Clinical Concepts Exam 3 Practice Questions

An 82 year old man has been told by his nurse practitioner that it is no longer safe for him to drive a car. Which statement by the patient would indicate beginning positive adaptation to this loss? "I told my son that I would stop driving, but I am not going to yet." "I always knew this day would come, but I hoped it wouldn't be now." "What does he know? I am a better driver than he'll ever be." "Well, at least I have friends and family who can take me places."

"Well, at least I have friends and family who can take me places."

The nurse is caring for a 15-year-old client who is dying. The client tells the nurse, "I know I am not going home again. I think it is harder for my parents than me. Will you talk to them for me?" Which of the following is the best response by the nurse? "It is true that you will be dying soon, but you must be honest with your parents." "That's not true, but I will talk to your parents." "You are having a bad day, so I will be back later to see if you need anything else." "Yes, I will talk to your parents, but you need to talk to them also. I will help you with that."

"Yes, I will talk to your parents, but you need to talk to them also. I will help you with that."

At what age does a child first have a clear picture of god or a supreme being, morality and the difference between right and wrong 3-6 years 1-3 years 6-12 years 12-15 years

6-12 years

Which of the following would provide meaningful stimuli for a client? Select all that apply. A clock or calendar with large numbers A radio that is kept on all day at low volume Family pictures and possessions Interaction with nurse or other patients

A clock or calendar with large numbers Family pictures and possessions Interaction with nurse or other patients

A nurse working on a surgery floor is assigned four patients. The nurse assesses each patient, noting behaviors and physical signs and symptoms. Which of the following patients is more likely to be violent toward the nurse? 1. The first patient maintains eye contact with the nurse, is calm during the nurse's assessment, and asks questions frequently. 2. The second patient is very drowsy, loses attention span when the nurse asks questions, and mumbles when speaking. 3. The third patient moves nervously in bed, swears and grimaces when trying to cough, and speaks in a low volume. 4. The fourth patient speaks in a loud voice and becomes irritable when the nurse arrives to help walk the patient

Answer 4. Patients who are most likely to enact violence include those who have an increased volume of speech, are irritable, demonstrate prolonged or intense glaring, mumble, use abusive language toward the nurse, and pace around the waiting area or bed.

A patient who has been placed on Contact Precautions for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. What is the most appropriate information to include in patient teaching? (Select all that apply.) 1. The organism is usually transmitted through the fecal-oral route. 2. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. 3. Everyone coming into the room must be wearing a gown and gloves. 4. While the patient is in Contact Precautions, he cannot leave the room. 5. C. difficile dies quickly once outside the body

Answer: 1, 2, 3 Clostridium difficile is transmitted through the oral-fecal route and spread through contact with contaminated feces or surfaces touched by hands not appropriately cleaned after providing care to a patient infected with C. difficile. The organism develops a hard spore and can live for long periods of time on surfaces, making it very hard to eradicate. As long as patient is continent of stool and first cleans hands and changes gown, a patient with C. difficile may leave the room.

The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing health care-acquired infections? (Select all that apply.) 1. Teaching correct handwashing to assigned patients 2. Using correct procedures in starting and caring for an intravenous infusion 3. Providing perineal care to a patient with an indwelling urinary catheter 4. Isolating a patient on antibiotics who has been having loose stool for 24 hours 5. Decreasing a patient's environmental stimuli to decrease nausea

Answer: 1, 2, 3 Nausea is not typically associated with transmission of infection, and loose stools are a common side effect with antimicrobials. All the other interventions break the cycle of infection transmission

The nurse recognizes that which factors influence a person's approach to death? (Select all that apply.) 1. Culture 2. Spirituality 3. Personal beliefs 4. Previous experiences with death 5. Gender 6. Level of education

Answer: 1, 2, 3, 4. Culture, spirituality, personal beliefs and values, and previous experiences with death influence how a person approaches death.

To best assist a patient in the grieving process, which factors are most important for the nurse to assess? (Select all that apply.) 1. Previous experiences with grief and loss 2. Religious affiliation and denomination 3. Ethnic background and cultural practices 4. Current financial status 5. Current medications

Answer: 1, 2, 3. Previous experiences, religious affiliation, and cultural practices help individuals develop coping and can be a source of support at the end of life.

Which of these statements are true regarding disinfection and cleaning? (Select all that apply.) 1. Proper cleaning requires mechanical removal of all soil from an object or area. 2. General environmental cleaning is an example of medical asepsis. 3. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound. 4. Cleaning in a direction from the least to the most contaminated area helps reduce infections. 5. Disinfecting and sterilizing medical devices and equipment involve the same procedures

Answer: 1, 2, 4 Proper cleaning and disinfection are processes that occur prior to sterilization, with cleaning always done from dirty to clean to decrease the risk of further infection and contamination.

When planning care for a dying patient, which interventions promote the patient's dignity? (Select all that apply.) 1. Providing respect 2. Viewing the patient as a whole 3. Providing symptom management 4. Showing interest 5. Being present 6. Inserting a straight catheter when the patient has difficulty voiding

Answer: 1, 2, 4, 5. A sense of dignity includes a person's positive self-regard, the ability to find meaning in life, to feel valued by others, and by how one is treated by caregivers.

A patient who returned from surgery 3 hours ago following a kidney transplant is reporting pain at a 7 on a scale of 0 to 10. The nurse has tried repositioning with no improvement in the patient's pain report. Unmanaged surgical pain can lead to which of the following problems? (Select all that apply.) 1. Delayed ambulation 2. Reduced ventilation 3. Catheter-associated urinary tract infection 4. Retained pulmonary secretions 5. Reduced appetite

Answer: 1, 2, 4, 5. Unmanaged surgical pain can lead to delayed ambulation, reduced ventilation, retained pulmonary secretions, or reduced appetite. Unmanaged surgical pain is not associated with catheter-associated urinary tract infection.

An 85-year-old patient returns to the inpatient surgical unit after leaving the PACU. Which of the following place the patient at risk during surgery? (Select all that apply.) 1. Stiffened lung tissue 2. Reduced diaphragmatic excursion 3. Increased laryngeal reflexes 4. Reduced blood flow to kidneys 5. Increased cholinergic transmission

Answer: 1, 2, 4. Older adults have stiffened lung tissue, reduced diaphragmatic excursion, and reduced blood flow to kidneys. Laryngeal reflexes are reduced, increasing risk for aspiration, and reduced cholinergic transmission puts them at risk for cognitive changes.

Which comments to a patient by a new nurse regarding palliative care needs are correct? (Select all that apply.) 1. "Even though you're continuing treatment, palliative care is something we might want to talk about." 2. "Palliative care is appropriate for people with any diagnosis." 3. "Only people who are dying can receive palliative care." 4. "Children are able to receive palliative care." 5. Palliative care is only for people with uncontrolled pain

Answer: 1, 2, 4. Palliative care is available to all patients regardless of age, diagnosis, and prognosis.

Which type of personal protective equipment should the nurse wear when caring for a pediatric patient who is placed on Airborne Precautions for confirmed chickenpox/herpes zoster? (Select all that apply.) 1. Disposable gown 2. N95 respirator mask 3. Face shield or goggles 4. Disposable mask 5. Gloves

Answer: 1, 2, 5 Chicken pox is an airborne organism that can travel great distances, so it is important that the air breathed by the nurse is filtered, and hands and clothes are covered, as required for airborne precautions.

Which actions by the nurse help grieving families? (Select all that apply.) 1. Encourage involvement in nonthreatening group social activities. 2. Follow up with the family in their home. 3. Remind them that feelings of sadness or pain can return around anniversaries. 4. Encourage survivors to ask for help. 5. Look for overuse of alcohol, sleeping aids, or street drugs.

Answer: 1, 3, 4, 5. Providing education, encouraging, and monitoring for healthy and unhealthy coping responses during grief are ways to support and help families grieve. Encouraging survivors to seek available resources helps survivors cope with grief.

A nurse working on a medicine unit in the hospital hears the fire alarm go off. As the nurse walks down the hallway, there is smoke coming from the family waiting area. Which of the following steps should the nurse take? (Select all that apply.) 1. Immediately phone in to the hospital alert system the exact location of the fire. 2. Direct the nurse technician to place empty stretchers behind the fire doors. 3. Go to each patient room, and direct ambulatory patients to walk themselves to a safe area. 4. Work with the nurse technician to help move patients requiring wheelchairs from their rooms. 5. Close the room doors of patients who cannot get out of bed, and keep them in their rooms

Answer: 1, 3, 4. If a fire occurs in a health care agency, protect patients from immediate injury, report the exact location of the fire, contain it, and extinguish it if possible. The nurse should alert the hospital about the fire immediately. The nurse technician should not place stretchers behind fire doors; the fire doors need to be able to close when a fire alarm sounds. It is important to keep equipment from blocking these doors. Patients who are close to a fire, regardless of its size, are at risk of injury and need to be moved to another area. Direct all ambulatory patients to walk by themselves to a safe area. In some cases, they can help move patients in wheelchairs. Move patients who cannot get out of bed from the scene of a fire by a stretcher, their bed, or a wheelchair. Do not leave them in their rooms.

Put the following steps for removal of protective barriers after leaving an isolation room in order. 1. Remove and dispose of gloves. 2. Perform hand hygiene. 3. Remove eyewear or goggles. 4. Untie top and then bottom mask strings and remove from face. 5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side.

Answer: 1, 3, 5, 4, 2 Removing isolation PPE correctly decreases the risk of self-contamination. The gloves are considered the most contaminated pieces of PPE and are therefore removed first. The face shield or goggles are next because they interfere with removal of other PPE. The gown is third, followed by the mask or respirator.

The nurse is caring for a 50-year-old woman visiting the outpatient medicine clinic. The patient has had type 1 diabetes since age 13. She has numerous complications from her disease, including reduced vision, heart disease, and severe numbness and tingling of the extremities. Knowing that spirituality helps patients cope with chronic illness, which of the following principles should the nurse apply in practice? (Select all that apply.) 1. Pay attention to the patient's spiritual identity throughout the course of her illness. 2. Select interventions that you know scientifically support spiritual well-being. 3. Listen to the patient's story each visit to the clinic, and offer a compassionate presence. 4. When the patient questions the reason for her long-time suffering, try to provide answers. 5. Consult with a spiritual care adviser, and have the adviser recommend useful interventions.

Answer: 1, 3. A person's spiritual well-being can change over time; therefore, it is important to pay attention to it over the course of his or her illness. Listening is a powerful way to support a patient's spirituality. Evidence-based interventions are preferred, but they must be agreed on by the patient and tailored to his or her perspectives and not just those of the nurse. Patients are not looking for answers. What is spoken as a spiritual question is most often an expression of spiritual pain. Using spiritual care advisers is a valuable resource but should be selected by the patient, not independently by the nurse, and any interventions should be mutually agreed on among nurse, patient, and adviser.

The nurse prepares a patient with type 2 diabetes for a surgical procedure. The patient weighs 112.7 kg (248 lb) and is 5 feet, 2 inches in height. Which factors increase this patient's risk for surgical complications? (Select all that apply.) 1. Obesity 2. Prolonged bleeding time 3. Delayed wound healing 4. Ineffective vital capacity 5. Immobility secondary to height

Answer: 1, 3. Secondary to the physiological stress of surgery that increases cortisol levels in patients with type 2 diabetes, these patients are at risk for surgical complications. This patient is also obese, which increases surgical risk.

Which assessment questions should the nurse ask a preoperative patient preparing for surgery? (Select all that apply.) 1. "Are you experiencing any pain?" 2. "Do you exercise on a daily basis?" 3. "When do you regularly take your medications?" 4. "Do you have any medication allergies?" 5. "Do you use drugs and/or tobacco products?"

Answer: 1, 4, 5. Although regular exercise and adherence to the medication regimen are important, for the preoperative patient, the nurse needs to focus on factors that impact the surgical experience.

A nurse cares for a postoperative patient in the PACU. Upon assessment, the nurse finds the surgical dressing is saturated with serosanguineous drainage. Which interventions are a priority? (Select all that apply.) 1. Notify surgeon. 2. Maintain the intravenous fluid infusion. 3. Provide 2 L/min of oxygen via nasal cannula. 4. Monitor the patient's vital signs every 5 to 10 minutes. 5. Reinforce the dressing

Answer: 1, 5. The first two priorities are for the nurse to report to the surgeon immediately and to reinforce the dressing as needed. Maintaining intravenous fluids and monitoring vital signs are routine aspects of the patient's plan of care. Providing oxygen requires a prescription; the surgeon has to be notified for a prescription for oxygen

Which is the best intervention the nurse should implement to promote bowel function? 1. Early ambulation 2. Deep-breathing exercises 3. Repositioning on the left side 4. Lowering the head of the patient's bed

Answer: 1. Early ambulation promotes peristalsis and thus the return of bowel function. Deep-breathing activities prevent the onset of respiratory complications. Positioning on the left side and lowering the head of the patient's bed do not promote peristalsis

A postoperative patient experiences tachypnea during the first hour of recovery. Which nursing intervention is a priority? 1. Elevate the head of the patient's bed. 2. Give ordered oxygen through a mask at 4 L/min 3. Ask the patient to use an incentive spirometer. 4. Position the patient on one side with the face down and the neck slightly extended so that the tongue falls forward.

Answer: 1. Elevating the head of the patient's bed is a quick intervention that does not require a prescription, but it will promote lung expansion and allow secretions to move via gravity. Administration of oxygen requires a prescription. While using the incentive spirometer expands the lungs, it would not be the first action as positioning the patient to breath effectively is necessary

The nurse is caring for a patient who has just had a near-death experience (NDE) following a cardiac arrest. Which intervention by the nurse best promotes the spiritual well-being of the patient after the NDE? 1. Allowing the patient to discuss the experience 2. Referring the patient to pastoral care 3. Having the patient talk to another patient who had an NDE 4. Offering to pray for the patient

Answer: 1. Patients who have a near death experience (NDE) are often reluctant to speak of the experience. Allowing the patient to discuss the NDE helps the patient find acceptance of and meaning from the event. It also allows the patient to explore what happened and promotes spiritual well-being.

Match the fall prevention intervention on the left with the scientific rationale on the right. 1. Prioritize nurse call system responses to patients at high risk. 2. Place patient in a wheelchair with wedge cushion. 3. Establish elimination schedule with bedside commode. 4. Use a low bed for patient. 5. Provide a hip protector. 6. Place nonskid floor mat on floor next to bed. A. Maintains comfort and makes exit difficult B. Makes it difficult for patients with lower extremity weakness to stand C. Reduces slipping when walking D. Reduces fall impact E. Ensures rapid response for help F. Reduces chance of patient trying to get out of bed on own

Answer: 1E, 2A, 3F, 4B, 5D, 6C.

The nurse is caring for a patient who is very depressed and decides to complete a spiritual assessment using the FICA tool. Using the FICA assessment tool, match the criteria on the left with the appropriate assessment question on the right. 1. F—Faith ___ 2. I—Importance of spirituality ___ 3. C—Community ___ 4. A—Interventions to address spiritual needs ___ a. Tell me if you have a higher power or authority that helps you act on your beliefs b. Describe which activities give you comfort spiritually c. To whom do you go for support in times of difficulty? d. Your illness has kept you from attending church. Is that a problem for you?

Answer: 1a, 2d, 3c, 4b.

Patient-to-patient transmission of infection cannot occur if gloves are routinely used. 1. True 2. False

Answer: 2 Although gloves are an additional tool to decrease the spread of infection from patient to patient, touching gloves with unclean hands as you put them on contaminates the gloves so that they are no longer clean.

A patient is diagnosed with meningitis. Which type of isolation precaution is most appropriate for this patient? 1. Reverse isolation 2. Droplet Precautions 3. Standard Precautions 4. Contact Precautions

Answer: 2 Because the patient is diagnosed with meningitis, which can be spread when the patient coughs or sneezes, droplet precautions are most appropriate

Which of the following actions by the nurse demonstrate the practice of core principles of surgical asepsis? (Select all that apply.) 1. The front and sides of the sterile gown are considered sterile from the waist up. 2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated. 4. Only health care personnel within the sterile field must wear personal protective equipment. 5. After cleansing the hands with antiseptic rub, apply clean disposable gloves.

Answer: 2, 3 Maintaining sterility throughout the procedure requires constant vigilance and strict rules to ensure sterility, such as keeping the sterile field in sight at all times, making sure everyone in the room is in protective clothing like gowns, masks, eyewear and gloves, and considering anything beyond the front or below the waist of the gown to be contaminated. To make sure the sides of the sterile field are not contaminated, there is an outer one-inch border not considered sterile

A nurse working the night shift is assigned a patient who has a history of having fallen in the hospital during a previous admission. The nurse wants to review the admission assessment completed by the nurse on the day shift. Which of the following sections in the assessment are most likely to provide information about the patient's current fall risks? (Select all that apply.) 1. Allergy history 2. Medication history 3. Patient age 4. Patient's occupation 5. Physical exam of neuromuscular function

Answer: 2, 3, 5. A patient's age will reveal his or her developmental status. The medication history is important to determine whether the patient is taking medications that typically predispose patients to falling. The examination of neuromuscular function will reveal whether the patient has any problems with cognitive status, muscle strength and coordination, balance, and gait—all of which can predispose to falls. The allergy history and occupational history will not reveal risk factors for patients to fall.

A nurse is preparing to teach an older adult who has chronic arthritis how to practice meditation. Which of the following strategies are appropriate? (Select all that apply.) 1. Encourage family members to participate in the exercise. 2. Have patient identify a quiet room in the home that has minimal interruptions. 3. Suggest the use of a quiet fan running in the room. 4. Explain that it is best to meditate about 5 minutes 4 times a day. 5. Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer.

Answer: 2, 3, 5. A quiet room with no distractions is conducive to meditation. The low buzz of a fan also blocks distractive noises. A patient should relax comfortably during meditation. Meditation is usually recommended 10 to 20 minutes twice a day. The activity should be conducted alone without distraction.

Which interventions does a nurse implement to help a patient at the end of life maintain autonomy while in a hospital? (Select all that apply.) 1. Use therapeutic techniques when communicating with the patient. 2. Allow the patient to determine timing and scheduling of interventions. 3. Allow patients to have visitors at any time. 4. Provide the patient with a private room close to the nurses' station. 5. Encourage the patient to eat whenever he or she is hungry

Answer: 2, 3, 5. Allowing patients to make choices about their care and end-of-life experience provides opportunities for them to maintain their autonomy.

Communication between a nurse caring for a patient in the preoperative holding area and the circulating nurse in the operating room (OR) can best be enhanced by which of the following? (Select all that apply.) 1. Documenting assessment findings in the medical record 2. Using a standardized SBAR tool 3. Being responsive in using nonverbal communication techniques 4. Giving specific information to a transport technician 5. Listening to the OR nurse's questions

Answer: 2, 3, 5. Documentation does not ensure clear communication of all findings and does not allow the OR nurse to raise questions. Giving information to another staff member to communicate important information is not acceptable in a hand-off. Using standardized tools designed for hand-offs and using communication skills will enhance communication.

A 44-year-old male patient has just been told that his wife and child were killed in an auto accident while coming to visit him in the hospital. Which of the following statements are assessment findings that support a nursing diagnosis of Spiritual Distress related to loss of family members? (Select all that apply.) 1. "I need to call my sister for support." 2. "I have nothing to live for now." 3. "Why would my God do this to me?" 4. "I need to pray for a miracle." 5. "I want to be more involved in my church."

Answer: 2, 3. Patients most likely to have a diagnosis of Spiritual Distress are facing loss or terminal or serious illness and have poor personal relationships. Indicating that there is nothing to live for now and wondering why God would do this to him reflect dispiritedness (e.g., expressing lack of hope, meaning, or purpose in life; anger toward God). The other responses show a potential for enhancement of spiritual well-being.

A patient is diagnosed with a multidrug-resistant organism (MDRO) in his surgical wound and asks the nurse what this means. What is the nurse's best response? (Select all that apply.) 1. There is more than one organism in the wound that is causing the infection. 2. The antibiotics the patient has received are not strong enough to kill the organism. 3. The patient will need more than one type of antibiotic to kill the organism. 4. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively. 5. There are no longer any antibiotic options available to treat the patient's infection

Answer: 2, 4 An MDRO is a single organism that is resistant to one or more classes of antibiotics, which makes it harder to treat, but there is treatment available.

Which of the following are safe practices to follow in the safe preparation and storage of food? (Select all that apply.) 1. Always use a single cutting board to prepare foods for cooking. 2. Refrigerate leftovers as soon as possible. 3. Always buy vegetables in packages marked "prewashed." 4. Cook meats to the proper temperature. 5. Wash hands thoroughly before food preparation

Answer: 2, 4, 5. The Centers for Disease Control and Prevention (CDC) recommends washing hands thoroughly before food preparation and to wash cooking surfaces often. Keep raw meat, poultry, seafood, and their juices away from other foods, and use separate cutting boards for each. Rinse fruits and vegetables thoroughly, and always cook food to the proper temperature. Refrigerate leftovers promptly. A single cutting board can cause cross contamination. Even if packages show that vegetables have been prewashed, thoroughly wash when opening a package.

A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks whether the patient is dying and now in "hospice." What does the nurse tell the family member about palliative care? (Select all that apply.) 1. Palliative care and hospice are the same thing. 2. Palliative care is for any patient, any time, any disease, in any setting. 3. Palliative care strategies are primarily designed to treat the patient's illness. 4. Palliative care relieves the symptoms of illness and treatment. 5. Palliative care selects home health care services.

Answer: 2, 4. Palliative care and hospice care are different. Palliative care is available to all patients regardless of age, diagnosis, and prognosis. The focus of palliative care is on management of symptoms.

A patient has just learned she has been diagnosed with a malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. The nurse has been caring for her for only 2 hours but has a good relationship with her. What is the most appropriate intervention for support of her spiritual well-being at this time? 1. Make a referral to a professional spiritual care adviser. 2. Sit down and talk with the patient; have her discuss her feelings and listen attentively. 3. Move the patient's Bible from her bedside cabinet drawer to the top of the over-bed table. 4. Ask the patient whether she would like to learn more about the implications of having this type of tumor.

Answer: 2. Establishing presence contributes to a patient's sense of well-being. It helps to prevent emotional and environmental isolation. Automatically making a referral to a spiritual care adviser might not be the patient's wish. She may not see an adviser as a resource. Reading a Bible can be an important ritual, but at this time the patient needs to make a connection with someone who can help minimize loneliness and powerlessness. Providing instruction will be important, but the patient is unlikely to be receptive at this time

What are the physical circulatory changes that occur as death approaches? 1. Skin irritation 2. Mottling 3. Increased urine output 4. Weakness

Answer: 2. Patients experience circulatory changes resulting in mottling. Weakness, skin irritation, and incontinence are some of the physical changes that occur as death nears but are not related to circulatory changes

A patient is placed on Airborne Precautions for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? 1. Provide a dark, quiet room to calm the patient. 2. Reduce the level of precautions to keep the patient from becoming angry. 3. Explain the reasons for isolation procedures and provide meaningful stimulation. 4. Limit family and other caregiver visits to reduce the risk of spreading the infection.

Answer: 3 By providing a rationale for the isolation, the patient is able to better understand the safety risks and cooperate with care. Providing reading material or other distractions for the patient will also help with times when alone in the room.

A nurse enters the hospital room of a patient who had a total knee replacement the day before. Which of the following pose potential safety risks? (Select all that apply.) 1. A current safety inspection sticker is on the IV fluids pump. 2. A walker is positioned near the patient's bedside. 3. The hospital bed is in the high position. 4. There is no gait belt at the bedside. 5. The overbed table with the patient's glasses is positioned against the wall opposite the end of the bed

Answer: 3, 4, 5. All electrical equipment should be inspected routinely and have current safety inspection stickers. The patient has had knee surgery, so the presence of a walker is needed for him to ambulate. Safety risks include the absence of a gait belt; one should always be available for a patient who will need assistance in ambulation. The bed position is incorrect; it should be in low position. The position of the bedside table does not allow the patient to reach personal or care items easily

A nursing student is developing a plan of care for a 74-year-old-female patient who has spiritual distress over losing a spouse. As the nurse develops appropriate interventions, which characteristics of older adults should be considered? (Select all that apply.) 1. Older adults do not routinely use complementary medicine to cope with illness. 2. Older adults dislike discussing the afterlife and what might have happened to people who have passed on. 3. Older adults achieve spiritual resilience through frequent expressions of gratitude. 4. Have the patient determine whether her husband left a legacy behind. 5. Offer the patient her choice of rituals or participation in exercise

Answer: 3, 4, 5. Older-adult patients achieve spiritual resiliency in expressing gratitude and finding ways to maintain purpose in life. Leaving legacies maintains a connection between the person left behind and the lost loved one. Older adults frequently use complementary medicine, rituals, and exercise to cope with illness and pain. Belief in the afterlife grows with aging

The nurse finds a 68-year-old woman wandering in the hallway and exhibiting confusion. The patients says she is looking for the bathroom. Which interventions are appropriate for this patient? (Select all that apply.) 1. Ask the health care provider to order a restraint. 2. Recommend insertion of a urinary catheter. 3. Provide scheduled toileting rounds every 2 to 3 hours. 4. Institute a routine exercise program for the patient. 5. Keep the bed in high position with side rails down. 6. Keep the pathway from the bed to the bathroom clear

Answer: 3, 4, 6. There are no appropriate conditions for this patient to be restrained. A patient who repeatedly wanders may require the temporary use of restraints to keep him or her safe. However, the use of alternatives to restraints is preferred, and if a restraint is required, use the least restrictive. A urinary catheter is not inserted to avoid having a patient use the bathroom. The patient should have a low bed so that if the patient falls, the risk of injury may be lessened.

When providing postmortem care, which actions are necessary for the nurse to complete? 1. Locating the patient's clothing 2. Calling the funeral home 3. Providing culturally and religiously sensitive care in body preparation 4. Providing postmortem care to protect the family of the deceased from having to view the body

Answer: 3. A deceased person's body deserves the same respect and dignity as that of a living person and needs to be prepared in a manner consistent with the patient's cultural and religious beliefs.

A nurse is caring for a patient who is Muslim and has diabetes. Which of the following items does the nurse need to remove from the meal tray when it is delivered to the patient? 1. Small container of vanilla ice cream 2. A dozen red grapes 3. Bacon and eggs 4. Garden salad with ranch dressing

Answer: 3. Islam prohibits the consumption of pork.

A nurse used spiritual rituals as an intervention in a patient's care. Which of the following questions is most appropriate to evaluate its efficacy? 1. Do you feel the need to forgive your wife over your loss? 2. What can I do to help you feel more at peace? 3. Did either prayer or meditation prove helpful to you? 4. Should we plan on having your family try to visit you more often in the hospital?

Answer: 3. Rituals include participation in worship, prayer, sacraments (e.g., baptism, Holy Eucharist), fasting, singing, meditating, scripture reading, and making offerings or sacrifices. When you include the use of rituals in a patient's plan of care, evaluate whether the patient perceived these activities as useful. If not, other interventions will be necessary

Which postoperative intervention best prevents atelectasis? 1. Use of intermittent compression stockings 2. Heel-toe flexion 3. Use of the incentive spirometer 4. Abdominal splinting when coughing

Answer: 3. Use of the incentive spirometer expands the lungs, thus preventing the onset of atelectasis. Heel-toe flexion and the use of intermittent compression stockings prevent the onset of deep vein thrombosis. Abdominal splinting keeps pressure on abdominal incisions to prevent pain during coughing and wound dehiscence

Which statement made by a patient who is recovering after recently experiencing third-degree burns shows connectedness? 1. "My pain medicine helps me feel better." 2. "I know I will get better if I just keep trying." 3. "I see God's grace and become relaxed when I watch the sun set at night." 4. "I feel so much closer to God after I read my Bible and pray."

Answer: 4. Connectedness is a dimension of spirituality that is related to the human need of belonging. Individuals can be connected to themselves, others, God or another Supreme Being, or nature. Individuals often stay connected to God through prayer

A nurse has the responsibility of managing a patient's postmortem care. What is the proper order for postmortem care when there is no autopsy ordered? 1. Bathe the body of the deceased. 2. Collect any needed specimens. 3. Remove all tubes and indwelling lines. 4. Position the body for family viewing. 5. Speak to the family members about their possible participation. 6. Ensure that the request for organ/tissue donation and/or autopsy was completed. 7. Notify support person (e.g., spiritual care provider, bereavement specialist) for the family. 8. Accurately tag the body, including the identity of the deceased and safety issues regarding infection control. 9. Elevate the head of the bed.

Answer: 6, 9, 2, 5, 7, 3, 1, 4, 8. This order provides dignity to the deceased and ensures that the nurse is adhering to all policies and laws concerning autopsies, organ donation, or an investigation.

Stoicism and denial of grief are examples of how family coping with death is affected by Socioeconomic status Culture Developmental level Prior experience

Culture

The nurse is caring for a client who is expected to die within a month. The client states: "I can't go on anymore, help me!" which of the following best describes this client's stage of dying Anger Denial Acceptance Depression

Depression

An aspect of caring that plays a tremendous role in promoting a client's spiritual well being is Making decisions for the client Helping the client to always look on the bright side of things Identifying spiritual cues Establishing a nursing presence

Establishing a nursing presence

One month after the death of her spouse of 60 years, a widow can be expected to Have a reawakening of interest in life Experience intense grief Not yet feel the impact of the death Reject assistance that may be offered

Experience intense grief

A dying patient is withdrawing, crying, making comments regarding the regret she will feel at not getting to see her grandchildren grow. Your best action is to Tell her, "You will soon be with God, so don't worry. Encourage her to cheer up and make the most of the time she has left. Hold her hand and allow her to express her feelings. Give her privacy and time alone to work through these feelings.

Hold her hand and allow her to express her feelings.

Which patient comment should the nurse identify as a demonstration of faith I go to church every sunday I believe there is a life after death I have something to look forward to each day I get a feeling of awe when looking at the sunset

I believe there is a life after death

The lab has just notified you that the stool specimen you sent down on your patient is positive for Clostridium Difficile. You should Begin to implement standard precautions for him. Plan to wear a mask whenever you enter his room. Do nothing until you speak to his physician. Implement contact precautions immediately

Implement contact precautions immediately

A client who is a Jehovah's Witness is scheduled for surgery tomorrow. There is need to consider that person of this religion Must have removed body parts buried Has a religious leader present during surgery Is opposed to blood transfusion Receives holy communion before surgery

Is opposed to blood transfusion

Which of the following best describes anticipatory grief It occurs after the actual death It occurs when death was sudden and unexpected Only the family of the dying client experiences it It can be colored by ambivalent feelings

It can be colored by ambivalent feelings

Which of the following is a characteristic of palliative care? It only involves care of the client. It provides grief support for family only while the client is alive. It bears no resemblance to hospice care. It is a clinical approach designed to improve quality of life.

It is a clinical approach designed to improve quality of life.

The nursing is caring for a patient who has been diagnosed with a terminal illness. The patient states "I just do not 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? It sounds like you have lost energy It sounds like you have lost the ability to sleep It sounds like you have lost your appetite It sounds like you have lost hope

It sounds like you have lost hope

How can the nurse best support the spiritual development of a hospitalized 5 year old? Listen to the child's routine bedtime prayer Encourage the child to pray before each meal Ask the child who god is Bring a bible storybook in to read to the child at bedtime

Listen to the child's routine bedtime prayer

Which of the following parents need additional instruction regarding safety? Parent A states "Now that my child is 2 years old I can let her sit in the front seat of the car with me." Parent B states "I make sure Tommy wears a helmet when he rides his bicycle." Parent C states " I have spoken to my teenager about safe sex practices." Parent D states "My 8 year old is taking swimming lessons at the YMCA."

Parent A states "Now that my child is 2 years old I can let her sit in the front seat of the car with me."

Which of the following is true of spirituality in health care: Patients who display anger at their caregivers may be experiencing spiritual distress Nurses play a key role in helping patients resolve Sudden unexpected illness often creates spiritual distress Conflicts between a person's beliefs and prescribed health care regimens rarely occur When confronted with acute illness, patients always look for ways to remain faithful to their spiritual beliefs

Patients who display anger at their caregivers may be experiencing spiritual distress Nurses play a key role in helping patients resolve Sudden unexpected illness often creates spiritual distress

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: Place a bed alarm device on the bed. Place the patient in a belt restraint. Provide one-on-one observation of the patient. Apply wrist restraints.

Place a bed alarm device on the bed.

Interventions for the client with actual or potential sensory alterations include all of the following except Promoting optimal function of existing senses Preventing additional sensory loss Promoting client's acceptance of dependency Controlling the environment to create meaningful sensory stimuli

Promoting client's acceptance of dependency

A client's adult children call the nurse hourly with concerns about their mother's end of life care. The nurse's best response is to Provide detailed, scientific information Discuss physical symptoms Withhold information to avoid unnecessary fears Provide frequent updates

Provide frequent updates

Your patient needs an indwelling urinary catheter. Which of the following are important nursing actions? Select all that apply. If you find that the drain of the catheter bag has been left open, cleanse it with alcohol prior to refastening it. Reassess the continued need for the catheter daily. Use clean technique for the insertion of the catheter. Use good handwashing before and after handling the catheter. Secure the catheter to the patient's leg to prevent trauma to the meatus.

Reassess the continued need for the catheter daily. Use good handwashing before and after handling the catheter. Secure the catheter to the patient's leg to prevent trauma to the meatus.

Which of the following is true about grief Grief always occurs immediately after a loss Support for a grieving client includes closed communication Recurring, wavelike feelings of sadness and loss are common feelings in a client who is grieving It is normal for grief to be exaggerated

Recurring, wavelike feelings of sadness and loss are common

A patient has been in contact isolation for 4 days because of an infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Which are the correct nursing interventions to reduce sensory deprivation? (Select all that apply.) Teaching how activities such as reading and using crossword puzzles provide stimulation Moving him to a room away from the nurse's station Turning on the lights and opening the room blinds Sitting down, speaking, touching, and listening to his feelings and perceptions Providing auditory stimulation for the patient by keeping the television on continuously

Teaching how activities such as reading and using crossword puzzles provide stimulation Turning on the lights and opening the room blinds Sitting down, speaking, touching, and listening to his feelings and perceptions

Match the nursing interventions on the left with the complication to be prevented on the right. An intervention may apply to more than one complication. 1. Offering glasses or hearing aid 2. Early ambulation 3. Strict aseptic technique 4. Deep breathing exercise 5. Hydration a. Deep vein thrombosis b. Wound infection c. Delirium d. Atelectasis

The correct answers are 1. c; 2. a, c; 3. b; 4. d; 5. a, d

The nurse is admitting a patient to the hospital. The patient states that he is a very spiritual person and does not practice any specific religion. How will the nurse interpret this finding* This statement is reasonable This statement is contradictory This indicates a strong religious affiliation This indicates a lack of hope

This statement is reasonable

During the morning bath, the patient asks if the nurse is religious and believes in god. What guidelines would be the most helpful to the nurse in formulating a response to the question: a. Religion and politics are two subjects not discusses with patients b. Will sharing this information positively contribute to the nurse patient relationship? c. The nurse's personal life is none of the patient's business d. What is the policy of the health care facility regarding self disclosure

b

The most effective nursing action for controlling the spread of infection is thorough hand washing wearing gloves and masks when providing direct patient care implementing appropriate isolation precautions administering broad spectrum prophylactic antibiotics

thorough hand washing