MCC block 1 week 4 fundamentals Q/A chps ( 4, 5, 21, 23, 26, 46)

A nurse uses Malsows Hierarchy of basic human needs to direct care for patients on an intensive care unit. For which nursing activities is this approach most useful? A) making accurate nursing diagnoses B) Establishing priorities of care C) Communicating concerns more concisely D) integrating science into nursing

B, Maslow's hierarchy of basic human needs is useful for establishing priorities of care.

The nurse practitioner sees patients in a community clinic that is located in a predominately White neighborhood. After performing assessments on the majority of the patients visiting the clinic, the nurse notes that many of the minority groups living within the neighborhood have lost the cultural characteristics that made them different. What is the term for this process? A) Cultural assimilation B) Cultural imposition C) Culture shock D) Ethnocentrism

a. When minority groups live within a dominant group, many members lose the cultural characteristics that once made them different in a process called assimilation. Cultural imposition occurs when one person believes that everyone should conform to his or her own belief system. Culture shock occurs when a person is placed in a different culture perceived as strange, and ethnocentrism is the belief that the ideas, beliefs, and practices of one's own cultural group are best, superior, or most preferred to those of other groups.

A nurse is using the circular technique to palpate the breast of a woman during an assessment. The nurse uses the pads of the first three fingers to gently compress the breast tissue against the chest wall. How would the nurse proceed with the palpation? A) Start at the tail of Spence and move in increasing smaller circles. B) Start at the outer edge of the breast and palpate up and down the breast. C) Work in a counterclockwise direction and palpate from the periphery toward the areola. D) Start at the inner edge of the breast and palpate up and down the breast.

a. When palpating the breast, the nurse would palpate each quadrant of each breast in a systematic method using either the circular, wedge, or vertical strip technique and then use the pads of the first three fingers to gently compress the breast tissue against the chest wall. In the circular method, the nurse would start at the tail of Spence and move in increasing smaller circles. In the wedge method, the nurse would work in a clockwise direction and palpate from the periphery toward the areola. In the vertical strip method, the nurse would start at the outer edge of the breast and palpate up and down the breast.

Following a fall that left an older adult temporarily bedridden, the nurse is using the SPICES assessment tool to evaluate for cascade iatrogenesis. Which are correct aspects of this tool? Select all that apply. A) S—Senility B) P—Problems with feeding C) I—Irritability D) C—Confusion E) E—Edema of the legs F) S—Skin breakdown

b, d, f. The SPICES acronym is used to identify common problems in older adults and stands for: S—Sleep disorders P—Problems with eating or feeding I—Incontinence C—Confusion E—Evidence of falls S—Skin breakdown

During a physical assessment, a nurse inspects a patient's abdomen. What assessment technique would the nurse perform next? A) Percussion B) Palpation C) Auscultation D) Whichever is more comfortable for the patient

c. When assessing the abdomen, the sequence is inspection, auscultation, percussion, and palpation. Auscultation follows inspection because percussion and palpation stimulate bowel sounds.

A nurse working in an "Aging in Place" facility interviews a married couple in their late seventies. Based on Duvall's Developmental Tasks of Families, which developmental task would the nurse assess for this couple? A) Maintenance of a supportive home base B)Strength of the marital relationship C)Ability to cope with loss of energy and privacy D)Adjustment to retirement years

d. The developmental tasks of the family with older adults are to adjust to retirement and possibly to adjust to the loss of a spouse and loss of independent living. Maintaining a supportive home base and strengthening marital relationships are tasks of the family with adolescents and young adults. Coping with loss of energy and privacy is a task of the family with children.

When assessing a patient's breath sounds, the nurse hears a high-pitched continuous sound. What does this finding indicate? A) Secretions in the lungs B) Fluid in the airways C) Normal breath sounds D) Narrowed airways

d. Wheezes are musical or squeaking high-pitched, continuous sounds heard as air passes through narrowed airways. Rhonchi are low-pitched, continuous sounds with a snoring quality that occur when air passes through secretions. Crackles are bubbling, cracking or popping, low- to high-pitched, discontinuous sounds that occur when air passes through fluid in the airways.

When inspecting the skin of a patient who has cirrhosis of the liver, the nurse notes that the skin has a yellow tint. What would the nurse document related to this finding? A) Jaundice B) Cyanosis C) Erythema D) Pallor

a. Jaundice is a yellowish skin color caused by liver disease. Cyanosis is a bluish skin color caused by a cold environment or decreased oxygenation. Erythema is a reddish color caused by blushing, alcohol intake, fever, injury trauma, or infection. Pallor is a paleness caused by anemia or shock.

A nurse caring for older adults in a long-term care facility encourages an older adult to reminisce about past life events. This life review, according to Erikson, is demonstrating what developmental stage of the later adult years? A) Ego integrity B) Generativity C) Intimacy D) Initiative

a. Reminiscence during the older years of a person's life provides a sense of fulfillment and purpose (ego integrity). Generativity is a developmental stage of the middle adult years. Intimacy is a developmental task of the adolescent to adult years, and initiative is a task of the preschooler to early school-age years.

A nurse is caring for patients admitted to a long-term care facility. Which nursing actions are appropriate based on the religious beliefs of the individual patients? Select all that apply. A) The nurse dietitian asks a Buddhist if he has any diet restrictions related to the observance of holy days. B) A nurse asks a Christian Scientist who is in traction if she would like to try nonpharmacologic pain measures. C) A nurse administering medications to a Muslim patient avoids touching the patient's lips D) A nurse asks a Roman Catholic woman if she would like to attend the local Mass on Sunday. E) The nurse is careful not to schedule treatment and procedures on Saturday for a Hindu patient. F) The nurse consults with the medicine man of a Native American patient and incorporates his suggestions into the care plan.

a, b, d, f. The nurse dietitian should ask a Buddhist if he has any diet restrictions related to the observance of holy days. Since Catholic Scientists avoid the use of pain medications, the nurse should ask a Christian Scientist who is in traction if she would like to try nonpharmacologic pain measures. A nurse administering medications to a Hindu woman avoids touching the patient's lips. A nurse should ask a Roman Catholic woman if she would like to attend the local Mass on Sunday. The nurse is careful not to schedule treatment and procedures on Saturday for a Jewish patient due to observance of the Sabbath. The nurse would appropriately consult with the medicine man of a Native American patient and incorporates his or her suggestions into the care plan.

A nurse researcher studies the effects of genomics on current nursing practice. Which statements identify genetic principles that will challenge nurses to integrate genomics in their research, education, and practice? Select all that apply. A) Genetic tests plus family history tools have the potential to identify people at risk for diseases. B) Pharmacogenetic tests can determine if a patient is likely to have a strong therapeutic response to a drug or suffer adverse reactions from the medication. C) Evidence-based review panels are in place to evaluate the possible risks and benefits related to genetic testing. D) Valid and reliable national data are available to establish baseline measures and track progress toward targets. E) Genetic variation can either accelerate or slow the metabolism of many drugs. F) It is beyond the role of the nurse to answer questions and discuss the impact of genetic findings on health and illness.

a, b, e. In the very near future, all health care providers will be challenged to integrate genomics into their research, education, and practice (Healthy People 2020, 2018). Genetic tests plus family history tools have the potential to identify people at risk for diseases. Pharmacogenetics is the study of how genetic variation affects a person's response to drugs. Pharmacogenetic tests can determine if a patient is likely to have a strong therapeutic response to a drug or suffer adverse reactions from the medication. Genetic variation can either accelerate or slow the metabolism of many drugs (see Chapter 29). Two emerging challenges exist related to genomic discoveries: (1) the need for evidence-based review panels to thoroughly evaluate the possible benefits and harms related to the expanding number of genetic tests and family health history tools; and (2) the need for valid and reliable national data to establish baseline measures and track progress toward targets (Healthy People 2020, 2018). Nurses must be prepared to answer questions and discuss the impact of genetic findings on health and illness.

A nurse caring for older adults in a skilled nursing home observes physical changes in patients that are part of the normal aging process. Which changes reflect this process? Select all that apply. A) Fatty tissue is redistributed. B) The skin is drier and wrinkles appear. C) Cardiac output increases. D) Muscle mass increases. E) Hormone production increases. F) Visual and hearing acuity diminishes.

a, b, f. Physical changes occurring with aging include these: fatty tissue is redistributed, the skin is drier and wrinkles appear, and visual and hearing acuity diminishes. Cardiac output decreases, muscle mass decreases, and hormone production decreases, causing menopause or andropause.

The nurse caring for infants in a hospital nursery knows that newborns continue to grow and develop according to individual growth patterns and developmental levels. Which terms describe these patterns? Select all that apply. A) Orderly B) Simple C) Sequential D) Unpredictable E) Differentiated F) Integrated

a, c, e, f. Growth and development are orderly and sequential, as well as continuous and complex. Growth and development follow regular and predictable trends, and are both differentiated and integrated.

A nurse caring for culturally diverse patients in a health care provider's office is aware that patients of certain cultures are more prone to specific disease states than the general population. Which patients would the nurse screen for diabetes mellitus based on the patient's race? Select all that apply. A) A Native American patient B) An African-American patient C) An Alaska Native D) An Asian patient E) A White patient F) A Hispanic patient

a, c, e, f. Native Americans, Alaska Natives, Hispanics, and Whites are more prone to developing diabetes mellitus. African Americans are prone to hypertension, stroke, sickle cell anemia, lactose intolerance, and keloids. Asians are prone to hypertension, liver cancer, thalassemia, and lactose intolerance.

A nurse caring for patients in a long-term care facility is performing a functional assessment of a new patient. Which questions would the nurse ask? Select all that apply. A) Are you able to dress yourself? B) Do you have a history of smoking? C) What is the problem for which you are seeking care? D) Do you prepare your own meals? E) Do you manage your own finances? F) Whom do you rely on for support?

a, d, e. A functional health assessment focuses on the effects of health or illness on a patient's quality of life, including the strengths of the patient and areas that need to improve. The nurse would assess the patient's ability to perform ADLs and IADLs such as dressing, grooming, preparing meals, and managing finances. A history of smoking is a lifestyle factor and the chief complaint is the reason for seeking health care, both assessed during the health history. Social networks and support personnel are assessed as psychosocial factors related to the health history.

A nurse is teaching parents of preschoolers what type of behavior to expect from their children based on developmental theories. Which statements describe this stage of development? Select all that apply. A) According to Freud, the child is in the phallic stage. B) According to Erikson, the child is in the trust versus mistrust stage. C) According to Havighurst, the child is learning to get along with others. D) According to Fowler, the child imitates religious behavior of others. E) According to Kohlberg, the child defines satisfying acts as right. F)According to Havighurst, the child is achieving gender-specific roles.

a, d, e. According to Freud, the child is in the phallic stage. According to Fowler, the child imitates religious behavior of others. According to Kohlberg, the child defines satisfying acts as right. According to Erikson, the child is in the initiative versus guilt stage. According to Havighurst, the child is learning sex differences, forming concepts, and getting ready to read. According to Havighurst, the adolescent, not the preschooler, is achieving gender-specific social roles.

A nurse who is working with women in a drop-in shelter studies Carol Gilligan's theory of morality in women to use when planning care. According to Gilligan, what is the motivation for female morality? A) Law and justice B) Obligations and rights C) Response and care D) Order and selfishness

c. In Gilligan's theory, men and women have different ways of looking at the world. Men are more likely to associate morality with obligations, rights, and justice, whereas women are more likely to see moral requirements emerging from the needs of others within the context of a relationship. This moral orientation of women is called the ethic of care, which develops through three levels: Level 1—Preconventional: Selfishness, Level 2—Conventional: Goodness, Level 3—Postconventional: Nonviolence.

In order to provide culturally competent care, nurses must be alert to factors inhibiting sensitivity to diversity in the health care system. Which nursing actions are examples of cultural imposition? Select all that apply. A) A hospital nurse tells a nurse's aide that patients should not be given a choice whether or not to shower or bathe daily. B) A nurse treats all patients the same whether or not they come from a different culture. C) A nurse tells another nurse that Jewish diet restrictions are just a way for them to get a special tray of their favorite foods. D) A Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. E) A nurse directs interview questions to an older adult's daughter even though the patient is capable of answering them. F) A nurse refuses to care for a married gay man who is HIV positive because she is against same-sex marriage.

a, d. Cultural imposition occurs when a hospital nurse tells a nurse's aide that patients should not be given a choice whether or not to shower or bathe daily, and when a Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. Cultural blindness occurs when a nurse treats all patients the same whether or not they come from a different culture. Culture conflict occurs when a nurse ridicules a patient by telling another nurse that Jewish diet restrictions are just a way for Jewish patients to get a special tray of their favorite foods. When a nurse refuses to respect an older adult's ability to speak for himself or herself, or if the nurse refuses to treat a patient based on that patient's sexual orientation, the nurse is engaging in stereotyping.

A nurse performs an assessment of a family consisting of a single mother, a grandmother, and two children. Which interview questions directed to the single mother could the nurse use to assess the affective and coping family function? Select all that apply. A) Who is the person you depend on for emotional support? B) Who is the breadwinner in your family? C) Do you plan on having any more children? D)Who keeps your family together in times of stress? E)What family traditions do you pass on to your children? F)Do you live in an environment that you consider safe?

a, d. The five major areas of family function are physical, economic, reproductive, affective and coping, and socialization. Asking who provides emotional support in times of stress assesses the affective and coping function. Assessing the breadwinner focuses on the economic function. Inquiring about having more children assesses the reproductive function, asking about family traditions assesses the socialization function, and checking the environment assesses the physical function.

A school nurse is studying Kohlberg's theory of moral development to prepare a parent discussion addressing the problem of bullying. According to Kohlberg, which factor initially influences the moral development of children? A) Parent/caregiver-child communications B) Societal rules and regulations C) Social and religious rules D) A person's beliefs and values

a. A child's beginnings of moral development result from caregiver-child communications during the early childhood years, as the young child tries to please his or her parents and other caregivers. Kohlberg's stages of moral development begin in childhood but may develop well into adolescence and adulthood. Rules and regulations established by society are eventually challenged and evaluated as a person either accepts societal rules into his or her own internal set of values or rejects them.

The school nurse uses the principles and theories of growth and development when planning programs for high school students. According to Havighurst, what is a developmental task for this age group? A) Finding a congenial social group B) Developing a conscience, morality, and a scale of values C) Achieving personal independence D) Achieving a masculine or feminine gender role

a. A child's beginnings of moral development result from caregiver-child communications during the early childhood years, as the young child tries to please his or her parents and other caregivers. Kohlberg's stages of moral development begin in childhood but may develop well into adolescence and adulthood. Rules and regulations established by society are eventually challenged and evaluated as a person either accepts societal rules into his or her own internal set of values or rejects them.

A nurse is caring for an 80-year-old patient who is living in a long-term care facility. To help this patient adapt to the present circumstances, the nurse is using reminiscence as therapy. Which question would encourage reminiscence? A) "Tell me about how you celebrated Christmas when you were young." B) "Tell me how you plan to spend your time this weekend." C) "Did you enjoy the choral group that performed here yesterday? D) "Why don't you want to talk about your feelings?"

a. Asking questions about events in the past can encourage the older adult to relive and restructure life experiences. Asking about a recent event, upcoming plans, or feelings would be unlikely to encourage reminiscence.

After having an abortion, a patient tells the visiting nurse, "I shouldn't have had that abortion because I'm Catholic, but what else could I do? I'm afraid I'll never get close to my mother or back in the Church again." She then talks with her priest about this feeling of guilt. Which evaluation statement shows a solution to the problem? A) Patient states, "I wish I had talked with the priest sooner. I now know God has forgiven me, and even my mother understands." B) Patient has slept from 10 PM to 6 AM for three consecutive nights without medication. C) Patient has developed mutually caring relationships with two women and one man. D) Patient has identified several spiritual beliefs that give purpose to her life.

a. Because this patient's nursing diagnosis is Spiritual Distress: Guilt, an evaluative statement that demonstrates diminished guilt is necessary. Only answer a directly deals with guilt.

A 2-year-old grabs a handful of cake from the table and stuffs it in his mouth. According to Freud, what part of the mind is the child satisfying? A) Id B) Superego C) Ego D) Unconscious mind

a. Freud defined the id as the part of the mind concerned with self-gratification by the easiest and quickest available means.

A nurse is practicing community-based nursing in a mobile health clinic. What typically is the central focus of this type of nursing care? A) Individual and family health care needs B) Populations within the community C)Local health care facilities D) Families in crisis

a. In contrast to community health nursing, which focuses on populations within a community, community-based nursing is centered on individual and family health care needs. Community-based nurses may help families in crisis and work in health care facilities, but these are not the focus of community-based nursing.

A nurse auscultates the thorax and lungs and hears coarse, low-pitched, continuous sounds on expiration. When the patient coughs, the sounds clear up somewhat. What would be the nurse's response to this finding? A) Document and report the finding of abnormal Rhonchi breath sounds B) Document the finding of normal bronchovesicular breath sounds C) Document and report the finding of abnormal stridor breath sounds D) Document the finding of normal bronchial sounds

a. Rhonchi breath sounds are abnormal low-pitched, continuous sounds auscultated during inspiration and expiration that signify air passing through or around secretions. Bronchovesicular breath sounds are normal sounds heard on inspiration and expiration. Stridor are harsh, loud, high-pitched sounds auscultated on inspiration that signal narrowing of the upper airway or presence of a foreign body in the airway. Bronchial sounds are normal blowing, hollow sounds, auscultated over the larynx and trachea.

A nurse performing a spiritual assessment collects assessment data from a patient who is homebound and unable to participate in religious activities. Which type of spiritual distress is this patient most likely experiencing? A) Spiritual Alienation B) Spiritual Despair C) Spiritual Anxiety D) Spiritual Pain

a. Spiritual Alienation occurs when there is a "separation from the faith community." Spiritual Despair occurs when the patient is feeling that no one (not even God) cares. Spiritual Anxiety is manifested by a challenged belief and value system, and Spiritual Pain may occur when a patient is unable to accept the death of a loved one.

A nurse is telling a new mother from Africa that she shouldn't carry her baby in a sling created from a large rectangular cloth. The African woman tells the nurse that everyone in Mozambique carries babies this way. The nurse believes that bassinets are safer for infants. This nurse is displaying what cultural bias? A) Cultural imposition B) Clustering C) Cultural competency D) Stereotyping

a. The nurse is trying to impose her belief that bassinets are preferable to baby slings on the African mother—in spite of the fact that African women have safely carried babies in these slings for years.

Which actions would the nurse perform when using the technique of palpation during the physical assessment of a patient? Select all that apply. A) The nurse compares the patient's bilateral body parts for symmetry. B) The nurse takes a patient's pulse. C) The nurse touches a patient's skin to test for turgor. D) The nurse checks a patient's lymph nodes for swelling. E) The nurse taps a patient's body to check the organs. F) The nurse uses a stethoscope to listen to a patient's heart sounds.

b, c, d. During palpation, the nurse uses the sense of touch to take a pulse, test for skin turgor, and check lymph nodes. With inspection, a comparison of bilateral body parts is necessary for recognizing abnormal findings. During percussion, the fingertips are used to tap the body over body tissues to produce vibrations and sound waves. The characteristics of the sounds produced are used to assess the location, shape, size, and density of tissues. Auscultation is the act of listening with a stethoscope to sounds produced within the body.

The nurse places a patient in the dorsal recumbent position during a physical assessment. Which nursing actions could the nurse perform with the patient in this position? Select all that apply. A) Assessing the abdomen B) Taking peripheral pulses C) Performing a breast examination D) Auscultating the heart E) Assessing vital signs F) Assessing balance and gait

b, c, d. In the dorsal recumbent position, the patient lies on the back with legs separated, knees flexed, and soles of the feet on the bed. It is used to assess the head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses. It should not be used for abdominal assessment because it causes contraction of the abdominal muscles. Taking vital signs should be done in the sitting position, and assessing balance and gait is done in the standing position.

A nurse is caring for older adults in a senior adult day services (ADS) center. Which findings related to the normal aging process would the nurse be likely to observe? Select all that apply. A) Patients with wrinkles on the face and arms due to increased skin elasticity B) A patient with skin pigmentation caused by exposure to sun over the years C) A patient with thinner toenails with a bluish tint to the nail beds D) A patient healing from a hip fracture that occurred due to porous and brittle bones E) Bruising on a patient's forearms due to fragile blood vessels in the dermis F) Decreased patient voiding due to increased bladder capacity

b, d, e. Exposure to sun over the years can cause older adults' skin to be pigmented. Bone demineralization occurs with aging, causing bones to become porous and brittle, making fractures more common. The blood vessels in the dermis become more fragile, causing an increase in bruising and purpura. Wrinkling and sagging of skin occur with decreased (not increased) skin elasticity. Older adults' toenails may become thicker (not thinner), with a yellowish tint (not a bluish tint) to the nail beds. Voiding becomes more frequent in older adults because bladder capacity decreases by 50%.

The nurse is prioritizing nursing care for a patient in a long-term care facility. Which examples of nursing interventions help meet physiologic needs? Select all that apply A) Preventing falls in the facility B) Changing a patient's oxygen tank C)Providing materials for a patient who likes to draw D)Helping a patient eat his dinner E)Facilitating a visit from a spouse F)Referring a patient to a cancer support group.

b, d. Physiologic needs—oxygen, water, food, elimination, temperature, sexuality, physical activity, and rest—must be met at least minimally to maintain life. Providing food and oxygen are examples of interventions to meet these needs. Preventing falls helps meet safety and security needs; providing art supplies may help meet self-actualization needs; facilitating visits from loved ones helps meet self-esteem needs; and referring a patient to a support group helps meet love and belonging needs.

A nurse is assessing a patient's eyes for accommodation. What actions would the nurse perform during this test? Select all that apply. A) Bring a penlight from the side of the patient's face and briefly shine the light on the pupil. B) Hold a forefinger, a pencil, or other straight object about 10 to 15 cm (4 to 6 in) from the bridge of the patient's nose. C) Hold a finger about 6 to 8 in from the bridge of the patient's nose. D) Darken the room. E) Ask the patient to look straight ahead. F) Ask the patient to first look at a close object, then at a distant object, then back to the close object.

b, f. To test accommodation the nurse would hold the forefinger, a pencil, or other straight object about 10 to 15 cm (4 to 6 in) from the bridge of the patient's nose. Then the nurse would ask the patient to first look at the object, then at a distant object, then back to the object being held. The pupil normally constricts when looking at a near object and dilates when looking at a distant object. To test for convergence, the nurse would darken the room and ask the patient to look straight ahead. The nurse would then bring the penlight from the side of the patient's face and briefly shine the light on the pupil, observing the reaction. When testing convergence the nurse would hold a finger about 6 to 8 in from the bridge of the patient's nose and move it toward the patient's nose.

A nurse caring for patients in a primary care setting refers to Erikson's theory that middle adults who do not achieve their developmental tasks may be considered to be in stagnation. Which patient statement is an example of this finding? A) "I am helping my parents move into an assisted-living facility." B) "I spend all of my time going to the doctor to be sure I am not sick." C) "I have enough money to help my son and his wife when they need it." D) "I earned this gray hair and I like it!"

b. According to Erikson (1963), the middle adult is in a period of generativity versus stagnation. The tasks are to establish and guide the next generation, accept middle-age changes, adjust to the needs of aging parents, and reevaluate goals and accomplishments. Middle adults who do not reach generativity tend to become overly concerned about their own physical and emotional health needs.

The nurse caring for patients postoperatively uses careful hand hygiene and sterile techniques when handling patients. Which of Maslow's basic human needs is being met by this nurse? A) Physiologic B) Safety and security C)Self-esteem D)Love and belonging

b. By carrying out careful hand hygiene and using sterile technique, nurses provide safety from infection. An example of a physiologic need is clearing a patient's airway. Self-esteem needs may be met by allowing an older adult to talk about a past career. An example of helping meet a love and belonging need is contacting a hospitalized patient's family to arrange a visit.

A nurse who is comfortable with spirituality is caring for patients who need spiritual counseling. Which nursing action would be most appropriate for these patients? A) Calling the patient's own spiritual adviser first B) Asking whether the patient has a spiritual adviser the patient wishes to consult C) Attempting to counsel the patient and, if unsuccessful, making a referral to a spiritual adviser D) Advising the patient and spiritual adviser concerning health options and the best choices for the patient

b. Even when a nurse feels comfortable discussing spiritual concerns, the nurse should always check first with patients to determine whether they have a spiritual adviser they would like to consult. Calling the patient's own spiritual adviser may be premature if it is a matter the nurse can handle. The other two options deny patients the right to speak privately with their spiritual adviser from the outset, if this is what they prefer.

The nurse caring for families in a free health care clinic identifies psychosocial risk factors for altered family health. Which example describes one of these risk factors? A) The family does not have dental care insurance or resources to pay for it. B) Both parents work and leave a 12-year-old child to care for his younger brother. C) Both parents and their children are considerably overweight. D)The youngest member of the family has cerebral palsy and needs assistance from community services.

b. Inadequate childcare resources is a psychosocial risk factor. Not having access to dental care and obese family members are lifestyle risk factors. Having a family member with birth defects is a biologic risk factor.

A nurse is using the ESFT model to understand a patient's conception of a diagnosis of chronic obstructive pulmonary disease (COPD). Which interview question would be MOST appropriate to assess the E aspect of this model—Explanatory model of health and illness? A) How do you get your medications? B) How does having COPD affect your lifestyle? C) Are you concerned about the side effects of your medications? D) Can you describe how you will take your medications?

b. The ESFT model guides providers in understanding a patient's explanatory model (a patient's conception of her or his illness), social and environmental factors, and fears and concerns, and also guides providers in contracting for therapeutic approaches. Asking the questions: "How does having COPD affect your lifestyle?" explores the explanatory model, "How do you get your medications?" refers to the social and environmental factor, "Are you concerned about the side effects of your medications?" addresses fears and concerns, and "Can you describe how you will take your medications?" involves therapeutic contracting.

A young Hispanic mother comes to the local clinic because her baby is sick. She speaks only Spanish and the nurse speaks only English. What is the appropriate nursing intervention? A) Use short words and talk more loudly. B) Ask an interpreter for help. C)Explain why care can't be provided. D) Provide instructions in writing.

b. The nurse should ask an interpreter for help. Many facilities have a qualified interpreter who understands the health care system and can reliably provide assistance. Using short words, talking loudly, and providing instructions in writing will not help the nurse communicate with this patient. Explaining why care can't be provided is not an acceptable choice because the nurse is required to provide care; also, since the patient doesn't speak English, she won't understand what the nurse is saying.

An RN working in a hospital setting is responsible for patient assessment. For which patient would the nurse perform a focused assessment? A) A patient newly admitted to the unit B) A patient with diabetes who develops secondary hypertension C) A patient who presents with signs of acute respiratory distress syndrome (ARDS) D) A patient who is recovering from abdominal surgery with no complications

b. The nurse would perform a focused assessment for a patient with diabetes who develops secondary hypertension. A patient newly admitted to the unit would require a comprehensive assessment. The nurse would perform an emergency assessment on a patient who presents with signs of ARDS. A patient who is recovering from abdominal surgery with no complications would receive an ongoing partial assessment to ensure no complications occur.

A nurse is assessing the level of consciousness of a patient who sustained a head injury in a motor vehicle accident. The nurse notes that the patient appears drowsy most of the time but makes spontaneous movements. The nurse is able to wake the patient by gently shaking him and calling his name. What level of consciousness would the nurse document? A) Awake and alert B) Lethargic C) Stuporous D) Comatose

b. The stages of consciousness are: Awake and alert: fully awake; oriented to person, place, and time; responds to all stimuli, including verbal commands. Lethargic: appears drowsy or asleep most of the time but makes spontaneous movements; can be aroused by gentle shaking and saying patient's name. Stuporous: unconscious most of the time; has no spontaneous movement; must be shaken or shouted at to arouse; can make verbal responses, but these are less likely to be appropriate; responds to painful stimuli with purposeful movements. Comatose: cannot be aroused, even with use of painful stimuli; may have some reflex activity (such as gag reflex); if no reflexes present, is in a deep coma.

A nurse is assessing a patient's eyes for extraocular movements. Which action correctly describes a step the nurse would take when performing this test? A) Ask the patient to sit about 3 ft away facing the nurse. B) Keep a penlight about 1 ft from the patient's face and move it slowly through the cardinal positions. C) Move a penlight in a circular motion in front of the patient's eyes. D) Ask the patient to cover one eye with a hand or index card.

b. The steps in testing for extraocular movement are: (1) Ask the patient to sit or stand about 2 ft away, facing the nurse, who is sitting or standing at eye level with the patient; (2) ask the patient to hold the head still and follow the movement of a forefinger or a penlight with the eyes; (3) keeping the finger or light about 1 foot from the patient's face, move it slowly through the cardinal position—up and down, left and right, diagonally up and down to the left, diagonally up and down to the right.

A nurse is using the FOUR coma scale to assess the neurologic status of a patient following surgery to remove a brain tumor. The nurse rates the patient as M2 for motor response. What condition does this number represent? A) Localizing to pain B) Flexion response to pain C) Extension response to pain D) No response to pain

b. To assess motor response, patients are asked to make a peace sign, a fist, and show thumbs up. Patients are scored as follows: M4 Thumbs-up, fist, or peace sign M3 Localizing to pain M2 Flexion response to pain M1 Extension response to pain M0 No response to pain

A nurse caring for adults in a provider's office researches aging theories to understand why some patients age more rapidly than others. Which statements describe the immunity theory of the aging process? Select all that apply. A) Chemical reactions in the body produce damage to the DNA. B) Free radicals have adverse effects on adjacent molecules. C) Decrease in size and function of the thymus results in more infections. D) There is much interest in the role of vitamin supplementation. E) Lifespan depends on a great extent to genetic factors. F) Organisms wear out from increased metabolic functioning.

c, d. The immunity theory of aging focuses on the functions of the immune system and states that the immune response declines steadily after younger adulthood as the thymus loses size and function, resulting in more infections. There is much interest in vitamin supplements (such as vitamin E) to improve immune function. The cross-linkage theory proposed that a chemical reaction produces damage to the DNA and cell death. The free radical theory states that free radicals—molecules with separated high-energy electrons—formed during cellular metabolism can have adverse effects on adjacent molecules. The genetic theory of aging holds that lifespan depends to a great extent on genetic factors. According to the wear-and-tear theory, organisms wear out from increased metabolic functioning, and cells become exhausted from continual energy depletion from adapting to stressors.

A nurse caring for patients in a long-term care facility uses available resources to help patients achieve Maslow's highest level of needs: self-actualization needs. Which statements accurately describe these needs? Select all that apply. A)Humans are born with a fully developed sense of self-actualization. B) Self-actualization needs are met by depending on others for help. C) The self-actualization process continues throughout life. D) Loneliness and isolation occur when self-actualization needs are unmet. E) A person achieves self-actualization by focusing on problems outside self. F) Self-actualization needs may be met by creatively solving problems.

c, e, f. Self-actualization, or reaching one's full potential, is a process that continues throughout life. A person achieves self-actualization by focusing on problems outside oneself and using creativity as a guideline for solving problems and pursuing interests. Humans are not born with a fully developed sense of self-actualization, and self-actualization needs are not met specifically by depending on others for help. Loneliness and isolation are not always the result of unmet self-actualization needs.

A visiting nurse working in a new community performs a community assessment. What assessment finding is indicative of a healthy community? A) It meets all the needs of its inhabitants B) It has mixed residential and industrial areas C) It offers access to health care services D) It consists of modern housing and condominiums

c. A healthy community offers access to health care services to treat illness and to promote health. A healthy community does not usually meet all the needs of its residents, but should be able to help with health issues such as nutrition, education, recreation, safety, and zoning regulations to separate residential sections from industrial ones. The age of housing is irrelevant as long as residences are maintained properly according to code.

A nursing instructor teaching classes in gerontology to nursing students discusses myths related to the aging of adults. Which statement is a myth about older adults? A) Most older adults live in their own homes. B) Healthy older adults enjoy sexual activity. C) Old age means mental deterioration. D) Older adults want to be attractive to others.

c. Although response time may be longer, intelligence does not normally decrease because of aging. Most older adults own their own homes. Although sexual activity may be less frequent, the ability to perform and enjoy sexual activity lasts well into the 90s in healthy older adults. Older adults want to be attractive to others.

A nurse is interviewing a newly admitted patient. Which question is considered culturally sensitive? A) "Do you think you will be able to eat the food we have here?" B) "Do you understand that we can't prepare special meals?" C) "What types of food do you eat for meals?" D) "Why can't you just eat our food while you are here?"

c. Asking patients what types of foods they eat for meals is culturally sensitive. The other questions are culturally insensitive.

A nurse who is caring for patients on a pediatric ward is assessing the children for their spiritual needs. Which is the most important source of learning for a child's own spirituality? A) The child's church or religious organization B) What parents say about God and religion C) How parents behave in relationship to one another, their children, others, and to God D) The spiritual adviser for the family

c. Children learn most about their own spirituality from how their parents behave in relationship to one another, their children, others, and God (or a higher being). What parents say about God and religion, the family's spiritual advisor, and the child's church or religious organization are less important sources of learning.

A nurse is helping to prepare a calendar for an older adult patient with cognitive impairment. What is the leading cause of cognitive impairment in old age? A) Stroke B) Malnutrition C) AD D) Loss of cardiac reserve

c. Dementia, AD, depression, and delirium may occur and cause cognitive impairment. AD is the most common degenerative neurologic illness and the most common cause of cognitive impairment. It is irreversible, progressing from deficits in memory and thinking skills to an inability to perform even the simplest of tasks. The leading causes of death in adults aged 65 and older are heart disease, cancer, chronic respiratory disease, stroke, AD, and diabetes.

Mr. Brown's teenage daughter had been involved in shoplifting. He expresses much anger toward her and states he cannot face her, let alone discuss this with her: "I just will not tolerate a thief." Which nursing intervention would the nurse take to assist Mr. Brown with his deficit in forgiveness? A) Assure Mr. Brown that many parents feel the same way. B) Reassure Mr. Brown that many teenagers go through this kind of rebellion and that it will pass. C) Assist Mr. Brown to identify how unforgiving feelings toward others hurt the person who cannot forgive. D) Ask Mr. Brown if he is sure he has spent sufficient time with his daughter.

c. Helping Mr. Brown identify how his unforgiving feelings may be harmful to him is the only nursing intervention that directly addresses his unmet spiritual need concerning forgiveness. Assuring Mr. Brown that many parents would feel the same way or that many teenagers shoplift out of rebelliousness may make him feel better initially, but neither option addresses his need to forgive. Suggesting that Mr. Brown may not have spent enough time with his daughter is likely to make him feel guilty.

A nurse is teaching a novice nurse how to provide care for patients in a culturally diverse community health clinic. Although all these actions are recommended, which one is MOST basic to providing culturally competent care? A) Learning the predominant language of the community B) Obtaining significant information about the community C) Treating each patient at the clinic as an individual D) Recognizing the importance of the patient's family

c. In all aspects of nursing, it is important to treat each patient as an individual. This is also true in providing culturally competent care. This basic objective can be accomplished by learning the predominant language in the community, researching the patient's culture, and recognizing the influence of family on the patient's life.

A nurse is interviewing a 42-year-old patient who is visiting an internist for a blood pressure screening. The patient states: "I'm currently a sales associate, but I'm considering a different career and I'm a little anxious about the process." According to Levinson, what phase of adult life is this patient experiencing? A) Entering the adult world B) Settling down C) Midlife transition D) Entering middle-adulthood

c. Midlife transition (ages 40 to 45) involves a reappraisal of goals and values. The established lifestyle may continue, or the person may choose to reorganize and change careers. This is an unsettled time, with the person often anxious and fearful. The years of the middle to late 20s (ages 22 to 28) are a time to build on previous decisions and choices and to try different careers and lifestyles. In the settling-down phase (ages 33 to 40), the adult invests energy into the areas of life that are most personally important. The years of entering middle adulthood (ages 45 to 50) revolve around having made choices and having formed a new life structure, and committing to new tasks.

A nurse is conducting an assessment of a patient's cranial nerves. The nurse asks the patient to raise the eyebrows, smile, and show the teeth to assess which cranial nerve? A) Olfactory B) Optic C) Facial D) Vagus

c. Motor function of the facial nerve (cranial nerve VII) is assessed by asking the patient to raise the eyebrow, smile, and show the teeth. The olfactory nerve (cranial nerve I) is tested by testing smell reception with various agents. The nurse tests the optic nerve (cranial nerve II) for acuity and visual fields and the vagus nerve (cranial nerve X) by asking the patient to swallow and speak, noting hoarseness.

A patient's visual acuity is assessed as 20/40 in both eyes using the Snellen chart. The nurse interprets this finding as: A) The patient can see twice as well as normal. B) The patient has double vision. C) The patient has less than normal vision. D) The patient has normal vision.

c. Normal vision is 20/20. A finding of 20/40 would mean that a patient has less than normal vision.

A nurse working in an emergency department assesses how patients' religious beliefs affect their treatment plan. With which patient would the nurse be most likely to encounter resistance to emergency lifesaving surgery? A) A patient of the Adventist faith B) A patient who practices Buddhism C) A patient who is a Jehovah's Witness D) A patient who is an Orthodox Jew

c. Patients who practice the Jehovah's Witness faith believe blood transfusions violate God's laws and do not allow them. The other religious groups do not restrict modern lifesaving treatment for their members.

A nurse examining a toddler in a pediatric office documents that the child is in the 90th percentile for height and weight and has blue eyes. These physical characteristics are primarily determined by which of the following? A) Socialization with caregivers B) Maternal nutrition during pregnancy C) Genetic information on chromosomes D) Meeting developmental tasks

c. Physical appearance and growth have a predetermined genetic base in inheritance patterns carried on the chromosomes.

A nurse is performing spirituality assessments of patients living in a long-term care facility. What is the best question the nurse might use to assess for spiritual needs? A) Can you describe your usual spiritual practices and how you maintain them daily? B) Are your spiritual beliefs causing you any concern? C) How can I and the other nurses help you maintain your spiritual practices? D) How do your religious beliefs help you to feel at peace?

c. Questioning how the staff can meet patients' spiritual practices assesses spiritual needs. Asking the patient to describe spiritual practices assesses spiritual practices. Asking about concerns assesses spiritual distress, and asking about feeling at peace assesses the need for forgiveness.

A nurse who was raised as a strict Roman Catholic but who is no longer a practicing Catholic stated she couldn't assist patients with their spiritual distress because she recognizes only a "field power" in each person. She said, "My parents and I hardly talk because I've deserted my faith. Sometimes I feel real isolated from them and also from God—if there is a God." Analysis of these data reveals which unmet spiritual need? A) Need for meaning and purpose B) Need for forgiveness C) Need for love and relatedness D) Need for strength for everyday living

c. The data point to an unmet spiritual need to experience love and belonging, given the nurse's estrangement from her family and God after leaving the church. The other options may represent other needs this nurse has, but the data provided do not support them.

A man who is a declared agnostic is extremely depressed after losing his home, his wife, and his children in a fire. His nursing diagnosis is Spiritual Distress: Spiritual Pain related to inability to find meaning and purpose in his current condition. What is the most important nursing intervention to plan? A) Ask the patient which spiritual adviser he would like you to call. B) Recommend that the patient read spiritual biographies or religious books. C) Explore with the patient what, in addition to his family, has given his life meaning and purpose in the past. D) Introduce the belief that God is a loving and personal God.

c. The nursing intervention of exploring with the patient what, in addition to his family, has given his life meaning and purpose in the past is more likely to correct the etiology of his problem, Spiritual Pain, than any of the other nursing interventions listed.

A patient states she feels so isolated from her family and church, and even from God, "in this huge medical center so far from home." A nurse is preparing nursing goals for this patient. Which is the best goal for the patient to relieve her spiritual distress? A) The patient will express satisfaction with the compatibility of her spiritual beliefs and everyday living. B) The patient will identify spiritual beliefs that meet her need for meaning and purpose. C) The patient will express peaceful acceptance of limitations and failings. D) The patient will identify spiritual supports available to her in this medical center.

d. Each of the four options represents an appropriate spiritual goal, but identifying spiritual supports available to this patient in the medical center demonstrates a goal to decrease her sense of isolation.

A hospice nurse is caring for a patient who is dying of pancreatic cancer. The patient tells the nurse "I feel no connection to God" and "I'm worried that I find no real meaning in life." What would be the nurse's best response to this patient? A) Give the patient a hug and tell him that his life still has meaning. B) Arrange for a spiritual adviser to visit the patient. C) Ask if the patient would like to talk about his feelings. D) Call in a close friend or relative to talk to the patient.

c. When caring for a patient who is in spiritual distress, the nurse should listen to the patient first and then ask whether the patient would like to visit with a spiritual adviser. To arrange for a spiritual adviser first may not respect the wishes of the patient. A hug and false reassurances do not address the diagnosis of spiritual distress. Talking to friends or relatives may be helpful, but only if the patient desires their visits.

A nurse is caring for patients of diverse cultures in a community health care facility. Which characteristics of cultural diversity that exist in the United States should the nurse consider when planning culturally competent care? Select all that apply. A) The United States has become less inclusive of same-sex couples. B) Cultural diversity is limited to people of varying cultures and races. C) Cultural diversity is separate and distinct from health and illness. D)People may be members of multiple cultural groups at one time. E) Culture guides what is acceptable behavior for people in a specific group. F)Cultural practices may evolve over time but mainly remain constant.

d, e, f. A person may be a member of multiple cultural, ethnic, and racial groups at one time. Culture guides what is acceptable behavior for people in a specific group. Cultural practices and beliefs may evolve over time, but they mainly remain constant as long as they satisfy a group's needs. The United States has become more (not less) inclusive of same-sex couples. The definition of cultural diversity includes, but is not limited to, people of varying cultures, racial and ethnic origin, religion, language, physical size, biological sex, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location. Cultural diversity, including culture, ethnicity, and race, is an integral component of both health and illness.

An experienced nurse tells a less-experienced nurse who is working in a retirement home that older adults are different and do not have the same desires, needs, and concerns as other age groups. The nurse also comments that most older adults have "outlived their usefulness." What is the term for this type of prejudice? A) Harassment B) Whistle blowing C) EA D) Ageism

d. Ageism is a form of prejudice in which older adults are stereotyped by characteristics found in only a few members of their age group. Harassment occurs when a dominant person takes advantage of or overpowers a less dominant person; it may involve sexual harassment or power struggles. Whistle blowing involves reporting illegal or unethical behavior in the workplace. EA is an intentional act or failure to act by a caregiver that causes or creates a risk of harm to an older adult.

A nurse works with families in crisis at a community mental health care facility. What is the BEST broad definition of a family? A) A father, a mother, and children B) A group whose members are biologically related C) A unit that includes aunts, uncles, and cousins D) A group of people who live together and depend on each other for support

d. Although all the responses may be true, the best definition is a group of people who live together and depend on each other for physical, emotional, or financial support.

The Roman Catholic family of a baby who was born with hydroencephalitis requests a baptism for their infant. Why is it imperative that the nurse provides for this baptism to be performed? A) Baptism frequently postpones or prevents death or suffering. B) It is legally required that nurses provide for this care when the family makes this request. C) It is a nursing function to assure the salvation of the baby. D) Not having a Baptism for the baby when desired may increase the family's sorrow and suffering.

d. Failure to ensure that an infant baptism is performed when parents desire it may greatly increase the family's sorrow and suffering, which is an appropriate nursing concern. Whether baptism postpones or prevents death and suffering is a religious belief that is insufficient to bind all nurses. There is no legal requirement regarding baptism, and although some nurses may believe part of their role is to ensure the salvation of the baby, this function would understandably be rejected by many.

Even though the nurse performs a detailed nursing history in which spirituality is assessed on admission, problems with spiritual distress may not surface until days after admission. What is the probable explanation? A) Patients usually want to conceal information about their spiritual needs. B) Patients are not concerned about spiritual needs until after their spiritual adviser visits. C) Family members and close friends often initiate spiritual concerns. D) Illness increases spiritual concerns, which may be difficult for patients to express in words.

d. Illness may increase spiritual concerns, which many patients find difficult to express. The other options do not correspond to actual experience.

A nurse providing health services for a 55 plus community setting formulates diagnoses for patients. Which of the following nursing diagnoses would be most appropriate for many middle adults? A) Risk for Imbalanced Nutrition: Less Than Body Requirements B) Delayed Growth and Development C) Self-Care Deficit D) Caregiver Role Strain

d. Many middle adults help care for aging parents and have concerns about their own health and ability to continue to care for an older family member. Caregivers often face 24-hour care responsibilities for extended periods of time, which creates physical and emotional problems for the caregiver. Risk for Imbalanced Nutrition: Less Than Body Requirements would be most appropriate for an adolescent with an eating disorder or an older adult who has conditions (such as ill-fitting dentures, financial restraints, or GI issues) preventing proper nutrition. Delayed growth and development would be most appropriate for infancy to school-age patients, and self-care deficit would be most appropriate for older adults whose health prevents them from performing ADLs

A patient whose last name is Goldstein was served a kosher meal ordered from a restaurant on a paper plate because the hospital made no provision for kosher food or dishes. Mr. Goldstein became angry and accused the nurse of insulting him: "I want to eat what everyone else does—and give me decent dishes." Analysis of these data reveals what finding? A) The nurse should have ordered kosher dishes also. B) The staff must have behaved condescendingly or critically. C) Mr. Goldstein is a problem patient and difficult to satisfy. D) Mr. Goldstein was stereotyped and not consulted about his dietary preferences.

d. On the basis of his name alone, the nurse jumped to the premature and false conclusion that this patient would want a kosher diet.

A nurse states, "That patient is 78 years old—too old to learn how to change a dressing." What is the nurse demonstrating? A) Cultural imposition B) Clustering C) Cultural competency D) Stereotyping

d. Stereotyping is assuming that all members of a group are alike. This is not an example of cultural competence nor is the nurse imposing her culture on the patient. Clustering is not an applicable concept.