MedSurg - Exam 1

A class of nursing students is in their first semester of nursing school. The instructor explains that one of the changes they will undergo while in nursing school is learning to "think like a nurse." What is the most current model of this thinking process? A. Critical-thinking Model B. Nursing Process Model C. Clinical Judgment Model D. Active Practice Model

C. Clinical Judgment Model To depict the process of "thinking like a nurse," Tanner (2006) developed a model known as the clinical judgment model.

In the process of planning a patient's care, the nurse has identified a nursing diagnosis of Ineffective Health Maintenance related to alcohol use. What must precede the determination of this nursing diagnosis? A. Establishment of a plan to address the underlying problem B. Assigning a positive value to each consequence of the diagnosis C. Collecting and analyzing data that corroborates the diagnosis D. Evaluating the patient's chances of recovery

C. Collecting and analyzing data that corroborates the diagnosis In the diagnostic phase of the nursing process, the patient's nursing problems are defined through analysis of patient data. Establishing a plan comes after collecting and analyzing data; evaluating a plan is the last step of the nursing process and assigning a positive value to each consequence is not done.

You are the nurse caring for an 85-year-old patient who has been hospitalized for a fractured radius. The patient's daughter has accompanied the patient to the hospital and asks you what her father can do for his very dry skin, which has become susceptible to cracking and shearing. What would be your best response? A. "He should likely take showers rather than baths, if possible." B. "Make sure that he applies sunscreen each morning." C. "Dry skin is an age-related change that is largely inevitable." D. "Try to help your father increase his intake of dairy products."

A. "He should likely take showers rather than baths, if possible." Showers are less drying than hot tub baths. Sun exposure should indeed be limited, but daily application of sunscreen is not necessary for many patients. Dry skin is an age-related change, but this does not mean that no appropriate interventions exist to address it. Dairy intake is unrelated

The nurse is conducting patient teaching about cholesterol levels. When discussing the patient's elevated LDL and lowered HDL levels, the patient shows an understanding of the significance of these levels by stating what? A. "Increased LDL and decreased HDL increase my risk of coronary artery disease." B. "Increased LDL has the potential to decrease my risk of heart disease." C. "The decreased HDL level will increase the amount of cholesterol moved away from the artery walls." D. "The increased LDL will decrease the amount of cholesterol deposited on the artery walls."

A. "Increased LDL and decreased HDL increase my risk of coronary artery disease." Elevated LDL levels and decreased HDL levels are associated with a greater incidence of coronary artery disease.

The nurse is caring for a 65-year-old patient who has previously been diagnosed with hypertension. Which of the following blood pressure readings represents the threshold between high-normal blood pressure and hypertension? A. 140/90 mm Hg B. 145/95 mm Hg C. 150/100 mm Hg D. 160/100 mm Hg

A. 140/90 mm Hg Hypertension is the diagnosis given when the blood pressure is greater than 140/90 mm Hg. This makes the other options incorrect

The nurse is calculating a cardiac patient's pulse pressure. If the patient's blood pressure is 122/76 mm Hg, what is the patient's pulse pressure? A. 46 mm Hg B. 99 mm Hg C. 198 mm Hg D. 76 mm Hg

A. 46 mm Hg Pulse pressure is the difference between the systolic and diastolic pressure. In this case, this value is 46 mm Hg.

A nurse uses critical thinking every day when going through the nursing process. Which of the following is an outcome of critical thinking in nursing practice? A. A comprehensive plan of care with a high potential for success B. Identification of the nurse's preferred goals for the patient C. A collaborative basis for assigning care D. Increased cost efficiency in health care

A. A comprehensive plan of care with a high potential for success Critical thinking in nursing practice results in a comprehensive plan of care with maximized potential for success. Critical thinking does not identify the nurse's goal for the patient or provide a collaborative basis for assigning care. Critical thinking may or may not lead to increased cost efficiency; the patient's outcomes are paramount.

A nurse is caring for an 86-year-old female patient who has become increasingly frail and unsteady on her feet. During the assessment, the patient indicates that she has fallen three times in the month, though she has not yet suffered an injury. The nurse should take action in the knowledge that this patient is at a high risk for what health problem? A. A hip fracture B. A femoral fracture C. Pelvic dysplasia D. Tearing of a meniscus or bursa

A. A hip fracture The most common fracture resulting from a fall is a fractured hip resulting from osteoporosis and the condition or situation that produced the fall. The other listed injuries are possible, but less likely than a hip fracture.

You are providing care for a patient who has a diagnosis of pneumonia attributed to Streptococcus pneumonia infection. Which of the following aspects of nursing care would constitute part of the planning phase of the nursing process? A. Achieve SaO2 > 92% at all times. B. Auscultate chest q4h. C. Administer oral fluids q1h and PRN. D. Avoid overexertion at all times.

A. Achieve SaO2 > 92% at all times. The planning phase entails specifying the immediate, intermediate, and long-term goals of nursing action, such as maintaining a certain level of oxygen saturation in a patient with pneumonia. Providing fluids and avoiding overexertion are parts of the implementation phase of the nursing process. Chest auscultation is an assessment.

A nurse will conduct an influenza vaccination campaign at an extended care facility. The nurse will be administering intramuscular (IM) doses of the vaccine. Of what age-related change should the nurse be aware when planning the appropriate administration of this drug? A. An older patient has less subcutaneous tissue and less muscle mass than a younger patient. B. An older patient has more subcutaneous tissue and less durable skin than a younger patient. C. An older patient has more superficial and tortuous nerve distribution than a younger patient. D. An older patient has a higher risk of bleeding after an IM injection than a younger patient.

A. An older patient has less subcutaneous tissue and less muscle mass than a younger patient. When administering IM injections, the nurse should remember that in an older patient, subcutaneous fat diminishes, particularly in the extremities. Muscle mass also decreases. There are no significant differences in nerve distribution or bleeding risk.

While receiving report on a group of patients, the nurse learns that a patient with terminal cancer has granted power of attorney for health care to her brother. How does this affect the course of the patient's care? A. Another individual has been identified to make decisions on behalf of the patient. B. There are binding parameters for care even if the patient changes her mind. C. The named individual is in charge of the patient's finances. D. There is a document delegating custody of children to other than her spouse.

A. Another individual has been identified to make decisions on behalf of the patient. A power of attorney is said to be in effect when a patient has identified another individual to make decisions on her behalf. The patient has the right to change her mind. A power-of-attorney for health care does not give anyone the right to make financial decisions for the patient nor does it delegate custody of minor children.

The nurse working on a cardiac care unit is caring for a patient whose stroke volume has increased. The nurse is aware that afterload influences a patient's stroke volume. The nurse recognizes that afterload is increased when there is what? A. Arterial vasoconstriction B. Venous vasoconstriction C. Arterial vasodilation D. Venous vasodilation

A. Arterial vasoconstriction Arterial vasoconstriction increases the systemic vascular resistance, which increases the afterload. Venous vasoconstriction decreases preload thereby decreasing stroke volume. Venous vasodilation increases preload.

The nurse caring for a patient who is two days post hip replacement notifies the physician that the patient's incision is red around the edges, warm to the touch, and seeping a white liquid with a foul odor. What type of problem is the nurse dealing with? A. Collaborative problem B. Nursing problem C. Medical problem D. Administrative problem

A. Collaborative Problem In addition to nursing diagnoses and their related nursing interventions, nursing practice involves certain situations and interventions that do not fall within the definition of nursing diagnoses. These activities pertain to potential problems or complications that are medical in origin and require collaborative interventions with the physician and other members of the health care team. The other answers are incorrect because the signs and symptoms of infection are a medical complication that requires interventions by the nurse.

Achieving adequate pain management for a postoperative patient will require sophisticated critical thinking skills by the nurse. What are the potential benefits of critical thinking in nursing? Select all that apply. A. Enhancing the nurse's clinical decision making B. Identifying the patient's individual preferences C. Planning the best nursing actions to assist the patient D. Increasing the accuracy of the nurse's judgments E. Helping identify the patient's priority needs

A. Enhancing the nurse's clinical decision making C. Planning the best nursing actions to assist the patient D. Increasing the accuracy of the nurse's judgments E. Helping identify the patient's priority needs Independent judgments and decisions evolve from a sound knowledge base and the ability to synthesize information within the context in which it is presented. Critical thinking enhances clinical decision making, helping to identify patient needs and the best nursing actions that will assist patients in meeting those needs. Critical thinking does not normally focus on identify patient desires; these would be identified by asking the patient.

A gerontologic nurse practitioner provides primary care for a large number of older adults who are living with various forms of cardiovascular disease. This nurse is well aware that heart disease is the leading cause of death in the aged. What is an age-related physiological change that contributes to this trend? A. Heart muscle and arteries lose their elasticity. B. Systolic blood pressure decreases. C. Resting heart rate decreases with age. D. Atrial-septal defects develop with age.

A. Heart muscle and arteries lose their elasticity. The leading cause of death for patients over the age of 65 years is cardiovascular disease. With age, heart muscle and arteries lose their elasticity, resulting in a reduced stroke volume. As a person ages, systolic blood pressure does not decrease, resting heart rate does not decrease, and the aged are not less likely to adopt a healthy lifestyle.

You are writing a care plan for an 85-year-old patient who has community-acquired pneumonia and you note decreased breath sounds to bilateral lung bases on auscultation. What is the most appropriate nursing diagnosis for this patient? A. Ineffective airway clearance related to tracheobronchial secretions B. Pneumonia related to progression of disease process C. Poor ventilation related to acute lung infection D. Immobility related to fatigue

A. Ineffective airway clearance related to tracheobronchial secretions Nursing diagnoses are not medical diagnoses or treatments. The most appropriate nursing diagnosis for this patient is "ineffective airway clearance related to copious tracheobronchial secretions." "Pneumonia" and "poor ventilation" are not nursing diagnoses. Immobility is likely, but is less directly related to the patient's admitting medical diagnosis and the nurse's assessment

An emergency department nurse is caring for a 7-year-old child suspected of having meningitis. The patient is to have a lumbar puncture performed, and the nurse is doing preprocedure teaching with the child and the mother. The nurse's action is an example of which therapeutic communication technique? A. Informing B. Suggesting C. Expectation-setting D. Enlightening

A. Informing Informing involves providing information to the patient regarding his or her care. Suggesting is the presentation of an alternative idea for the patient's consideration relative to problem solving. This action is not characterized as expectation-setting or enlightening.

A medical nurse has obtained a new patient's health history and completed the admission assessment. The nurse has followed this by documenting the results and creating a care plan for the patient. Which of the following is the most important rationale for documenting the patient's care? A. It provides continuity of care. B. It creates a teaching log for the family. C. It verifies appropriate staffing levels. D. It keeps the patient fully informed.

A. It provides continuity of care This record provides a means of communication among members of the health care team and facilitates coordinated planning and continuity of care. It serves as the legal and business record for a health care agency and for the professional staff members who are responsible for the patient's care. Documentation is not primarily a teaching log; it does not verify staffing; and it is not intended to provide the patient with information about treatments.

The nurse is providing patient teaching to a patient with early stage Alzheimer's disease (AD) and her family. The patient has been prescribed donepezil hydrochloride (Aricept). What should the nurse explain to the patient and family about this drug? A. It slows the progression of AD. B. It cures AD in a small minority of patients. C. It removes the patient's insight that he or she has AD. D. It limits the physical effects of AD and other dementias.

A. It slows the progression of AD. There is no cure for AD, but several medications have been introduced to slow the progression of the disease, including donepezil hydrochloride (Aricept). These medications do not remove the patient's insight or address physical symptoms of AD.

An elderly patient, while being seen in an urgent care facility for a possible respiratory infection, asks the nurse if Medicare is going to cover the cost of the visit. What information can the nurse give the patient to help allay her concerns? A. Medicare has a copayment for many of the services it covers. This requires the patient to pay a part of the bill. B. Medicare pays for 100% of the cost for acute-care services, so the cost of the visit will be covered. C. Medicare will only pay the cost for acute-care services if the patient has a very low income. D. Medicare will not pay for the cost of acute-care services so the patient will be billed for the services provided.

A. Medicare has a copayment for many of the services it covers. This requires the patient to pay a part of the bill. The two major programs that finance health in the United States are Medicare and Medicaid, both of which are overseen by the Centers for Medicaid and Medicare Services (CMS). Both programs cover acute-care needs such as inpatient hospitalization, physician care, outpatient care, home health services, and skilled nursing care in a nursing. Medicare is a plan specifically for the elderly population, and Medicaid is a program that provides services based on income.

You have just taken report for your shift and you are doing your initial assessment of your patients. One of your patients asks you if an error has been made in her medication. You know that an incident report was filed yesterday after a nurse inadvertently missed a scheduled dose of the patient's antibiotic. Which of the following principles would apply if you give an accurate response? A. Veracity B. Confidentiality C. Respect D. Justice

A. Veracity The obligation to tell the truth and not deceive others is termed veracity. The other answers are incorrect because they are not obligations to tell the truth.

Falls, which are a major health problem in the elderly population, occur from multifactorial causes. When implementing a comprehensive plan to reduce the incidence of falls on a geriatric unit, what risk factors should nurses identify? Select all that apply. A. Medication effects B. Overdependence on assistive devices C. Poor lighting D. Sensory impairment E. Ineffective use of coping strategies

A. Medication effects C. Poor lighting D. Sensory impairment Causes of falls are multifactorial. Both extrinsic factors, such as changes in the environment or poor lighting, and intrinsic factors, such as physical illness, neurologic changes, or sensory impairment, play a role. Mobility difficulties, medication effects, foot problems or unsafe footwear, postural hypotension, visual problems, and tripping hazards are common, treatable causes. Overdependence on assistive devices and ineffective use of coping strategies have not been shown to be factors in the rate of falls in the elderly population.

The physician has placed a central venous pressure (CVP) monitoring line in an acutely ill patient so right ventricular function and venous blood return can be closely monitored. The results show decreased CVP. What does this indicate? A. Possible hypovolemia B. Possible myocardial infarction (MI) C. Left sided heart failure D. Aortic valve regurgitation

A. Possible hypovolemia Hypovolemia may cause a decreased CVP. MI, valve regurgitation and heart failure are less likely causes of decreased CVP.

Based on a patient's vague explanations for recurring injuries, the nurse suspects that a community-dwelling older adult may be the victim of abuse. What is the nurse's primary responsibility? A. Report the findings to adult protective services. B. Confront the suspected perpetrator. C. Gather evidence to corroborate the abuse. D. Work with the family to promote healthy conflict resolution.

A. Report the findings to adult protective services. If neglect or abuse of any kind—including physical, emotional, sexual, or financial abuse—is suspected, the local adult protective services agency must be notified. The responsibility of the nurse is to report the suspected abuse, not to prove it, confront the suspected perpetrator, or work with the family to promote resolution.

Your older adult patient has a diagnosis of rheumatoid arthritis (RA) and has been achieving only modest relief of her symptoms with the use of nonsteroidal anti-inflammatory drugs (NSAIDs). When creating this patient's plan of care, which nursing diagnosis would most likely be appropriate? A. Self-care deficit related to fatigue and joint stiffness B. Ineffective airway clearance related to chronic pain C. Risk for hopelessness related to body image disturbance D. Anxiety related to chronic joint pain

A. Self-care deficit related to fatigue and joint stiffness Nursing diagnoses are actual or potential problems that can be managed by independent nursing actions. Self-care deficit would be the most likely consequence of rheumatoid arthritis. Anxiety and hopelessness are plausible consequences of a chronic illness such as RA, but challenges with self-care are more likely. Ineffective airway clearance is unlikely.

For several years, a community health nurse has been working with a 78-year-old man who requires a wheelchair for mobility. The nurse is aware that the interactions between disabilities and aging are not yet clearly understood. This interaction varies, depending on what variable? A. Socioeconomics B. Ethnicity C. Education D. Pharmacotherapy

A. Socioeconomics Large gaps exist in our understanding of the interaction between disabilities and aging, including how this interaction varies, depending on the type and degree of disability, and other factors such as socioeconomics and gender. Ethnicity, education, and pharmacotherapy are not identified as salient influences on this interaction.

A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. The instructor categorizes this action of the heart as what? A. Systole B. Diastole C. Repolarization D. Ejection fraction

A. Systole Systole is the action of the chambers of the heart becoming smaller and ejecting blood. This action of the heart is not diastole (relaxations), ejection fraction (the amount of blood expelled), or repolarization (electrical charging).

A group of students have been challenged to prioritize ethical practice when working with a marginalized population. How should the students best understand the concept of ethics? A. The formal, systematic study of moral beliefs B. The informal study of patterns of ideal behavior C. The adherence to culturally rooted, behavioral norms D. The adherence to informal personal values

A. The formal, systematic study of moral beliefs In essence, ethics is the formal, systematic study of moral beliefs, whereas morality is the adherence to informal personal values.

You are the nurse who is caring for a patient with a newly diagnosed allergy to peanuts. Which of the following is an immediate goal that is most relevant to a nursing diagnosis of "deficient knowledge related to appropriate use of an EpiPen"? A. The patient will demonstrate correct injection technique with today's teaching session. B. The patient will closely observe the nurse demonstrating the injection. C. The nurse will teach the patient's family member to administer the injection. D. The patient will return to the clinic within 2 weeks to demonstrate the injection.

A. The patient will demonstrate correct injection technique with today's teaching session. Immediate goals are those that can be reached in a short period of time. An appropriate immediate goal for this patient is that the patient will demonstrate correct administration of the medication today. The goal should specify that the patient administer the EpiPen. A 2-week time frame is inconsistent with an immediate goal.

The critical care nurse is caring for a patient with a pulmonary artery pressure monitoring system. The nurse is aware that pulmonary artery pressure monitoring is used to assess left ventricular function. What is an additional function of pulmonary artery pressure monitoring systems? A. To assess the patient's response to fluid and drug administration B. To obtain specimens for arterial blood gas measurements C. To dislodge pulmonary emboli D. To diagnose the etiology of chronic obstructive pulmonary disease

A. To assess the patient's response to fluid and drug administration Pulmonary artery pressure monitoring is an important tool used in critical care for assessing left ventricular function (cardiac output), diagnosing the etiology of shock, and evaluating the patient's response to medical interventions, such as fluid administration and vasoactive medications. Pulmonary artery monitoring is preferred for the patient with heart failure over central venous pressure monitoring. Arterial catheters are useful when arterial blood gas measurements and blood samples need to be obtained frequently. Neither intervention is used to clear pulmonary emboli.

The admissions department at a local hospital is registering an elderly man for an outpatient diagnostic test. The admissions nurse asks the man if he has an advanced directive. The man responds that he does not want to complete an advance directive because he does not want anyone controlling his finances. What would be appropriate information for the nurse to share with this patient? A. "Advance directives are not legal documents, so you have nothing to worry about." B. "Advance directives are limited only to health care instructions and directives." C. "Your finances cannot be managed without an advance directive." D. "Advance directives are implemented when you become incapacitated, and then you will use a living will to allow the state to manage your money."

B. "Advance directives are limited only to health care instructions and directives." An advance directive is a formal, legally endorsed document that provides instructions for care (living will) or names a proxy decision maker (durable power of attorney for health care) and covers only issues related specifically to health care, not financial issues. They do not address financial issues. Advance directives are implemented when a patient becomes incapacitated, but financial issues are addressed with a durable power of attorney for finances, or financial power of attorney.

While auscultating a patient's heart sounds, the nurse hears an extra heart sound immediately after the second heart sound (S2). An audible S3 would be considered an expected finding in what patient? A. An older adult B. A 20 year old patient C. A patient who has undergone valve replacement D. A patient who takes a beta adrenergic blocker

B. A 20 year old patient S3 represents a normal finding in children and adults up to 35 or 40 years of age. In these cases, it is called a physiologic S3. It is an abnormal finding in a patient with an artificial valve, an older adult, or a patient who takes a beta blocker.

You are the nurse planning an educational event for the nurses on a subacute medical unit on the topic of normal, age-related physiological changes. What phenomenon would you include in your teaching plan? A. A decrease in cognition, judgment, and memory B. A decrease in muscle mass and bone density C. The disappearance of sexual desire for both men and women D. An increase in sebaceous and sweat gland function in both men and women

B. A decrease in muscle mass and bone density Normal signs of aging include a decrease in the sense of smell, a decrease in muscle mass, a decline but not disappearance of sexual desire, and decreased sebaceous and sweat glands for both men and women. Cognitive changes are usually attributable to pathologic processes, not healthy aging.

The nurse is caring for a patient who has a history of heart disease. What factor should the nurse identify as possibly contributing to a decrease in cardiac output? A. A change in position from standing to sitting B. A heart rate of 54 bpm C. A pulse oximetry reading of 94% D. An increase in preload related to ambulation

B. A heart rate of 54 bpm Cardiac output is computed by multiplying the stroke volume by the heart rate. Cardiac output can be affected by changes in either stroke volume or heart rate, such as a rate of 54 bpm. An increase in preload will lead to an increase in stroke volume. A pulse oximetry reading of 94% does not indicate hypoxemia, as hypoxia can decrease contractility. Transitioning from standing to sitting would more likely increase rather than decrease cardiac output.

An occupational health nurse overhears an employee talking to his manager about a 65-year-old coworker. What phenomenon would the nurse identify when hearing the employee state, "He should just retire and make way for some new blood."? A. Intolerance B. Ageism C. Dependence D. Nonspecific prejudice

B. Ageism Ageism refers to prejudice against the aged. Intolerance is implied by the employee's statement, but the intolerance is aimed at the coworker's age. The employee's statement does not raise concern about dependence. The prejudice exhibited in the statement is very specific.

An adult patient has requested a "do not resuscitate" (DNR) order in light of his recent diagnosis with late stage pancreatic cancer. The patient's son and daughter-in-law are strongly opposed to the patient's request. What is the primary responsibility of the nurse in this situation? A. Perform a "slow code" until a decision is made. B. Honor the request of the patient. C. Contact a social worker or mediator to intervene. D. Temporarily withhold nursing care until the physician talks to the family.

B. Honor the request of the patient. The nurse must honor the patient's wishes and continue to provide required nursing care. Discussing the matter with the physician may lead to further communication with the family, during which the family may reconsider their decision. It is not normally appropriate for the nurse to seek the assistance of a social worker or mediator. A "slow code" is considered unethical.

A gerontologic nurse is making an effort to address some of the misconceptions about older adults that exist among health care providers. The nurse has made the point that most people aged 75 years remains functionally independent. The nurse should attribute this trend to what factor? A. Early detection of disease and increased advocacy by older adults B. Application of health-promotion and disease-prevention activities C. Changes in the medical treatment of hypertension and hyperlipidemia D. Genetic changes that have resulted in increased resiliency to acute infection

B. Application of health-promotion and disease-prevention activities Even among people 75 years of age and over, most remain functionally independent, and the proportion of older Americans with limitations in activities is declining. These declines in limitations reflect recent trends in health-promotion and disease-prevention activities, such as improved nutrition, decreased smoking, increased exercise, and early detection and treatment of risk factors such as hypertension and elevated serum cholesterol levels. This phenomenon is not attributed to genetics, medical treatment, or increased advocacy.

The nurse has just taken report on a newly admitted patient who is a 15-year-old girl who is a recent immigrant to the United States. When planning interventions for this patient, the nurse knows the interventions must be which of the following? Select all that apply. A. Appropriate to the nurse's preferences B. Appropriate to the patient's age C. Ethical D. Appropriate to the patient's culture E. Applicable to others with the same diagnosis

B. Appropriate to the patient's age C. Ethical D. Appropriate to the patient's culture Planned interventions should be ethical and appropriate to the patient's culture, age, and gender. Planned interventions do not have to be in alignment with the nurse's preferences nor do they have to be shared by everyone with the same diagnosis.

A gerontologic nurse has been working hard to change the perceptions of the elderly, many of which are negative, by other segments of the population. What negative perceptions of older people have been identified in the literature? Select all that apply. A. As being the cause of social problems B. As not contributing to society C. As draining economic resources D. As competing with children for resources E. As dominating health care research

B. As not contributing to society C. As draining economic resources D. As competing with children for resources Retirement and perceived nonproductivity are responsible for negative feelings because a younger working person may falsely see older people as not contributing to society and as draining economic resources. Younger working people may actually feel that older people are in competition with children for resources. However, the older population is generally not seen as dominating health care research or causing social problems.

A nurse is unsure how best to respond to a patient's vague complaint of "feeling off." The nurse is attempting to apply the principles of critical thinking, including metacognition. How can the nurse best foster metacognition? A. By eliciting input from a variety of trusted colleagues B. By examining the way that she thinks and applies reason C. By evaluating her responses to similar situations in the past D. By thinking about the way that an "ideal" nurse would respond in this situation

B. By examining the way that she thinks and applies reason Critical thinking includes metacognition, the examination of one's own reasoning or thought processes, to help refine thinking skills. Metacognition is not characterized by eliciting input from others or evaluating previous responses.

The case manager is working with an 84-year-old patient newly admitted to a rehabilitation facility. When developing a care plan for this older adult, which factors should the nurse identify as positive attributes that benefit coping in this age group? Select all that apply. A. Decreased risk taking B. Effective adaptation skills C. Avoiding participation in untested roles D. Increased life experience E. Resiliency during change

B. Effective adaptation skills D. Increased life experience E. Resiliency during change Because changes in life patterns are inevitable over a lifetime, older people need resiliency and coping skills when confronting stresses and change. It is beneficial if older adults continue to participate in risk taking and participation in new, untested roles.

In response to a patient's complaint of pain, the nurse administered a PRN dose of hydromorphone (Dilaudid). In what phase of the nursing process will the nurse determine whether this medication has had the desired effect? A. Analysis B. Evaluation C. Assessment D. Data collection

B. Evaluation Evaluation, the final step of the nursing process, allows the nurse to determine the patient's response to nursing interventions and the extent to which the objectives have been achieved.

A 47-year-old patient who has come to the physician's office for his annual physical is being assessed by the office nurse. The nurse who is performing routine health screening for this patient should be aware that one of the first physical signs of aging is what? A. Having more frequent aches and pains B. Failing eyesight, especially close vision C. Increasing loss of muscle tone D. Accepting limitations while developing assets

B. Failing eyesight, especially close vision Failing eyesight, especially close vision, is one of the first signs of aging in middle life. More frequent aches and pains begin in the "early" late years (between ages 65 and 79). Increase in loss of muscle tone occurs in later years (ages 80 and older). Accepting limitations while developing assets is socialization development that occurs in adulthood.

Gerontologic nursing is a specialty area of nursing that provides care for the elderly in our population. What goal of care should a gerontologic nurse prioritize when working with this population? A. Helping older adults determine how to reduce their use of external resources B. Helping older adults use their strengths to optimize independence C. Helping older adults promote social integration D. Helping older adults identify the weaknesses that most limit them

B. Helping older adults use their strengths to optimize independence Gerontologic nursing is provided in acute care, skilled and assisted living, community, and home settings. The goals of care include promoting and maintaining functional status and helping older adults identify and use their strengths to achieve optimal independence. Goals of gerontologic nursing do not include helping older adults "promote social integration" or identify their weaknesses. Optimal independence does not necessarily involve reducing the use of available resources.

The critical care nurse is caring for a patient with a central venous pressure (CVP) monitoring system. The nurse notes that the patient's CVP is increasing. Of what may this indicate? A. Psychosocial stress B. Hypervolemia C. Dislodgment of the catheter D. Hypomagnesemia

B. Hypervolemia CVP is a useful hemodynamic parameter to observe when managing an unstable patient's fluid volume status. An increasing pressure may be caused by hypervolemia or by a condition, such as heart failure, that results in decreased myocardial contractility. Stress, dislodgement of the catheter, and low magnesium levels would not typically result in increased CVP.

Older people have many altered reactions to disease that are based on age-related physiological changes. When the nurse observes physical indicators of illness in the older population, that nurse must remember which of the following principles? A. Potential life-threatening problems in the older adult population are not as serious as they are in a middle-aged population. B. Indicators that are useful and reliable in younger populations cannot be relied on as indications of potential life-threatening problems in older adults. C. The same physiological processes that indicate serious health care problems in a younger population indicate mild disease states in the elderly. D. Middle-aged people do not react to disease states the same as a younger population does.

B. Indicators that are useful and reliable in younger populations cannot be relied on as indications of potential life-threatening problems in older adults. Physical indicators of illness that are useful and reliable in young and middle-aged people cannot be relied on for the diagnosis of potential life-threatening problems in older adults. Option A is incorrect because a potentially life-threatening problem in an older person is more serious than it would be in a middle-aged person because the older adult does not have the physical resources of the middle-aged person. Physical indicators of serious health care problems in a young or middle-aged population do not indicate disease states that are considered "mild" in the elderly population. It is true that middle-aged people do not react to disease states the same as a younger population, but this option does not answer the question.

A nurse provides care on an orthopedic reconstruction unit and is admitting two new patients, both status post knee replacement. What would be the best explanation why their care plans may be different from each other? A. Patients may have different insurers, or one may qualify for Medicare. B. Individual patients are seen as unique and dynamic, with individual needs. C. Nursing care may be coordinated by members of two different health disciplines. D. Patients are viewed as dissimilar according to their attitude toward surgery.

B. Individual patients are seen as unique and dynamic, with individual needs. Regardless of the setting, each patient situation is viewed as unique and dynamic. Differences in insurance coverage and attitude may be relevant, but these should not fundamentally explain the differences in their nursing care. Nursing care should be planned by nurses, not by members of other disciplines.

During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where will the nurse best palpate the PMI? A. Left midclavicular line of the chest at the level of the nipple B. Left midclavicular line of the chest at the fifth intercostal space C. Midline between the xiphoid process and the left nipple D. Two to three centimeters to the left of the sternum

B. Left midclavicular line of the chest at the fifth intercostal space The left ventricle is responsible for the apical beat or the point of maximum impulse, which is normally palpated in the left midclavicular line of the chest wall at the fifth intercostal space.

You are providing care for an 82-year-old man whose signs and symptoms of Parkinson disease have become more severe over the past several months. The man tells you that he can no longer do as many things for himself as he used to be able to do. What factor should you recognize as impacting your patient's life most significantly? A. Neurologic deficits B. Loss of independence C. Age-related changes D. Tremors and decreased mobility

B. Loss of independence This patient's statement places a priority on his loss of independence. This is undoubtedly a result of the neurologic changes associated with his disease, but this is not the focus of his statement. This is a disease process, not an age-related physiological change.

The physical therapist notifies the nurse that a patient with coronary artery disease (CAD) experiences a much greater than average increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a patient with CAD may result in what? A. Development of an atrialseptal defect B. Myocardial ischemia C. Formation of a pulmonary embolism D. Release of potassium ions from cardiac cells

B. Myocardial ischemia Unlike other arteries, the coronary arteries are perfused during diastole. An increase in heart rate shortens diastole and can decrease myocardial perfusion. Patients, particularly those with CAD, can develop myocardial ischemia. An increase in heart rate will not usually result in a pulmonary embolism or create electrolyte imbalances. Atrialseptal defects are congenital.

A nurse has begun creating a patient's plan of care shortly after the patient's admission. It is important that the wording of the chosen nursing diagnoses falls within the taxonomy of nursing. Which organization is responsible for developing the taxonomy of a nursing diagnosis? A. American Nurses Association (ANA) B. NANDA C. National League for Nursing (NLN) D. Joint Commission

B. NANDA NANDA International is the official organization responsible for developing the taxonomy of nursing diagnoses and formulating nursing diagnoses acceptable for study. The ANA, NLN, and Joint Commission are not charged with the task of developing the taxonomy of nursing diagnoses.

While developing the plan of care for a new patient on the unit, the nurse must identify expected outcomes that are appropriate for the new patient. What resource should the nurse prioritize for identifying these appropriate outcomes? A. Community Specific Outcomes Classification (CSO) B. Nursing-Sensitive Outcomes Classification (NOC) C. State Specific Nursing Outcomes Classification (SSNOC) D. Department of Health and Human Services Outcomes Classification (DHHSOC)

B. Nursing-Sensitive Outcomes Classification (NOC) Resources for identifying appropriate expected outcomes include the NOC and standard outcome criteria established by health care agencies for people with specific health problems. The other options are incorrect because they do not exist.

The nurse is caring for a patient who is withdrawing from heavy alcohol use and who is consequently combative and confused, despite the administration of benzodiazepines. The patient has a fractured hip that he suffered in a traumatic accident and is trying to get out of bed. What is the most appropriate action for the nurse to take? A. Leave the patient and get help. B. Obtain a physician's order to restrain the patient. C. Read the facility's policy on restraints. D. Order soft restraints from the storeroom.

B. Obtain a physician's order to restrain the patient. It is mandatory in most settings to have a physician's order before restraining a patient. Before restraints are used, other strategies, such as asking family members to sit with the patient, or utilizing a specially trained sitter, should be tried. A patient should never be left alone while the nurse summons assistance.

Mrs. Harris is an 83-year-old woman who has returned to the community following knee replacement surgery. The community health nurse recognizes that Mrs. Harris has prescriptions for nine different medications for the treatment of varied health problems. In addition, she has experienced occasional episodes of dizziness and lightheadedness since her discharge. The nurse should identify which of the following nursing diagnoses? A. Risk for infection related to polypharmacy and hypotension B. Risk for falls related to polypharmacy and impaired balance C. Adult failure to thrive related to chronic disease and circulatory disturbance D. Disturbed thought processes related to adverse drug effects and hypotension

B. Risk for falls related to polypharmacy and impaired balance Polypharmacy and loss of balance are major contributors to falls in the elderly. This patient does not exhibit failure to thrive or disturbed thought processes. There is no evidence of a heightened risk of infection.

The nursing instructor cites a list of skills that support critical thinking in clinical situations. The nurse should describe skills in which of the following domains? Select all that apply. A. Self-esteem B. Self-regulation C. Inference D. Autonomy E. Interpretation

B. Self-regulation C. Inference E. Interpretation Skills needed in critical thinking include interpretation, analysis, evaluation, inference, explanation, and self-regulation. Self-esteem and autonomy would not be on the list because they are not skills.

You are the nurse caring for an elderly patient with cardiovascular disease. The patient comes to the clinic with a suspected respiratory infection and is diagnosed with pneumonia. As the nurse, what do you know about the altered responses of older adults? A. Treatments for older adults need to be more holistic than treatments used in the younger population. B. The altered responses of older adults reinforce the need for the nurse to monitor all body systems to identify possible systemic complications. C. The altered responses of older adults define the nursing interactions with the patient. D. Older adults become hypersensitive to antibiotic treatments for infectious disease states.

B. The altered responses of older adults reinforce the need for the nurse to monitor all body systems to identify possible systemic complications. Older people may be unable to respond effectively to an acute illness, or, if a chronic health condition is present, they may be unable to sustain appropriate responses over a long period. Furthermore, their ability to respond to definitive treatment is impaired. The altered responses of older adults reinforce the need for nurses to monitor all body system functions closely, being alert to signs of impending systemic complication. Holism should be integrated into all patients' care. Altered responses in the older adult do not define the interactions between the nurse and the patient. Older adults do not become hypersensitive to antibiotic treatments for infectious disease states.

You are caring for a patient with late-stage Alzheimer's disease. The patient's wife tells you that the patient has now become completely dependent and that she feels guilty if she takes any time for herself. What outcomes would be appropriate for the nurse to develop to assist the patient's wife? A. The caregiver learns to explain to the patient why she needs time for herself. B. The caregiver distinguishes essential obligations from those that can be controlled or limited. C. The caregiver leaves the patient at home alone for short periods of time to encourage independence. D. The caregiver prioritizes her own health over that of the patient

B. The caregiver distinguishes essential obligations from those that can be controlled or limited. For prolonged periods, it is not uncommon for caregivers to neglect their own emotional and health needs. The caregiver must learn to distinguish obligations that she must fulfill and limit those that are not completely necessary. The caregiver can tell the patient when she leaves, but she should not expect that the patient will remember or will not become angry with her for leaving. The caregiver should not leave the patient home alone for any length of time because it may compromise the patient's safety. Being thoughtful and selective with her time and energy is not synonymous with prioritizing her own health over than of the patient; it is more indicative of balance and sustainability.

A nurse has been offered a position on an obstetric unit and has learned that the unit offers therapeutic abortions, a procedure which contradicts the nurse's personal beliefs. What is the nurse's ethical obligation to these patients? A. The nurse should adhere to professional standards of practice and offer service to these patients. B. The nurse should make the choice to decline this position and pursue a different nursing role. C. The nurse should decline to care for the patients considering abortion. D. The nurse should express alternatives to women considering terminating their pregnancy.

B. The nurse should make the choice to decline this position and pursue a different nursing role. To avoid facing ethical dilemmas, nurses can follow certain strategies. For example, when applying for a job, a nurse should ask questions regarding the patient population. If a nurse is uncomfortable with a particular situation, then not accepting the position would be the best option. The nurse is only required by law (and practice standards) to provide care to the patients the clinic accepts; the nurse may not discriminate between patients and the nurse expressing his or her own opinion and providing another option is inappropriate.

A medical nurse is caring for a patient who is palliative following metastasis. The nurse is aware of the need to uphold the ethical principle of beneficence. How can the nurse best exemplify this principle in the care of this patient? A. The nurse tactfully regulates the number and timing of visitors as per the patient's wishes. B. The nurse stays with the patient during his or her death. C. The nurse ensures that all members of the care team are aware of the patient's DNR order. D. The nurse liaises with members of the care team to ensure continuity of care.

B. The nurse stays with the patient during his or her death. Beneficence is the duty to do good and the active promotion of benevolent acts. Enacting the patient's wishes around visitors is an example of this. Each of the other nursing actions is consistent with ethical practice, but none directly exemplifies the principle of beneficence.

A resident of a longterm care facility has complained to the nurse of chest pain. What aspect of the resident's pain would be most suggestive of angina as the cause? A. The pain is worse when the resident inhales deeply. B. The pain occurs immediately following physical exertion. C. The pain is worse when the resident coughs. D. The pain is most severe when the resident moves his upper body.

B. The pain occurs immediately following physical exertion. Chest pain associated with angina is often precipitated by physical exertion. The other listed aspects of chest pain are more closely associated with noncardiac etiologies.

An elderly patient is admitted to your unit with a diagnosis of community-acquired pneumonia. During admission the patient states, "I have a living will." What implication of this should the nurse recognize? A. This document is always honored, regardless of circumstances. B. This document specifies the patient's wishes before hospitalization. C. This document that is binding for the duration of the patient's life. D. This document has been drawn up by the patient's family to determine DNR status.

B. This document specifies the patient's wishes before hospitalization A living will is one type of advance directive. In most situations, living wills are limited to situations in which the patient's medical condition is deemed terminal. The other answers are incorrect because living wills are not always honored, they are not binding for the duration of the patient's life, and they are not drawn up by the patient's family.

You are the nurse caring for a 91-year-old patient admitted to the hospital for a fall. The patient complains of urge incontinence and tells you he most often falls when he tries to get to the bathroom in his home. You identify the nursing diagnosis of risk for falls related to impaired mobility and urinary incontinence. The older adult's risk for falls is considered to be which of the following? A. The result of impaired cognitive functioning B. The accumulation of environmental hazards C. A geriatric syndrome D. An age-related health deficit

C. A geriatric syndrome A number of problems commonly experienced by the elderly are becoming recognized as geriatric syndromes. These conditions do not fit into discrete disease categories. Examples include frailty, delirium, falls, urinary incontinence, and pressure ulcers. Impaired cognitive functioning, environmental hazards in the home, and an age-related health deficit may all play a part in the episodes in this patient's life that led to falls, but they are not diagnoses and are, therefore, incorrect.

A gerontologic nurse is aware of the demographic changes that are occurring in the United States, and this affects the way that the nurse plans and provides care. Which of the following phenomena is currently undergoing the most rapid and profound change? A. More families are having to provide care for their aging members. B. Adult children find themselves participating in chronic disease management. C. A growing number of people live to a very old age. D. Elderly people are having more accidents, increasing the costs of health care.

C. A growing number of people live to a very old age. As the older population increases, the number of people who live to a very old age is dramatically increasing. The other options are all correct, but none is a factor that is most dramatically increasing in this age group.

An audit of a large, university medical center reveals that four patients in the hospital have current orders for restraints. You know that restraints are an intervention of last resort, and that it is inappropriate to apply restraints to which of the following patients? A. A postlaryngectomy patient who is attempting to pull out his tracheostomy tube B. A patient in hypovolemic shock trying to remove the dressing over his central venous catheter C. A patient with urosepsis who is ringing the call bell incessantly to use the bedside commode D. A patient with depression who has just tried to commit suicide and whose medications are not achieving adequate symptom control

C. A patient with urosepsis who is ringing the call bell incessantly to use the bedside commode Restraints should never be applied for staff convenience. The patient with urosepsis who is frequently ringing the call bell is requesting assistance to the bedside commode; this is appropriate behavior that will not result in patient harm. The other described situations could plausibly result in patient harm; therefore, it is more likely appropriate to apply restraints in these instances.

A recent nursing graduate is aware of the differences between nursing actions that are independent and nursing actions that are interdependent. A nurse performs an interdependent nursing intervention when performing which of the following actions? A. Auscultating a patient's apical heart rate during an admission assessment B. Providing mouth care to a patient who is unconscious following a cerebrovascular accident C. Administering an IV bolus of normal saline to a patient with hypotension D. Providing discharge teaching to a postsurgical patient about the rationale for a course of oral antibiotics

C. Administering an IV bolus of normal saline to a patient with hypotension Although many nursing actions are independent, others are interdependent, such as carrying out prescribed treatments, administering medications and therapies, and collaborating with other health care team members to accomplish specific, expected outcomes and to monitor and manage potential complications. Irrigating a wound, administering pain medication, and administering IV fluids are interdependent nursing actions and require a physician's order. An independent nursing action occurs when the nurse assesses a patient's heart rate, provides discharge education, or provides mouth care.

A home health nurse makes a home visit to a 90-year-old patient who has cardiovascular disease. During the visit the nurse observes that the patient has begun exhibiting subtle and unprecedented signs of confusion and agitation. What should the home health nurse do? A. Increase the frequency of the patient's home care. B. Have a family member check in on the patient in the evening. C. Arrange for the patient to see his primary care physician. D. Refer the patient to an adult day program.

C. Arrange for the patient to see his primary care physician. In more than half of the cases, sudden confusion and hallucinations are evident in multi-infarct dementia. This condition is also associated with cardiovascular disease. Having the patient's home care increased does not address the problem, neither does having a family member check on the patient in the evening. Referring the patient to an adult day program may be beneficial to the patient, but it does not address the acute problem the patient is having, the nurse should arrange for the patient to see his primary care physician.

Critical thinking and decision-making skills are essential parts of nursing in all venues. What are examples of the use of critical thinking in the venue of genetics-related nursing? Select all that apply. A. Notifying individuals and family members of the results of genetic testing B. Providing a written report on genetic testing to an insurance company C. Assessing and analyzing family history data for genetic risk factors D. Identifying individuals and families in need of referral for genetic testing E. Ensuring privacy and confidentiality of genetic information

C. Assessing and analyzing family history data for genetic risk factors D. Identifying individuals and families in need of referral for genetic testing E. Ensuring privacy and confidentiality of genetic information Nurses use critical thinking and decision-making skills in providing genetics-related nursing care when they assess and analyze family history data for genetic risk factors, identify those individuals and families in need of referral for genetic testing or counseling, and ensure the privacy and confidentiality of genetic information. Nurses who work in the venue of genetics-related nursing do not notify family members of the results of an individual's genetic testing, and they do not provide written reports to insurance companies concerning the results of genetic testing.

A patient has been diagnosed with small-cell lung cancer. He has met with the oncologist and is now weighing the relative risks and benefits of chemotherapy and radiotherapy as his treatment. This patient is demonstrating which ethical principle in making his decision? A. Beneficence B. Confidentiality C. Autonomy D. Justice

C. Autonomy Autonomy entails the ability to make a choice free from external constraints. Beneficence is the duty to do good and the active promotion of benevolent acts. Confidentiality relates to the concept of privacy. Justice states that cases should be treated equitably.

You are the nurse caring for patients in the urology clinic. A new patient, 78 years old, presents with complaints of urinary incontinence. An anticholinergic is prescribed. Why might this type of medication be an inappropriate choice in the elderly population? A. Gastrointestinal hypermotility can be an adverse effect of this medication. B. Detrusor instability can be an adverse effect of this medication. C. Confusion can be an adverse effect of this medication. D. Increased symptoms of urge incontinence can be an adverse effect of this medication.

C. Confusion can be an adverse effect of this medication. Although medications such as anticholinergics may decrease some of the symptoms of urge incontinence (detrusor instability), the adverse effects of these medications (dry mouth, slowed gastrointestinal motility, and confusion) may make them inappropriate choices for the elderly.

An 84-year-old patient has returned from the post-anesthetic care unit (PACU) following hip arthroplasty. The patient is oriented to name only. The patient's family is very upset because, before having surgery, the patient had no cognitive deficits. The patient is subsequently diagnosed with postoperative delirium. What should the nurse explain to the patient's family? A. This problem is self-limiting and there is nothing to worry about. B. Delirium involves a progressive decline in memory loss and overall cognitive function. C. Delirium of this type is treatable and her cognition will return to previous levels. D. This problem can be resolved by administering antidotes to the anesthetic that was used in surgery.

C. Delirium of this type is treatable and her cognition will return to previous levels. Surgery is a common cause of delirium in older adults. Delirium differs from other types of dementia in that delirium begins with confusion and progresses to disorientation. It has symptoms that are reversible with treatment, and, with treatment, is short term in nature. It is patronizing and inaccurate to reassure the family that there is "nothing to worry about." The problem is not treated by the administration of antidotes to anesthetic.

As the population of the United States ages, research has shown that this aging will occur across all racial and ethnic groups. A community health nurse is planning an initiative that will focus on the group in which the aging population is expected to rise the fastest. What group should the nurse identify? A. Asian-Americans B. White non-Hispanics C. Hispanics D. African-Americans

C. Hispanics Although the older population will increase in number for all racial and ethnic groups, the rate of growth is projected to be fastest in the Hispanic population that is expected to increase from 6 million in 2004 to an estimated 17.5 million by 2050.

A nurse is preparing a patient for scheduled transesophageal echocardiography. What action should the nurse perform? A. Instruct the patient to drink 1 liter of water before the test. B. Administer IV benzodiazepines and opioids. C. Inform the patient that she will remain on bed rest following the procedure. D. Inform the patient that an access line will be initiated in her femoral artery.

C. Inform the patient that she will remain on bed rest following the procedure. During the recovery period, the patient must maintain bed rest with the head of the bed elevated to 45 degrees. The patient must be NPO 6 hours preprocedure. The patient is sedated to make him or her comfortable, but will not be heavily sedated, and opioids are not necessary. Also, the patient will have a peripheral IV line initiated preprocedure.

The care team has deemed the occasional use of restraints necessary in the care of a patient with Alzheimer's disease. What ethical violation is most often posed when using restraints in a long-term care setting? A. It limits the patient's personal safety. B. It exacerbates the patient's disease process. C. It threatens the patient's autonomy. D. It is not normally legal.

C. It threatens the patient's autonomy. Because safety risks are involved when using restraints on elderly confused patients, this is a common ethical problem, especially in long-term care settings. By definition, restraints limit the individual's autonomy. Restraints are not without risks, but they should not normally limit a patient's safety. Restraints will not affect the course of the patient's underlying disease process, though they may exacerbate confusion. The use of restraints is closely legislated, but they are not illegal.

The presence of a gerontologic advanced practice nurse in a long-term care facility has proved beneficial to both the patients and the larger community in which they live. Nurses in this advanced practice role have been shown to cause what outcome? A. Greater interaction between younger adults and older adults occurs. B. The elderly recover more quickly from acute illnesses. C. Less deterioration takes place in the overall health of patients. D. The elderly are happier in long-term care facilities than at home.

C. Less deterioration takes place in the overall health of patients. The use of advanced practice nurses who have been educated in geriatric nursing concepts has proved to be very effective when dealing with the complex care needs of an older patient. When best practices are used and current scientific knowledge applied to clinical problems, significantly less deterioration occurs in the overall health of aging patients. This does not necessarily mean that patients are happier in long-term care than at home, that they recover more quickly from acute illnesses, or greater interaction occurs between younger and older adults.

The nurse, in collaboration with the patient's family, is determining priorities related to the care of the patient. The nurse explains that it is important to consider the urgency of specific problems when setting priorities. What provides the best framework for prioritizing patient problems? A. Availability of hospital resources B. Family member statements C. Maslow's hierarchy of needs D. The nurse's skill set

C. Maslow's hierarchy of needs Maslow's hierarchy of needs provides a useful framework for prioritizing problems, with the first level given to meeting physical needs of the patient. Availability of hospital resources, family member statements, and nursing skill do not provide a framework for prioritization of patient problems, though each may be considered.

A patient has had a myocardial infarction and has been diagnosed as having damage to the layer of the heart responsible for the pumping action. You are aware that the damage occurred where? A. Endocardium B. Pericardium C. Myocardium D. Visceral pericardium

C. Myocardium The myocardium is the layer of the heart responsible for the pumping action.

An 83-year-old woman was diagnosed with Alzheimer's disease 2 years ago and the disease has progressed at an increasing pace in recent months. The patient has lost 16 pounds over the past 3 months, leading to a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements. What intervention should the nurse include in this patient's plan of care? A. Offer the patient rewards for finishing all the food on her tray. B. Offer the patient bland, low-salt foods to limit offensiveness. C. Offer the patient only one food item at a time to promote focused eating. D. Arrange for insertion of a gastrostomy tube and initiate enteral feeding.

C. Offer the patient only one food item at a time to promote focused eating. To avoid any "playing" with food, one dish should be offered at a time. Foods should be familiar and appealing, not bland. Tube feeding is not likely necessary at this time and a reward system is unlikely to be beneficial.

Your patient has been admitted for a liver biopsy because the physician believes the patient may have liver cancer. The family has told both you and the physician that if the patient is terminal, the family does not want the patient to know. The biopsy results are positive for an aggressive form of liver cancer and the patient asks you repeatedly what the results of the biopsy show. What strategy can you use to give ethical care to this patient? A. Obtain the results of the biopsy and provide them to the patient. B. Tell the patient that only the physician knows the results of the biopsy. C. Promptly communicate the patient's request for information to the family and the physician. D. Tell the patient that the biopsy results are not back yet in order temporarily to appease him.

C. Promptly communicate the patient's request for information to the family and the physician. Strategies nurses could consider include the following: not lying to the patient, providing all information related to nursing procedures and diagnoses, and communicating the patient's requests for information to the family and physician. Ethically, you cannot tell the patient the results of the biopsy and you cannot lie to the patient.

A nurse has been providing ethical care for many years and is aware of the need to maintain the ethical principle of nonmaleficence. Which of the following actions would be considered a contradiction of this principle? A. Discussing a DNR order with a terminally ill patient B. Assisting a semi-independent patient with ADLs C. Refusing to administer pain medication as ordered D. Providing more care for one patient than for another

C. Refusing to administer pain medication as ordered The duty not to inflict as well as prevent and remove harm is termed nonmaleficence. Discussing a DNR order with a terminally ill patient and assisting a patient with ADLs would not be considered contradictions to the nurse's duty of nonmaleficence. Some patients justifiably require more care than others.

A terminally ill patient you are caring for is complaining of pain. The physician has ordered a large dose of intravenous opioids by continuous infusion. You know that one of the adverse effects of this medicine is respiratory depression. When you assess your patient's respiratory status, you find that the rate has decreased from 16 breaths per minute to 10 breaths per minute. What action should you take? A. Decrease the rate of IV infusion. B. Stimulate the patient in order to increase respiratory rate. C. Report the decreased respiratory rate to the physician. D. Allow the patient to rest comfortably.

C. Report the decreased respiratory rate to the physician. End-of life issues that often involve ethical dilemmas include pain control, "do not resuscitate" orders, life-support measures, and administration of food and fluids. The risk of respiratory depression is not the intent of the action of pain control. Respiratory depression should not be used as an excuse to withhold pain medication for a terminally ill patient. The patient's respiratory status should be carefully monitored and any changes should be reported to the physician.

After a sudden decline in cognition, a 77-year-old man who has been diagnosed with vascular dementia is receiving care in his home. To reduce this man's risk of future infarcts, what action should the nurse most strongly encourage? A. Activity limitation and falls reduction efforts B. Adequate nutrition and fluid intake C. Rigorous control of the patient's blood pressure and serum lipid levels D. Use of mobility aids to promote independence

C. Rigorous control of the patient's blood pressure and serum lipid levels Because vascular dementia is associated with hypertension and cardiovascular disease, risk factors (e.g., hypercholesterolemia, history of smoking, diabetes) are similar. Prevention and management are also similar. Therefore, measures to decrease blood pressure and lower cholesterol levels may prevent future infarcts. Activity limitation is unnecessary and infarcts are not prevented by nutrition or the use of mobility aids.

During discussion with the patient and the patient's husband, you discover that the patient has a living will. How does the presence of a living will influence the patient's care? A. The patient is legally unable to refuse basic life support. B. The physician can override the patient's desires for treatment if desires are not evidence-based. C. The patient may nullify the living will during her hospitalization if she chooses to do so. D. Power-of-attorney may change while the patient is hospitalized.

C. The patient may nullify the living will during her hospitalization if she chooses to do so. Because living wills are often written when the person is in good health, it is not unusual for the patient to nullify the living will during illness. A living will does not make a patient legally unable to refuse basic life support. The physician may disagree with the patient's wishes, but he or she is ethically bound to carry out those wishes. A power-of-attorney is not synonymous with a living will.

The nurse is caring for a patient admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this patient. The nurse should recognize what implication of this assessment finding? A. This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours. B. Because the patient has a history of unstable angina, this is a poor indicator of myocardial injury. C. This is an accurate indicator of myocardial injury. D. This result indicates muscle injury, but does not specify the source.

C. This is an accurate indicator of myocardial injury. Troponin I, which is specific to cardiac muscle, is elevated within hours after myocardial injury. Even with a diagnosis of unstable angina, this is an accurate indicator of myocardial injury.

A patient with migraines does not know whether she is receiving a placebo for pain management or the new drug that is undergoing clinical trials. Upon discussing the patient's distress, it becomes evident to the nurse that the patient did not fully understand the informed consent document that she signed. Which ethical principle is most likely involved in this situation? A. Sanctity of life B. Confidentiality C. Veracity D. Fidelity

C. Veracity Telling the truth (veracity) is one of the basic principles of our culture. Three ethical dilemmas in clinical practice that can directly conflict with this principle are the use of placebos (nonactive substances used for treatment), not revealing a diagnosis to a patient, and revealing a diagnosis to persons other than the patient with the diagnosis. All involve the issue of trust, which is an essential element in the nurse-patient relationship. Sanctity of life is the perspective that life is the highest good. Confidentiality deals with privacy of the patient. Fidelity is promise-keeping and the duty to be faithful to one's commitments.

During report, a nurse finds that she has been assigned to care for a patient admitted with an opportunistic infection secondary to AIDS. The nurse informs the clinical nurse leader that she is refusing to care for him because he has AIDS. The nurse has an obligation to this patient under which legal premise? A. Good Samaritan Act B. Nursing Interventions Classification (NIC) C. Patient Self-Determination Act D. ANA Code of Ethics

D. ANA Code of Ethics The ethical obligation to care for all patients is clearly identified in the first statement of the ANA Code of Ethics for Nurses. The Good Samaritan Act relates to lay people helping others in need. The NIC is a standardized classification of nursing treatment that includes independent and collaborative interventions. The Patient Self-Determination Act encourages people to prepare advance directives in which they indicate their wishes concerning the degree of supportive care to be provided if they become incapacitated.

You are the nurse caring for an elderly patient who is being treated for community-acquired pneumonia. Since the time of admission, the patient has been disoriented and agitated to varying degrees. Appropriate referrals were made and the patient was subsequently diagnosed with dementia. What nursing diagnosis should the nurse prioritize when planning this patient's care? A. Social isolation related to dementia B. Hopelessness related to dementia C. Risk for infection related to dementia D. Acute confusion related to dementia

D. Acute confusion related to dementia Acute confusion is a priority problem in patients with dementia, and it is an immediate threat to their health and safety. Hopelessness and social isolation are plausible problems, but the patient's cognition is a priority. The patient's risk for infection is not directly influenced by dementia.

Nurses and members of other health disciplines at a state's public health division are planning programs for the next 5 years. The group has made the decision to focus on diseases that are experiencing the sharpest increases in their contributions to the overall death rate in the state. This team should plan health promotion and disease prevention activities to address what health problem? A. Stroke B. Cancer C. Respiratory infections D. Alzheimer's disease

D. Alzheimer's disease In the past 60 years, overall deaths, and specifically, deaths from heart disease, have declined. Recently, deaths from cancer and cerebrovascular disease have declined. However, deaths from Alzheimer's disease have risen more than 50% between 1999 and 2007.

You are following the care plan that was created for a patient newly admitted to your unit. Which of the following aspects of the care plan would be considered a nursing implementation? A. The patient will express an understanding of her diagnosis. B. The patient appears diaphoretic. C. The patient is at risk for aspiration. D. Ambulate the patient twice per day with partial assistance.

D. Ambulate the patient twice per day with partial assistance. Implementation refers to carrying out the plan of nursing care. The other listed options exemplify goals, assessment findings, and diagnoses.

You are caring for an 82-year-old man who was recently admitted to the geriatric medical unit in which you work. Since admission, he has spoken frequently of becoming a burden to his children and "staying afloat" financially. When planning this patient's care, you should recognize his heightened risk of what nursing diagnosis? A. Disturbed thought processes B. Impaired social interaction C. Decisional conflict D. Anxiety

D. Anxiety Economic concerns and fear of becoming a burden to families often lead to high anxiety in older people. There is no clear indication that the patient has disturbed thought processes, impaired social interaction, or decisional conflict.

The physician has recommended an amniocentesis for an 18-year-old primiparous woman. The patient is 34 weeks' gestation and does not want this procedure. The physician is insistent the patient have the procedure. The physician arranges for the amniocentesis to be performed. The nurse should recognize that the physician is in violation of what ethical principle? A. Veracity B. Beneficence C. Nonmaleficence D. Autonomy

D. Autonomy The principle of autonomy specifies that individuals have the ability to make a choice free from external constraints. The physician's actions in this case violate this principle. This action may or may not violate the principle of beneficence. Veracity centers on truth-telling and nonmaleficence is avoiding the infliction of harm.

A gerontologic nurse is basing the therapeutic programs at a long-term care facility on Miller's Functional Consequences Theory. To actualize this theory of aging, the nurse should prioritize what task? A. Attempting to control age-related physiological changes B. Lowering expectations for recovery from acute and chronic illnesses C. Helping older adults accept the inevitability of death D. Differentiating between age-related changes and modifiable risk factors

D. Differentiating between age-related changes and modifiable risk factors The Functional Consequences Theory requires the nurse to differentiate between normal, irreversible age-related changes and modifiable risk factors. This theory does not emphasize lowering expectations, controlling age-related changes, or helping adults accept the inevitability of death.

A nurse has been using the nursing process as a framework for planning and providing patient care. What action would the nurse do during the evaluation phase of the nursing process? A. Have a patient provide input on the quality of care received. B. Remove a patient's surgical staples on the scheduled postoperative day. C. Provide information on a follow-up appointment for a postoperative patient. D. Document a patient's improved air entry with incentive spirometric use.

D. Document a patient's improved air entry with incentive spirometric use. During the evaluation phase of the nursing process, the nurse determines the patient's response to nursing interventions. An example of this is when the nurse documents whether the patient's spirometry use has improved his or her condition. A patient does not do the evaluation. Removing staples and providing information on follow-up appointments are interventions, not evaluations.

A gerontologic nurse is overseeing the care that is provided in a large, long-term care facility. The nurse is educating staff about the significant threat posed by influenza in older, frail adults. What action should the nurse prioritize to reduce the incidence and prevalence of influenza in the facility? A. Teach staff how to administer prophylactic antiviral medications effectively. B. Ensure that residents receive a high-calorie, high-protein diet during the winter. C. Make arrangements for residents to limit social interaction during winter months. D. Ensure that residents receive influenza vaccinations in the fall of each year.

D. Ensure that residents receive influenza vaccinations in the fall of each year. The influenza and the pneumococcal vaccinations lower the risks of hospitalization and death in elderly people. The influenza vaccine, which is prepared yearly to adjust for the specific immunologic characteristics of the influenza viruses at that time, should be administered annually in autumn. Prophylactic antiviral medications are not used. Limiting social interaction is not required in most instances. Nutrition enhances immune response, but this is not specific to influenza prevention.

A patient admitted with right leg thrombophlebitis is to be discharged from an acute-care facility. Following treatment with a heparin infusion, the nurse notes that the patient's leg is pain-free, without redness or edema. Which step of the nursing process does this reflect? A. Diagnosis B. Analysis C. Implementation D. Evaluation

D. Evaluation The nursing actions described constitute evaluation of the expected outcomes. The findings show that the expected outcomes have been achieved. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process where the nurse puts the care plan into action. This nurse's actions do not constitute diagnosis.

The nursing instructor is explaining critical thinking to a class of first-semester nursing students. When promoting critical thinking skills in these students, the instructor should encourage them to do which of the following actions? A. Disregard input from people who do not have to make the particular decision. B. Set aside all prejudices and personal experiences when making decisions. C. Weigh each of the potential negative outcomes in a situation. D. Examine and analyze all available information.

D. Examine and analyze all available information. Critical thinking involves reasoning and purposeful, systematic, reflective, rational, outcome-directed thinking based on a body of knowledge, as well as examination and analysis of all available information and ideas. A full disregard of one's own experiences is not possible. Critical thinking does not denote a focus on potential negative outcomes. Input from others is a valuable resource that should not be ignored.

An elderly patient has come in to the clinic for her twice-yearly physical. The patient tells the nurse that she is generally enjoying good health, but that she has been having occasional episodes of constipation over the past 6 months. What intervention should the nurse first suggest? A. Reduce the amount of stress she currently experiences. B. Increase carbohydrate intake and reduce protein intake. C. Take herbal laxatives, such as senna, each night at bedtime. D. Increase daily intake of water.

D. Increase daily intake of water. Constipation is a common problem in older adults and increasing fluid intake is an appropriate early intervention. This should likely be attempted prior to recommending senna or other laxatives. Stress reduction is unlikely to wholly resolve the problem and there is no need to increase carbohydrate intake and reduce protein intake.

The nurse is providing care for a patient with chronic obstructive pulmonary disease (COPD). The nurse's most recent assessment reveals an SaO2 of 89%. The nurse is aware that part of critical thinking is determining the significance of data that have been gathered. What characteristic of critical thinking is used in determining the best response to this assessment finding? A. Extrapolation B. Inference C. Characterization D. Interpretation

D. Interpretation Nurses use interpretation to determine the significance of data that are gathered. This specific process is not described as extrapolation, inference, or characterization.

A nurse is planning discharge teaching for an 80-year-old patient with mild short-term memory loss. The discharge teaching will include how to perform basic wound care for the venous ulcer on his lower leg. When planning the necessary health education for this patient, what should the nurse plan to do? A. Set long-term goals with the patient. B. Provide a list of useful Web sites to supplement learning. C. Keep visual cues to a minimum to enhance the patient's focus. D. Keep teaching periods short.

D. Keep teaching periods short. To assist the elderly patient with short-term memory loss, the nurse should keep teaching periods short, provide glare-free lighting, link new information with familiar information, use visual and auditory cues, and set short-term goals with the patient. The patient may or may not be open to the use of online resources.

A care conference has been organized for a patient with complex medical and psychosocial needs. When applying the principles of critical thinking to this patient's care planning, the nurse should most exemplify what characteristic? A. Willingness to observe behaviors B. A desire to utilize the nursing scope of practice fully C. An ability to base decisions on what has happened in the past D. Openness to various viewpoints

D. Openness to various viewpoints Willingness and openness to various viewpoints are inherent in critical thinking; these allow the nurse to reflect on the current situation. An emphasis on the past, willingness to observe behaviors, and a desire to utilize the nursing scope of practice fully are not central characteristics of critical thinkers.

The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the SA node and then proceeds in what sequence? A. SA node to bundle of His to AV node to Purkinje fibers B. SA node to AV node to Purkinje fibers to bundle of His C. SA node to bundle of His to Purkinje fibers to AV node D. SA node to AV node to bundle of His to Purkinje fibers

D. SA node to AV node to bundle of His to Purkinje fibers The normal electrophysiological conduction route is SA node to AV node to bundle of HIS to Purkinje fibers.

The home health nurse is making an initial home visit to a 76-year-old widower. The patient takes multiple medications for the treatment of varied chronic health problems. The patient states that he has also begun taking some herbal remedies. What should the nurse be sure to include in the patient's teaching? A. Herbal remedies are consistent with holistic health care. B. Herbal remedies are often cheaper than prescribed medication. C. It is safest to avoid the use of herbal remedies. D. There is a need to inform his physician and pharmacist about the herbal remedies.

D. There is a need to inform his physician and pharmacist about the herbal remedies. Herbal remedies combined with prescribed medications can lead to interactions that may be toxic. Patients should notify the physician and pharmacist of any herbal remedies they are using. Even though herbal remedies are considered holistic, this is not something that is necessary to include in the patient's teaching. Herbal remedies may be cheaper than prescribed medicine, but this is still not something that is necessary to include in the patient's teaching. For most people, it is not necessary to wholly avoid herbal remedies.

A nurse is admitting a new patient to the medical unit. During the initial nursing assessment, the nurse has asked many supplementary open-ended questions while gathering information about the new patient. What is the nurse achieving through this approach? A. Interpreting what the patient has said B. Evaluating what the patient has said C. Assessing what the patient has said D. Validating what the patient has said

D. Validating what the patient has said Critical thinkers validate the information presented to make sure that it is accurate (not just supposition or opinion), that it makes sense, and that it is based on fact and evidence. The nurse is not interpreting, evaluating, or assessing the information the patient has given.

The nurse admits a patient to an oncology unit that is a site for a study on the efficacy of a new chemotherapeutic drug. The patient knows that placebos are going to be used for some participants in the study but does not know that he is receiving a placebo. When is it ethically acceptable to use placebos? A. Whenever the potential benefits of a study are applicable to the larger population B. When the patient is unaware of it and it is deemed unlikely that it would cause harm C. Whenever the placebo replaces an active drug D. When the patient knows placebos are being used and is involved in the decision-making process

D. When the patient knows placebos are being used and is involved in the decision-making process Placebos may be used in experimental research in which a patient is involved in the decision-making process and is aware that placebos are being used in the treatment regimen. Placebos may not ethically be used solely when there is a potential benefit, when the patient is unaware, or when a placebo replaces an active drug.

The nurse is caring for an 82 year old patient. The nurse knows that changes in cardiac structure and function occur in older adults. What is a normal change expected in the aging heart of an older adult? A. Decreased left ventricular ejection time B. Decreased connective tissue in the SA and AV nodes and bundle branches C. Thinning and flaccidity of the cardiac values D. Widening of the aorta

D. Widening of the aorta Changes in cardiac structure and function are clearly observable in the aging heart. Aging results in decreased elasticity and widening of the aorta, thickening and rigidity of the cardiac valves, increased connective tissue in the SA and AV nodes and bundle branches, and an increased left ventricular ejection time (prolonged systole).

A student nurse has been assigned to provide basic care for a 58-year-old man with a diagnosis of AIDS-related pneumonia. The student tells the instructor that she is unwilling to care for this patient. What key component of critical thinking is most likely missing from this student's practice? A. Compliance with direction B. Respect for authority C. Analyzing information and situations D. Withholding judgment

D. Withholding judgment Key components of critical thinking behavior are withholding judgment and being open to options and explanations from one patient to another in similar circumstances. The other listed options are incorrect because they are not components of critical thinking.