N266 EXAM 3 ch 24-26, 33-37, 42, 45-47

10. The nurse uses silence as a therapeutic communication technique. What are the purposes of the nurse's silence? (Select all that apply.) CH 24 1. Allows the nurse time to focus and avoid saying the wrong thing 2. Prompts the patient to talk when he or she is ready 3. Allows the patient time to think and gain insight 4. Allows time for the patient to drift off to sleep 5. Determines whether the patient would prefer to talk with another staff member

10. Answer: 2, 3. Silence can provide that patient an opportunity to think and gain insight. Often the patient feels compelled to break the silence and is prompted to talk.

10. A 53-year-old female being treated for breast cancer tells the nurse that she has no interest in sex since her surgery 2 months ago. The nurse is aware that: (Select all that apply.) CH 34 1. Sexual issues are expected in a woman this age. 2. Women experience sexual dysfunction more frequently than men. 3. Hypoactive sexual desire disorder (HSDD) occurs in women over 65 years of age. 4. Medical conditions such as cancer often contribute to HSDD. 5. Disturbances in self-concept affect sexual functioning

10. Answer: 2, 4, 5. Women of all ages (not just older women) can experience reduced sexual desire or libido. Biological, organic, or psychosocial factors; pain; depression; and body image concerns can result in sexual problems in men and women. Sexual dysfunction is common in men and women, but it occurs more frequently in women. Self-concept issues, including changes in body image, identity, and role performance, can impact self-esteem and sexual functioning

8. A 34-year-old single father who is anxious, tearful, and tired from caring for his three young children tells the nurse that he feels depressed and doesn't see how he can go on much longer. Which statement would be the nurse's best response? CH 37 1. "Are you thinking of suicide?" 2. "You've been doing a good job raising your children. You can do it!" 3. "Is there someone who can help you during the evenings and weekends?" 4. "Tell me what you mean when you say you can't go on any longer."

. Answer: 4. You need to get information about what the gentleman means when he says he can't go on any longer. He might be thinking of turning his children over to a grandparent or seeking other child-care arrangements. Asking about suicide initially might be premature. Asking "Are you thinking of suicide?" prematurely might shut the patient down entirely. If the patient talks about suicide, for safety reasons it is very important to further discuss his suicidal thoughts and refer to the appropriate health care professional. Asking the open-ended question provides an opportunity to understand what the person is thinking and open lines of communication.

1. To best assist a patient in the grieving process, which factors are most important for the nurse to assess? (Select all that apply.) CH 36 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

1. 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

1. An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.) CH 42 1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 3. Roller clamp wide open 4. Tubing kinked in bedrails 5. Circulatory overload

1. Answer: 1, 2, 4. Factors that could slow an IV infusion even if the infusion pump is set correctly include increased pressure at the outflow site (e.g., infiltration) and compression of the tubing lumen (e.g., patient lying on the tubing or tubing kinked in bedrails).

1. 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? CH 35 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

1. 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

1. The nurse is caring for a client with pneumonia, who has severe malnutrition. The nurse should assess the patient for which of the following assessment findings? (Select all that apply.) CH 45 1. Heart disease 2. Sepsis 3. Hemorrhage 4. Skin breakdown 5. Diarrhea

1. Answer: 2, 3, 4. Patients who are malnourished on admission are at greater risk of life-threatening complications such as arrhythmia, skin breakdown, sepsis, or hemorrhage during hospitalization.

1. The nurse contacts a provider about a change in a patient's condition and receives several new orders for the patient over the phone. When documenting telephone orders in the electronic health record, most hospitals require a nurse to do which of the following? CH 26 1. Print out a copy of all telephone orders entered into the electronic health record in order to keep them in personal records for legal purposes. 2. "Read back" all telephone orders to the provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the electronic health record. 3. Record telephone orders in the electronic health record, but wait to implement the order(s) until they are electronically signed by the health care provider who gave them. 4. Implement telephone order(s) immediately, but insist that the health care provider come to the patient care unit to personally enter the order(s) into the electronic health record within the next 24 hours.

1. Answer: 2. Guidelines from TJC require a "read-back" on all telephone (and verbal) orders. The nurse reads a telephone order back word for word and receives confirmation that the order is correct from the health care provider who gave the order.

1. A patient asks a nurse to provide instruction on how to perform a breast self-exam. Which domains are required to learn this skill? (Select all that apply.) CH 25 1. Affective domain 2. Sensory domain 3. Cognitive domain 4. Attentional domain 5. Psychomotor domain

1. Answer: 3 and 5. For a patient to perform a breast self-exam it will be necessary to understand the purpose of the exam and why it is performed the way it is. Cognitive learning in this scenario involves a patient acquiring information to further develop his or her understanding and thinking processes so that the patient can make a decision based on a self-exam finding. Psychomotor learning in this case involves actual use of the hands to palpate in symmetrical areas of the breast correctly. Affective domain does not apply unless the nurse decides the patient's values prevent self-exam adherence. There are no attentional or sensory learning domains. 2. Answer: 2. T

1. The nurse is interviewing a patient in the community clinic and gathers the following information about her: she is intermittently homeless, a single parent with two children who have developmental delays. She has had asthma since she was a teenager. She does not laugh or smile, does not volunteer any information, and at times appears close to tears. She has no support system and does not work. She is experiencing an allostatic load. As a result, which of the following would be present during complete patient assessment? (Select all that apply.) CH 37 1. Post-traumatic stress disorder 2. Rising hormone levels 3. Chronic illness 4. Insomnia 5. Depression

1. Answer: 3, 4, 5. An increased allopathic load can result in longterm physiological and psychological problems such as chronic illness, depression, sleep deprivation, chronic fatigue syndrome, and autoimmune disorders. Post-traumatic stress disorder results from a single traumatic event. Hormone levels rise in the alarm stage.

1. A 16-year-old female tells the school nurse that she doesn't need the human papillomavirus (HPV) vaccine since her partner always uses condoms. The best response by the nurse to this statement is:CH 34 1. "Latex condoms are the most effective way to eliminate the risk of HPV transmission." 2. "Your parents may not want you to receive the HPV vaccine since it has been shown to increase sexual risk taking and sexual activity." 3. "The HPV 9-valent vaccine is recommended for males and females even if they use condoms because it targets the specific viruses that cause cancer and genital warts." 4. "You are past the recommended age to receive the vaccine."

1. Answer: 3. An HPV vaccine that protects both men and women against the types of HPV that cause serious health issues is available and recommended for individuals ages 11 to 26. The use of latex condoms reduces the risk of contracting a sexually transmitted infection (STI), but abstinence is the only practice that eliminates the risk. Longitudinal research indicates that vaccination does not increase sexual risk-taking behaviors among youths and is safe.

1. A 50-year-old woman is recovering from a bilateral mastectomy. She refuses to eat, discourages visitors, and pays little attention to her appearance. One morning the nurse enters the room to see the patient with her hair combed and makeup applied. Which of the following is the best response from the nurse? CH 33 1. "What's the special occasion?" 2. "You must be feeling better today." 3. "This is the first time I've seen you look this good." 4. "I see that you've combed your hair and put on makeup."

1. Answer: 4. When the nurse uses a matter-of-fact approach and acknowledges a change in the patient's behavior or appearance, it allows the patient to establish its meaning. Telling the patient she has never looked this good conveys criticism; making assumptions about it being a special occasion or about an obvious improvement in mood superimposes the nurse's opinion and limits the assessment.

10. Which actions by the nurse help grieving families? (Select all that apply.) CH36 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.

10. 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.

10. A crisis intervention nurse is working with a mother whose child with Down syndrome has been hospitalized with pneumonia and who has lost her child's disability payment while the child is hospitalized. The mother worries that her daughter will fall behind in her classes during hospitalization. Which strategies are effective in helping this mother cope with these stressors? (Select all that apply.) CH 37 1. Referral to social service process reestablishing the child's disability payment 2. Sending the child home in 72 hours and having the child return to school 3. Coordinating hospital-based and home-based schooling with the child's teacher 4. Teaching the mother signs and symptoms of a respiratory tract infection 5. Telling the mother that the stress will decrease in 6 weeks when everything is back to normal

10. Answer: 1, 3, 4. The stressors for this parent are her child's illness, missing school, and loss of disability payments. Obtaining resources to resolve these stressors will reduce the mother's stress load and allow her to focus on helping her child improve and on preventing another respiratory tract infection. Discharging the child in 72 hours with a return to school may not be best for the child's physical condition and may make the situation worse. Giving the mother a 6-week time frame is unrealistic because everyone's time frame is different. The mother may also need to adjust.

10. 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.) CH 35 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.

10. 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.

10. A patient is receiving total parenteral nutrition (TPN). What are the primary interventions the nurse should follow to prevent a central line infection? (Select all that apply.) CH 45 1. Change the dressing using sterile technique. 2. Change TPN containers every 48 hours. 3. Change the TPN tubing every 24 hours. 4. Monitor glucose levels to watch and assess for glucose intolerance. 5. Elevate head of the bed 45 degrees to prevent aspiration

10. Answer: 1, 3. The central line is inserted into a large vein that leads to the superior vena cava. This increases risk for infection. Therefore to prevent infection, change the TPN infusion tubing every 24 hours. Do not hang a single container of PN for more than 24 hours or lipids more than 12 hours. Use sterile technique during central line dressing changes (see Chapter 42). Monitoring glucose levels and elevating the head of bed are not interventions that will prevent central line infections.

10. When assessing a patient's adjustment to the role changes brought about by a medical condition such as a stroke, the nurse asks about which of the following? (Select all that apply.) CH 33 1. What are your thoughts about returning to work? 2. What questions do you have about your medications? 3. How has your health affected your relationship with your partner? 4. What level of physical activity are you able to perform? 5. What concerns do you have about another stroke?

10. Answer: 1, 3. The nurse must assess role performance as related to professional identity (work) and personal relationships (partner). The other questions are important, but not related to self-concept

10. Which of the following scenarios demonstrate that learning has taken place? (Select all that apply.) 1. A patient listens to a nurse's review of the warning signs of a stroke. 2. A patient describes how to set up a pill organizer for newly ordered medicines. 3. A patient attends a spinal cord injury support group. 4. A patient demonstrates how to take his blood pressure at home. 5. A patient reviews written information about resources for cancer survivors.

10. Answer: 2, 4. Steps 2 and 4 are examples of patients exhibiting behaviors that demonstrate learning. The other three steps are examples of patient involvement in instruction

10. Which assessment does the nurse use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit? CH 42 1. Dryness of mucous membranes 2. Skin turgor 3. Fullness of neck veins when supine 4. Fullness of neck veins when upright

10. Answer: 3. ECV deficit involves decreased vascular and interstitial volume. One way to assess vascular volume is to examine the fullness of neck veins when an individual is supine. With normal ECV, neck veins are full when the individual is supine. With ECV deficit, they are flat

10. The nurse is changing the dressing over the midline incision of a patient who had surgery. Assessment of the incision reveals changes from what was documented by the previous nurse. After documenting the current wound assessment, the nurse contacts the surgeon (Dr. Oakman) by telephone to discuss changes in the incision that are of concern. Which of the following illustrates the most appropriate way for the nurse to document this conversation? CH 26 1. Health care provider notified about change in assessment of abdominal incision. T. Wright, RN 2. 09-3-18: Notified Dr. Oakman by phone that there is a new area of redness around the patient's incision. T. Wright, RN 3. 1015: Contacted Dr. Oakman and notified about changes in abdominal incision. T. Wright, RN 4. 09-3-18 (1015): Dr. Oakman contacted by phone. Notified about new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN

10. Answer: 4. This statement includes the date and time the health care provider was contacted, the specific name of the health care provider, descriptive details of the changes of concern noted in the patient assessment, whether any orders were received, and the name and credentials of the nurse who contacted the health care provider.

2. The nurse is working in an agency that has recently implemented an electronic health record. Which of the following are acceptable practices for maintaining the security and confidentiality of electronic health record information? (Select all that apply.) CH 26 1. Using a strong password and changing your password frequently according to agency policy 2. Allowing a temporary staff member to use your computer user name and password to access the electronic record 3. Ensuring that work lists (and any other data that must be printed from the electronic health record) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed 4. Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other health care providers who are not involved in that patient's care 5. Remaining logged in to a computer to save time if you only need to step away to administer a medication

2. Answer: 1, 3, 4. Mechanisms to protect the privacy and confidentiality of protected health information in the electronic health record include: not sharing passwords, not leaving computers with open electronic health records unattended, and preventing those not involved with a patient's care from seeing information displayed on a monitor.

2. An adolescent who is pregnant for the first time is at her initial prenatal visit. The women's health nurse practitioner (WHNP) informs the patient that she will be screening her for sexually transmitted infections (STIs). The patient replies, "I know I don't have an STI because I don't have any symptoms." Which responses by the WHNP would be appropriate? (Select all that apply.) CH34 1. "Untreated STIs can cause serious complications in pregnancy, so we routinely screen pregnant women." 2. "Bacterial STIs don't usually cause symptoms, or you could have an asymptomatic viral STI." 3. "Chlamydia screening is recommended for all sexually active women up to age 25 even if asymptomatic." 4. "People between the ages of 15 and 24 are often asymptomatic and have the highest incidence of STIs." 5. "There is no need to screen for infection since you aren't having any problems or symptoms."

2. Answer: 1, 3, 4. Serious complications can result from untreated STIs in pregnancy, complications such as preterm labor, rupture of membranes, and premature delivery of the newborn. The risk of untreated STIs in any female is pelvic inflammatory disease, which, if untreated, can cause serious problems such as infertility. Routine screening for chlamydia is recommended for all sexually active women up to age 25. Many people do not know they are infected because they do not experience symptoms. Bacterial STIs are more likely to cause symptoms, whereas viral STIs are often asymptomatic.

2. The nurse is evaluating the recent lab results for a patient. Which labs are the best indicators for malnutrition? (Select all that apply.) CH 45 1. Serum total protein 2. Potassium 3. Lipids 4. Albumin 5 Serum BUN

2. Answer: 1, 5. When a client is malnourished, he or she is in a state of negative nitrogen balance—meaning, the body is experiencing protein loss and requires more protein to maintain healing. Therefore, total protein will indicate the amount of muscle breakdown and protein loss. Albumin is a serum binding protein, and lower levels can be an indicator of malnutrition, but it is really more indicative of inflammation or kidney and liver disease. As a result, this is not the gold standard for diagnosing malnutrition. BUN is also an indicator because urea is the end product of protein metabolism, and when a patient is not getting enough protein, you will see a decreased BUN.

2. A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1c, a measure of blood sugar control over the past 90 days, has increased by saying, "The hemoglobin A1c is wrong. My blood sugar levels have been excellent for the last 6 months." Which defense mechanism is the patient using? CH 37 1. Denial 2. Conversion 3. Dissociation 4. Displacement

2. Answer: 1. Denial is avoiding emotional stress by refusing to consciously acknowledge anything that causes intolerable anxiety. This patient's statements reflect denial about poorly controlled blood sugars.

2. 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. CH 35 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?

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

2. 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.) CH 36 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.

2. 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.

2. A patient suddenly experiences a severe headache with numbness and decreased movement in the left arm. The emergency room physician suspects a stroke and is going to have the patient undergo an emergent angiogram to remove the clot. Which teaching approach is most appropriate? CH 25 1. Selling approach 2. Telling approach 3. Entrusting approach 4. Participating approach

2. Answer: 2. Telling is the best approach when there is limited time for teaching information.

2. A 30-year-old patient diagnosed with major depressive disorder has a nursing diagnosis of Situational Low Self-Esteem related to negative view of self. Which of the following are appropriate interventions by the nurse? (Select all that apply.) CH 33 1. Encourage reconnecting with high school friends. 2. Role-play to increase assertiveness skills. 3. Focus on identifying strengths and accomplishments. 4. Provide time for journaling to explore underlying thoughts and feelings. 5. Explore new job opportunities.

2. Answer: 3, 4. Focusing on strengths and accomplishments to minimize the emphasis on failures helps the patient alter distorted and negative thinking. Journaling can allow a patient to explore thoughts and feelings that can promote insight and eventual behavioral change. The other interventions represent the nurse imposing ideas on what needs to occur for the patient to be healthier; allowing the patient to direct the change process is important.

2. The nurse assesses pain and redness at a vascular access device (VAD) site. Which action is taken first? CH 42 1. Apply a warm, moist compress. 2. Aspirate the infusing fluid from the VAD. 3. Report the situation to the health care provider. 4. Discontinue the intravenous infusion.

2. Answer: 4. Pain and redness at a VAD site are indicators of phlebitis. When phlebitis occurs, the infusion must be stopped and the VAD removed as the highest priority.

3. The nurse recognizes that which factors influence a person's approach to death? (Select all that apply.) CH 36 1. Culture 2. Spirituality 3. Personal beliefs 4. Previous experiences with death 5. Gender 6. Level of education

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

3. A patient who is depressed is crying and verbalizes feelings of low self-esteem and self-worth, such as "I'm such a failure ... I can't do anything right." What is the nurse's best response? CH 33 1. Remain with the patient until he or she validates feeling more stable. 2. Tell the patient that is not true and that every person has a purpose in life. 3. Review recent behaviors or accomplishments that demonstrate skill ability. 4. Reassure the patient that you know how he or she is feeling and that things will get better.

3. Answer: 1. Demonstrating acceptance of the patient by supportively sitting with him or her builds a therapeutic nurse-patient relationship. The nurse's presence signals value and allows the patient to explore issues of self-concept and self-esteem. In contrast, giving false hope is neither therapeutic nor conveys acceptance, while focusing on skill ability signals conditional approval.

3. A nurse is caring for a young patient who has been told he has multiple sclerosis. The nurse has planned time to conduct a teaching session that will focus on the disease and principles of management. The nurse chooses to use the EDUCATE model to proceed with instruction. Which of the following are components of the model? (Select all that apply.) CH 25 1. State goals of the session for the patient. 2. Repeat the most important information. 3. Practice empathetic skills. 4. Be aware of nonverbal messages. 5. Use a standard question list for the chosen topic.

3. Answer: 2, 3, 4. Repetition of important information, using empathetic skills, and being aware of nonverbal messages are all a part of the EDUCATE model. The nurse is not the source of the goals for a teaching session. Ask patients to state their goals of care to begin a discussion. A standard list of questions may not be relevant to a patient. A more patient-centered approach is to use a question list that includes questions patients can ask so that providers can answer them.

3. When delegating input and output (I&O) measurement to assistive personnel, the nurse instructs them to record what information for ice chips? CH 42 1. Two-thirds of the volume 2. One-half of the volume 3. One-quarter of the volume 4. Two times the volume

3. Answer: 2. When ice chips melt, their water volume is one-half the volume of the ice chips. The water volume should be recorded as intake.

3. A nurse who recently graduated from nursing school is providing discharge instructions to a patient who suffered a myocardial infarction (MI). The nurse knows that sexual issues are common after an MI but feels uncomfortable bringing up this topic. What is the best way for the nurse to handle this situation? (Select all that apply.) CH 34 1. Instruct the patient to discuss any sexual concerns with his or her partner after discharge. 2. Avoid discussing the topic unless the patient brings it up. 3. Ask a more experienced nurse to cover this with the patient and learn from the example. 4. Plan to attend conferences or training soon on how to discuss such issues. 5. Encourage the patient to discuss any personal concerns with the cardiologist.

3. Answer: 3, 4. Nurses often avoid discussing sexual issues with patients because they are uncomfortable, lack knowledge, or have personal values in conflict with the patients' values. Nurses who have difficulty addressing sexual issues need to seek education and experiences to increase knowledge and explore their personal values.

3. When documenting an assessment of a patient's cardiac system in an electronic health record, the nurse uses the computer mouse to select the "WNL" statement to document the following findings: "Heart sounds S1 & S2 auscultated. Heart rate between 80-100 beats per minute, and regular. Denies chest pain." This is an example of using which of the following documentation formats? CH 26 1. Focus charting incorporating "Data, Action & Response" (DAR) 2. Problem-intervention-evaluation (PIE) 3. Charting-by-exception (CBE) 4. Narrative documentation

3. Answer: 3. Charting-by-exception (CBE) is a unique documentation format designed with the philosophy that all standards are met unless otherwise documented. Many computerized nursing documentation systems have incorporated a CBE design. Exception-based documentation systems incorporate clearly defined criteria for nursing assessment and documentation of "normal" findings. Predefined statements used to document "normal" assessment of body systems are called "within defined limits" (WDL) or "within normal limits" (WNL) definitions. They consist of written criteria for a "normal" assessment for each body system. Automated documentation within a computerized documentation system allows nurses to select a WNL (or WDL) statement or to choose other statements from a drop-down menu.

3. Which statement made by a patient who is recovering after recently experiencing third-degree burns shows connectedness? CH 35 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."

3. 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.

3. The nurse is caring for a client with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? CH 45 1. Suction her mouth and throat. 2. Turn her on her side. 3. Put on oxygen at 2 L nasal cannula. 4. Stop feeding her.

3. Answer: 4. Stop feeding and then place patient on side. If choking persists, suction airway. Notify health care provider. Keep patient NPO.

3. When assessing a young woman who was a victim of a home invasion 3 months earlier, the nurse learns that the woman has vivid images of the event whenever she hears loud yelling or a sudden noise. The nurse recognizes this as ____________. CH 37

3. Answer: Post-traumatic stress disorder (PTSD). PTSD originates with a person's experiencing or witnessing a traumatic event and responding with intense fear or helplessness. The home break-in is the traumatic event that is causing intense fear and/or flashbacks when the noises of the break-in are replicated.

4. A nurse is teaching an older adult patient about ways to detect a melanoma. Which of the following are age-appropriate teaching techniques for this patient? (Select all that apply.) CH 25 1. Speak in a low tone. 2. Begin and end the session with the most important information regarding melanoma. 3. Provide a pamphlet about melanoma with large font in blues and greens. 4. Provide specific information in frequent, small amounts for older adult patients. 5. Speak quickly so that you do not take up much of the patient's time.

4. Answer: 1, 2, 4. Lower tones are easier for patients with hearing deficits to hear. Reinforce important information at the beginning and end of each teaching session to enhance understanding. Providing information in small amounts helps the older adult understand information better. A pamphlet should be written in a color that contrasts with the background (e.g., black 14-point print on matte white paper). Blues and greens are hard to distinguish. Take your time with an older adult. Speaking quickly can easily lead to misunderstanding.

4. While assessing an older woman who is recently widowed, the nurse suspects that this woman is experiencing a developmental crisis. Which questions provide information about the impact of this crisis? (Select all that apply.) CH 37 1. With whom do you talk on a routine basis? 2. What do you do when you feel lonely? 3. Tell me what your husband was like. 4. I know this must be hard for you. Let me tell you what might help. 5. Have you experienced any changes in lifestyle habits, such as sleeping, eating, smoking, or drinking?

4. Answer: 1, 2, 5. A developmental crisis occurs as a person moves through the stages of life, including widowhood. It is important to gather information about how this crisis affects the woman's interactions, how she is currently coping with loneliness, and any changes in her lifestyle habits. Although losing her husband is a source of stress, discussing him now does not focus on her current situation. Saying "I know this must be hard for you. Let me tell you what might help" is unacceptable because the purpose of assessment is to gather data and let the patient tell his or her story

4. A 20-year-old patient diagnosed with an eating disorder has a nursing diagnosis of Situational Low Self-Esteem. Which of the following nursing interventions are appropriate to address self-esteem? (Select all that apply.) CH 33 1. Offer independent decision-making opportunities. 2. Review previously successful coping strategies. 3. Provide a quiet environment with minimal stimuli. 4. Support a dependent role throughout treatment. 5. Increase calorie intake to promote weight stabilization.

4. Answer: 1, 2. Offering opportunities for decision making promotes a sense of control, which is essential for promoting independence and enhancing self-esteem. Reviewing successful coping strategies is also a priority intervention to signal previous mastery and promote effective coping in an individual with self-esteem issues. The amount of stimuli is unrelated to self-esteem. Promoting independence is an important part of treatment. Although weight stabilization may be needed, it is likely to have a negative effect on self-esteem early in treatment.

4. What assessments does a nurse make before hanging an intravenous (IV) fluid that contains potassium? (Select all that apply.) CH 42 1. Urine output 2. Arterial blood gases 3. Fullness of neck veins 4. Serum potassium laboratory value in EHR 5. Level of consciousness

4. Answer: 1, 4. Increased potassium intake when potassium output is decreased or during hyperkalemia are major risks for hyperkalemia. Before increasing IV potassium intake, check to see that urine output is normal and that the serum potassium level in the health record is not above normal.

4. A client who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What should be the nurse's priority action? CH 45 1. Have the patient turn on the left side and perform a Valsalva maneuver. 2. Clamp the intravenous (IV) tubing to prevent more air from entering the line. 3. Have the patient take a deep breath and hold it. 4. Notify the health care provider immediately.

4. Answer: 1. Turn the patient on his or her left side to prevent air from entering the left side of the heart. Then have the patient perform a Valsalva maneuver (holding the breath and "bearing down").

4. The nurse is gathering a history from a 72-year-old male patient being admitted to a nursing home. The patient requests a private room. The nurse understands that: CH 34 1. The patient cannot be sexually active since he is moving into a nursing home. 2. The patient may be requesting a private room to facilitate an intimate relationship with his partner. 3. There is no need to take a sexual history since most older adults are uncomfortable discussing intimate details of their lives. 4. Older adults in nursing homes usually do not participate in sexual activity.

4. Answer: 2. Studies have shown an increase in sexual dysfunction with aging but no decrease in sexual activity or interest. Sometimes sexual health is not addressed by the nurse, but it is important to include a sexual history as a routine aspect of assessment to communicate that sexual activity is normal. Long-term care facilities need to make arrangements to allow for continuation of sexual experiences of residents as long as no health risks are involved.

4. The nurse works at an agency where military time is used for documentation, and needs to document that a patient was transported to the operating room for an emergency procedure at 8 in the evening. Point to the area on the clockface below that indicates 8 in the evening in military time: CH 26 GRAPH

4. Answer: 2000. The military clock begins at 1 minute after midnight as 0001 and ends with midnight at 2400. Noon is 1200. 1 pm is 1300, 2 pm is 1400, 3 pm is 1500, and so on.

4. 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? CH 35 1. Small container of vanilla ice cream 2. A dozen red grapes 3. Bacon and eggs 4. Garden salad with ranch dressing

4. Answer: 3. Islam prohibits the consumption of pork.

4. 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? CH 36 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.

4. 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.

5. The nurse can increase a patient's self-awareness and self-concept through which of the following actions? (Select all that apply.) CH 33 1. Helping the patient define personal problems clearly 2. Allowing the patient to openly explore thoughts and feelings 3. Reframing the patient's thoughts and feelings in a more positive way 4. Having family members assume more responsibility during times of stress 5. Recommending self-help reading materials

5. Answer: 1, 2, 3. Helping a patient define problems clearly, allowing him or her to openly explore thoughts and feelings, and reframing his or her thoughts and feelings in a more positive way are designed to promote self-awareness and a positive self-concept. Having the family assume more responsibility does not help a patient achieve self-awareness; instead it is important to encourage the patient to assume more self-responsibility. The nurse should refrain from offering self-help reading materials unless directly asked; the nurse should then provide numerous options.

5. The nurse is providing education on sexually transmitted infections (STIs) to a group of older adults. The nurse knows that further teaching is needed when the participants make which statements? (Select all that apply.) CH 34 1. "I don't need to use condoms since there is no risk for pregnancy." 2. "I should be screened for an STI each time I'm with a new partner." 3. "I know I'm not infected because I don't have discharge or sores." 4. "I was tested for STIs last year, so I know I'm not infected." 5. "The infection rate in older adults is low because most are not sexually active."

5. Answer: 1, 3, 4, 5. One of the challenges in reducing the incidence of STIs is that most STIs have few symptoms in males or females. Asymptomatic STIs can be diagnosed during a physical examination with appropriate laboratory tests. Older adults may engage in risky sexual behaviors because of lack of knowledge about STIs and condom usage. Research indicates that older adults are remaining sexually active longer than previously believed and the incidence of STI and human immunodeficiency virus (HIV) infections has steadily increased for the past 12 years. Screening after each new sex partner is the most effective method to detect and manage STIs, so this statement shows understanding of the teaching by the patient.

5. The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following? (Select all that apply.) CH 37 1. Loss of autonomy caused by health problems 2. Physical appearance and body image 3. Accepting one's personal identity 4. Separation from family 5. Taking tests in school

5. Answer: 2, 3, 4, 5. As adolescents search for identity with peer groups and separate from their families, they also experience stress. In addition, they face stressful questions about sex, jobs, school, career choices, and using mind-altering substances. During this stage of development, stress can occur because of a preoccupation with appearance and body image. A loss of autonomy caused by health problems usually applies to the older adult.

5. 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.) CH 35 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."

5. 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.

5. The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate does the nurse program into the infusion pump? CH 42 1. 100 mL/hr 2. 125 mL/hr 3. 167 mL/hr 4. 200 mL/hr

5. Answer: 2. To infuse 500 mL in 4 hours, set the rate at 125 mL/hr. (500 divided by 4 = 125)

5. A 55-year-old adult male has been in the hospital over a week following surgical complications. The patient has had limited activity but is now finally ordered to begin a mobility program. The patient just returned from several diagnostic tests and tells the nurse he is feeling quite fatigued. The nurse prepares to instruct the patient on the mobility program protocol. Which of the following learning principles will likely be affected by this patient's condition? CH 25 1. Motivation to learn 2. Developmental stage 3. Stage of grief 4. Readiness to learn

5. Answer: 4. A patient's readiness to learn is affected by his or her attentional set. Physical discomfort, fatigue, anxiety, confusion, and environmental distractions influence the ability to concentrate and learn.

5. A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request a discontinuation of parenteral nutrition? CH 45 1. When 25% of the patient's nutritional needs are met by the tube feedings 2. When bowel sounds return 3. When the central line has been in for 10 days 4. When 75% of the patient's nutritional needs are met by the tube feedings

5. Answer: 4. When meeting 75% of nutritional needs by enteral feedings or reliable dietary intake, it is usually safe to discontinue PN therapy.

5. The nurse who works at the local hospital is transferring a patient to an acute rehabilitation center in another town. To complete the transfer, information from the patient's electronic health record must be printed and faxed to the acute rehabilitation center. Which of the following actions is most appropriate for the nurse to take to maintain privacy and confidentiality of the patient's information when faxing this information? (Select all that apply.) CH 26 1. Confirm that the fax number for the acute rehabilitation center is correct before sending the fax. 2. Use the encryption feature on the fax machine to encode the information and make it impossible for staff at the acute rehabilitation center to read the information unless they have the encryption key. 3. Fax the patient's information without a cover sheet so that the person receiving the information at the acute rehabilitation center can identify it more quickly. 4. After sending the fax, place the information that was printed out in a standard trash can after ripping it into several pieces. 5. After sending the fax, place the information that was printed out in a secure canister marked for shredding.

5. Answers: 1, 2, 5. Nurses have the legal and ethical obligation to safeguard any patient information that is printed or extracted from the electronic (or paper) health record. Best practice is to use all measures to fax information securely, and to shred any printed health record material after it has been used for the purpose intended.

6. The nurse is providing community education about how the sexual response changes with age. Which statement made by one of the adults indicates the need for further information? CH 34 1. "Health problems such as diabetes, chronic obstructive pulmonary disease, and hypertension have little effect on sexual functioning and desire." 2. "It usually takes longer for both sexes to reach an orgasm." 3. "Most of the normal changes in function are related to alteration in circulation and hormone levels." 4. "Many medications can interfere with sexual function."

6. Answer: 1. Pathological processes can interfere with sexual function and desire. Changes in circulation, neurological pathways, and hormone levels account for many of the normal physiological changes that occur with the aging process. Common medications such as diuretics, antihypertensives, antianxiety medications, and antidepressants can contribute to sexual dysfunction. Older males and females take longer to reach orgasm, and the refractory period lengthens.

6. Which of the following assessment findings suggest an altered self-concept? (Select all that apply.) CH 33 1. Uneven gait 2. Slumped posture and poor personal hygiene 3. Avoidance of eye contact when answering a question 4. Requests for visits from the chaplain 5. Frequent use of the call light

6. Answer: 2, 3. Common assessment findings for an individualwith altered self-concept can mirror depressive symptoms, such as slumped posture, poor hygiene, and avoiding intermittent eye contact.An individualwith an unsteady or uneven gait may have successfully adjusted to an underlying condition; this does not automatically signal an altered self-concept. Requests for spiritual support and nursing care should be honored and are not related to an altered self-concept.

6. A 10-year-old girl was playing on a slide at a playground during a summer camp. She fell and broke her arm. The camp notified the parents and took the child to the emergency department according to the camp protocol for injuries. The parents arrive at the emergency department and are stressed and frantic. The 10-yearold is happy in the treatment room, eating a Popsicle and picking out the color of her cast. List in order of priority what the nurse should say to the parents. CH 37 1. "Can I contact someone to help you?" 2. "Your daughter is happy in the treatment room, eating a Popsicle and picking out the color of her cast." 3. "I'll have the doctor come out and talk to you as soon as possible." 4. "I want to be sure you are ok. Let's talk about what your concerns are about your daughter before we go see her."

6. Answer: 2, 4, 3, 1. First and most important the parents need to know the immediate status of their daughter. Letting them know the situation will help to relieve their immediate stress. Second, helping the parents discuss their concerns will reduce their stress and will allow them to see their daughter without increasing the 10-year-old's anxiety. Third, let the parents know that you recognize their need to talk to the doctor as soon as possible and that you will act as their advocate to get that accomplished. Last, but also important, you want to ask whether there is anyone you can call to help. There may be children who need to be picked up from camp/ day care, for example, and a neighbor or grandparent may be able to assist.

6. 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.) CH 36 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.

6. 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

6. 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? CH 35 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.

6. 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.

6. An older-adult patient is receiving intravenous (IV) 0.9% NaCl. The nurse detects new onset of crackles in the lung bases. What is the priority action? CH 42 1. Notify a health care provider. 2. Decrease the IV flow rate. 3. Lower the head of the bed. 4. Discontinue the IV site.

6. Answer: 2. When an IV fluid is infusing, monitor for excess infusion. Crackles in the lung bases are an indication of ECV excess. For patient safety, the IV flow rate must be decreased immediately. Then notify the health care provider

6. A client is receiving an enteral feeding at 65 mL/hr. The gastric residual volume in 4 hours was 125 mL. What is the priority nursing intervention? CH 45 1. Assess bowel sounds. 2. Raise the head of the bed to at least 45 degrees. 3. Continue the feedings; this is normal gastric residual for this feeding. 4. Hold the feeding until you talk to the primary care provider.

6. Answer: 3. Delayed gastric emptying is a concern if 250 mL or more remains in a patient's stomach on two consecutive assessments (1 hour apart) or if a single GRV measurement exceeds 500 mL. Therefore the best action is to continue the tube feedings at this time.

6. A patient recovering from open heart surgery is taught how to cough and deep breathe using a pillow to support or splint the chest incision. Following the teaching session, which of the following is the best way for the nurse to evaluate whether learning has taken place? CH 25 1. Verbalization of steps to use in splinting 2. Selecting from a series of flash cards the images showing the correct technique 3. Return demonstration 4. Cloze test

6. Answer: 3. Return demonstration permits a patient to perform a skill as the nurse observes. It provides excellent feedback and reinforcement.

6. The nurse is administering a dose of metoprolol to a patient, and is completing the steps of bar code medication administration within the EHR. As the bar code information on the medication is scanned, an alert that states "Do not administer dose if apical heart rate (HR) is <60 beats/minute or systolic blood pressure (SBP) is <90 mm Hg" appears on the computer screen. The alert that appeared on the computer screen is an example of what type of system? CH 26 1. Electronic health record (EHR) 2. Charting by exception 3. Clinical decision support system (CDSS) 4. Computerized physician order entry (CPOE)

6. Answer: 3.Computer decision support systems(CDSS) are computerized programs that prompt health care providers with clinical knowledge and relevant patient information that assists with clinical decision making. A nursing CDSS uses a complex system of rules to analyze data and provide alerts to support clinical decisions made by nurses.

7. The nurse applying effective communication skills throughout the nursing process should: (Place the following interventions in the correct order.) CH 24 1. Validate health care needs through verbal discussion with the patient. 2. Compare actual and expected patient care outcomes with the patient. 3. Provide support through therapeutic communication techniques. 4. Complete a nursing history using verbal communication techniques.

7. 4, 1, 3, 2. The correct order for the nurse to communicate with the patient is to first complete the history (part of assessment), then corroborate findings through a validation process. After this, the nurse would use therapeutic communication to address needs, and finally would complete an evaluation process to see whether the actual outcomes matched the expected outcome.

7. When planning care for a dying patient, which interventions promote the patient's dignity? (Select all that apply.) CH 36 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

7. 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.

7. The nurse is gathering a sexual health history on a patient being admitted to the hospital for surgery. Which question demonstrates a nonjudgmental attitude? CH 34 1. Can you tell me your sexual orientation? 2. How do you and your wife feel about intimacy? 3. Do you have sex with men, women, or both? 4. Do you have sexual intercourse at your age? 8. The nurse reviews the health history of a 48-yea

7. Answer: 1. A nonjudgmental attitude facilitates trust and open communication between the nurse and patient. Using a term such as sexual orientation and asking about preferred pronouns allows the patient to identify his or her unique sexuality and sexual health needs.

7. Which action can a nurse delegate to assistive personnel (AP)? CH 45 1. Performing glucose monitoring every 6 hours on a patient 2. Teaching the client about the need for enteral feeding 3. Administering enteral feeding bolus after tube placement has been verified 4. Evaluating the client's tolerance of the enteral feeding

7. Answer: 1. The skills of measuring blood glucose level after skin puncture (capillary puncture) can be delegated to AP. The nurse needs to administer enteral feeding because of the risk of aspiration. The nurse is responsible for teaching the client and evaluating the tolerance to the enteral feeding.

7. A patient's cultural background affects the motivation for learning. Using the ACCESS model, match the nursing approach with the correct model component. CH 25 ACCESS model component 1. Assessment 2. Communication 3. Cultural 4. Establishment 5. Sensitivity 6. Safety Nursing approach A. Help patients feel culturally secure and able to maintain their cultural identity. B. Remain aware of verbal and nonverbal responses. C. Be aware of how patients from diverse backgrounds perceive their care needs. D. Become aware of your patient's culture and your own cultural biases. E. Learn about the patient's health beliefs and practices. F. Show respect by creating a caring rapport.

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

7. 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.) CH 35 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.

7. 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.

7. When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, what is the first assessment the nurse conducts? CH 37 1. The amount of family support 2. A 3-day diet recall 3. A thorough physical assessment 4. Threats to safety in her home

7. Answer: 3. Stress often causes symptoms similar to physical illnesses. Physical causes for problems need to be investigated and treated before treatment for stress-related symptoms can be initiated.

7. The home health nurse is visiting a 90-year-old man who lives with his 89-year-old wife. He is legally blind and is 3 weeks' post right hip replacement. He ambulates with difficulty with a walker. He comments that he is saddened now that his wife has to do more for him and he is doing less for her. Which of the following is the priority nursing diagnosis? CH 33 1. Impaired Self Toileting 2. Lack of Knowledge Regarding Resources for the Visually Impaired 3. Disturbed Body Image 4. Risk for Situational Low Self-Esteem

7. Answer: 4. Blindness coupled with difficulty ambulating places him at risk for situational low self-esteem. He and his wife most likely have adapted to the blindness, but his difficulty with ambulation affects many aspects of his life, including self-esteem. However, this low self-esteem is situational; as his mobility improves, his low self-esteem will also resolve. Nothing in the question itself suggests that the other diagnoses are true.

7. Place the following steps for discontinuing intravenous (IV) access in the correct order: CH 42 1. Perform hand hygiene and apply gloves. 2. Explain procedure to patient. 3. Remove IV site dressing and tape. 4. Use two identifiers to ensure correct patient. 5. Stop the infusion and clamp the tubing. 6. Carefully check the health care provider's order. 7. Clean the site, withdraw the catheter, and apply pressure.

7. Answer: 6, 4, 2, 1, 5, 3, 7. A health care provider's order is necessary before discontinuing IV access, unless there is a complication such as infiltration or phlebitis. Identifying the patient and explaining the procedure are performed before hand hygiene and glove application in order to maintain clean gloves. Removing the site dressing before stopping the infusion and then withdrawing the catheter keeps the VAD patent without forming a clot that could embolize during catheter withdrawal.

7. The nurse is writing a narrative progress note. Identify each of them following statements as subjective data (S) or objective data (O): CH 26 1. April 24, 2019 (0900) 2. Repositioned patient on left side. 3. Medicated with hydrocodone-acetaminophen 5/325 mg, 2 tablets PO. 4. "The pain in my incision increases every time I try to turn on my right side." 5. S. Eastman, RN 6. Surgical incision right lower quadrant, 3 inches in length, well approximated, sutures intact, no drainage 7. Rates pain 7/10 at location of surgical incision.

7. Answer: O: 1, 2, 3, 5, 6, 7. S: 4. Statement 4 is the only example of a subjective statement. All other statements in the list are objective data. Logical order for placement of these statements includes "1, 4, 6, 7, 3, 2, and 5." The date and time of a narrative note are recorded first, followed by information from the patient that informs clinical decisions, followed by assessment data, and interventions made. A narrative note is closed with the nurse's signature (first initial, last name, credentials).

8. 8. A nurse works with a patient using therapeutic communication and the phases of the therapeutic relationship. Place the nurse's statements in order according to these phases. CH 24 1. The nurse states, "Let's work on learning injection techniques." 2. The nurse is mindful of his/her own biases and knowledge in working with the patient with B12 deficiency. 3. The nurse summarizes progress made during the nursing relationship. 4. After providing introductions, the nurse defines the scope and purpose of the nurse-patient relationship

8. 2, 4, 1, 3. In the therapeutic relationship the nurse begins by understanding the self (preinteraction), then provides introductions, followed by a working phase and finally termination and summarization.

8. A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions? (Select all that apply.) CH 42 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increased fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights

8. Answer: 1, 4. Hypokalemia causes bilateral skeletal muscle weakness, especially in the quadriceps, which creates a risk for falling. Hypokalemia also causes gastrointestinal smooth muscle weakness, which produces constipation.

8. A nurse is working with an older adult who recently moved to an assisted-living center because of declining physical capabilities associated with the normal aging process. Which nursing interventions are directed at promoting self-esteem in this patient? CH 33 1. Commending the patient's efforts at completing self-care tasks 2. Assuming that the patient's physical complaints are attention-seeking measures 3. Minimizing time discussing memories and past achievements spent with the patient 4. Limiting decision-making opportunities for the patient to reduce stress

8. Answer: 1. Reinforce efforts to complete tasks, allowing additional time to complete tasks if needed and support efforts directed at independence. This fosters self-esteem and confidence. It is important for the nurse to refrain from assumptions, as in assuming that physical complaints are attention seeking or that limiting decisions will reduce stress. Time should be allocated to review of past accomplishments and memories.

8. The nurse reviews the health history of a 48-year-old man and notes that he was started on medications for elevated blood pressure and depression at his last annual physical. He tells the nurse that over the past 6 months he is having difficulty sustaining an erection. The nurse understands that: (Select all that apply.) CH 34 1. Nurses are not expected to discuss sexual issues with male patients and the physician should address this. 2. Sexual function can be affected by some medications. 3. Sexually transmitted infections (STIs) can cause complications such as erectile dysfunction and screening should be done. 4. Some men with health issues experience erectile dysfunction. 5. Medications used to treat hypertension and depression seldom interfere with sexual function.

8. Answer: 2, 4. Nurses should complete a holistic assessment on all patients to be able to personalize a plan of care. Nurses who are uncomfortable discussing sexual concerns of patients should seek out training and resources to develop this skill. Many drugs and illnesses can affect sexual function. Antidepressants can alter sexual functioning by blocking neurotransmitters. Antihypertensives can affect sexual function by altering circulation. Erectile dysfunction occurs more frequently in older men but can occur in men as young as 40. STIs may affect sexual functioning but are less likely than medications or illness to be the cause of erectile dysfunction.

8. What are the physical circulatory changes that occur as death approaches? CH 36 1. Skin irritation 2. Mottling 3. Increased urine output 4. Weakness

8. 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.

8. 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.) CH 35 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.

8. 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.

8. A 63-year-old woman is a family caregiver for her 88-year-old mother who has dementia. The caregiver asked the home health nurse how to manage her mother when she becomes confused and violent. The best instructional method a nurse can use for this situation is: CH 25 1. Demonstration 2. Preparatory instruction 3. Role-playing 4. Group instruction with other family caregivers

8. Answer: 3. Role-playing is effective in teaching a person how to respond to another person's behavior. The technique involves rehearsing a desired behavior. Preparatory instruction is for an individual who is about to undergo a procedure that typically causes anxiety. Demonstration is used when psychomotor skills are being taught. Group instruction would be useful as a way for the caregiver to discuss problems confronted during caregiving but is less effective for responding to a specific behavior.

8. The nurse is discussing the advantages of using computerized provider order entry (CPOE) with a nursing colleague. Which statement best describes the major advantage of a CPOE system within an electronic health record? CH 26 1. CPOE reduces the time necessary for health care providers to write orders. 2. CPOE reduces the time needed for nurses to communicate with health care providers. 3. Nurses do not need to acknowledge orders entered by CPOE in an electronic health record. 4. CPOE improves patient safety by reducing transcription errors.

8. Answer: 4. Although the other answers loosely describe some positive aspects of CPOE, option 4 provides the best description of the major advantage CPOE offers—the reduction of transcription errors, which reduces medical errors and creates a safer patient care environment.

8. Which statement made by the parents of a 2-month-old infant requires further education by the nurse? CH 45 1. "I'll continue to use formula for the baby until he is at least a year old." 2. "I'll make sure that I purchase iron-fortified formula." 3. "I'll start feeding the baby cereal at 4 months." 4. "I'm going to alternate formula with whole milk, starting next month."

8. Answer: 4. Infants should not have regular cow's milk during the first year of life. It is too concentrated for the infant's kidneys to manage. There is also an increased risk for developing milk-product allergies.

9. The school nurse is counseling an adolescent male who is returning to school after attempting suicide. He denies substance abuse and has no history of treatment for depression. He says he has no friends or family who understand him. Critical thinking encourages the nurse to consider all possibilities, including which of the following? (Select all that apply.) CH 34 1. Adolescents often explore their sexual identity and expose themselves to complications such as sexually transmitted infections (STIs) or unplanned pregnancy. 2. Peer approval and acceptance are not important in this agegroup. 3. Lesbian, gay, bisexual, and transgender (LGBTQ+) youth often experience stress from identification with a sexual minority group. 4. Knowledge about normal changes associated with puberty and sexuality can decrease stress and anxiety. 5. Adolescence is a time of emotional stability and self-acceptance.

9. Answer: 1, 3, 4. Adolescents are establishing their identity and exploring their sexual preference. Those who identify with a sexual minority group often experience stress and isolation from peers. They need clear and accurate information about physiological and emotional changes occurring in their body. Peer influence is high during this time, but support from family and health care professionals is equally important to adolescents.

9. Which strategies should a nurse use to facilitate a safe transition of care during a patient's transfer from the hospital to a skilled nursing facility? (Select all that apply.) CH 24 1. Collaboration between staff members from sending and receiving departments 2. Requiring that the patient visit the facility before a transfer is arranged 3. Using a standardized transfer policy and transfer tool 4. Arranging all patient transfers during the same time each day 5. Relying on family members to share information with the new facility

9. Answer: 1, 3. Providing a standardized process, policy, and tool can assist in a predictable, safe transfer of important patient information between health care facilities. Communication and collaboration between the sender and receiver of information enable the staff to validate that the information was received and understood. Requiring a patient visit is not always necessary, and relying on family members to share information does not release staff from their responsibilities. Doing patient transfers on the same day and time has no effect on creating a safe patient transfer.

9. A nurse is caring for a 40-year-old male diagnosed with Crohn's disease several years ago, resulting in numerous hospitalizations each year for the past 3 years. Which of the following behaviors interfere with the developmental tasks of middle adulthood? (Select all that apply.) CH 33 1. Sends birthday cards to friends and family 2. Refuses visitors while hospitalized 3. Self-absorbed in physical and psychological issues 4. Performs self-care activities 5. Communicates feelings of inadequacy

9. Answer: 2, 3, 5. Developmental tasks of adulthood can be impacted by chronic illness. Self-absorption and the refusal to stay connected with others are of concern to the nurse, as are verbalizations of inadequacy. Staying in touch with friends and performing self-care behaviors demonstrate developmental mastery of adulthood.

9. A nurse sees an assistive personnel (AP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention by the nurse? CH 45 1. Fastening tube to the gown with new tape 2. Placing client supine while giving a bath 3. Monitoring the client's weight as ordered 4. Ambulating patient with enteral feedings still infusing

9. Answer: 2. A patient receiving continuous enteral feedings should never be placed supine because it increases the risk for pulmonary aspiration. If the nurse needs to lay the patient in the supine position, the feedings should be stopped and restarted when the head of the bed is at 45 degrees.

9. The nurse is evaluating how well a patient newly diagnosed with multiple sclerosis and psychomotor impairment is coping. Which statements indicate that the patient is beginning to cope with the diagnosis? (Select all that apply.) CH 37 1. "I'm going to learn to drive a car, so I can be more independent." 2. "My sister says she feels better when she goes shopping, so I'll go shopping." 3. "I'm going to let the occupational therapist assess my home to improve efficiency." 4. "I've always felt better when I go for a long walk. I'll do that when I get home." 5. "I'm going to attend a support group to learn more about multiple sclerosis."

9. Answer: 3, 5. Inviting the occupational therapist into the patient's home and attending support groups are early indicators that the patient is recognizing some of the challenges of the disease and participating in positive realistic activities to cope with the stressors related to changes in physical functioning. The other options relate to independence and other coping strategies but do not address coping with the specific challenges of the disease.

9. When providing postmortem care, which actions are necessary for the nurse to complete? CH 36 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

9. 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.

9. A nurse is preparing to teach a patient who has sleep apnea how to use a CPAP machine at night. Which action is most appropriate for the nurse to perform first? 1. Allow patient to manipulate machine and look at parts. 2. Provide a teach-back session. 3. Set mutual goals for the education session. 4. Discuss the purpose of the machine and how it works.

9. Answer: 3. Planning should occur before any form of implementation or evaluation. The nurse should build from simple to more complex information. Learning about the purpose of the machine and how it works is basic information needed for the patient to understand and be motivated to use it. Allowing the patient to manipulate the machine will precede instruction on its actual use. Teach-back will inform the nurse as to the patient's level of learning.

9. 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? CH 35 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?

9. 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

9. A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and HCO3-, 24. How does the nurse interpret these laboratory values? CH 42 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

9. Answer: 3. The pH is abnormally low, which indicates acidosis. The PaCO2 is high, which indicates respiratory acidosis. The HCO3 - is in the normal range, which indicates an acute respiratory acidosis that has not had time for renal compensation. The low PaO2 and the severe dyspnea and wheezing are consistent with this interpretation.

9. The nurse is reviewing health care provider orders that were handwritten on paper when all computers were down during a system upgrade. Which of the following orders contain an inappropriate abbreviation included on The Joint Commission's "Do Not Use" list and should be clarified with the health care provider? CH 26 1. Change open midline abdominal incision daily using wet-tomoist normal saline and gauze. 2. Lorazepam 0.5 mg PO every 4 hours prn anxiety 3. Morphine sulfate 1 mg IVP every 2 hours prn severe pain 4. Insulin aspart 8u SQ every morning before breakfast

9. Answer: 4. In option 4, the word "unit(s)" should be written out because the letter "u" can be mistaken for "0," the number "4," or "cc." The other orders are written appropriately.

5. Which comments to a patient by a new nurse regarding palliative care needs are correct? (Select all that apply.) CH 36 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.

Nurses must communicate effectively with the health care team for which of the following reasons? (Select all that apply.) CH. 24 1. Improve the nurse's status with the health team members 2. Reduce the risk of errors to the patient 3. Provide optimum level of patient care 4. Improve patient outcomes 5. Prevent issues that need to be reported to outside agencies

Answer: 1, 3, 4. Communication techniques such as assessing the need for adaptive equipment, keeping communication short and direct, and giving the patient time to respond assist the nurse in providing clear, effective communication. Patients may have difficulty with rapid or lengthy explanations. Exaggerated lip movements may be difficult to interpret or demeaning to individuals with hearing deficits.

Motivational Interviewing (MI) is a technique that applies understanding a patient's values and goals in helping the patient make behavioral changes. When using motivational interviewing, which outcome does the nurse expect? (Select all that apply.) CH 24 1. Gaining an understanding of the patients motivations 2.directing the patient to avoid poor heath choices. 3.recognizing the patients strengths and supporting his or her efforts 4. providing assessment date that can be shared with the families to promote change. 5. identifying differences in patient's goals health goals and current behaviors.

Answer: 1, 3, 5. Motivational interviewing is a technique used to promote an understanding of the patient's motivations, health goals, and current behaviors in a nonjudgmental environment while focusing on the patient's strengths and efforts. The nurse provides a supportive approach to assist the patient in establishing and promoting positive health care changes.

6. The patient states, "I don't have confidence in my doctor. She looks so young." The nurse therapeutically responds: (Select all that apply.) CH 24 1. Tell me more about your concern. 2. You have nothing to worry about. Your doctor is perfectly competent. 3. You are worried about your care? 4. You can go online and see how others have rated your doctor. I do that. 5. You should ask your doctor to tell you her background.

Answer: 1, 3.The nurse responding to the patient's concern about the physician's age would not disagree with the patient by simply claiming the doctor was competent but would rather ask questions to elicit more information about the area of concern, such as asking a broader question about concerns. Telling the patient to look the physician up online or advising the patient to query the physician directly are ways that the nurse unhelpfully gives advice to the patient.

The nurse therapeutically responds to an adult patient who is anxious by: (Select all that apply.) CH 24 1. Matching the rate of speech to be the same as that of the patient 2. Providing good eye contact 3. Demonstrating a calm presence 4. Spending time attentively with the patient 5. Assuring the patient that all will be well

Answer: 2, 3, 4. An adult patient who is anxious is reassured by the nurse who demonstrates good eye contact and a calm presence. Also, when the adult is anxious, remaining supportively present and calm assists the patient to begin to experience less anxiety. Telling the patient all will be well is false reassurance, and the nurse may escalate the patient's anxiety if the nurse's speech is speeded up to match the patient's speech.

When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply) CH 24 1. Check for needed adaptive equipment. 2.Exaggerate lip movements to help the patient lip-read. 3. Give the patient time to respond to the questions. 4. keep communication short and to the point. 5. Communicate only through written information.

Answer: 2, 3, 4. Effective communication in health care has been linked to a decrease in medical errors and an improvement in quality of care and patient outcomes. The status of the nurse or the prevention of reportable issues is not the focus of communication with patients.

5. A nurse prepares to contact a patient's physician about a change in the patient's condition. Put the following statements in the correct order using SBAR (Situation, Background, Assessment, and Recommendation) communication. CH 24 1. "She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on levofloxacin at 5 pm yesterday. She states she has a poor appetite; her weight has remained stable over the past 2 days." 2. "The patient reported feeling very nauseated after her dose of levofloxacin an hour ago." 3. "Is it possible to make a change in antibiotics, or could we give her a nutritional supplement before her medication?" 4. "The patient started to complain of nausea yesterday evening and has vomited several times during the night.

Answer: 4S, 1B, 2A, 3R. The nurse describes the patient's complaint of nausea and vomiting to the physician (Situation). Specific patient demographic information and reason for admission with current symptomology are provided (Background). The physician is informed of the patient's complaint of nausea after receiving levofloxacin (Assessment). Physician is asked if he or she would like to make a change in the antibiotic or provide a nutritional supplement before medication administration (Recommendation).