Exam 3 N266
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. 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.
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. Chapter 24
The nurse applying effective communication skills throughout the nursing process should: (Place the following interventions in the correct order.) 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.
4, 1, 3, 2. Chapter 24
1. As Beth inserts the catheter into Mr. Kelter's penis, she feels resistance. She should use more force to guide the catheter through his urethra. A. True B. False
Answer B case Study, Chapter 46
The nurse recognizes that which factors influence a person's approach to death? (Select all that apply.) 1. Culture 2. Spirituality 3. Personal beliefs 4. Previous experiences with death 5. Gender 6. Level of education
Answer: 1, 2, 3, 4. Chapter 36
Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. How to irrigate the colostomy 5. How to determine whether the ostomy is healing appropriately
Answer: 1, 2, 3, 5. Chapter 47
The nurse can increase a patient's self-awareness and self-concept through which of the following actions? (Select all that apply.) 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 posi-tive way 4. Having family members assume more responsibility during times of stress 5. Recommending self-help reading materials
Answer: 1, 2, 3. Chapter 33
To best assist a patient in the grieving process, which factors are most important for the nurse to assess? (Select all that apply.) 1. Previous experiences with grief and loss 2. Religious affiliation and denomination 3. Ethnic background and cultural practices 4. Current financial status 5. Current medications
Answer: 1, 2, 3. Chapter 36
When planning care for a dying patient, which interventions promote the patient's dignity? (Select all that apply.) 1. Providing respect 2. Viewing the patient as a whole 3. Providing symptom management 4. Showing interest 5. Being present 6. Inserting a straight catheter when the patient has difficulty voiding
Answer: 1, 2, 4, 5. Chapter 36
Which comments to a patient by a new nurse regarding palliative care needs are correct? (Select all that apply.) 1. "Even though you're continuing treatment, palliative care is something we might want to talk about." 2. "Palliative care is appropriate for people with any diagnosis." 3. "Only people who are dying can receive palliative care." 4. "Children are able to receive palliative care." 5. Palliative care is only for people with uncontrolled pain
Answer: 1, 2, 4. Chapter 36
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.) 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
Answer: 1, 2, 4. Chapter 42
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.) 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.
Answer: 1, 2, 4. Chapter 25
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.) 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?
Answer: 1, 2, 5. Chapter 37
Which symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) 1. Change in bowel habits 2. Blood in the stool 3. A larger-than-normal bowel movement 4. Fecal impaction 5. Muscle aches 6. Incomplete emptying of the colon 7. Food particles in the stool 8. Unexplained abdominal or back pain
Answer: 1, 2, 6, 8. Chapter 47
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-es- teem? (Select all that apply.) 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.
Answer: 1, 2. Chapter 33
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.) 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."
Answer: 1, 3, 4, 5. Chapter 34
Which actions by the nurse help grieving families? (Select all that apply.) 1. Encourage involvement in nonthreatening group social activities. 2. Follow up with the family in their home. 3. Remind them that feelings of sadness or pain can return around anniversaries. 4. Encourage survivors to ask for help. 5. Look for overuse of alcohol, sleeping aids, or street drugs.
Answer: 1, 3, 4, 5. Chapter 36
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.) 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
Answer: 1, 3, 4. Chapter 37
What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.) 1. Maintain regular bowel elimination. 2. Limit water intake to 1 to 2 glasses a day. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back. 5. Practice pelvic muscle exercise (Kegel) daily
Answer: 1, 3, 4. Chapter 46
When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply.) 1. Check for needed adaptive equipment. 2. Exaggerate lip movements to help the patient lip-read. 3. Give the patient time to respond to questions. 4. Keep communication short and to the point. 5. Communicate only through written information.
Answer: 1, 3, 4. Chapter 24
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.) 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
Answer: 1, 3, 4. Chapter 26
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.) 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."
Answer: 1, 3, 4. Chapter 34
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.) 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
Answer: 1, 3, 4. Chapter 34
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, what outcomes does the nurse expect? (Select all that apply.) 1. Gaining an understanding of the patient's motivations 2. Directing the patient to avoid poor health choices 3. Recognizing the patient's strengths and supporting his or her efforts 4. Providing assessment data that can be shared with families to promote change 5. Identifying differences in patient's health goals and current behaviors
Answer: 1, 3, 5. Chapter 24
The patient states, "I don't have confidence in my doctor. She looks so young." The nurse therapeutically responds: (Select all that apply.) 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. Chapter 24
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.) 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
Answer: 1, 3. Chapter 45
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.) 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
Answer: 1, 3. Chapter 24
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.) 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 part- ner? 4. What level of physical activity are you able to perform? 5. What concerns do you have about another stroke?
Answer: 1, 3. Chapter 33
The nurse is caring for a 50-year-old woman visiting the outpatient medicine clinic. The patient has had type 1 diabetes since age 13. She has numerous complications from her disease, including reduced vision, heart disease, and severe numbness and tingling of the extremities. Knowing that spirituality helps patients cope with chronic illness, which of the following principles should the nurse apply in practice? (Select all that apply.) 1. Pay attention to the patient's spiritual identity throughout the course of her illness. 2. Select interventions that you know scientifically support spiritual well-being. 3. Listen to the patient's story each visit to the clinic, and offer a compassionate presence. 4. When the patient questions the reason for her long-time suffering, try to provide answers. 5. Consult with a spiritual care adviser, and have the adviser recommend useful interventions.
Answer: 1, 3. Chapter 35
A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.) 1. Ask the patient about any allergies and reactions. 2. Instruct the patient that a full bladder is required for the test. 3. Instruct the patient to save all urine in a special container. 4. Ensure that informed consent has been obtained. 5. Instruct the patient that facial flushing can occur when the contrast media is given.
Answer: 1, 4, 5. Chapter 46
A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions? (Select all that apply.) 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
Answer: 1, 4. Chapter 42
What assessments does a nurse make before hanging an intravenous (IV) fluid that contains potassium? (Select all that apply.) 1. Urine output 2. Arterial blood gases 3. Fullness of neck veins 4. Serum potassium laboratory value in EHR 5. Level of consciousness
Answer: 1, 4. Chapter 42
Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet. 2. Use a low-volume enema daily. 3. Avoid gluten in the diet. 4. Take laxatives twice a day. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day. 7. Take probiotics 5 times a week
Answer: 1, 5, 6. Chapter 47
The nurse is evaluating the recent lab results for a patient. Which labs are the best indicators for malnutrition? (Select all that apply.) 1. Serum total protein 2. Potassium 3. Lipids 4. Albumin 5 Serum BUN
Answer: 1, 5. Chapter 45
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 inter- ventions are directed at promoting self-esteem in this patient? 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
Answer: 1. Chapter 33
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? 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.
Answer: 1. Chapter 33
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? 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
Answer: 1. Chapter 45
Which action can a nurse delegate to assistive personnel (AP)? 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
Answer: 1. Chapter 45
During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first? 1. Stop the instillation. 2. Ask the patient to take deep breaths to decrease the pain. 3. Tell the patient to bear down as he would when having a bowel movement. 4. Continue the instillation; then administer a pain medication
Answer: 1. Chapter 47
The nurse is gathering a sexual health history on a patient being admitted to the hospital for surgery. Which question demonstrates a nonjudgmental attitude? 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?
Answer: 1. Chapter 34
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? 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."
Answer: 1. Chapter 34
The nurse is caring for a patient who has just had a near-death experience (NDE) following a cardiac arrest. Which intervention by the nurse best promotes the spiritual well-being of the patient after the NDE? 1. Allowing the patient to discuss the experience 2. Referring the patient to pastoral care 3. Having the patient talk to another patient who had an NDE 4. Offering to pray for the patient
Answer: 1. Chapter 35
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? 1. Denial 2. Conversion 3. Dissociation 4. Displacement
Answer: 1. Chapter 37
A patient's cultural background affects the motivation for learning. Using the ACCESS model, match the nursing approach with the correct model component. 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.
Answer: 1E, 2B, 3D, 4F, 5C, 6A. Chapter 25
The nurse is caring for a patient who is very depressed and decides to complete a spiritual assessment using the FICA tool. Using the FICA assessment tool, match the criteria on the left with the appropriate assessment question on the right. 1. F—Faith ___ 2. I—Importance of spirituality ___ 3. C—Community ___ 4. A—Interventions to address spiritual needs ___ a. Tell me if you have a higher power or authority that helps you act on your beliefs b. Describe which activities give you comfort spiritually c. To whom do you go for support in times of difficulty? d. Your illness has kept you from attending church. Is that a problem for you?
Answer: 1a, 2d, 3c, 4b. Chapter 35
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.) 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
Answer: 2, 3, 4, 5. Chapter 37
The nurse therapeutically responds to an adult patient who is anxious by: (Select all that apply.) 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. Chapter 24
Nurses must communicate effectively with the health care team for which of the following reasons? (Select all that apply.) 1. To improve the nurse's status with the health team members 2. To reduce the risk of errors to the patient 3. To provide an optimum level of patient care 4. To improve patient outcomes 5. To prevent issues that need to be reported to outside agencies
Answer: 2, 3, 4. Chapter 24
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.) 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
Answer: 2, 3, 4. Chapter 25
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.) 1. Heart disease 2. Sepsis 3. Hemorrhage 4. Skin breakdown 5. Diarrhea
Answer: 2, 3, 4. Chapter 45
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.) 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
Answer: 2, 3, 5. Chapter 33
A nurse is preparing to teach an older adult who has chronic arthritis how to practice meditation. Which of the following strategies are appropriate? (Select all that apply.) 1. Encourage family members to participate in the exercise. 2. Have patient identify a quiet room in the home that has minimal interruptions. 3. Suggest the use of a quiet fan running in the room. 4. Explain that it is best to meditate about 5 minutes 4 times a day. 5. Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer
Answer: 2, 3, 5. Chapter 35
Which interventions does a nurse implement to help a patient at the end of life maintain autonomy while in a hospital? (Select all that apply.) 1. Use therapeutic techniques when communicating with the patient. 2. Allow the patient to determine timing and scheduling of interventions. 3. Allow patients to have visitors at any time. 4. Provide the patient with a private room close to the nurses' station. 5. Encourage the patient to eat whenever he or she is hungry
Answer: 2, 3, 5. Chapter 36
Which of the following assessment findings suggest an altered self-concept? (Select all that apply.) 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
Answer: 2, 3. Chapter 33
A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention(s)? (Select all that apply.) 1. Increase the rate of the CBI. 2. Assess the patency of the drainage system. 3. Measure urine output. 4. Assess vital signs. 5. Administer ordered pain medication
Answer: 2, 3. Chapter 46
Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) 1. Attach a 3-mL syringe to the inflation port. 2. Allow the balloon to drain into the syringe by gravity. 3. Initiate a voiding record/bladder diary. 4. Pull the catheter quickly. 5. Clamp the catheter before removal.
Answer: 2, 3. Chapter 46
A 44-year-old male patient has just been told that his wife and child were killed in an auto accident while coming to visit him in the hospital. Which of the following statements are assessment findings that support a nursing diagnosis of Spiritual Distress related to loss of family members? (Select all that apply.) 1. "I need to call my sister for support." 2. "I have nothing to live for now." 3. "Why would my God do this to me?" 4. "I need to pray for a miracle." 5. "I want to be more involved in my church
Answer: 2, 3. Chapter 35
The nurse uses silence as a therapeutic communication technique. What are the purposes of the nurse's silence? (Select all that apply.) 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
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. Chapter 24
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. 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."
Answer: 2, 4, 3, 1. Chapter 37
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.) 1. Sexual issues are expected in a woman this age. Copyright 2021 © by Elsevier, Inc. All rights reserved. 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
Answer: 2, 4, 5. Chapter 34
A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks whether the patient is dying and now in "hospice." What does the nurse tell the family member about palliative care? (Select all that apply.) 1. Palliative care and hospice are the same thing. 2. Palliative care is for any patient, any time, any disease, in any setting. 3. Palliative care strategies are primarily designed to treat the patient's illness. 4. Palliative care relieves the symptoms of illness and treatment. 5. Palliative care selects home health care services
Answer: 2, 4. Chapter 36
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.
Answer: 2, 4. Chapter 25
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.) 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.
Answer: 2, 4. Chapter 34
Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.) 1. Lift the patient's hips off the bed and slide the bedpan under the patient. 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 3. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient. 4. Have the patient stand beside the bed, and then have him or her sit on the bedpan on the edge of the bed. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed
Answer: 2, 5. Capter 47
What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? 1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks. 2. Initiate bowel or habit training program to promote continence. 3. Help the patient to toilet once every hour. 4. Use sanitary pads in the patient's underwear
Answer: 2. Chapter 47
What are the physical circulatory changes that occur as death approaches? 1. Skin irritation 2. Mottling 3. Increased urine output 4. Weakness
Answer: 2. Chapter 36
The nurse detects new onset of crackles in the lung bases. What is the priority action? 1. Notify a health care provider. 2. Decrease the IV flow rate. 3. Lower the head of the bed. 4. Discontinue the IV site.
Answer: 2. Chapter 42
When delegating input and output (I&O) measurement to assistive personnel, the nurse instructs them to record what information for ice chips? 1. Two-thirds of the volume 2. One-half of the volume 3. One-quarter of the volume 4. Two times the volume
Answer: 2. Chapter 42
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? 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
Answer: 2. Chapter 45
There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next? 1. Remove the catheter and start all over with a new kit and catheter. 2. Leave the catheter there and start over with a new catheter. 3. Pull the catheter back and reinsert at a different angle. 4. Ask the patient to bear down and insert the catheter farther.
Answer: 2. Chapter 46
Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? 1. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution 2. Hanging the urinary drainage bag below the level of the bladder 3 Emptying the urinary drainage bag daily 4. Irrigating the urinary catheter with sterile water
Answer: 2. Chapter 46
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? 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
Answer: 2. Chapter 26
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: 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
Answer: 2. Chapter 34
A patient has just learned she has been diagnosed with a malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. The nurse has been caring for her for only 2 hours but has a good relationship with her. What is the most appropriate intervention for support of her spiritual well-being at this time? 1. Make a referral to a professional spiritual care adviser. 2. Sit down and talk with the patient; have her discuss her feelings and listen attentively. 3. Move the patient's Bible from her bedside cabinet drawer to the top of the over-bed table. 4. Ask the patient whether she would like to learn more about the implications of having this type of tumor.
Answer: 2. Chapter 35
An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? 1. Recommend that she be evaluated for an overactive bladder (OAB) medication. 2. Establish a toileting schedule. 3. Recommend that she be evaluated for an indwelling catheter. 4. Start a bladder-retraining program.
Answer: 2. Chapter 46
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? 1. Selling approach 2. Telling approach 3. Entrusting approach 4. Participating approach
Answer: 2. Telling is the best approach when there is limited time for teaching information. Chapter 25
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? 1. 100 mL/hr 2. 125 mL/hr 3. 167 mL/hr 4. 200 mL/hr
Answer: 2. To infuse 500 mL in 4 hours, set the rate at 125 mL/hr. (500 divided by 4 = 125) Chapter 42
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:
Answer: 2000. Chapter 26
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.) 1. Affective domain 2. Sensory domain 3. Cognitive domain 4. Attentional domain 5. Psychomotor domain
Answer: 3 and 5. Chapter 25
A nursing student is developing a plan of care for a 74-year-old-female patient who has spiritual distress over losing a spouse. As the nurse develops appropriate interventions, which characteristics of older adults should be considered? (Select all that apply.) 1. Older adults do not routinely use complementary medicine to cope with illness. 2. Older adults dislike discussing the afterlife and what might have happened to people who have passed on. 3. Older adults achieve spiritual resilience through frequent expressions of gratitude. 4. Have the patient determine whether her husband left a legacy behind. 5. Offer the patient her choice of rituals or participation in exercise
Answer: 3, 4, 5. Chapter 35
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.) 1. Post-traumatic stress disorder 2. Rising hormone levels 3. Chronic illness 4. Insomnia 5. Depression
Answer: 3, 4, 5. Chapter 37
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 inter- ventions by the nurse? (Select all that apply.) 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.
Answer: 3, 4. Chapter 33
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.) 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.
Answer: 3, 4. Chapter 34
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.) 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."
Answer: 3, 5. Chapter 37
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? 1. Electronic health record (EHR) 2. Charting by exception 3. Clinical decision support system (CDSS) 4. Computerized physician order entry (CPOE)
Answer: 3. Chapter 26
When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, what is the first assessment the nurse conducts? 1. The amount of family support 2. A 3-day diet recall 3. A thorough physical assessment 4. Threats to safety in her home
Answer: 3. Chapter 37
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? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosi
Answer: 3. Chapter 42
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? 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
Answer: 3. Chapter 45
What is a critical step when inserting an indwelling catheter into a male patient? 1. Slowly inflate the catheter balloon with sterile saline. 2. Secure the catheter drainage tubing to the bedsheets. 3. Advance the catheter to the bifurcation of the drainage and balloon ports. 4. Advance the catheter until urine flows, then insert ¼ inch more
Answer: 3. Chapter 46
Which instruction should the nurse give the assistive personnel (AP) concerning a patient who has had an indwelling urinary catheter removed that day? 1. Limit oral fluid intake to avoid possible urinary incontinence. 2. Expect patient complaints of suprapubic fullness and discomfort. 3. Report the time and amount of first voiding. 4. Instruct patient to stay in bed and use a urinal or bedpan
Answer: 3. Chapter 46
A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen? 1. Get three fecal smears from one bowel movement. 2. Obtain one fecal smear from an early-morning bowel movement. 3. Collect one fecal smear from three separate bowel movements. 4. Get three fecal smears when you see blood in your bowel movement.
Answer: 3. Chapter 47
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? 1. Focus charting incorporating "Data, Action & Response" (DAR) 2. Problem-intervention-evaluation (PIE) 3. Charting-by-exception (CBE) 4. Narrative documentation
Answer: 3. Chapter 26
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: 1. Demonstration 2. Preparatory instruction 3. Role-playing 4. Group instruction with other family caregiver
Answer: 3. Chapter 25
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
Answer: 3. Chapter 25
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? 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
Answer: 3. Chapter 25
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: 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."
Answer: 3. Chapter 34
A nurse used spiritual rituals as an intervention in a patient's care. Which of the following questions is most appropriate to evaluate its efficacy? 1. Do you feel the need to forgive your wife over your loss? 2. What can I do to help you feel more at peace? 3. Did either prayer or meditation prove helpful to you? 4. Should we plan on having your family try to visit you more often in the hospital?
Answer: 3. Chapter 35
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? 1. Dryness of mucous membranes 2. Skin turgor 3. Fullness of neck veins when supine 4. Fullness of neck veins when uprigh
Answer: 3. Chapter 42
A nurse is caring for a patient who is Muslim and has diabetes. Which of the following items does the nurse need to remove from the meal tray when it is delivered to the patient? 1. Small container of vanilla ice cream 2. A dozen red grapes 3. Bacon and eggs 4. Garden salad with ranch dressing
Answer: 3. Islam prohibits the consumption of pork Chapter 35
When providing postmortem care, which actions are necessary for the nurse to complete? 1. Locating the patient's clothing 2. Calling the funeral home 3. Providing culturally and religiously sensitive care in body preparation 4. Providing postmortem care to protect the family of the deceased from having to view the body
Answer: 3. A Chapter 36
1. Josh calculates Elyse's body mass index (BMI). Her BMI is _________.
Answer: 37.3 Case Study, Chapter 45
The nurse assesses pain and redness at a vascular access device (VAD) site. Which action is taken first? 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.
Answer: 4. Chapter 42
The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance
Answer: 4. Chapter 47
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? 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."
Answer: 4. Chapter 33
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? 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
Answer: 4. Chapter 33
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? 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. Chapter 37
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? 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
Answer: 4. Chapter 45
Which statement made by the parents of a 2-month-old infant requires further education by the nurse? . "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."
Answer: 4. Chapter 45
A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? 1. Have you eaten more high-fiber foods lately? 2. Have you taken antibiotics recently? 3. Do you have gluten intolerance? 4. Have you experienced frequent, small liquid stools recently
Answer: 4. Chapter 47
lowing 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? 1. Motivation to learn 2. Developmental stage 3. Stage of grief 4. Readiness to learn
Answer: 4. Chapter 25
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? 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
Answer: 4. Chapter 26
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? 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
Answer: 4. Chapter 26
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? 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
Answer: 4. Chapter 26
Which statement made by a patient who is recovering after recently experiencing third-degree burns shows connectedness? 1. "My pain medicine helps me feel better." 2. "I know I will get better if I just keep trying." 3. "I see God's grace and become relaxed when I watch the sun set at night." 4. "I feel so much closer to God after I read my Bible and pray
Answer: 4. Chapter 35
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? 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.
Answer: 4. Chapter 45
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. 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. Chapter 24
Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. 1. Insert and advance catheter. 2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus with antiseptic solution. 5. Drape patient with the sterile square and fenestrated drapes. 6. When urine appears, advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.
Answer: 5, 7, 2, 4, 1, 6, 3, 8, 9. Chapter 46
Place the steps for an ileostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.
Answer: 5, 8, 7, 2, 6, 3, 4, 1. Chapter 47
Place the following steps for discontinuing intravenous (IV) access in the correct order: 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 pressur
Answer: 6, 4, 2, 1, 5, 3, 7. Chapter 42
A nurse has the responsibility of managing a patient's postmortem care. What is the proper order for postmortem care when there is no autopsy ordered? 1. Bathe the body of the deceased. 2. Collect any needed specimens. 3. Remove all tubes and indwelling lines. 4. Position the body for family viewing. 5. Speak to the family members about their possible participation. 6. Ensure that the request for organ/tissue donation and/or autopsy was completed. 7. Notify support person (e.g., spiritual care provider, bereavement specialist) for the family. 8. Accurately tag the body, including the identity of the deceased and safety issues regarding infection control. 9. Elevate the head of the bed
Answer: 6, 9, 2, 5, 7, 3, 1, 4, 8. Chapter 36
Beth should advance the catheter ________ to _______ inches or until urine flows out of it.
Answer: 7 to 9 Case Study, Chapter 46
Mrs. McIntosh is a 72-year-old Caucasian woman whose husband of 50 years recently passed away. She had been his primary caregiver. Since her husband's death 3 months ago, she has lost 20 pounds as a result of her lack of interest in food. She tells her daughter that she feels "so heavy and tired all of the time." Mrs. McIntosh, once vivacious and very active, now confesses that she has trouble getting out of bed in the morning because she doesn't have much purpose in life since she no longer needs to care for Mr. McIntosh. Mrs. McIntosh's daughter brings Mrs. McIntosh to the behavioral health clinic for assistance. Walter is the nursing student assigned to her. He takes a patient history and asks her several questions about her mood and recent habits. 1. Mrs. McIntosh no longer has to care for Mr. McIntosh. Because of this, she is most likely experiencing which of the following? A. Role performance stressor B. Body image disturbance C. Identity attainment D. Self-esteem freedom
Answer: A Case Study, Chapter 33
Mr. Matt Wexler is being admitted to the psychiatric unit at the Veteran's Affairs (VA) hospital for violent behavior. He is a 28-year-old soldier who has just returned from three tours in Afghanistan. His girlfriend stated that he tried to strangle her when he confused her with an undercover Afghani secret agent. Marlene is the nursing student assigned to Mr. Wexler. She reviews his intake forms and health care provider's orders. His diagnoses are posttraumatic stress disorder (PTSD), paranoia, and psychosis. 1. Marlene talks with Mr. Wexler about his diagnoses and care plan. She explains to him that he is experiencing both situational and adventitious crises as a result of his experience in the Middle East. The frame of reference for Mr. Wexler's crises is which of the following? A. Mr. Wexler's point of view B. Mr. Wexler's medical history C. Mr. Wexler's girlfriend's point of view D. Mr. Wexler's care plan
Answer: A Case Study, Chapter 37
1. Franz studies acid-base balance. Which two organs are responsible for acid excretion, which helps maintain acid-base balance? A. Lungs and kidneys B. Kidneys and liver A. Bladder and bowel B. Lungs and bladder
Answer: A Case Study, Chapter 42
Mrs. Pearl Butler is a 71-year-old Caucasian who is admitted to the medical-surgical unit after undergoing a thyroidectomy secondary to thyroid cancer. Chemotherapy and radiation were not aggressive enough in treatments; thus she opted to have her thyroid gland removed. She is resting comfortably in her room with her husband present. The nurse assigned to care for Mrs. Butler has already taken her vital signs: temperature 98.7° F, blood pressure 112/82 mm Hg, pulse = 62 beats/min, and respirations 22 breaths/min on room air. The nurse is now checking the medication administration record (MAR) to see what medications Mrs. Butler has ordered. 1. The nurse notices that Mrs. Butler has been taking her as needed (prn) pain medication, hydrocodone 5mg/acetaminophen 500mg, every 4 hours as ordered. While the nurse is assessing Mrs. Butler's pain to determine if another dose of pain medication is needed, Mrs. Butler states that she hasn't had a bowel movement (BM) since her surgery 3 days ago. The nurse knows that Mrs. Butler's constipation is most likely caused by which of the following? A. Opioid use for pain management B. Mrs. Butler's age C. Too much fat in Mrs. Butler's diet D. The thyroidectomy procedure
Answer: A Case Study, Chapter 47
1. Boris takes Mr. Scalini's vital signs at 0800. When should Boris chart Mr. Scalini's vital signs? A. At the time of occurrence B. At the end of shift C. Before the lunch break At 1200
Answer: A Case Study Chapter 26
1. Mrs. Yang says to Mattie, "Where is my hula? This isn't my hula!" Mattie replies, "I'm not sure I understand. Your hula? Perhaps do you mean your house? You don't know where your house is? Did you mean house but mistakenly said hula?" Mrs. Yang snaps, "Yes! My house. That's what I meant. The right word wouldn't come." Mattie uses the communication technique of clarifying to explain further what Mrs. Yang is trying to say. A. True B. False
Answer: A Rationale: Alzheimer's patients typically confuse words. Clarifying by giving an example of what the patient means helps resolve any confusion and improves communication between the nurse and patient. Case Study, Chapter 24
1. Michelle sits in on a counseling session with her nursing mentor and a childless couple. The choices for infertile couples include which of the following? (Select all that apply.) A. Pursuing adoption B. Remaining childless C. Undergoing fertilization treatment D. Medicating with St. John's wort
Answer: A, B, C Case Study, Chapter 34
1. To determine which bowel elimination methods work best for Mrs. Butler, the nurse asks which of the following pertinent assessment questions? (Select all that apply.) A. "What is your regular bowel routine?" B. "Do you use laxatives, enemas, or stool softeners at home?" C. "What is your typical daily diet?" D. "Do you take iron supplements at home?" E. "What time do you go to sleep each evening?""What time do you go to sleep each evening?"
Answer: A, B, C, D Case Study Chapter 47
Mrs. McIntosh displays signs of altered self-concept during the patient interview with Walter. What are the signs of altered self-concept? (Select all that apply.) A. Avoidance of eye contact B. Lack of interest C. Difficulty in making a decision D. Rapid speech E. Unkempt appearance
Answer: A, B, C, E Case Study Chapter 33
1. Mr. Smith tells Margaret that he doesn't think he can hold the spoon on his own and feed himself. Mr. Smith lacks self-efficacy. Self-efficacy comes from which of the following sources? (Select all that apply.) A. Enactive mastery experiences B. Vicarious experiences C. Auditory persuasion D. Physiological states
Answer: A, B, D Case Study, Chapter 25
Mrs. McIntosh is diagnosed with situational altered self-concept related to loss of husband. Walter develops the following goal for Mrs. McIntosh: "Patient's self-concept will improve in 2 weeks." Which of the following are examples of expected outcomes directed to this goal? (Select all that apply.) A. The patient will attend a bereavement support group twice a week. B. The patient will become less depressed. C. The patient will get out of bed each morning at 8 am. D. The patient will bathe and dress each morning after rising. E. The patient will become more balanced.
Answer: A, C, D Case Study Chapter 33
1. Marlene teaches Mr. Wexler how to interpret the impact of his military experience and violent act toward his girlfriend. She is teaching him how to take an ________________ of himself.
Answer: Appraisal Chapter 37
1. Sara further explores the concept of grief. Suicide is a risk for people who experience masked grief. A. True False
Answer: B Case Study Chapter 36
1. Mr. Smith becomes agitated as Margaret tries to retrain him in his use of eating utensils. Margaret knows that, as his anxiety increases, his ability to pay attention also increases. A. True B. False
Answer: B Case Study, Chapter 25
1. Franz knows that hypercalcemia and hypermagnesemia increase neuromuscular excitability. A. True B. False
Answer: B Case Study, Chapter 42
1. Josh emphasizes the importance of taking vitamins to Elyse, especially since she is malnourished as a result of the excessive vomiting. Water-soluble vitamins include vitamins A, D, E, and K. A. True B. False
Answer: B Case Study, Chapter 45
Elyse Russo is a 17-year-old high-school student who struggles with obesity. She is 5 feet 4 inches and weighs 210 pounds. She goes to a weight-loss clinic to try to get her weight and eating habits under control. Josh is a nursing student who works at the weight-loss clinic two times a week while in nursing school. He took the job to help pay for nursing school and also to help him learn how to interact with various types of people since he knew that as a nurse he would have to interact with the public. At first Josh didn't enjoy his job because he couldn't understand how people allowed themselves to become obese. Over time he learned to develop compassion for his patients, and he gained an understanding of the various causes of obesity. In addition, he learned a great deal about nutrition, healthy cooking, and controlling portions. 1. Josh teaches Elyse about proper nutrition. Elyse states, "I can't control my eating. I vomit after I eat to try to lose weight, but I'm still fat." The adolescent suffers from which of the following? A. Anorexia nervosa B. Bulimia nervosa C. Impaired reality D. Fad dieting
Answer: B Case Study, Chapter 45
1. Marlene teaches Mr. Wexler about crisis management. Most crises are resolved within 2 weeks. A. True B. False
Answer: B Chapter 37
1. Boris charts Mr. Scanlini's vital signs and intake and output on a flow sheet. Documenting on a flow sheet ensures duplication of data as required by The Joint Commission. A. True B. False
Answer: B Case Study Chapter 26
1. Boris charts Mr. Scalini's pain assessment in Mr. Scalini's chart. Which of the following is a correct example of charting as it appears in the chart? A. "Patient appears to be free from pain." B. "Patient states a 0 on a pain-rating scale of 1 to 10." C. "Patient seems to be resting comfortably." D. "Patient seems to have pain at the incision site."
Answer: B Case Study, Chapter 26
1. During the counseling session with Michelle, the nursing mentor, and the childless couple, sexual dysfunction is discussed. Sexual dysfunction is higher in men than in women. A. True False
Answer: B Case Study, Chapter 34
Michelle is a nursing student who has always been interested in the creation of life, the process of conception, and newborns. Because of this interest, she volunteers at a fertility clinic one afternoon a week. She enjoys working with singles and couples who wish to have children; she finds great satisfaction in helping her patients' dreams come true. 1. Michelle knows that infertility is the inability to conceive after 6 months of unprotected intercourse. A. True False
Answer: B Case Study, Chapter 34
Franz is a first-semester nursing student who struggles with the concepts associated with electrolyte and acid-base balance. He knows that he needs to get a handle on these concepts because they are the foundation of understanding pathophysiology and as a nurse he will be responsible for understanding and interpreting laboratory reports so he may deliver the best patient care possible. Franz reviews the concepts of fluid, electrolyte, and acid-base balance as he studies for his midterm examination. 1. Franz learns that hyperkalemia may be the result of chronic diarrhea. A. True False
Answer: B Rationale: Chronic diarrhea causes hypokalemia, a loss of potassium Case Study, Chapter 42
1. Which of the following nursing assessment questions posed by Max to Mrs. Gupta will help him develop her plan of care? (Select all that apply.) A. "How long have you been a Hindu?" B. "How happy are you with your life?" C. "How does your faith help you cope?" D. "How has your illness changed your life?" E. "Do you pray?"
Answer: B, C, D, E Chapter 35
1. Sara teaches the bereavement group Kübler-Ross' five stages of dying. Rank them in order. A. Bargaining B. Denial C. Depression D. Acceptance Anger
Answer: B, E, A, C, D Case Study, Chapter 36
Sara is in her last semester of nursing school. She works as a student nurse twice a week with the local hospice to fulfill her community health rotation course requirement. Hospice offers bereavement counseling to the family members of deceased patients. The hospice director asks Sara to prepare an educational lesson to present at the next bereavement group meeting. 1. Sara plans to teach the bereavement group about the different kinds of grief. A gay man's grief over the loss of his partner to acquired immunodeficiency syndrome (AIDS) signifies which type of grief? A. Normal grief B. Anticipatory grief C. Disenfranchised grief Ambiguous grief
Answer: C Case Study Chapter 36
Margaret is a first-semester nursing student who is doing her clinical rotation in an assisted-living care facility. She is assigned to Mr. Alfred Smith, an 81-year-old African-American male who has dementia. Mr. Smith's family could no longer take care of him at home because he became combative in the evenings as a result of the effects of sundowner's syndrome. to preserve his safety, Mr. Smith now lives on the locked unit at the assisted-living facility where one or more members of his immediate and extended family come to visit every day. In addition, Mr. Smith's great niece, Harriet, works at the same facility and checks on Mr. Smith during each of her shifts. 1. Because of Mr. Smith's progressing dementia, he has difficulty feeding himself. When Margaret prompts him to eat his oatmeal at breakfast, he just stares at his spoon. Margaret picks up his spoon and wraps his hand around the handle. For which psychomotor learning skill is Margaret trying to retrain Mr. Smith? A. Set B. Mechanism C. Perception D. Guided response
Answer: C Case Study, Chapter 25
Mrs. Anna Gupta is a 54-year-old Hindu woman admitted to the medical-surgical unit for recovery from a total hysterectomy. The hysterectomy was required because she suffered from heavy bleeding secondary to fibroid tumors. She is in her room surrounded by family, including her husband, two sons, and a daughter. Max is the nursing student assigned to Mrs. Gupta. Max reviews her surgical record, laboratory results, and medication orders before entering her room to perform an admission history and physical examination. He notes that Mrs. Gupta is Hindu; therefore he plans to ask about her cultural and spiritual preferences during the patient interview. 1. Max asks Mrs. Gupta to explain her medical history, including the decision to undergo a hysterectomy. Which of the following statements made by Mrs. Gupta is a reflection of her religious beliefs? A. "I can only have a female nurse examine me." B. "My fibroids were caused by nonhuman spirits that invaded my body." C. "My past sins are responsible for my fibroid tumors." D. "Singing will help me heal faster."
Answer: C Case Study, Chapter 35
Mrs. Elaine Yang is an 82-year-old Chinese woman who lives in a long-term care facility. She has early-onset Alzheimer's disease, which causes her to not always be oriented to person, time, and place. She used to smoke 1.5 packs of cigarettes per day, but she quit smoking 10 years ago. Other than having an occasional headache, she is healthy and does not require any medication except acetaminophen for the headaches. Mattie is the nursing student assigned to Mrs. Yang. Mattie's priorities in caring for Mrs. Yang are to maintain safety and help orient Mrs. Yang when she becomes confused. 1. Mrs. Yang is very stoic and never asks for help. Mattie has learned this and thus pretends that she is running an errand on the other side of the building to secretly assist Mrs. Yang to the dining room to ensure that she arrives safely to lunch. Mattie gently touches Mrs. Yang's shoulder as they walk along the hallway. Which zone of touch is Mattie exhibiting? A. Consent zone B. Intimate zone C. Social zone D. Vulnerable zone
Answer: C Rationale: The social zone of touch includes the hands, arms, shoulders, and back; permission is not required to touch these areas Case Study Chapter 24
1. Sara teaches the bereavement group the Grief Tasks Model by Worden. Rank in order the tasks of this grief theory. A. Emotionally relocate the deceased and move on with life. B. Experience the pain of grief. C. Accept the reality of the loss. D. Adjust to a world in which the deceased is missing.
Answer: C, B, D, A Case Study , Chapter 36
1. Mrs. Yang tells Mattie that she has something important to tell her. Mattie uses the active listening techniques of SOLER when communicating with Mrs. Yang. Which of the following are techniques of SOLER? (Select all that apply.) A. Listen to the patient. B. Establish constant eye contact. C. Sit facing the patient. D. Observe an open posture. E. Reiterate the patient's statements.
Answer: C, D Rationale: The techniques of SOLER are: sit facing the patient; observe an open posture; lean toward the patient; establish and maintain intermittent eye contact; and relax. Case Study, Chapter 24
Mr. Ryan Kelter is a 33-year-old Caucasian who lives in an acute rehabilitation center. He was injured in a motorcycle accident that caused a spinal cord injury (SCI). As a result of the SCI, he has neurogenic bladder that prevents him from fully emptying his bladder. Because of this, he needs to be straight catheterized several times a day. Beth is the student nurse assigned to Mr. Kelter. She understands the importance of keeping him on his bladder schedule to prevent a urinary tract infection (UTI). 1. Beth enters Mr. Kelter's room after lunch to perform straight catheterization. List in order the steps Beth takes to perform straight catheterization on Mr. Kelter. A. Lubricate the catheter. B. Clean penis with dominant hand. C. Apply sterile gloves. D. Advance catheter into penis. E. Apply fenestrated drape. F. Hold penis with nondominant hand. G. Ask patient to bear down. H. Coil catheter in dominant hand.
Answer: C, E, A, F, B, H, G, D Case Study, Chapter 46
1. Franz learns the difference between Chvostek's and Trousseau's signs. A positive Chvostek's sign elicits which of the following? A. Bilateral muscle weakness in the quadriceps B. Bilateral muscle weakness of the respiratory muscles C. Carpal spasm with hypoxia D. Contraction of facial muscles when a facial nerve is tapped
Answer: D Case Study, Chapter 42
Boris is a nursing student on the medical-surgical unit who is assigned a new admission from the postanesthesia care unit (PACU), Mr. Rudolpho Scalini. Mr. Scalini is 54 years old and status post-right total hip replacement (THR). He is an owner of a local Italian restaurant chain and is 5'6" and 220 pounds. Mr. Scalini's hip replacement was precipitated by his obesity and refusal to engage in a regular exercise program. Boris conducts his admission assessment of Mr. Scalini and charts his findings in the electronic health record (EHR). 1. Boris completes Mr. Scalini's admission paperwork. Which of the following establishes reimbursement to the hospital for Mr. Scalini's care? A. Patient care plan B. Joint Commission standards C. Nanda diagnoses D. Diagnosis-related groups
Answer: D Case Study Chapter 26
1. Mr. Smith constantly denies that he has dementia by stating, "I'm old. A little forgetfulness is normal." Mr. Smith is in the _________ or _________ stage of grieving.
Answer: Denial or disbelief Case Study, Chapter 25
As Max concludes his assessment and patient interview, Mrs. Gupta states, "You are very kind...a good boy. You make me feel better. Good things will come to you." Max took the time to develop a holistic view of Mrs. Gupta and her care. Therefore he created a ____________ relationship with her.
Answer: Healing Case Study, Chapter 35
1. The nurse knows that it is important to immediately start Mrs. Butler on a bowel medication regimen to prevent fecal impaction. Unresolved fecal impaction can result in _______________ ______________.
Answer: Intestinal obstruction Case Study Chapter 47
1. Franz studies the difference between metabolic acidosis and alkalosis. _____________ _____________ increases blood HCO-3.
Answer: Metabolic alkalosis Case Study, Chapter 42
The nurse is writing a narrative progress note. Identify each of the following statements as subjective data (S) or objective data (O): 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
Answer: O: 1, 2, 3, 5, 6, 7. Chapter 26
1. Mattie says to Mrs. Yang, "You look wonderful today, Mrs. Yang. You seem very rested. And what a beautiful scarf! Did that come from China?" Mattie is sharing ___________ with Mrs. Yang.
Answer: Observations Case Study, Chapter 24
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 ____________.
Answer: Post-traumatic stress disorder (PTSD). Chapter 37
1. Mr. Wexler says to Marlene, "I'm worried about how my hospital stay and illness affects the rest of my life. How am I supposed to support myself and my girlfriend if I'm in the hospital?" The uncertainty associated with hospitalization and illness is a _______________ factor.
Answer: Situational Case Study, Chapter 37
Max uses the SWB scale to assess Mrs. Gupta's spirituality. What does SWB stand for?
Answer: Spiritual well-being Case Study, Chapter 35
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.) 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
Answers: 1, 2, 5. Chapter 26
