11. The nurse is giving an IM injection. Upon aspiration, the nurse notices blood return in the syringe. What should the nurse do? a. Administer the injection at a slower rate. b. Withdraw the needle and prepare the injection again. c. Pull the needle back slightly and inject the medication. d. Give the injection and hold pressure over the site for 3 minutes.

B

40.A nurse is caring for a group of patients. Which patient will the nurse see first? a. Patient receiving total parenteral nutrition of 2-in-1 for 50 hours b. Patient receiving total parenteral nutrition infusing with same tubing for 26 hours c. Patient receiving continuous enteral feeding with same feeding bag for 12 hours d. Patient receiving continuous enteral feeding with same tubing for 24 hours

B

7. A patient is receiving vancomycin. Which function is the priority for the nurses to assess? a. Vision b. Hearing c. Heart tones d. Bowel sounds

B

26. A patient is at risk for aspiration. Which nursing action is most appropriate? a. Give the patient a straw to control the flow of liquids. b. Have the patient self-administer the medication. c. Thin out liquids so they are easier to swallow. d. Turn the head toward the stronger side

B Aspiration occurs when food, fluid, or medication intended for GI administration inadvertently enters the respiratory tract. To minimize aspiration risk, allow the patient, if capable, to selfadminister medication. Patients should also hold their own cup to control how quickly they take in fluid. Some patients at risk for aspiration may require thickened liquids; thinning liquids does not decrease aspiration risk. Patients at risk for aspiration should not be given straws because use of a straw decreases the control the patient has over volume intake. Turning the head toward the weaker side helps the medication move down the stronger side of the esophagus.

2. A nurse is preparing to administer an injection to a patient. Which statement made by the patient is an indication for the nurse to use the Z-track method? a. "I am allergic to many medications." b. "I'm really afraid that a big needle will hurt." c. "The last shot like that turned my skin colors." d. "My legs are too obese for the needle to go through."

C

20.The patient presents to the clinic with reports of irritability, being sleepy during the day, chronically not being able to fall asleep, and being tired. Which nursing diagnosis will the nurse document in the plan of care? a. Anxiety b. Fatigue c. Insomnia d. Sleep deprivation

C

6.In providing diet education for a patient on a low-fat diet, which information is important for the nurse to share? a. Polyunsaturated fats should be less than 7% of the total calories. b. Trans fat should be less than 7% of the total calories. c. Unsaturated fats are found mostly in animal sources. d. Saturated fats are found mostly in animal sources.

d