NUR3632 Foundations Exam 3 Study

9. A patient diagnosed with breast cancer who is in the end stages of her illness has been in the medical intensive care unit for 3 weeks. Her husband tells the nurse caring for the patient that he and his wife often talked about the end of her life and that she was very clear about not wanting aggressive treatment that would merely prolong her dying. The nurse and husband both agree that this seems to be all that therapy is now doing for her. The nurse would suggest that the husband speak to his wife's physician about which type of order? Comfort-measures-only Do-not-hospitalize Do-not-resuscitate Slow-code-only

9. a. Comfort-measures-only order. The wife would want all aggressive treatment to be stopped at this point and all care to be directed to a comfortable, dignified death.

Chapter 7 1. A state attorney decides to charge a nurse with manslaughter for allegedly administering a lethal medication. This is an example of what type of law? Public law Private law Civil law Criminal law

1. d. Criminal law concerns state and federal criminal statutes, which define criminal actions such as murder, manslaughter, criminal negligence, theft, and illegal possession of drugs. Public law regulates relationships between people and the government. Private or civil law includes laws relating to contracts, ownership of property, and the practice of nursing, medicine, pharmacy, and dentistry.

11. To promote sleep in a patient, a nurse suggests what intervention? Follow the usual bedtime routine if possible. Drink two or three glasses of water at bedtime. Have a large snack at bedtime. Take a sedative-hypnotic every night at bedtime.

11. a. Keeping the same bedtime schedule helps promote sleep. Drinking two or three glasses of water at bedtime will probably cause the patient to awaken during the night to void. A large snack may be uncomfortable right before bedtime; instead, a small protein and carbohydrate snack is recommended. Taking a sedative-hypnotic every night disturbs REM and NREM sleep, and sedatives also lose their effectiveness quickly.

11. Mr. Wright is recovering from abdominal surgery. When the nurse assists him to walk, she observes that he grimaces, moves stiffly, and becomes pale. She is aware that he has consistently refused his pain medication. What would be a priority nursing diagnosis for this patient? Acute Pain related to fear of taking prescribed postoperative medications Impaired Physical Mobility related to surgical procedure Anxiety related to outcome of surgery Risk for Infection related to surgical incision

11. a. Mr. Wright's immediate problem is his pain that is unrelieved because he refuses to take his pain medication for an unknown reason. The other nursing diagnoses are plausible, but not a priority in this situation.

11. A college freshman away from home for the first time says, "Why did I have to be born into a family of big bottoms and short fat legs! No one will ever ask me out for a date. Oh, why can't I have long thin legs like everyone else in my class? What a frump I am." Answer: _______________

11. b. Clearly, this patient's concern is with body image.

11. All of the following diagnoses may apply to a young couple who gave birth to a premature infant with serious respiratory problems who has been in the neonatal intensive care unit for the last 3 months. The couple has a 22-month-old son at home. Which diagnosis would be most appropriate based on the following assessment data: report of chronic fatigue and decreased energy, guilt about neglecting son at home, shortness of temper with one another, and apprehension about continued ability to go on this way? Grieving Ineffective Coping Caregiver Role Strain Powerlessness

11. c. The defining characteristics for the NANDA diagnosis Caregiver Role Strain fit the set of assessment data provided.

12. A nurse formulates the following diagnosis for an elderly patient who is having trouble getting to sleep at night: Disturbed Sleep Pattern: Initiation of Sleep. Which of the following nursing interventions would the nurse perform related to this diagnosis? Select all that apply. Arrange for assessment for depression and treatment. Discourage napping during the day. Decrease fluids during the evening. Administer diuretics in the morning. Encourage patient to engage in some type of physical activity. Assess medication for side effects of sleep pattern disturbances.

12. a, b, e, f. For patients who are having trouble initiating sleep, the nurse should arrange for assessment for depression and treatment, discourage napping, promote activity, and assess medications for sleep disturbance side effects. Limiting fluids and administering diuretics in the morning are appropriate interventions for Disturbed Sleep Pattern: Maintaining Sleep.

14. The family of a patient who has just died asks to be alone with the body and asks for supplies to wash the body. The nurse providing care knows that the mortician usually washes the body. Which response would be most appropriate? Inform the family that there is no need for them to wash the body since the mortician typically does this. Explain that hospital policy forbids their being alone with the deceased patient and that hospital supplies are to be used only by hospital personnel. Give the supplies to the family but maintain a watchful eye to make sure that nothing unusual happens. Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help.

14. d. The family may want to wash the body for personal, religious, or cultural reasons and should be allowed to do so.

14. A pregnant woman is receiving an epidural analgesic prior to delivery. The nurse provides vigilant monitoring of this patient to prevent the occurrence of: Pruritus Urinary retention Vomiting Respiratory depression

14. d. Too much of an opioid drug given by way of an epidural catheter or a displaced catheter may result in the occurrence of respiratory depression. Pruritus, urinary retention, and vomiting may occur but are not life threatening.

2. A nurse asks a 25-year-old patient to make a list of 20 words that describe him. After 15 minutes, the patient listed the following: 25 years old, male, named Joe; then declared he couldn't think of anything else. The nurse documents that the patient has demonstrated: Lack of self-esteem Deficient self-knowledge Unrealistic self-expectation Inability to evaluate himself

2. b. The patient's inability to list more than three items about himself indicates deficient self-knowledge. There are not enough data provided to determine whether he lacks self-esteem, has unrealistic self-expectations, or is unable to evaluate himself.

3. A nurse asks a patient to close her eyes, state when she feels something, and describe the feeling. The nurse then brushes the patient's skin with a cotton ball, and touches the patient's skin with both sides of a safety pin. Which sense is the nurse assessing? Gustatory Olfactory Tactile Kinesthetic

3. c. The nurse is assessing for tactile (touch) disturbances by brushing the skin with a cotton ball and touching the skin with a safety pin. Gustatory disturbances involve taste, olfactory disturbances involve the sense of smell, and kinesthetic disturbances are related to body positioning.

3. Those bringing the charges against Jean are called: Appellates Defendants Plaintiffs Attorneys

3. c. The person or government bringing suit against another is called the plaintiff. Appellates are courts of law, defendants are the ones being accused of a crime or tort, and attorneys are the lawyers representing both the plaintiff and defendant.

3. A nurse is teaching a 50-year-old male patient how to care for his new ostomy appliance. Which teaching aid would be most appropriate to confirm that the patient has learned the information? Ask Me 3 Newest Vital Sign Teach-back tool TEACH acronym

3. c. The teach-back tool is a method of assessing literacy and confirming that the learner understands health information received from a health professional. The Ask Me 3 is a brief tool intended to promote understanding and improve communication between patients and their providers. The Newest Vital Sign (NVS) is a reliable screening tool to assess low health literacy, developed to improve communications between patients and providers. The TEACH acronym is used to maximize the effectiveness of patient teaching by tuning into the patient, editing patient information, acting on every teaching moment, clarifying often, and honoring the patient as a partner in the process.

3. A nurse asks the same patient in question 2 to list facts, traits, or qualities that he would like to be descriptive of himself. The patient quickly lists 25 traits, all of which are characteristic of a successful man. When asked if he knows anyone like this, he replies, "My father." This discrepancy between the patient's description of himself as he is and as he would like to be indicates: Negative self-concept Joe's modesty (lack of conceit) Body image disturbance Low self-esteem

3. d. Low self-esteem is characterized by great discrepancy between the ideal and real selves. There are no data given here that suggest that Joe has either a negative self-concept or a body image disturbance. The data do indicate something more serious than modesty.

4. A nurse is counseling a husband and wife who have decided that the wife will get a job so that the husband can go to pharmacy school, as he has wanted to do for some time. Their three teenagers, who were involved in the decision, are also getting jobs to buy their own clothes. The husband plans to work 12 to 16 hours weekly and states, "I was always an A student, but I may have to settle for Bs now because I don't want to neglect my family, and I need to work a few hours so that my wife won't have to work overtime." How would the nurse document the husband's self-expectations? Realistic and positively motivating his development Unrealistic and negatively motivating his development Unrealistic but positively motivating his development Realistic but negatively motivating his development

4. a. The patient's self-expectations are realistic, given his multiple commitments, and seem to be positively motivating his development.

4. A home health care nurse has been visiting a patient with AIDS who says, "I'm no longer afraid of dying. I think I've made my peace with everyone, and I'm actually ready to move on." This reflects the patient's progress to which stage of death and dying? Acceptance Anger Bargaining Denial

4. a. The patient's statement reflects the acceptance stage of death and dying defined by Kübler-Ross.

5. If review of this patient's record revealed that she had never consented to the eye surgery, of which intentional tort might the surgeon have been guilty? Assault Battery Invasion of privacy False imprisonment

5. b. Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Battery is an assault that is carried out. Every person is granted freedom from bodily contact by another person unless consent is granted. The Fourth Amendment gives citizens the right of privacy and the right to be left alone; a nurse who disregards these rights is guilty of invasion of privacy. Unjustified retention or prevention of the movement of another person without proper consent can constitute false imprisonment.

5. Which action would be most important for a nurse to include in the plan of care for a patient who is 85 years old and has presbycusis? Obtaining large-print written material Speaking distinctly, using lower frequencies Decreasing tactile stimulation Initiating a safety program to prevent falls

5. b. Presbycusis is a normal loss of hearing as a result of the aging process. Speaking distinctly in lower frequencies is indicated. The other choices refer to interventions for other sensory problems.

5. A professional nurse with a commitment to social justice is most apt to: Provide honest information to patients and the public Promote universal access to health care Plan care in partnership with patients Document care accurately and honestly

5. b. The American Association of Colleges of Nursing lists promoting universal access to health care as an example of social justice. Providing honest information and documenting care accurately and honestly are examples of integrity, and planning care in partnership with patients is an example of autonomy.

5. A nurse is visiting a male patient with pancreatic cancer who is dying at home. During the visit, he breaks down and cries and tells the nurse that it is unfair that he should have to die now when he's finally made peace with his family and wants to live. Which response by the nurse would be most appropriate? "You can't be feeling this way. You know you are going to die." "It does seem unfair. Tell me more about how you are feeling." "You'll be all right; who knows how much time any of us has" "Tell me about your pain. Did it keep you awake last night?"

5. b. The nurse would want to validate that what the patient is saying has been heard and invite him to share more of his feelings, concerns, and fears.

5. A school nurse is teaching parents how to foster a healthy development of self in their children. Which statement made by one of the parents needs to be followed up with further teaching? "I love my child so much I 'hug him to death' every day." "I think children need challenges, don't you?" "My husband and I both grew up in very restrictive families. We want our children to be free to do whatever they want." "My husband and I have different ideas about discipline, but we're talking this out because we know it's important for Johnny that we be consistent."

5. c. Each option with the exception of c correctly addresses some aspect of fostering healthy development in children. Because children need effective structure and development, giving them total freedom to do as they please may actually hinder their development.

5. A nurse is discussing with an older female patient the factors that affect sleep. What fact does the nurse teach her? Drinking a cup of regular tea at night induces sleep. Using alcohol moderately promotes a deep sleep. Aging decreases the amount of REM sleep a person experiences. Exercising decreases REM and NREM sleep.

5. c. The nurse would teach the patient that the amount of REM sleep decreases with age. Regular tea contains caffeine and increases alertness. Large quantities of alcohol limit REM and delta sleep. Physical activity increases both REM and NREM sleep.

Chapter 42 1. A nurse midwife is assisting a patient to deliver a full-term baby. The patient is firmly committed to natural childbirth and has attended each natural childbirth class in preparation for labor and delivery. A cesarean delivery becomes necessary when her fetus displays signs of distress. Inconsolable, the patient cries and calls herself a failure as a mother. The nurse notes that the patient is experiencing what type of loss? Select all that apply. Actual Perceived Psychological Anticipatory Physical Maturational

1. a, b, c. The loss experienced by the woman is actual, perceived, and psychological. Actual loss can be recognized by others as well as by the person sustaining the loss, perceived loss is experienced by the person but is intangible to others, and psychological loss is a loss that is felt mentally as opposed to physically. Anticipatory loss occurs when one grieves prior to the actual loss, physical loss is loss that is tangible and perceived by others, and maturational loss is experienced as a result of natural developmental processes.

Chapter 6 1. A nurse caring for patients in the intensive care unit develops values from experience to form a personal code of ethics. Which statements best describe a characteristic of the development of a personal value system? Select all that apply. People are born with values. Values act as standards to guide behavior. Values are ranked on a continuum of importance. Values influence beliefs about health and illness. Value systems are not related to personal codes of conduct. Nurses should not let their values influence patient care.

1. b, c, d. A value is a belief about the worth of something, about what matters, which acts as a standard to guide one's behavior. A value system is an organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct. A person's values influence beliefs about human needs, health, and illness; the practice of health behaviors; and human responses to illness. Values guide the practice of nursing care. An individual is not born with values; rather, values are formed during a lifetime from information from the environment, family, and culture.

Chapter 34 1. A nurse instructor is teaching a class of student nurses about the nature of pain. Which statements accurately describe this phenomenon? Select all that apply. Pain is whatever the physician treating the pain says it is. Pain exists whenever the person experiencing it says it exists. Pain is an emotional and sensory reaction to tissue damage. Pain is a simple, universal, and easy-to-describe phenomenon. Pain that occurs without a known cause is psychological in nature. Pain is classified by duration, location, source, transmission, and etiology.

1. b, c, f. Margo McCaffery (1979, p. 11) offers the classic definition of pain that is probably of greatest benefit to nurses and their patients: "Pain is whatever the experiencing person says it is, existing whenever he (or she) says it does." The International Association for the Study of Pain (IASP) further defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage (IASP, 1994). Pain is an elusive and complex phenomenon, and despite its universality, its exact nature remains a mystery. Pain is present whenever a person says it is, even when no specific cause of the pain can be found. Pain may be classified according to its duration, its location or source, its mode of transmission, or its etiology.

Chapter 43 1. A nurse who is assessing an older female patient in a long-term care facility notes that the patient is at risk for sensory deprivation related to severe rheumatoid arthritis limiting her activity. Which interventions would the nurse recommend based on this finding? Select all that apply. Use a lower tone when communicating with the patient. Provide interaction with children and pets. Decrease environmental noise. Ensure that the patient shares meals with other patients. Discourage the use of sedatives. Provide adequate lighting and clear pathways of clutter.

1. b, d, e. For a patient who has sensory deprivation, the nurse should provide interaction with children and pets, ensure that the patient shares meals with other patients, and discourage the use of sedatives. Using a lower tone of voice is appropriate for a patient who has a hearing deficit, decreasing environmental noise is an intervention for sensory overload, and providing adequate lighting and removing clutter is an intervention for a vision deficit.

Chapter 33: 1. A nurse assesses a patient's body temperature in the late afternoon as 37.2°C (99°F). What would be the nurse's best action related to this slight elevation in temperature? Assess the patient for infection. Record the temperature as a normal finding. Call the physician for an order for antipyretics. Decrease the room temperature.

1. b. A slight increase in body temperature in the late afternoon is the result of a normal circadian rhythm and does not need to be reported unless it becomes higher. This slight variation from normal does not necessarily mean an infection is present. A warm environment might cause an elevation in body temperature, but the most likely cause is normal circadian rhythm.

Chapter 21 1. A nurse is teaching first aid to counselors of a summer camp for children with asthma. This is an example of what aim of health teaching? Promoting health Preventing illness Restoring health Facilitating coping

1. b. Teaching first aid is a function of the goal to prevent illness. Promoting health involves helping patients to value health and develop specific health practices that promote wellness. Restoring health occurs once a patient is ill, and teaching focuses on developing self-care practices that promote recovery. When facilitating coping, nurses help patients come to terms with whatever lifestyle modification is needed for their recovery or to enable them to cope with permanent health alterations.

Chapter 40 1. A nurse is performing a psychological assessment of a 19-year-old male patient who has Down syndrome. The patient is mildly developmentally disabled with an intelligence quotient of 82. He told his nurse, "I'm a good helper. You see I can carry these trays because I'm so strong. But I'm not very smart, so I have just learned to help with the things I know how to do." The patient most likely has which of the following? Negative self-concept and low self-esteem Negative self-concept and high self-esteem Positive self-concept and fairly high self-esteem Positive self-concept and low self-esteem

1. c. The data point to the patient having a positive self-concept ("I'm a good helper") and fairly high self-esteem (realizes his strengths and limitations). The statement "But I'm not very smart" is accurate and is not an indication of a negative self-concept.

10. A nurse is preparing a family for a terminal weaning of a loved one. Which nursing actions would facilitate this process? Select all that apply. Participate in the decision-making process by offering the family information about the advantages and disadvantages of continued ventilatory support. Explain to the family what will happen at each phase of the weaning and offer support. Check the orders for sedation and analgesia, making sure that the anticipated death is comfortable and dignified. Tell the family that death will occur almost immediately after the patient is removed from the ventilator. Tell the family that the decision for terminal weaning of a patient must be made by the primary care provider. Set up mandatory counseling sessions for the patient and family to assist them in making this end-of-life decision.

10. a, b, c. A nurse's role in terminal weaning is to participate in the decision-making process by offering helpful information about the benefits and burdens of continued ventilation and a description of what to expect if terminal weaning is initiated. Supporting the patient's family and managing sedation and analgesia are critical nursing responsibilities. In some cases, competent patients decide that they wish their ventilatory support ended; more often, the surrogate decision makers for an incompetent patient determine that continued ventilatory support is futile. Because there are no guarantees how any patient will respond once removed from a ventilator, and because it is possible for the patient to breathe on one's own and live for hours, days, and, rarely, even weeks, the family should not be told that death will occur immediately. Counseling sessions may be arranged if requested but are not mandatory to make this decision

10. A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply. Daily mental activities Daily physical activities Morning and evening body temperature Daily measurement of fluid intake and output Presence of anxiety or worries affecting sleep Morning and evening blood pressure readings

10. a, b, e. A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure is not usually kept in a sleep diary.

10. A student nurse begins a clinical rotation in a long-term care facility and quickly realizes that certain residents have unmet needs. The student wants to advocate for these residents. Which statements reflect a correct understanding of advocacy? Select all that apply. Advocacy is the protection and support of another's rights. Patient advocacy is primarily done by nurses. Patients with special advocacy needs include the very young and the elderly, those who are seriously ill, and those with disabilities. Nurse advocates make good health care decisions for patients and residents. Nurse advocates do whatever patients and residents want. Effective advocacy may entail becoming politically active.

10. a, c, f. Advocacy is the protection and support of another's rights. Among the patients with special advocacy needs are the very young and the elderly, those who are seriously ill, and those with disabilities; this is not a comprehensive list. Effective advocacy may entail becoming politically active. Patient advocacy is the responsibility of every member of the professional caregiving team—not just nurses. Nurse advocates do not make health care decisions for their patients and residents. Instead, they facilitate their decision making. Advocacy does not entail supporting patients in all their preferences.

10. The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient? CRIES scale COMFORT scale FLACC scale FACES scale

10. a. The CRIES Pain Scale is a tool intended for use with neonates and infants from 0 to 6 months. The COMFORT Scale, used to assess pain and distress in critically ill pediatric patients, relies on six behavioral and two physiologic factors that determine the level of analgesia needed to adequately relieve pain in these children. The FLACC scale (F—Faces, L—Legs, A—Activity, C—Cry, C—Consolability) was designed for infants and children from age 2 months to 7 years who are unable to validate the presence or severity of pain. The FACES scale is used for children who can compare their pain to the faces depicted on the scale.

10. A nurse who is caring for a morbidly obese male teenager forms a contractual agreement with him to achieve his weight goals. Which statement best describes the nature of this agreement? "This agreement forms a legal bond between the two of us to achieve your weight goals." "This agreement will motivate the two of us to do what is necessary to meet your weight goals." "This agreement will help us determine what learning outcomes are necessary to achieve your weight goals." "This agreement will limit the scope of the teaching session and make stated weight goals more attainable."

10. b. A contractual agreement is a pact two people make setting out mutually agreed-on goals. Contracts are usually informal and not legally binding. When teaching a patient, such an agreement can help motivate both the patient and the teacher to do what is necessary to meet the patient's learning outcomes. The agreement notes the responsibilities of both the teacher and the learner, emphasizing the importance of the mutual commitment.

10. A nursing student asks the charge nurse about legal liability when performing clinical practice. Which statement regarding liability is true? Students are not responsible for their acts of negligence resulting in patient injury. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. Hospitals are exempt from liability for student negligence if the student nurse is properly supervised by an instructor. Most nursing programs carry group professional liability making student personal professional liability insurance

10. b. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. Student nurses are responsible for their own acts of negligence if these result in patient injury. A hospital may also be held liable for the negligence of a student nurse enrolled in a hospital-controlled program because the student is considered an employee of the hospital. Nursing instructors may share responsibility for damages in the event of patient injury if an assignment called for clinical skills beyond a student's competency or the instructor failed to provide reasonable and prudent clinical supervision. Most nursing programs require students to carry personal professional liability insurance.

10. A sophomore in high school has missed a lot of school this year because of leukemia. He said he feels like he is falling behind in everything and misses "hanging out at the mall" with his friends most of all. Answer: _______________

10. d. Important roles for this patient are being a student and a friend. His illness is preventing him from doing either of these well. This self-concept disturbance is basically one that concerns role performance.

12. A nurse is caring for terminally ill patients in a hospital setting. Which example describes appropriate end-of-life care? To eliminate confusion, taking care not to speak too much when caring for a comatose patient Sitting on the side of the bed of a dying patient, holding the patient's hand, and crying with the patient Referring to a counselor the daughter of a dying patient who is complaining about the care associated with artificially feeding her father Telling a dying patient to sit back and relax and performing patient hygiene for the patient because it is easier than having the patient help

12. b. The nurse should not be afraid to show compassion and empathy for the dying person, including crying with the patient if it occurs. The sense of hearing is believed to be the last sense to leave the body; many patients retain a sense of hearing almost to the moment of death; therefore nurses should explain to the comatose patient the nursing care being given. The nurse should address caregiver role endurance by actively listening to family members who are experiencing it. Because it is good to encourage dying patients to be as active as possible for as long as possible, it is generally not good practice to perform basic self-care measures the patient can perform simply because it is "easier" to do it this way.

12. When developing the plan of care for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain is most effectively relieved when analgesics are administered in what matter? On a PRN (as needed) basis Conservatively Around the clock (ATC) Intramuscularly

12. c. The PRN protocol is totally inadequate for patients experiencing chronic pain. ATC doses of analgesics are more effective, whereas conservative pain management for whatever reason may also prove ineffective. Intramuscular administration is not practical on a long-range basis for a patient with chronic pain.

12. A 33-year-old businessperson is now in counseling attempting to deal with a long-repressed history of sexual abuse by her father. "I guess I should feel satisfied with what I've achieved in life, but I'm never content, and nothing I achieve makes me feel good about myself . . . I hate my father for making me feel like I'm no good. This is an awful way to live." Answer: _______________

12. c. This patient's self-concept disturbance is mainly one of devaluing herself and thinking that she is no good. This is a self-esteem disturbance.

13. A nurse is providing postmortem care. Which nursing action violates the standards of caring for the body after a patient has been pronounced dead and is not scheduled for an autopsy? The nurse places the patient in a sitting position while the family visits. The nurse places identification tags on both the shroud and the ankle. The nurse removes soiled dressings and tubes. The nurse makes sure a death certificate is issued and signed.

13. a. Because the body should be placed in normal anatomic position to avoid pooling of blood, leaving the body in a sitting position is contraindicated. The other actions are appropriate nursing responsibilities related to postmortem care.

13. When assessing pain in a child, the nurse needs to be aware of what considerations? Immature neurologic development results in reduced sensation of pain. Inadequate or inconsistent relief of pain is widespread. Reliable assessment tools are currently unavailable. Narcotic analgesic use should be avoided.

13. b. Health care personnel are only now becoming aware of pain relief as a priority for children in pain. The evidence supports the fact that children do indeed feel pain and reliable assessment tools are available specifically for use with children. Opioid analgesics may be safely used with children as long as they are carefully monitored.

13. A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. Which diagnosis would be most appropriate for this patient? Ineffective Coping: Multiple Stressors of New Job Sleep Deprivation: Difficulty Falling Asleep Disturbed Sleep Pattern: Altered Sleep-Wake Pattern Risk for Injury: Activity Intolerance/Sleep Deprivation

13. c. When assessment data point to a sleep problem that is amenable to nursing therapy, it receives the label Disturbed Sleep Pattern if the problem is time limited (such as changing shifts) or Sleep Deprivation if the problem is prolonged. The labels Ineffective Coping and Risk for Injury have not yet been determined.

13. A 36-year-old female who was divorced 5 years earlier enters the emergency department with severe burns and cuts on her face after an auto accident in a car driven by her fiancé of 3 months. Three weeks later, her fiancé has not yet contacted her. The patient states that he is very busy and she is too tired to have visitors anyway. The patient frequently lies with her eyes closed and head turned away. These data suggest that: There is no disturbance in self-concept. This patient has ego strength and high self-esteem but may have a disturbance of body image. The area of self-esteem has very low priority at this time and should be ignored until much later. It is probable that there are disturbances in self-esteem and body image.

13. d. The traumatic nature of this patient's injuries, her fiancé's failure to contact her, and her withdrawal response all point to potential problems with both body image and self-esteem. It is not true that self-esteem needs are of low priority.

14. A nurse is performing patient care for a severely ill patient who has cancer. Which nursing interventions are likely to assist a severely ill patient with cancer to maintain a positive sense of self? Select all that apply. The nurse makes a point to address the patient by name upon entering the room. The nurse avoids fatiguing the patient by performing all procedures in silence. The nurse performs care in a manner that respects the patient's privacy and sensibilities. The nurse offers the patient a simple explanation before moving her in any way. The nurse ignores negative feelings from the patient since they are part of the grieving process. The nurse avoids conversing with the patient about her life, family, and occupation.

14. a, c, d. When assisting the patient to maintain a positive sense of self, the nurse should address the patient by name when entering the room; perform care in a manner that respects the patient's privacy; offer a simple explanation before moving the patient's body in any way; acknowledge the patient's status, role, and individuality; and converse with the patient about the patient's life experiences.

14. A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep? Keep the room light dimmed during the day. Keep the room cool. Keep the door of the room open. Offer a sleep aid medication to patients on a regular basis.

14. b. The nurse should keep the room cool and provide earplugs and eye masks. The nurse should also maintain a brighter room environment during daylight hours and dim lights in the evening, and keep the door of the room closed. Sleep aid medications should only be offered as prescribed.

15. A 70-year-old female patient who has had a number of strokes refuses further life-sustaining interventions, including artificial nutrition and hydration. She is competent, understands the consequences of her actions, is not depressed, and persists in refusing treatment. Her doctor is adamant that she cannot be allowed to die this way, and her daughter agrees. An ethics consult has been initiated. Who would be the appropriate decision maker? Patient Daughter Doctor Ethics consult team

15. a. Because this patient is competent, she has the right to refuse therapy that she finds to be disproportionately burdensome, even if this hastens her death. Neither her daughter nor her doctor has the authority to assume her decision-making responsibilities unless she asks them to do this. The ethics consult team is not a decision-making body; it can make recommendations but has no authority to order anything.

15. A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in elderly patients. Which action is recommended for these patients? Increase physical activities during the day. Encourage short periods of napping during the day. Increase fluids during the evening. Dispense diuretics during the afternoon hours.

15. a. In order to promote sleep in the elderly patient, the nurse should encourage daily physical activity such as walking or water aerobics, discourage napping during the day, decrease fluids at night, and dispense diuretics in the morning or early evening.

15. A 16-year-old patient has a nursing diagnosis of Body Image Disturbance related to severe acne. In planning nursing care, what is an appropriate goal for this nursing diagnosis? The patient will make above-B grades in all tests at school." The patient will demonstrate by diet control and skin care increased interest in control of acne. The patient reports that she feels more self-confidence in her music and art, which she enjoys. The patient expresses that she is very smart in school.

15. b. All of these patient goals may be appropriate for the patient but the only goal that directly addresses her body image disturbance is b.

15. When assessing a patient receiving a continuous opioid infusion, the nurse immediately notifies the physician when the patient has: A respiratory rate of 10/min with normal depth A sedation level of 4 Mild confusion Reported constipation

15. b. Sedation level is more indicative of respiratory depression because a drop in level usually precedes it. A sedation level of 4 calls for immediate action because the patient has minimal or no response to stimuli. A respiratory level of 10 with normal depth of breathing is usually not a cause for alarm. Mild confusion may be evident with the initial dose and then disappear; additional observation is necessary. Constipation should be reported to the physician, but is not the priority in this situation.

2. A nurse who cared for a dying patient and his family documents that the family is experiencing a period of mourning. Which behaviors would the nurse expect to see at this stage? Select all that apply. The family arranges for a funeral for their loved one. The family arranges for a memorial scholarship for their loved one. The coroner pronounces the patient's death. The family arranges for hospice for their loved one. The patient is diagnosed with terminal cancer. The patient's daughter writes a poem expressing her sorrow.

2. a, b, f. Mourning is defined as the period of acceptance of loss and grief, during which the person learns to deal with loss. It is the actions and expressions of that grief, including the symbols and ceremonies (e.g., a funeral or final celebration of life), that make up the outward expressions of grief. People who are bereaved are in a state of grieving from loss of a loved one.

2. One of the most common distinctions of pain is whether it is acute or chronic. Which examples describe chronic pain? Select all that apply. A patient is receiving chemotherapy for bladder cancer. An adolescent is admitted to the hospital for an appendectomy. A patient is experiencing a ruptured aneurysm. A patient who has fibromyalgia requests pain medication. A patient has back pain related to an accident that occurred last year. A patient is experiencing pain from second-degree burns.

2. a, d, e. Chronic pain is pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period. Examples are cancer pain, fibromyalgia pain, and back pain. Acute pain is generally rapid in onset and varies in intensity from mild to severe, as occurs with an emergency appendectomy, a ruptured aneurysm, and pain from burns

2. Newly hired nurses in a busy suburban hospital are required to read the state Nurse Practice Act as part of their training. Which topics are covered by this act? Select all that apply. Violations that may result in disciplinary action Clinical procedures Medication administration Scope of practice Delegation policies Medicare reimbursement

2. a, d. Each state has a Nurse Practice Act that protects the public by broadly defining the legal scope of nursing practice. Practicing beyond those limits makes nurses vulnerable to charges of violating the state Nurse Practice Act. Nurse Practice Acts also list the violations that can result in disciplinary actions against nurses. Clinical procedures are covered by the health care institutions themselves. Medication administration and delegation are topics covered by the board of nursing. Laws governing Medicare reimbursement are enacted through Federal legislation.

2. A nurse observes some involuntary muscle jerking in a sleeping patient. The nurse determines that the patient is most likely in which stage of sleep? Stage I NREM sleep Stage II NREM sleep Stage IV NREM sleep REM sleep

2. a. Involuntary muscle jerking occurs in stage I NREM sleep. In the other stages, the muscles proceed from a relaxed state to large muscle immobility.

2. A nurse is teaching patients of all ages in a hospital setting. Which examples demonstrate teaching that is appropriately based on the patient's developmental level? Select all that apply. The nurse plans long teaching sessions to discuss diet modifications for an older adult diagnosed with type 2 diabetes. The nurse recognizes that a female adolescent diagnosed with anorexia is still dependent on her parents and includes them in all teaching sessions. The nurse designs an exercise program for a sedentary older adult male patient based on the activities he prefers. The nurse includes an 8-year-old patient in the teaching plan for managing cystic fibrosis. The nurse demonstrates how to use an inhaler to an 11-year-old male patient and includes his mother in the session to reinforce the teaching. The nurse continues a teaching session on STIs for a sexually active male adolescent despite his protest that "I've heard enough already!"

2. c, d, e. Successful teaching plans for older adults incorporate extra time, short teaching sessions, accommodation for sensory deficits, and reduction of environmental distractions. Older adults also benefit from instruction that relates new information to familiar activities or information. School-aged children are capable of logical reasoning and should be included in the teaching-learning process whenever possible; they are also open to new learning experiences but need learning to be reinforced by either a parent or health care provider as they become more involved with their friends and school activities. Teaching strategies designed for an adolescent patient should recognize the adolescent's need for independence, as well as the need to establish a trusting relationship that demonstrates respect for the adolescent's opinions.

2. A nurse is assessing a 78-year-old male patient for kinesthetic and visceral disturbances. Which techniques would the nurse use for this assessment? Select all that apply. The nurse asks the patient if he is bored, and if so, why. The nurse asks the patient if anything interferes with the functioning of his senses. The nurse asks the patient if he noticed any changes in the way he perceives his body. The nurse asks the patient if he has found it difficult to communicate verbally. The nurse notes if the patient withdraws from being touched. The nurse notes if the patient seems unsure of his body parts and/or position.

2. c, e, f. To assess for kinesthetic and visceral disturbances, the nurse would assess for perceived body changes inside and out, and changes in body parts or position. Asking if the patient is bored assesses stimulation, asking if anything interferes with his senses assesses reception, and asking about difficulty communicating assesses for transmission-perception-reaction.

2. Five-year-old Bobby has dietary modifications related to his diabetes. His parents want him to value good nutritional habits and they decide to deprive him of a favorite TV program when he becomes angry after they deny him foods not on his diet. This is an example of what mode of value transmission? Modeling Moralizing Laissez-faire Rewarding and punishing

2. d.When rewarding and punishing are used to transmit values, children are rewarded for demonstrating values held by parents and punished for demonstrating unacceptable values. Through modeling, children learn what is of high or low value by observing parents, peers, and significant others. Children whose caregivers use the moralizing mode of value transmission are taught a complete value system by parents or an institution (e.g., church or school) that allows little opportunity for them to weigh different values. Those who use the laissez-faire approach to value transmission leave children to explore values on their own (no single set of values is presented as best for all) and to develop a personal value system.

3. A nurse who is working in a hospital setting after graduation from a local college uses value clarification to help understand the values that motivate patient behavior. Which examples denote "prizing" in the process of values clarification? Select all that apply. A patient decides to quit smoking following a diagnosis of lung cancer. A patient shows off a new outfit that she is wearing after losing 20 pounds. A patient chooses to work fewer hours following a stress-related myocardial infarction. A patient incorporates a new low-cholesterol diet into his daily routine. A patient joins a gym and schedules classes throughout the year. A patient proudly displays his certificate for completing a marathon.

3. b, f. Prizing something one values involves pride, happiness, and public affirmation, such as losing weight or running a marathon. When choosing, one chooses freely from alternatives after careful consideration of the consequences of each alternative, such as quitting smoking and working fewer hours. Finally, the person who values something acts by combining choice into one's behavior with consistency and regularity on the value, such as joining a gym for the year and following a low-cholesterol diet faithfully.

3. A patient complains of abdominal pain that is difficult to localize. The nurse documents this as which type of pain? Cutaneous Visceral Superficial Somatic

3. b. The patient's pain would be categorized as visceral pain, which is poorly localized and can originate in body organs in the abdomen. Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue. A paper cut that produces sharp pain with a burning sensation is an example of cutaneous pain. Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain.

3. A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply. He is aware of his surroundings at this point. He is in delta sleep at this time. It would be most difficult to awaken him at this time. This is most likely an NREM stage. This stage constitutes around 20% to 25% of total sleep. The muscles are relaxed in this stage.

3. c, e. This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20% to 25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. Delta sleep is NREM stages III and IV sleep. In stage IV NREM sleep, the muscles are relaxed, whereas small muscle twitching may occur in REM sleep.

3. A nurse interviews an 82-year-old resident of a long-term care facility who says that she has never gotten over the death of her son 20 years ago. She reports that her life fell apart after that and she never again felt like herself or was able to enjoy life. What type of grief is this woman experiencing? Abbreviated Anticipatory Dysfunctional Inhibited

3. c. Dysfunctional grief extends the mourning period for an abnormally long time, characterized by abnormal or distorted expressions of grief.

4. A nurse is planning teaching strategies for patients addicted to alcohol, in the affective domain of learning. What are examples of strategies promoting behaviors in this domain? Select all that apply. The nurse prepares a lecture on the harmful long-term effects of alcohol on the body. The nurse explores the reasons alcoholics drink and promotes other methods of coping with problems. The nurse asks patients for a return demonstration for using relaxation exercises to relieve stress. The nurse helps patients to reaffirm their feelings of self-worth and relate this to their addiction problem. The nurse uses a pamphlet to discuss the tenants of the Alcoholics Anonymous program to patients. The nurse reinforces the mental benefits of gaining self-control over an addiction.

4. b, d, f. Affective learning includes changes in attitudes, values, and feelings (e.g., the patient expresses renewed self-confidence to be able to give up drinking). Cognitive learning involves the storing and recalling of new knowledge in the brain, such as the learning that occurs during a lecture or by using a pamphlet for teaching. Learning a physical skill involving the integration of mental and muscular activity is called psychomotor learning, which may involve a return demonstration of a skill.

4. A nurse observes that a patient who has cataracts is sitting closer to the television than usual. The nurse would interpret that the etiologic basis of this sensory problem is an alteration in: Environmental stimuli Sensory reception Nerve impulse conduction Impulse translation

4. b. Cataracts are interfering with the patient's ability to receive visual stimuli: altered sensory reception. The nature of incoming stimuli, the conduction of nerve impulses, and the translation of incoming impulses in the brain are not a problem here.

4. Jean's attorney was careful to explain in her defense that Jean had specialty knowledge, experience, and clinical judgment and had met certain criteria established by a nongovernmental association, as a result of which she was granted recognition in a specified practice area. What is this sort of credential called? Accreditation Licensure Certification Board approval

4. c. Certification is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area. Nursing is one of the groups operating under state laws that promote the general welfare by determining minimum standards of education through accreditation of schools of nursing. Licensure is a legal document that permits a person to offer to the public skills and knowledge in a particular jurisdiction, where such practice would otherwise be unlawful without a license. State board of approval ensures that nurses have received the proper training to practice nursing.

4. A nurse working the night shift at a hospital observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. REM sleep constitutes much of the sleep cycle of a preschool child. By the age of 8 years, most children no longer take naps. Sleep needs usually decrease when physical growth peaks. Many adolescents do not get enough sleep. Total sleep decreases in adults with a decrease in stage IV sleep. Sleep is less sound in older adults and stage IV sleep may be absent.

4. d, e, f. Many adolescents do not get enough sleep due to the stresses of school, activities, and part-time employment causing restless sleep. Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older adults, and stage IV sleep is absent or considerably decreased. REM sleep constitutes much of the sleep cycle of a young infant, and by the age of 5 years, most children no longer nap. Sleep needs usually increase when physical growth peaks.

4. A female patient who is having a myocardial infarction complains of pain that is situated in her jaw. The nurse documents this as what type of pain? Transient pain Superficial pain Phantom pain Referred pain

4. d. Referred pain is perceived in an area distant from its point of origin, whereas transient pain is brief and passes quickly. Superficial pain originates in the skin or subcutaneous tissue. Phantom pain may occur in a person who has had a body part amputated, either surgically or traumatically.

4. The American Association of Colleges of Nursing identified five values that epitomize the caring professional nurse. Which of these is best described as acting in accordance with an appropriate code of ethics and accepted standards of practice? Altruism Autonomy Human dignity Integrity

4. d. The American Association of Colleges of Nursing defines integrity as acting in accordance with an appropriate code of ethics and accepted standards of practice. Altruism is a concern for the welfare and well-being of others. Autonomy is the right to self-determination, and human dignity is respect for the inherent worth and uniqueness of individuals and populations.

5. The three types of responses to pain are physiologic, behavioral, and affective. Which are examples of behavioral responses to pain? Select all that apply. A patient cradles a wrist that was injured in a car accident. A child is moaning and crying due to a stomachache. A patient's pulse is increased following a myocardial infarction. A patient in pain strikes out at a nurse who attempts to bathe him. A patient who has chronic cancer pain is depressed and withdrawn. A child pulls away from a nurse trying to give him an injection.

5. a, b, f. Protecting or guarding a painful area, moaning and crying, and moving away from painful stimuli are behavioral responses. Examples of a physiologic or involuntary response would be increased blood pressure or dilation of the pupils. Affective responses, such as anger, withdrawal, and depression, are psychological in nature.

5. A nurse is preparing to teach a 45-year-old male patient with asthma how to use his inhaler. Which teaching tool is one of the best methods to teach the patient this skill? Demonstration Lecture Discovery Panel session

5. a. Demonstration of techniques, procedures, exercises, and the use of special equipment is an effective patient teaching strategy for a skill. Lecture can be used to deliver information to a large group of patients but is more effective when the session is interactive; it is rarely used for individual instruction, except in combination with other strategies. Discovery is a good method for teaching problem-solving techniques and independent thinking. Panel discussions can be used to impart factual material but are also effective for sharing experiences and emotions.

9. A patient has been in the United States only 3 months and has recently suffered the loss of her husband and job. She states that nothing feels familiar . . . "I don't know who I am supposed to be here" and she misses home (Nicaragua) terribly. Answer: _______________

9. a. An unfamiliar culture, coupled with traumatic life events and loss of husband and job, result in this patient's total loss of her sense of self: "I don't know who I am supposed to be here." Her very sense of identity is at stake, not merely her body image, self-esteem, or role performance.

6. A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply. A patient who has uncontrolled hypothyroidism A patient with coronary artery disease A patient who has gastroesophageal reflux (GERD) A patient who is HIV positive A patient who is taking corticosteroids for arthritis A patient with a urinary tract infection

6. a, b, c. A patient who has uncontrolled hypothyroidism tends to have a decreased amount of NREM sleep, especially stages II and IV. The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep, and a patient who has gastroesophageal reflux (GERD) may awaken at night with heartburn pain. Being HIV positive, taking corticosteroids, and having a urinary tract infection does not usually change sleep patterns.

6. An elderly patient is confined to bedrest following cervical spine surgery to treat nerve pinching. The nurse is vigilant about turning the patient and assessing the patient regularly to prevent the formation of pressure ulcers. What type of agent is the stimulus for pressure ulcers? Mechanical Thermal Chemical Electrical

6. a. Receptors in the skin and superficial organs may be stimulated by mechanical, thermal, chemical, and electrical agents. Friction from bed linens causing pressure sores and pressure from a cast are mechanical stimulants. Sunburn is a thermal stimulant. An acid burn is the result of a chemical stimulant. The jolt from a lightening bolt is an electrical stimulant

6. When an older nurse complains to a younger nurse that nurses just aren't ethical anymore, which reply reflects the best understanding of moral development? "Behaving ethically develops gradually from childhood; maybe my generation doesn't value this enough to develop an ethical code." "I don't agree that nurses were more ethical in the past. It's a new age and the ethics are new!" "Ethics is genetically determined ... it's like having blue or brown eyes. Maybe we're evolving out of the ethical sense your generation had." "I agree! It's impossible to be ethical when working in a practice setting like this!"

6. a. The ability to be ethical, to make decisions, and to act in an ethically justified manner begins in childhood and develops gradually

6. A nurse has taught a diabetic patient how to administer his daily insulin. The nurse should evaluate the teaching-learning process by: Determining the patient's motivation to learn Deciding if the learning outcomes have been achieved Allowing the patient to practice the skill he has just learned Documenting the teaching session in the patient's medical record

6. b. The nurse cannot assume that the patient has actually learned the content unless there is some type of proof of learning. The key to evaluation is meeting the learner outcomes stated in the teaching plan.

6. A nurse is caring for a terminally ill patient during the 11 PM to 7 AM shift. The patient says, "I just can't sleep. I keep thinking about what my family will do when I am gone." What response by the nurse would be most appropriate? "Oh, don't worry about that now. You need to sleep." "What seems to be concerning you the most?" "I have talked to your wife and she told me she will be fine." "I have to go and give medicines, you should discuss this with your wife."

6. b. Using an open-ended question allows the patient to continue talking. False reassurances are not helpful. Also, the patient's feelings and restlessness should be addressed as soon as possible.

6. A mother of a 10-year-old daughter tells the nurse: "I feel incompetent as a parent and don't know how to discipline my daughter." What should be the nurse's first intervention when counseling this patient? Recommend that she discipline her daughter more strictly and consistently. Make a list of things her husband can do to give her more time and help her improve her parenting skills. Assist the mother to identify both what she believes is preventing her success and what she can do to improve. Explore with the mother what the daughter can do to improve her behavior and make the mother's role as a parent easier.

6. c. The first intervention priority with a mother who feels incompetent to parent a daughter is to assist the mother to identify what is preventing her from being an effective parent and then to explore solutions aimed at improving her parenting skills. The other interventions may prove helpful, but they do not directly address the mother's problem with her feelings of incompetence

6. A patient is in the late stages of AIDS, which is now affecting his brain as well other major organ systems. The patient confides to the nurse that he feels terribly alone because most of his friends are afraid to visit. The nurse determines that the least likely underlying etiology for his sensory problems would be: Stimulation Reception Transmission-perception-reaction Emotional responses

6. d. Emotional responses are an effect of sensory deprivation, and although they may be occurring with this patient, they are not the underlying etiology for his condition. This patient is receiving decreased environmental stimuli (a) (e.g., from his friends), is more than likely experiencing problems with reception because of major organ involvement (b), and his impaired brain function will impair impulse transmission-perception- reaction (c).

6. What must be established to prove that malpractice or negligence has occurred in this case? The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. The fact that this patient should not have died—she was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. The nurse intended to harm the patient and was willfully negligent. The nurse had a duty to monitor the patient's vital signs, failed to do so, the patient died, and it was Jean's failure to do her duty that caused the patient's death.

6. d. Liability involves four elements that must be established to prove that malpractice or negligence has occurred: duty, breach of duty, causation, and damages. Duty refers to an obligation to use due care (what a reasonably prudent nurse would do) and is defined by the standard of care appropriate for the nurse-patient relationship. Breach of duty is the failure to meet the standard of care. Causation, the most difficult element of liability to prove, shows that the failure to meet the standard of care (breach) actually caused the injury. Damages are the actual harm or injury resulting to the patient.

9. A patient's spinal cord was severed, and he is paralyzed from the waist down. When obtaining data about this patient, which component of the sensory experience would be most important for the nurse to assess? Transmission of tactile stimuli Adequate stimulation in the environment Reception of visual and auditory stimuli General orientation and ability to follow commands

9. a. Below-the-waist paralysis makes the transmission of tactile stimuli a problem. Although the other options may be assessed, they are indirectly related to his paralysis and of lesser importance at this time.

7. A nurse is counseling parents attending a parent workshop on how to build self-esteem in their children. Which teaching points would the nurse include to help parents achieve this goal? Select all that apply. Teach the parents to reinforce their child's positive qualities. Teach the parents to overlook occasional negative behavior. Teach parents to ignore neutral behavior that is a matter of personal preference. Teach parents to listen and "fix things" for their children. Teach parents to describe the child's behavior and judge it. Teach parents to let their children practice skills and make it safe to fail.

7. a, c, f. The nurse should include the following teaching points for parents: (1) reinforce their child's positive qualities; (2) address negative qualities constructively; (3) ignore neutral behavior that is a matter of taste, preference, or personal style; (4) don't feel they have to "fix things" for their children; (5) describe the child's behavior in a nonjudgmental manner; and (6) let their child know what to expect, practice the necessary skills, be patient, and make it safe to fail.

7. A registered nurse assumes the role of nurse coach to provide teaching to patients who are recovering from strokes. One example of an intervention the nurse may provide related to this role is: The nurse uses discovery to identify the patients' personal goals and create an agenda that will result in change. The nurse is the expert in providing teaching and education strategies to provide dietary and activity modifications. The nurse becomes a mentor to the patients and encourages them to create their own fitness programs. The nurse assumes an authoritative role to design the structure of the coaching session and support the achievement of patient goals.

7. a. A nurse coach establishes a partnership with a patient and, using discovery, facilitates the identification of the patient's personal goals and agenda to lead to change rather than using teaching and education strategies with the nurse as the expert. A nurse coach explores the patient's readiness for coaching, designs the structure of a coaching session, supports the achievement of the patient's desired goals, and with the patient determines how to evaluate the attainment of patient goals.

7. When the attorney representing the patient's family calls Jean and asks to talk with her about the case so that he can better understand her actions, how should Jean respond? "I'm sorry, but I can't talk with you. You'll have to contact my attorney." Answer the attorney's questions honestly and make sure that he understands her side of the story. Appeal to the attorney's sense of compassion and try to enlist his sympathy by telling him how busy it was that morning. "Why are you doing this to me? This could ruin me!"

7. a. One of the cardinal rules for nurse defendants is: Do not discuss the case with anyone at your agency (with the exception of the risk manager), with the plaintiff, with the plaintiff's lawyer, with anyone testifying for the plaintiff, or with reporters.

7. Which patient would a nurse assess as being at greatest risk for sensory deprivation? An older man confined to bed at home after a stroke An adolescent in an oncology unit working on homework supplied by friends A woman in labor A toddler in a playroom awaiting same-day surgery

7. a. The patient confined to bedrest at home is at risk for greatly reduced environmental stimuli. All of the other patients are in environments in which environmental stimuli are at least adequate

7. A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply. A patient who is taking iron supplements for anemia A patient with Parkinson disease who is taking dopamine An elderly patient taking diuretics for congestive heart failure A patient who is taking antibiotics for an ear infection A patient who is prescribed antidepressants A patient who is taking low-dose aspirin prophylactically

7. b, c, e. Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications are seen as additional common causes of sleep problems.

7. A nurse uses a whirlpool to relax a patient following intense physical therapy to restore movement in her legs. What is a potent pain-blocking neuromodulator, released through relaxation techniques? Prostaglandins Substance P Endorphins Serotonin

7. c. Endorphins are produced at neural synapses at various points along the CNS pathway. They are powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria. It is thought that endorphins are released through pain relief measures, such as relaxation techniques. Prostaglandins, substance P, and serotonin (a hormone that can act to stimulate smooth muscles, inhibit gastric secretion, and produce vasoconstriction) are neurotransmitters or substances that either excite or inhibit target nerve cells.

7. A patient tells a nurse that he has no one he trusts to make health care decisions for him should he become incapacitated. What should the nurse suggest he prepare? Combination advance medical directive Durable power of attorney for health care Living will Proxy for health care

7. c. The living will is a document whose precise purpose is to allow individuals to record specific instructions about the type of health care they would like to receive in particular end-of-life situations. A durable power of attorney for health care appoints an agent (proxy) the person trusts to make decisions in the event of subsequent incapacity. The combination advance medical directive also appoints a proxy for the patient.

7. A home health nurse who performs a careful safety assessment of the home of a frail elderly patient to prevent harm to the patient is acting in accordance with which of the principles of bioethics? Autonomy Beneficence Justice Fidelity Nonmaleficence

7. e. Nonmaleficence is defined as the obligation to prevent harm. Autonomy is respect for another's right to make decisions, beneficence obligates us to benefit the patient, justice obligates us to act fairly, and fidelity obligates us to keep our promises.

8. A patient in an intensive care burn unit for 1 week is in pain much of the time and has his face and both arms heavily bandaged. His wife visits every evening for 15 minutes at 6, 7, and 8 PM. A heart monitor beeps for a patient on one side, and another patient moans frequently. Assessment would suggest that that the patient probably is experiencing: Sufficient sensory stimulation Deficient sensory stimulation Excessive sensory stimulation Both sensory deprivation and overload

8. d. This patient's bandages may result in deficient sensory stimulation (sensory deprivation), and the monitors and other sounds in the intensive care burn unit may cause a sensory overload. All other options are incomplete responses.

8. A nurse practicing in a physician's office assesses self-concept in patients during the patient interview. Which patient is least likely to develop problems related to self-concept? A 55-year-old woman television news reporter undergoing a hysterectomy (removal of uterus) A young clergyperson whose vocal cords are paralyzed after a motorbike accident A 32-year-old accountant who survives a massive heart attack A 23-year-old model who just learned that she has breast cancer For questions 9 to 12, read the patient data and use the following letters to indicate the nursing diagnosis that the data suggest (each response may be used only once): a. Personal Identity Disturbance b. Body Image Disturbance c. Self-Esteem Disturbance d. Altered Role Performance

8. a. Based simply on the facts given, the 55-year-old news reporter would be least likely to experience body image or role performance disturbance because she is beyond her childbearing years, and the hysterectomy should not impair her ability to report the news. The young clergyperson's inability to preach (b), the 32-year-old's massive myocardial infarction (c), and the model's breast resection (d) have much greater potential to result in self-concept problems.

8. A hospice nurse is caring for a patient who is terminally ill and who is on a ventilator. After a restless night, the patient hands the nurse a note with the request: "Please help me end my suffering." Which response by a nurse would best reflect adherence to the position of the American Nurses Association regarding assisted suicide? The nurse promises the patient that he or she will do everything possible to keep the patient comfortable but cannot administer an injection or overdose to cause the patient's death. The nurse tells the patient that under no condition can he be removed from the ventilator because this is active euthanasia and is expressly forbidden by the Code for Nurses. After exhausting every intervention to keep a dying patient comfortable, the nurse says, "I think you are now at a point where I'm prepared to do what you've been asking me. Let's talk about when and how you want to die." The nurse responds: "I'm personally opposed to assisted suicide, but I'll find you a colleague who can help you."

8. a. The American Nurses Association (ANA, 1994, 2013) issued position statements stating that assisting in suicide and participating in active euthanasia are in violation of the Code for Nurses, the ethical traditions and goals of the profession, and its covenant with society.

8. A professional nurse committed to the principle of autonomy would be careful to: Provide the information and support a patient needed to make decisions to advance one's own interests Treat each patient fairly, trying to give everyone his or her due Keep any promises made to a patient or another professional caregiver Avoid causing harm to a patient

8. a. The principle of autonomy obligates nurses to provide the information and support patients and their surrogates need to make decisions that advance their interests. Acting with justice means giving each person his or her due, acting with fidelity involves keeping promises to patients, and acting with nonmaleficence means avoiding doing harm to patients.

8. A patient is postoperative following an emergency cesarean section birth. The patient asks the nurse about the use of pain medications following surgery. What would be a correct response by the nurse? "It's not a good idea to ask for pain medication regularly as it can be addictive." "It is better to wait until the pain gets unbearable before asking for pain medication." "It's natural to have to put up with pain after surgery and it will lessen in intensity in a few days." "Your doctor has ordered pain medications for you, which you should not be afraid to request any time you have pain."

8. d. Many pain medications are ordered on a PRN (as needed) basis. Therefore, nurses must be diligent to assess patients for pain and administer medications as needed. A patient should not be afraid to request these medications and should not wait until the pain is unbearable. Few people become addicted to the medications if used for a short period of time. Pain following surgery can be controlled and should not be considered a natural part of the experience that will lessen in time.

8. A nurse administers the wrong medication to a patient and the patient is harmed. The physician who ordered the medication did not read the documentation that the patient was allergic to the drug. Which statement is true regarding liability for the administration of the wrong medication? The nurse is not responsible, because the nurse was merely following the doctor's orders. Only the nurse is responsible, because the nurse actually administered the medication. Only the physician is responsible, because the physician actually ordered the drug. Both the nurse and the physician are responsible for their respective actions.

8. d. Nurses are legally responsible for carrying out the orders of the physician in charge of a patient unless an order would lead a reasonable person to anticipate injury if it were carried out. If the nurse should have anticipated injury and did not, both the prescribing physician and the administering nurse are responsible for the harms to which they contributed.

8. A nurse working the night shift in a pediatric unit observes a 10-year-old male patient walking the hallway in a sleep state. The child is unaware of his environment and doesn't recall the incident in the morning. Which sleep disorder would the nurse expect? Bruxism Cataplexy Restless leg syndrome Somnambulism

8. d. Somnambulism (sleepwalking) may range from sitting up in bed to walking around the room or the house to walking outside the house. The sleepwalker is unaware of the environment. Bruxism is grinding of one's teeth and frequently is an indicator of stress. Cataplexy is a sudden loss of motor tone that may cause the person to fall asleep; it is usually experienced during a period of strong emotion. People with restless leg syndrome (RLS) cannot lie still and report unpleasant creeping, crawling, or tingling sensations in the legs.

8. A nurse is counseling a 19-year-old male athlete who had his right leg amputated below the knee following a motorcycle accident. During the rehabilitation process, the patient refuses to eat or get up to ambulate on his own. He says to the nurse, "What's the point. My life is over now and I'll never be the football player I dreamed of becoming." What is the nurse counselor's best response to this patient? "You're young and have your whole life ahead of you. You should focus on your rehabilitation and make something of your life." "I understand how you must feel. I wanted to be a famous singer, but I wasn't born with the talent to be successful at it." "You should concentrate on other sports that you could play even with a prosthesis." "I understand this is difficult for you. Would you like to talk about it now or would you prefer me to make a referral to someone else?"

8. d. This answer communicates respect and sensitivity to the patient's needs and offers an opportunity to discuss his feelings with the nurse or another health care professional. The other answers do not allow the patient to express his feelings and receive the counseling he needs.

9. A nurse answers a patient's call light and finds the patient on the floor by the bathroom door. After calling for assistance and examining the patient for injury, the nurse helps the patient back to bed and then fills out an incident report. Which statements accurately describe aspects of this procedure? Select all that apply. An incident report is used as disciplinary action against staff members. An incident report is used as a means of identifying risks. An incident report is used for quality control. The facility manager completes the incident report. An incident report makes facts available in case litigation occurs. Filing of an incident report should be documented in the patient record.

9. b, c, e. Incident reports are used for quality improvement and should not be used for disciplinary action against staff members. They are a means of identifying risks and are filled out by the nurse responsible for the injured party. An incident report makes facts available in case litigation occurs and in some states, incident reports may be used in court as evidence. A physician completes the incident form with documentation of the medical examination of the patient, employee, or visitor with an actual or potential injury. Documentation in the patient record should not include the fact that an incident report was filed.

9. Janie wants to call an ethics consult to clarify treatment goals for a patient no longer able to speak for himself. She believes his dying is being prolonged painfully. She is troubled when the patient's doctor tells her that she'll be fired if she raises questions about his care or calls the consult. This is a good example of: Ethical uncertainty Ethical distress Ethical dilemma Ethical residue

9. b. Ethical distress results from knowing the right thing to do but finding it almost impossible to execute because of institutional or other constraints (in this case, fear of losing her job). Ethical uncertainty results from feeling troubled by a situation but not knowing if it is an ethical problem. Ethical dilemmas occur when the principles of bioethics justify two or more conflicting courses of action. Ethical residue is what nurses experience when they seriously compromise themselves or allow themselves to be compromised.

9. A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder? REM behavior disorder Narcolepsy Enuresis Sleep apnea

9. b. Narcolepsy is an uncontrollable desire to sleep; the person may fall asleep in the middle of a conversation. REM Behavior Disorder (RBD) is characterized by "acting out" dreams while asleep. Enuresis is urinating during sleep or bedwetting. Sleep apnea is a condition in which breathing ceases for a period of time between snoring.

9. Applying the gate control theory of pain, what would be an effective nursing intervention for a patient with lower back pain? Encouraging regular use of analgesics Applying a moist heating pad to the area at prescribed intervals Reviewing the pain experience with the patient Ambulating the patient after administering medication

9. b. Nursing measures such as applying warmth to the lower back stimulate the large nerve fibers to close the gate and block the pain. The other choices do not involve attempts to stimulate large nerve fibers that interfere with pain transmission as explained by the gate control theory.

9. A nurse is caring for a 42-year-old male patient who is admitted to the hospital with injuries sustained in a motor vehicle accident. While he is in the hospital, his wife tells him that the bottom level of their house flooded, damaging their belongings. When the nurse enters his room, she notes that the patient is visibly upset. The nurse is aware that the patient will most likely be in need of which type of counseling? Long-term developmental Short-term situational Short-term motivational Long-term motivational

9. b. Short-term counseling might be used during a situational crisis, which occurs when a patient faces an event or situation that causes a disruption in life, such as a flood. Long-term counseling extends over a prolonged period; a patient experiencing a developmental crisis, for example, might need long-term counseling. Motivational interviewing is an evidence-based counseling approach that involves discussing feelings and incentives with the patient. A caring nurse can motivate patients to become interested in promoting their own health.