Unit 4 Fundamentals

A nurse is providing spiritual care to a group of patients. Match the group to their belief. a. Nature controls life and health. b. Organ transplantation or donation is not considered. c. Observance of the Sabbath is important. d. Past sins cause illness. e. Nonhuman spirits invading the body cause illness. 1. Hinduism 2. Buddhism 3. Islam 4. Judaism 5. Appalachians

1) D 2) E 3) B 4) C 5) A

An outcome for an older-adult patient living alone is to be free from falls. Which statement indicates the patient correctly understands the teaching on safety concerns? 1. "I'll take my time getting up from the bed or chair." 2. "I should dim the lighting outside to decrease the glare in my eyes." 3. "I'll leave my throw rugs in place so that my feet won't touch the cold tile." 4. "I should wear my favorite smooth bottom socks to protect my feet when walking around."

1. "I'll take my time getting up from the bed or chair."

Which assessment finding of an older adult, who has a urinary tract infection, requires an immediate nursing intervention? 1. Confusion 2. Presbycusis 3. Temperature of 97.9° F 4. Death of a spouse 2 months ago

1. Confusion

A recently widowed older-adult patient is dehydrated and is admitted to the hospital for intravenous fluid replacement. During the evening shift, the patient becomes acutely confused. Which possible reversible causes will the nurse consider when assessing this patient? (Select all that apply.) 1. Electrolyte imbalance 2. Sensory deprivation 3. Hypoglycemia 4. Drug effects 5. Dementia

1. Electrolyte imbalance 2. Sensory deprivation 3. Hypoglycemia 4. Drug effects

A nurse suspects an older-adult patient is experiencing caregiver neglect. Which assessment findings are consistent with the nurse's suspicions? 1. Flea bites and lice infestation 2. Left at a grocery store 3. Refuses to take a bath 4. Cuts and bruises

1. Flea bites and lice infestation

An older patient with dementia and confusion is admitted to the nursing unit after hip replacement surgery. Which action will the nurse include in the plan of care? 1. Keep a routine. 2. Continue to reorient. 3. Allow several choices. 4. Socially isolate patient.

1. Keep a routine.

Which information from a co-worker on a gerontological unit will cause the nurse to intervene? 1. Most older people have dependent functioning. 2. Most older people have strengths we should focus on. 3. Most older people should be involved in care decision. 4. Most older people should be encouraged to have independence.

1. Most older people have dependent functioning.

A nurse's goal for an older adult is to reduce the risk of adverse medication effects. Which action will the nurse take? 1. Review the patient's list of medications at each visit. 2. Teach that polypharmacy is to be avoided at all cost. 3. Avoid information about adverse effects. 4. Focus only on prescribed medications.

1. Review the patient's list of medications at each visit.

An older-adult patient has developed acute confusion. The patient has been on tranquilizers for the past week. The patient's vital signs are normal. What should the nurse do? 1. Take into account age-related changes in body systems that affect pharmacokinetic activity. 2. Increase the dose of tranquilizer if the cause of the confusion is an infection. 3. Note when the confusion occurs and medicate before that time. 4. Restrict phone calls to prevent further confusion.

1. Take into account age-related changes in body systems that affect pharmacokinetic activity.

A nurse is assessing a community. Match each community element the nurse will assess with the correct example. a. Education level b. Housing c. Government 1. Structure 2. Population 3. Social system

1.ANS:BDIF:Understand (comprehension)REF:38 OBJ: Describe elements of a community assessment. TOP: Assessment MSC:Health Promotion and Maintenance 2.ANS:ADIF:Understand (comprehension)REF:38 OBJ: Describe elements of a community assessment. TOP: Assessment MSC:Health Promotion and Maintenance 3.ANS:CDIF:Understand (comprehension)REF:38 OBJ: Describe elements of a community assessment. TOP: Assessment MSC:Health Promotion and Maintenance

Which patient statement is the most reliable indicator that an older adult has the correct understanding of health promotion activities? 1. "I need to increase my fat intake and limit protein." 2. "I still keep my dentist appointments even though I have partials now." 3. "I should discontinue my fitness club membership for safety reasons." 4. "I'm up-to-date on my immunizations, but at my age, I don't need the influenza vaccine."

2. "I still keep my dentist appointments even though I have partials now."

A nurse is obtaining a history on an older adult. Which finding will the nurse most typically find? 1. Lives in a nursing home 2. Lives with a spouse 3. Lives divorced 4. Lives alone

2. Lives with a spouse

A nurse is observing for the universal loss in an older-adult patient. What is the nurse assessing? 1. Loss of finances through changes in income 2. Loss of relationships through death 3. Loss of career through retirement 4. Loss of home through relocation

2. Loss of relationships through death

A nurse is developing a plan of care for an older adult. Which information will the nurse consider? 1. Should be standardized because most geriatric patients have the same needs 2. Needs to be individualized to the patient's unique needs 3. Focuses on the disabilities that all aging persons face 4. Must be based on chronological age alone

2. Needs to be individualized to the patient's unique needs

A nurse is discussing sexuality with an older adult. Which action will the nurse take? 1. Ask closed-ended questions about specific symptoms the patient may experience. 2. Provide information about the prevention of sexually transmitted infections. 3. Discuss the issues of sexuality in a group in a private room. 4. Explain that sexuality is not necessary as one ages.

2. Provide information about the prevention of sexually transmitted infections.

26. A nurse is using different strategies to meet older patients' psychosocial needs. Match the strategy the nurse is using to its description. Term Respecting the older adult's uniqueness Improving level of awareness Listening to the patient's past recollections Accepting describing of patient's perspective Offering help with grooming and hygiene Definitions 1 Body image 2 Validation therapy 3 Therapeutic communication 4 Reality orientation 5 Reminiscence

3 Respecting the older adult's uniqueness 4 Improving level of awareness 5 Listening to the patient's past recollections 2 Accepting describing of patient's perspective 1 Offering help with grooming and hygiene

A nurse is teaching a health promotion class for older adults. In which order will the nurse list the most common to least common conditions that can lead to death in older adults? 1. Chronic obstructive lung disease 2. Cerebrovascular accidents 3. Heart disease 4. Cancer 4, 1, 2, 3 3, 4, 1, 2 2, 3, 4, 1 1, 2, 3, 4

3, 4, 1, 2

A 70-year-old patient who suffers from worsening dementia is no longer able to live alone. The nurse is discussing health care services and possible long-term living arrangements with the patient's only son. What will the nurse suggest? 1. An apartment setting with neighbors close by 2. Having the patient utilize weekly home health visits 3. A nursing center because home care is no longer safe 4. That placement is irrelevant because the patient is retreating to a place of inactivity

3. A nursing center because home care is no longer safe

A nurse is caring for an older adult. Which goal is priority? 1. Adjusting to career 2. Adjusting to divorce 3. Adjusting to retirement 4. Adjusting to grandchildren

3. Adjusting to retirement

A nurse is teaching a group of older-adult patients. Which teaching strategy is best for the nurse to use? 1. Provide several topics of discussion at once to promote independence and making choices. 2. Avoid uncomfortable silences after questions by helping patients complete their statements. 3. Ask patients to recall past experiences that correspond with their interests. 4. Speak in a high pitch to help patients hear better.

3. Ask patients to recall past experiences that correspond with their interests.

A nurse is observing skin integrity of an older adult. Which finding will the nurse document as a normal finding? 1. Oily skin 2. Faster nail growth 3. Decreased elasticity 4. Increased facial hair in men

3. Decreased elasticity

What is the best suggestion a nurse could make to a family requesting help in selecting a local nursing center? 1. Have the family members evaluate nursing home staff according to their ability to get tasks done efficiently and safely. 2. Make sure that nursing home staff members get patients out of bed and dressed according to staff's preferences. 3. Explain that it is important for the family to visit the center and inspect it personally. 4. Suggest a nursing center that has standards as close to hospital standards as possible.

3. Explain that it is important for the family to visit the center and inspect it personally.

A nurse is helping an older-adult patient with instrumental activities of daily living. The nurse will be assisting the patient with which activity? 1. Taking a bath 2. Getting dressed 3. Making a phone call 4. Going to the bathroom

3. Making a phone call

A nurse is assessing an older adult for cognitive changes. Which symptom will the nurse report as normal? 1. Disorientation 2. Poor judgment 3. Slower reaction time 4. Loss of language skills

3. Slower reaction time

An older-adult patient in no acute distress reports being less able to taste and smell. What is the nurse's best response to this information? 1. Notify the health care provider immediately to rule out cranial nerve damage. 2. Schedule the patient for an appointment at a smell and taste disorders clinic. 3. Perform testing on the vestibulocochlear nerve and a hearing test. 4. Explain to the patient that diminished senses are normal findings.

4. Explain to the patient that diminished senses are normal findings.

An older patient has fallen and suffered a hip fracture. As a consequence, the patient's family is concerned about the patient's ability to care for self, especially during this convalescence. What should the nurse do? 1. Stress that older patients usually ask for help when needed. 2. Inform the family that placement in a nursing center is a permanent solution. 3. Tell the family to enroll the patient in a ceramics class to maintain quality of life. 4. Provide information and answer questions as family members make choices among care options.

4. Provide information and answer questions as family members make choices among care options.

A 72-year-old woman was recently widowed. She worked as a teller at a bank for 40 years and has been retired for the past 5 years. She never learned how to drive. She lives in a rural area that does not have public transportation. Which psychosocial change does the nurse focus on as a priority? 1. Sexuality 2. Retirement 3. Environment 4. Social isolation

4. Social isolation

A male older-adult patient expresses concern and anxiety about decreased penile firmness during an erection. What is the nurse's best response? 1. Tell the patient that libido will always decrease, as well as the sexual desires. 2. Tell the patient that touching should be avoided unless intercourse is planned. 3. Tell the patient that heterosexuality will help maintain stronger libido. 4. Tell the patient that this change is expected in aging adults.

4. Tell the patient that this change is expected in aging adults.

A patient asks the nurse what the term polypharmacy means. Which information should the nurse share with the patient? 1. This is multiple side effects experienced when taking medications. 2. This is many adverse drug effects reported to the pharmacy. 3. This is the multiple risks of medication effects due to aging. 4. This is concurrent use of many medications.

4. This is concurrent use of many medications.

11. During a routine physical assessment, the nurse obtaining a health history notes that a 50-year-old female patient reports pain and redness in the right breast. Which action is best for the nurse to take in response to this finding? a.Assess the patient as thoroughly as possible. b.Explain to the patient that breast tenderness is normal at her age. c.Tell the patient that redness is not a cause for concern and is quite common. d.Inform her that redness is the precursor to normal unilateral breast enlargement.

ANS: A A comprehensive assessment offers direction for health promotion recommendations, as well as for planning and implementing any acutely needed intervention. Redness or painful breasts are abnormal physical assessment findings in the middle-aged adult. Increased size of one breast is an abnormal physical assessment finding in the middle-aged adult.

17. The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient saying that God has left and there is no reason for living. b. A patient refusing treatment on the Sabbath. c. A patient having a folk healer in the room. d. A patient praying to Allah.

ANS: A A patient saying that God has left and there is no reason for living must be seen first for safety reasons. It must be determined by the nurse if the patient is planning suicide or is just angry and frustrated. A patient refusing treatment on the Sabbath is within that patient's right and doesn't need to be seen first. A patient with a folk healer is within the patient's right and does not need to be seen first. A patient praying to Allah is within the patient's right and does not need to be seen first.

24. A nurse is teaching parents about appropriate activities for different age groups. Which toy, if selected by the parent of a 12-month-old infant, will indicate a correct understanding of the teaching? a.Busy box b.Electronic games c.Game requiring two to four people d.Small, plastic alphabet letters and magnets

ANS: A Adults facilitate infant learning by planning activities that promote the development of milestones and by providing toys that are safe for the infant to explore with the mouth and manipulate with the hands, such as rattles, wooden blocks, plastic stacking rings, squeezable stuffed animals, and busy boxes. For the toddler (not the infant), television, videos, electronic games, and computer programs help support development and learning of basic skills. Infants are not capable of participating in small group activities. By age 4, children play in groups of two or three. Adults should provide toys that are safe for the infant to explore with the mouth. Small, plastic letters and magnets could be choking hazards for an infant.

1. A mother has delivered a healthy newborn. Which action is priority? a.Encourage close physical contact as soon as possible after birth. b.Isolate the newborn in the nursery during the first hour after delivery. c.Never leave the newborn alone with the mother during the first 8 hours after delivery. d.Do not allow the newborn to remain with parents until the second hour after delivery.

ANS: A After immediate physical evaluation and application of identification bracelets, the nurse promotes the parents' and newborn's need for close physical contact. Early parent-child interaction encourages parent-child attachment. Most healthy newborns are awake and alert for the first half-hour after birth. This is a good time for parent-child interaction to begin. No evidence in the scenario suggests that the baby cannot be left alone with the parents during the first 8 hours or that the baby should remain in the nursery during the first hour.

15. The nurse is caring for a patient who has been diagnosed with a terminal illness. The patient states, "I just don't feel like going to work. I have no energy, and I can't eat or sleep." The patient shows no interest in taking part in the care by saying, "What's the use?" Which response by the nurse is best? a. It sounds like you have lost hope. b. It sounds like you have lost energy. c. It sounds like you have lost your appetite. d. It sounds like you have lost the ability to sleep.

ANS: A All of the patient's description are describing a loss of hope. While losses of energy, appetite, and sleep are indicated, they only address a part of patient's problems. A loss of hope encompasses the holistic view of the patient.

18. A nurse is providing spiritual care to patients. Which action is essential for the nurse to take? a. Know one's own personal beliefs. b. Learn about other religions. c. Visit churches, temples, mosques, or synagogues. d. Travel to other areas that do not have the same beliefs.

ANS: A Because each person has a unique spirituality, you need to know your own beliefs so you are able to care for each patient without bias. While learning about religions, visiting other religious areas of worship, and traveling to areas that do not have the same beliefs are beneficial, they are not essential.

7. A patient states that she is pregnant and concerned because she does not know what to expect, and she wants her husband to play an active part in the birthing process. Which information should the nurse share with the patient? a.Lamaze classes can prepare pregnant women and their partners for what is coming. b.The frequency of sexual intercourse is key to helping the husband feel valued. c.After the birth, the stress of pregnancy will disappear and will be replaced by relief. d.After the baby is born, the wife should accept the extra responsibilities of motherhood.

ANS: A Childbirth education classes (like Lamaze) can prepare pregnant women, their partners, and other support persons to participate in the birthing process. The psychodynamic aspect of sexual activity is as important as the type or frequency of sexual intercourse to young adults; however, this does not relate to the issue the patient reports (lack of knowledge and participation). The stress that many women experience after childbirth has a significant impact on the health of postpartum women. Ideally partners should share all responsibilities; however, this does not relate to the patient's concerns.

13. A patient in a motor vehicle accident states, "I did not run the red light," despite very clear evidence on the street surveillance tape. Which defense mechanism is the patient using? a. Denial b. Conversion c. Dissociation d. Compensation

ANS: A Denial consists of avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain. Dissociation involves creating subjective numbness and less awareness of surroundings. Conversion involves repressing anxiety and manifesting it into nonorganic symptoms. Compensation occurs when an individual makes up for a deficit by strongly emphasizing another feature. DIF:Apply (application)REF:774 OBJ:Discuss the integration of stress theory with nursing theories.

3. A nurse is working in the delivery room. Which action is priority immediately after birth? a.Open the airway. b.Determine gestational age. c.Monitor infant-parent interactions. d.Promote parent-newborn physical contact.

ANS: A Opening the airway is the priority. The most extreme physiological change occurs when the newborn leaves the utero circulation and develops independent respiratory functioning. Direct nursing care includes maintaining an open airway, stabilizing and maintaining body temperature, and protecting the newborn from infection. After immediate physical evaluation and application of identification bracelets, the nurse promotes the parents' and newborn's need for close physical contact. Following a comprehensive physical assessment, the nurse assesses gestational age and interactions between infant and parents.

8. The nurse is caring for a patient with a chronic illness who is having conflicts with beliefs. Which health care team member will the nurse ask to see this patient? a. The clergy b. A psychiatrist c. A social worker d. An occupational therapist

ANS: A Other important resources to patients are spiritual advisors and members of the clergy. Spiritual care helps people identify meaning and purpose in life, look beyond the present, and maintain personal relationships, as well as a relationship with a higher being or life force. A psychiatrist is for emotional health. A social worker focuses on social, financial, and community resources. An occupational therapist provides care with vocational issues and functioning within physical limitations.

12. A trauma survivor is requesting sleep medication because of "bad dreams." The nurse is concerned that the patient may be experiencing post-traumatic stress disorder (PTSD). Which question is a priority for the nurse to ask the patient? a. "Are you reliving your trauma?" b. "Are you having chest pain?" c. "Can you describe your phobias?" d. "Can you tell me when you wake up?"

ANS: A People who have PTSD often have flashbacks, recurrent and intrusive recollections of the event. The other answers involve assessment of problems not specific to PTSD. DIF:Apply (application)REF:774 OBJ:Describe characteristics of post-traumatic stress disorder.

16. A young-adult patient is brought to the hospital by police after crashing the car in a high-speed chase when trying to avoid arrest for spousal abuse. Which action should the nurse take? a.Question the patient about drug use. b.Offer the patient a cup of coffee to calm nerves. c.Discretely assess the patient for sexually transmitted infections. d.Deal with the issue at hand, not asking about previous illnesses.

ANS: A Reports of arrests because of driving while intoxicated, wife or child abuse, or disorderly conduct are reasons for the nurse to investigate the possibility of drug abuse more carefully. Caffeine is a naturally occurring legal stimulant that stimulates the central nervous system and is not the choice for calming nerves. Although sexually transmitted infections occur in the young adult, this is not an action a nurse should take in this situation. The nurse may obtain important information by making specific inquiries about past medical problems, changes in food intake or sleep patterns, and problems of emotional lability.

18. Which assessment finding of a school-aged patient should alert the nurse to a possible developmental delay? a.Verbalization of "I have no friends" b.Absence of secondary sex characteristics c.Curiosity about sexuality d.Lack of group identity

ANS: A School-aged children should begin to develop friendships and to socialize with others. Interaction with peers allows them to define their own accomplishments in relation to others as they work to develop a positive self-image. The absence of secondary sex characteristics is a major concern of adolescents, not school-aged children, because physical evidence of maturity encourages the development of masculine and feminine behaviors in the adolescent. Lack of group relationships is also a concern of adolescents, not of school-aged children, because adolescents seek a group identity to fulfill their esteem and acceptance needs. Today many researchers believe that school-aged children have a great deal of curiosity about their sexuality. Some experiment, but this is usually transitory.

2. The nurse is caring for a hospitalized young-adult male who works as a dishwasher at a local restaurant. He states that he would like to get a better job but has no education. How can the nurse best assist this patient psychosocially? a.By providing information and referrals b.By focusing on the patient's medical diagnoses c.By telling the patient that he needs to go back to school d.By expecting the patient to be flexible in decision making

ANS: A Support from the nurse, access to information, and appropriate referrals provide opportunities for achievement of a patient's potential. Health is not merely the absence of disease (focusing on medical diagnoses) but involves wellness in all human dimensions. Telling a patient what to do (go back to school) is inappropriate. Each person (not the nurse) needs to make these decisions based on individual factors. Insecure persons tend to be more rigid in making decisions.

14. A nurse is teaching the staff about the general adaptation syndrome. In which order will the nurse list the stages, beginning with the first stage? 1. Resistance 2. Exhaustion 3. Alarm a. 3, 1, 2 b. 3, 2, 1 c. 1, 3, 2 d. 1, 2, 3

ANS: A The general adaptation syndrome (GAS), a three-stage reaction to stress, describes how the body responds physiologically to stressors through stages of alarm, resistance, and exhaustion. DIF:Understand (comprehension)REF:772 OBJ:Describe the three stages of the general adaptation syndrome.

17. A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful in the role of providing culturally congruent care? a.Provides care that fits the patient's valued life patterns and set of meanings b.Provides care that is based on meanings generated by predetermined criteria c.Provides care that makes the nurse the leader in determining what is needed d.Provides care that is the same as the values of the professional health care system

ANS: A The goal of transcultural nursing is to provide culturally congruent care, or care that fits the person's life patterns, values, and system of meaning. Patterns and meanings are generated from people themselves, rather than from predetermined criteria. Discovering patients' cultural values, beliefs, and practices as they relate to nursing and health care requires you to assume the role of learner (not become the leader) and to partner with your patients and their families to determine what is needed to provide meaningful and beneficial nursing care. Culturally congruent care is sometimes different from the values and meanings of the professional health care system.

13. A nurse is caring for a preschooler. Which fear should the nurse most plan to minimize? a.Fear of bodily harm b.Fear of weight gain c.Fear of separation d.Fear of strangers

ANS: A The greatest fear of preschoolers appears to be that of bodily harm; this is evident in children's fear of the dark, animals, thunderstorms, and medical personnel. Toddlers who become ill and require hospitalization are most stressed by the separation from their parents. Persons with anorexia nervosa have an intense fear of gaining weight. By 8 months, most infants are able to differentiate a stranger from a familiar person and respond differently to the two.

12. A 55-year-old female presents to the outpatient clinic describing irregular menstrual periods and hot flashes. Which information should the nurse share with the patient? a.The patient's assessment points toward normal menopause. b.Those symptoms are normal when a woman undergoes the climacteric. c.An assessment is not really needed because these problems are normal for older women. d.The patient should stop regular exercise because that is probably causing these symptoms.

ANS: A The most significant physiological changes during middle age are menopause in women and the climacteric in men. Menopause typically occurs between 45 and 60 years of age. The nurse should continue with the examination because a comprehensive assessment offers direction for health promotion recommendations, as well as for planning and implementing any acutely needed interventions. Exercise should not be stopped, especially in middle-aged adults.

21. Which information from the parent of an 8-month-old infant will cause the nurse to intervene? a.My baby rides in the front-facing car seat when I go to the grocery store. b.I made sure the slats on the crib were less than 2 inches apart. c.I removed the mobile after my baby could reach it. d.My baby cries every time he sees a new person.

ANS: A The nurse should intervene when parents let infants and toddlers ride in a front-facing car seat. All infants and toddlers should ride in a rear-facing car safety seat until they are 2 years of age or until they reach the highest weight or height allowed by the manufacturer or their car safety seat. Parents also need to inspect an older crib to make sure the slats are no more than 6 cm (2.4 inches) apart. Instruct parents to remove mobiles as soon as the infant is able to reach them. By 8 months, most infants are able to differentiate a stranger from a familiar person and respond differently to the two; this is a normal finding.

13. In caring for the patient's spiritual needs, the nurse asks 20 questions to assess the patient's relationship with God and a sense of life purpose and satisfaction. Which method is the nurse using? a. The spiritual well-being scale b. The FICA assessment tool c. Belief tool d. Hope scale

ANS: A The spiritual well-being scale (SWB) has 20 questions that assess a patient's relationship with God and his or her sense of life purpose and life satisfaction. The FICA assessment tool evaluates spirituality and is closely correlated to quality of life. This does not describe belief or hope.

20. A nurse is helping parents who have a child with attention-deficit/hyperactivity disorder. Which strategy will the nurse share with the parents to reduce stress regarding homework assignments? a. Time-management skills b. Speech articulation skills c. Routine preventative health visits d. Assertiveness training for the family

ANS: A Time-management skills are most related to homework assignment completion. Time-management techniques include developing lists of prioritized tasks. Routine health visits are important but do not directly affect ability to complete homework. Speech and other developmental aspects need to be developed if the child is to be successful, but skill development will not directly reduce homework-related stress. Assertiveness includes skills for helping individuals communicate effectively regarding their needs and desires, but it does not help with homework assignments. DIF:Apply (application)REF:781 OBJ: Describe stress management techniques beneficial for coping with stress.

18. A nurse is assessing the patient's meaning of illness. Which area of focus by the nurse is priority? a.On the way a patient reacts to disease b.On the malfunctioning of biological processes c.On the malfunctioning of psychological processes d.On the way a patient reacts to family/social interactions

ANS: A To provide culturally congruent care, you need to understand the difference between disease and illness. Illness is the way that individuals and families react to disease, whereas disease is a malfunctioning of biological or psychological processes. The way a patient interacts to family/social interactions is communication processes and family dynamics.

2. A home health nurse is providing care to a middle-aged couple with children at home. The patient has a debilitating chronic illness. Which areas will the nurse need to assess? (Select all that apply.) a.Adherence to treatment and rehabilitation regimens b.Coping mechanisms of patient and family c.Need for community services or referrals d.Knowledge base of patient only e.Use of a doula for care

ANS: A, B, C Along with the current health status of the chronically ill middle-aged adult, you need to assess the knowledge base of both the patient and family. In addition, you must determine the coping mechanisms of the patient and family; adherence to treatment and rehabilitation regimens; and the need for community and social services, along with appropriate referrals. A doula is a support person to be present during labor to assist women who have no other source of support.

1. A nurse is assessing a patient with prolonged stress. Which conditions will the nurse monitor for in this patient? (Select all that apply.) a. Cancer b. Diabetes c. Infections d. Allostasis e. Low blood pressure

ANS: A, B, C Stress causes prolonged changes in the immune system, which can result in impaired immune function, and this increases the person's susceptibility to changes in health, such as increased risk for infection, high blood pressure, diabetes, and cancers. Allostasis is a return to a state of balance; allostatic load occurs with prolonged stress. DIF:Apply (application)REF:772 OBJ:Develop a care plan for patients who are experiencing stress.

1. A nurse is evaluating a patient's spiritual care. Which areas will the nurse include in the evaluation process? (Select all that apply.) a. Review the patient's view of the purpose in life. b. Ask whether the patient's expectations were met. c. Discuss with family and friends the patient's connectedness. d. Review the patient's self-perception regarding spiritual health. e. Impress on the patient that spiritual health is permanent once obtained.

ANS: A, B, C, D In evaluating care include a review of the patient's self-perception regarding spiritual health, the patient's view of his or her purpose in life, discussion with the family and friends about connectedness, and determining whether the patient's expectations were met. Attainment of spiritual health is a lifelong goal; it is not permanent once obtained.

1. A nurse is teaching a parenting class for families with adolescents. Which health concerns will the nurse include in the teaching session? (Select all that apply.) a.Suicide b.Eating disorders c.Violence/Homicide d.Sexually transmitted infections e.Gonadotropic hormone stimulation

ANS: A, B, C, D Suicide is a major leading cause of death in adolescents 15 to 24 years of age. Adolescent overweight and obesity are current concerns in the United States, and most teens try dieting at some time to control weight. Unfortunately the number of eating disorders is on the rise in adolescent girls. Homicide is the second leading cause of death in the 15- to 24-year-old age-group, and for African-American teenagers it is the most likely cause of death. Sexually transmitted diseases annually affect three million sexually active adolescents. Gonadotropic hormones stimulate ovarian cells to produce estrogen and testicular cells to produce testosterone. These hormones are normally occurring and contribute to the development of secondary sex characteristics, such as hair growth and voice changes, and play an essential role in reproduction. It is not a health concern.

1. A nurse is assessing a middle-aged patient's barriers to change in eating habits. Which areas will the nurse assess that are external barriers? (Select all that apply.) a.Lack of facilities b.Lack of materials c.Lack of knowledge d.Lack of social supports e.Lack of short- and long-term goals

ANS: A, B, D External barriers to change include lack of facilities, materials, and social supports. Internal barriers are lack of knowledge, insufficient skills, and undefined short- and long-term goals.

2. Spiritual distress has been identified in a patient who has been diagnosed with a chronic illness. Which interventions will the nurse add to the care plan? (Select all that apply.) a. Offer to pray with the patient. b. Avoid time with the support group. c. Have the patient avoid church attendance. d. Develop activities to heal body, mind, and spirit. e. Teach relaxation, guided imagery, and meditation.

ANS: A, D, E Interventions that are appropriate for spiritual distress include (1) helping the patient develop/identify activities to heal body, mind, and spirit; (2) offering to pray with the patient; and (3) teaching relaxation, guided imagery, and medication. Attendance at church should be encouraged as well as spending time with a support group.

6. A nurse is assessing the risk of intimate partner violence (IPV) for patients. Which population should the nurse focus on most for IVP? a.White males b.Pregnant females c.Middle-aged adults d. Nonsubstance abusers

ANS: B The greatest risk of violence occurs during the reproductive years. A pregnant woman has a 35.6% greater risk of being a victim of IPV than a nonpregnant woman. White males, middle-aged adults, and nonsubstance abusers are not as high risk as pregnant women.

4. A nurse is assessing a newborn that was just born. Which newborn finding will cause the nurse to intervene immediately? a.Molding b.A lack of reflexes c.Cyanotic hands and feet d.A soft, protuberant abdomen

ANS: B A lack of reflexes must be addressed quickly. Assessment of these reflexes is vital because the newborn depends largely on reflexes for survival and in response to its environment. Molding, or overlapping of the soft skull bones, allows the fetal head to adjust to various diameters of the maternal pelvis and is a common occurrence with vaginal births. Normal physical characteristics include the continued presence of lanugo on the skin of the back; cyanosis of the hands and feet for the first 24 hours; and a soft, protuberant abdomen.

9. A senior college student visits the college health clinic about a freshman student living on the same dormitory floor. The senior student reports that the freshman is crying and is not adjusting to college life. The clinic nurse recognizes this as a combination of situational and maturational stress factors. Which is the best response by the nurse? a. "Let's call 911 because this freshman student is suicidal." b. "Give the freshman student this list of university and community resources." c. "I recommend that you help the freshman student start packing bags to go home." d. "You must make an appointment for the freshman student to obtain medications."

ANS: B A nurse can help reduce situational stress factors for individuals. Inform the patient about potential resources. Providing the student with a list of resources is one way to begin this process, as part of secondary prevention strategies. This is not a medical or psychiatric emergency, so calling 911 is not necessary. Not everyone who has sadness needs medications; some need counseling only. Not enough information is given to know whether the student would be best suited to leave college. DIF:Apply (application)REF:774 | 778 | 783 OBJ:Develop a care plan for patients who are experiencing stress.

16. The patient is having a difficult time dealing with an AIDS diagnosis. The patient states, "It's not fair. I'm totally isolated from God and my family because of this. Even my father hates me for this. He won't even speak to me." What should the nurse do? a. Tell the patient to move on and focus on getting better. b. Use therapeutic communication to establish trust and caring. c. Assure the patient that the father will accept this situation soon. d. Point out that the patient has no control and that he or she must face the consequences.

ANS: B Application of therapeutic communication principles and caring helps you establish therapeutic trust with patients. The nurse should not offer false hope (father will accept the situation soon). The nurse should help the patient maintain feelings of control, not no control. The nurse should encourage renewing relationships if possible and establishing connections with self, significant others, and God.

20. A nurse is teaching the parents of a school-aged child about accidents most common in this age group. Which topic should the nurse address? a.Falls b.Fires c.Drownings d.Poisonings

ANS: B Because accidents such as fires and car and bicycle crashes are the leading cause of death and injury in the school-age period, safety is a priority health teaching consideration. Falls, drownings, and poisonings are priority for toddlers.

19. The nurse is teaching a parent about developmental needs of a 9-month-old infant. Which statement from the parent indicates a correct understanding of the teaching? a."My child will begin to speak in sentences by 1 year of age." b."My child will probably enjoy playing peek-a-boo." c."My child will sleep about 7 to 8 hours a night." d."My child will be ready to try low-fat milk.

ANS: B By 9 months, infants play simple social games such as patty-cake and peek-a-boo. By 1 year, infants not only recognize their own names but are also able to say three to five words and understand almost 100 words; a 2 year old is generally able to speak in two-word sentences. The use of whole cow's milk, 2% cow's milk, or alternate milk products before the age of 12 months is not recommended. By 6 months, most infants are nocturnal and sleep between 9 and 11 hours at night. Total daily sleep averages 15 hours.

5. After a natural disaster occurred, an emergency worker referred a family for crisis intervention services. One family member refused to attend the services, stating, "No way, I'm not crazy." What is the nurse's best response? a. "Many times disasters can create mental health problems, so you really should participate with your family." b. "Seeking this kind of help does not mean that you have a mental illness; it is a short-term problem-solving technique." c. "Don't worry now. The psychiatrists are well trained to help." d. "This will help your family communicate better."

ANS: B Crisis intervention is a type of brief therapy that is more directive than traditional psychotherapy or counseling. It focuses on problem solving and involves only the problem created by the crisis. The other options do not properly reassure the patient and build trust. Giving advice in the form of "you really should participate" is inappropriate. "Don't worry now" is false reassurance. While crisis intervention may help families communicate better, the goal is to return to precrisis level of functioning; family therapy will focus on helping families communicate better. DIF:Apply (application)REF:782 OBJ:Discuss the process of crisis intervention. TOP: Communication and Documentation MSC: Psychosocial Integrity

9. The nurse is caring for a patient with a terminal disease. The nurse sits down and lightly touches the patient's hand. Which technique is the nurse using? a. "Doing for" b. Establishing presence c. Offering transcendence d. Providing health promotion

ANS: B Establishing presence by sitting with a patient to attentively listen to his or her feelings and situation, talking with the patient, crying with the patient, and simply offering time are powerful spiritual care approaches. Benner explains that presence involves "being with" a patient versus "doing for" a patient. Transcendence is the belief that a force outside of and greater than the person exists beyond the material world. In settings where health promotion activities occur, patients often need information, counseling, and guidance to make the necessary choices to remain healthy.

6. A nurse hears the following comments from different patients. Which patient comment does the nurse identify as faith? a. I go to church every Sunday. b. I believe there is life after death. c. I have something to look forward to each day. d. I get a feeling of awe when looking at the sunset.

ANS: B Faith allows people to have firm beliefs despite lack of physical evidence (life after death). Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality (go to church). When a person has the attitude of something to live for and look forward to, hope is present (look forward to each day). Self-transcendence is the belief that there is a force outside of and greater than the person (awe when looking at a sunset).

1. A nurse is caring for a young adult. Which goal is priority? a.Maintain peer relationships. b.Maintain family relationships. c.Maintain parenteral relationships. d.Maintain recreational relationships.

ANS: B Family is important during young adulthood. Challenges may include the demands of working and raising families. Peer is more important in the adolescent years. Young adults are much freer from parental control. While recreation is important, the family and work are the priorities in young adults.

9. A nurse is planning care for a 30 year old. Which goal is priority? a.Refine self-perception. b.Master career plans. c.Examine life goals. d.Achieve intimacy.

ANS: B From 29 to 34, the person directs enormous energy toward achievement and mastery of the surrounding world. The years from 35 to 43 are a time of vigorous examination of life goals and relationships. Between the ages of 23 and 28, the person refines self-perception and ability for intimacy.

11. A nurse makes a connection with the patient when providing spiritual care. Which type of connectedness did the nurse experience? a. Intrapersonal b. Interpersonal c. Transpersonal d. Multipersonal

ANS: B Interpersonal means connected with others and the environment. Intrapersonal means connected within oneself. Transpersonal means connected with God or an unseen higher power. There is no such term as multipersonal for connectedness.

3. The nurse is caring for an Islam patient who wants a snack. Which action by the nurse is most appropriate? a. Offers a ham sandwich b. Offers a beef sandwich c. Offers a kosher sandwich d. Offers a bacon sandwich

ANS: B Islam religion does allow beef. Islam does not allow pork or alcohol. Ham and bacon are pork. Kosher is allowed for Judaism.

3. Which goal is priority when the nurse is caring for a middle-aged adult? a.Maintain immediate family relationships. b.Maintain future generation relationships. c.Maintain personal career relationships. d.Maintain work relationships.

ANS: B Many middle-aged adults find particular joy in helping their children and other young people become productive and responsible adults. While immediate family is important, this goal is priority in young adults, not as important in middle-aged adults. During this period, personal and career achievements have often already been experienced; therefore, these goals are not priority.

2. A woman who was sexually assaulted a month ago presents to the emergency department with reports of recurrent nightmares, fear of going to sleep, repeated vivid memories of the sexual assault, and inability to feel much emotion. Which medical problem will the nurse expect to see documented in the chart? a. General adaptation syndrome b. Post-traumatic stress disorder c. Acute stress disorder d. Alarm reaction

ANS: B Post-traumatic stress disorder is characterized by vivid recollections of the traumatic event and emotional detachment and often is accompanied by nightmares. General adaptation syndrome is the expected reaction to a major stressor. Acute stress disorder is a similar diagnosis that differs from PTSD in duration of symptoms. Alarm reaction involves physiological events such as increased activation of the sympathetic nervous system that would have occurred at the time of the sexual assault. DIF:Apply (application)REF:774 OBJ:Describe characteristics of post-traumatic stress disorder.

6. A preadolescent patient is experiencing maturational stress. Which area will the nurse focus on when planning care? a. Identity issues b. Self-esteem issues c. Physical appearance d. Major changing life events

ANS: B Preadolescents experience stress related to self-esteem issues, changing family structure as a result of divorce or death of a parent, or hospitalizations. Adolescent stressors include identity issues with peer groups and separation from their families. Children identify stressors related to physical appearance, families, friends, and school. Adult stressors centralize around major changes in life circumstances. DIF:Apply (application)REF:775 OBJ:Discuss the integration of stress theory with nursing theories.

7. A nurse is comparing physical growth patterns between school-aged children and adolescents. Which principle should the nurse consider? a.Physical growth usually slows during the adolescent period. b.Secondary sex characteristics usually develop during the adolescent years. c.Boys usually exceed girls in height and weight by the end of the school years. d.The distribution of muscle and fat remains constant during the adolescent years.

ANS: B Sexual maturation in adolescence occurs with the development of primary and secondary sexual characteristics. Physical growth usually slows during the school-aged period, and then a growth spurt occurs during adolescence. Girls usually exceed boys in height and weight by the end of the school years. As height and weight increase during adolescence, the distribution of muscle and fat changes.

8. The parent brings a child to the clinic for a 12-month well visit. The child weighed 6 pounds 2 ounces and was 21 inches long at birth. Which finding will cause the nurse to intervene? a.Height of 30 inches b.Weight of 16 pounds c.Is not yet potty-trained d.Is not yet walking up stairs

ANS: B Size increases rapidly during the first year of life. Birth weight doubles in approximately 5 months and triples by 12 months. This infant should weigh at least 18 (6 × 3) pounds by this calculation. This child needs the nurse to intervene for further assessment. Height increases an average of 1 inch during each of the first 6 months and about 1/2 inch each month until 12 months: 21 + 6 + 3 = 30 (30 inches is the predicted height). Patterns of body function are just now starting to stabilize. It is quite normal for a 12-month-old child to not be potty-trained or walking up stairs yet. These milestones usually occur in the toddler period of development (12 to 36 months).

1. A co-worker asks the nurse to explain spirituality. What is the nurse's best response? a. It has a minor effect on health. b. It is awareness of one's inner self. c. It is not as essential as physical needs. d. It refers to fire or giving of life to a person.

ANS: B Spirituality is often defined as an awareness of one's inner self and a sense of connection to a higher being, to nature, or to some purpose greater than oneself. Spirituality is an important factor that helps individuals achieve the balance needed to maintain health and well-being and to cope with illness. Florence Nightingale believed that spirituality was a force that provided energy needed to promote a healthy hospital environment and that caring for a person's spiritual needs was just as essential as caring for his or her physical needs. The word spirituality comes from the Latin word spiritus, which refers to breath or wind. The spirit gives life to a person.

10. Despite working in a highly stressful nursing unit and accepting additional shifts, a new nurse has a strategy to prevent burnout. Which strategy will be best for the nurse to use? a. Delegate complex nursing tasks to nursing assistive personnel. b. Strengthen friendships outside the workplace. c. Write for 10 minutes in a journal every day. d. Use progressive muscle relaxation.

ANS: B Strengthening friendships outside of the workplace, arranging for temporary social isolation for personal "recharging" of emotional energy, and spending off-duty hours in interesting activities all help reduce burnout. Journaling and muscle relaxation are good stress-relieving techniques but are not directed at the cause of the workplace stress. Delegating complex nursing tasks to nursing assistive personnel is an inappropriate. DIF:Apply (application)REF:781-782 OBJ: Discuss how stress in the workplace affects nurses. TOP: Implementation

7. A nurse is performing a cultural assessment using the ETHNIC mnemonic for communication. Which area will the nurse assess for the "H"? a.Health b.Healers c.History d.Homeland

ANS: B The "H" in ETHNIC stands for healers: Has the patient sought advice from alternative health practitioners? While health, history, and homeland are important, they are not components of "H."

14. A male patient in stable condition is in the intensive care unit (ICU) and is asking to see his spouse and two daughters. What should the nurse do? a. Allow only 5 to 10 minutes with the family. b. Allow the wife and daughters to visit at the patient's request. c. Allow the two daughters to visit, and let the wife visit when they leave. d. Allow the wife and one daughter to enter the ICU but not the other daughter.

ANS: B Use of support systems is important in any health care setting. Allowing the family to visit is appropriate since the patient is in stable condition. When patients depend on family and friends for support, encourage them to visit the patient. As long as no interference with active patient care is involved, there is no reason to limit visitation. Limiting the visit is not necessary since the patient is stable. Breaking the family apart is not needed; the patient is stable and can see all three at once.

15. Upon assessment of a middle-aged adult, the nurse observes uneven weight bearing and decreased range of joint motion. Which area is priority? a.Abuse potential b.Fall precautions c.Stroke prevention d.Self-esteem issues

ANS: B With uneven weight bearing and decreased range of joint motion, falling is a priority. Abuse potential would indicate other findings such as bruising or unkept appearance. While stroke prevention is important in a middle-aged adult, these are not the signs of stroke. While self-esteem issues may arise from physical changes, safety is a priority over self-esteem issues.

3. A nurse is providing prenatal care to a first-time mother. Which information will the nurse share with the patient? (Select all that apply.) a.Regular trend for postpartum depression b.Protection against urinary infection c.Strategies for empty nest syndrome d.Exercise patterns e.Proper diet

ANS: B, D, E Prenatal care includes a thorough physical assessment of the pregnant woman during regularly scheduled intervals. Information regarding STIs and other vaginal infections and urinary infections that will adversely affect the fetus and counseling about exercise patterns, diet, and child care are important for a pregnant woman. Empty nest syndrome occurs as children leave the home. Postpartum depression is rare.

15. The nurse is caring for an infant. Which activity is most appropriate for the nurse to offer to the infant? a.Set of cards to organize and separate into groups b.Set of sock puppets with movable eyes c.Set of plastic stacking rings d.Set of paperback book

ANS: C Adults and nurses facilitate infant learning by planning activities that promote the development of milestones and providing toys that are safe for the infant to explore with the mouth and manipulate with the hands such as rattles, wooden blocks, plastic stacking rings, squeezable stuffed animals, and busy boxes. Preschoolers demonstrate their ability to think more complexly by classifying objects according to size or color, making the cards more appropriate for them. Neither group is ready for paperback books. The sock puppet with movable eyes could create a choking hazard if one of the eyes comes off.

10. The nurse is teaching a parenting class. One of the topics is development. Which statement from a parent indicates more teaching is needed? a."The toddler may use parallel play." b."The preschooler has the ability to play in small groups." c."The school-aged child still needs total assistance in all safety activities." d."The toddler may have temper tantrums from parent's acting on safety rules."

ANS: C At this age (school-age), encourage children to take responsibility for their own safety. The toddler continues to engage in solitary play but also begins to participate in parallel play, which is playing beside rather than with another child. The play of preschool children becomes more social after the third birthday as it shifts from parallel to associative play with others in small groups. The toddler's strong will is frequently exhibited in negative behavior when caregivers attempt to direct actions. Temper tantrums result when parental restrictions frustrate toddlers.

6. A nurse is teaching the staff about development. Which information indicates the nurse needs to follow up? a."Development proceeds in a cephalocaudal pattern." b."Development proceeds in a proximal-distal pattern." c."Development proceeds at a slower rate during the embryonic stage." d."Development proceeds at a predictive rate from the moment of conception."

ANS: C Development proceeds at a slower rate during embryonic stage indicates the nurse needs to follow up to correct the misconception. From the moment of conception until birth, human development proceeds at a predictive and rapid rate. All the rest of the information is correct and does not need follow-up. Development proceeds in a cephalocaudal and proximal-distal pattern.

12. The patient is admitted with chronic anxiety. Which action is most appropriate for the nurse to take? a. Focus on finding quick remedies for the anxiety. b. Realize that the patient's only goal is relief of the anxiety. c. Look at how anxiety influences the patient's ability to function. d. Help the patient realize that there is little hope of relief from anxiety.

ANS: C Do not just look at the patient's anxiety as a problem to solve with quick remedies, but rather look at how the anxiety influences the patient's ability to function and achieve goals established in life (not just anxiety relief). Mobilizing the patient's hope is central to a healing relationship.

18. A nurse is planning care for a patient that uses displacement. Which information should the nurse consider when planning interventions? a. This copes with stress directly. b. This evaluates an event for its personal meaning. c. This protects against feelings of worthlessness and anxiety. d. This triggers the stress control functions of the medulla oblongata.

ANS: C Ego-defense mechanisms, like displacement, regulate emotional distress and thus give a person protection from anxiety and stress. Everyone uses them unconsciously to protect against worthlessness and feelings of anxiety. Ego-defense mechanisms help a person cope with stress indirectly and offer psychological protection from a stressful event. Evaluation of an event for its personal meaning is primary appraisal. The medulla oblongata controls heart rate, blood pressure, and respirations and is not triggered by ego defense mechanisms. DIF:Understand (comprehension)REF:774 OBJ:Discuss the integration of stress theory with nursing theories.

19. Which sociocultural finding in the history of a patient will alert the nurse to a possible developmental problem? a. Family relocation b. Childhood obesity c. Prolonged poverty d. Loss of stamina

ANS: C Environmental and social stressors often lead to developmental problems. Sociocultural refers to societal or cultural factors; poverty is a sociocultural factor. Stamina loss and obesity are health problems, and family relocation is a situational factor. DIF:Apply (application)REF:775 OBJ:Discuss the integration of stress theory with nursing theories.

12. A nurse is communicating with a newly admitted teenaged patient. Which action should the nurse take? a.Avoid questioning the patient about cigarette use when the nurse observes a cigarette lighter lying on the bedside table. b.Complete the admission database as quickly as possible by asking yes and no questions. c.Look for meaning behind the patient's words and actions. d.Ignore the patient's withdrawn behavior.

ANS: C Good communication skills are critical for adolescents. Look for meaning behind the adolescent's words and actions. Following are some hints for communicating with adolescents: Do not avoid discussing sensitive issues. Asking questions about sex, drugs, and school opens the channels for further discussion. Ask open-ended questions. (Yes and no questions are closed-ended questions.) The nurse should inquire about a patient's withdrawn behavior to seek out the meaning of such behaviors. Be alert to clues about adolescents' emotional states.

2. A nurse teaches a new mother about the associated health risks to the infant. Which statement by the mother indicates a correct understanding of the teaching? a."I will feed my baby every 4 hours around-the-clock." b."I need to leave the blankets off my baby to prevent smothering." c."I need to remind friends who want to hold my baby to wash their hands." d."I will throw away the bulb syringe now because my baby is breathing fine."

ANS: C Good handwashing technique is the most important factor in protecting the newborn from infection. You can help prevent infection by instructing parents and visitors to wash their hands before touching the infant. The nurse can help parents identify ways to meet needs by counseling them to feed their baby on demand rather than on a rigid schedule. Newborns are susceptible to heat loss and cold stress. Place the healthy newborn directly on the mother's abdomen, covering with warm blankets. Removal of nasopharyngeal and oropharyngeal secretions remains a priority of care to maintain a patent airway; keeping the bulb syringe is important.

10. The nurse and the patient have the same religious affiliation. Which action will the nurse take? a. Must use a formal assessment tool to determine patient's beliefs. b. Assume that both have the same spiritual beliefs. c. Do not impose personal values on the patient. d. Skip the spiritual belief assessment.

ANS: C It is important not to impose personal value systems on the patient. This is particularly true when the patient's values and beliefs are similar to those of the nurse because it then becomes very easy to make false assumptions. It is not a must to use a formal assessment tool when assessing a patient's beliefs. It is important to conduct the spiritual belief assessment; conducting an assessment is therapeutic because it expresses a level of caring and support.

4. A nurse is teaching young adults about health risks. Which statement from a young adult indicates a correct understanding of the teaching? a."It's probably safe for me to start smoking. At my age, there's not enough time for cancer to develop." b."My mother had appendicitis so this increases my chance for developing appendicitis." c."Controlling the amount of stress in my life may decrease the risk of illness." d."I don't do drugs. I do drink coffee, but caffeine is not a drug."

ANS: C Lifestyle habits that activate the stress response increase the risk of illness; so, controlling this will decrease risk. Smoking is a well-documented risk factor for pulmonary, cardiac, and vascular disease as well as cancer in smokers and in individuals who receive secondhand smoke. The presence of certain chronic illnesses (not acute illnesses—appendicitis) in the family increases the family member's risk of developing a disease. Caffeine is a naturally occurring legal stimulant that is readily available. Caffeine stimulates catecholamine release, which, in turn, stimulates the central nervous system; it also increases gastric acid secretion, heart rate, and basal metabolic rate.

1. In a natural disaster relief facility, the nurse observes that an older-adult male has a recovery plan, while a 25-year-old male is still overwhelmed by the disaster situation. A nurse is planning care for both patients. Which factors will the nurse consider about the different coping reactions? a. Restorative care factors b. Strong financial resource factors c. Maturational and situational factors d. Immaturity and intelligence factors

ANS: C Maturational factors and situational factors can affect people differently depending on their life experiences. An older individual would have more life experiences to draw from and to analyze on why he was successful, whereas a younger individual would have fewer life experiences based on chronological age to analyze for patterns of previous success. Nothing in the scenario implies that either man is in restorative care, has strong financial resources, or is immature or intelligent. DIF:Apply (application)REF:775 OBJ:Discuss the integration of stress theory with nursing theories.

17. A nurse determines that a middle-aged patient is a typical example of the "sandwich generation." What did the nurse discover the patient is caught between? a.Job responsibilities or family responsibilities b.Stopping old habits and starting new ones c.Caring for children and aging parents d.Advancing in career or retiring

ANS: C Middle-aged adults also begin to help aging parents while being responsible for their own children, placing them in the sandwich generation. It does not include job and family responsibilities; old habits and new ones; or career and retiring.

14. A nurse discusses the risks of repeated sun exposure with a young-adult patient. Which response will the nurse most expect from this patient? a."I should consider participating in a health fair about safe sun practices." b."I'll make an appointment with my doctor right away for a full skin check." c."I've had this mole my whole life. So what if it changed color? My skin is fine." d."I have a mole that has been bothering me. I'll call my family doctor for an appointment to get it checked."

ANS: C Most typically young adults would say that their skin is fine. Young adults often ignore physical symptoms and often postpone seeking health care. Making an appointment right away with the doctor and participating in health fairs are not typical behaviors of young adults for the same reason.

5. A nurse performs an assessment on a healthy newborn. Which assessment finding will the nurse document as normal? a. Cyanosis of the feet and hands for the first 48 hours b.Triangle-shaped anterior fontanel c.Sporadic motor movements d.Weight of 4800 grams

ANS: C Movements in the newborn are generally sporadic, but they are symmetric and involve all four extremities. Cyanosis of the hands and feet is normal for the first 24 hours, not 48 hours. The diamond shape of the anterior fontanel and the triangular shape of the posterior fontanel are found between the unfused bones of the skull. The average newborn is 2700 to 4000 grams (6 to 9 pounds), not 4800 grams.

2. The nurse is caring for a patient who is an agnostic. Which information should the nurse consider when planning care for this patient? a. The patient is devoid of spirituality. b. The patient does not believe in God. c. The patient believes there is no known ultimate reality. d. The patient finds no meaning through relationship with others.

ANS: C Some people do not believe in the existence of God (atheist), or they believe that there is no known ultimate reality (agnostic). Nonetheless, spirituality is important regardless of a person's religious beliefs. Agnostics discover meaning in what they do or how they live because they find no ultimate meaning for the way things are. They believe that people bring meaning to what they do.

15. A young male patient is diagnosed with testicular cancer. Which action will the nurse take first? a. Provide information to the patient. b. Allow time for the patient's friends. c. Ask about the patient's priority needs. d. Find support for the family and patient.

ANS: C Take time to understand a patient's meaning of the precipitating event and the ways in which stress is affecting his life. For example, in the case of a woman who has just been told that a breast mass was identified on a routine mammogram, it is important to know what the patient wants (priority needs) and needs most from the nurse. Providing information, allowing time with friends, and finding support may be implemented after finding out what the patient wants or needs. DIF:Apply (application)REF:776 OBJ:Develop a care plan for patients who are experiencing stress.

3. The nurse teaches stress-reduction and relaxation training to a health education group of patients after cardiac bypass surgery. Which level of intervention is the nurse using? a. Primary b. Secondary c. Tertiary d. Quad

ANS: C Tertiary-level interventions assist the patient in readapting and can include relaxation training and time-management training. At the primary level of prevention, you direct nursing activities to identifying individuals and populations who are possibly at risk for stress. Nursing interventions at the secondary level include actions directed at symptoms such as protecting the patient from self-harm. Quad level does not exist. DIF:Understand (comprehension)REF:778 OBJ:Discuss the integration of stress theory with nursing theories.

16. A nurse is teaching the staff about a nursing theory that views a person, family, or community developing a normal line of defense. Which theory is the nurse describing? a. Ego defense model b. Immunity model c. Neuman Systems Model d. Pender's Health Promotion Model

ANS: C The Neuman Systems Model uses a systems approach, and it helps you understand your patients' individual responses to stressors and also families' and communities' responses. Every person develops a set of responses to stress that constitute the "normal line of defense." This line of defense helps to maintain health and wellness. Ego defense mechanisms are unconscious coping mechanisms. Immunity is a body's natural protection mechanism. Pender's Health Promotion Model focuses on promoting health and managing stress. DIF:Apply (application)REF:774 OBJ:Discuss the integration of stress theory with nursing theories.

11. The nurse is observing a 2-year-old hospitalized patient in the playroom. Which activity will the nurse most likely observe? a.Seeking out same sex children to play with b.Participating as the leader of a small group activity c.Sitting beside another child while playing with blocks d.Separating building blocks into groups by size and color

ANS: C The child beside another child and playing is exhibiting parallel play, characteristic of a toddler. Participating as a group leader does not usually occur until around age 5. Preschoolers (ages 3 to 5) demonstrate their ability to think more complexly by classifying objects according to size or color. A 2-year-old child does not have this ability yet. Gender does not become a factor until the child reaches school-age when the child prefers same sex peers to opposite sex peers.

23. Which statement, if made by a parent, will require further instruction from the nurse? a."I should not be surprised that my teenage son has so many friends." b."I get worried because my teenage son thinks he's indestructible." c."I should cover for my 10-year-old son when he makes mistakes until he learns the ropes." d."I usually have nutritious snacks available because my 10-year-old son is always hungry right after school."

ANS: C The nurse will need to teach the parent of a school-aged child covering for the child's mistakes; this is a misconception that needs to be corrected. Parents have to learn to allow their school-aged child (6 to 12 years old) to make decisions, accept responsibility, and learn from life's experiences. All the other statements are normal and do not need further teaching. Teenagers typically are very social and have many friends. Adolescents seek a group identity because they need esteem and acceptance. Adolescents feel they are indestructible, which leads to risk-taking behaviors. School-age children are developing eating patterns that are independent of parental supervision. Having nutritious snacks available is a healthy option.

5. The nurse is admitting a patient to the hospital. The patient is a very spiritual person but does not practice any specific religion. How will the nurse interpret this finding? a. This indicates a strong religious affiliation. b. This statement is contradictory. c. This statement is reasonable. d. This indicates a lack of hope.

ANS: C The patient's statement is reasonable and is not contradictory. Many people tend to use the terms spirituality and religion interchangeably. Although closely associated, these terms are not synonymous. Religious practices encompass spirituality, but spirituality does not need to include religious practice. When a person has the attitude of something to live for and look forward to, hope is present.

4. A nurse is teaching a patient how to meditate. Which information from the patient indicates effective learning? a. I will lie on the floor. b. I will breathe quickly. c. I will focus on an image. d. I will do this for 10 minutes every day.

ANS: C The steps of meditation include sitting in a comfortable position with the back straight; breathe slowly; and focus on a sound, prayer, or image. Meditation should occur for 10 to 20 minutes twice a day.

8. Which information from the nurse indicates a correct understanding of emerging adulthood? a.It is a type of young adulthood. b.It is a type of extended adolescence. c.It is a type of independent exploration. d.It is a type of marriage and parenthood.

ANS: C This newly identified stage of development from age 18 to 25 (emerging adulthood) has been described as neither an extended adolescence, as it is much freer from parental control and is much more a period of independent exploration, nor young adulthood, as most young people in their twenties have not made the transitions historically associated with adult status, especially marriage and parenthood.

8. An adult male reports new-onset, seizure-like activity. An EEG and a neurology consultant's report rule out a seizure disorder. It is determined the patient is using conversion. Which action should the nurse take next? a. Suggest acupuncture. b. Confront the patient on malingering. c. Obtain history of any recent life stressors. d. Recommend a regular exercise program.

ANS: C Unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms (e.g., difficulty sleeping, loss of appetite) describes conversion. The nurse must assess the patient fully for emotional conflict and stress before implementing any nursing interventions (acupuncture or exercise program). Although the patient may be malingering, confrontation is nontherapeutic because the patient is using this type of defense mechanism in response to some type of stressor. DIF:Apply (application)REF:774 | 776 OBJ:Develop a care plan for patients who are experiencing stress.

The nurse is making a home visit to a Korean mother after the birth of girl. The spouse is pressing different parts of the patient's hand and lower arm to relieve a headache. What is the nurse's next action? a. Tell the spouse to stop and give the mother acetaminophen. b. Let the spouse finish and then give the mother medication. c. Ask the mother and/or spouse to explain the procedure. d. Explain to the spouse that it will not work. A nurse is assessing the social system of a community.

ANS: C The nurse should not judge the patient's/family's beliefs and values about health. The nurse needs to understand cultural beliefs, values, and practices to determine their specific needs. Acetaminophen may not be an acceptable alternative for this family. Criticizing the family's beliefs and practices or saying they will not work may only create a barrier to care. DIF:Analyze (analysis)REF:34 OBJ: Identify characteristics of patients from vulnerable populations that influence the community-based nurse's approach to care. TOP: Implementation MSC: Psychosocial Integrity

22. The nurse is preparing to teach a group of parents with infants about growth and development. Which information should the nurse include in the teaching session? a.3-month-old infants will be able to bang objects together. b.4-month-old infants will be able to sit alone with support. c.5-month-old infants will be able to creep on hands and knees. d.6-month-old infants will be able to turn from back to abdomen.

ANS: D 6-month-old infants will be able to turn from back to abdomen. 6 to 8 month olds can sit alone without support and bang objects together. 8 to 10 month olds can creep on hands and knees.

17. A school nurse is encouraging children to play a game of kickball. Which group of children is the nurse most likely addressing? a.Infant b.Toddler c.Preschool d.School-aged

ANS: D A game of kickball would be best suited for school-aged children because in this age group, play involves peers and the pursuit of group goals. Although solitary activities are not eliminated, group play overshadows them. Younger children typically are not able to participate cooperatively in groups yet. Infants begin to play simple social games such as patty-cake and peek-a-boo. Toddlers engage in solitary play but also begin to participate in parallel play. Preschoolers playing together engage in similar if not identical activities; however, no division of labor or rigid organization or rules are observed. By the age of 5, the group has a temporary leader for each activity.

16. A mother expresses concern because her 5-year-old child frequently talks about friends who don't exist. What is the nurse's best response to this mother's concern? a."Have you considered a child psychological evaluation?" b."You should stop your child from playing electronic games." c."Pretend play is a sign your child watches too much television." d."It's very normal for a child this age to have imaginary playmates."

ANS: D At age 5, some children have imaginary playmates. Imaginary playmates are a sign of health and allow the child to distinguish between reality and fantasy. The child does not need a psychological evaluation because this is normal behavior. Television, videos, electronic games, and computer programs help support development and the learning of basic skills. However, these should be only one part of the child's total play activities. Pretend play is not a sign of watching too much television.

17. An adult who was in a motor vehicle accident is brought into the emergency department by paramedics, who report the following in-transit vital signs: Oral temperature: 99.0° F Pulse: 102 beats/min Respiratory rate: 26 breaths/min Blood pressure: 140/106 Which hormones should the nurse consider as the most likely causes of the abnormal vital signs? a. ADH and ACTH b. ACTH and epinephrine c. ADH and norepinephrine d. Epinephrine and norepinephrine

ANS: D During the alarm stage, rising hormone levels result in increased blood volume, blood glucose levels, epinephrine and norepinephrine amounts, heart rate, blood flow to muscles, oxygen intake, and mental alertness. ACTH originates from the anterior pituitary gland and stimulates cortisol release; ADH originates from the posterior pituitary and increases renal reabsorption of water. ACTH, cortisol, and ADH do not increase heart rate. DIF:Apply (application)REF:772 OBJ:Describe the three stages of the general adaptation syndrome.

7. A nurse is caring for a patient with stress and is in the evaluation stage of the critical thinking model. Which actions will the nurse take? a. Select nursing interventions and promote patient's adaptation to stress. b. Establish short- and long-term goals with the patient experiencing stress. c. Identify stress management interventions and achieve expected outcomes. d. Reassess patient's stress-related symptoms and compare with expected outcomes.

ANS: D During the evaluation stage, the nurse compares current stress-related symptoms against established measurable outcomes to evaluate the effectiveness of the intervention. Selecting appropriate interventions and establishing goals are part of the planning process. DIF:Apply (application)REF:783-784 OBJ:Develop a care plan for patients who are experiencing stress.

13. The nurse is teaching a class to pregnant women about common physiological changes during pregnancy. Which information should the nurse include in the teaching session? a.Pregnancy is not a time to be having sexual activity. b.Urinary frequency will occur early in the pregnancy. c.Breast tenderness should be reported as soon as possible. d.Late in the pregnancy Braxton Hicks contraction may occur.

ANS: D During the third trimester (late pregnancy), increases in Braxton Hicks contractions (irregular, short contractions), fatigue, and urinary frequency (not early) occur. Normally, women commonly have morning sickness, breast enlargement and tenderness, and fatigue. Women need to be reassured that sexual activity will not harm the fetus.

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

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

4. A nurse is teaching guided imagery to a prenatal class. Which technique did the nurse describe? a. Singing b. Massaging back c. Listening to music d. Using sensory peaceful words

ANS: D Guided imagery is used as a means to create a relaxed state through the person's imagination, often using sensory words. Imagination allows the person to create a soothing and peaceful environment. Singing, back massage, and listening to music are other types of stress management techniques. DIF:Understand (comprehension)REF:781 OBJ: Describe stress management techniques beneficial for coping with stress.

7. A nurse is caring for a Hindu patient. Which action will the nurse take? a. Allow time to practice the Five Pillars. b. Allow time to practice Blessingway. c. Allow time for Holy Communion. d. Allow time for purity rituals.

ANS: D Hindus practice prayer and purity rituals. Blessingway is a practice of the Navajos that attempts to remove ill health by means of stories, songs, rituals, prayers, symbols, and sand paintings. Islams must be able to practice the Five Pillars of Islam. Holy Communion is practiced in the Christian religion.

16. A nurse works at a hospital that uses equity-focused quality improvement. Which strategy is the hospital using? a.Document staff satisfaction. b.Focus on the family. c.Implement change on a grand scale. d.Reduce disparities.

ANS: D Organizations can implement equity-focused quality improvement by recognizing disparities and committing to reducing them. Staff diversity is a priority for equity-focused quality improvement, not staff satisfaction. While the family is important, the focus is on the patients. Organizations should start by implementing a change on a small scale (pilot testing), learning from each test, and refining the intervention through performance improvement cycles (e.g., plan, do, study, and act).

9. A nurse is assessing the cognitive changes in a preschooler. Which standard will the nurse use to determine normal? a.The ability to think abstractly and deal effectively with hypothetical problems b.The ability to think in a logical manner about the here and now c.The ability to assume the view of another person d.The ability to classify objects by size or color

ANS: D Preschoolers demonstrate their ability to think more complexly by classifying objects according to size or color. Cognitive changes that provide the ability to think in a logical manner about the here and now occur during the school-aged years. It is during the teenaged years when the individual thinks abstractly and deals effectively with hypothetical problems. The toddler is unable to assume the view of another.

11. A female teen with celiac disease continues to eat food she knows will make her ill several hours after ingestion. While planning care, the nurse considers maturational and tertiary-level interventions. Which intervention will the nurse add to the care plan? a. Teach the teen about the food pyramid. b. Administer antidiarrheal medications with meals. c. Gently admonish the teen and her parents regarding the consistently poor diet choices. d. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends.

ANS: D Tertiary-level interventions assist the patient in readapting to life with an illness. By adjusting the diet to meet dietary guidelines and also addressing adolescent maturational needs, the nurse will help the teen to eat an appropriate diet without health complications and see herself as a "typical and normal" teenager. Teaching about the food pyramid will not address the real issue, which is that the teen is still eating what she knows will make her ill and the food pyramid is usually a primary intervention. Administering antidiarrheal medications may help but is not a tertiary-level or maturational intervention. Admonishing the teen and parents is not a tertiary-level intervention, and because this approach is nontherapeutic, it may cause communication problems. DIF:Analyze (analysis)REF:775 | 778 OBJ:Develop a care plan for patients who are experiencing stress.

14. A nurse is teaching a class about the effects of nutrition on fetal growth and development. A pregnant patient asks the nurse how much weight should normally be gained over the pregnancy. Which information should the nurse share with the patient? a.About 10 to 20 pounds b.About 15 to 25 pounds c.About 20 to 30 pounds d.About 25 to 35 pounds

ANS: D The diet of a woman both before and during pregnancy has a significant effect on fetal development. For women who are at normal weight for height, the recommended weight gain is 25 to 35 pounds over three trimesters. Weight gains of 10 to 20, 15 to 25, and 20 to 30 pounds are too low.

5. A nurse is choosing an appropriate topic for a young-adult health fair. Which topic should the nurse include? a.Retirement b.Menopause c.Climacteric factors d.Unplanned pregnancies

ANS: D Unplanned pregnancies are a continued source of stress that can result in adverse health outcomes for the mother (young adult), infant, and family. Retirement is an issue for middle-aged, not young adults. The onset of menopause and the climacteric affect the sexual health of the middle-aged adult, not the young adult.

10. A nurse is planning care for young-adult patients. Which information should the nurse consider when planning care? a.Fertility issues do not occur in young adulthood. b.Young adults tend to suffer more from severe illness. c.Substance abuse is easy to observe in young-adult patients. d.Young adults are quite active but are at risk for illness in later years.

ANS: D Young adults are generally active and experience severe illnesses less frequently. However, their lifestyles may put them at risk for illnesses or disabilities during their middle or older-adult years. An estimated 10% to 15% of reproductive couples are infertile, and many are young adults. Substance abuse is not always diagnosable, particularly in its early stages.

When developing a plan of care concerning growth and development for a hospitalized adolescent, what should the nurse do? (Select all that apply.) A. Stick with one developmental theory for consistency. B. Apply developmental theories when making observations of the individual's patterns of growth and development. C. Compare the individual's assessment findings versus established normal findings. D. Recognize his/her own moral developmental level. E. Apply a unidimensional life span perspective.

B, C, and D.

A nurse encounters a family who experienced the death of their adult child last year. The parents are talking about the upcoming anniversary of their child's death. The nurse spends time with them discussing their child's life and death. Which nursing principle does the nurse's action best demonstrate? a. Facilitation of normal mourning b. Pain-management technique c. Grief evaluation d. Palliative care

a

A nurse is caring for a dying patient. When is the best time for the nurse to discuss end-of-life care? a. During assessment b. During planning c. During implementation d. During evaluation

a

A nurse is providing postmortem care. Which action will the nurse take? a. Leave dentures in the mouth. b. Lower the head of the bed. c. Cover the body with a sterile sheet. d. Remove all tubes for an autopsy.

a

A patient has had two family members die during the past 2 days. Which coping strategy is most appropriate for the nurse to suggest to the patient? a. Writing in a journal b. Drinking alcohol to go to sleep c. Exercising vigorously rather than sleeping d. Avoiding talking with friends and family members

a

The mother of a child who died recently keeps the child's room intact. Family members are encouraging her to redecorate and move forward in life. Which type of grief will the home health nurse recognize the mother is experiencing? a. Normal b. End-of-life c. Abnormal d. Complicated

a

15. A nurse hears a co-worker state that anybody could be a nurse since it is so automated with infusion devices and electronic monitoring; technology is doing the work. What is the nurse's best response? a. "Technology use has to be combined with nursing judgment." b. "The focus of effective nursing care is technology." c. "If it's so easy, why don't you do it?" d. "That is true in the 20th century."

a. "Technology use has to be combined with nursing judgment."

7. A nurse is following the PDSA cycle for quality improvement. Which action will the nurse take for the letter "A"? a. Act b. Alter c. Assess d. Approach

a. Act

16. A nurse is completing a minimum data set. Which area is the nurse working? a. Nursing center b. Psychiatric facility c. Rehabilitation center d. Adult day care center

a. Nursing center

A nursing assistive personnel (NAP) is caring for a dying patient. Which action by the NAP will cause the nurse to intervene? a. Elevating head of bed b. Making the patient eat c. Giving mouth care every 2 to 4 hours d. Keeping skin clean, dry, and moisturized

b

A previously toilet trained toddler has started wetting again. A nurse is gathering a health history from the grandparent. Which health history finding will the nurse most likely consider as the cause of the wetting? a. Dietary changes b. Recent parental death c. Playmate moved away d. Sibling was sick 2 days

b

A veteran is hospitalized after surgical amputation of both lower extremities owing to injuries sustained during military service. Which type of loss will the nurse focus the plan of care on for this patient? a. Perceived loss b. Situational loss c. Maturational loss d. Uncomplicated loss

b

An Orthodox Jewish rabbi has been pronounced dead. The nursing assistive personnel respectfully ask family members to leave the room and go home as postmortem care is provided. Which statement from the supervising nurse is best? a. "I should have called a male colleague to handle the body." b. "Family members stay with the body until burial the next day." c. "I wish they would go home because we have work to do here." d. "Family will quietly leave after praying and touching the rabbi's head."

b

During a follow-up visit, a female patient is describing new onset of marital discord with her terminally ill spouse to the hospice nurse. Which Kübler-Ross stage of dying is the patient experiencing? a. Denial b. Anger c. Bargaining d. Depression

b

A nurse is documenting end-of-life care. Which information will the nurse include in the patient's electronic medical record? (Select all that apply.) a. Reason for the death b. Time and date of death c. How ethically the family grieved d. Location of body identification tags e. Time of body transfer and destination

b, d, e

14. A nurse is providing home care to a home-bound patient treated with intravenous (IV) therapy and enteral nutrition. What is the home health nurse's primary objective? a. Screening b. Education c. Dependence d. Counseling

b. Education

8. The nurse is trying to determine how well a certain health plan compares with other health plans. To gather this type of data, which information will the nurse utilize? a. Pew Health Professions Commission b. Healthcare Effectiveness Data and Information Set (HEDIS) c. American Nurses Credentialing Center (ANCC) Magnet Recognition Program d. Hospital Consumer of Assessment of Healthcare Providers and Systems (HCAHPS)

b. Healthcare Effectiveness Data and Information Set (HEDIS)

"I know it seems strange, but I feel guilty being pregnant after the death of my son last year," said a woman during her routine obstetrical examination. The nurse spends extra time with this woman, helping her realize bonding with this unborn child will not mean she is replacing the one who died. Which nursing technique does this demonstrate? a. Providing curative therapy b. Promoting spirituality c. Facilitating mourning d. Eradicating grief

c

A female nurse is called into the supervisor's office regarding her deteriorating work performance since the loss of her spouse 2 years ago. The woman begins sobbing and says that she is "falling apart" at home as well. Which type of grief is the female nurse experiencing? a. Normal grief b. Perceived grief c. Complicated grief d. Disenfranchised grief

c

A severely depressed patient cannot state any positive attributes to life. The nurse patiently sits with this patient and assists the patient to identify several activities the patient is actually looking forward to in life. Which spiritual concept is the nurse trying to promote? a. Time management b. Reminiscence c. Hope d. Faith

c

Family members gather in the emergency department after learning that a family member was involved in a motor vehicle accident. After learning of the family member's unexpected death, the surviving family members begin to cry and scream in despair. Which phase does the nurse determine the family is in according to the Attachment Theory? a. Numbing b. Reorganization c. Yearning and searching d. Disorganization and despair

c

3. A nurse is teaching a family about health care plans. Which information from the nurse indicates a correct understanding of the Affordable Care Act? a. A family can choose whether to have health insurance with no consequences. b. Primary care physician payments from Medicaid services can equal Medicare. c. Adult children up to age 26 are allowed coverage on the parent's plan. d. Private insurance companies can deny coverage for any reason.

c. Adult children up to age 26 are allowed coverage on the parent's plan.

A cancer patient asks the nurse what the criteria are for hospice care. Which information should the nurse share with the patient? a. It is for those needing assistance with pain management. b. It is for those having a terminal illness, such as cancer. c. It is for those with completion of an advance directive. d. It is for those expected to live less than 6 months.

d

A nurse is caring for a dying patient. One of the nurse's goals is to promote dignity and validation of the dying person's life. Which action will the nurse take to best achieve this goal? a. Take pictures of visitors. b. Provide quiet visiting time. c. Call the organ donation coordinator. d. Listen to family stories about the person.

d

A nurse is caring for a patient in the last stages of dying. Which finding indicates the nurse needs to prepare the family for death? a. Redness of skin b. Clear-colored urine c. Tense muscles tone d. Cheyne-Stokes breathing

d

A nurse lets the transplant coordinator make a request for organ and tissue donation from the patient's family. What is the primary rationale for the nurse's action? a. The nurse is not as knowledgeable as the coordinator. b. The nurse is uncomfortable asking the family. c. The nurse does not want to upset the family. d. The nurse is following a federal law.

d

A palliative team is caring for a dying patient in severe pain. Which action is the priority? a. Provide postmortem care for the patient. b. Support the patient's nurse in grieving. c. Teach the patient the stages of grief. d. Enhance the patient's quality of life.

d

A patient cancels a scheduled appointment because the patient will be attending a Shivah for a family member. Which response by the nurse is best? a. "When families come together for end-of-life decisions, it provides connections." b. "We will reschedule so the appointment does not fall on the Sabbath." c. "Missionary outreach is so important for spiritual comfort." d. "I'm so sorry for your loss."

d

A patient's father died a week ago. Both the patient and the patient's spouse talk about the death. The patient's spouse is experiencing headaches and fatigue. The patient is having trouble sleeping, has no appetite, and gets choked up most of the time. How should the nurse interpret these findings as the basis for a follow-up assessment? a. The patient is dying and the spouse is angry. b. The patient is ill and the spouse is malingering. c. Both the patient and the spouse are likely in denial. d. Both the patient and the spouse are likely grieving.

d

A terminally ill patient is experiencing constipation secondary to pain medication. Which is the best method for the nurse to improve the patient's constipation problem? a. Contact the health care provider to discontinue pain medication. b. Administer enemas twice daily for 7 days. c. Massage the patient's abdomen. d. Use a laxative.

d

In preparation for the eventual death of a female hospice patient of the Muslim faith, the nurse organizes a meeting of all hospice caregivers. A plan of care to be followed when this patient dies is prepared. Which information will be included in the plan? a. Prepare the body for autopsy. b. Prepare the body for cremation. c. Allow male Muslims to care for the body after death has occurred. d. Allow female Muslims to care for the body after death has occurred.

d

2. A nurse is teaching the staff about managed care. Which information should the nurse include in the teaching session? a. Managed care insures full coverage of health care costs. b. Managed care only assumes the financial risk involved. c. Managed care allows providers to focus on illness care. d. Managed care causes providers to focus on prevention.

d. Managed care causes providers to focus on prevention.

9. An older adult patient has extensive wound care needs after discharge from the hospital. Which facility should the nurse discuss with the patient? a. Hospice b. Respite care c. Assisted living d. Skilled nursing

d. Skilled nursing

10. A nurse working in a community hospital's emergency department provides care to a patient having chest pain. Which level of care is the nurse providing? a. Continuing care b. Restorative care c. Preventive care d. Tertiary care

d. Tertiary care

8. The nurse is caring for a patient of Hispanic descent who speaks no English. The nurse is working with an interpreter. Which action should the nurse take? a.Use long sentences when talking. b.Look at the patient when talking. c.Use breaks in sentences when talking. d.Look at only nonverbal behaviors when talking.

ANS: B Direct your questions to the patient. Look at the patient, instead of looking at the interpreter. Pace your speech by using short sentences, but do not break your sentences. Observe the patient's nonverbal and verbal behaviors.

The nurse is planning playroom activities for a hospitalized 6-year-old patient. Which of the following age appropriate items that the nurse should ensure are available? (Select all that apply.) A. Crayons and paper B. Children's books C. 500-piece puzzle D. Building blocks E. Magazines and newspapers

A, B, and D.

When utilizing Freud's psychoanalytical/psychosocial theory, the nurse recalls that A. Adult personality is the result of resolved conflicts between sources of sexual pleasure and the mandates of reality. B. Development occurs throughout the life span and focuses on psychosocial stages. C. The genital stage precedes the phallic stage of development. D. Problems evident in adult life are due to early successes and resolution of earlier developmental stages.

A. Adult personality is the result of resolved conflicts between sources of sexual pleasure and the mandates of reality.

The teaching plan for a 3-year-old child who is at risk for developmental delay should include which of these instructions for the parents? A. Encourage play as your child is exploring his or her surroundings. B. Insist that your child discuss various points of view, not just his or her own. C. Discuss world events with your child to foster language development. D. Actively encourage your child to read lengthy books to expedite reading and writing abilities.

A. Encourage play as your child is exploring his or her surroundings.

Jean Piaget's cognitive developmental theory focuses on four stages of development, including A. Formal operations. B. Intimacy versus isolation. C. Latency. D. The postconventional level.

A. Formal operations.

The nurse is teaching a young adult couple about promoting the health of their 8-year-old child. The nurse knows that the parents understand the developmental stage their child is in according to Erikson when they state, "We should A. Provide proper support for learning new skills." B. Encourage devoted relationships with others." C. Limit choices and provide harsh punishment for mistakes." D. Not leave our child at school for longer than 3 hours at a time."

A. Provide proper support for learning new skills."

The nurse knows that a priority reason for being knowledgeable about biophysical developmental theories is to A. Understand how the physical body grows. B. Predict definite patterns of cognitive development. C. Anticipate how patients' social behaviors develop. D. Describe the process of psychological development.

A. Understand how the physical body grows.

9. Which action indicates the nurse is meeting a primary goal of cultural competent care for patients? a.Provides care to transgender patients b.Provides care to restore relationships c.Provides care to patients that is individualized d.Provides care to surgical patients

ANS: A Although cultural competence and patient-centered care both aim to improve health care quality, their focus is slightly different. The primary aim of cultural competence care is to reduce health disparities and increase health equity and fairness by concentrating on people of color and other marginalized groups, like transgender patients. Patient-centered care, rather than cultural competence care, provides individualized care and restores an emphasis on personal relationships; it aims to elevate quality for all patients.

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

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

6. A nurse is beginning to use patient-centered care and cultural competence to improve nursing care. Which step should the nurse take first? a.Assessing own biases and attitude b.Learning about the world view of others c.Understanding organizational forces d.Developing cultural skills

ANS: A Becoming more aware of your biases and attitudes about human behavior is the first step in providing patient-centered care, leading to culturally competent care. It is helpful to think about cultural competence as a lifelong process of learning about others and also about yourself. Learning about the world view, developing cultural skills, and understanding organizational forces are not the first steps.

13. A nurse is assessing population groups for the risk of suicide requiring medical attention. Which group should the nurse monitor most closely? a.Young bisexuals b.Young caucasians c.Asian Americans d.African-Americans

ANS: A Gay, lesbian, and bisexual young people have a significantly increased risk for depression, anxiety, suicide attempts, and substance use disorders, being 4 times as likely as their straight peers to make suicide attempts that require medical attention. Caucasian youth, Asian Americans, and African-Americans are not as likely to attempt suicide resulting in medical attention.

12. A nurse is designing a form for lesbian, gay, bisexual, and transgender (LGBT) patients. Which design should the nurse use? a.Use partnered rather than married. b.Use mother rather than father. c.Use parents rather than guardian. d.Use wife/husband rather than significant other.

ANS: A Include LGBT-inclusive language on forms and assessments to facilitate disclosure, knowing that disclosure is a choice impacted by many factors. For example, provide options such as "partnered" under relationship status. For parents, use parent/guardian, instead of mother/father. Use neutral and inclusive language when talking with patients (e.g., partner or significant other), listening and reflecting patient's choice. Remember that some LGBT patients are also legally married.

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

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

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

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

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

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

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

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

2. A nurse is caring for an immigrant with low income. Which information should the nurse consider when planning care for this patient? a.There is a decreased frequency of morbidity. b.There is an increased incidence of disease. c.There is an increased level of health. d.There is a decreased mortality rate.

ANS: B Populations with health disparities (immigrant with low income) have a significantly increased incidence of disease or increased morbidity and mortality when compared with the general population. Although Americans' health overall has improved during the past few decades, the health of members of marginalized groups has actually declined.

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

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

A nurse is teaching about the transtheoretical model of change. In which order will the nurse place the progression of the stages from beginning to end? 1. Action 2. Preparation 3. Maintenance 4. Contemplation 5. Precontemplation a. 5, 4, 2, 1, 3 b. 2, 5, 4, 3, 1 c. 4, 5, 3, 1, 2 d. 1, 5, 2, 3, 4

ANS: A The stages of change in the transtheoretical model of change include five stages. These stages range from no intention to change (precontemplation), considering a change within the next 6 months (contemplation), making small changes (preparation), and actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance stage).

3. A nurse is assessing the health care disparities among population groups. Which area is the nurse monitoring? a.Accessibility of health care services b.Outcomes of health conditions c.Prevalence of complications d.Incidence of diseases

ANS: A While health disparities are the differences among populations in the incidence, prevalence, and outcomes of health conditions, diseases and related complications, health care disparities are differences among populations in the availability, accessibility, and quality of health care services (e.g. screening, diagnostic, treatment, management, and rehabilitation) aimed at prevention, treatment, and management of diseases and their complications.

The nurse uses statistics on increased incidence of communicable disease to influence legislatures to pass a bill for mandatory vaccinations to enroll in school. Which type of nursing will the nurse use in this process? a. Public health nursing b. Community-based nursing c. Community health nursing d. Vulnerable population nursing

ANS: A A public health nurse understands factors that influence health promotion and health maintenance, the trends and patterns influencing the incidence of disease within populations, environmental factors contributing to health and illness, and the political processes used to affect public policy. Community health nursing is nursing practice in the community, with the primary focus on the health care of individuals, families, and groups within the community. Community-based nursing care takes place in community settings such as the home or a clinic, where the focus is on the needs of the individual or family. While there is no specific vulnerable population nursing, all types of nursing should care for these populations. DIF:Analyze (analysis)REF:33 OBJ: Explain the relationship between public health and community health nursing. TOP:EvaluationMSC:Health Promotion and Maintenance

A nurse is working as a community health nurse. Which action is a priority for this nurse? a. Provide direct care to subpopulations. b. Focus on the needs of the ill individual. c. Provide first level of contact to health care systems. d. Focus on providing care in various community settings.

ANS: A Community health nursing is nursing practice in the community, with the primary focus on the health care of individuals, families, and groups within the community. In addition, the community health nurse provides direct care services to subpopulations within a community. Community-based nursing centers function as the first level of contact between members of a community and the health care system. Community-based nursing focuses on providing care in various community settings, such as the home or a clinic and involves acute and chronic care. DIF:Apply (application)REF:33 OBJ: Differentiate community health nursing from community-based nursing. TOP: Implementation MSC: Health Promotion and Maintenance

While conducting a community assessment, the nurse seeks data on the average household income and the number of residents on public assistance. In doing so, the nurse is evaluating which component of a community assessment? a. Structure b. Population c. Social system d. Welfare system

ANS: A Economic status is part of the community structure. Population would involve age and gender distribution, growth trends, density, education level, and ethnic or religious groups. The welfare system is part of the social system that also includes the education, government, communication, and health systems. DIF:Understand (comprehension)REF:38 OBJ: Describe elements of a community assessment. TOP: Assessment MSC:Health Promotion and Maintenance

A nurse is working in community-based nursing. Which competency is priority for this nurse? a. Caregiver b. Collaborator c. Change agent d. Case manager

ANS: A First and foremost is the role of caregiver. While collaborator, change agent, and case manager are important, they are not the priority. DIF:Apply (application)REF:35 OBJ: Describe the competencies important for success in community-based nursing practice. TOP:ImplementationMSC:Management of Care

Which community-based nursing activities indicate the nurse is working in the role of educator? (Select all that apply.) a. Offers prenatal classes b. Offers a child safety program c. Offers to defend patients' decisions d. Offers creative solutions to local problems e. Offers coordinate resources after discharge

ANS: A, B Prenatal classes, infant care, child safety, and cancer screening are just some of the health education programs provided in a community practice setting. Offers to defend patients' decisions is the role of patient advocate. Offers creative solutions to local problems indicates a change agent. Collaborator will offer to coordinate resources after discharge. DIF:Apply (application)REF:37 OBJ: Describe the competencies important for success in community-based nursing practice. TOP: Teaching/Learning MSC: Health Promotion and Maintenance

A community-based nursing is working with a family. For which key areas will the nurse need a strong knowledge base? (Select all that apply.) a. Family theory b. Communication c. Group dynamics d. Cultural diversity e. Individual-centered care

ANS: A, B, C, D With the individual and family as the patients, the context of community-based nursing is family-centered care (not individual-centered care) within the community. This focus requires a strong knowledge base in family theory, principles of communication, group dynamics, and cultural diversity. The nurse leans to partner with patients and families, not just with individuals. DIF:Understand (comprehension)REF:34 OBJ:Discuss the role of the nurse in community-based practice. TOP: Teaching/Learning MSC: Health Promotion and Maintenance

A nurse meets the following goals: helps a patient maintain health and helps a patient with an illness. Which factors assist the nurse in achieving these goals? (Select all that apply.) a. Understands the challenges of today's health care system b. Identifies actual and potential risk factors c. Has coined the term "illness behavior" d. Minimizes the effects of illnesses e. Experiences compassion fatigue

ANS: A, B, D Nurses are in a unique position to assist patients in achieving and maintaining optimal levels of health. Nurses understand the challenges of today's health care system. Nurses can identify actual and potential risk factors that predispose a person or group to illness. Nurses who understand how patients react to illness can minimize the effects of illness and assist patients and their families in maintaining or returning to the highest level of functioning. Nurses did not coin the phrase "illness behavior." While nurses can experience compassion fatigue, it does not help in meeting patient goals.

A nurse is caring for vulnerable populations in a local community. Which patients will the nurse care for in this community? (Select all that apply.) a. A 47-year-old immigrant who speaks only Spanish b. A 35-year-old living in own home c. A 22-year-old pregnant woman d. A 40-year-old schizophrenic e. A 15-year-old rape victim

ANS: A, D, E Individuals living in poverty, older adults, people who are homeless, immigrant populations, individuals in abusive relationships (rape), substance abusers, and people with severe mental illnesses (schizophrenic) are examples of vulnerable populations. Middle-aged people living in their own home are not an example of a vulnerable population. Pregnancy is not an example of a vulnerable population. DIF:Analyze (analysis)REF:34-35 OBJ: Identify characteristics of patients from vulnerable populations that influence the community-based nurse's approach to care. TOP: Implementation MSC: Psychosocial Integrity

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

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

15. A nurse is teaching patients about health care information. Which patient will the nurse assess closely for health literacy? a.A patient 35 years old b.A patient 68 years old c.A patient with a college degree d.A patient with a high-school diploma

ANS: B About 9 out of 10 people in the United States experience challenges in using health care information. Patients who are especially vulnerable are the elderly (age 65+), immigrants, persons with low incomes, persons who do not have a high-school diploma or GED, and persons with chronic mental and/or physical health conditions. A 35-year-old patient and patients with high-school and college education are not identified in the vulnerable populations.

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

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

14. A nurse is assessing a patient's ethnohistory. Which question should the nurse ask? a.What language do you speak at home? b.How different is your life here from back home? c.Which caregivers do you seek when you are sick? d.How different is what we do from what your family does when you are sick?

ANS: B An ethnohistory question is the following: How different is your life here from back home? Caring beliefs and practice questions include the following: Which caregivers do you seek when you are sick and How different is what we do from what your family does when you are sick? The language and communication is the following: What language do you speak at home?

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

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

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

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

4. A nurse is providing care to a patient from a different culture. Which action by the nurse indicates cultural competence? a.Communicates effectively in a multicultural context b.Functions effectively in a multicultural context c.Visits a foreign country d.Speaks a different language

ANS: B Cultural competence refers to a developmental process that evolves over time that impacts ability to effectively function in the multicultural context. Communicates effectively and speaking a different language indicates linguistic competence. Visiting a foreign country does not indicate cultural competence.

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

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

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

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

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

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

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

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

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

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

11. A nurse is using core measures to reduce health disparities. Which group should the nurse focus on to cause the most improvement in core measures? a.Caucasians b.Poor people c.Alaska Natives d.American Indians

ANS: B To improve results, the nurse should focus on the highest disparity. Poor people received worse care than high-income people for about 60% of core measures. American Indians and Alaska Natives received worse care than Caucasians for about 30% of core measures.

1. A nurse is working at a health fair screening people for liver cancer. Which population group should the nurse monitor most closely for liver cancer? a.Hispanic b.Asian Americans c.Non-Hispanic Caucasians d.Non-Hispanic African-Americans

ANS: B While Asian Americans generally have lower cancer rates than the non-Hispanic Caucasian population, they also have the highest incidence rates of liver cancer for both sexes compared with Hispanic, non-Hispanic Caucasians, or non-Hispanic African-Americans.

The community health nurse is administering flu shots to children at a local playground. What is the rationale for this nurse's action? a. To prevent individual illness b. To prevent community outbreak of illness c. To prevent outbreak of illness in the family d. To prevent needs of the local population groups

ANS: B The nurse is trying to prevent a community outbreak of illness. By focusing on subpopulations (children), the community health nurse cares for the community as a whole and considers the individual or the family as only one member of a group at risk. Community-based nursing, as opposed to community health nursing, focuses on the needs of the individual or family. Public health nursing focuses on meeting the population groups' needs. DIF:Apply (application)REF:33 OBJ: Discuss the role of the community health nurse. TOP: Planning MSC:Health Promotion and Maintenance

A nurse is using the Healthy People 2020 to establish goals for the community. Which goal is priority? a. Reduce health care costs. b. Increase life expectancy. c. Provide services close to where patients live. d. Isolate patients to prevent the spread of disease.

ANS: B The overall goals of Healthy People 2020 are to increase life expectancy and quality of life and eliminate health disparities through an improved delivery of health care services. It does not focus on reducing health care costs, providing services close to where patients live, or isolating patients to prevent the spread of disease. DIF:Understand (comprehension)REF:31 OBJ:Discuss the role of the nurse in community-based practice. TOP:PlanningMSC:Health Promotion and Maintenance

Before a patient with beginning stage of Alzheimer's disease is discharged, the community-based nurse is making a visit to the patient's home. The patient's daughter and family live in the home with the patient. What is the major focus of this visit? a. Teach the family how to monitor blood pressure. b. Demonstrate techniques for providing care. c. Stress to the family how difficult it will be to provide care at home. d. Encourage the family to send the patient to an extended care facility.

ANS: B The role of the community health nurse, when dealing with patients with Alzheimer's disease, is to maintain the best possible functioning, protection, and safety for the patient. The nurse should demonstrate to the primary family caregiver techniques for dressing, feeding, and toileting the patient while providing encouragement and emotional support to the caregiver. Monitoring blood pressure is not necessary for an Alzheimer's patient; blood pressure would be for a patient with hypertension. The nurse should protect the patient's rights and maintain family stability, not encourage placement in an extended care facility. DIF:Apply (application)REF:36 OBJ: Describe the competencies important for success in community-based nursing practice. TOP:ImplementationMSC:Management of Care

A nurse is providing screening at a health fair. Which finding indicates the person may be a vulnerable patient who is most likely to develop health problems? a. One who is pregnant b. One who has excessive risks c. One who has unlimited access to health care d. One who uses nontraditional healing practices

ANS: B Vulnerable populations are the patients who are more likely to develop health problems as a result of excess risks or limits in access to health care services or who are dependent on others for care. Pregnancy is not a cause of vulnerability, except in cases where the mother is an adolescent, is addicted to drugs, or is at high risk for other reasons. A person who has unlimited access to health care is not vulnerable. Frequently, the immigrant population practices nontraditional healing practices. Many of these healing practices are effective and complement traditional therapies. DIF:Understand (comprehension)REF:34 OBJ: Identify characteristics of patients from vulnerable populations that influence the community-based nurse's approach to care. TOP: Assessment MSC:Health Promotion and Maintenance

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

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

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

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

10. The nurse is caring for a Chinese patient using the Teach-Back technique. Which action by the nurse indicates successful implementation of this technique? a.Asks, "Does this make sense?" b.Asks, "Do you think you can do this at home?" c.Asks, "What will you tell your spouse about changing the dressing?" d.Asks, "Would you tell me if you don't understand something so we can go over it?"

ANS: C The Teach-Back technique asks open-ended questions, like what will you tell your spouse about changing the dressing, to verify a patient's understanding. When using the Teach-Back technique do not ask a patient, "Do you understand?" or "Do you have any questions?" Does this make sense and do you think you can do this at home are closed-ended questions. Would you tell me if you don't understand something so we can go over it is not verifying a patient's understanding about the teaching.

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

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

The nurse is working with a 16-year-old pregnant female who tells the nurse that she needs an abortion. The nurse, acting as a counselor, provides the patient with information on alternatives to abortion, but after several sessions, the patient still insists on having the abortion. What should the nurse, in the counselor role, do next? a. Encourage the patient to speak with a "Right-to-Life" advocate. b. Refuse to provide a referral to an abortion service. c. Provide referral to an abortion service. d. Delay referral to an abortion service.

ANS: C As a counselor, the nurse is responsible for providing information, listening objectively, and being supportive, caring, and trustworthy and providing a referral to an abortion service. The nurse does not make decisions, like going to a "Right-to-Life" advocate, but rather helps the patient reach decisions that are best for him or her. To refuse to provide a referral or to delay referral would not be supportive of the patient's decision. DIF:Apply (application)REF:37 OBJ: Describe the competencies important for success in community-based nursing practice. TOP: Implementation MSC: Psychosocial Integrity

A nurse attended a seminar on community-based health care. Which information indicates the nurse has a good understanding of community-based health care? a. It occurs in hospitals. b. Its focus is on ill individuals. c. Its priority is health promotion. d. It provides services primarily to the poor.

ANS: C Community-based health care is a model of care that reaches everyone in the community (including the poor and underinsured), focuses on primary rather than institutional or acute care, and provides knowledge about health and health promotion and models of care to the community. Community-based health care occurs outside traditional health care institutions such as hospitals. DIF:Understand (comprehension)REF:31 OBJ: Explain the relationship between public health and community health nursing. TOP: Teaching/Learning MSC: Health Promotion and Maintenance

A nurse is focusing on acute and chronic care of individuals and families within a community while enhancing patient autonomy. Which type of nursing care is the nurse providing? a. Public health b. Community health c. Community-based d. Community assessment

ANS: C Community-based nursing involves acute and chronic care of individuals and families and enhances their capacity for self-care while promoting autonomy in decision making. Public health nursing focuses on the needs of a population. Community health nursing cares for the community as a whole and considers the individual or the family as only one member of a group at risk. Community assessment is the systematic data collection on the population, monitoring the health status of the population, and making information available about the health of the community. DIF:Understand (comprehension)REF:33 OBJ: Differentiate community health nursing from community-based nursing. TOP:ImplementationMSC:Management of Care

A nurse is working as a public health nurse. What will be the nurse's primary focus? a. The individual as one member of a group b. Individuals and families c. Needs of a population d. Health promotion

ANS: C Public health nursing primary focus is understanding the needs of a population. Community-based care focuses on health promotion. Community health nursing focuses on health care of individuals, families, and groups within the community. DIF:Understand (comprehension)REF:33 OBJ: Explain the relationship between public health and community health nursing. TOP:CaringMSC:Management of Care

A nurse is assessing the social system of a community. Which area should the nurse assess? a. Housing b. Economic status c. Volunteer programs d. Predominant ethnic groups

ANS: C Social systems include volunteer programs, education system, government, and health systems. Housing and economic status are included in the structure assessment. Predominant ethnic groups are a component of the population assessment. DIF:Understand (comprehension)REF:37-38 OBJ: Describe elements of a community assessment. TOP: Assessment MSC: Psychosocial Integrity

Which areas should the nurse assess to determine the effects of external variables on a patient's illness? (Select all that apply.) a. Patient's perception of the illness b. Patient's coping skills c. Socioeconomic status d. Cultural background e. Social support

ANS: C, D, E External variables influencing a patient's illness behavior include the visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, and social support. Internal variables include the patient's perceptions of symptoms and the nature of the illness, as well as the patient's coping skills and locus of control.

5. The nurse learns about cultural issues involved in the patient's health care belief system and enables patients and families to achieve meaningful and supportive care. Which concept is the nurse demonstrating? a.Marginalized groups b.Health care disparity c.Transcultural nursing d.Culturally congruent care

ANS: D The nurse is demonstrating culturally congruent care. Culturally congruent care, or care that fits a person's life patterns, values, and system of meaning, provides meaningful and beneficial nursing care. Marginalized groups are populations left out or excluded. Health care disparities are differences among populations in the availability, accessibility, and quality of health care services (e.g. screening, diagnostic, treatment, management, and rehabilitation) aimed at prevention, treatment, and management of diseases and their complications. Transcultural nursing is a comparative study of cultures in order to understand their similarities (culture that is universal) and the differences among them (culture that is specific to particular groups).

A nurse wants to become a specialist in public health nursing. Which educational requirement will the nurse have to obtain? a. A baccalaureate degree in nursing b. Preparation at the basic entry level c. The same level of education as the community health nurse d. A graduate level education with a focus in public health science

ANS: D A specialist in public health has a graduate level education with a focus in public health science. Public health nursing requires preparation at the basic entry level and sometimes requires a baccalaureate degree in nursing. A community health nurse is not the same thing as a public health nursing specialist. DIF:Understand (comprehension)REF:33 OBJ: Explain the relationship between public health and community health nursing. TOP:Teaching/LearningMSC:Management of Care

A nurse observes an outbreak of lice in a certain school district. The nurse collects data and identifies a common practice of sharing lockers, caps, and hair brushes. The nurse shares the information with the school. Which community-based nursing competency did the nurse use? a. Educator b. Caregiver c. Case manager d. Epidemiologist

ANS: D As an epidemiologist, you are involved in case finding, health teaching, and tracking incident rates of an illness (outbreak of lice). The nurse did not teach the students about lice. The nurse did not provide care for the lice. The nurse did not coordinate needed resources and services for a group of patient's well-being (case manager). DIF:Apply (application)REF:37 OBJ: Describe the competencies important for success in community-based nursing practice. TOP: Implementation MSC: Safety and Infection Control

The instructor is teaching student nurses about identifying members of vulnerable populations when the nursing student asks, "Why is it that not all poor people are considered members of vulnerable populations?" How should the nurse respond? a. "All poor people are members of a vulnerable population." b. "Poor people are members of a vulnerable population only if they take drugs." c. "Poor people are members of a vulnerable population only if they are homeless." d. "Members of vulnerable groups frequently have a combination of risk factors."

ANS: D Members of vulnerable groups frequently have many risks or a combination of risk factors that make them more sensitive to the negative effects of individual risk factors. Individual risk factors are not always overwhelming, depending on the patient's beliefs and values and sources of social support. DIF:Apply (application)REF:34 OBJ: Identify characteristics of patients from vulnerable populations that influence the community-based nurse's approach to care. TOP: Teaching/Learning MSC:Health Promotion and Maintenance

An 18-month-old patient is brought into the clinic for evaluation because the mother is concerned. The 18-month-old child hits her siblings and says only "No" when communicating verbally. According to Piaget's theory, what recommendation should the nurse make a priority? A. Consult the social worker because the child is hitting other children. B. Reassure the mother that the child is developmentally within specified norms. C. Encourage the mother to seek psychological counseling for the child. D. Remove all toys from the child's room until this behavior ceases.

C. Encourage the mother to seek psychological counseling for the child.

The parents of a 14-year-old boy express concern over their child's rebellious behavior. The nurse should plan to respond to the parents' concern by informing them that their A. Child should be referred to a juvenile correctional facility. B. Child's behavior is normal because the adolescent is trying to adjust to his emerging identity. C. Child's behavior is a matter of concern because he is likely conflicted about establishing companionship with a partner. D. Child's behavior is expected because he is expressing his need to support future generations.

B. Child's behavior is normal because the adolescent is trying to adjust to his emerging identity.

The parents of a 15-month-old child express concern to the nurse about their child's thumb-sucking habit. Which of these explanations related to the child's age and developmental level would be most appropriate for the nurse to give the parents? A. Thumb sucking at this age indicates a developmental delay and should be further assessed. B. Sucking achieves a pleasing result for infants, and generalizing that action by thumb sucking is normal. C. Thumb sucking at this age demonstrates a transition away from egocentric thinking. D. At this age, thumb sucking will enhance language development.

B. Sucking achieves a pleasing result for infants, and generalizing that action by thumb sucking is normal.

According to Piaget's theory of cognitive development, the nurse should allow a hospitalized 4-year-old patient to safely play with A. The pump administering intravenous fluids. B. The blood pressure cuff. C. A baseball bat. D. A book to read alone in a quiet place.

B. The blood pressure cuff.

Which of these statements would be most appropriate for a nurse to state when assessing an adult patient for growth and developmental delays? A. "How many times per week do you exercise?" B. "Are you able to stand on one foot for 5 seconds?" C. "Would you please describe your usual activities during the day?" D. "How many hours a day do you spend watching television or sitting in front of a computer?"

C. "Would you please describe your usual activities during the day?"

A formerly independent and active older adult becomes severely withdrawn upon admission to a nursing home. When approaching this patient, which intervention should the nurse plan first? A. Offer a reward for participation in all events. B. Encourage the patient to attend all social events scheduled for the patients. C. Allow the patient to incorporate personal belongings into her room. D. Advise the patient of the importance of attending mandatory activities.

C. Allow the patient to incorporate personal belongings into her room.

A nurse should instruct the parents of a 10-year-old child to keep which of the following theoretical principles in mind when dealing with a behavioral problem at home? A. Strategies that worked well with the first child will be equally as effective for the second child. B. Encourage the child to volunteer some time at a local hospital to instill a sense of fulfillment. C. Bargaining about chores in exchange for privileges may be an effective method of encouraging helpful activities. D. Do not offer praise for accomplishments and punishment for behavioral issues.

C. Bargaining about chores in exchange for privileges may be an effective method of encouraging helpful activities.

According to Piaget's formal operations level, a 13-year-old adolescent will likely A. Hit other students to deal with environmental change. B. Use play to understand her surroundings. C. Question her parents about an upcoming presidential election. D. Question where the ice is hiding when ice has melted in her drink.

C. Question her parents about an upcoming presidential election.

Which of these manifestations, if identified in a 6-year-old patient, should the nurse associate with a possible developmental delay based on Piaget's theory? A. The child speaks in complete sentences but often talks only about himself. B. The child still plays with a favorite doll that he has had since he was a toddler. C. The child continues to suck his thumb. D. The child describes an event from his own perspective, even though the entire family was present.

C. The child continues to suck his thumb.

The nursing instructor will need to provide further instruction to the student who states A. "Intellectual development is affected by cognitive processes." B. "Socioemotional processes can influence an individual's growth and development." C. "Breast development is an example of a change resulting from biological processes." D. "An individual's biological processes determine physical characteristics and do not affect growth and development."

D. "An individual's biological processes determine physical characteristics and do not affect growth and development."

While assessing an 18-month-old toddler, the nurse distinguishes normal from abnormal findings by remembering that Gesell's theory of development states A. "The developmental stage of the toddler is affected solely by environmental influence." B. "Developmental patterns are not affected by gene activity." C. "Skill development should be identical to that of other toddlers in the playroom." D. "Environmental influence does not affect the sequence of development."

D. "Environmental influence does not affect the sequence of development."

Which of these approaches would be most appropriate for the nurse to use when teaching a 4-year-old patient about a scheduled surgery? A. Give the parents a book to read about the procedure and do not discuss the procedure with the child to decrease anxiety. B. Set boundaries before teaching by telling the child that she can ask only three questions because time is limited. C. Insist that the parents wait outside the room to ensure privacy of the child. D. Allow the child to touch and hold medical equipment such as thermometers and syringes.

D. Allow the child to touch and hold medical equipment such as thermometers and syringes.

When caring for a middle-aged adult exhibiting maladaptive coping skills, the nurse is trying to determine the cause of the patient's behavior. From a growth and development perspective, what should the nurse recall? A. Individuals have uniform patterns of growth and development. B. Health is promoted based on how many developmental failures a patient experiences. C. Culture usually has no effect on predictable patterns of growth and development. D. When individuals experience repeated developmental failures, inadequacies sometimes result.

D. When individuals experience repeated developmental failures, inadequacies sometimes result.

4. A nurse is working in a health care organization that has achieved Magnet status. Which components are indicators of this status? (Select all that apply.) a. Empirical quality results b. Structural empowerment c. Transformational leadership d. Exemplary professional practice e. Willingness to recommend the agency

a. Empirical quality results b. Structural empowerment c. Transformational leadership d. Exemplary professional practice

11. A nurse is teaching about the effects of globalization. Which information should the nurse include in the teaching session? a. Increased spread of communicable diseases b. Increased homogeneous mix of nursing staff c. Decreased poverty and increased "health tourism" d. Decreased urbanization as populations shift to the suburbs

a. Increased spread of communicable diseases

12. A nurse is using research findings to improve clinical practice. Which technique is the nurse using? a. Performance improvement b. Integrated delivery networks c. Nursing-sensitive outcomes d. Utilization review committees

a. Performance improvement

1. Which government-instituted programs should the nurse include in a teaching session about controlling health care costs? (Select all that apply.) a. Professional standards review organizations b. Prospective payment systems c. Diagnosis-related groups d. Third-party payers e. "Never events"

a. Professional standards review organizations b. Prospective payment systems c. Diagnosis-related groups

13. Which finding indicates the best quality improvement process? a. Staff identifies the wait time in the emergency department is too long. b. Administration identifies the design of the facility's lobby increases patient stress. c. Director of the hospital identifies the payment schedule does not pay enough for overtime. d. Health care providers identify the inconsistencies of some of the facility's policy and procedures.

a. Staff identifies the wait time in the emergency department is too long.

2. A nurse is teaching the staff about the Institute of Medicine competencies. Which examples indicate the staff has a correct understanding of the teaching? (Select all that apply.) a. Use informatics. b. Use transparency. c. Apply globalization. d. Apply quality improvement. e. Use evidence-based practice.

a. Use informatics. d. Apply quality improvement. e. Use evidence-based practice.

3. A nurse is evaluating care based upon the nursing quality indicators. Which areas should the nurse evaluate? (Select all that apply.) a. Patient satisfaction level b. Hospital readmission rates c. Nursing hours per patient day d. Patient falls/falls with injuries e. Value stream analysis for quality

b. Hospital readmission rates c. Nursing hours per patient day d. Patient falls/falls with injuries

6. A nurse provides immunization to children and adults through the public health department. Which type of health care is the nurse providing? a. Primary care b. Preventive care c. Restorative care d. Continuing care

b. Preventive care

1. The nurse is caring for a patient whose insurance coverage is Medicare. The nurse should consider which information when planning care for this patient? a. Capitation provides the hospital with a means of recovering variable charges. b. The hospital will be paid for the full cost of the patient's hospitalization. c. Diagnosis-related groups (DRGs) provide a fixed reimbursement of cost. d. Medicare will pay the national average for the patient's condition.

c. Diagnosis-related groups (DRGs) provide a fixed reimbursement of cost.

5. The nurse is applying for a position with a home care organization that specializes in spinal cord injury. In which type of health care facility does the nurse want to work? a. Secondary acute b. Continuing c. Restorative d. Tertiary

c. Restorative

4. A nurse is caring for a patient in the hospital. When should the nurse begin discharge planning? a. When the patient is ready b. Close to the time of discharge c. Upon admission to the hospital d. After an order is written/prescribed

c. Upon admission to the hospital