Theory 5

A patient is diagnosed with pneumonia after an abrupt onset of fever, cough, and malaise. The patient is started on antibiotic therapy and is expected to improve in 2 to 3 weeks. Which statement by the nurse correctly identifies this illness? a. Acute b. Chronic c. Remission d. Exacerbation

ANS: A Acute illness is typically characterized by an abrupt onset and short duration (<6 months). Clinical manifestations of acute illness appear quickly. They may be severe or lethal, or they may soon resolve because they respond to treatment or are self-limiting. Chronic illness is characterized by a loss or abnormality of body function that lasts longer than 6 months and requires ongoing long-term care. Chronic health conditions may be controlled with lifestyle management or drug therapy, but they are considered to be irreversible. Chronic illness may be characterized by periods of wellness (i.e., remission) and exacerbation (worsening) of clinical manifestations, which can be life threatening. Individuals learn to adjust their lifestyles accordingly.

The nurse knows which law protects health care professionals from charges of negligence when providing emergency care at the scene of an accident? a. Good Samaritan Act b. HIPPA c. Licensure d. Living wills

ANS: A All 50 states have enacted Good Samaritan laws offering protection for physicians and other health care professionals who provide emergency care at the scene of a disaster, emergency, or accident. Good Samaritan laws protect health care professionals from charges of negligence in providing emergency care if: (1) the care is within the professional's scope of knowledge and standards of care and (2) no fee is received or charged for services. The Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996 to protect the privacy of health care information. Licensure and certification of nurses seek to ensure professional competence. The laws of each state require graduates of accredited nursing schools and colleges pass the National Council Licensure Examination (NCLEX) before beginning professional practice. A living will specifies the treatment a person wants to receive when he/she is unconscious or no longer capable of making decisions independently.

The nurse is caring for a patient who had a colonoscopy earlier that day. The patient states that he still feels very bloated after the procedure. What is the best action of the nurse? a. Assist the patient to ambulate in the hall. b. Insert a rectal tube to remove retained flatus. c. Administer an enema to stimulate peristalsis. d. Encourage oral intake of fluids and high-fiber foods.

ANS: A Ambulation is a good way to promote peristalsis and relieve bloating. An enema should not be used after colonoscopy. A rectal tube is not needed. Eating high-fiber foods soon after colonoscopy may increase gas and bloating.

The public health nurse volunteers for a missionary group caring for Ebola patients in Africa. The nurse is reviewing the data using analytic epidemiology methods. What information does the nurse collect as the priority? a. Cultural norms in burial practices b. Genetic variables in disease acquisition c. Statistics related to incidence and prevalence d. Autopsy data on direct cause of death

ANS: A Analytic epidemiology hypothesizes why a disease is occurring in a community and looks at cultural practices, nutrition, and extrinsic factors such as the environment for links. Genetic variables and direct cause of death data are more related to epidemiology.

The nurse is caring for a patient whose family does not want the patient to be told about the new diagnosis of cancer because of the poor prognosis. Keeping this secret from the patient is in direct conflict with which ethical concepts? a. Autonomy and veracity b. Veracity and advocacy c. Justice and nonmaleficence d. Confidentiality and justice

ANS: A Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. Truthfulness defines the ethical concept of veracity. Supporting or promoting the interests of others or to do so for a cause greater than ourselves defines advocacy. To do justice is to act fairly and equitably. First, do no harm is the colloquial definition of nonmaleficence. Unlike beneficence, which requires actively doing good, nonmaleficence requires only the avoidance of harm. Confidentiality is the ethical concept that limits sharing private patient information

The nurse is caring for a patient who periodically has small streaks of fresh red blood in the stool. The patient denies abdominal pain or loss of appetite. The nurse identifies what to be the most likely cause of this patient's bleeding? a. Hemorrhoids b. Bleeding gastric ulcer c. Colon polyps d. Perforated colon

ANS: A Bleeding hemorrhoids can lead to small streaks of fresh red blood in the stool. Bleeding gastric ulcer would lead to black, tarry stools as the blood is digested. Colon polyps do not cause bleeding.

The nurse is caring for a patient from a different culture. After assessing the patient and formulating the care plan, what action by the nurse is best? a. Review the care plan for acceptance by the patient. b. Delegate appropriate tasks to unlicensed assistive personnel. c. Go over the care plan with the charge nurse. d. Begin implementing the planned interventions.

ANS: A Care plans, with their goals and interventions, should always be validated by the patient. This is especially true when the patient is from a different culture than the nurse. The charge nurse may or may not need to view the care plan, but after validation with the patient, the nurse can begin implementing the plan, including delegating appropriate tasks.

The nurse is caring for a terminally ill patient who is actively dying and refuses to eat anything other than a few bites of ice cream. The patient's family member approaches the nurse and requests that a feeding tube be inserted so that her loved one will not starve to death. What is the best response of the nurse? a. "Loss of appetite is a natural part of the dying process. Tube feedings would be uncomfortable and cause nausea." b. "I will contact the provider to obtain an order to insert the tube and start tube feedings." c. "Intravenous fluids would be more comfortable for the patient than a tube feeding. I will call the doctor to get the order." d. "I will listen to the patient's abdomen to make sure that bowel sounds are present and try encouraging oral fluids."

ANS: A Common physical symptoms at the end of life include anorexia and cachexia. Tube feedings will cause discomfort as the tube is inserted and nausea as the GI tract is given food that it cannot handle. Encouraging oral intake will lead to increased secretions and congestion as well as possible aspiration of fluids. Intravenous fluids will increase congestion and edema. The nurse would educate the family on this part of the dying process.

The nurse is caring for a patient who will undergo colonoscopy testing. Which intervention will the nurse include in the patient's plan of care for the day before the test? a. Provide the patient with zinc oxide skin barrier cream for the perineal area. b. Obtain an order for a gentle laxative to be given once the test is completed. c. Carefully assess the patient's ability to swallow liquids through a straw. d. Check the patient for allergies to shellfish and iodine-based contrast dyes.

ANS: A Complete bowel evacuation is required prior to colonoscopy so that the physician can visualize the interior of the large intestine. The patient will have multiple soft-liquid bowel movements as part of the bowel prep for the test, so skin barrier cream will be helpful to prevent perineal irritation. Laxatives will not be needed after the colonoscopy, and no contrast dyes are used.

The nurse is caring for a patient from a different cultural background. What action by the nurse best demonstrates cultural maintenance? a. Assist the patient with a healing ritual. b. Teach the patient a heart healthy diet. c. Instruct the patient on monitoring blood glucose. d. Discuss what self-care activities the patient is willing to do.

ANS: A Cultural maintenance maintains and preserves relevant cultural care values pertaining to health care. Assisting the patient with a healing ritual important to him/her is an example. Teaching a heart-healthy diet and blood glucose monitoring falls into cultural care repatterning. Discussing what changes the patient is willing to accommodate is an example of cultural care accommodation.

The nurse is providing patient care and pays special attention to meeting the needs of the patient while maintaining the patient's right to privacy, confidentiality, autonomy, and dignity. This nurse is applying what ethical theory? a. Deontology b. Utilitarianism c. Autonomy d. Accountability

ANS: A Deontology is an ethical theory that stresses the rightness or wrongness of individual behaviors, duties, and obligations without concern for the consequences of specific actions. Meeting the needs of patients while maintaining their right to privacy, confidentiality, autonomy, and dignity is consistent with the tenets of deontology. Compared with deontology, utilitarianism is on the opposite end of the ethical theory continuum. Utilitarianism maintains that behaviors are determined to be right or wrong solely based on their consequences. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. Accountability is the willingness to accept responsibility for one's actions.

The nurse is caring for a patient who has just completed 2 weeks of IV antibiotics for a severe infection. The patient now has frequent loose watery stools and a low-grade temperature. What is the most likely cause of the patient's new symptoms? a. Clostridium difficile infection b. Paralytic ileus c. Fecal impaction d. Salmonella food poisoning

ANS: A Diarrhea, abdominal pain, and low-grade temperature after completing IV antibiotics are often caused by C. difficile infection.

The new nurse tells the preceptor that since she is not prejudiced against ethnic minorities, they will not be discriminated against while in the hospital. What statement by the preceptor is most appropriate? a. Discrimination can occur at the societal level. b. The hospital needs more nurses like her. c. Prejudice and discrimination are not the same thing. d. There is always some discrimination against minorities.

ANS: A Discrimination can occur at the societal level, so even though this nurse is not prejudiced, patients from ethnic and cultural minorities can still suffer from discrimination. The other answers do not explain how discrimination can occur.

Which nurse has committed a serious documentation error? a. The nurse who documents all medications for assigned patients prior to administration. b. The nurse who documents medication administration as the medications are given. c. The nurse who documents assessments as soon as they are completed. d. The nurse who documents meal intake as meal trays are picked up.

ANS: A Documentation must be accurate to provide a realistic view of a patient's condition. Serious documentation errors include: (1) omitting documentation from patient records, (2) recording assessment findings obtained by another nurse or unlicensed assistive personnel (UAP), and (3) recording care not yet provided. Nurses sometimes document that a patient has received medication before its administration; this is a serious violation of the law and becomes a medication error of omission if the nurse is distracted before administering the patient's medication.

A home health care nurse has been working with a patient who has the Nursing diagnosis Spiritual Distress. After a few weeks of implementing the care plan, what method is best for the nurse to determine if goals have been met? a. Ask the patient to what extent he/she feels goals have been met. b. Ask the patient to rate the distress on a scale of 1 to 10. c. Assess for objective data to support goal attainment. d. Determine if the patient thinks the interventions are helpful.

ANS: A For a diagnosis with a large subjective component, getting the patient's feedback on goal attainment is best. There may be no objective data the nurse can use to rate goal attainment. Using a scale can be a part of the evaluation, but the patient's determination is best.

A nurse is discharging a patient and is planning on what material to give the patient to take home. What action by the nurse is best? a. Assess the patient's ability to read and understand. b. Determine if the patient wants to take written material home. c. Give the patient the same material as other patients get. d. Ask the patient if he/she has a need for writtenOmaterial.

ANS: A Health literacy in an important concept in health. If the patient cannot read or comprehend written material, it will be of limited use. The nurse first assesses the patient's ability to read and comprehend written material before choosing the material with which to send him/her home. Patients may or may not realize what they need for discharge, if anything. Giving the patient the same material other patients get does not acknowledge their need for holistic and individualized care.

A nurse has been asked to care for a patient who is an inmate from a nearby prison. During shift report, the nurse asks, "Why was the man convicted and imprisoned?" Another nurse responds that this is not important since nurses are required to provide compassionate care for all people in all circumstances. The responding nurse has displayed what concept? a. Beneficence b. Advocacy c. Confidentiality d. Autonomy

ANS: A In its simplest form, beneficence can be defined as doing good. Nurses demonstrate beneficence by acting on behalf of others and placing a priority on the needs of others rather than on personal thoughts and feelings. The ethical concept of beneficence necessitates providing care for the prisoner without reproach and provide compassionate care for all people in all circumstances. Supporting or promoting the interests of others or doing so for a cause greater than ourselves defines advocacy. Confidentiality is the ethical concept that limits sharing private patient information. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence.

According to the Health Belief Model, which of the following patients would be most likely to change health behavior? a. The person who perceives that he is at risk for colon cancer b. The person who recognizes that colon cancer is easily cured c. The person who believes that behavior can change outcomes d. The patient who faces multiple social barriers

ANS: A In the three primary components of the Health Belief Model, six main constructs influence an individual's decision to take action about disease prevention, screening, and controlling illness. The model suggests that individuals are motivated to take action if they believe that they are susceptible to the condition (i.e., perceived susceptibility), that the condition has serious consequences (i.e., perceived severity), that taking action would reduce the susceptibility or severity of the condition (i.e., perceived benefit), that the costs of taking action (i.e., perceived barriers) are outweighed by the benefits, that those who are exposed to factors (e.g., media campaigns, postcard reminders, and advice from others) will be prompted to action (i.e., cues to action), and that those who have confidence in their ability to perform an action will do so (i.e., perceived self-efficacy).

The nurse has been involved sexually with a patient. The nurse manager becomes aware of this situation and tells the nurse this behavior is a which type of crime? a. Malpractice b. Libel c. Slander d. Battery

ANS: A Malpractice may occur when a professional such as nurse acts unethically, demonstrates deficient skills, or fails to meet standards of care required for safe practice. Examples of these types of malpractice include engaging in sexual activity with a patient and administering penicillin to a patient with a documented penicillin allergy, resulting in the patient's death from a severe allergic (anaphylactic) reaction. Written forms of defamation of character are considered libel. Broadcasting or reading statements aloud that have the potential to hurt the reputation of another person is considered libel. Oral defamation of character is slander. Actual physical harm caused to another person is battery.

Several models exist that describe the relationship between health and wellness. Which model is used to understand the interrelationship between elements of basic requirements for survival and the desires that drive personal growth and development and is represented as a pyramid? a. Maslow's hierarchy of needs b. Health Belief Model c. Health Promotion Model d. Holistic Health Model

ANS: A Maslow's hierarchy of needs describes the relationships between the basic requirements for survival and the desires that drive personal growth and development. The model is most often presented as a pyramid consisting of five levels. The lowest level is related to physiologic needs, and the uppermost level is associated with self-actualization needs, specifically those related to purpose and identity. The Health Belief Model was developed by psychologists Hochbaum, Rosenstock, and Kegels. It explores how patients' attitudes and beliefs predict health behavior. The Health Promotion Model, developed by Pender and colleagues, defines health as a positive, dynamic state of well-being rather than the absence of disease in the physiologic state. Holistic health models in nursing care are based on the philosophy that a synergistic relationship exists between the body and the environment. Holistic care is an approach to applying healing therapies. Holistic models focus on the interrelatedness of body and mind.

The nurse caring for a patient with chronic pain uses guided imagery, therapeutic touch, and relaxation techniques as interventions for pain. The nurse is using what type of approach? a. Holistic b. Eastern holistic c. Risk factor reduction d. Health protection

ANS: A Nurses participate in holistic care through the use of natural healing remedies and complementary interventions. These include the use of art and guided imagery, therapeutic touch, music therapy, relaxation techniques, and reminiscence. Eastern holistic therapists have been using techniques such as acupuncture, yoga, and tai chi for thousands of years as methods of healing and, more recently, in conjunction with modern allopathic medical therapies. Risk factor reduction is step-by-step improvement of individual health factors. These combined improvements lower the likelihood of developing a disease. Health protection includes intentional behaviors aimed at circumventing illness, detecting it early, and maintaining the best possible level of mental and physiologic function within the boundaries of illness.

The nurse recognizes the nursing goal for individuals and families seeking preventative care is to have those groups carry out which action? a. Take responsibility for their health and wellness. b. Abandon the use of electronic educational media. c. Make lifestyle changes after diseases occur. d. Use temporary changes until the danger has passed.

ANS: A Nursing goals for all individuals and their families seeking preventive care are improvement of quality of life through positive lifestyle choices and taking responsibility for health and wellness. Nurses can refer patients to a variety of personal health quizzes, located in the online version of Healthy People 2020, for risk assessments of their health status and lifestyle. The quizzes allow people to track their health and wellness status over a period of years and identify trends in disease risk factors that can be modified through lifestyle interventions or preventive measures before the disease occurs. The Healthy People 2020 initiative helps nurses provide educational materials for individuals, families, and communities, enabling them to lead healthier lifestyles and to make permanent changes in wellness habits.

A patient who claims to be very involved in church is near death. What action by the nurse is best? a. Get permission to contact the religious leader. b. Allow the family to stay at the patient's bedside. c. Call the hospital chaplain to come to the bedside. d. Ask if the patient and family want to pray.

ANS: A Organized religions use rituals to mark important life events such as birth, marriage, and death. This patient would most likely want end-of-life rituals as practiced in his/her church. The nurse's best action is to contact the religious leader (with permission) of that church or institution. Allowing the family to remain at the bedside is important but not the best option to care for the patient's spirituality needs. The hospital chaplain is a valuable resource, but the patient's own religious leader would be better. Praying with the family is always acceptable, but it is best to let the family take the lead in prayer.

When discussing immunizations for infants and children with new parents, the nurse should focus on which approach? a. Providing scientific evidence to parents b. Stressing that nonimmunization is a crime c. Acknowledging that immunizations are not needed d. Informing the parents that they have no choice

ANS: A Parents need to have scientific, evidence-based information about immunizations and their consequences before choosing to accept or reject immunizations for their children. The parent's ability to make an informed decision is the primary goal for nurses educating people about childhood immunizations.

A patient has the Nursing diagnosis Spiritual Distress. What assessment by the patient best indicates that an important goal has been met? a. Observed praying quietly. b. Indecisive about treatment. c. Asks nurse if God exists. d. Executes living will.

ANS: A Patients may have spiritual distress when facing situations that threaten their meaning and purpose in life, such as in the face of a terminal diagnosis. Patients often express anger, frustration, neediness, or crying. The patient who has worked through this situation and is able to pray has best shown goal attainment. Indecision and questioning do not indicate the resolution of this diagnosis. Executing a living will may be an indication of pragmatism.

The nurse is caring for a patient who is to have a cleansing enema. Which assessment finding b the nurse indicates a need to contact the prescriber and question the order? a. The patient is recovering from a traumatic brain injury. b. The patient has not had a bowel movement for 3 days. c. The patient is to have a lower GI series the following morning. d. The patient had an upper GI series performed the previous day.

ANS: A Patients with a traumatic brain injury often have increased intracranial pressure, which can be worsened with enema administration, thus putting the patient at risk for additional neurologic damage. The provider should be contacted and the order should be questioned. Constipation, preparation for a lower GI series, and removal of barium from the colon after upper GI series are all indications for a cleansing enema.

A patient refuses to take his blood pressure medication because "I feel totally fine and don't need it." What action should the nurse take first? a. Assess the patient's time orientation. b. Document the patient's noncompliance. c. Educate the patient about the medication. d. Warn the patient about possible complications.

ANS: A People with a present time orientation typically live in the "here and now" and may not see the benefit of adhering to medical regimens when they are not symptomatic. The nurse should assess the patient's time orientation. Documentation and education are both important but are not likely to secure the patient's cooperation.

The nurse is providing care for a patient who demands discharge from the hospital against the physician's orders. What action by the nurse is most appropriate? a. Have the patient sign an "Against medical advice" form. b. Follow the guidelines as presented in the code of Academic and Clinical Conduct. c. Review the ANA's Nursing Code of Ethics for guidance. d. Permit the patient to leave after an informed consent form is signed.

ANS: A Preventing patients from leaving a health care facility at their request may be considered false imprisonment. To prevent health care providers and institutions from being held liable if a patient chooses to leave a facility when physicians and nurses think that it is in the patient's best interest to remain hospitalized, the patient is asked to sign an against medical advice (AMA) form. A signed AMA form documents that the patient has chosen to leave the facility when leaving could jeopardize the patient's condition. The National Student Nurses Association adopted the Code of Academic and Clinical Conduct, in which students agree to "promote the highest level of moral and ethical principles" and "promote an environment that respects human rights, values, and choice of cultural and spiritual beliefs." This document does not apply to the issue at hand. The Code of Ethics for Nurses is "a succinct statement of the ethical obligations and duties of every individual who enters the nursing profession." While this is resource for nurses the described situation requires nurses to follow facility policy. Informed consent is permission granted by a patient after discussing each of the following topics with the physician, surgeon, or advanced practice nurse who will perform the surgery or procedure: (1) exact details of the treatment, (2) necessity of the treatment, (3) all known benefits and risks involved, (4) available alternatives, and (5) risks of treatment refusal. This does not apply to the stated situation.

A nurse is planning primary prevention activities. Which activity would the nurse include in this plan? a. Safer sex education for teens b. Mammogram screening c. Medication compliance d. Annual physical exams

ANS: A Primary prevention includes activities designed to prevent a disease or condition from occurring in the first place. Examples of primary prevention activities include vaccinations, wellness programs, good nutrition for health, and safer sex programs. Mammograms and physical exams are secondary prevention measures. Medication compliance would be tertiary prevention.

A nurse is working with a patient who has limited English proficiency. What action by the nurse is best? a. Use a qualified interpreter. b. Ask family members to translate. c. Use drawings and pictures. d. Speak in simple sentences.

ANS: A Qualified interpreters should be utilized when working with non- or limited-English speaking persons. Using a family member to interpret can upset the balance of power within the family, cause embarrassment, and lead to inaccuracies. Using drawings and pictures or speaking in simple sentences is not as effective as using an interpreter.

The nurse is caring for a patient who has just died in a motor vehicle accident. What is the priority action of the nurse before the patient's family arrives to see the patient's body? a. Gently wash the body and provide perineal care. b. Remove the patient's dentures and jewelry. c. Ensure that the death certificate has been signed. d. Determine which funeral home will pick up the body

ANS: A Release of bowel and bladder contents often occur at the time of death, and the perineal care is a priority before the family arrives. The body should be gently cleaned to remove blood and debris from the accident. The patient's dentures and jewelry should not be removed from the body. The death certificate does not need to be signed before the family arrives. The family can decide which funeral home will be used and notify the nurse after their arrival.

An overweight, sedentary middle-aged smoker with a family history of cardiac disease has noticed a steady rise in resting blood pressure over a 3- to 4-year period. The patient is concerned about his slightly elevated blood pressure and begins walking 20 to 30 minutes in the evenings with his wife and reduces his pack-a-day cigarette habit to ten cigarettes a day. The nurse identifies these actions are the initial step of which behavior? a. Risk factor reduction b. Self-actualization c. Self-transcendence d. Health promotion

ANS: A Risk factor reduction is step-by-step improvement of individual health factors. These combined improvements lower the likelihood of developing a disease. Maslow considered self-actualization the highest level of optimal functioning and involves the integration of cognition, consciousness, and physiologic utility in a single entity. In later years, Maslow described a level above self-actualization called self-transcendence. He refers to self-transcendence as a peak experience, in which analysis of reality or thought changes a person's view of the world and his/her position in the greater structure of life. Health promotion is behavior motivated by the desire to increase well-being (as opposed to preventing illness) and optimize health status.

A nurse is caring for a refugee patient who wants the community shaman to perform a healing ritual at the bedside. What action by the nurse is best? a. Work with the patient to allow the shaman to perform the ritual. b. Investigate whether the ritual will harm the patient. c. Check to see if the ritual breaks laws or policies. d. Offer to call the hospital chaplain instead.

ANS: A Rituals are deeply powerful and have great meaning for individuals who practice them. The nurse should work with the patient to facilitate the ritual. Investigating the ritual for patient harm or illegality is ethnocentric; the nurse's first thoughts should not be on the potential negative aspects of a deeply meaningful activity. The patient has not requested the chaplain; offering to call the chaplain shows ethnocentrism and lack of respect for the patient. While working to facilitate the ritual, the nurse will discover if any aspect of it might be problematic and can collaborate with the patient and shaman to resolve the situation (e.g., if lighted candles are needed but prohibited by policy and fire code).

When planning interventions for a community, what action by the nurse is best? a. Involve community leaders in planning. b. Create a plan of action addressing priorities. c. Determine what resources are available. d. Attempt to find funding for the plan

ANS: A Stakeholders need to be involved in planning to ensure buy-in from the community. The stakeholders could be community or business leaders. The other actions are important, but if the community leaders are not committed to the plan, the plan is unlikely to work.

The nurse is providing care for a patient who has had a stroke recently and has multiple self-care deficits. The nurse is coordinating care with in-home agencies and arranging for the delivery of needed equipment. Which ethical concept is the nurse applying? a. Advocacy b. Confidentiality c. Autonomy d. Accountability

ANS: A Supporting or promoting the interests of others or doing so for a cause greater than ourselves defines advocacy. Confidentiality is the ethical concept that limits sharing private patient information. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. Accountability is the willingness to accept responsibility for one's actions.

The nurse knows which statement indicates an appropriate understanding of ethical practice by the student nurse? a. "I will be held to the same ethical standards as professional nurses." b. "I will not be held ethically accountable until I graduate." c. "My nurse educators are responsible for my ethical standards." d. "Ethics are not important as a student."

ANS: A The Code of Ethics for Nurses is "a succinct statement of the ethical obligations and duties of every individual (not just nurse educators) who enters the nursing profession," the profession's "nonnegotiable ethical standard," and "an expression of nursing's own understanding of its commitment to society." This is a powerful mandate for all nurses to communicate and act professionally to prevent inflicting physical or emotional pain on others while pursuing nursing education and engaging in nursing practice.

A patient in the hospital is an adherent Muslim. Which of the five pillars of Islam can the nurse assist the patient in meeting? a. Praying five times a day b. Having privacy c. Personal cleanliness d. Giving alms e. Maintaining modesty

ANS: A The five pillars of Islam are: believe in one God, pray five times a day facing Mecca, giving alms to the less fortunate, fasting during Ramadan, and making a pilgrimage to Mecca. The nurse is best able to help the patient maintain the practice of praying five times a day while hospitalized.

The nurse recognizes which concept that correctly completes the definition of the genetic vulnerability of an organism (risk of disease expression based on genotype)? a. It is involuntarily passed from biologic parents to offspring. b. It is totally unrelated to environmental factors. c. It is nonresponsive to alteration by way of lifestyle modification. d. It is not a factor in mental illness because it is behavioral.

ANS: A The genetic vulnerability of an organism, or risk of disease expression based on genotype, is involuntarily passed from biologic parents to their offspring. Societal attitudes about testing and management of high-risk populations depend on the potential for expression of genetic disorders that may be triggered by environmental factors. Controlling factors that place stress on physiologic function can reduce pathologic genetic expression and susceptibility to disease. For example, a person with a family history of hyperlipidemia and atherosclerosis is at risk for developing cardiovascular disease later in life. Lifestyle-modifying factors, such as weight reduction, daily exercise, and balanced nutritional intake, can help reduce the likelihood that the genetic risk factor for heart disease will be expressed. Diabetes, cancer, mental illness, and renal disease also have genetic components and are amenable to interventions that reduce risk.

The nurse is caring for a patient who has an ileostomy. Which Nursing diagnosis has the highest priority for the patient? a. Impaired skin integrity r/t localized skin irritation from liquid stool b. Social isolation r/t potential leakage of stool from ostomy appliance c. Lack of knowledge r/t care and maintenance of ostomy appliance d. Disturbed body image r/t presence of stoma and altered elimination

ANS: A The highest priority Nursing diagnosis for this patient is impaired skin integrity because the liquid stool from the ileostomy quickly leads to breakdown when in contact with the skin. Open sores can lead to bacterial infection and significant discomfort for the patient. In addition, ostomy appliances do not adhere well to open wounds, increasing the risk for continuing skin breakdown. The other nursing diagnoses are appropriate for this patient but are not the highest priority.

The nurse is caring for a patient who is having difficulty coping after being in a motor vehicle crash in which her brother was killed. The patient was driving the car and blames herself for the accident. What is the priority nursing intervention of the nurse? a. Check to make sure that the patient does not want to hurt or kill herself. b. Educate the patient about available support systems for grief resolution. c. Enhance the patient's coping skills to alleviate depression and anxiety. d. Encourage the patient to meet with a spiritual leader for guidance.

ANS: A The highest priority for the nurse is to ensure the safety of the patient, so assessment of potential suicidal tendencies is paramount. The other interventions can take place once the nurse is confident that the patient will not try to hurt or kill herself.

The nurse is caring for a patient who has had a severe stroke and requires assistance to use the toilet. Which goal is the highest priority for this patient? a. The patient will remain continent with no perineal skin breakdown. b. The patient will state satisfaction with use of gait belt for toilet transfers. c. The patient will regain ability to pull up clothing after using the toilet. d. The patient will have privacy once properly positioned on the toilet.

ANS: A The highest priority goal for this patient is continence with no perineal skin breakdown to maintain skin integrity and self-esteem. Patient statements of satisfaction and the ability to pull up clothing are important but not the priority over preventing skin breakdown. Privacy is an intervention to be performed by the staff rather than a goal for the patient.

The nurse is caring for a patient who is recovering after hip surgery. The patient requires assistance to use the bathroom because no weight bearing is allowed on the right leg. Which goal is most important for the nurse to include for the diagnosis Impaired self-toileting? a. The patient will demonstrate safe transfer technique between wheelchair and toilet. b. The call light will be answered promptly when the patient needs to use the toilet. c. Toileting will be scheduled in the morning when the patient needs to defecate. d. Toilet paper and handwashing items will be kept within easy reach of the patient.

ANS: A The highest priority goal for this patient is the demonstration of safe transfer technique between the chair and the toilet. The other statements are interventions performed by staff rather than goals that will be accomplished by the patient.

The nurse is caring for a patient who lost her husband 1 year ago after 55 years of marriage. The patient no longer takes care of herself or cooks and rarely eats, stating she has no appetite. The nurse determines that the Nursing diagnosis of complicated grieving applies to the patient. Which is the priority goal for the patient? a. The patient will shower every other day and eat at least two meals a day. b. The patient will identify personal strengths that will increase coping ability. c. The patient will discuss the meaning of her loss with a family member or friend. d. The patient will be provided with phone numbers for local community resources.

ANS: A The highest priority goal of this patient is self-care including showering and eating in order to protect her health and safety. The other goals are lower priority after the patient's necessary activities of daily living are addressed. Goals should also reflect what the patient accomplishes; so the goal of being provided with phone numbers is actually something for the nurse to do.

A nurse has assessed a community and has found many areas in which health can be improved. As a result, the nurse has multiple ideas for programming. What action by the nurse is best? a. Determine what the community thinks is most important. b. Use vital statistics to determine which is most important. c. See what other communities are focusing programming on. d. Choose the easiest problem to address first.

ANS: A The nurse's priorities may be very different from the community's. For programming to be successful, there must be buy-in from members of the community. Unless programming addresses a need the community thinks is important, it is unlikely to be successful.

The nurse is caring for a terminally ill patient whose children have come home to be with their mother during her last few days. They spend time looking through picture albums, watching old home movies, and remembering fun times spent together. The nurse identifies which term that best describes the activity of the patient's children? a. Anticipatory grieving b. Bereavement c. Caregiver role strain d. Death anxiety

ANS: A The patient and her children are experiencing anticipatory grief as they prepare for the expected death of the patient. Reminiscence and life review are used to assist those experiencing anticipatory grief with the realization that death is approaching.

The nurse is caring for a patient who suffered a miscarriage at 24 weeks of pregnancy. The patient is devastated by the loss but her husband minimizes her grief by stating, "Quit crying. It's not like you lost a real baby." What term best describes the anguish felt by the patient? a. Disenfranchised grief b. Delayed grief c. Moral distress d. Masked grief

ANS: A The patient is experiencing disenfranchised grief because she cannot share the pain of her loss with her husband. The husband is not willing to support his wife as she mourns the loss of her pregnancy or recognize the grief that she is going through. Delayed grief is suppression of the grief process. Moral distress occurs when people cannot act according to their moral values. Masked grief occurs when a person's bereavement behaviors interfere with his or her life, but the person does not notice this.

The hospice nurse is caring for a terminally ill patient who will probably die within the next hour or two. The patient's daughter is keeping a vigil by the bedside and asks what she can do to help her father at this time. What is the appropriate response of the nurse? a. "Just let him know you are here, talk to him, and let him know that you love him." b. "You can try to feed him a few bites of ice cream to keep his mouth from getting dry." c. "You can take this time to ensure that arrangements are set with the funeral home." d. "You should let me know when your father's breathing pattern changes."

ANS: A The patient's daughter should be encouraged to spend the last moments of her father's life with him, reassuring him with her presence. The daughter should be encouraged to continue talking with him because the patient may still hear her even if his eyes are closed and he does not speak. The nurse is responsible for monitoring the patient for breathing changes. Oral intake will lead to nausea and/or aspiration. This is not the time to make arrangements with the funeral home.

The nurse is caring for a patient who is terminally ill with metastatic bone cancer. The patient tells the nurse that he is not afraid of death but does not want to be in pain and suffer before he dies. Which intervention by the nurse will be most appropriate to meet this patient's wishes? a. Establish around-the-clock dosing for pain medications with additional doses for breakthrough pain. b. Assist the patient to reminisce and review his life, spending as much time as possible with loved ones. c. Use therapeutic touch, guided imagery, and soft music to put the patient at ease and relieve anxiety. d. Encourage the patient to participate in prayer and meditation along with preferred religious practices.

ANS: A The patient's primary wish is to die without pain, and the best intervention to meet this goal is administration of pain medication around the clock with extra doses for breakthrough pain. The other interventions may make the patient more comfortable but will not address his primary desire for adequate pain management.

The nurse is caring for a patient who is taking narcotic pain medication after surgery. Which breakfast choices will help prevent constipation and promote return to regular bowel function? a. Raisin bran with skim milk, fresh fruit, and wheat toast b. Pancakes with maple syrup, bacon, and coffee with cream c. Omelet with cheddar cheese, green pepper, and onions d. Bagel with cream cheese, and strawberry nonfat yogurt

ANS: A The postoperative patient taking narcotic pain medications is at risk for developing constipation. A high-fiber diet with plenty of liquids will help prevent this from occurring. Raisin bran, fruit, and wheat bread are all good sources of fiber.

The nurse is caring for a patient who is recovering from bowel surgery. Which assessment finding best indicates that the bowel is starting to resume function and the patient will be able to resume oral intake soon? a. The patient has bowel sounds x 4 quadrants and is passing gas. b. The patient has no nausea, and abdominal pain is minimal. c. The patient feels hungry for chicken soup and hot tea. d. The patient's nasogastric tube was discontinued the previous day

ANS: A The presence of bowel sounds and passage of flatus indicate that the patient's bowels are starting to resume function and the patient will be able to resume oral intake soon. Hunger, discontinuation of the NG tube, or absence of nausea are not definite indicators of readiness to resume oral feedings.

The nurse is caring for a postoperative patient who underwent bowel resection surgery that morning. The nurse assesses the patient's abdomen and notes that there are hypoactive bowel sounds. The patient is resting quietly without nausea or vomiting. What is the appropriate action of the nurse? a. Keep the patient NPO and document the findings in the chart. b. Administer a laxative suppository to stimulate peristalsis. c. Insert a Salem sump nasogastric tube to low continuous suction. d. Notify the surgeon and prepare the patient to return to surgery.

ANS: A The presence of hypoactive bowel sounds is an expected finding for the first hours after abdominal surgery. The patient should be kept NPO to prevent nausea and vomiting. A laxative should not be administered. A nasogastric tube is not needed unless the patient starts vomiting or a paralytic ileus develops.

A nurse is wondering if home health care nursing is a good fit. What characteristic or ability does the experienced home health care nurse suggest is most important? a. Clinical reasoning b. Organization c. Assessment skills d. Time management

ANS: A The role of the registered nurse in home health care is essentially autonomous in that the nurse must be highly proficient in health assessment (physical and psychosocial), be well versed in complex technical and clinical skills, possess strong critical-thinking and clinical reasoning abilities, and demonstrate excellent organizational skills. All choices are important characteristics or abilities of home health care nurses. However, since the nurse working out in the community may not have the resources (personnel or materiel) available in an acute care facility and often must improvise, clinical reasoning would be the most important of the choices provided.

A nurse is concerned about not consistently meeting the spiritual needs of patients. What action by the nurse is best? a. Care for own spiritual needs. b. Begin a meditation practice. c. Consult the chaplain. d. Read books on the subject.

ANS: A To avoid burnout and a decreased ability to attend to the spiritual needs of patients, nurses must take care of their own spiritual needs first. This may include meditation, consultations, and reading, but other activities can guide the nurse into a reflective practice that will allow better spiritual care.

Which recommendations would the nurse identify as appropriate screening guidelines? (Select all that apply.) a. Women ages 21 to 29 should have a Pap test every 3 years. b. Self-breast exams should be addressed with male and female patients. c. Adolescent males should perform monthly self-testicular exams. d. Women ages 30 to 65 should receive Pap tests every 10 years. e. After a total hysterectomy, Pap testing should be more frequent

ANS: A, B, C All women should begin cervical cancer screening at the age of 21 years. Women between the ages of 21 and 29 years should have a Papanicolaou (Pap) test every 3 years. A priority assessment task for nurses in a variety of care settings is to ask female and male patients about breast self-examination. An adolescent male should be assessed for testicular self-examination habits, and older males should have an annual prostate examination. Women between the ages of 30 and 65 years should have a Pap test plus a human papillomavirus (HPV) test (i.e., co-testing) every 5 years. Women 65 years of age or older who have had normal results for previous Pap tests should no longer be screened. Women who have had a total hysterectomy (i.e., removal of the uterus and cervix) should not be tested, unless the surgery was done as a treatment for cervical cancer or pre-cancer.

The home health care nurse educates patients on which goals of hospice care? (Select all that apply.) a. Relieve suffering. b. Support the patient and family. c. Provide grief support. d. Keep patients out of the hospital. e. Lower medical expenses.

ANS: A, B, C The goals of hospice care include relief of suffering, supporting the family and patient, and providing grief support after the patient dies. Goals do not include keeping patients out of the hospital or lowering medical costs.

The student studying culture learns that which are characteristics of all cultures? (Select all that apply.) a. Integrated b. Shared c. Learned d. Symbolic e. Inherited

ANS: A, B, C, D Cultures are learned, symbolic, shared, and integrated. Since culture refers to patterns of beliefs, actions, values, and ways of life that are taught, they are not inherited.

The nurse explains to the patient that which services will be covered under Medicare? (Select all that apply.) a. Infusion therapy b. Ostomy management c. Renal dialysis d. Chemotherapy e. Grocery shopping

ANS: A, B, C, D Medicare will reimburse for professionally rendered services provided by a licensed health care provider. Grocery shopping would not be covered. If homemaker services are provided to a patient also receiving skilled care, then they too are reimbursed.

The nurse assessing a patient using the SPIRIT framework would ask which questions? (Select all that apply.) a. "Do you follow a particular religion?" b. "How involved in your church are you?" c. "Are there any practices I can help you with?" d. "How will your religion affect your care?" e. "What gives you hope in bad situations?"

ANS: A, B, C, D SPIRIT stands for Spiritual belief system, personal spirituality, integration and involvement in a spiritual community, ritualized practices and restrictions, implications for medical care, and terminal events planning. Hope is a good thing to assess but is more related to the HOPE framework.

The nurse manager of the unit is implementing a program to assist the nursing staff in managing compassion fatigue. Which interventions will be the most successful? (Select all that apply.) a. Support group that nurses can participate in that meets on the unit b. Exercise competitions to encourage nurse to exercise and log their time c. Organized break times so nurses can get off the unit for breaks and lunches d. Quiet area on the unit where the nurses can go during break e. Promotion of work-life balance

ANS: A, B, C, D, E To care most effectively for others, nurses must first take time to care for themselves. Many of the stress reduction interventions incorporated into patient care plans can be effective in addressing the stressors faced by nurses. Exercise, balanced nutrition, and mindfulness therapy have been shown to help health care professionals in coping with the demands of patient care. Interventions designed specifically to prevent nurse burnout and address compassion fatigue include mentoring programs, quiet areas on a nursing unit for relaxation, availability of pastoral care, the sharing of feelings with trusted colleagues, and promotion of work-life balance.

The nurse is caring for a patient who has just died. Which assessment findings by the physician and nurse are used to confirm that death has occurred? (Select all that apply.) a. The patient was incontinent of bowel and bladder b. The patient's pupils are fixed and dilated. c. The provider does not hear a heartbeat d. The patient's extremities are cool and mottled e. The patient has no palpable peripheral pulses. f. The patient's face is relaxed and the mouth is open.

ANS: A, B, C, E Assessment findings that confirm death has occurred include lack of pulse/heartbeat and fixed dilated pupils. Cool, mottled extremities, relaxed muscles, and incontinence of bowel and/or stool are common assessment findings in patients who are dying.

The nurse manager of a busy oncology unit is concerned about compassion fatigue among the nursing staff. Which signs and symptoms would alert the nurse to this problem? (Select all that apply.) a. Nurses become very emotionally upset without an apparent cause. b. Nurses start to avoid caring for certain patients. c. Nurses start to call in sick more often. d. Nurses begin working more overtime. e. Nurses have difficulty showing empathy for patients.

ANS: A, B, C, E Compassion fatigue occurs when deeply caring and empathetic nurses become overwhelmed by the constant needs of patients and families. Symptoms include mood swings, avoidance of working with some patients, frequent sick days, irritability, reduced memory, poor concentration, and a decreased ability to show empathy.

The nurse understands that which are important in the process of developing a cultural identity? (Select all that apply.) a. School b. Church/religious institution c. Family d. History e. Community

ANS: A, B, C, E Many institutions and groups, both formal and informal, assist an individual in developing a cultural identity, including school, religious institutions, family, and community.

The nurse is using Giger and Davidhizar's Transcultural Assessment Model to gain information about a patient from an unfamiliar culture. What questions does the nurse ask that are relevant to this mode? (Select all that apply.) a. "Who would you like present to help answer questions?" b. "What do you believe caused your current illness?" c. "How important is planning for the future to you?" d. "Why don't you want to shake my hand?" e. "What activities would you do to control your health?"

ANS: A, B, C, E The Giger and Davidhizar Transcultural Assessment Model looks at communication, space, social orientation, time, environmental control, and biological variation. The questions all address these factors; however, asking why the patient does not want to shake the nurse's hand sounds judgmental and "why" questions are a communication barrier.

When does the nurse assess patients' spirituality? (Select all that apply.) a. Upon admission b. New diagnosis c. Life-changing diagnosis d. When the chaplain makes rounds e. When facing treatment decisions

ANS: A, B, C, E There are many times at which a spiritual assessment is necessary. All patients should have their spirituality assessed upon admission at a minimum. Other assessments should be conducted at times when the patient is at risk for spiritual distress. Assessment should be done based on patient need, not when the chaplain is available.

The nurse who incorporates the HOPE framework assesses a Native American patient for which of the following? (Select all that apply.) a. Desire for shaman to be present b. Personal use of herbs and prayers c. Desire to create a living will d. Power of storytelling for healing e. Involvement in church activities

ANS: A, B, D Native Americans often use shamans; prayers, songs, and dances; storytelling; and herbs in health care. The HOPE framework assesses sources of hope, meaning comfort, strength, peace, love, and connection; organized religion; personal spirituality and practice; and effects on medical care and end-of-life issues. The nurse who knows about both topics will assess this patient for the desire for a shaman to be present, the personal use of herbs and prayers, and storytelling. A living will is more accurately assessed with the SPIRIT framework. Involvement in church activities can be best assessed using either the SPIRIT or FICA framework.

The nurse is caring for a patient who will be having a colonoscopy the following morning. Which items must be removed from the patient's dinner tray since they are not allowed prior to the test? (Select all that apply.) a. Cherry-flavored gelatin b. Cream of chicken soup c. Glass of apple juice d. Coffee with cream and sugar e. Lemon-flavored Italian ice f. Can of ginger ale

ANS: A, B, D Patients who will undergo colonoscopy testing should have a clear liquid diet the day before the exam, so cream of chicken soup and coffee creamer should not be consumed. Foods with red food coloring should also be avoided prior to colonoscopy.

The nurse recognizes which personality factors that have been shown to buffer the impact of stress? (Select all that apply.) a. Resilience b. Sense of coherence c. Gender d. Hardiness e. Coping style

ANS: A, B, D Personality factors such as resilience, hardiness, and sense of coherence can buffer the impact of stress, reducing the negative consequences. Gender is not a personality factor. Coping style refers to a pattern of measures taken to relieve stress but is not a personality factor.

A nurse is assessing social determinants of health. Which does the nurse include in the assessment? (Select all that apply.) a. Vaccination compliance b. Family structure c. Communication patterns d. Roles for women e. Education

ANS: A, B, D, E Income, education, health literacy, where people live or work, early childhood development, social exclusion, family structure, the status and role of women, and vaccination adherence are just some of the social determinants of health recognized worldwide. Communication patterns often are important to assess in culturally diverse individuals, families, and communities, but this is not considered a social determinant of health care.

In addition to maintaining current professional practice knowledge, competent practice skills, and professional relationships with patients and their families, what additional actions should the nurse take to practice within the law? (Select all that apply.) a. Maintain confidentiality. b. Follow legal guidelines for sharing information. c. Block document once per shift. d. Change nursing procedures according to latest journal articles. e. Meet licensure and continuing education requirements.

ANS: A, B, E In addition to maintaining current professional practice knowledge, competent practice skills, and professional relationships with patients and their families, nurses should follow guidelines to practice legally and avoid charges of malpractice, maintain confidentiality, follow legal and ethical guidelines when sharing information, document punctually and accurately, adhere to established institutional policies governing safety and procedures, comply with legal requirements for handling and disposing of controlled substances, meet licensure and continuing education requirements, and practice responsibly within the scope of personal capabilities, professional experience, and education.

The nurse is caring for a patient who just died after a lengthy illness. Which portions of postmortem care may be delegated by the nurse to the nursing assistant? (Select all that apply.) a. Gently washing the body and closing the patient's eyes b. Offering support and empathy to the patient's family members c. Documenting the patient's time of death in the medical record d. Notifying all of the patient's consulting providers of the patient's death e. Removing the patient's hospital ID band, IV lines, and urinary catheter f. Gathering the patient's belongings so they may be taken home by the family

ANS: A, B, F The nurse assistant can gently wash the patient's body, close the patient's eyes, and gather the patient's belongings. Offering support and empathy to the patient's family members would be done by all of the involved members of the nursing staff. Documenting the time of death in the chart and notifying all of the patient's providers is performed by the nurse. The nurse assistant can remove the patient's IV lines and urinary catheter if allowed by policy, but the hospital ID band would be left in place.

The nursing student learns which facts about religion and spirituality? (Select all that apply.) a. Spirituality focuses on the meaning of life to people. b. Religion and spirituality are mutually exclusive. c. Religion implies an organized way of worship. d. Religion provides the structure by which to understand spirituality. e. Spirituality is an individual practice that does not include others.

ANS: A, C, D Spirituality focuses on the meanings of life, death, and existence. Religion is an organized and structured method of practicing or expressing one's spirituality, so they are interconnected and not mutually exclusive. Religion provides the structure for expressing spirituality. Spirituality can be expressed through relationships with others.

A nurse wants to create a community action plan for health problems related to air pollution from a nearby factory. Which stakeholders does the nurse consult as the priority? (Select all that apply.) a. Factory owners b. Stock shareholders c. Community residents d. Local health care providers e. Factory employees

ANS: A, C, D Stakeholders have a significant interest in a topic. The priority stakeholders the nurse would want to consult for this project include the factory owners, community residents, and health care providers. The stockholders would probably not be consulted. The employees could be a significant stakeholder if the action plan affected employment.

The nurse is conducting a windshield survey. What items does the nurse assess? (Select all that apply.) a. Types of housing available b. Cars seen in parking lots c. Recreational facilities d. Health care facilities e. Places of worship

ANS: A, C, D, E A windshield survey is a type of community health assessment. The nurse walks or drives through a neighborhood and notes the type of housing available, the presence and condition of recreational facilities, the presence of health care facilities, and places of worship among other items. Types of cars noted in the neighborhood are not one of the assessments.

The student using the FICA Spiritual Health Assessment will consider which factors? (Select all that apply.) a. Faith and belief b. Focused practices c. Importance of faith d. Faith community involvement e. Address spirituality in care

ANS: A, C, D, E FICA stands for faith and belief, importance of faith, faith community involvement, and address spirituality in care.

Which actions by a nurse constitute spiritual care? (Select all that apply.) a. Baptizing a critically ill child per the parent's request b. Leaving the room, giving the patient and family privacy for prayer c. Considering developmental stage when planning care d. Notifying the hospital chaplain of a patient's request e. Praying with patients and families when requested

ANS: A, C, D, E Many activities fall into the realm of spiritual nursing care, including baptizing an infant in an emergency, notifying the chaplain or other religious leader of patient requests for service, and praying with the patient and family. The nurse always considers the patient's developmental level when planning or providing any type of care. The patient and/or family may or may not want privacy for prayer; the nurse should assess the situation and not just leave.

Which statements by the nurse are correct regarding informed consent and someone who requires an interpreter? (Select all that apply.) a. A professional interpreter is needed. b. A family member may interpret when convenient. c. Detailed medical information remains a priority. d. Professional interpreters are not effective in providing medical information. e. If necessary, family members can make decisions regarding informed consent.

ANS: A, C, E If a patient is illiterate or requires an interpreter, the method of obtaining informed consent must be adapted appropriately. Use of a professional interpreter rather than a family member is essential to provide detailed medical information accurately. A patient whose culture prefers to allow other family members to make final health care decisions is inconsistent with nursing's ethical belief in autonomy. However, in this situation, the method of obtaining informed consent may need to be adapted to meet the patient's beliefs within the scope of the law.

The nurse knows that when patients are experiencing stress, which physiologic changes can be seen in their signs and symptoms? (Select all that apply.) a. Increase in heart rate b. Flaccid muscles c. Pupil dilation d. Decrease in blood pressure e. Increase in respiratory rate

ANS: A, C, E The physiologic response to stress, whether physical or psychological, is activation of the autonomic nervous system, resulting in an increase in heart rate, blood pressure, and respirations along with pupil dilation and muscle tension and decreased blood flow to the skin.

The nurse is caring for a postoperative patient who had a colostomy placed 2 days ago. The appliance needs to be changed for the first time. Which ostomy care actions can the nurse delegate to the nursing assistant? (Select all that apply.) a. Gently cleaning the stoma with warm water and a washcloth b. Assessing the stoma and incision for signs of infection or ischemia c. Obtaining needed supplies from the clean utility room d. Teaching the patient how to care for the ostomy after discharge e. Determining which type of ostomy appliance to use f. Application of skin protectant to the area surrounding the stoma

ANS: A, C, F The nursing assistant can gently clean the stoma with warm water and a washcloth, obtain needed supplies, and apply skin protectant. The nurse is responsible for assessment, teaching, and determining which ostomy appliance to use.

The nurse identifies which factors that center on the childhood stress related to school experiences? (Select all that apply.) a. Goal achievement b. Family dissolution c. Life changes d. Test anxiety e. Competition

ANS: A, D, E Childhood stress related to the school experience centers on competition, goal achievement, and test anxiety. Family dissolution and life changes are not related to the school experience.

The nurse recognizes which of the following to be a benefit of regular physical exercise? (Select all that apply.) a. Enhances the immune system. b. Decreases bone density. c. Limits joint mobility. d. Improves mental health. e. Helps to prevent type 2 diabetes.

ANS: A, D, E Exercise is essential for the prevention of illness and promotion of wellness. Physical exercise is any bodily activity or movement that enhances or maintains physical fitness levels and overall health. Exercise strengthens muscles, improves cardiovascular performance, hones athletic skills and endurance, and reduces or maintains weight, and it is performed for enjoyment (Powers and Howley, 2012). Regular physical exercise enhances the immune system, builds and maintains healthy bone density, increases joint mobility, and helps to prevent cardiovascular disease, type 2 diabetes, and obesity. Exercise also improves mental health and helps to prevent depression through the release of endorphins and other neurotransmitters that are responsible for exercise-induced euphoria (Powers and Howley, 2012).

The student nurse learns that spirituality consists of practices that lead to connection to which items? (Select all that apply.) a. Other people b. Nature c. Religious institutions d. Oneself e. Higher power

ANS: A, D, E Spiritual practices generally promote three categories of activity: connection with oneself, with others, and with a higher power.

A nurse is studying intrinsic factors that influence the development of asthma in a community. What factors does the nurse assess? (Select all that apply.) a. Socioeconomic status b. Genetics c. Pollution in the area d. Water cleanliness e. Immunization status

ANS: A, E Host, or intrinsic factors are individual variables such as genetics, age, gender, ethnic group, immunization status, and human behavior that impact a person's health. The other options are all extrinsic factors, which pertain to environmental characteristics.

The nurse is working with a patient from an unfamiliar culture. After assessing the patient and the patient's cultural beliefs related to health care, what action by the nurse is best? a. Create a nursing plan of care for the patient. b. Recheck cultural beliefs with the patient. c. Use a standard plan of care for consistency. d. Have an interpreter validate the information

ANS: B According to Leininger, the nurse should recheck assumptions and findings related to culture with the patient. This is an important step prior to creating a care plan. A standard plan will not be culturally congruent. The stem does not indicate that the patient has limited English, but if he did, using an interpreter would be important.

The nurse realizes that a medication error has been made. The nurse then reports the error and takes responsibility to ensure patient safety despite personal consequences. This nurse has exhibited what ethical concept? a. Autonomy b. Accountability c. Justice d. Advocacy

ANS: B Accountability is the willingness to accept responsibility for one's actions. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. Supporting or promoting the interests of others or doing so for a cause greater than oneself defines advocacy. To do justice is to act fairly and equitably.

The nurse recognizes that starting an intravenous (IV) infusion line on a patient against his will may be classified as which wrongdoing? a. Assault b. Battery c. Felony d. Misdemeanor

ANS: B Actual physical harm caused to another person is battery. Battery may involve angry, forceful touching of people, their clothes, or anything attached to them. Performing a surgical procedure without informed consent is an example of battery. Actions much more subtle, such as inserting an intravenous catheter or urinary catheter against the will of a patient, also may be classified as battery. Assault is a threat of bodily harm or violence caused by a demonstration of force by the perpetrator. A feeling of imminent harm or feeling of immediate danger must exist for assault to be claimed. A misdemeanor is a crime of lesser consequence that is punishable by a fine or incarceration in a local or county jail for up to 1 year. A felony is a more serious crime that results in the perpetrator's being imprisoned in a state or federal facility for more than 1 year.

The nurse is caring for an Islamic patient who has just died. The family is traveling from overseas. Which action is the priority for the nurse to take right after the patient dies? a. Arranging for embalming to preserve the body until burial b. Rearrange the furniture so the bed can face Mecca c. Arranging for transportation of the body to the crematorium d. Bringing in fruit for the patient's journey to the other world

ANS: B After death, a patient's body can be turned to face Mecca which is the holy site for Muslims. The nurse would need to find out which direction that is. The family will work with the funeral home to determine when and where burial will take place. Buddhists often bring fruit when someone dies.

Which statement by the nurse indicates comprehension of ethical issues? a. Ethical issues are rare occurrences but take a great deal of time to resolve. b. Ethical issues have required The Joint Commission to mandate ethics committees. c. Ethical issues most frequently lead to legal intervention in patient care matters. d. Ethical issues lead to ethics committees made up entirely by nurses.

ANS: B All nurses are faced with ethical decisions each day in practice, and some choose to obtain further education and experience in the field of bioethics and participate on institutional ethics committees along with physicians, ethicists, attorneys, and academicians. Ethics committees are required by The Joint Commission to respond to ethical challenges related to patient care requiring consultation. The work of the ethics committees in health care institutions helps to prevent unnecessary legal intervention in patient care matters. Ethics committee members come from all areas of health care, not just nursing. If acceptable resolutions are not achieved through consultation with the ethics committee, patients, families, and health care providers, the legal system may become involved.

The nurse is educating the patient about alternative therapies. Which statement by the patient indicates a need for more information? a. Alternative therapies can include relaxation techniques. b. Alternative therapies are used in conjunction with medical therapies. c. Alternative therapies can be used when patients are experiencing stress. d. Some alternative therapists require certification.

ANS: B Alternative therapies are used in place of medical treatment. These types of interventions are useful when patients are experiencing physiologic and psychological responses to stress. Some complementary and alternative therapies such as therapeutic touch, Reiki, biofeedback, and massage therapy require additional certification and training, whereas muscle relaxation and guided imagery do not.

A patient has recently been given a terminal diagnosis. When family members offer to help, the patient snaps and yells at them, but then angrily accuses them of not helping. The patient's spouse is frustrated and asks the hospice nurse what to do about this situation. What response by the nurse is best? a. "Don't worry. Your spouse will get over this phase soon." b. "Anger is an expected part of the grieving process." c. "Would your spouse be open to professional counseling?" d. "This diagnosis is difficult to handle; just be patient."

ANS: B Anger is one of the stages of grief as identified by Elizabeth Kubler-Ross. The nurse would first explain this to the spouse. Telling the spouse the patient will get over the phase soon or that the diagnosis is difficult to handle is false reassurance and dismissive of the concerns. It is too early to consider counseling although the patient may need it later. This is also a yes/no question which is not therapeutic.

A home health care nurse is working with the family of a patient who has Alzheimer disease and requires 24-hour care. What assessment by the nurse indicates the family is meeting an important goal for caregiver role stress? a. Family eats dinner together every night. b. Family uses respite care one night a week. c. Family investigates research trials for patient. d. Family verbalizes exhaustion from caregiving.

ANS: B Caregiver role stress can occur when the caregiver(s) is unable to meet obligations or unable to take care of personal needs. Using a respite caregiver once a week gives the family a little time off to accomplish needed tasks. The other observations are not tied to this diagnosis.

The nurse recognizes which action by the nursing student would be considered uncivil? a. Prompt arrival to class b. Texting during class c. Attentive listening d. Active participation in class

ANS: B Civility (i.e., acting politely) is essential in all interactions among faculty and nursing students. Respectful interaction between students and faculty members establishes professional communication patterns and affects the way in which students interact with patients. Texting in class is disrespectful and is an example of incivility. Arriving on time, listening attentively, and participating in class all show respect and civility.

A new graduate nurse tells the manager that she does not believe she needs more in-service training on culturally congruent care because she already recognizes that there are significant differences among cultures to consider when providing care. What response by the manager is best? a. "You have done a great job becoming culturally competent." b. "Providing culturally congruent care takes ongoing work and effort." c. "That is a great start but be sure to sign up for the in-service." d. "Cultural sensitivity and cultural competence are not the same."

ANS: B Cultural sensitivity is the recognition that there are profound differences among cultures that can affect health care. But to provide culturally congruent care, the nurse must do more than just recognize these differences. This is an ongoing process. Option B is the only one that provides useful information to the nurse as to why she must continue to work on this aspect of her profession.

A nursing faculty member is contrasting culture and ethnicity to students. Which statement is most accurate? a. Culture is biologically determined; ethnicity is chosen. b. Culture is socially transmitted; ethnicity is identification with a group. c. Culture is a chosen identity whereas ethnicity is biologically based. d. Culture and ethnicity are similar constructs used interchangeably.

ANS: B Culture refers to the learned, shared, and transmitted knowledge of values, beliefs, and ways of life of a group that generally are transmitted from one generation to another and influence the individual person's thinking, decisions, and actions in patterned or certain ways. Ethnicity is the person's identification with or membership in a racial, national, or cultural group and observation of the group's customs, beliefs, and language. The words may be used interchangeably by some people, but this is not correct.

The nurse is caring for a patient who is prescribed diphenoxylate-atropine (Lomotil). Which assessment finding by the nurse indicates a need to contact the prescriber and question the order? a. The patient has skin breakdown from loose stools. b. The patient is constipated with last BM 3 days ago. c. The patient is on a low-fiber, gluten-free diet. d. The patient has painful bleeding hemorrhoids.

ANS: B Diphenoxylate-atropine is an antidiarrheal medication. It should not be given to patients who are constipated until the patient is checked for impaction. The other assessment findings are not contraindications.

The student nurse learning about ethics expresses good knowledge when making which appropriate statement? a. "Ethics are internal values developed outside the influence of societal norms." b. "Ethics are influenced by many variables including family and friends." c. "Ethics are societal in nature and do not involve personal influences." d. "Ethics are totally independent from a person's character."

ANS: B Family, friends, beliefs, education, culture, and socioeconomic status influence the development of ethical behavior. The study of ethics considers the standards of moral conduct in a society. Personal ethics are influenced by values, societal norms, and practices. Behaviors that are judged as ethical or unethical, right or wrong, reflect a person's character.

The nurse is providing discharge instructions for a patient with multiple sclerosis. Which discharge instruction is aimed at preventing a future exacerbation? a. Engage in some form of exercise as tolerated. b. Avoid highly stressful situations. c. Check your skin regularly for pressure sores. d. Eat a diet with lots of fiber.

ANS: B High stress levels are known to exacerbate multiple sclerosis and other autoimmune diseases. Exercise helps keep muscles loose and helps with balance. Assessing skin for pressure sores and eating a diet with high fiber prevents complications from multiple sclerosis.

Which statement by the patient indicates to the nurse that it may be an appropriate time to consider hospice care rather than further aggressive measures to treat his terminal illness? a. "I am praying every day that this last round of chemotherapy will work." b. "I want to spend what time I have left at home with my grandchildren." c. "I need to meet with my financial planner to make sure my life insurance is all set." d. "I am concerned that my wife won't be able to live on her own after my death."

ANS: B Hospice care is provided to patients who are terminally ill and wish to have no further aggressive treatment in attempt to cure the disease. The patient's statement that she just wants to be home with her grandchildren indicates a readiness for hospice care.

A nurse works in a pediatric oncology unit and is feeling depressed and discouraged. What initial action by the nurse is best? a. Apply for a job transfer to another unit. b. Consult with the hospital chaplain. c. Make an appointment with Employee Assistance. d. Ask other nurses how they deal with the stress.

ANS: B Hospital chaplains are great resources for nurses experiencing burnout, moral distress, or spiritual distress. The nurse can take all options, but a consultation with the chaplain is the best place to start to see if the issue can be resolved. The chaplain has a wider range of perceptions and tools than do the other staff nurses.

The nurse knows that when coordination between multiple health care disciplines is needed, which role should be utilized? a. Pastoral care b. Case manager c. Social worker d. Dietitian

ANS: B If coordination of care between multiple health care disciplines is needed, a case manager is used. Pastoral care plays a significant role in addressing stress and anxiety issues when the patient has a preferred religion or strong faith background. A social worker identifies appropriate services and resources. A dietitian can provide education regarding dietary needs and food choices.

A patient in the emergency department needs an emergency operation. The patient refuses to consent and wants the nurse to call a respected elder in the community for consent. What action by the nurse is best? a. Explain that this violates privacy laws. b. Call the elder to get consent for the operation. c. Tell the woman she has the right to consent. d. Arrange for admission without the operation.

ANS: B In some cultures, decisions are made by men or community leaders. Although the patient may have the legal right to consent, if she comes from a culture in which gender and/or social roles do not permit decision making, she will likely refuse to consent. The best action is for the nurse to contact the elder and have him participate in the decision-making process per the patient's wishes. If the patient has given permission to share the information, doing so does not violate privacy laws. Admitting the patient without the operation does not help her medically.

The patient is asking about using the Internet for resources regarding lifestyle behaviors and benefits of modification. What is the best response that the nurse should provide the patient? a. Information on lifestyle behaviors is not available on the Internet. b. The patient should use websites that are easy to understand. c. Most websites are designed for health care providers only. d. Only negative outcomes are evaluated on the Internet.

ANS: B Information on lifestyle behaviors that lead to disease is available at research-sponsored websites that have peer-reviewed material and expert analyses. Website content should be easy to read and understandable for the general population. Most sites that discuss the latest information about health risks, lifestyle behaviors, and outcomes have separate information specifically for health care providers. Research that evaluates positive and negative lifestyle-behavior outcomes is constantly evolving as discoveries are made about the physiologic changes bodies experience with disease and illness.

The student nurse learns that which item is the most important symbolic aspect of culture? a. Flags b. Language c. Art d. Music

ANS: B Language is the most extensively used set of symbols in a culture. The other items are important symbols but are not as important as language because words are used to represent objects and ideas.

The nurse is caring for a terminally ill patient whose family is insistent that additional chemotherapy be administered even though the patient will most likely die within the next few days. What is the best response of the nurse? a. "The insurance company will not pay for chemotherapy at this stage." b. "The focus right now needs to be on keeping your loved one comfortable." c. "I will call the provider and relay your wishes." d. "The patient needs to get stronger first before chemotherapy can be administered."

ANS: B Nurses advocate for patients to ensure that they are aware of their options for care that include interventions, treatments, anticipated outcomes, as well as risk and benefits of any decision made concerning medical care. The nurse must function as the patient's advocate and encourage what is in the best interest of the patient. Chemotherapy will not extend the patient's life when death is expected within the next few days and will only make the patient suffer needlessly when it is administered. The patient will not get stronger over the next few days, and this criterion for chemotherapy will never be met.

A charge nurse works on an inpatient unit in a diverse city. To provide culturally congruent care to the patient, which action by the nurse would be most appropriate? a. Using puns and sarcasm to help draw the patient into sharing information b. Working to understand the socioeconomic status of the patient so teaching is culturally sensitive and appropriate c. Assuming a patient from a minority population does not have the economic means to pay for home care follow-up d. Admonishing a Hispanic patient for showing up for a preoperative teaching class 15 minutes late

ANS: B Nurses need to be cognizant of the impact of a patient's socioeconomic status to health care practices. The use of puns, sarcasm, and colloquialisms are not easily comprehended or interpreted by those who speak a different primary language. While the level of poverty in minority populations within all cultures is disproportionally higher, it is inappropriate to base an action on an assumption. According to research, some Hispanics believe that time is flexible and events will begin when they arrive. However, admonishment is not the best approach to dealing with this behavior.

A home health care nurse is visiting the home of a patient whose culture is totally unfamiliar to the nurse. What action by the nurse is best? a. Perform nursing care with a high degree of professionalism. b. Watch family interaction patterns closely and try to copy them. c. Tell the family you need to learn about their culture. d. Apologize after performing tasks that make the patient uncomfortable.

ANS: B Nurses should observe family dynamics carefully, including communication, and try to copy them as much as possible. For instance, if the family does not make eye contact with the nurse, he/she should avoid trying to make direct eye contact with the family. The other options are reasonable, although telling the family you need to learn about their culture may place the burden of educating the nurse on them.

A nurse is completing an OASIS assessment on a patient. What data would be most important for the nurse to assess? a. Presence of grocery stores nearby b. Safety concerns within the home c. Number and kind of pets d. Proximity to a health care facility

ANS: B OASIS (Outcomes and Assessment Information Set) is a data set of outcome measures for adult home health care clients that is used to track outcome-based quality improvement. Factors that could potentially affect patient safety in the home are particularly important. The other options are not included in this assessment.

A nurse has referred a patient to a community agency. When talking to the patient later, he states that he did not find the agency helpful. What action by the nurse is best? a. Determine what the patient would find helpful b. Review the agency's mission and scope. c. Make another appointment with the agency. d. Warn the patient that nonadherence affects payment.

ANS: B One of the most important aspects of a community health nurse's role is to be familiar with referral agencies. Awareness of the scope of an agency's influence and services helps the community nurse to pinpoint which agencies are best able to address specific needs. The nurse may have sent this patient to an agency that did not meet his needs. The nurse should ask the patient's opinion about what services are needed. Making another appointment without ensuring that this is the right agency for the patient will not solve the problem. Telling the patient that payment might not be ensured for nonadherence is not therapeutic communication.

The nurse is assessing a patient's environment and its impact on outdoor activity and notes that the child rarely plays outside. Which is true regarding the indoor environment? a. Indoor environments protect the patient from toxics chemicals. b. Indoor activity is sometimes a result of unsafe outdoor conditions. c. Indoor activity decreases the risk of respiratory illness. d. Indoor lifestyles reduce the risk for sedentary behaviors.

ANS: B Outdoor environments affect individual health in the areas of sanitation and waste disposal, water quality, air quality, and safety. Children living in areas where there are safety issues related to gang activity, sexual predators, or heavy traffic are less likely to engage in outdoor play activities. Their limited access to safe outdoor play space increases their risk for sedentary behaviors, excessive calorie intake, and obesity. Indoor environments may harbor toxic household cleaning agents, chemicals (e.g., radon, carbon monoxide, unused drugs), tobacco smoke, and energy sources (e.g., microwave ovens). Exposure to mold, household pests (e.g., dust mites, spiders), and unsanitary living conditions in an enclosed space increases the likelihood of respiratory illness and skin disorders.

The nurse is caring for a terminally ill patient who appears to be calmly having a conversation with someone even though there is nobody else in the room. The patient reaches out and appears to take something out of thin air and hold it close. Which is the appropriate action of the nurse? a. Reorient the patient and reassure that nobody else is in the room. b. Be present but quiet and let the patient continue the conversation. c. Carefully assess the patient's mental status and level of attention. d. Obtain a set of vital signs and check thTe patienOt's pulse oximetry.

ANS: B Patients who are near death sometimes have a special communication with loved ones who have already died. It is important to recognize that these experiences can be comforting to the dying patient, and nurses would not contradict or argue with the person. It is imperative to simply be present with the person, listen, and be open to any attempts to communicate. It is acceptable to ask gentle questions such as "What are you seeing?" or "How does that make you feel?" Having an open discussion with the family while describing what is occurring may provide further insight to the nurse as the health care provider, as well as promoting a sense of understanding and acceptance for the family. As long as the patient is calm and content, the best action of the nurse is to be present but let the patient continue the conversation undisturbed.

A patient died suddenly in the emergency department. Which action by the nurse best provides the family connection with others? a. Offering the family written information on grief support groups. b. Asking the family if there is someone the nurse can call for them. c. Having the hospital social worker or chaplain sit with the family. d. Offering to stay with the family during this difficult time.

ANS: B Promoting connectedness means recognizing that family and friends are providing at least some of the patient's spiritual care. The nurse best assists when offering to call someone for the patient or family. The other options may be appropriate but are not directly related to connectedness.

What does the nursing student learn about race? a. It is biologically based. b. It is a social construct. c. It is chosen by the person. d. It helps establish superiority.

ANS: B Race is often thought to be inherited and biologically based, but this is not true. Race is a social construct that is used to group people together based on common physical characteristics, heredity, or common descent. People are placed into racial categories by the larger society. One race is not superior to any other.

A nurse wants to volunteer for a community group providing secondary prevention. What activity would the nurse attend? a. Stroke rehabilitation support group b. Blood pressure screening at the mall c. Bicycle safety class at the elementary school d. Drop by nutrition station at the grocery store

ANS: B Secondary prevention activities are aimed at early diagnosis and prompt intervention. Blood pressure screening events are a good example. Stroke rehabilitation is tertiary prevention. Bicycle safety classes and nutrition education are examples of primary prevention.

The nurse knows the one theory explaining the variation in response to stress among individuals is identified by which term? a. Stress appraisal b. Sense of coherence c. Allostasis d. Homeostasis

ANS: B Sense of coherence (SOC) is a characteristic of personality that references one's perception of the world as comprehensible, meaningful, and manageable. Stress appraisal is the automatic, often unconscious assessment of a demand or stressor. Allostasis is an alternative term for the stress response. Homeostasis is the tendency of the body to seek and maintain a condition of balance or equilibrium.

The student nurse asks why spirituality is important in health care. What response by the registered nurse is best? a. "All people have a spiritual aspect to their beings." b. "Spirituality affects behavior, which also affects health." c. "Knowledge of it is needed to understand a patient holistically." d. "People who are less spiritual have worse outcomes."

ANS: B Spirituality affects behavior, which has a direct impact on health. Spirituality is a universal concept, but all people may not recognize it in themselves. Holistic knowledge is indeed based in part on spirituality, but that does not give the student information on a concrete link. Less spiritual people may or may not have worse outcomes.

The nurse understands state legislatures give authority to administrative bodies, such as state boards of nursing, to carry out what action? a. Create statutory laws. b. Establish regulatory laws. c. Try case law cases. d. Create laws based on social mores

ANS: B Statutory law is created by legislative bodies such as the U.S. Congress and state legislatures. Statutory laws are often referred to as statutes. State legislatures give authority to administrative bodies, such as state boards of nursing, to establish regulatory law, which outlines how the requirements of statutory law will be met. Judicial decisions from individual court cases determine case law. Case law was historically referred to as common law because it originally was determined by customs or social mores that were common at the time.

A nurse is a case manager for a home health care agency. The nurse often orders supplies for patients seen by the agency. What action by the nurse is best? a. Negotiate for cheaper prices from suppliers. b. Investigate what each patient's insurance will cover. c. Refer the patient to the closest supply source. d. Use the same supplier for all patients' needs.

ANS: B The case manager in home health care must be a well-versed financial steward and understand what each patient's insurance will cover to maximize the patient's benefit. The home health care nurse serves as a case manager (coordinator) of client care, needed services, and needed supplies in the home setting. The nurse must be well versed as a financial resource manager, who needs to be aware of what is or is not covered on the client's insurance plan

The nurse identifies that The Code of Ethics for Nurses is defined in which terms? a. Like the Constitution and not revisable b. A succinct statement of ethical obligations c. Required by entry level nurses only d. A negotiable document dependent on individual conscience

ANS: B The current nursing code, the Code of Ethics for Nurses with interpretive statements, was published in 2015. The Code of Ethics for Nurses is "a succinct statement of the ethical obligations and duties of every individual who enters the nursing profession," the profession's "nonnegotiable ethical standard," and "an expression of nursing's own understanding of its commitment to society."

When the nurse measures the patient's blood glucose levels after an acute myocardial infarction (MI), the nurse knows this action is based on which rationale? a. Damaged muscle tissue releases glucose. b. Corticosteroids increase glucose. c. Myocardial infarctions are often seen in diabetics. d. All patients should have their blood glucose checked.

ANS: B The endocrine system responds to stress on the body such as what happens during an acute MI. Corticosteroids are important in the stress response because they increase serum glucose levels and inhibit the inflammatory response. Although MIs can be seen in diabetics, there is nothing to indicate this patient is diabetic. All patients do not routinely have their blood glucose checked regularly.

A nurse is interested in epidemiology. What work activity would best fit this role? a. Studying census data to determine common causes of death b. Researching population variables that contribute to disease c. Developing sanitary measures to prevent foodborne illness d. Designing research to determine the connection between pollution and cancer

ANS: B The epidemiologist works to develop programs to prevent the development and spread of disease. Studying census data, researching population variables, and designing studies do not fall in this field.

The nurse sees a young child in the clinic whose mother has only a few weeks to live. The child has been misbehaving at school recently and is suspended after picking fights with other students and defying teachers. The nurse identifies which stage of grieving that the patient is experiencing? a. Denial b. Anger c. Bargaining d. Depression

ANS: B The patient is angry over the impending death of the mother and is acting out this anger at school by picking fights and defying his teachers. Denial is a temporary defense while processing the information. Bargaining is negotiation to change the predicted outcome. Depression includes crying and sadness.

The hospice nurse is caring for a terminally ill patient. The patient's son is distraught because the patient will probably die within the next few days and there is nothing he can do about it. What is the most appropriate nursing diagnosis for the patient's son currently? a. Chronic grief related to impending death of mother b. Death anxiety related to feeling powerless over situation c. Powerlessness related to progression of mother's terminal illness d. Complicated grieving related to desired avoidance of mourning

ANS: B The patient's son is experiencing death anxiety because he is unable to change the outcome of his mother's imminent death. The son makes no mention of religious beliefs, so impaired religiosity is not appropriate. Complicated grieving is applicable to individuals who have recently experienced a loss. Chronic grief is grief that continues for a long period of time.

The nurse is caring for four patients. Which one should the nurse assess for spirituality needs as a priority? a. New mother, older child at home. b. Faces terminal diagnosis c. Needs to change medications. d. Pleasant but quiet.

ANS: B There are many cues to alert the nurse that a patient might have unmet spiritual needs, including facing a terminal illness. The nurse should conduct spiritual assessments on all patients, but this one is the priority.

A nurse is caring for a homeless patient and tells the manager, "I will make sure he doesn't steal food from our nourishment center." What action by the manager is best? a. Tell the nurse she is right to monitor the patient's activity. b. Inform the nurse that not all homeless people will steal. c. Educate the nurse that hunger might make the patient steal. d. Remind the nurse to initiate a social work consultation.

ANS: B This nurse is guilty of being prejudiced against the patient, who is a member of the homeless culture. Although hunger might drive a homeless person to steal, prejudice leads the nurse to believe that all homeless people steal. The manager informs the nurse of this information, gently pointing out the nurse's bias. A social work consultation may be a good idea for the patient but does not address the prejudiced nurse.

The student studying community health nursing learns that vulnerable populations can be best assisted by which activity? a. Researching their genetic risk for health problems b. Working with the community to decrease health risks c. Studying vital statistics to determine their causes of death d. Making sure the population maintains immunizations

ANS: B Vulnerable populations have some characteristic that puts them at higher risk for identified health problems. The nurse can best assist vulnerable populations by identifying and working with them to decrease their risks. Researching genetic risks, studying vital statistics, and improving immunizations are all part of the solution, but the overarching priority action is to help the community decrease its risks.

The nurse knows when the body responds to the release of hormones during "fight or flight," that response includes which physiological signs? (Select all that apply.) a. Decreased respiratory rate b. Slowing of the digestive process c. Glucose being mobilized from the liver d. Pupils dilating e. Smooth muscles in the bronchi constricting

ANS: B, C, D The release of hormones increases the heart rate, resulting in increased cardiac output, and elevated blood pressure. There is an increase in the flow of blood to muscles at the expense of the digestive and other systems not immediately needed in the fight-or-flight response. Smooth muscles in the bronchi relax and dilate the bronchi and smaller airways, and the respiratory rate increases, allowing for an enhanced flow of well-oxygenated blood to muscles and other organs. The motility of the digestive tract is decreased, slowing digestive processes, but glucose and fatty acids are mobilized from the liver and other stores to support increased mental activities (alertness) and skeletal muscle function. Pupillary dilation produces a larger visual field.

The nurse who is aware of spirituality practices of major religions knows that which religions view health and illness as a process of balance or imbalance? (Select all that apply.) a. Catholicism b. Native American c. Hinduism d. Greek Orthodox e. Buddhism

ANS: B, C, E Native American, Hindu, and Buddhist practitioners believe that health and illness are a matter of balance or imbalance in the body.

The nurse working with older adults wants to support healthy coping strategies. What actions by the nurse are most appropriate? (Select all that apply.) a. Installing boxing equipment in the recreation room b. Provide reminiscing sessions for the adults to share personal stories c. Arrange for gentle yoga to be provided at the senior center d. Create activities designed to distract them from their losses e. Encourage the adults to eat frequent, healthy snacks

ANS: B, C, E To promote health coping in older adults, the nurse would provide reminiscing sessions, yoga, and would encourage small healthy snacks as this population frequently loses their appetite when stressed. Boxing equipment might cause the adults to focus on anger. Distraction can be a negative or positive coping mechanism.

The nursing student learns that which are correct regarding acculturation and assimilation? (Select all that apply.) a. Assimilation is forced entry into a different culture. b. Acculturation depends on first-hand contact between groups. c. Acculturation results in changes to the minority culture only. d. Assimilation can occur at the group or individual level. e. Assimilation causes a minority group member to blend into the majority group.

ANS: B, D, E Acculturation occurs from first-hand contact between a minority group and the majority cultural group and can result in changes to one or both cultures. Assimilation occurs when members of a minority group blend into the majority group and can occur at the group or individual level. Assimilation is not a forced change.

The economic stability of individuals or families can determine whether they are willing to seek preventive care or screening examinations. The nurse knows which statements about screening examinations to be true? (Select all that apply.) a. Free or low-cost screening ensures patient screening. b. People may not screen due to fear of testing positive. c. Early screening ensures minimal treatment costs. d. Employment stability is enhanced by early screening. e. Treatment of disorders often means lost wages.

ANS: B, E The economic stability of individuals or families can determine whether they are willing to seek preventive care or screening examinations. Even if screening is free or low cost, the patient or family members may decline because of the potential for testing positive for a disease. Treatment of a disorder often requires time spent away from work, lost wages, and expensive drug therapies and diagnostic tests. The financial impact can be devastating to families or individuals who have a limited or fixed income and fear that employment stability may be compromised.

The student learns that which is the best definition of a public health nurse? a. Works with the public. b. Works in public areas. c. Works with the greater community. d. Works with public funding.

ANS: C A public health nurse works with communities as a larger whole and is concerned with specific target or vulnerable groups within that community. The other options are inaccurate.

A patient asks the nurse to pray with him. The nurse is an atheist and uncomfortable with this request. What action by the nurse is best? a. Deny the request because of atheistic beliefs. b. Offer to call the chaplain instead. c. Agree to sit with the patient while he prays. d. Ask the patient if he will meditate instead.

ANS: C Although the nurse is uncomfortable with the request, the patient's needs (not the nurse's) come first. The nurse should attempt to honor the request while not imposing his/her ideas of religion and spirituality on the patient. The best option is to agree to sit with the patient while he prays himself. This is consistent with caring behaviors and fulfilling the patient's needs. Denying the request does nothing to address the patient's needs. The nurse can offer to call the chaplain in addition to sitting with the patient. Asking the patient to change his practices is unethical.

The student nurse asks why he needs to assess a patient's spirituality when he can call the chaplain. What response by the nurse is best? a. "This way you learn what is involved in a spiritual assessment." b. "Students need to perform all aspects of patient care." c. "Regulatory organizations list this as a required BSN competence." d. "All patients should have a spirituality assessment."

ANS: C Although there is some truth to all options, several regulatory groups list conducting a spiritual assessment as a vital skill for nurses, including the American Association of Colleges of Nursing, The Joint Commission, and the American Nurses Association.

The nurse identifies which goal to be appropriate for the nursing diagnosis of Difficulty coping? a. The patient will report an ability to remember discharge instructions. b. The patient's family will understand how to access respite care services. c. The patient will discuss possible coping strategies during weekly counseling sessions. d. The patient will attend an online support group weekly.

ANS: C An appropriate goal for Difficulty coping would be to discuss coping strategies. Remembering discharge instructions is an appropriate goal for Anxiety. Understanding how to access respite care services is an appropriate goal for Caregiver stress. Attending a support group is an appropriate goal for Difficulty coping.

The nurse recognizes which goal to be appropriate for the nursing diagnosis of Anxiety? a. The patient will attend a weekly support group. b. The patient will discuss possible coping strategies during weekly office visits. c. The patient will report increased ability to concentrate on care instructions before discharge. d. The patient's family will use respite care once a week for the next month.

ANS: C Attending a weekly support group is an appropriate goal for Difficulty coping. An appropriate goal for Ineffective coping would be to discuss possible coping strategies during weekly visits. Using respite care once a week for the next month is an appropriate goal for Caregiver stress.

The nurse correctly recognizes which one of the following illnesses to trigger the broadest range of emotional and behavioral responses? a. Ear infection b. Mild concussion c. Rheumatoid arthritis d. Influenza

ANS: C Chronic, debilitating disease such as rheumatoid arthritis and severe illness can produce a broad range of emotional or behavioral responses in patients and their families. A short-term, self-limited illness that is not life threatening does not evoke emotions or actions that cause fundamental changes in daily lifestyle. More often, illnesses such as the flu, ear infections, and sore throats are viewed as minor irritations or inconveniences. They usually require a short-term adjustment in daily routines, and treatment of symptoms is the priority so that the individual can continue with normal activities. The emotional and behavioral changes associated with non-life-threatening illness are usually minimal, and the individual quickly returns to the previous baseline level of emotional functioning.

The hospice nurse is caring for a several adult children shortly after the death of a parent. They have various reactions as they deal with their loss. The nurse recognizes which reactions to be in the cognitive domain? a. They let the house get filthy because they can't be bothered to clean it. b. They are tossing and turning all night and are unable to get a good night's sleep. c. They are easily distracted and often lose train of thought during conversation. d. They have lost their appetites and have no desire to eat anything.

ANS: C Cognitive deficits include the inability to concentrate and follow a conversation. Letting the house get filthy is a sign of apathy, which is in the behavioral domain. Insomnia falls within the behavioral and physical domains. Loss of appetite is within the physical domain.

A patient from an unfamiliar culture appears disinterested when the physician is telling her about options for treatment of a new diagnosis. After the physician leaves, the nurse attempts to talk to the patient and notices the same behavior. What action by the nurse is best? a. Give the patient the information in writing to read later. b. Ask the patient about the meaning of the patient's behavior. c. Investigate nonverbal communication patterns of this group. d. Leave the patient alone to come to terms with the diagnosis.

ANS: C Communication differences can lead to misunderstandings and possible medical errors. Many cultural groups have verbal and nonverbal communication patterns that differ from other groups. Variations can occur due to personal or social situations. The nurse should attempt to learn about the cultural group's communication patterns. Giving the patient written material and leaving the patient alone do not help solve this dilemma, and the patient may not have the literacy skills to understand the material. Asking the patient the meaning of behavior is unlikely to elicit useful information because the patient herself may not totally understand it or be able to articulate it. This may be a deeply seated cultural custom that is simply part of who the patient is.

The nurse is caring for a patient recently diagnosed with cancer that is being asked to participate in a new chemotherapy trial. How would the nurse respond if working under the ethical principle of utilitarianism? a. "The patient should be allowed to decide." b. "As your nurse, I'll support your right to refuse." c. "You should do this because many could benefit from it." d. "If this is against your beliefs, you should not do it."

ANS: C Compared with deontology, utilitarianism is on the opposite end of the ethical theory continuum. Utilitarianism maintains that behaviors are determined to be right or wrong solely based on their consequences. Deontology is an ethical theory that stresses the rightness or wrongness of individual behaviors, duties, and obligations without concern for the consequences of specific actions. Meeting the needs of patients while maintaining their right to privacy, confidentiality, autonomy, and dignity is consistent with the tenets of deontology. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. The remaining responses are examples of either deontology or autonomy.

The nurse is caring for a patient who has diarrhea and identifies which priority nursing diagnosis for this patient? a. Lack of knowledge related to prescribed diet modifications b. Impaired nutritional intake related to poor appetite c. Diarrhea related to excessive loss of fluid through stool d. Anxiety related to incontinence with loose stools and need for clothing change

ANS: C Dehydration is the priority nursing problem for this patient, so diarrhea is the most important Nursing diagnosis. Impaired nutritional intake, lack of knowledge, and anxiety can be addressed once fluid balance is restored.

A patient has hypertension and is on a very-low-sodium diet. However, the patient is going to celebrate an important religious holiday soon that includes many food items high in sodium. What action by the nurse is best? a. Tell the patient you are so sorry she can't have any of these foods. b. Consult with the prescriber about increasing the blood pressure medications. c. Collaborate with the patient and dietitian to include some of these foods. d. Tell the patient eating these foods once won't hurt her condition.

ANS: C Food has important meaning to many people, especially when they are part of celebrations, religious, or cultural activities. The nurse should collaborate with the patient and dietitian and try to find ways to incorporate some of these items. The nurse should not just tell the patient she can't have them. Increasing the medications or encouraging the patient to be nonadherent could lead to adverse outcomes.

The nurse recognizes that intentional behaviors to circumvent illness, detect it early, and maintain the best possible level of mental and physiologic function within the boundaries of illness is the definition of which term? a. Health promotion b. Self-actualization c. Health protection d. Self-transcendence

ANS: C Health protection includes intentional behaviors aimed at circumventing illness, detecting it early, and maintaining the best possible level of mental and physiologic function within the boundaries of illness. Health promotion is behavior motivated by the desire to increase well-being and optimize health status. Maslow considered self-actualization the highest level of optimal functioning and involves the integration of cognition, consciousness, and physiologic utility in a single entity. In later years, Maslow described a level above self-actualization called self-transcendence. He refers to self-transcendence as a peak experience, in which analysis of reality or thought changes a person's view of the world and his or her position in the greater structure of life.

A patient presents to the clinic for illness, and the sick role is legitimized by the provider. The nurse recognizes this as what stage of illness according to Suchman's Model? a. I b. II c. III d. IV

ANS: C In stage III (Medical care contact), professional advice from health care providers is sought by the individual. A professional health care provider identifies and validates the illness and legitimizes the sick role. During stage II (Assumption of the sick role), the person decides that the illness is genuine and that care is necessary. This stage gives an individual permission to act sick and to be excused temporarily from typical social and personal obligations. During stage I (Symptom experience), a clinical manifestation of disease is experienced, and the person acknowledges that something is wrong and seeks a cure. The outcome of stage I is that the person accepts the reality of symptoms and decides to take action in seeking care. During stage IV (Dependent patient role), the person, who is designated as a patient, usually undergoes treatment. During this stage, patients often feel dependent on others and may experience ambivalent or fearful thoughts that cause them to reject treatment, the advice of health care providers, and the illness

The nurse is caring for a patient who is undergoing a major cardiac procedure. When the patient complains of a racing heart and nausea, the nurse recognizes these complaints as part of what hormone response? a. Sense of coherence b. Stress appraisal c. Fight or flight d. Sympathoadrenal response

ANS: C In the "fight or flight" response, the corticotropin-releasing hormone (CRH) released by the hypothalamus stimulates the pituitary to release adrenocorticotropic hormone (ACTH). These hormones increase the heart rate, resulting in increased cardiac output, and the motility of the digestive tract is decreased, slowing digestive processes that could result in abdominal distress. Sense of coherence (SOC) is a characteristic of personality that references one's perception of the world as comprehensible, meaningful, and manageable. Stress appraisal is the automatic, often unconscious, assessment of a demand, or stressor. The sympathoadrenal response is a consequence of hypothalamic activation in sympathetic stimulation, which triggers epinephrine and norepinephrine release from the adrenal medulla.

The nurse is developing a plan of care for a patient with a hip fracture. Which model would the nurse use to prioritize the patient's care? a. The Health Belief Model b. Pender's Health Promotion Model c. Maslow's hierarchy of needs d. The Holistic Health Model

ANS: C Maslow's hierarchy of needs describes the relationships between the basic requirements for survival and the desires that drive personal growth and development. The model is most often presented as a pyramid consisting of five levels. The lowest level is related to physiologic needs, and the uppermost level is associated with self-actualization needs, specifically those related to purpose and identity. The Health Belief Model was developed by psychologists Hochbaum, Rosenstock, and Kegels. It explores how patients' attitudes and beliefs predict health behavior. The Health Promotion Model, developed by Pender and colleagues, defines health as a positive, dynamic state of well-being rather than the absence of disease in the physiologic state. Holistic Health Models in nursing care are based on the philosophy that a synergistic relationship exists between the body and the environment. Holistic care is an approach to applying healing therapies. Holistic models focus on the interrelatedness of body and mind.

A patient is hesitating to accept a blood transfusion as a course of treatment. What Nursing diagnosis is most appropriate for this patient? a. Spiritual distress b. Anxiety c. Moral distress d. Decisional conflict

ANS: C Moral distress is cultural conflict between medical treatment and religious beliefs, expressions of concern about rejection by religious community, hesitation in accepting blood transfusion. The other diagnoses are not related.

The nurse needs to consider which approach when caring for patients with chronic illness? a. Help the patient face the reality that he will not get better. b. Emphasize to the patient that the illness is not his fault. c. Focus on improving quality of life through preventive behaviors. d. Acknowledge the limitations placed on the patient by his suffering.

ANS: C Nurses can help patients establish a daily routine of care by educating them about how to manage their care and the symptoms associated with the condition, including emergency or life-threatening situations. Emphasis is on improving quality of life through preventive behaviors. The attitude of being a victim, suffering with, or being afflicted by a chronic illness is viewed by nurses as a counterproductive behavior that needs positive intervention. Nurses can assist patients with strategies that help them cope with their chronic conditions and associated feelings of anger, frustration, and depression. Encouragement and positive support from a professional nurse can help individuals gain control over the alternating periods of health and illness and improve their quality of life.

The hospice nurse is caring for a patient who is terminally ill. The patient's spouse is the primary caregiver, providing constant care and spending all his or her time meeting the patient's needs. The spouse says to the nurse "After my spouse dies, I will finally get that colonoscopy my provider has been bugging me about." What does the nurse understand about this statement? a. The spouse is looking forward to being freed from the caretaker role. b. The spouse has neglected his or her own physical needs for too long. c. The spouse is making some realistic plans for life after the death. d. The spouse is in denial that the patient is dying and the important role of caregiver will end.

ANS: C Often caregivers neglect their own needs while in the caregiver role. The spouse understands the patient will die soon and is being realistic in understanding his or her own physical needs have been neglected. This shows healthy coping

The nurse is seeing a patient during a follow-up visit after discharge in which the patient had a nursing diagnosis of Difficulty coping. Which statement by the patient would be a cause for concern? a. "I am sleeping better most nights." b. "I feel less anxious." c. "I do not need to do the relaxation exercises anymore." d. "I am continuing my exercises every day."

ANS: C Patients need to continue using the stress-reduction techniques to maintain a feeling of well-being. Once stress decreases, patients typically report feeling better, sleeping more soundly, and feeling less anxious. Continuing their positive activities such as exercising is good.

The nurse knows practicing nursing without a license is what wrongdoing? a. Misdemeanor b. Statute c. Felony d. Tort

ANS: C Practicing nursing without a license is a felony. A misdemeanor is a minor crime, such as stealing an item from a patient that does not have much value. A statute is a law created by legislative bodies. Torts are crimes committed against another person. An intentional tort example is assault and battery. Negligence and malpractice are examples of unintentional torts.

The nurse is caring for a patient who has been belligerent and is in 4-point "leather" restraints. When the patient continues to be verbally abusive and still tries to kick and punch staff even though he is restrained, the nurse should carry out which action? a. Do not attempt to meet patient needs until the patient has calmed down. b. Only provide care while security is in the room. c. Continue to attempt to meet the patient's needs. d. Inform the patient the police will be called if the patient's behavior does not stop.

ANS: C Provision 1.5 (of the Nursing Code of Ethics) states, "The principle of respect for persons extends to all individuals with whom the nurse interacts. The nurse maintains compassionate and caring relationships with colleagues and others with a commitment to the fair treatment of individuals, to integrity-preserving compromise, and to resolving conflict. The nurse should make all attempts to provide for the patient's needs. It is unrealistic to only provide care if security is present. Telling the patient that the police will be called is threatening.

A 40-year-old patient presents to her provider for a yearly physical. The provider notes a family history of breast cancer in the patient's mother. The provider schedules the patient for a mammogram. The nurse recognizes this as what level of prevention? a. Tertiary b. Primary c. Secondary d. Holistic

ANS: C Secondary prevention is undertaken in cases of latent (hidden) disease. Although the patient may be asymptomatic, the disease process can be detected by medical tests. Nurses may use screening tests to assess for latent disease in vulnerable populations. Examples of screening tests used as secondary prevention strategies include the purified protein derivative (PPD) skin test for tuberculosis, fecal occult blood test for colorectal cancer, and mammograms for breast cancer. Primary prevention is instituted before disease becomes established by removing the causes or increasing resistance. Examples include the use of seatbelts and airbags in automobiles, helmet use when riding bicycles or motorcycles, and the occupational use of mechanical devices when lifting heavy objects. Tertiary prevention, also known as the treatment or rehabilitation stage of preventive care, is implemented when a condition or illness is permanent and irreversible. The aim of care is to reduce the number and impact of complications and disabilities resulting from a disease or medical condition. Interventions are intended to reduce suffering caused by poor health and assist the patients in adjusting to incurable conditions. Nursing care is focused on rehabilitation efforts in the tertiary stage of prevention. Holistic care is an approach to applying healing therapies. Nurses participate in holistic care through the use of natural healing remedies and complementary interventions. These include the use of art and guided imagery, therapeutic touch, music therapy, relaxation techniques, and reminiscence.

The nurse concerned about a patient's spiritual needs can best address this by which action? a. Leaving a note on the chart for other professionals b. Calling the chaplain to come see the patient c. Collaborating during interdisciplinary rounds d. Informing the provider of the patient's needs

ANS: C Spiritual care must be multidisciplinary to be most effective. The nurse best addresses patients' spiritual needs by discussing them during interdisciplinary rounds.

A nurse has been told he has many obvious stereotypes about a specific cultural group. What action by the nurse is best? a. Ask to not care for members of this cultural group. b. Ask to take care of as many members of this group as possible. c. Begin to educate himself on aspects of this cultural group. d. Vow to not allow his stereotypes to show when providing care.

ANS: C Stereotypes are fixed ideas, often unfavorable, about groups of people. They occur because of being unwilling to gather all the information needed to make fair determinations. The nurse would benefit most from beginning to learn about this cultural group. Caring or not caring for members of this group will not help him obtain new information. The nurse should not let stereotypes show, but this is not the best option.

The nurse is providing education to a patient around anger management strategies. Which statement indicates a need for further education by the patient? a. "Exercise can help me deal with the anger." b. "I can use humor." c. "I can punch things." d. "I can take a time-out."

ANS: C Strategies should focus on nonviolent methods. Some anger management interventions include expressing feelings in a calm, non-confrontational manner; exercising; identifying potential solutions; taking a time-out; forgiving; diffusing the situation with humor; owning one's feelings; and breathing deeply.

A nurse is orienting to a new job in a home health care agency and is told that most of her patients need tertiary prevention. What activity does the nurse plan to include in the daily routine? a. Household safety checks b. Well-baby checkups c. Antibiotic administration d. Monthly blood pressure assessments

ANS: C Tertiary care is aimed at people who are already experiencing a health alteration, such as those with an infection who need antibiotics. The other options are secondary prevention.

The nurse knows the World Health Organization defines health in which of the following terms? a. The absence of disease b. The lack of infirmity c. Complete well-being d. Being independent of fiscal responsibility

ANS: C The World Health Organization offers a definition for health: "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." Nurses are responsible for helping patients reach their optimal levels of physiologic and mental health, but they also must provide health care in a system that requires cost containment and fiscal responsibility.

The nurse is assessing level of stress in a patient from another culture. Which question is the most appropriate in helping the nurse understand the impact of the patient's belief system? a. "Do you engage in prayer to help you during times of stress?" b. "Do you go to church or other form of organized worship?" c. "Do you have certain beliefs that are helpful during times of stress?" d. "Do you want spiritual counseling while you are here?"

ANS: C The nurse needs to obtain a knowledge base of the patient's culture as well as identify health beliefs and cultural values from the patient's worldview. Asking the patient specific questions about prayer or church or spiritual counseling is inappropriate until the nurse first understands what the patient's own beliefs and practices are.

The nurse is caring for a patient who will be undergoing upper GI series testing the next day. Which instruction will the nurse provide to the patient about the upcoming exam? a. "The back of your throat will be sprayed with numbing medicine." b. "You will need to have a clear liquid diet and take a laxative tonight." c. "You will be given a milky liquid to drink shortly before the test starts." d. "You should not take your dose of warfarin (Coumadin) tonight."

ANS: C The patient is given a milky barium liquid to drink as part of the upper GI series, so the patient should be informed of this. The back of the throat is numbed for upper GI endoscopy, not an upper GI series. Warfarin is not contraindicated prior to an upper GI series, and no bowel prep is required.

A student nurse is working with a preceptor to administer an enema to the patient. Which action by the student prompts intervention and redirection by the preceptor? a. Water-soluble lubricant is applied to the end of the enema tubing. b. The enema tubing is primed with solution that has been warmed. c. The patient is positioned comfortably in the right side-lying Sims position. d. The patient's bedpan is put at the bedside in preparation for use.

ANS: C The patient should be placed in the left side-lying Sims position prior to enema administration so that the enema fluid will readily flow through the colon without having to go uphill. The other actions demonstrate correct enema administration steps.

The nurse is caring for an immobile patient who has abdominal pain and frequent small, liquid stools. The patient vomited his breakfast and is still nauseated. Which action by the nurse is the highest priority? a. Provide oral care after each episode of emesis. b. Apply a skin barrier to the patient's perineal area. c. Check the patient for a fecal impaction. d. Administer antiemetic medication with a sip of water

ANS: C The patient who has abdominal pain and frequent small liquid stools should be checked for fecal impaction, especially since the patient is vomiting. Immobility is a risk factor for the development of fecal impaction. The other actions can be performed once fecal impaction is ruled out.

The nurse knows which goal to be appropriate for the nursing diagnosis of Caregiver stress? a. The patient will report an ability to focus on discharge instructions. b. The caregiver will attend a coping skills class on a weekly basis. c. Caregiver will use respite care for the family loved one once a week for the next month. d. The patient will discuss strategies for coping with relationship violence within 24 hours.

ANS: C The patient will discuss possible coping strategies during weekly office visits is an appropriate goal for Difficulty coping. The patient will report an ability to focus on discharge instructions is an appropriate goal for Anxiety. Relationship violence is not related.

The nurse is caring for a terminally ill patient who will probably die within the next 2 weeks. What is the priority nursing intervention? a. Encouraging the patient to limit fluid intake to minimize congestion b. Limiting the use of pain medications so that the patient can visit with family c. Helping the patient to identify and complete desired tasks and activities d. Completing funeral arrangements with the patient's next of kin

ANS: C The priority intervention for the nurse currently is to help the patient identify and complete desired tasks and activities while the patient is still able to do so. Pain management is a high priority at this time, so analgesics should never be limited unless requested by the patient. The patient can drink as much or as little fluid as desired.

The nurse is performing a physical assessment of patient who is undergoing a bone marrow biopsy. What finding by the nurse indicates the patient is experiencing stress? a. Blood pressure of 120/84 b. Temperature of 99.5 °F (37.5 °C) c. Heart rate of 110 beats/min d. Respiratory rate of 10 breaths/min

ANS: C The release of hormones increases the heart rate, resulting in increased cardiac output and elevated blood pressure. A reading of 120/84 is a normal blood pressure, and temperature is elevated is indicative of an infection. The respiratory rate increases in stress not decreases.

The nurse is assessing the patient's use of coping skills in response to stressful situations. The nurse identifies which question to be the most useful? a. "Have you been evaluated for stress?" b. "Do you have someone you can go to for help when you are stressed?" c. "How have you managed stressful situations in the past?" d. "Does stress cause you to experience muscle tension or headaches?"

ANS: C The use of open-ended questions assists in obtaining accurate information regarding the patient's stressors and coping skills. Questions that elicit yes/no answers will not allow the patient to provide as much information. Asking the patient about headaches and tension is asking about physical symptoms, not coping skills.

A community was devastated by a tornado several months ago. What nursing diagnosis would be most appropriate for the nurse to consider? a. Social isolation b. Deficient community resources c. Ineffective community coping d. Deficient community health

ANS: C This diagnosis considers those in a community who may be feeling helpless, hopeless, or frustrated because of an extraordinary event. Financial and physical resources may not be available for rebuilding. Social isolation refers to unacceptable social behavior. Deficient community resources is not an approved diagnosis. Deficient community health may become a problem if sanitary conditions lead to an outbreak of disease.

The nurse is educating the patient on the use of relaxation therapy. Which statement by the patient indicates a need for further education? a. "I should relax my muscles from head to toe." b. "I visual the relaxed muscle." c. "I should do this three times a week." d. "I focus on muscles that are tense."

ANS: C This technique should be done daily. Typically, relaxation progresses from head to toe. With practice, the patient visualizes an image of the relaxed muscles and will be able to relax muscles from the mental image. Progressive relaxation is implemented by having patient's focus on muscles that are tensed and then intentionally relax those muscle groups.

The nurse is caring for a patient who is to have testing for fecal occult blood. What step will the nurse perform during this testing? a. Keep the patient on a clear liquid diet for 72 hours. b. Send the samples to the laboratory while they are still warm. c. Inform the patient that several stool samples will be needed. d. Use a sterile container when collecting the stool samples.

ANS: C Three stool samples are required for fecal occult testing to avoid missing blood that appears intermittently. A sterile container is not required, and the patient does not need to be on a clear liquid diet for the test. Stool samples for culture and sensitivity should be sent to the laboratory when they are fresh and warm.

The nurse is caring for a patient on a medical-surgical inpatient unit when the patient tells the nurse he is very sad and is considering suicide. What is the first thing the nurse should do? a. Notify the health care provider. b. Make a referral to psychiatric services. c. Implement one-on-one observations. d. Document in the electronic medical record.

ANS: C Verbalization of suicidal ideation or a suicide plan must be taken seriously. In the case of a hospitalized patient, one-on-one observation should be implemented to ensure patient safety. Once the patient is under observation, the health care provider is notified to put in the referral; nurses generally do not put in the referral. Documentation is always done after the patient's safety is ensured.

The nurse is caring for a patient with a new diagnosis of diabetes type 2. Which statement indicates a negative coping response? a. "I will look up information on the Internet about diabetes." b. "I will join a support group." c. "I will only focus on learning to manage my medication first." d. "I will make changes slowly so I can adapt to each change."

ANS: C When the patient puts limits on learning by stating he/she will only learn about medication, he/she is using avoidance strategies to alleviate stress. Using strategies such as information gathering (seeking information about diabetes) is positive. Joining support groups and making changes slowly to adapt is also taking direct action by moving forward.

A patient, who is an adherent Muslim, is in a burn unit with severe burns. The patient has high caloric requirements but is refusing to eat during Ramadan. What action by the nurse is best? a. Insert a feeding tube and provide enteral feedings. b. Ask the provider about Total Peripheral Nutrition. c. Call the patient's religious leader for advice. d. Tell the patient he has to eat to get better.

ANS: C With permission, the nurse should consult with the patient's religious leader on this situation. There may be exceptions to the rule to fast during Ramadan for medical conditions. The other options ignore the patient's religious preferences, and both the tube feeding and parenteral nutrition have potential serious side effects.

The student nurse learns the ANA's Scope and Standards of Practice for public health nursing include components? (Select all that apply.) a. Team membership b. Developing research c. Ethical behavior d. Responsible resource use e. Advocacy

ANS: C, D, E The ANA's Scope and Standards of Practice for public health nursing requires participation in research, responsible resource utilization, ethical behavior, leadership, and advocacy like the standards of practice for all nurses. Team membership and developing one's own research are not included.

The community health nurse knows that which are standards of professional performance for home care nurses according to the ANA? (Select all that apply.) a. Collegiality b. Performance appraisal c. Ethical behavior d. Outcome identification e. Resource utilization

ANS: C, E The ANA's Public Health Nursing: Scope and Standards of Practice (2013) requires participation in research, responsible resource utilization, ethical behavior, leadership, and advocacy similar to the standards of practice for all nurses.

A student nurse is caring for a patient who is a refugee. The patient will take his own blood glucose readings and will self-administer a set dose of insulin but will not follow a sliding scale regimen in which the patient has to choose what dose of insulin to give. What action by the student nurse is best? a. Ask the provider to prescribe only a set insulin regimen. b. Instruct the patient on the benefits of sliding scale insulin. c. Teach the patient that strict carbohydrate limits are needed. d. Ask the patient to explain the meaning of making this decision.

ANS: D The patient may have a more fatalistic world view then is common in Western societies. The patient may follow "orders" from an authority figure but may feel like it is not his place to determine his insulin dose, or the patient may not feel competent in making that decision. Many explanations are possible. The student needs to determine what the patient feels related to this type of decision making before doing anything else.

The home care nurse is caring for a terminally ill patient who states that he wants to set up a scholarship in his name at the local university before he dies. What is the best action by the nurse? a. Suggest that the patient think it over and wait a few days before contacting the school. b. Direct the patient to ask his family about the possibility of starting a scholarship. c. Assess the patient's mental status to ensure that he is competent to make the decision. d. Assist the patient to find the necessary information about endowed scholarships.

ANS: D As the patient's advocate, the nurse should help provide the necessary information for the patient to set up a scholarship if that is his decision. The patient does not need to discuss the subject with his family first, and assessment of the patient's mental status is not needed. The patient may not have the time to wait a few days before contacting the university.

When considering factors influencing health and the impact of illness, specifically age, the nurse would correctly identify which patient as having the greatest risk? a. 10-year-old girl b. 23-year-old woman c. 47-year-old man d. 85-year-old woman

ANS: D Assessment of the patient begins with risk factors that take into account the person's age and the associated level of immune system function. The very young, especially neonates and infants born prematurely, are more susceptible to infections because of the immaturity of their immune systems. Likewise, older adults have decreased immune system function because of the aging process. Older patients are at risk for opportunistic infections resulting from harmless organisms that become pathogenic and illness from the spread of community-acquired disease. Complications from comorbidities of chronic disease may also increase suffering in the aged population.

The nurse is caring for a patient who is recovering from gastroenteritis. The nurse teaches the patient about dietary recommendations as the digestive system recovers. Which menu selection by the patient indicates that additional teaching is needed? a. Applesauce b. Orange Popsicle c. White toast d. Coffee with cream

ANS: D Coffee with cream should be avoided by patients recovering from gastroenteritis because milk proteins are difficult for the digestive system and caffeine increases peristalsis. Caffeine is also a diuretic, which can lead to continued dehydration.

The patient asks the nurse to explain collaborative health care partnerships. The nurse gives a correct description when making which statement regarding collaborative care? a. Does not require participation of the patient. b. Is individual and cannot be mandated or legislated. c. Education needs are delegated to assistive personnel. d. Is designed to provide care to the patient as a whole.

ANS: D Collaborative health care partnerships are designed to deliver well-balanced care to the patient as a whole, rather than rendering fragmented care involving a single element of a disease process. Prevention is not solely the responsibility of the nurse; it involves active participation by the individual and the combined services of practitioners in a spectrum of health care disciplines as varied as nutrition, physical therapy, exercise physiology, and pharmacy. Collaborative preventive care can be mandated in the form of health care legislation, with rates for reimbursement of practitioners determined by the individual provider's ability to collaborate and develop innovative methods for delivering high-quality, cost-effective health care services. The role of the professional nurse is to collaborate and communicate health education to the patient and family, care provider, or surrogate. Patient education responsibilities are not delegated to assistive personnel or other members of the health care team and are considered a cornerstone of nursing care.

A patient is finding conflict when trying to maintain personal beliefs while making health care decisions. What Nursing diagnosis is a priority as the nurse plans care? a. Spiritual distress b. Impaired religiosity c. Moral distress d. Decisional conflict

ANS: D Decisional conflict is unclear personal beliefs, questioning of personal beliefs while making decisions, delayed decision making. The other diagnoses may exist as well, but they are not manifested by this conflict.

The nurse is caring for a patient who has had many admissions and readmissions. The nurse believes that the patient keeps coming to the hospital because the patient "wants his drugs," and is "non-compliant" at home with diabetic therapy. To reduce the risk of slander against this patient, the nurse should carry out which action? a. Write opinions in the medical record only. b. Never share observations. c. Make judgmental statements in private. d. Avoid making judgmental statements.

ANS: D Defamation of character occurs when a public statement is made that is false and injurious to another person. Oral defamation of character is slander. Slander is spoken information that is untrue, causing prejudice against someone or jeopardizing that person's reputation. The nurse should not make opinionated, slanderous comments about patients, orally or in writing. Written forms of defamation of character are considered libel.

A nursing student wants to observe enculturation practices of an ethnic minority community. What action by the student is best? a. Attend a community dance. b. Learn to cook an ethnic meal. c. Visit the group's worship service. d. Observe a grandmother teaching a child.

ANS: D Enculturation is the process of passing a culture down from generation to generation. Culture can be taught directly, for instance, with the grandmother teaching the child. Culture can also be taught indirectly as when a child observes a role in the community. The student observing the grandmother teaching a child is the best example of enculturation.

The nurse frequently cares for patients who are nearing the end of life. The nurse identifies what strategy that is designed to prolong the time of death rather than restoring life? a. Establishing a do-not-resuscitate (DNR) order b. Adherence to living will requests c. Removal of extraordinary measures already in place d. Continuance of futile care

ANS: D Ethical dilemmas in end-of-life care exist regarding the establishment of do-not-resuscitate (DNR) orders, adherence to living will and organ donation requests, removal of extraordinary measures already initiated, and continuance of futile care (i.e., care that is useless and prolongs the time until death rather than restoring life).

The nurse is caring for a patient from a culture that is unfamiliar. The patient nodded her head "yes" when asked if she will take her prescriptions as ordered, but the nurse discovers the patient does not take the medication but uses herbs for treatment. What action by the nurse is best? a. Warn the patient of the consequences on noncompliance. b. Tell the patient how the medication will help the condition. c. Ask the patient why herbal preparations are preferred. d. Ask the patient to explain the meaning of the herbal products.

ANS: D Ethnocentrism is the belief that one's cultural beliefs are superior to others. To avoid practicing in an ethnocentric manner, the nurse needs to understand the meaning of the herbal preparation to the patient. Warning the patient of bad outcomes will not achieve the desired results if the herbs are culturally important and meaningful to her. Patient education is always important but is not the best answer because it does not allow the nurse to learn from the patient. Asking "why" question is a communication barrier likely to put the patient on the defensive

The nurse understands "First, do no harm" defines what ethical principle? a. Beneficence b. Justice c. Fidelity d. Nonmaleficence

ANS: D First, do no harm is the colloquial definition of nonmaleficence. Unlike beneficence, which requires actively doing good, nonmaleficence requires only the avoidance of harm. In its simplest form, beneficence can be defined as doing good. To do justice is to act fairly and equitably. Keeping promises or agreements made with others constitutes fidelity.

The nurse is caring for a patient whose mother recently passed away. The patient states that she has not been able to concentrate or sleep since the funeral and is consuming increasing amounts of alcohol to get through each day. The nurse knows which goal to be most appropriate for this patient? a. The patient will be referred to medical social services for evaluation and counseling. b. The patient will be encouraged to describe previous stressors and coping mechanisms. c. Nursing staff support patient's coping attempts and encourage verbalization of feelings. d. The patient will use effective coping strategies with no alcohol consumption.

ANS: D Goals are met by the patient rather than nursing or medical staff. The patient's use of effective coping strategies without drinking alcohol is an appropriate goal. Referring the patient for counseling and encouraging the patient to verbalize stressors are interventions rather than goals

The nurse understands who is ultimately responsible for explaining the content of the informed consent? a. The registered nurse b. The hospital social worker c. Educated family members d. The provider of the procedure

ANS: D Informed consent is permission granted by a patient after discussing each of the following topics with the physician, surgeon, or advanced practice nurse who will perform the surgery or procedure: (1) exact details of the treatment, (2) necessity of the treatment, (3) all known benefits and risks involved, (4) available alternatives, and (5) risks of treatment refusal.

The nurse is providing care to a patient experiencing pain. The nurse assesses the pain and promptly administers the ordered analgesics as promised to the patient. This nurse has applied what concept? a. Autonomy b. Accountability c. Confidentiality d. Fidelity

ANS: D Keeping promises or agreements made with others constitutes fidelity. In nursing, fidelity is essential for building trusting relationships with patients and their families. Following through on promises is a critical factor in establishing strong professional relationships with patients and their families. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. Accountability is the willingness to accept responsibility for one's actions. Confidentiality is the ethical concept that limits sharing private patient information.

After studying legal issues important to nursing, the student shows appropriate understanding with which statement? a. Laws change often, creating liability issues for nurses. b. Licensure laws are devised to protect the nurse. c. The nurse is not responsible for other disciplines' mistakes. d. Keeping current with changing laws can protect the nurse.

ANS: D Laws delineate acceptable nursing practice, provide a basis on which many health care decisions are determined, and protect nurses from liability in cases in which safe practice is maintained. Each state has a nurse practice act that establishes the standards of care required for legal nursing practice. Licensure, laws, rules, and regulations governing nursing practice are enforced to protect the public from harm. In many cases, the nurse is the last line of defense to prevent an error in medication administration or other types of patient care. Keeping current with changing laws related to nursing practice and technology can ensure safety for nurses and their patients.

The nurse is caring for an emergency room patient who died because of a mishap with a loaded gun. The patient's body will be transported to the coroner's office for an autopsy. Which items will the nursing staff remove from the body before it leaves the hospital? a. Endotracheal tube b. Foley catheter and IV line c. Dentures d. Necklace and watch

ANS: D Medical devices and tubes are not removed from the body if an autopsy is to be performed. The patient's necklace and watch may be removed and given to the patient's family members before the body is transported to the coroner's office for autopsy. Dentures should be left in the patient's mouth.

The nurse is teaching a patient about the difference between mild anxiety and moderate anxiety. Which statement by the patient indicates a need for further education? a. "Mild anxiety can help me remember things." b. "Moderate anxiety will narrow my focus." c. "Mild anxiety will help me be creative." d. "Moderate anxiety will increase my perception."

ANS: D Moderate anxiety narrows a person's focus, dulls perception, and may challenge a person to pay attention or use appropriate problem-solving skills. Mild anxiety can be motivational, foster creativity, and increase a person's ability to think clearly.

The nurse is caring for a patient with a history of dementia who is incontinent of stool because of the inability to communicate the need to defecate. What is the priority action of the nurse? a. Administer a daily laxative and take the patient to the toilet afterward. b. Digitally remove stool from the patient's rectum every other day. c. Insert a rectal tube to facilitate drainage of soft or liquid stool. d. Begin a prompted toileting program to facilitate bowel continence.

ANS: D Patients who cannot communicate the need to use the toilet often benefit from a prompted toileting program in which the patient is brought to the toilet at the same times each day to promote urinary and bowel continence. A rectal tube should not be used. Digital removal of the impaction should be avoided whenever possible. Laxatives should be used only when necessary because continued use will lead to dependence.

The nurse knows that use of seatbelts and airbags in automobiles is an example of which term? a. Secondary prevention b. Tertiary prevention c. Holistic care d. Primary prevention

ANS: D Primary prevention is instituted before disease becomes established by removing the causes or increasing resistance. Examples include the use of seatbelts and airbags in automobiles, helmet use when riding bicycles or motorcycles, and the occupational use of mechanical devices when lifting heavy objects. Secondary prevention is undertaken in cases of latent (hidden) disease. Although the patient may be asymptomatic, the disease process can be detected by medical tests. Nurses may use screening tests to assess for latent disease in vulnerable populations. Examples of screening tests used as secondary prevention strategies include the purified protein derivative (PPD) skin test for tuberculosis, fecal occult blood test for colorectal cancer, and mammograms for breast cancer. Tertiary prevention, also known as the treatment or rehabilitation stage of preventive care, is implemented when a condition or illness is permanent and irreversible. The aim of care is to reduce the number and impact of complications and disabilities resulting from a disease or medical condition. Interventions are intended to reduce suffering caused by poor health and assist the patients in adjusting to incurable conditions. Nursing care is focused on rehabilitation efforts in the tertiary stage of prevention. Holistic care is an approach to applying healing therapies. Nurses participate in holistic care through the use of natural healing remedies and complementary interventions. These include the use of art and guided imagery, therapeutic touch, music therapy, relaxation techniques, and reminiscence.

Self-concept refers to the way in which individuals perceive unchanging aspects of themselves, such as social character, cognitive abilities, physical appearance, and body image. Which additional point does the nurse the nurse recognize as part of the definition of self-concept? a. If negative, self-concept will allow the patient to compensate for weaknesses. b. If positive, self-concept will cause the patient to see challenges as devastating. c. Self-concept is a concept that is derived from the patient internally. d. Self-concept depends on relationships with family and friends.

ANS: D Self-concept refers to the way in which individuals perceive unchanging aspects of themselves, such as social character, cognitive abilities, physical appearance, and body image. It is a mental image of self in relation to others and the surroundings. If the image is positive, the person will develop strengths, compensate for weaknesses, and experience life in a healthy way. If the image is negative (e.g., frail), the person will find life's challenges devastating and sometimes insurmountable. The impact of illness on the self-concept of a patient and the patient's family members depends on how secure the parties' relationships are with one another.

The nurse is preparing a patient teaching plan and is seeking a way to determine the patient's readiness and motivation to act regarding lifestyle changes to best manage diabetes mellitus. Which model would be useful for this nurse? a. Maslow's hierarchy of needs b. Holistic Health Model c. Health Promotion Model d. Health Belief Model

ANS: D The Health Belief Model was developed by psychologists Hochbaum, Rosenstock, and Kegels. It explores how patients' attitudes and beliefs predict health behavior. Maslow's hierarchy of needs describes the relationships between the basic requirements for survival and the desires that drive personal growth and development. The model is most often presented as a pyramid consisting of five levels. The lowest level is related to physiologic needs, and the uppermost level is associated with self-actualization needs, specifically those related to purpose and identity. Holistic Health Models in nursing care are based on the philosophy that a synergistic relationship exists between the body and the environment. Holistic care is an approach to applying healing therapies. Holistic models focus on the interrelatedness of body and mind. The Health Promotion Model, developed by Pender and colleagues, defines health as a positive, dynamic state of well-being rather than the absence of disease in the physiologic state.

The nurse has implemented a community-wide immunization program for seasonal influenza. Once the program has ended, what action by the nurse is best? a. Begin planning for next year's program. b. Send mail surveys to participants. c. Determine financial gains or losses. d. Evaluate the program and outcomes.

ANS: D The last step of the nursing process is evaluation. The nurse should evaluate the program to see if interventions had the desired effect. Evaluation could include surveys or looking at financial outcomes, but those are only limited aspects of the process. Planning for next year's event should not occur until after evaluation has been completed

The nurse is caring for a female patient who died a few minutes previously. The patient's family comes in to the room and immediately starts to wash the body in preparation for burial. What is the most appropriate action of the nurse currently? a. Inform the patient's family that the body must be transported to the morgue. b. Instruct the patient's family that hospital staff will provide postmortem care. c. Obtain needed signatures for organ donation and autopsy. d. Offer to provide any needed supplies and provide privacy for the family.

ANS: D The most appropriate action of the nurse currently is to allow the family to wash the patient's body in accordance with their wishes and cultural values. The family may wish to participate in this procedure or may complete this procedure in private. Health care personnel should abide by their wishes as much as possible. Signatures may be obtained from the next of kin when washing is complete. The patient's body may be transported to the morgue or funeral home after washing is completed.

The nurse is caring for a patient who died a few minutes ago. The patient's family is at the bedside and very demonstrative in their grief, weeping loudly and holding on to the patient's body. What is the most appropriate action of the nurse? a. Inform the family that the patient's body must be taken to the morgue shortly. b. Ask the family members to step outside while postmortem care is provided. c. Obtain required signatures for the body to be taken to the funeral home. d. Provide privacy and allow the patient's family to grieve over the body.

ANS: D The nurse should allow the patient's family to grieve in private over the loss of their loved one. Some cultures favor free expression of emotions after death, and the nurse should respect this. Signatures can be obtained, postmortem care can be provided, and the body brought to the morgue after an appropriate time of grieving has been provided to the family.

The nurse is caring for a patient who has not had a bowel movement for 2 days. Which is the priority nursing intervention for this patient? a. Obtain an order to administer a soap suds cleansing enema. b. Teach the patient how to use the Valsalva maneuver. c. Discontinue medications that can cause constipation. d. Assess the patient's usual pattern of bowel movements.

ANS: D The nurse should assess the patient's usual pattern of bowel movements to determine if it is normal for the patient to have a bowel movement every 2 to 3 days. Patients should be taught not to use the Valsalva maneuver because it can lead to bradycardia or death. Medications are not independently discontinued by the nurse and this would require a conversation with the provider.

The charge nurse overhears a new nurse telling a patient that he should no longer follow his vegetarian diet because his protein needs are so high and because "God made animals for us to eat." What action by the charge nurse is best? a. No action is necessary for the charge nurse to take. b. Reinforce the nurse's teaching on proper diet. c. Offer to call the dietitian to work with the patient. d. Privately speak to the nurse about this conversation.

ANS: D The nurse should not share opinions or religious edicts with patients when those beliefs contradict the patient's. The charge nurse should counsel the new nurse about this practice. The patient may hold deep convictions about being a vegetarian and may feel disapproval from the nurse, which will impact the nurse-patient relationship. The other options are not appropriate, although the charge nurse could suggest the new nurse collaborate with the dietitian and patient to determine high-protein foods the patient finds acceptable.

The nurse is caring for a patient who is constipated and has not had a bowel movement for 3 days. The nurse performs a rectal examination and finds hard dry stool in the rectum. What is the best option to help the patient have a bowel movement? a. Glass of warmed prune juice b. Loperamide (Imodium) c. Oral fiber supplement d. An oil retention enema

ANS: D The patient with hard, dry stool in the rectum will benefit from an oil retention enema because it will soften the stool and make it easier to pass. Imodium is an antidiarrheal that will worsen the constipation. An oral fiber supplement and prune juice should be given after the patient has a bowel movement to prevent constipation from recurring.

A patient is scheduled to have an MRI and has a metal religious icon pinned to his gown, which can't go in the scanner. What action by the nurse is best? a. Take the icon off the patient's gown until she returns. b. Give the icon to the patient's family for safekeeping. c. Pin the icon to the patient's pillow so it can go to radiology. d. Explain the restriction and ask the patient's preference.

ANS: D The religious icon has profound significance for the patient and should not be removed by the nurse. Since the icon cannot go into the MRI scanner itself, the nurse should explain the situation to the patient and get the patient's opinion of various options. All other options are possibilities, but it should be the patient's determination.

When providing end-of-life care, the nurse knows it is essential to carry out which action? a. Tell the patient what he might like to hear to relieve anxiety. b. Begin making health care decisions for the patient. c. Provide the patient with the nurse's personal opinions. d. Offer unconditional support for the patient and family.

ANS: D Two major roles of a nurse caring for a dying patient are: (1) providing accurate information regarding the disease process and treatment options and (2) offering support for the patient and family without interjecting personal opinions. An essential ethical concept is autonomy, which underscores the importance of allowing patients to make their own health care decisions. Limiting information to what will relieve anxiety, providing personal opinions, and making decisions for the patient do not demonstrate respect for patient autonomy.