Ch 6, 27, 34, 49, 37, 36

The nurse is teaching a 10-year-old patient about personal hygiene. What observation would indicate that the child has not reached an age-appropriate developmental stage? 1 An inability to understand and master brushing technique 2 An inability to accept age-related body changes 3 An inability to assess life goals 4 An inability to decide on a future career

1 As per Erikson's developmental stages, a 10-year-old child should be able to understand and reinforce information provided and master new skills, such as the basic hygiene tasks the nurse discusses. A person starts to accept age-related body changes and begins to establish goals in adolescence, but may not do so as young as 10 years of age. The assessment of life goals is not expected until adulthood. Setting goals for the future, such as deciding which school to attend or what career to pursue, is a developmental behavior for children 12 to 20 years old.

The nurse is trying to assess if a patient is free from identity stressors. What would suggest that the patient has a strong identity? 1 The patient has been happily married for 10 years. 2 The patient exercises daily. 3 The patient does not abuse substances. 4 The patient is involved in church activities.

1 Identity achievement is reflected by a patient's intimate relationships. The patient who has been happily married for 10 years probably has a strong identity. Positive behaviors such as exercising daily, not abusing substances, and being involved in church activities do not indicate that the patient is free of identity stressors.

What is the most common reason for elective cosmetic surgery? 1 Improve self-image 2 Remove deep acne scars 3 Lighten the skin in individuals with pigmentation problems 4 Prevent skin changes associated with aging

1 Improvement of body image is the most common reason for undergoing cosmetic surgery, because appearance is an important part of confidence and self-assurance. Acne scars, pigmentation problems, and wrinkling can also be treated with cosmetic surgery, but the surgery does not prevent the skin changes associated with aging.

A 20-year-old woman who lives with her parents gives birth to a baby. Around the same time, her parents adopt a 5-year-old child. The young woman is overwhelmed and has difficulty balancing her role as a mother with her role as a sister. What kind of role performance stressor does the woman experience? 1 Role conflict 2 Role ambiguity 3 Role strain 4 Role overload

1 Role conflict happens when a person has to assume two or more inconsistent roles. This new mother is trying to cope with the physical and psychological burdens of raising a child and is stressed by the addition of a new relationship with a young sibling, creating role conflicts. Role ambiguity occurs when a person is confused and not sure of his or her role. Role strain results from role conflict and role ambiguity. When a person has more responsibilities within a role than she can manage, she experiences role overload.

Based on knowledge of the developmental tasks of Erikson's industry-versus-inferiority stage, the nurse emphasizes proper technique for use of an inhaler with a 10-year-old boy. Why does the nurse do this? 1 It increases the patient's self-esteem with the mastery of a new skill. 2 It helps him to accept changes in his appearance and physical endurance. 3 It helps him to experience success in role transitions and increased responsibilities. 4 It helps him appreciate his body appearance and function.

1 The developmental stage of industry versus inferiority (ages 8 to 12) is focused on incorporating feedback from peers and teachers, increasing self-esteem with the mastery of new skills, and promoting awareness of strengths and limitations.

Which factor will the nurse observe in the 22-year-old patient with low self-esteem who is in the intimacy-versus-isolation stage of psychosocial development, according to Erikson's theory of self-concept? 1 Increased responsibilities 2 Negative feelings about the sense of self 3 Changes in appearance and physical endurance 4 Need for the provision of a legacy for the next generation

1 The intimacy-versus-isolation stage of psychosocial development occurs from the mid-20s to the mid-40s. Due to increased responsibilities of caring for children and older adults, these individuals are said to be living in the sandwich generation. Therefore, increased responsibilities are found in this stage. Negative feelings about themselves result in role confusion in individuals from 12 to 20 years of age. Changes in appearance and physical endurance occur in individuals in the mid-40s to mid-60s age group. Failure to accept the changes results in self-absorption, not isolation. The need for the provision of a legacy for the next generation occurs in the psychosocial development stage of ego integrity versus despair.

An adult woman is recovering from a mastectomy for breast cancer and is frequently tearful when left alone. On what should the nurse's approach be based? 1 Patients need support in dealing with the loss of a body part. 2 The patient's family should take the lead role in providing support. 3 The nurse should explain that breast tissue is not essential to life. 4 The patient should focus on the cure of the cancer rather than loss of the breast.

1 The nurse should encourage the patient to talk about the threats to body image, including the meaning of the loss, the reactions of others, and the ways in which the patient is grieving.

When developing an appropriate outcome for a 15-year-old girl, what primary developmental task of adolescence should the nurse consider? 1 The ability to form a sense of identity 2 The ability to create intimate relationships 3 The ability to separate from parents and live independently 4 The ability to achieve a positive self-esteem through experimentation

1 Understanding developmental tasks across the life span is essential in designing nursing care. Adolescents are focused on establishing their identities outside of their families and should be supported in meeting this developmental task.

What are common characteristics seen among different cultures? (Select all that apply.) 1. Culture is learned from birth through language and socialization. 2. Culture is dynamic and ever changing, but it remains stable. 3. Members of the same cultural group have different patterns of socialization than other cultural groups. 4. Culture is an adaptation to specific conditions in a specific location. 5. Child-rearing practices are approximately the same in all cultures.

1, 2 Rationale: Culture is learned, dynamic, and adapted to specific conditions in a specific location. All members of the same cultural group share the patterns that are present in every culture. Though all cultures appear to value children, child-rearing practices are very different. REF: Page 95

The nurse is examining a patient who just had a spontaneous abortion. What observations suggest to the nurse that the patient has good self-esteem post incident and is coping well? Select all that apply. 1 The patient's husband stays by her side and holds her hand. 2 The patient seems depressed but is asking the health care provider about conceiving again. 3 The patient does not want to conceive another child. 4 The patient does not talk to anybody about the incident. 5 The patient asks the health care provider about permanent contraception methods.

1, 2 The fact that the patient's spouse is supportive helps her cope with the stress and loss of self-esteem. Healthy social support from family and loved ones has a very positive effect on a person's self-esteem. The patient's willingness and ability to make decisions about conceiving again show that the patient has a good self-esteem level. A patient who does not want to conceive another child may be depressed and fears that she could face the situation again. If the patient does not talk to anybody about the incident, she may not want to face the emotions related to the incident. Asking the health care provider about permanent contraceptive methods indicates that the patient does not want to go through the process of childbirth again. This behavior may indicate that the patient has low self-esteem and is not coping well.

After assessing a 2-year-old child, the nurse observes that the child is in the psychosocial development stage of autonomy versus shame and doubt, according to Erikson's theory of self-concept. Which developmental tasks does the nurse observe in the child? Select all that apply. 1 Communication of likes and dislikes 2 Appreciation of body appearance and function 3 Increased independence in thoughts and actions 4 Incorporation of feedback from peers and teachers 5 Increased language skills, including identification of feelings

1, 2, 3 Children between the ages of 1 and 3 years of age are in the psychosocial development stage of autonomy versus shame and doubt. During this stage, children begin to communicate likes and dislikes that promote the development of self-concept. The positive appreciation of body appearance and function increases the self-esteem and self-concept. Children from 1 to 3 years of age gain independence in actions and thoughts due to self-exploration. This also promotes development of self-concept due to increased autonomy. Children between 1 and 3 years of age cannot understand feedback given by peers and teachers. Children from 3 to 6 years of age have increased language skills, including the identification of feelings.

How can the nurse increase a patient's self-awareness? Select all that apply. 1 Help the patient define his or her problems clearly. 2 Allow the patient to openly explore thoughts and feelings. 3 Reframe the patient's thoughts and feelings in a more positive way. 4 Have family members assume more responsibility during times of stress. 5 Arrange for the patient to work with an occupational therapist.

1, 2, 3 Helping a patient define his or her problems, allowing the patient to explore his or her feelings, and reframing the patient's thoughts and feelings in a more positive way are techniques designed to promote self-awareness and a positive self-concept. Having a family member assume more responsibility does not help a patient achieve self-awareness; instead it is important to encourage a patient to assume more self-responsibility.

In assessing a patient for self-concept and self-esteem, on what components should the nurse focus? Select all that apply. 1 Identity 2 Body image 3 Role performance 4 Physical condition 5 Medical condition

1, 2, 3 When assessing a patient's self-esteem, the nurse should focus on assessing individual components such as identity, body image, and role performance. This helps the nurse determine which factor is affecting the self-concept. The physical and medical conditions are not components of self-concept.

A 50-year-old female patient with breast cancer is admitted to the hospital for surgical management. On the second postoperative day, the nurse finds the patient crying. She tells the nurse that she had agreed to take care of her 8-month-old granddaughter but knows she will be unable to do so. The patient also expresses concern about her looks and that she feels worthless. Which aspects of the patient's self-concept are affected? Select all that apply. 1 Body image 2 Self-esteem 3 Concentration 4 Role performance 5 Memory and recall

1, 2, 4 Body image is the way a person perceives her body including physical appearance, structure, and function. The patient is unhappy with the way she looks. Self-esteem is the feeling of self-worth. The patient indicates a negative self-esteem. Role performance is the way in which a person perceives the ability to carry out a significant role. The patient doubts she can handle the responsibility of looking after her granddaughter. This shows negative role performance. Concentration, memory, and recall are intellectual aspects and are unaffected in this patient.

The nurse is assessing a patient who lost his fingers in an accident with a meat mincer. What patient behavior is suggestive of an altered self-concept? Select all that apply. 1 The patient does not make eye contact while talking. 2 The patient discusses prosthetics with the nurse. 3 The patient still cannot believe he was so careless. 4 The patient states that he wants to be left alone. 5 The patient informs a co-worker that he will be back to work in a few days.

1, 3, 4 Avoiding eye contact, excessive self-criticism, and denial of self-expression are all signs of altered self-concept. A patient who discusses treatment options and future goals has a high self-concept and has a good chance of a speedy recovery. The patient who is positive about going to work and not blaming others for his condition also has a very good self-concept.

A 55-year-old male patient recently underwent a colostomy. Prior to the colostomy, the patient underwent coronary artery bypass graft (CABG) surgery. The nurse finds the patient depressed and weeping. The patient expresses that he is fed up with his poor health. He feels that he has become a burden on his family because he can't work now. Which factors are responsible for lowering the patient's self-esteem? Select all that apply. 1 The colostomy 2 Abuse or neglect 3 Dependency on others 4 A change in marital status 5 A physical deficit preventing role assumption

1, 3, 5 Procedures such as colostomies alter the physical appearance of people, thereby lowering their self-esteem. This patient is dependent on his family due to his physical deficits. This can be a major stressor and further reduce his self-esteem. His self-esteem is also lowered by the fact that he is unable to handle his responsibilities. Abuse or neglect and change in marital status do affect a person's self-esteem, but in this case, these factors are not evident.

Jehovah's Witness patient has been admitted to the medical floor. Which treatment will this patient most likely refuse based on religious beliefs? 1. Blood transfusion 2. Antibiotics 3. Cardiac medications 4. Aerosol treatments

1. Blood transfusion Rationale: Jehovah's Witness believe blood transfusions violate God's law and therefore are not allowed. Jehovah's Witnesses will allow antibiotics, cardiac medications, and aerosol treatments. Pg 103

nurse is caring for a Muslim patient and knows that individuals of this religion pray several times a day. Which intervention is most appropriate in caring for this patient? 1. Schedule patient care around these prayer times. 2. Encourage the patient to plan prayers around treatments 3. Activities take precedence over religious beliefs. 4. If the patient is praying, interrupt for care and allow him or her to finish later.

1. Schedule pt care around these prayer times Rationale: To respect religious beliefs and provide for privacy during prayer, schedule care around prayer times. Even though a Muslim patient may be ill, it does not mean he or she needs to totally change religious beliefs. Religious beliefs should always be taken into consideration when providing patient care. Unless an emergency arises, allow prayer time to be finished and for care completed later. Pg 101

Several staff members complain about a patient's constant questions such as "Should I have a cup of coffee or a cup of tea" and "Should I take a shower now or wait until later?" Which interpretation of the patient's behavior helps the nurses provide optimal care? 1 Asking questions is attention-seeking behavior. 2 The inability to make decisions reflects a self-concept issue. 3 A dependence on staff must be stopped immediately. 4 Indecisiveness is aimed at testing how the staff reacts.

2 Patients with deficits in self-concept often have difficulty making decisions. It is essential for the nurse to remain accepting of the patient and to support him or her in decision making.

A 55-year-old male patient underwent a colostomy. Earlier he underwent coronary artery bypass graft (CABG) surgery. The nurse finds the patient depressed and weeping. The patient expresses that he is fed up with his poor health. He feels that he has become a burden on his family because he can't work now. The nurse concludes that the patient is experiencing role performance issues. Which statement is true about role performance? 1 It is an individual's holistic feeling of self-worth or emotional appraisal. 2 It is the way an individual perceives his or her ability to responsibly carry out significant roles. 3 It involves the ideas and views of an individual related to physical appearance, structure, and function. 4 It is a conflict experienced when an individual has to perform two or more mutually exclusive responsibilities.

2 Role performance is the way in which an individual perceives his or her ability to carry out significant roles responsibly. Self-esteem is an individual's holistic feeling of self-worth or emotional appraisal. Body image involves ideas and views of an individual related to the body including physical appearance, structure, or function. Role conflict is a conflict a person experiences when he or she has to perform two or more mutually exclusive responsibilities.

What term describes how one thinks of oneself? 1 Self-awareness 2 Self-concept 3 Self-esteem 4 Self-expression

2 Self-concept is how one thinks of oneself. It is subjective and is a mixture of conscious and unconscious thoughts, attitudes, and perceptions. Self-awareness is having knowledge about one's feelings, thoughts, and attitudes. Self-esteem is how one feels about oneself. Self-expression is expressing one's own character, feelings, thoughts, and mind-sets.

In planning nursing care for an 85-year-old male, what is the most important, basic need that must be met? 1 Assurance of sexual intimacy 2 Preservation of self-esteem 3 Expanded socialization 4 Increase in monthly income

2 Self-esteem is essential for physical and psychological health across the life span.

The nurse asks the patient, "How do you feel about yourself?" What is the nurse assessing? 1 Identity 2 Self-esteem 3 Body image 4 Role performance

2 Self-esteem is how a person feels about himself or herself. Asking open-ended questions about self-esteem is important during the nursing assessment.

A patient underwent six cycles of chemotherapy for her cancer. She lost all of her hair due to drug effects. She is very worried and says, "My children may find me ugly. I will not be able to tolerate that." What stressor is most affecting her self-concept? 1 Chemotherapy 2 Body Image 3 Role performance 4 Identity

2 The patient is very concerned about her physical appearance and is worried that her children will be shocked on seeing her with no hair. She has low self-concept related to body image. Chemotherapy does not affect the patient's self-concept as much as body image. The patient does not doubt herself in the role of a mother and is not facing any identity issues.

A 55-year-old male patient underwent a colostomy. Earlier he underwent coronary artery bypass graft (CABG) surgery. The nurse finds the patient depressed and weeping. The patient expresses that he is fed up with his poor health. He feels that he has become a burden on his family because he can't work now. The nurse finds that the patient's body language is suggestive of altered self-concept. Which behaviors suggest low self-esteem? Select all that apply. 1 Normal speech 2 Frequent crying 3 Hesitant speech 4 Avoidance of eye contact 5 Maintaining good eye contact

2, 3 ,4 Behaviors that are suggestive of altered self-esteem include frequent crying, hesitant speech, avoiding eye contact, slumped posture, and an unkempt appearance. Normal speech and maintaining good eye contact are suggestive of a normal and positive self-esteem.

A Hispanic-American child is brought to the clinic by her mother to be examined by the physician. Which nursing intervention is most important when gathering data about the child? 1. Avoid using eye contact. 2. Be sure to touch the child during the examination. 3. Avoid any talking with the child. 4. Only use body language.

2. Be sure to touch the child during the exam Rationale: They believe women and children are susceptible to mal de ojo (evil eye). It is believed that touch will neutralize mal de ojo. They will avoid sustained eye contact because they think it is rude, immodest, or dangerous. The child may be the one who knows English, so the nurse would need to speak to the child to gain necessary information. Body language will not gather much data.

When assessing a patient from a different culture, what is the most important area to consider? 1. Religious beliefs 2. Language spoken 3. Health practices 4. Social organizations

2. Language Spoken Rationale: is important to determine whether the nurse and patient can understand what the other is saying. It may be possible to find an interpreter in the event of a language barrier. Religious beliefs, health practices, and social organizations are an important area of cultural assessment, but not the most important. Pg 97

The nurse is doing discharge teaching with an African American patient regarding nutrition intake. What food customs should the nurse consider when developing this educational plan? 1. Raw fish is the main component of the diet. 2. Many meats and vegetables are fried in lard. 3. Red meat is the primary source of protein in the diet. 4. Rice is eaten with all meals.

2. Many meats and vegetables are fried in lard. Rationale: Dietary intake for African Americans includes the traditional soul food, which is high in fat.

Due to a shortage of staff, the nurse has been on duty for both morning and night shifts for the last 2 days. Which role performance is the nurse experiencing? 1 Role strain 2 Role conflict 3 Role overload 4 Role ambiguity

3 Every person undergoes numerous role changes throughout life. Role overload is not being able to meet the demands of work and carve out some personal time for family. Therefore, the nurse is experiencing role overload in this situation. Role strain is the expression of feelings of frustration due to an illness or inadequate satisfaction. Role conflict occurs when a person has to assume two or more roles that are inconsistent and contradictory. Role ambiguity is unclear role expectations that create stress and confusion.

A patient diagnosed with major depressive disorder has long-term low self-esteem related to negative view of the self. Which action would be the most appropriate cognitive intervention by the nurse? 1 Promote active socialization with other patients. 2 Role-play to increase assertiveness skills. 3 Focus on identifying strengths and accomplishments. 4 Encourage journaling of underlying feelings.

3 Focusing on strengths and accomplishments to minimize the emphasis on failures assists the patient in altering distorted and negative thinking. The other interventions are important, but they are not designed to impact thoughts.

A 50-year-old female patient is admitted to the hospital for surgical management of breast cancer. On the second postoperative day, the nurse finds the patient crying. She tells the nurse that she had agreed to take care of her 8-month-old granddaughter, but knows she will be unable to do so. The patient also expresses concern about her looks and that she feels worthless. Identify the stressor that influenced the patient's self-esteem. 1 Pain 2 Job loss 3 Mastectomy 4 Repeated failures

3 Mastectomy is a surgical procedure for removal of affected breast tissues. Mastectomy has a negative effect on the physical appearance of a female and may be unacceptable to many women. This can be a major factor in lowering their self-esteem. Chronic illness and the idea of depending on others also lower self-esteem. In this case, there is no mention of pain, job loss, or repeated failure, which may also reduce self-esteem.

A person tries to meet the strenuous demands of employment while taking care of a family of six and manages to fulfill the responsibilities with great difficulty. What kind of role performance stressor is affecting this person? 1 Role conflict 2 Role ambiguity 3 Role overload 4 Role strain

3 When the expectations and responsibilities of a role are unmanageable, it is referred to as role overload. A person may experience role overload when trying to meet employment demands and caring for a family. Role conflict happens when a person has to assume two or more inconsistent and mutually exclusive roles. Role ambiguity occurs when a person is confused and not sure of his or her role. Role strain results from role conflict and role ambiguity combined.

The nurse is teaching a group of young adults about the normal changes in role performance associated with maturation. What are the common stressors related to role performance in this stage of life? Select all that apply. 1 Societal attitudes 2 Dependency on others 3 Transition from school to work setting 4 Physical, emotional, or cognitive deficits preventing role assumption 5 Death of a loved one

3, 4, 5 Role performance is the way in which individuals perceive their abilities to carry out significant roles (e.g., parent, supervisor, or close friend). Normal changes associated with maturation result in changes in role performance. The common stressors include transition from school to work setting, and the physical, emotional, or cognitive deficits preventing role assumption. The death of a loved one creates an emotional deficit that may prevent a person from assuming his or her roles. Societal attitudes and dependency on others are related to identity.

What is a set of learned values, beliefs, customs, and practices taught, shared by a group, and passed from one generation to another? 1. Subculture 2. Ethnicity 3. Culture 4. Religion

3. Culture Rationale: Culture is a set of learned values, beliefs, customs, and practices taught, shared by a group, and passed from one generation to another. Subculture shares many characteristics with the primary culture, but it has characteristic patterns of behavior and ideals that distinguish it from the rest of the culture. Ethnicity refers to a group of people who share a common social and cultural heritage based on shared traditions. Religion is a preference that falls within the social, cultural, or ethnic norms. Pg 94

Which nursing diagnosis is appropriate for a 35-year-old Hispanic patient who does not speak English? 1. Deficient knowledge 2. Noncompliance 3. Impaired verbal communication 4. Ineffective coping

3. Impaired verbal communication Rationale: Impaired verbal communication occurs when there is a problem in the patient and staff understanding each other. Knowledge deficit is used cautiously because there simply may be a language barrier, not a lack of knowledge. Noncompliance has nothing to do with this situation. The problem identified is the language barrier. Impaired coping has nothing to do with this situation. The problem identified is the language barrier. Pg 108

A female Muslim patient has been assigned to a male nurse. As the nurse enters the room, the patient becomes very upset. The nurse understands this patient is upset because of what component of this patient's religious beliefs? 1. She does not think she is ill. 2. Her husband is not present. 3. She prefers to be taken care of by a female. 4. She cannot speak English.

3. She prefers to be taken care of by a female. Rationale: Due to modesty, Muslim women prefer to be cared for by female staff, a preference that should be respected. Pg 110-111

The nurse is caring for an 87-year-old patient. What factor most directly influences this patient's current self-concept? 1 Attitude and behaviors of relatives providing care 2 Caring behaviors of the nurse and health care team 3 Level of education, economic status, and living conditions 4 Adjustment to role change, loss of loved ones, and physical energy

4 Older adults experience significant challenges to self-concept, including mental and physical changes associated with aging and changes in identity and roles following retirement and/or loss of significant others. The adjustment to stressors is most important. The other influences are important but to a lesser degree.

A patient suffers from situational low self-esteem following the death of her pet dog. What are the appropriate questions for the nurse to ask during assessment of her self-esteem? 1 "What recreational activities do you like?" 2 "What is your favorite food?" 3 "What are the three activities that you used to do with your dog?" 4 "How do you feel about yourself?"

4 The nurse's assessment should focus on individual components, and asking the patient how she feels about herself helps the nurse to identify any identity crises the patient might have. Asking about recreational activities, favorite foods, and activities with the pet would not be useful in assessing the problems related to the patient's identity, role performance, or body image.

Following a bilateral mastectomy, a 50-year-old patient refuses to eat, discourages visitors, and pays little attention to her appearance. One morning the nurse enters the room to see the patient with her hair combed and makeup applied. Which statement is the best response from the nurse? 1 "What's the special occasion?" 2 "You must be feeling better today." 3 "This is the first time I have seen you look this good." 4 "I see that you've combed your hair and put on makeup."

4 When the nurse uses a matter-of-fact approach and acknowledges a change in the patient's behavior or appearance, it allows the patient to establish its meaning.

Which statement made by a patient with cancer reflects positive thoughts about personal health? 1 "I will not get better soon." 2 "I am a burden to my family." 3 "I have the ability to get well quickly." 4 "I can't stand to look at myself anymore."

A person's belief about personal health helps the nurse to understand the patient's self-concept. The patient who feels he or she has the ability to get well reflects positive thoughts about personal health. A verbalization such as, "I will not get better soon," indicates that the patient is suffering from chronic illnesses. If the patient states that he or she is a burden to his or her family, it indicates negative perceptions about personal health. The patient who states, "I can't stand to look at myself anymore" is indicating that he or she does not have positive thoughts about personal health.

The nurse at an outpatient clinic asks a patient who is Chinese American with newly diagnosed hypertension if he is limiting his sodium intake as directed. The patient does not make eye contact with the nurse but nods his head. What should the nurse do next? A. Ask the patient how much salt he is consuming each day B. Discuss the health implications of sodium and hypertension C. Remind the patient that many foods such as soy sauce contain "hidden" sodium D. Suggest some low-sodium dietary alternatives

A. Ask the patient how much salt he is consuming each day In an Asian culture spoken messages often have little to do with their meanings. It is important for the nurse to clarify how much salt the patient is consuming in his diet.

When action is taken on one's prejudices: A. Discrimination occurs. B. Delivery of culturally congruent care is ensured. C. Effective intercultural communication develops. D. Sufficient comparative knowledge of diverse groups is obtained.

A. Discrimination occurs. Prejudices associate negative permanent characteristics with people who are different from the valued group. When a person acts on these prejudices, discrimination occurs.

When interviewing a Native American patient on admission to the hospital emergency department, which questions are appropriate for the nurse to ask? (Select all that apply.) A. Do you use any folk remedies? B. Do you have a family physician? C. Do you use a Shaman? D. Does your family have a history of alcohol abuse?

A. Do you use any folk remedies? B. Do you have a family physician? C. Do you use a Shaman? Obtain information about folk remedies and cultural healers that the patient uses. Assessment data yield information about the patients beliefs about the illness and the meaning of the signs and symptoms.

A community health nurse is making a healthy baby visit to a new mother who recently emigrated to the United States from Ghana. When discussing contraceptives with the new mom, the mother states that she won't have to worry about getting pregnant for the time being. The nurse understands that the mom most likely made this statement because: A. She won't resume sexual relations until her baby is weaned. B. She is taking the medroxyprogesterone (Depo-Provera) shot. C. Her husband was recently deployed to Afghanistan. D. She has access to free condoms from the clinic.

A. She won't resume sexual relations until her baby is weaned. In some African cultures such as in Ghana and Sierra Leone some women will not resume sexual relations with their husbands until the baby is weaned.

A nurse is teaching a community group of school-aged parents about safety. The most important item to prioritize and explain is how to check the proper fit of a. a bicycle helmet. b. swimming goggles. c. soccer shin guards. d. baseball sliding shorts.

ANS: A Bicycle-related injuries are a major cause of death and disability among children. Proper fit of the helmet helps to decrease head injuries resulting from bicycle accidents. Goggles, shin guards, and sliding shorts are important sports safety equipment and should fit properly, but they do not protect from this leading cause of death.

The nurse is caring for an elderly patient admitted with nausea, vomiting, and diarrhea. Upon completing the health history, which priority concern would require collaboration with social services to address the patient's health care needs? a. The electricity was turned off 2 days ago. b. The water comes from the county water supply. c. A son and family recently moved into the home. d. The home is not furnished with a microwave oven.

ANS: A Electricity is needed for refrigeration of food, and lack of electricity could have contributed to the nausea, vomiting, and diarrhea—potential food poisoning. This discussion about the patient's electrical needs can be referred to social services. The water supply, the increased number of individuals in the home, and not having a microwave may or may not be concerns but do not pertain to the current health care needs of this patient.

Equipment-related accidents are risks in the health care agency. The nurse assesses for this risk when using a. Sequential compression devices. b. A measuring device that measures urine. c. Computer-based documentation. d. A manual medication-dispensing device

ANS: A Sequential compression devices are used on a patient's extremities to assist in prevention of deep vein thrombosis and have the potential to malfunction and harm the patient. Measuring devices used by the nurse to measure urine, computer documentation, and manual dispensing devices can break or malfunction but are not used directly on a patient

The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes. Which question would be the most important to ask this group? a. "Are you able to hear the tornado sirens in your area?" b. "Are you able to read your favorite book?" c. "Are you able to remember the name of the person you just met?" d. "Are you able to open a jar of pickles?"

ANS: A The ability to hear safety alerts and seek shelter is imperative to life safety. Although age-related changes may cause a decrease in sight that affects reading, and although difficulties in remembering short-term information and opening jars as arthritis sets in are important to patients and to those caring for them, being able to hear safety alerts is the priority.

The patient has been diagnosed with a respiratory illness and complains of shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. What is the usual comfort range for most patients? a. 65° F to 75° F b. 60° F to 75° F c. 15° C to 17° C d. 25° C to 28° C

ANS: A The comfort zone for most individuals is the range between 65° F and 75° F (18.3° C to 23.9° C). The other ranges do not reflect the average person's comfort zone.

A confused patient is restless and continues to try to remove his oxygen and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient? a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail. b. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter. c. Disturbed body image: Encourage patient to express concerns about body. d. Caregiver role strain: Identify resources to assist with care.

ANS: A The priority nursing diagnosis is risk for injury. This patient could cause harm to himself by interrupting the oxygen therapy or by damaging the urethra by pulling the urinary catheter out. Before restraining a patient, it is important to implement and exhaust alternatives to restraint. Alternatives can include distraction and providing companionship or supervision. Patients may be moved to a location closer to the nurses' station; trained sitters or family members may be involved. Nurses need to ensure that patients are provided adequate food, liquid, toileting, and relief from pain. If these and other alternatives fail, this individual may need restraints; in this case, an order would need to be obtained for the restraint. This patient may have deficient knowledge; educating the patient about treatments could be considered as an alternative to restraints; however, the nursing diagnosis of highest priority is risk for injury. This scenario does not indicate that the patient has a disturbed body image or that the patient's caregiver is strained.

The nurse is preparing a patient for surgery. The nurse explains that the reason for writing in indelible ink on the surgical site the word "correct" is to a. Distinguish the correct surgical site. b. Label the correct patient. c. Comply with the surgeon's preference. d. Adhere to the correct regulatory standard.

ANS: A The purpose of writing on the surgical site as part of the Universal Protocol from the Joint Commission is to distinguish the correct site on the correct patient and match with the correct surgeon for patient safety and prevention of wrong site surgery. All patients who are having an invasive procedure should receive labeling in many different ways, including the record and patient armbands. Writing in indelible ink may comply with the surgeon's preference, but safety is the driving factor. Although labeling of the site helps to meet regulatory standards, this is not the reason to do this activity—the reason is to keep the patient safe.

The nurse is instructing the student nurse regarding discharge teaching and medications. Which response by the student would indicate that learning has occurred? a. "I need to be precise when teaching a patient about Zyprexa (olanzapine) and Zyrtec (cetirizine)." b. "The medications can be picked up at the pharmacy on the way out of the hospital." c. "I need to be sure to give the patient leftover medications from the medication drawer." d. "I need to remember to teach the patient to take all medications at the same time of the day."

ANS: A Zyprexa and Zyrtec are sound-alike, look-alike medications. Zyprexa is an antipsychotic and Zyrtec an antihistamine; these agents treat two different conditions. Bringing the differences and similarities in spelling and sound to the attention of the patient is important for patient safety. Medications are not distributed by the hospital, and medications do not need to be administered at the same time each day.

A nurse is caring for an adult patient who has had a minor motor vehicle accident. The health history reveals that the patient is currently in the process of obtaining a divorce. Which of the following actions should the nurse take? (Select all that apply.) a. Agree upon and make time for the patient to talk. b. Use active listening skills and therapeutic touch as appropriate. c. Teach stress reduction strategies. d. Inform patient that stressed individuals are more likely to have accidents. e. Agree to witness telephone conversations with separated husband. f. Refer the patient to the nurse's church marriage counselor.

ANS: A, B, C, D Agreeing and making time for conversation, using active listening skills and therapeutic touch, teaching stress reduction strategies, and informing the patient of the risk to health associated with stress are interventions that are within the nurse's scope of practice. Agreeing to witness a telephone conversation could draw the nurse into divorce proceedings when the focus should be on the patient and his health. Referring the patient to the nurse's church counselor without a specific request from the patient may not take into consideration cultural care and could be considered unprofessional. If the patient requested a marriage counselor, a better solution would be to provide a referral to social services that may include a list of possible counselors from which the patient could choose.

The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which of the following should the nurse implement? (Select all that apply.) a. Close all doors. b. Note evacuation routes. c. Note oxygen shut-offs. d. Await direction from the fire department. e. Evacuate everyone from the building. f. Review "Stop, drop, and roll" with the nursing staff

ANS: A, B, C, D Closing all doors helps to contain smoke and fire. Noting the evacuation routes and oxygen shut-offs is important in case the direction to evacuate comes from established channels. Evacuation from the building is determined by the established chain of command or the fire department. Evacuation is done only when necessary. Review of "stop, drop, and roll," although important, is not a priority at this time.

The nurse suspects the possibility of a bioterrorist attack. Which of the following factors is most likely related to this possibility? (Select all that apply.) a. A rapid increase in patients presenting with fever or respiratory or gastrointestinal symptoms b. Lower rates of symptoms among patients who spend time primarily indoors c. Large number of rapidly fatal cases of patients with presenting symptoms d. Shortage of personal protective equipment available from central supply e. An increase in the number of staff calling in sick for their assigned shift f. Patients with symptoms all coming from one location in the area

ANS: A, B, C, F A rapid increase in patients presenting with a specific symptom, lower rates of symptoms among individuals indoors, and large numbers of fatalities with these symptoms all coming from one location are triggers that lead the nurse to suspect a bioterrorist attack. A shortage of personal protective equipment and an increase in the number of staff calling in sick can occur and does occur at times in the hospital setting and may have nothing to do with bioterrorism.

The home health nurse is caring for a patient in the home who is using an electrical infusion device. While visiting the patient, the nurse smells smoke and notices an electrical fire started by this device. The nurse uses the fire extinguisher and fights the fire when (Select all that apply.) a. All occupants have left the home. b. Fire department has been called. c. Fire is confined to one room. d. An exit route is available. e. The correct extinguisher is available. f. The nurse thinks she can use the fire extinguisher.

ANS: A, B, D, E In a home setting, if the nurse is present during a fire, she first should remove all occupants and then should call the fire department by dialing 911. If the fire is small—not confined to just one room (this could be too large for the fire extinguisher), if the correct extinguisher is available, and if the nurse knows (not thinks) that she can use it, the nurse may attempt to extinguish the fire. Utilize PASS (Pull the pin, Aim low, Squeeze the handles, Sweep area from side to side) to activate the extinguisher.

The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which of the following should the patient avoid? (Select all that apply.) a. Watering outdoor plants with a nozzle and hose b. Purchasing light bulbs with strength greater than 60 watts c. Missing yearly eye examinations d. Using bathtubs without safety strips e. Unsecured rugs throughout the home f. Walking to the mailbox in the summer

ANS: A, C, D, E Unsecured rugs, using a hose to water plants, missing yearly eye examinations, and using tubs without safety strips are all items the patient should avoid to help in the prevention of falls in the home. Exercise is beneficial and increases strength, which helps with the prevention of falls. It is important that the home is well lit, so encourage the purchase of bulbs with strength of 60 watts or higher for the home.

The nurse identifies that a patient has received Mylanta (simethicone) instead of the prescribed Pepto-Bismol (bismuth subsalicylate) for the problem of indigestion. The nurse's next intervention is to a. Do nothing, no harm has occurred. b. Assess and monitor the patient. c. Notify the physician, treat and document. d. Complete an incident report.

ANS: B After providing an incorrect medication, assessing and monitoring the patient to determine the effects of the medication is the first step. Notifying the physician and providing treatment would be the best next step. After the patient has stabilized, completing an incident report would be the last step in the process.

A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 100/56, apical pulse 56, respiratory rate 12. Which of the vital signs should be addressed immediately? a. Respiratory rate b. Temperature c. Apical pulse d. Blood pressure

ANS: B Hypothermia is defined as a core body temperature of 95° F or below. Homeless individuals are more at risk for hypothermia owing to exposure to the elements.

The nurse has been called to a hospital room where a patient is using a hair dryer from home. The patient has received an electrical shock from the dryer. The patient is unconscious and is not breathing. What is the best next step? a. Ask the family to leave the room. b. Check for a pulse. c. Begin compressions. d. Defibrillate the patient.

ANS: B In this scenario, the patient is in a hospital setting, and it has been determined that the patient is not conscious and is not breathing. The next step is to check the pulse. An electrical shock can interfere with the heart's normal electrical impulses and can cause arrhythmias. Checking the pulse helps to determine the need for cardiopulmonary resuscitation (CPR) and defibrillation.

The patient presents to the clinic with a family member. The family member states that the patient has been wandering around the house and mumbling. What is the first assessment the nurse should do? a. Ask the patient why she has been wandering around the house. b. Introduce self and ask the patient her name. c. Take the patient's blood pressure, pulse, temperature, and respiratory rate. d. Immediately do a complete head-to-toe neurologic assessment.

ANS: B Introduce self and engage the patient by asking her name to assess orientation; ask the patient why she is visiting the clinic today. Continue the assessment with vital signs and a complete workup, including a neurologic assessment.

An elderly patient presents to the hospital with a history of falls, confusion, and stroke. The nurse determines that the patient is at high risk for falls. Which of the following interventions is most appropriate for the nurse to take? a. Place the patient in restraints. b. Lock beds and wheelchairs when transferring. c. Place a bath mat outside the tub. d. Silence fall alert alarm upon request of family

ANS: B Locking the bed and wheelchairs when transferring will help to prevent these pieces of equipment from moving during transfer and will assist in the prevention of falls. Patients are not automatically placed in restraints. The restraint process consists of many steps, including thorough assessment and exhausting of alternatives. All mats and rugs should be secured to help prevent falls. Silencing alarms upon the request of family is not appropriate and could contribute to an unsafe environment.

A patient with an intravenous infusion requests a new gown after bathing. Which of the following actions is most appropriate? a. Disconnect the intravenous tubing, thread the end through the sleeve of the old gown and through the sleeve of the new gown, and reconnect. b. Thread the intravenous bag and tubing through the sleeve of the old gown and through the sleeve of the new gown without disconnecting. c. Inform the patient that a new gown is not an option while receiving an intravenous infusion in the hospital. d. Call the charge nurse for assistance because linen use is monitored and this is not a common procedure.

ANS: B Procedure-related accidents such as contamination of sterile items can occur in the health care setting. Keeping the intravenous tubing intact without breaks in the system is imperative to decrease the risk of infection while changing a patient's gown and satisfying the patient's request.

The nurse has placed a patient on high-risk alert for falls. Which of the following observations by the nurse would indicate that the patient has an understanding of this alert? a. The patient removes the high alert armband to bathe. b. The patient wears the red nonslip footwear. c. The call light is kept on the bedside table. d. The patient insists on taking a "water" pill on home schedule in the evening.

ANS: B Red nonslip footwear helps to grip the floor and decreases the chance of falling. The communication armband should stay in place and should not be removed, so that all members of the interdisciplinary team have the information about the high risk for falls. Call lights should be kept within reach of the patient. Taking diuretics early in the day assists with decreasing the number of bathroom trips at night—the time when falls are most frequent

The nurse is caring for a hospitalized patient. Which of the following behaviors alerts the nurse to consider the need for restraint? a. The patient refuses to call for help to go to the bathroom. b. The patient continues to remove the nasogastric tube. c. The patient gets confused regarding the time at night. d. The patient does not sleep and continues to ask for items.

ANS: B Restraints are utilized only when alternatives have been exhausted, the patient continues a behavior that can be harmful to himself or others, and the restraint is clinically justified. In this circumstance, continuing to remove a needed nasogastric tube would meet these criteria. Refusing to call for help, although unsafe, is not a reason for restraint. Getting confused at night regarding the time or not sleeping and bothering the staff to ask for items is not a reason for restraint.

The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which of the following nursing diagnoses will the nurse add to the patient's plan of care? a. Risk for poisoning b. Deficient knowledge c. Risk for imbalanced body temperature d. Risk for suffocation

ANS: B The patient needs to understand the purpose of the compression devices and that proper application is needed for them to be effective. The patient has a knowledge need and requires instruction regarding the device and its purpose and procedure. The nurse will intervene by teaching the patient about the sequential compression device and instructing the patient to call for assistance when getting up to go to the bathroom in the future, so that the nurse may assist with removal and proper reapplication. No data support a risk for poisoning, imbalanced body temperature, or suffocation.

The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. The nurse diagnoses risk for injury with a goal of keeping the patient safe in the event of a seizure. Which interventions should the nurse utilize for this patient? (Select all that apply.) a. Teach the family how to insert an oral airway during the seizure. b. Assess the home for items that could harm the patient during a seizure. c. Provide information on how to obtain a Medical Alert bracelet. d. Teach the patient to communicate to the caregiver plans for bathing. e. Discuss with family steps to take if the seizure does not discontinue. f. Demonstrate how to restrain the patient in the event of a seizure.

ANS: B, C, D, E Assessment of the home for safety, providing information on Medical Alert bracelets, teaching the patient to communicate before bathing, and discussing steps to take with status epilepticus are important interventions for the patient who is having seizures. Inserting an airway may harm the patient by forcing the object into the mouth or by biting down on a hard object. Never restrain a patient who is having a seizure, but protect the patient from hitting his body on objects around him to prevent traumatic injury

The nurse is caring for a patient in restraints. Which of the following pieces of information about restraints requires nursing documentation in the medical record? (Select all that apply.) a. The patient states that her gown is soiled and needs changing. b. Attempts to distract the patient with television are unsuccessful. c. The patient has been placed in bilateral wrist restraints at 0815. d. One family member has gone to lunch. e. Bilateral radial pulses present, 2+, hands warm to touch f. Released from restraints, active range-of-motion exercises complete

ANS: B, C, E, F Attempts at alternatives are documented in the medical record, as are type of restraint and time restrained. Assessments related to oxygenation, orientation, skin integrity, circulation, and position are documented, along with release from restraints and patient response. Comments about hygiene or the activities of one family member are not necessarily required in nursing documentation of restraints.

Which of the following concepts are important to utilize when evaluating orders for restraints (Select all that apply.) a. Behaviors that necessitate the use of restraint are part of the nursing plan of care. b. A physician's order is required for restraint and includes a face-to-face evaluation. c. The physician's preference for the format of the order can override agency policy. d. Orders are time limited. Restraints are not ordered prn (as needed). e. It should be specified that restraints are to be removed periodically. f. Restraint orders are time dated and signed by the physician

ANS: B, D, E, F Physicians are responsible for writing restraint orders and conducting face-to-face evaluations, as well as for putting time limits, specifying when to remove, and time dating and signing orders. Behaviors that necessitate the use of restraint not only are part of the nursing documentation but are to be included as part of the order for restraint. The physician's formatting is not a consideration for evaluating restraint orders. Formatting of restraint orders typically follows state rules and regulations, as well as regulatory agency standards.

During the admission assessment, the nurse assesses the patient for fall risk. Which of the following has the greatest potential to increase the patient's risk for falls? a. The patient is 59 years of age. b. The patient walks 2 miles a day. c. The patient takes Benadryl (diphenhydramine) for allergies. d. The patient recently became widowed

ANS: C Benadryl (diphenhydramine) has the potential to cause drowsiness and dizziness as a side effect, thereby increasing the risk for falls. Over 60 is the age typically found on fall assessments that increase the risk for falls. Walking has many benefits, including increasing strength, which would be beneficial in decreasing risk.

The emergency department has been notified of a potential bioterrorist attack. The nurse assigned to the department realizes that the most important task for safety in this situation is to a. Carry out the role and responsibilities of the nurse quickly and efficiently. b. Cluster all patients with the same symptoms to a specific part of the department. c. Determine the biologic agent and manage all patients using Standard Precautions. d. Prepare for post-traumatic stress associated with this bioterrorist attack

ANS: C It is essential to determine the agent and manage all patients who are symptomatic with the suspected or confirmed bioterrorism-related illness using Standard Precautions. For certain diseases, additional precautions may be necessary. Clustering patients may be helpful with staffing and, depending on the illness, may decrease the spread. All nurses every day should carry out their roles quickly and efficiently. Psychosocial concerns are important but are not the first priority at this moment.

The nurse preceptor recognizes the new nurse's ability to determine patient safety risks when which behavior is observed? a. Checking patient identification once every shift b. Multitasking by gathering two patients' medications c. Disposing of used needles in a red needle container d. Raising all four side rails per family request

ANS: C Needles, syringes, and other single-use injection devices should be used once and disposed of in safety red needle containers that will be disposed of properly. Patient identification should be checked multiple times a day, including before each medication, treatment, procedure, blood administration, and transfer, and at the beginning of each shift. Gathering more than one patient's medication increases the likelihood of error. Raising all four side rails is considered a restraint and requires special orders, assessment, and monitoring of the patient

The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. Immediately, the nurse assigns a nursing diagnosis of risk for injury with a goal for the patient to be safe. Which of the following actions should the nurse take first? a. Activate the alarm. b. Extinguish the fire. c. Remove the patient. d. Confine the fire.

ANS: C Nurses use the mnemonic RACE to set priorities in case of fire. All of these interventions are necessary, but this patient is in immediate danger with the fire being over his head and should be rescued and removed from the situation.

The nurse is discussing with a patient's physician the need for restraint. The nurse indicates that alternatives have been utilized. What behaviors would indicate that the alternatives are working? a. The patient continues to get up from the chair at the nurses' station. b. The patient apologizes for being "such a bother." c. The patient folds three washcloths over and over. d. The sitter leaves the patient alone to go to lunch.

ANS: C Offering diversionary activities such as something to hold is a way to keep the hands busy and provides an alternative to restraints. Assigning a room near the nurses' station or a chair at the desk can be an alternative for continuous monitoring. Getting up constantly can be cause for concern. Apologizing is not an alternative to restraints. Having a sitter sit with the patient to keep him occupied can be an alternative to restraints, but the sitter needs to be continuous.

The nurse is presenting an educational session on safety for parents of adolescents. The nurse should include which of the following teaching points? a. Adolescents need unsupervised time with friends two to three times a week. b. Parents and friends should teach adolescents how to drive. c. Adolescents need information about the effects of beer on the liver. d. Adolescents need to be reminded to use seatbelts on long trips

ANS: C Providing information about drugs and alcohol is important because adolescents may choose to participate in risk-taking behaviors. Adolescents need to socialize but need supervision. Parents can encourage and support learning processes associated with driving, but organized classes can help to decrease motor vehicle accidents. Seatbelts should be used all the time.

The nurse knows that four categories of risk have been identified in the health care environment. Which of the following provides the best examples of those risks? a. Tile floors, cold food, scratchy linen, and noisy alarms b. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach c. Wet floors, pinching fingers in door, failure to use lift for patient, and alarms not functioning properly d. Dirty floors, hallways blocked, medication room locked, and alarms set

ANS: C The four categories are falls, patient-inherent accidents, procedure-related accidents, and equipment-related accidents. Wet floors contribute to falls, pinching finger in door is patient inherent, failure to use the lift is procedure related, and an alarm not functioning properly is equipment related. Tile floors and carpeted or dirty floors do not necessarily contribute to falls. Cold food, ice machine empty, and hallways blocked are not patient-inherent issues in the hospital setting but are more of patient satisfaction or infection control issues or fire safety issues. Scratchy linen, unlocked supply cabinet, and medication room locked are not procedure-related accidents. These are patient satisfaction issues and control of supply issues, and are examples of actually following a procedure correctly. Noisy alarms, call light within reach, and alarms set are not equipment-related accidents but are patient satisfaction issues and examples of following a procedure correctly.

A nurse is in the hallway assisting a patient to ambulate and hears an alarm sound. What is the best next step for the nurse to take? a. Seek out the source of the alarm. b. Wait to see if the alarm discontinues. c. Ask another nurse to check on the alarm. d. Continue ambulating the patient

ANS: C The nurse who heard the alarm has a duty to address it even though she is busy with another patient. Ask someone to check on the alarm. The nurse cannot leave the patient in the hallway to look for the source of the alarm and cause a potentially unsafe situation for this patient, but a patient on the unit may have an urgent need. Someone needs to seek out the source of the alarm and address it. Never ignore an alarm. Alarms are in place to maximize the safety of the patient. Waiting to see if an alarm stops may cause a delay in a possible emergency situation

The nurse is completing discharge education for the patient regarding home medications. Which patient behavior is an indication that the patient understands the directions regarding the antibiotic medication? a. The patient nods throughout the educational session. b. The patient reads the medication prescription out loud. c. The patient states, "I will finish the antibiotic in ten days." d. The patient asks where to get the prescription filled.

ANS: C The patient stating the time frame for when the medication will be complete is the best answer. Nodding, reading the prescription out loud, or knowing where to get the prescription filled does not indicate understanding regarding directions for taking the antibiotic.

The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous infusion. The nurse begins to develop a plan to care for the patient. Which nursing intervention should take priority? a. Gather restraint supplies. b. Try alternatives to restraint. c. Assess the patient. d. Call the physician for a restraint order

ANS: C When a patient becomes suddenly confused, the priority is to assess the patient, including checking laboratory test and oxygen status and treating and eliminating the cause of the change in mental status. If interventions and alternatives are exhausted, the nurse working with the physician may determine the need for restraints.

The nurse is caring for a patient with a urinary catheter. After the nurse empties the collection bag and disposes of the urine, the next step is to a. Use alcohol-based gel on hands. b. Wash hands with soap and water. c. Remove eye protection and dispose of in garbage. d. Remove gloves and dispose of in garbage.

ANS: D After disposing of the urine, the first step in removing personal protective equipment is removing gloves and disposing of them properly. In this scenario, the next step would be to remove eye protection followed by hand hygiene. Wash hands if the hands are visibly soiled; otherwise the use of alcohol-based gel is indicated for routine decontamination of hands.

A home health nurse is performing a home assessment for safety. Which of the following comments by the patient would indicate a need for further education? a. "I will schedule an appointment with a chimney inspector next week." b. "Daylight savings is the time to change batteries on the carbon monoxide detector." c. "If I feel dizzy when using the heater, I need to have it inspected." d. "When it is cold outside in the winter, I can warm my car up in the garage."

ANS: D Allowing a car to run in the garage introduces carbon monoxide into the environment and decreases the available oxygen for human consumption. Garages should be opened and not just cracked to allow fresh air into the space and allay this concern. Checking the chimney and heater, changing the batteries on the detector, and following up on symptoms such as dizziness, nausea, and fatigue are all statements that would indicate that the individual has understood the education.

The nurse knows that children in late infancy and toddlerhood are at risk for injury owing to a. Learning to walk. b. Trying to pull up on furniture. c. Being dropped by a caregiver. d. Growing ability to explore and oral activity.

ANS: D Injury is a leading cause of death in children over age 1, which is closely related to normal growth and development because of the child's increased oral activity and growing ability to explore the environment.

The nurse discussed threats to adult safety with a college group. Which of the following statements would indicate understanding of the topic? a. "Our campus is safe; we leave our dorms unlocked all the time." b. "As long as I have only two drinks, I can still be the designated driver." c. "I am young, so I can work nights and go to school with 2 hours' sleep." d. "I guess smoking even at parties is not good for my body."

ANS: D Lifestyle choices frequently affect adult safety. Smoking conveys great risk for pulmonary and cardiovascular disease. It is prudent to secure belongings. When an individual has been determined to be the designated driver, that individual does not consume alcohol, beer, or wine. Sleep is important no matter the age of the individual and is important for rest and integration of learning. The average young adult needs 6 1/2 to 8 hours of sleep each night.

The nurse is precepting a student nurse and is careful to check with the student all components of the medication process. The nurse explains to the student that most errors occur in a. Ordering and transcribing. b. Dispensing and administering. c. Dispensing and transcribing. d. Ordering and administering

ANS: D Most medication errors occur in the ordering and administering stages of the medication process

A patient has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include a. Encouraging visitors in the early evening. b. Placing all four side rails in the "up" position. c. Checking on the patient once a shift. d. Placing a high risk for falls armband on the patient.

ANS: D Placing a high risk for falls armband on the patient encourages communication among the whole interdisciplinary team. Anyone who interacts with the patient should see this armband, understand its meaning, and assist the patient as necessary. The timing of visitors would not affect falls. All four side rails are considered a restraint and can contribute to falling. Individuals on high risk for fall alerts should be checked frequently, at least every hour

The nurse is providing information regarding safety and accidental poisoning to a grandmother who will be taking custody of a 1-year-old grandchild. Which of the following comments would indicate that the grandmother needs further instruction? a. "The number for poison control is 800-222-1222." b. "Never induce vomiting if my grandchild drinks bleach." c. "I should call 911 if my grandchild loses consciousness." d. "If my grandchild eats a plant, I should provide syrup of ipecac."

ANS: D Syrup of ipecac to induce vomiting after ingestion of a poison has not been proven effective in preventing poisoning. This medication should not be administered to the child. The poison control number is 800-222-1222. After a caustic substance such as bleach has been drunk, do not induce vomiting. This can cause further burning and injury as the medication is eliminated. Loss of consciousness associated with poisoning requires calling 911.

The older patient presents to the emergency department after stepping in front of a car at a crosswalk. After the patient has been triaged, the nurse interviews the patient. Which of the following comments would require follow-up by the nurse? a. "I try to exercise, so I walk that block almost every day." b. "I waited and stepped out when the traffic sign said go." c. "The car was going too fast, the speed limit is 20." d. "I was so surprised; I didn't see or hear the car coming."

ANS: D The patient did not see or hear the car coming. As patients age, sensory impairment can increase the risk for injury. This statement by the patient would require follow-up by the nurse. The patient needs hearing and eye examinations. Exercise is important at every stage of development. The patient seemed to comprehend how to cross an intersection correctly and was able to determine the speed of the car.

The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. These data would help to support a nursing diagnosis of a. Risk for poisoning. b. Knowledge deficit. c. Impaired home maintenance. d. Risk for injury.

ANS: D The patient's behaviors support the nursing diagnosis of risk for injury. The patient is confused, is pulling at the intravenous line, and is trying to climb out of bed. Injury could result if the patient falls out of bed or begins to bleed from a pulled line. Nothing in the scenario indicates that this patient lacks knowledge or is at risk for poisoning. Nothing in the scenario refers to the patient's home maintenance

A 46-year-old woman from Bosnia came to the United States 6 years ago. Although she did not celebrate Christmas when she lived in Bosnia, she celebrates Christmas with her family now. This woman has experienced assimilation into the culture of the United States because she: A. Chose to be bicultural. B Adapted to and adopted the American culture. C. Had an extremely negative experience with the American culture. D. Gave up part of her ethnic identity in favor of the American culture.

B Adapted to and adopted the American culture. Assimilation results when an individual gradually adopts and incorporates the characteristics of the dominant culture.

Which of the following best represents the dominant values in American society on individual autonomy and self-determination? A. Physician orders B. Advance directive C. Durable power of attorney D. Court-appointed guardian

B. Advance directive Informed consent and advance directives protect the right of the individual to know and make decisions ensuring continuity of individual autonomy and self-determination.

During their clinical post-conference meeting, several nursing students were discussing their patients with their instructor. One student from a middle-class family shared that her patient was homeless. This is an example of caring for a patient from a different: A. Ethnicity. B. Culture. C. Heritage. D. Religion.

B. Culture. Culture is the context in which groups of people interpret and define their experiences relevant to life transitions. This includes events such as birth, illness, and dying. It is the system of meanings by which people make sense of their experiences.

A registered nurse is admitting a patient of French heritage to the hospital. Which question asked by the nurse indicates that the nurse is stereotyping the patient? A. "What are your dietary preferences?" B. "What time do you typically go to bed?" C. "Do you bathe and use deodorant more than one time a week?" D. "Do you have any health issues that we should know about?"

C. "Do you bathe and use deodorant more than one time a week?" Nurses need to avoid stereotypes or unwarranted generalizations about any particular group that prevents further assessment of the individual's unique characteristics.

A nursing student is taking postoperative vital signs in the postanesthesia care unit. She knows that some ethnic groups are more prone to genetic disorders. Which of the following patients is most at risk for developing malignant hypertension? A. Ashkenazi Jew B. Chinese American C. African American D. Filipino

C. African American Certain genetic disorders are linked with specific ethnic groups such as malignant hypertension among African Americans.

A female Jamaican immigrant has been late to her last two clinic visits, which in turn had to be rescheduled. The best action that the nurse could take to prevent the patient from being late to her next appointment is: A. Give her a copy of the city bus schedule. B. Call her the day before her appointment as a reminder to be on time. C. Explore what has prevented her from being at the clinic in time for her appointment. D. Refer her to a clinic that is closer to her home.

C. Explore what has prevented her from being at the clinic in time for her appointment. Present-time orientation is in conflict with the dominant organizational norm in health care that emphasizes punctuality and adherence to appointments. Nurses need to expect conflicts and make adjustments when caring for ethnic groups.

A nursing student is doing a community health rotation in an inner-city public health department. The student investigates sociodemographic and health data of the people served by the health department, and detects disparities in health outcomes between the rich and poor. This is an example of a(n): A. Illness attributed to natural and biological forces. B. Creation of the student's interpretation and descriptions of the data. C. Influence of socioeconomic factors in morbidity and mortality. D. Combination of naturalistic, religious, and supernatural modalities.

C. Influence of socioeconomic factors in morbidity and mortality. Health disparity populations are populations that have a significant increased incidence or prevalence of disease or that have increased morbidity, mortality, or survival rates compared to the health status of the general population.

Which of the following is required in the delivery of culturally congruent care? A. Learning about vast cultures B. Motivation and commitment to caring C. Influencing treatment and care of patients D. Acquiring specific knowledge, skills, and attitudes

D. Acquiring specific knowledge, skills, and attitudes Specific knowledge, skills, and attitudes are required in the delivery of culturally congruent care.

To enhance their cultural awareness, nursing students need to make an in-depth self-examination of their own: A. Motivation and commitment to caring. B. Social, cultural, and biophysical factors. C. Engagement in cross-cultural interactions. D. Background, recognizing her biases and prejudices.

D. Background, recognizing her biases and prejudices. Cultural awareness is an in-depth self-examination of one's own background, recognizing biases and prejudices and assumptions about other people.

A 6-month-old child from Guatemala was adopted by an American family in Indiana. The child's socialization into the American midwestern culture is best described as: A. Assimilation. B. Acculturation. C. Biculturalism. D. Enculturation.

D. Enculturation. Socialization into one's primary culture as a child is known as enculturation.

Culture strongly influences pain expression and need for pain medication. However, cultural pain is: A. Not expressed verbally or physically. B. Expressed only to others from a similar culture. C. Usually more intense than physical pain. D. Suffered by a patient whose valued way of life is disregarded by practitioners.

D. Suffered by a patient whose valued way of life is disregarded by practitioners. Patients suffer cultural pain when health care providers disregard values or cultural beliefs.