medical surg test 1

A nurse is meeting with a young woman who has recently lost her job after moving with her husband to a new city. She describes herself as being anxious and pretty depressed. What principle of stress and adaptation should be integrated into the nurses plan of care for this patient?

An accumulation of stressors can disrupt homeostasis and result in disease.

4. You are the nurse assessing a 28-year-old woman who has presented to the emergency department with vague complaints of malaise. You note bruising to the patients upper arm that correspond to the outline of fingers as well as yellow bruising around her left eye. The patient makes minimal eye contact during the assessment. How might you best inquire about the bruising? A) Is anyone physically hurting you? B) Tell me about your relationships. C) Do you want to see a social worker? D) Is there something you want to tell me?

Ans: A Feedback: Few patients will discuss the topic of abuse unless they are directly asked. Therefore, it is important to ask direct questions, such as, Is anyone physically hurting you? The other options are incorrect because they are not the best way to illicit information about possible abuse in a direct and appropriate manner.

18. A 30-year-old man is in the clinic for a yearly physical. He states, I found out that two of my uncles had heart attacks when they were young. This alerts the nurse to complete a genetic-specific assessment. What component should the nurse include in this assessment? A) A complete health history, including genogram along with any history of cholesterol testing or screening and a complete physical exam B) A limited health history along with a complete physical assessment with an emphasis on genetic abnormalities C) A limited health history and focused physical exam followed by safety-related education D) A family history focused on the paternal family with focused physical exam and genetic profile

Ans: A Feedback: A genetic-specific exam in this case would include a complete health history, genogram, a history of cholesterol testing or screening, and a complete physical exam. A broad examination is warranted and safety education is not directly relevant.

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

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

37. A team of community health nurses has partnered with the staff at a youth drop-in center to address some of the health promotion needs of teenagers. The nurses have identified a need to address nutritional assessment and intervention. Which of the following most often occurs during the teen years? A) Lifelong eating habits are acquired. B) Peer pressure influences growth. C) BMI is determined. D) Culture begins to influence diet.

Ans: A Feedback: Adolescence is a time of critical growth and acquisition of lifelong eating habits, and, therefore, nutritional assessment, analysis, and intervention are critical. Peer pressure does not influence growth. Cultural influences tend to become less important during the teen years, they do not emerge for the first time at this age. BMI can be assessed at any age.

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

Ans: A Feedback: Critical thinking in nursing practice results in a comprehensive plan of care with maximized potential for success. Critical thinking does not identify the nurses goal for the patient or provide a collaborative basis for assigning care. Critical thinking may or may not lead to increased cost efficiency, the patients outcomes are paramount.

25. A family whose religion limits the use of some forms of technology is admitting their grandfather to your unit. They express skepticism about the fact that you are recording the admission data on a laptop computer. What would be your best response to their concerns? A) Its been found that using computers improves our patients care and reduces their health care costs. B) We have found that it is easier to keep track of our patients information this way rather than with pen and paper. C) Youll find that all the hospitals are doing this now, and that writing information with a pen is rare. D) The government is telling us we have to do this, even though most people, like yourselves, are opposed to it.

Ans: A Feedback: Electronic health records are thought to improve the quality of care, reduce medical errors, and help reduce health care costs, therefore, their implementation is moving forward on a global scale. Electronic documentation is not always easier and most people are not opposed to it. Stating that all hospitals do this does not directly address their reluctance or state the benefits. The use of technology in health care settings is not specifically mandated by legislation.

10. In your role as a school nurse, you are working with a female high school junior whose BMI is 31. When planning this girls care, you should identify what goal? A) Continuation of current diet and activity level B) Increase in exercise and reduction in calorie intake C) Possible referral to an eating disorder clinic D) Increase in daily calorie intake

Ans: B Feedback: A BMI of 31 is considered clinically obese, dietary and exercise modifications would be indicated. People who have a BMI lower than 24 (or who are 80% or less of their desirable body weight for height) are at increased risk for problems associated with poor nutritional status. Those who have a BMI of 25 to 29.9 are considered overweight, those with a BMI of 30 or greater are considered to be obese.

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

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

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

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

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

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

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

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

6. You are taking a health history on an adult patient who is new to the clinic. While performing your assessment, the patient informs you that her mother has type 1 diabetes. What is the primary significance of this information to the health history? A) The patient may be at risk for developing diabetes. B) The patient may need teaching on the effects of diabetes. C) The patient may need to attend a support group for individuals with diabetes. D) The patient may benefit from a dietary regimen that tracks glucose intake.

Ans: A Feedback: Nurses incorporate a genetics focus into the health assessments of family history to assess for genetics- related risk factors. The information aids the nurse in determining if the patient may be predisposed to diseases that are genetic in origin. The results of diabetes testing would determine whether dietary changes, support groups or health education would be needed.

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

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

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

Ans: A Feedback: Nursing diagnoses are not medical diagnoses or treatments. The most appropriate nursing diagnosis for this patient is ineffective airway clearance related to copious tracheobronchial secretions. Pneumonia and poor ventilation are not nursing diagnoses. Immobility is likely, but is less directly related to the patients admitting medical diagnosis and the nurses assessment finding.

You are assessing an 80-year-old patient who has presented because of an unintended weight loss of 10 pounds over the past 8 weeks. During the assessment, you learn that the patient has ill-fitting dentures and a limited intake of high-fiber foods. You would be aware that the patient is at risk for what problem? A) Constipation B) Deficient fluid volume C) Malabsorption of nutrients D) Excessive intake of convenience foods

Ans: A Feedback: Patients with ill-fitting dentures are at a potential risk for an inadequate intake of high-fiber foods. The elderly are already at an increased risk for constipation because of other developmental factors and the potential for a decreased activity level. Ill-fitting dentures do not put a patient at risk for dehydration, malabsorption of nutrients, or a reliance on convenience foods.

33. A nurse practitioners assessment of a new patient includes each of the four basic assessment techniques. When using percussion, which of the following is the nurse able to assess? A) Borders of the patients heart B) Movement of the patients diaphragm during expiration C) Borders of the patients liver D) The presence of rectal distension

Ans: A Feedback: Percussion allows the examiner to assess such normal anatomic details as the borders of the heart and the movement of the diaphragm during inspiration. Movement of the diaphragm, delineation of the liver and the presence of rectal distention cannot be assessed by percussion.

5. You are the nurse performing a health assessment of an adult male patient. The man states, The doctor has already asked me all these questions. Why are you asking them all over again? What is your best response? A) This history helps us determine what your needs may be for nursing care. B) You are right, this may seem redundant and Im sure that its frustrating for you. C) I want to make sure your doctor has covered everything thats important for your treatment. D) I am a member of your health care team and we want to make sure that nothing falls through the cracks.

Ans: A Feedback: Regardless of the assessment format used, the focus of nurses during data collection is different from that of physicians and other health team members. Explaining to the patient the purpose of the nursing assessment creates a better understanding of what the nurse does. It also gives the patient an opportunity to add his or her own input into the patients care plan. The nurse should address the patients concerns directly and avoid casting doubt on the thoroughness of the physician.

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

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

41. A nurse who has practiced in the hospital setting for several years will now transition to a new role in the community. How does a physical assessment in the community vary in technique from physical assessment in the hospital? A) A physical assessment in the community consists of largely the same techniques as are used in the hospital. B) A physical assessment made in the community does not require the privacy that a physical assessment made in the hospital setting requires. C) A physical assessment made in the community requires that the patient be made more comfortable than would be necessary in the hospital setting. D) A physical assessment made in the community varies in technique from that conducted in the hospital setting by being less structured.

Ans: A Feedback: The physical assessment in the community and home consists of the same techniques used in the hospital, outpatient clinic, or office setting. Privacy is provided, and the person is made as comfortable as possible. The importance of comfort, privacy and structure are similar in both settings.

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

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

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

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

23. You are performing the admission assessment of a patient who is being admitted to the postsurgical unit following knee arthroplasty. The patient states, Youve got more information on me now than my own family has. How do you manage to keep it all private? What is your best response to this patients concern? A) Your information is maintained in a secure place and only those health care professionals directly involved in your care can see it. B) Your information is available only to people who currently work in patient care here in the hospital. C) Your information is kept electronically on a secure server and anyone who gets permission from you can see it. D) Your information is only available to professionals who care for you and representatives of your insurance company.

Ans: A Feedback: This written record of the patients history and physical examination findings is then maintained in a secure place and made available only to those health professionals directly involved in the care of the patient. Only those caring for the patient have access to the health record. Insurance companies have the right to know the patients coded diagnoses so that bills may be paid

29. The nurse is completing a family history for a patient who is admitted for exacerbation of chronic obstructive pulmonary disease (COPD). The nurse should include questions that address which of the following health problems? Select all that apply. A) Allergies B) Alcoholism C) Psoriasis D) Hypervitaminosis E) Obesity

Ans: A, B, E Feedback: In general, the following conditions are included in a family history: cancer, hypertension, heart disease, diabetes, epilepsy, mental illness, tuberculosis, kidney disease, arthritis, allergies, asthma, alcoholism, and obesity. Psoriasis and hypervitaminosis do not have genetic etiologies.

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

Ans: A, C, D, E Feedback: Independent judgments and decisions evolve from a sound knowledge base and the ability to synthesize information within the context in which it is presented. Critical thinking enhances clinical decision making, helping to identify patient needs and the best nursing actions that will assist patients in meeting those needs. Critical thinking does not normally focus on identify patient desires

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

Ans: B Feedback: A living will is one type of advance directive. In most situations, living wills are limited to situations in which the patients medical condition is deemed terminal. The other answers are incorrect because living wills are not always honored, they are not binding for the duration of the patients life, and they are not drawn up by the patients family.

8. A nurse on a medical unit is conducting a spiritual assessment of a patient who is newly admitted. In the course of this assessment, the patient indicates that she does not eat meat. Which of the following is the most likely significance of this patients statement? A) The patient does not understand the principles of nutrition. B) This is an aspect of the patients religious practice. C) This constitutes a nursing diagnosis of Risk for Imbalanced Nutrition. D) This is an example of the patients coping strategies.

Ans: B Feedback: Because this datum was obtained during a spiritual assessment, it could be that this is an aspect of the patients religious practice. It is indeed a personal choice, but this is not the primary significance of the statement. This practice may not be related to health-seeking if it is in fact a religious practice. This does not necessarily constitute a risk for malnutrition or a misunderstanding of nutrition.

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

Ans: B Feedback: Beneficence is the duty to do good and the active promotion of benevolent acts. Enacting the patients wishes around visitors is an example of this. Each of the other nursing actions is consistent with ethical practice, but none directly exemplifies the principle of beneficence.

34. A 51-year-old womans recent complaints of fatigue are thought to be attributable to iron-deficiency anemia. The patients subsequent diagnostic testing includes quantification of her transferrin levels. This biochemical assessment would be performed by assessing which of the following? A) The patients urine B) The patients serum C) The patients cerebrospinal fluid D) The patients synovial fluid

Ans: B Feedback: Biochemical assessments are made from studies of serum (albumin, transferrin, retinol-binding protein, electrolytes, hemoglobin, vitamin A, carotene, vitamin C, and total lymphocyte count) and studies of urine (creatinine, thiamine, riboflavin, niacin, and iodine). Transferrin is found in serum, not urine, CSF, or synovial fluid.

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

Ans: B Feedback: Critical thinking includes metacognition, the examination of ones own reasoning or thought processes, to help refine thinking skills. Metacognition is not characterized by eliciting input from others or evaluating previous responses.

You are performing a dietary assessment with a patient who has been admitted to the medical unit with community-acquired pneumonia. The patient wants to know why the hospital needs all this information about the way he eats, asking you, Are you asking me all these questions because I am Middle Eastern? What is your best response to this patient? A) We always try to abide by foreign-born patients dietary preferences in order to make them comfortable. B) We know that some cultural and religious practices include dietary guidelines, and we do not want to violate these. C) We wouldnt want to feed you anything you only eat on certain holidays. D) We know that patients who grew up in other countries often have unusual diets, and we want to accommodate this.

Ans: B Feedback: Culture and religious practices together often determine whether certain foods are prohibited and whether certain foods and spices are eaten on certain holidays or at specific family gatherings. A specific focus on holidays, however, does not convey the overall intent of the dietary interview. Dietary planning addresses all patients needs, not only those who are born outside the United States. It is inappropriate to characterize a patients diet as unusual.

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

Ans: B Feedback: Evaluation, the final step of the nursing process, allows the nurse to determine the patients response to nursing interventions and the extent to which the objectives have been achieved.

21. A nurse who provides care in a campus medical clinic is performing an assessment of a 21-year-old student who has presented for care. After assessment, the nurse determines that the patient has a BMI of 45. What does this indicate? A) The patient is a normal weight. B) The patient is extremely obese. C) The patient is overweight. D) The patient is mildly obese.

Ans: B Feedback: Individuals who have a BMI between 25 and 29.9 are considered overweight. Obesity is defined as a BMI of greater than 30 (WHO, 2011). A BMI of 45 would indicate extreme obesity.

30. The admitting nurse has just met a new patient who has been admitted from the emergency department. As the nurse introduces himself, he begins the process of inspection. What nursing action should the nurse include during this phase of assessment? A) Gather as many psychosocial details as possible. B) Pay attention to the details while observing. C) Write down as many details as possible during the observation. D) Do not let the patient know he is being assessed.

Ans: B Feedback: It is essential to pay attention to the details in observation. Vague, general statements are not a substitute for specific descriptions based on careful observation. It is specific information, not general information, that is being gathered. Writing while observing can be a conflict for the nurse. It is not necessary or appropriate to keep the patient from knowing he is being assessed.

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

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

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

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

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

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

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

Ans: B Feedback: Resources for identifying appropriate expected outcomes include the NOC and standard outcome criteria established by health care agencies for people with specific health problems. The other options are incorrect because they do not exist.

22. A nurse is conducting a home visit as part of the community health assessment of a patient who will receive scheduled wound care. During assessment, the nurse should prioritize which of the following variables? A) Availability of home health care, current Medicare rules, and family support B) The community and home environment, support systems or family care, and the availability of needed resources C) The future health status of the individual, and community and hospital resources D) The characteristics of the neighborhood, and the patients socioeconomic status and insurance coverage

Ans: B Feedback: The community or home environment, support systems or family care, and the availability of needed resources are the key factors that distinguish community assessment from assessments in the acute-care setting. The other options fail to address the specifics of either the community or home environment.

42. You are conducting an assessment of a patient in her home setting. Your patient is a 91-year-old woman who lives alone and has no family members living close by. What would you need to be aware of to aid in providing care to this patient? A) Where the closest relative lives B) What resources are available to the patient C) What the patients financial status is D) How many children this patient has

Ans: B Feedback: The nurse must be aware of resources available in the community and methods of obtaining those resources for the patient. The other data would be nice to know, but are not prerequisites to providing care to this patient.

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

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

An 89-year-old male patient is wheelchair bound following a hemorrhagic stroke and has been living in a nursing home since leaving the hospital. He returns to the adjacent primary care clinic by wheelchair for follow-up care of hypertension and other health problems. The nurse would modify his health history to include which question? A) Tell me about your medications: How do you usually get them each day? B) Tell me about where you live: Do you feel your needs are being met, and do you feel safe? C) Your wheelchair would seem to limit your ability to move around. How do you deal with that? D) What limitations are you dealing with related to your health and being in a wheelchair?

Ans: B Feedback: The question, Tell me about where you live: Do you feel your needs are being met and do you feel safe? seeks to explore the specific issue of the safety in the home environment. People who are older, have a disability, and live in the community setting are at a greater risk for abuse. An explicit focus on limitations may be counterproductive.

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

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

2. A nurse is conducting a health assessment of an adult patient when the patient asks, Why do you need all this health information and who is going to see it? What is the nurses best response? A) Please do not worry. It is safe and will be used only to help us with your care. Its accessible to a wide variety of people who are invested in your health. B) It is good you asked and you have a right to know your information helps us to provide you with the best possible care, and your records are in a secure place. C) Your health information is placed on secure Web sites to provide easy access to anyone wishing to see your medical records. This ensures continuity of care. D) Health information becomes the property of the hospital and we will make sure that no one sees it. Then, in 2 years, we destroy all records and the process starts over.

Ans: B Feedback: Whenever information is elicited from a person through a health history or physical examination, the person has the right to know why the information is sought and how it will be used. For this reason, it is important to explain what the history and physical examination are, how the information will be obtained, and how it will be used. Medical records allow access to health care providers who need the information to provide patients with the best possible care, and the records are always held in a secure environment. Telling the patient not to worry minimizes the patients concern regarding the safety of his or her health information and a wide variety of people should not have access to patients health information. Health information should not be placed on Web sites and health records are not destroyed every 2 years.

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

Ans: B, C, D Feedback: Planned interventions should be ethical and appropriate to the patients culture, age, and gender. Planned interventions do not have to be in alignment with the nurses preferences nor do they have to be shared by everyone with the same diagnosis.

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

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

38. A newly admitted patient has gained weight steadily over the past 2 years and the nurse recognizes the need for a nutritional assessment. What assessment parameters are included when assessing a patients nutritional status? Select all that apply. A) Ethnic mores B) BMI C) Clinical examination findings D) Wrist circumference E) Dietary data

Ans: B, C, E Feedback: The sequence of assessment of parameters may vary, but evaluation of nutritional status includes one or more of the following methods: measurement of BMI and waist circumference, biochemical measurements, clinical examination findings, and dietary data. Ethnic mores and wrist circumference are not assessment parameters for nutritional status.

A school nurse is teaching a 14-year-old girl of normal weight some of the key factors necessary to maintain good nutrition in this stage of her growth and development. What interventions should the nurse most likely prioritize? A) Decreasing her calorie intake and encouraging her to maintain her weight to avoid obesity B) Increasing her BMI, taking a multivitamin, and discussing body image C) Increasing calcium intake, eating a balanced diet, and discussing eating disorders D) Obtaining a food diary along with providing close monitoring for anorexia

Ans: C Feedback: Adolescent girls are considered to be at high risk for nutritional disorders. Increasing calcium intake and promoting a balanced diet will provide the necessary vitamins and minerals. If adolescents are diagnosed with eating disorders early, the recovery chances are increased. The question presents no information that indicates a need for decreasing her calories. There is no apparent need for an increase in BMI. A food diary is used for assessing eating habits, but the question asks for teaching factors related to good nutrition.

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

Ans: C Feedback: Although many nursing actions are independent, others are interdependent, such as carrying out prescribed treatments, administering medications and therapies, and collaborating with other health care team members to accomplish specific, expected outcomes and to monitor and manage potential complications. Irrigating a wound, administering pain medication, and administering IV fluids are interdependent nursing actions and require a physicians order. An independent nursing action occurs when the nurse assesses a patients heart rate, provides discharge education, or provides mouth care.

20. In your role as a school nurse, you are performing a sports physical on a healthy adolescent girl who is planning to try out for the volleyball team. When it comes time to listen to the students heart and lungs, what is your best nursing action? A) Perform auscultation with the stethoscope placed firmly over her clothing to protect her privacy. B) Perform auscultation by holding the diaphragm lightly on her clothing to eliminate the scratchy noise. C) Perform auscultation with the diaphragm placed firmly on her skin to minimize extra noise. D) Defer the exam because the girl is known to be healthy and chest auscultation may cause her anxiety.

Ans: C Feedback: Auscultation should always be performed with the diaphragm placed firmly on the skin to minimize extra noise and with the bell lightly placed on the skin to reduce distortion caused by vibration. Placing a stethoscope over clothing limits the conduction of sound. Performing auscultation is an important part of a sports physical and should never be deferred.

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

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

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

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

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

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

You are orienting a new nursing graduate to your medical unit. The new nurse has been assisting an elderly woman, who is Greek, to fill out her menu for the next day. To what resource should you refer your colleague to obtain appropriate dietary recommendations for this patient? A) The U.S. Department of Agricultures MyPlate B) Evidence-based resources on nutritional assessment C) Culturally sensitive materials, such as the Mediterranean Pyramid D) A Greek cookbook that contains academic references

Ans: C Feedback: Culturally sensitive materials, such as the food pagoda and the Mediterranean Pyramid, are available for making appropriate dietary recommendations. MyPlate is not explicitly culturally sensitive. Nursing resource books do not usually have culturally sensitive dietary specific material. A Greek cookbook would not be an appropriate clinical resource.

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

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

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

Ans: C Feedback: In the diagnostic phase of the nursing process, the patients nursing problems are defined through analysis of patient data. Establishing a plan comes after collecting and analyzing data, evaluating a plan is the last step of the nursing process and assigning a positive value to each consequence is not done.

31. During a comprehensive health assessment, which of the following structures can the nurse best assess by palpation? A) Intestines B) Gall bladder C) Thyroid gland D) Pancreas

Ans: C Feedback: Many structures of the body, although not visible, may be assessed through the techniques of light and deep palpation. Examples include the superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen and pelvis, and rectum. The intestines, muscles, and pancreas cannot be assessed through palpation.

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

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

A school nurse at a middle school is planning a health promotion initiative for girls. The nurse has identified a need for nutritional teaching. What problem is most likely to relate to nutritional problems in girls of this age? A) Protein intake in this age group often falls below recommended levels. B) Total calorie intake is often insufficient at this age. C) Calcium intake is above the recommended levels. D) Folate intake is below the recommended levels in this age group.

Ans: D Feedback: Adolescent girls are at particular nutritional risk, because iron, folate, and calcium intakes are below recommended levels, and they are a less physically active group compared to adolescent males. Protein and calorie intake is most often sufficient.

24. You are admitting an elderly woman who is accompanied by her husband. The husband wants to know where the information you are obtaining is going to be kept and you follow up by describing the system of electronic health records. The husband states, I sure am not comfortable with that. It is too easy for someone to break into computer records these days. What is your best response? A) The Institute of Medicine has called for the implementation of the computerized health record so all hospitals are doing it. B) Weve been doing this for several years with good success, so I can assure you that our records are very safe. C) This hospital is as concerned as you are about keeping our patients records private. So we take special precautions to make sure no one can break into our patients medical records. D) Your wifes records will be safe, because only people who work in the hospital have the credentials to access them.

Ans: C Feedback: Nurses must be sensitive to the needs of the older adults and others who may not be comfortable with computer technology. Special precautions are indeed taken. Not every hospital employee has access and referencing the IOM may not provide reassurance.

9. You are beginning your shift on a medical unit and are performing assessments appropriate to each patients diagnosis and history. When assessing a patient who has an acute staphylococcal infection, what is the most effective technique for assessing the lymph nodes of the patients neck? A) Inspection B) Auscultation C) Palpation D) Percussion

Ans: C Feedback: Palpation is a part of the assessment that allows the nurse to assess a body part through touch. Many structures of the body (superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen, pelvis, and rectum), although not visible, may be assessed through the techniques of light and deep palpation. The other options are incorrect because lymph nodes are not assessed through inspection, auscultation, or percussion.

39. The segment of the population who has a BMI lower than 24 has been found to be at increased risk for poor nutritional status and its resultant problems. What else is a low BMI associated with in the community-dwelling elderly? A) High risk of diabetes B) Increased incidence of falls C) Higher mortality rate D) Low risk of chronic disease

Ans: C Feedback: People who have a BMI lower than 24 (or who are 80% or less of their desirable body weight for height) are at increased risk for problems associated with poor nutritional status. In addition, a low BMI is associated with a higher mortality rate among hospitalized patients and community-dwelling elderly. Low BMI is not directly linked to an increased risk for falls or diabetes. Excessively low BMI does not result in a decreased incidence of overall chronic disease.

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

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

11. During your integumentary assessment of an adult female patient, you note that the patient has dry, dull, brittle hair and dry, flaky skin with poor turgor. When planning this patients nursing care, you should prioritize interventions that address what problem? A) Inadequate physical activity B) Ineffective personal hygiene C) Deficient nutritional status D) Exposure to environmental toxins

Ans: C Feedback: Signs of poor nutrition include dry, dull, brittle hair and dry, flaky skin with poor turgor. These findings do not indicate a lack of physical activity, poor personal hygiene, or damage from an environmental cause.

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

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

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

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

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

Ans: C Feedback: The duty not to inflict as well as prevent and remove harm is termed nonmaleficence. Discussing a DNR order with a terminally ill patient and assisting a patient with ADLs would not be considered contradictions to the nurses duty of nonmaleficence. Some patients justifiably require more care than others.

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

Ans: C Feedback: To depict the process of thinking like a nurse, Tanner (2006) developed a model known as the clinical judgment model.

15. You are the emergency department nurse obtaining a health history from a patient who has earlier told the triage nurse that she is experiencing intermittent abdominal pain. What question should you ask to elicit the probable reason for the visit and identify her chief complaint? A) Why do you think your abdomen is painful? B) Where exactly is your abdominal pain and when did it start? C) What brings you to the hospital today? D) What is wrong with you today?

Ans: C Feedback: The chief complaint should clearly address what has brought the patient to see the health care provider, an open-ended question best serves this purpose. The question What brings you to the hospital? allows the patient sufficient latitude to provide an answer that expresses the priority issue. Focusing solely on abdominal pain would be too specific to serve as the first question regarding the chief complaint. Asking, What is wrong with you today? is an open-ended question but still directs the patient toward the fact that there is a problem.

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

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

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

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

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

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

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

Ans: D Feedback: During the evaluation phase of the nursing process, the nurse determines the patients response to nursing interventions. An example of this is when the nurse documents whether the patients spirometry use has improved his or her condition. A patient does not do the evaluation. Removing staples and providing information on follow-up appointments are interventions, not evaluations.

7. A registered nurse is performing the admission assessment of a 37-year-old man who will be treated for pancreatitis on the medical unit. During the nursing assessment, the nurse asks the patient questions related to his spirituality. What is the primary rationale for this aspect of the nurses assessment? A) The patients spiritual environment can affect his physical activity. B) The patients spiritual environment can affect his ability to communicate. C) The patients spiritual environment can affect his quality of sexual relationships. D) The patients spiritual environment can affect his response to illness.

Ans: D Feedback: Illness may cause a spiritual crisis and can place considerable stresses on a persons internal resources. The term spiritual environment refers to the degree to which a person has contemplated his or her own existence. The other listed options may be right, but they are not the most important reasons for a nurse to assess a patients spiritual environment.

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

Ans: D Feedback: Implementation refers to carrying out the plan of nursing care. The other listed options exemplify goals, assessment findings, and diagnoses.

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

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

19. A patient has a newly diagnosed heart murmur. During the nurses subsequent health education, he asks if he can listen to it. What would be the nurses best response? A) Listening to the body is called auscultation. It is done with the diaphragm, and it requires a trained ear to hear a murmur. B) Listening is called palpation, and I would be glad to help you to palpate your murmur. C) Heart murmurs are pathologic and may require surgery. If you would like to listen to your murmur, I can provide you with instruction. D) If you would like to listen to your murmur, Id be glad to help you and to show you how to use a stethoscope.

Ans: D Feedback: Listening with a stethoscope is auscultation and it is done with both the bell and diaphragm. The diaphragm is used to assess high-frequency sounds such as systolic heart murmurs, whereas the bell is used to assess low-frequency sounds such as diastolic heart murmurs. It is also important to provide education whenever possible and actively include the patient in the plan of care. Teaching an interested patient how to listen to a murmur should be encouraged. Many heart murmurs are benign and do not require surgery.

40. Imbalanced nutrition can be characterized by excessive or deficient food intake. What potential effect of imbalanced nutrition should the nurse be aware of when assessing patients? A) Masking the symptoms of acute infection B) Decreasing wound healing time C) Contributing to shorter hospital stays D) Prolonging confinement to bed

Ans: D Feedback: Malnutrition interferes with wound healing, increases susceptibility to infection, and contributes to an increased incidence of complications, longer hospital stays, and prolonged confinement of patients to bed. Malnutrition does not mask the signs and symptoms of acute infection.

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

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

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

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

You are the nurse caring for a patient who is Native American who arrives at the clinic for treatment related to type 2 diabetes. Which question would best provide you with information about the role of food in the patients cultural practices and identify how the patients food preferences could be related to his problem? A) Do you feel any of your cultural practices have a negative impact on your disease process? B) What types of foods are served as a part of your cultural practices, and how are they prepared? C) As a nonnative, I am unaware of your cultural practices. Could you teach me a few practices that may affect your care? D) Tell me about foods that are important in your culture and how you feel they influence your diabetes.

Ans: D Feedback: The beliefs and practices that have been shared from generation to generation are known as cultural or ethnic patterns. Food plays a significant role in both cultural practices and type 2 diabetes. By asking the question, Tell me about the foods that are important in your culture and how you feel they influence your diabetes, the nurse demonstrates a cultural awareness to the client and allows an open-ended discussion of the disease process and its relationship to cultural practice. An overemphasis on negatives can inhibit assessment and communication. Assessing the types and preparation of foods specific to cultural practices without relating it to diabetes is inadequate. The question, As a nonnative, I am unaware of your cultural practices. Could you teach me a few practices that may affect your care? focuses on care and fails to address the significance of food in cultural practice or diabetes.

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

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

3. The nurse is performing an admission assessment of a 72-year-old female patient who understands minimal English. An interpreter who speaks the patients language is unavailable and no members of the care team speak the language. How should the nurse best perform data collection? A) Have a family member provide the data. B) Obtain the data from the old chart and physicians assessment. C) Obtain the data only from the patient, prioritizing aspects that the patient understands. D) Collect all possible data from the patient and have the family supplement missing details.

Ans: D Feedback: The informant, or the person providing the information, may not always be the patient. The nurse can gain information from the patient and have the family provide any missing details. The nurse should always obtain as much information as possible directly from the patient. In this case, it is not likely possible to get all the information needed only from the patient.

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

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

14. You are teaching a nutrition education class that is being held for a group of older adults at a senior center. When planning your teaching, you should be aware that individuals at this point in the lifespan have which of the following? A) A decreased need for calcium B) An increased need for glucose C) An increased need for sodium D) A decreased need for calories

Ans: D Feedback: The older adult has a decreased metabolism, and absorption of nutrients has decreased. The older adult has an increased need for sound nutrition but a decreased need for calories. The other options are incorrect because there is no decreased need for calcium and no increased need for either glucose or sodium.

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

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

32. During a health assessment of an older adult with multiple chronic health problems, the nurse practitioner is utilizing multiple assessment techniques, including percussion. What is the essential principle of percussion? A) To assess the sound created by the body B) To strike the abdominal wall with a soft object C) To create sound over dead spaces in the body D) To create vibration in a body wall

Ans: D Feedback: The principle of percussion is to set the chest wall or abdominal wall into vibration by striking it with a firm object. Percussion is not limited to dead spaces or the abdomen. The body does not create the sounds resulting from percussion, sound is referred from striking the surface of the body.

A home care nurse is teaching meal-planning to a patients son who is caring for his mother during her recovery from hip replacement surgery. Which of the following meals indicates that the son understands the concept of nutrition, based on the U.S. Department of Agricultures MyPlate? A) Cheeseburger, carrot sticks, and mushroom soup with whole wheat crackers B) Spaghetti and meat sauce with garlic bread and a salad C) Chicken and pepper stir fry on a bed of rice D) Ham sandwich with tomato on rye bread with peaches and yogurt

Ans: D Feedback: This menu has a choice from each of the food groups identified in MyPlate: grains, vegetables, fruits, dairy, and protein. The other selections are incomplete choices.

28. In the course of performing an admission assessment, the nurse has asked questions about the patients first-and second-order relatives. What is the primary rationale for the nurses line of questioning? A) To determine how many living relatives the patient has B) To identify the familys level of health literacy C) To identify potential sources of social support D) To identify diseases that may be genetic

Ans: D Feedback: To identify diseases that may be genetic, communicable, or possibly environmental in origin, the interviewer asks about the age and health status, or the age and cause of death, of first-order relatives (parents, siblings, spouse, children) and second-order relatives (grandparents, cousins). This is a priority over the number of living relatives, sources of support, or health literacy, though each of these may be relevant.

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

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

An older adults unexplained weight loss of 15 pounds over the past 3 months has prompted a thorough diagnostic workup. What is the nurses rationale for prioritizing biochemical assessment when appraising a persons nutritional status? A) It identifies abnormalities in the chemical structure of nutrients. B) It predicts abnormal utilization of nutrients. C) It reflects the tissue level of a given nutrient. D) It predicts metabolic abnormalities in nutritional intake.

Ans:C Feedback: Biochemical assessment reflects both the tissue level of a given nutrient and any abnormality of metabolism in the utilization of nutrients. It does not focus on abnormalities in the chemical structure of nutrients. Biochemical assessment is not predictive.

You are the nurse caring for an adult patient who has just received a diagnosis of prostate cancer. The patient states that he will never be able to cope with this situation. How should you best understand the concept of coping when attempting to meet this patients needs?

Coping is composed of the physiologic and psychological processes that people use to adapt to change.

You are caring for an older female patient who is being treated for acute anxiety. She has a nursing diagnosis of Ineffective Coping related to a feeling of helplessness. What would be the most appropriate nursing intervention?

Encourage an attitude of realistic hope to help her deal with helpless feelings.

A patient presents to the health center and the nurse practitioners assessment reveals an enlarged thyroid. The nurse practitioner believes the thyroid cells may be undergoing hyperplasia. How would the nurse practitioner explain this condition to the patient?

Hyperplasia is an abnormal increase in new cells and is reversible with the stimulus for cell growth removed.

The nurse is with a patient who has learned that he has glioblastoma multiforme, a brain tumor associated with an exceptionally poor prognosis. His heart rate increases, his eyes dilate, and his blood pressure increases. The nurse recognizes these changes as being attributable to what response?

Sympathetic nervous response

You are the nurse caring for a 72-year-old woman who is recovering from a hemicolectomy on the postsurgical unit. The surgery was very stressful and prolonged, and you note on the chart that her blood sugars are elevated, yet diabetes does not appear in her previous medical history. To what do you attribute this elevation in blood sugars?

The blood sugars are probably a result of the fight-or-flight reaction.

A patient tells the nurse that she does not like to go to the doctor and is feeling anxious about being in this place. When the nurse checks her blood pressure, it is elevated along with her heart rate. The nurse rechecks her blood pressure about 10 minutes later and it is normal. The patient asks the nurse if she should be concerned that she may have hypertension. What statement should guide the nurses response?

The first blood pressure was part of a simple stress response; our long-term blood pressure is controlled by negative feedback systems

A mother has brought her young son to the emergency department (ED). The mother tells the triage nurse that the boy was stung by a bee about an hour ago. The mother explains to the nurse, It hurts him so bad and it looks swollen, red, and infected. What can the triage nurse teach the mother?

The pain, redness, and swelling are part of the inflammatory process, but it is probably too early for an infection.