Topic 3 EAQ

The nurse is planning a teaching session a group of children who are in first grade about healthy nutrition. The nurse determines that after the teaching session the children will be able to name three examples of foods that are fruits. Of what is this is an example? A teaching plan A learning objective Reinforcement of content Enhancing the children's self-efficacy

A learning objective A learning objective describes what the learner will do after the teaching session. p. 338

The nurse understands that levels of preventive care include primary, secondary, and tertiary prevention. Which activities are included in primary prevention? Health education programs Immunizations Physical fitness activities Diagnostic tests Drug therapy

Health education programs Immunizations Physical fitness activities Health education programs, immunizations, and physical fitness activities aim at preventing illness and promoting health. These primary prevention activities are targeted towards physically and emotionally healthy people. Diagnostic tests and drug therapy are secondary levels of care and are performed when disease is already present. pp. 70-71

The nurse is teaching a group of young college-age women the importance of using sunscreen when going out in the sun. What type of content is the nurse providing? Simulation Restoring health Coping with impaired function Health promotion and illness prevention

Health promotion and illness prevention Health promotion and illness prevention are the focus when nurses provide information to help patients improve their health and avoid illness. p. 337

In the pyramid of Maslow's hierarchy of needs, which need of the patient is placed at the highest level? Food Love Self-actualization Physical safety

Self-actualization Maslow's model of the hierarchy of needs is used to understand the interrelationships of basic human needs. According to this model, basic needs are at the bottom and self-actualization is at the top. Self-actualization is considered the highest expression of one's individual potential, and it allows for the continual discovery of self. Food is considered a basic need and is thus placed at the bottom. The need for love comes after the need for physical safety. pp. 68-69

Which part of a sterile gown is actually considered sterile? Collar of the gown Area below the waist Underside of the sleeves Anterior surface of the sleeves

Anterior surface of the sleeves The anterior surface of the sleeves is considered sterile. The collar of the gown, the area below the waist, and the underside of the sleeves are not considered as sterile. p. 469

Which task is delegated to nursing assistive personnel (NAP)? Checking on a restraint Assessing a patient's behavior Applying restraints appropriately Orientating the patient to the environment

Checking on a restraint Checking on a restraint can be delegated to nursing assistive personnel (NAP). Assessing a patient's behavior, orientating the patient to the environment, and determining the need and appropriate use of the restraints should be performed by the nurse and are not delegated to NAP. p. 401

What major infections are caused by Escherichia coli? Hepatitis A Pneumonia Gastroenteritis Food poisoning Urinary tract infections

Gastroenteritis Urinary tract infections Gastroenteritis and urinary tract infections are major infections caused by Escherichia coli. The hepatitis A virus causes Hepatitis A. Pneumonia and food poisoning are major infections caused by Staphylococcus aureus. p. 444

The nurse is learning about various modes of infection transmission. What are the sources for vehicle transmission of infection? Mosquitoes Flies IV fluid Food Water

IV fluid Food Water Infections from vehicle transmissions are transmitted through IV fluids, food, and water. These act to help the microorganisms spread from one person to another. Mosquitoes and flies are vectors and can spread infection through external and internal transmission. p. 445

Which symptoms indicate the presence of a systemic infection? Fatigue Redness Swelling Warmth Malaise

Fatigue Malaise Fatigue, malaise, fever, and vomiting are the generalized symptoms of systemic infections. Localized infections can be assessed by redness, warmth, and swelling due to inflammation. pp. 450-451

Which should the nurse do first after discovering an electrical fire in a patient's room? Activate the fire alarm. Confine the fire by closing all doors and windows. Remove all patients in immediate danger. Extinguish the fire by using the nearest fire extinguisher.

Remove all patients in immediate danger. Follow the acronym RACE. The first step is to Rescue and Remove all patients in immediate danger. p. 392

According to the World Health Organization (WHO), what is the definition of health? Being free from illness or injury Complete physical, mental, and social well-being Absence of symptoms and signs with normal lab reports Total absence of all diseases, disorders, and syndromes

Complete physical, mental, and social well-being The World Health Organization (WHO) defines health as a "state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." Health is not only the state of being free from illness or injury or the absence of signs and symptoms. Health does not refer to the state of total absence of all diseases, disorders, and syndromes but also includes components of mental health and spiritual health. p. 66

Which activity represents secondary prevention? A home health care nurse visits a patient's home to change a wound dressing. A 50-year-old patient with no history of disease attends the local health fair and has blood pressure checked. The school health nurse provides a program to the first-year students on healthy eating. A patient attends cardiac rehabilitation sessions weekly.

A home health care nurse visits a patient's home to change a wound dressing. Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. The home health nurse changing the wound dressing is an activity that is focused on preventing complications. Much of the nursing care related to secondary prevention is delivered in homes, hospitals, or skilled nursing facilities. Educational programs and cardiac rehabilitation sessions are examples of primary preventive measures. pp. 70-71

While preparing to do a sterile dressing change, the nurse accidentally sneezes over the sterile field that is on the over-the-bed table. Which principles of surgical asepsis, if any, has the nurse violated? When a sterile field comes in contact with a wet surface, the sterile field is contaminated by capillary action. Fluid flows in the direction of gravity. A sterile field becomes contaminated by prolonged exposure to air. None of the principles were violated.

A sterile field becomes contaminated by prolonged exposure to air. Avoid activities that create air currents, such as sneezing. When you sneeze, microorganisms travel through the air by droplets, contaminating the sterile field . Therefore, "a sterile field becomes contaminated by prolonged exposure to air" is the principle violated. The other two choices are correct but they do not describe the principle violated. p. 468

Which is the desired outcome of the health promotion model? Healthy People 2020 Encouraging health-promoting behavior Modifying the personality of a person Improving the physical, mental, and social health of all age groups

Encouraging health-promoting behavior Health-promoting behavior is the desired behavioral outcome and the end point in the health promotion model. Healthy People 2020 is a health initiative. Modifying the personality of a person is not a goal of the health promotion model. The health promotion model acknowledges that people are different and each person is unique. Improving the physical, mental, and social health of all age groups is not included in the health promotion model. These are activities included in the primary level of preventive care. pp. 66, 68

Which assessment should be performed by the nurse to determine the patient's motivation to learn? Reading level Sensory deficits Cognitive function Learning style preference

Learning style preference The nurse should assess the patient's learning style preference to determine motivation to learn. Patient education is more effective if the patient and nurse have coordinate on the method of instruction. Reading level, sensory deficits, and cognitive function help to determine the patient's ability to learn. p. 345

Which behavior would lead the nurse to anticipate that patients are in the contemplation stage of change? They have integrated changes into their lifestyle. They are actively involved in changing their behavior. They have started developing a change in their behavior. They are defensive when confronted about their behavior.

They have started developing a change in their behavior. Patients in the contemplative stage will start to consider changing their behavior. Patients in the management stage will have successfully integrated the changes into their lifestyle. Patients in the action stage of health behavior changes will be actively involved in changing behavior. Patients in the precontemplation stage may become defensive about their behavior and refuse to change it. pp. 72-73

The nurse is teaching a group of parents about accidental poisoning. Which are effects of lead poisoning in a child? Adverse effects on child's growth Learning and behavioral problems Brain and kidney damage Gastrointestinal infection Increased susceptibility to fractures

Adverse effects on child's growth Learning and behavioral problems Brain and kidney damage Lead may be found in soil and water systems. It may cause poisoning if inhaled or ingested. Lead poisoning may affect the child's growth and cause learning and behavioral problems. In extreme cases, it may lead to kidney and brain damage. Lead poisoning is not known to cause gastrointestinal infections, because it is not a pathogen. It is also not associated with increased susceptibility to fractures. p. 375

A couple approaches the nurse to seek guidance regarding taking their 10-year-old child on a long ride in a car. During the discussion, the nurse learns that the car has front-seat passenger air bags. What advice should the nurse provide to this couple? Advise that the child ride in the back seat. Suggest that the child ride in the front seat. Suggest keeping the child free from any restraints. Advise of the need for an appropriate car seat for this child.

Advise that the child ride in the back seat. It is safe for a 10-year-old child to ride in the back seat. In case of accidents or a car crash, the child would sustain fewer injuries if seated in the back seat. In case of a sudden stop or a car crash, the child would be susceptible to suffering severe head injuries if unrestrained. Use of seat belts for the child is advised. An appropriate car seat is usually required for children less than 8 years of age or 80 pounds in weight. p. 386

Which safety precaution should be followed to reduce the risk of falls in a hemiparesis patient? When using a walker, stand on patient's unaffected side. Allow patient to use cane, stand on the patient's affected side and support him/her with gait belt. Performing range-of-motion exercises Touching one side frequently with other hand

Allow patient to use cane, stand on the patient's affected side and support him/her with gait belt. When an assistive device is used, stand on the patient's affected side AND support him or her with a gait belt. Providing support by holding the patient's arm is incorrect because the nurse cannot easily support the patient's weight to lower him or her to the floor if he or she faints or falls. Performing range-of-motion exercises for patients with muscle weakness can help them move more easily. Patients with a brain injury should be instructed to touch the other hand frequently to avoid the risk of paralysis. p. 385

Which factors contribute to an increase in falls in older patients? Safety devices Anticonvulsants High bed position Moderate lighting Secure rugs and carpeting

Anticonvulsants High bed position Drugs such as anticonvulsants, anti diuretics, and sedatives increase the risk of falls. Falls are the combination of individual and transient risk factors, such as high bed positioning and improper equipment. Safety devices should be kept at home to prevent the risk of falls. Poor lighting, not moderate lighting, increases the risk of falls. Loose rugs and carpeting may increase the risk of falls. p. 376

The nurse works in a psychiatric unit and understands that the use of restraints may be useful for ensuring patients' safety. A patient has been advised bed rest, but the patient often becomes anxious and moves out of bed by removing the intravenous (IV) lines. Which chemical restraint would the nurse anticipate the health care provider to order for this patient? Protective helmet A mechanical device Anxiolytic medicines Immobilizing equipment

Anxiolytic medicines Anxiolytic medicines, which are not a part of the patient's regular prescription, can be used as chemical restraints. These medications help to manage patients' behavior by making them calm and inducing sleep. A protective helmet only allows the patient to perform activities without the risk of physical injury. It does not prevent other risks such as the risk associated with removal of the intravenous (IV) line. A mechanical device and immobilizing equipment are used as physical restraints. p. 391

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What are the nurse's best actions to take first in this situation? Contact the nursing supervisor . Restrict the family's visiting privileges. Ask the family to stay with the patient if possible. Inform the family of the risks associated with side-rail use. Thank the family for being conscientious and put the four rails up. Discuss alternatives with the family that are appropriate for this patient.

Ask the family to stay with the patient if possible. Inform the family of the risks associated with side-rail use. Discuss alternatives with the family that are appropriate for this patient. The family is concerned about ensuring a safe environment for their loved one. The nurse should discuss their concerns, inform them of the risk of using four side rails, and offer safer alternatives such as the presence of a family member. If the family still insists on using four side rails, the nurse could contact the nursing supervisor to further discuss the situation with them. This is not a reason to restrict visitation; the nurse should appreciate their concern but should avoid the use of four side rails. pp. 391-392

The nurse is instructing the mother of an infant not to leave the mesh sides of playpens lowered. Which risk can be prevented by this intervention? Falls Choking Asphyxiation Strangulation

Asphyxiation If mesh sides of playpens are lowered, the possibility exists for a child's head to become wedged in the lowered mesh side and may result in asphyxiation. Falls in infants and toddlers can be prevented by instructing the mother not to leave crib sides down or babies unattended on changing tables or in infant seats. Choking can be prevented by avoiding the use of pacifiers or ribbons attached to the string around the child's neck. Strangulation can be prevented by avoiding pillows, bumper pads, large stuffed toys, or comforters in the cribs. p. 386

The nurse is performing fall prevention measures for a patient. During which step of the nursing process does the nurse perform "Timed Get up and Go" (TUG) if a patient is able to ambulate? Planning Evaluation Assessment Implementation

Assessment Performing TUG when the patient is able to ambulate is included in the assessment step of the nursing process. Planning involves gathering equipment to promote organization and performing hand hygiene to reduce the transmissions of microorganisms. Evaluation is the basic step involved when the nurse is performing visual checks in a patient. Implementation involves adjusting the bed to a proper height and inspecting the area to prevent injuries during restraint application. p. 397

Which equipment is used to sterilize surgical instruments? Autoclave Boiling water Chemical sterilants Ethylene oxide (ETO) gas

Autoclave Autoclaves use moist heat to kill pathogens and spores on surgical instruments to prevent infections. Boiling water is used to clean urinary catheters, suction tubes, and drainage collection devices. Chemical sterilants are used to disinfect heat-sensitive instruments and equipment such as endoscopes and respiratory therapy equipment. Ethylene oxide (ETO) gas is used for medical materials. p. 456

A couple is with their adolescent daughter for a school physical and state that they are worried about all the safety risks affecting this age. What are the greatest risks for injury for an adolescent? Home accidents Physiological changes of aging Poisoning and child abduction Automobile accidents, suicide, and substance abuse

Automobile accidents, suicide, and substance abuse Adolescents are at great risk for injury from automobile accidents, suicide, and substance abuse. According to the Centers for Disease Control and Prevention, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age group. In addition, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs, in an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures,. The risk of home accidents is low for this age group, because adolescents spend much of their time away from home and with their peers. p. 387

The nurse is caring for a 37-year-old male who had abdominal surgery 1 day ago. Upon examining the incision, the nurse notices a purulent exudate has formed around the incision site. Of what does a purulent exudate consist? Bacteria Neutrophils Monocytes White blood cells (WBCs) Red blood cells

Bacteria Neutrophils Monocytes White blood cells (WBCs) Accumulation of fluid, dead tissue cells, and WBCs form a purulent exudate at the site of inflammation. Exudate may be serous (clear, like plasma), sanguineous (containing red blood cells), or purulent (containing white blood cells and bacteria). Neutrophils and monocytes are forms of white blood cells. p. 446

Which environment would limit the growth of bacteria? Bacteria growing in a pH of 3.0 Bacteria growing under dressings Bacteria growing in a moist surgical wound Bacteria growing in at a temperature of 38° C

Bacteria growing in a pH of 3.0 Most bacteria prefer an environment within a pH range of 5.0 to 7.0. Therefore, bacterial growth may be prevented in a pH of 3.0. Bacteria grow vigorously in dark environments such as under dressings and within body cavities. Most bacteria require water or moisture for survival. Therefore, bacteria can grow in a moist surgical wound. Bacteria can grow vigorously if the temperature is 38° C because most bacteria grow in an ideal temperature that ranges from 20° to 43° C. p. 444

Which normal flora of the human colon can cause an infection when it enters the bloodstream? Escherichia coli Candida albicans Bacteroides fragilis Plasmodium falciparum

Bacteroides fragilis Bacteroides fragilis is a part of the normal flora of the human colon. This microorganism can cause infections if it enters the blood stream or tissue during injury or surgery. Escherichia coli causes gastroenteritis in the colon. Candida albicans causes candidiasis, pneumonia, and sepsis. Plasmodium falciparum causes malaria. p. 444

Which instrument used by the nurse requires surface disinfection? Endoscope Cardiac catheter Urinary catheter Blood pressure cuff

Blood pressure cuff There are two types of disinfection: disinfection of surfaces and high-level disinfection. Noncritical items such as blood pressure cuffs require a surface disinfection. Semi-critical items such as endoscopes require high-level disinfection. Critical items such as cardiac and urinary catheters require sterilization. p. 456

The nurse is attending to a patient who has a pressure ulcer that needs a dressing change. What actions should the nurse perform to ensure preparation of a sterile field?

Choose a clean, dry work surface above waist level. Remove bracelets and rings. Perform hand hygiene before handling equipment. Check the labels and condition of supply packaging and equipment. A clean, dry, work surface above waist level should be used because a sterile object that is held below the waist is considered contaminated. Bracelets and rings can harbor microorganisms and hence need to be removed. Performing hand hygiene before handling equipment helps to reduce the spread of microorganisms. Checking labels and the condition of the supply gives an idea of any previous opening as an open supply may cause soiling or contamination; also, labels provide information about the date of packaging and other important information about the sterility of the product. The outer edge of the outermost flap should be held when opening the commercial kit as the outer surface is considered unsterile but helps to keep the inner kit sterile. pp. 467-468

A child in the hospital starts to have a grand mal seizure while playing in the playroom. Which is the most important nursing intervention during this situation? Begin cardiopulmonary respiration. Restrain the child to prevent injury. Place a tongue blade over the tongue to prevent aspiration. Clear the area around the child to protect the child from injury.

Clear the area around the child to protect the child from injury. Once a seizure begins, the nurse needs to monitor the patient and provide a safe environment. A seizure is not an indication for cardiopulmonary resuscitation. A person having a seizure should not be restrained, but the environment should be made safe. Objects should not be forced into the mouth. p. 394

Which questions if asked by the nurse are useful for evaluating a patient's perception of safety? "Are you still afraid of falling?" "What factors led to your fall?" "What questions do you have about your safety?" "Do you feel safer as a result of the changes in home?" "Do you need help locating community resources to help make your home safer?"

"Are you still afraid of falling?" "Do you feel safer as a result of the changes in home?" Questions such as "Are you still afraid of falling?" and "Do you feel safer as a result of the changes?" help the nurse understand the patient's perceptions related to safety. When patient outcomes are not met, the nurse should ask questions such as "What factors led to your fall?" "What questions do you have about your safety?" and "Do you need help locating community resources to help make your home safer?" Test-Taking Tip: Look for answers that focus on the patient or are directed toward feelings. p. 395

A registered nurse teaches a nursing student about the nursing skills required to care for patients with infections. Which statements made by the nursing student indicate the need for further learning? "I should use only cleaned equipment." "I only need gloves when there is a risk of a splash." "I should use a mask while touching a patient's mucous membranes." "I should ensure that patients cover their mouths and noses when coughing and sneezing." "I should keep bedside surfaces clean and dry while performing aseptic procedures."

"I only need gloves when there is a risk of a splash." "I should use a mask while touching a patient's mucous membranes." When there is a risk of a splash, a nurse should use a gown, mask, and eye protection. The nurses should use clean glove when caring for a patient's mucous membranes. The nurses should use only cleaned equipment. The nurses should instruct and ensure that patients cover their mouths and noses when they cough and sneeze. The nurses should keep bedside table surfaces clutter-free, clean, and dry while performing aseptic techniques. p. 471

The nurse is teaching the parent of young child about car safety. Which statement by the parent indicates effective learning? "I should secure my 6-month-old child in a forward-facing car seat." "When my child is 1 year old, I can place his car safety seat in the front seat." "I should place my 3-month old child in the back seat with a rear-facing convertible seat." "I should not place my child in a front-facing seat before the age of 2."

"I should place my 3-month old child in the back seat with a rear-facing convertible seat." The American Academy of Pediatrics (AAP) recommends that all infants and toddlers ride in the back seat with a rear facing only seat or rear facing convertible seat until the age of 2 or when the child reaches the highest weight or height allowed by the manufacturer of the rear-facing safety seat. A 1-year-old child should not be allowed to sit in the front seat. The child should be allowed to use a front-facing seat at the age of 2 or when the child reaches the highest weight or height allowed by the manufacturer of the rear-facing safety seat. The child can be placed in a front-facing seat before the age of 2 if the child has outgrown the rear-facing seat. p. 375

The nurse is teaching the mother of a school-age child about interventions to promote safety. Which statement made by the mother indicates the need for further teaching? "I should teach child proper bicycle safety." "I should teach my child about the effects of using alcohol and drugs." "I should teach my child the safe use of equipment for play and work." "I should teach my child to operate electrical equipment under supervision."

"I should teach my child about the effects of using alcohol and drugs." The mother does not need to teach a school-age child about the effects of using alcohol and drugs at this age. This intervention would be more appropriate for adolescents, because they are more prone to risk-taking behaviors. The mother should teach the child about proper bicycle safety to reduce the risk of falls. The mother should teach the child the safe use of equipment for play and work to avoid injury. The mother should teach the child to operate electrical equipment only under supervision. p. 387

The registered nurse (RN) is teaching a nursing student about approaches to teaching a patient the proper use of a fire extinguisher at home. Which statement by the nursing student indicates a need for further teaching? "I should instruct the patient to memorize the mnemonic PASS." "I should explain how to choose the location for extinguishers." "I should describe the steps to be taken before the extinguisher is used." "I should teach the patient to attempt to control the fire before calling emergency services."

"I should teach the patient to attempt to control the fire before calling emergency services." The nurse should teach the patient to attempt to fight the fire only after calling emergency services. The nurse should instruct the patient to memorize the mnemonic PASS. The nurse should teach the patient to place an extinguisher in the kitchen, near the furnace, and in the garage. The nurse should teach the patient the steps to take before using the extinguisher. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses. p. 390

The nurse teaches the parent of an infant about interventions that promote the child's safety. Which statement by the parent does the nurse find effective for the prevention of choking? "I will immunize my child as recommended." "I will use large soft toys that have no small parts." "I will avoid leaving the mesh sides of playpens lowered." "I will make sure that my child sleeps on the back or side."

"I will use large soft toys that have no small parts." Small parts of toys may become dislodged. Therefore, the use of large, soft toys without small parts, such as buttons, would prevent choking and aspiration. Immunizing the infant would reduce the risk of sudden infant death syndrome (SIDS). When the mesh sides of a playpen are left lowered, the child's head may become lodged resulting in asphyxiation. The parent should ensure that the child sleeps on the back or side, because this prevents SIDS. p. 386

The registered nurse is teaching a group of student nurses about precautions to be taken when using oxygen tanks in a hospital. Which statement made by a student nurse indicates a need for further teaching? "Check the oxygen tank's tubing for kinks." "Post 'No Smoking' signs in patient rooms containing oxygen tanks." "Place the oxygen tanks in an upright position on the floor when not in use." "Take the primary healthcare provider's advice while changing the liter flow of oxygen."

"Place the oxygen tanks in an upright position on the floor when not in use." Oxygen tanks should be secured so they don't fall over, possibly damaging the tank. The tanks should not be placed upright on the floor when not is use; they can instead be placed flat on the floor or placed in an upright position in stands. The nurse should check for kinks in the tubing to promote the effective flow of oxygen through the tube. The contact of oxygen with heat or a spark can cause combustion. Therefore, the nurse should post "No Smoking" signs in patient rooms containing oxygen tanks. The nurse should change the liter flow of oxygen only after obtaining permission from the primary healthcare provider. p. 387

The nurse is planning discharge instructions for a patient diagnosed with human immunodeficiency virus (HIV). Which statement made by the patient would indicate effective teaching? "The virus cannot spread through sexual contact." "The virus can spread through feces only when I have symptoms of the disease." "The virus can be spread to another person by contact with body fluids." "The virus can cause Rocky Mountain spotted fever."

"The virus can be spread to another person by contact with body fluids." The primary routes of HIV infection are associated with contact of HIV-infected body fluids such as blood or semen, blood transfusions, sharing of infected needles, and needle-stick injuries. The virus spreads through sexual contact and does not spread through feces. The virus does not cause Rocky Mountain spotted fever, which is caused by Rickettsia rickettsii. pp. 444-445

The registered nurse (RN) is teaching a patient's family members about environmental assessments for substance abuse. Which statements should the nurse include in the teaching? "You should observe for increased aggressiveness." "You should check for the changes in style of dress." "You should observe for changes in interpersonal relationships." "You should check for the presence of drug-oriented magazines." "You should observe for the presence of blood spots on clothing."

"You should check for the presence of drug-oriented magazines." "You should observe for the presence of blood spots on clothing." The environmental clues that indicate substance abuse are the presence of drug-oriented magazines and the presence of blood spots on the patient's clothing, which could be caused by the injection of drugs into the body. Increased aggressiveness, changes in style of dress, and changes in interpersonal relationships are psychological clues that indicate substance abuse. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 377

The nurse finds that a patient is a chain smoker and bathes more than five times a day. On assessing medical reports, the nurse finds that the patient is on contraceptive therapy. Based on the nurse's findings, which of the patient's body defense mechanisms may weaken? Saliva Sebum Flora in the vagina Tearing and blinking of the eyes Macrophages in the respiratory tract Shedding of the outer layer of skin cells

Saliva Sebum Flora in the vagina Macrophages in the respiratory tract Smoking can result in poor oral hygiene and dehydration in the patient. Saliva contains microbial inhibitors, such as lysozyme, which plays an important role in the defense mechanism. However, poor oral hygiene and dehydration may alter this defense mechanism. Excessive bathing may result in the removal of the skin's sebum layer. Sebum is one of the skin's defense mechanisms; it contains fatty acid and kills some bacteria. Oral contraceptives and antibiotics disrupt the normal flora present in the vagina. Smoking affects macrophages and the cilia lining the upper airway, which play a crucial role in defending against microorganisms entering the body through the airway. The shedding of the outer layers of skin cells removes surface microorganisms from the body. Irregular, but not excessive, bathing can result in a failure to shed outer layers of skin cells. Smoking and excessive bathing do not affect any defense mechanisms related to the eyes. p. 447

To ensure safe use of oxygen in the home by a patient, which teaching points should the nurse include? Smoking is prohibited around oxygen. Demonstrate how to adjust the oxygen flow rate based on patient symptoms. Do not use electrical equipment around oxygen. Special precautions may be required when traveling with oxygen. It is safe to use oxygen around gas stoves, candles, or fireplaces that are in use.

Smoking is prohibited around oxygen. Do not use electrical equipment around oxygen. Special precautions may be required when traveling with oxygen. When oxygen is in use, the nurse must teach patients to take precautions to prevent fire and protect the patient. These precautions include posting "Oxygen in Use" signage, not using oxygen around electrical equipment or flammable products, properly handling oxygen cylinders/containers, ensuring that tubing is unobstructed, not adjusting liter flow without a physician's order, and taking precautions when traveling with oxygen. p. 387

What noncritical item used requires a surface disinfection? Endoscopes Stethoscope Intravascular catheter Anesthesia equipment

Stethoscope A stethoscope is a noncritical item that requires disinfection. An endoscope is a semi-critical item that requires high-level disinfection. An intravascular catheter is a critical item that requires sterilization. Anesthesia equipment is a semi-critical item that requires high-level disinfection. p. 456

A 47-year-old patient has arrived at the clinic after accidentally cutting his forearm with a pair of scissors. Which clinical manifestations would the nurse expect to indicate a local inflammation? Swelling Redness Pain Anorexia Vomiting

Swelling Redness Pain The local manifestations of inflammation include swelling, redness, and pain. These manifestations are caused by protective vascular reactions that help to combat inflammation. Anorexia and vomiting are systemic manifestations of inflammation. pp. 450-451

The nurse is admitting a 64-year-old patient who had a right hemisphere stroke and a recent fall. The spouse stated that the patient has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently the patient exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. The patient has moderate left-sided weakness that requires the assistance of two nurses and the use of a gait belt to transfer the patient to a chair. The patient currently has an intravenous (IV) line and a urinary catheter in place. Which factors increase the patient's fall risk at this time? Smokes a pack a day Used a cane to walk at home Takes antihypertensive and diuretics History of recent fall Neglect, spatial and perceptual abilities, impulsive Requires assistance with activity, unsteady gait IV line, urinary catheter

Takes antihypertensive and diuretics History of recent fall Neglect, spatial and perceptual abilities, impulsive Requires assistance with activity, unsteady gait IV line, urinary catheter Smoking is not a risk factor for falls. Using a cane at home is not a current risk factor for falls. Risk is determined by the patient's current status. p. 375

The primary healthcare provider asks the parents of an infant to provide formula feedings to the baby. Which instructions should the nurse give to the parents regarding preparation of the formula? Advise the parents to obtain the help of a health professional the first time they prepare the formula. Teach that overly diluted formula does not provide sufficient nutrients. Convince the parents that the manufacturer's instructions are not always reliable. Teach that feeding an infant undiluted formula may lead to obesity. Teach that undiluted formula causes fluid and electrolyte disturbances.

Teach that overly diluted formula does not provide sufficient nutrients. Teach that undiluted formula causes fluid and electrolyte disturbances. The nurse should teach the parents that overly diluted formula does not provide sufficient nutrients to the baby. Undiluted formula, on the other hand, may lead to a fluid and electrolyte disturbance, in which case the baby will need additional fluids. The parents need not obtain assistance from a health care professional to prepare the formula. They can simply follow the directions specified by the manufacturer, which are intended to ensure appropriate concentration of the formula. Undiluted formula does not cause obesity in children. p. 385

The nurse is assessing a group of patients in the medical surgical unit and ties colored wristbands (as per the American Hospital Association guidelines) to the patients based on the assessment. Which group of patients should receive red wristbands? The patients who have allergies The patients who are at risk of falling The patients who have a psychiatric illness The patients who have a do-not-resuscitate (DNR) order

The patients who have allergies According to the recommendations of the American Hospital Association (AHA), standardized wristband colors should be used for patients. Red bands should be given to patients with allergies. Yellow bands should be given to patients who are at risk of falls. There is no specific color for identifying patients with psychiatric illness according to the AHA. Purple bands are given to patients who have a do-not-resuscitate (DNR) order. p. 390

The nurse has used restraints for a disoriented patient. Which reasons would justify the use of restraints? To help reduce the risk of patient injury from falls To prevent the patient from removing IV infusions To help to control the patient To help to reduce the risk of injury to others by the patient To minimize the need for supervision of the patient

To help reduce the risk of patient injury from falls To prevent the patient from removing IV infusions To help to reduce the risk of injury to others by the patient Restraints are a means to maintain patient safety. Nurses use restraints to protect patients who are confused, disoriented, repeatedly fall, or try to remove medical devices such as intravenous (IV) infusions or oxygen equipment. A disoriented patient can harm others and should be restrained. A restraint is not used to control the patient or to discontinue care. STUDY TIP: Before using restraints, be clear about the requirements and the purposes of restraints. p. 391

Which age group is at the highest risk for accidental poisoning at home? Adults Toddlers Older adults Adolescents

Toddlers Toddlers, preschoolers, and young school-age children are at greater risk for accidental poisoning at home, as they tend to put objects in the mouth. Adults, older adults, and adolescents are generally not prone to accidental poisoning at home, because they are knowledgeable of poisonous substances. p. 376

In the home setting, what is the best method to sterilize a straight urinary catheter and suction tube? Use an autoclave. Use boiling water. Use ethylene oxide gas. Use chemicals for disinfection.

Use boiling water. The best sterilizer in a home setting is boiling water. Most homes do not come equipped with an autoclave. Chemicals for disinfection are used for sterilizing heat-sensitive equipment in the hospital setting and would not be appropriate for a urinary catheter. Test-Taking Tip: When the question asks about a particular setting, consider what is likely to be available in that setting. Autoclaves and ethylene oxide gas are not likely to be present in the home setting, so you can eliminate those choices. Even specific chemicals for disinfection may not be available. The availability of boiling water makes it the clear choice. p. 456

The nurse is changing the dressing of a patient at a bedside table. Which are the techniques of asepsis that the nurse should perform? Wearing a mask Using protective eyewear Using an instant alcohol hand antiseptic Having well-manicured nails Washing hands with soap and water followed by rinsing under a stream of water for 15 seconds

Using an instant alcohol hand antiseptic Having well-manicured nails Washing hands with soap and water followed by rinsing under a stream of water for 15 seconds Asepsis is the cleaning technique adopted for reducing the number of organisms present and preventing their transfer. It includes techniques such as using an instant alcohol hand antiseptic, having trimmed nails, and washing hands with soap and water. Wearing a mask and using protective eyewear are used in surgical asepsis. p. 458

Which statement regarding vascular and cellular responses is true? Vasodilation occurs at the site of injury. Chronic inflammation is an immediate response to cellular injury. Increased blood flow leads to coldness at the site of inflammation. The cellular response involves red blood cells at the site of infection.

Vasodilation occurs at the site of injury. Vasodilation occurs at the site of injury resulting in excessive blood loss at the site. The immediate response to a cellular injury is an acute inflammation. Increased blood flow at the site of inflammation leads to redness and warmth at the site of inflammation. The cellular response involves white blood cells at the site of inflammation. p. 446

Which nursing intervention should a nurse perform while dealing with a patient with a droplet infection? Wearing a gown while entering the room Wearing a respiratory device while entering the room Wearing a mask while working within 3 feet of the patient Placing the patient in a room with 12 air exchanges per hour

Wearing a mask while working within 3 feet of the patient While caring for a patient with a droplet infection, the nurse should wear a surgical mask when working within 3 feet of the patient to help prevent the spread of infection. Wearing a gown while entering the room is a contact precaution. Wearing a respiratory device and placing the patient in a room with 12 air exchanges per hour should be performed with a patient who has an airborne infection. p. 460

Which safety precaution should be taken by the patient with muscle weakness while walking? Using side rails Using crutches Using a belt restraint Wearing rubber-soled shoes

Wearing rubber-soled shoes Rubber-soled shoes are used by the patients with muscle weakness because they provide better grip on the floor. Side rails are placed on the sides of the bed to help patients in sitting and standing, but would not help the patients with ambulation. Crutches are assistive aids used by the patient who are unable to walk without support. Belt restraints are not used to support ambulation. p. 382

The nurse is instructed to clean a patient's infected surgical wound. How should the nurse apply antiseptic on the wound? Wipe around the edge of the wound first. Wipe the center of the wound first. Clean outward from the wound. Clean inward toward the wound. Clean the wound using strokes in any direction.

Wipe around the edge of the wound first. Clean outward from the wound. The surgical wound is considered sterile and the edges of the wound are contaminated. To reduce the risk of infecting the wound, the edge of the wound should be wiped first . Then the wound should be cleaned outward from the wound. This prevents the entry of microorganisms into the wound. Wiping the center of the wound first, cleaning inward toward the wound, and cleaning the wound in any direction increases risk of contamination. p. 465

The nurse is teaching a group of nursing assistive personnel about the types of fire extinguishers. Which type of fire can be extinguished using a type A fire extinguisher? Wood Cloth Gasoline Paper Paint

Wood Cloth Paper A type A fire extinguisher is used to extinguish fire caused by ordinary combustible materials such as wood, cloth, or paper. Fire caused by gasoline and paint is extinguished by type B fire extinguishers. STUDY TIP: Make up mnemonics to differentiate the uses of types A, B, and C fire extinguishers. For example, "Paint gasoline B(rown)." This is a silly idea, because how could you paint gasoline? But if you picture yourself doing so, while emphasizing the B of the color brown and imagining the B of brown as a capital B, you'll have the information memorized! Remember that B is for any flammable liquids, not just paint and gasoline. Or recall that A is an ordinAry letter, you don't want to Be flammable , and you can C ("see") electrical equipment. p. 393

A patient is diagnosed with a methicillin-resistant Staphylococcus aureus (MRSA) infection of the respiratory system and has a productive cough. The nurse auscultates the lungs and finds that the breath sounds are clear. The disposable thermometer used by the nurse indicates fever. The nurse collects a urine specimen of the patient as ordered. What interventions should the nurse perform to prevent the spread of infection? Confirm fever using an electronic thermometer. Clean the bell and diaphragm of the stethoscope with soap and water. Place specimen containers on a clean paper towel in the patient's bathroom. Label the specimen in the bathroom where samples of patients are collected. Review agency policies and precautions necessary for the specific isolation system. Eugene off target

Confirm fever using an electronic thermometer. Place specimen containers on a clean paper towel in the patient's bathroom. Review agency policies and precautions necessary for the specific isolation system. The nurse should be aware of the equipment used in an isolation room and the indications for isolation. If the disposable thermometer indicates fever, it is important to confirm it using an electronic thermometer. The nurse also needs to review agency policies and procedures. Methicillin-resistant Staphylococcus aureus (MRSA) can cause a health care-associated infection (HAI). Therefore, the nurse has to take precautions to prevent the spread of infections within the hospital. Specimen containers are to be kept in the patient's bathroom appropriately. If a stethoscope is to be reused, the diaphragm or bell should be cleaned with alcohol, rather than soap, and should be set aside on a clean surface to dry completely. After the sample is collected, labeling on the specimen container is to be done at the bedside of the patient to avoid errors. pp. 461-462

Which type of transmission-based precaution requires a gown and gloves? Droplet precautions Contact precautions Airborne precautions Protective environment precautions

Contact precautions Contact precautions require a gown and gloves because the handling of contaminated body fluids may cause infections. Droplet precautions require a surgical mask within three feet (0.9 meters) of a contagious patient. Airborne precautions require a specially equipped room with a negative airflow, referred to as an airborne infection isolation room. Protective environment precautions require a specialized room with a positive airflow set to greater than 12 air exchanges per hour. p. 460

Which nursing interventions should be followed to safely work with oxygen therapy? Maintain the oxygen at normal flow. Do not use oxygen around electrical equipment. Place the tanks upright on the floor when not in use. Check tubing for kinks that would affect the oxygen flow. Do not change the liter flow without the health care provider's order.

Do not use oxygen around electrical equipment. Place the tanks upright on the floor when not in use. Check tubing for kinks that would affect the oxygen flow. Do not change the liter flow without the health care provider's order. The necessary nursing interventions to meet basic needs related to oxygen include not using oxygen around the electrical equipment, checking the tubing for kinks that would affect the oxygen flow, and not changing the liter flow without the health care provider's order. The oxygen should be maintained at the liter flow prescribed. The tanks should be placed upright when they are not in use. p. 388

What would be the mode of transmission if a patient suspected of having tuberculosis is not isolated? Indirect Vectors Droplet Vehicles Airborne

Droplet Airborne If a patient is not isolated, he or she may spread a tuberculosis infection through droplet nuclei and airborne particles during coughing, sneezing and talking. Infections such as human immunodeficiency virus (HIV) are transmitted through indirect contact, such as needles. Malaria may be transmitted through vectors such as mosquitoes. Vehicles such as blood may transmit infection such hepatitis B, HIV, and hepatitis C. pp. 444-445

Which restraint should the nurse use to prevent nerve injury? Belt Elbow Mitten Extremity

Elbow Elbow restraint, or the freedom splint, is commonly used with infants and children to prevent elbow flexion. This helps keep the elbow extended and prevents nerve injury in cases where the IV line is placed in the antecubital fossa. Belt restraint is used to maintain the center of gravity and prevents patients from rolling off stretchers or sitting up while on stretchers, as well as from falling out of bed. Mitten restraints prevent patients from dislodging invasive equipment, removing dressings, or scratching. Extremity restraints maintain immobilization of extremities to protect patients from falling or accidental removal of therapeutic devices. p. 402

The nurse finds that an elderly patient responds slowly to any question asked and performs tasks very slowly. The nurse understands that the patient has reduced capabilities to respond to multiple stimuli. How can the nurse help the patient adapt to the condition? Inform the patient that this is a normal response to old age. Train the patient to improve reflexes. Encourage the patient's family to provide adequate stimuli. Encourage the patient's family to provide meaningful stimuli. Implement measures to prevent sensory overload of the patient.

Encourage the patient's family to provide adequate stimuli. Encourage the patient's family to provide meaningful stimuli. Implement measures to prevent sensory overload of the patient. The nurse should institute measures to educate the patient's family members so that they provide adequate and meaningful stimuli to the patient, which can preserve the patient's cognitive abilities. The nurse can also implement measures to prevent the patient from being exposed to multiple stimuli, which may cause sensory overload. Assuring the patient that losing cognitive ability is normal for old age will not necessarily help the patient adjust to the condition. In old age, learning capability diminishes, and it is not possible to train the patient to reduce the slowness of reflexes. pp. 387

Which factor can alter the defense mechanism of sebum? Abrasions Dehydration Excessive bathing Improper hand washing technique

Excessive bathing Excessive bathing can remove sebum present in the skin, which increases the risk of infections. Abrasions can provide an entrance for microbial infections on the skin. Dehydration can cause infections in the oral cavity. Improper hand washing can cause infections because many microorganisms remain on the skin. p. 447

The nurse works in a nursing home. Of which are common causes of death in the elderly population that the nurse should be aware? Falls Poisoning Hypothermia Heat stroke Motor vehicle accident

Falls Hypothermia Heat stroke Falls are a common cause of accidental death in elderly patients due to poor vision, gait and balance problems, and the effects of various medications. Hypothermia and heat stroke are also common causes of death in the elderly, becuse they are more vulnerable to temperature changes. Poisoning is more common in toddlers and small children, because they have a habit of ingesting chemicals such as cleaning solutions and medicines found in the house. Motor vehicle accidents are a more common cause of death in younger adults than in the elderly. p. 374

Which vaccinations are recommended to reduce the risk of infectious diseases in older adults? Flu vaccination DTaP vaccination Rubella vaccination Varicella vaccination Pneumonia vaccination

Flu vaccination Pneumonia vaccination Flu and pneumonia vaccinations are recommended for older adults to reduce the risk of infectious diseases. DTaP vaccinations are effective for preventing whooping cough in children. Children are vaccinated for rubella infections. Varicella vaccination is used to prevent chicken pox in children. p. 448

Which skill is implemented by the nurse when planning to prevent falls in patients? Reviewing the patient's medication Making the patient's environment safe Determining if the patient has a history of recent falls Gathering the equipment and performing hand hygiene

Gathering the equipment and performing hand hygiene During the planning phase, the nurse gathers the equipment and performs hand hygiene. During assessment, the nurse reviews the patient's medication. During implementation, the nurse makes the patient's environment safe. During assessment, the nurse determines if the patient has a history of recent falls. p. 397

Which action should the nurse avoid while opening a sterile item on a flat surface? Keeping the inner contents sterile before use Grasping 3.5 cm of the border to maneuver the field on the table surface Holding the item with one hand while pulling the wrapper away with the other hand Using 1 inch of the inner surface of the package border as a sterile field to add sterile items

Grasping 3.5 cm of the border to maneuver the field on the table surface The nurse should grasp only 2.5 cm (1 inch) of the border to maneuver the field on a table surface while opening a sterile item on a flat surface. The inner contents should be kept sterile before use to prevent infection. The nurse should hold the item in one hand while pulling the wrapper away with the other hand. The nurse should use nearly 1 inch of the inner surface of the package border around the edges as a sterile field to add sterile items. p. 468

Which is the most effective way to break the chain of infection? Hand hygiene Wearing gloves Placing patients in isolation Providing private rooms for patients

Hand hygiene Hands become contaminated through contact with the patient's environment. Clean hands interrupt the transmission of microorganisms. Wearing gloves, placing patients in isolation and providing private rooms also can help break the chain of infection, but hand hygiene is the most effective method. p. 458

Which is the most effective way to control the transmission of infection in health care facilities? Vaccinations Isolation precautions Hand hygiene practices Use of clean equipment

Hand hygiene practices Hand hygiene practices are the most effective way to break the chain of infection and control the transmission of infection. Vaccinations are effective measures to prevent the occurrence of infection in an individual. Even if a patient is isolated, the nurse caring for the patient has a risk of infection. Therefore, the nurse should perform hand hygiene before and after providing patient care. The use of clean equipment without hand hygiene may spread infection. pp. 443-445

The nurse is caring for an older adult in the home and is concerned about infection control in this patient. What should the nurse inquire about when assessing this patient's risk of food poisoning? Daily water intake Hand-washing practices Knowledge about food-storage practices Monthly consumption of fruits and vegetables Practice of checking expiration dates on milk products

Hand-washing practices Knowledge about food-storage practices Practice of checking expiration dates on milk products Good hand-washing practices include washing hands before and after handling food items. Proper knowledge about food-storage practices ensures that the food consumed is safe and free of contamination. Regular practice of checking expiration dates on milk products ensures that the products are safe for consumption. Knowledge of daily water intake does not help in assessing the risk of food poisoning. Knowledge of monthly consumption of fruits and vegetables is not related to the risk of food poisoning. pp. 381, 388

Which action made by the nurse may contaminate the surface of the sterile item? Disposing of the outer wrapper Holding the arm over the sterile field Peeling the wrapper onto the nondominant hand Allowing the drape to unfold on a surface above waist level

Holding the arm over the sterile field While adding sterile items, the nurse should not hold the arm over the sterile field because it may contaminate the surface of the sterile item. Disposing of the outer wrapper prevents accidental contamination of the sterile field. The nurse should carefully peel the wrapper onto the nondominant hand. The nurse should allow the drape to unfold on a surface above the waist and work surface to prevent contamination. p. 475

The nurse needs to teach a young woman newly diagnosed with asthma how to manage her disease. Which topics does the nurse teach first? How to use an inhaler during an asthma attack The need to avoid people who smoke to prevent asthma attacks Where to purchase a medical alert bracelet that says she has asthma The importance of maintaining a healthy diet and exercising regularly

How to use an inhaler during an asthma attack It is important to start with essential life-saving information when teaching people because they usually remember what you tell them first. p. 346

A patient reporting sore throat and pain while swallowing arrives at the hospital. The laboratory reports revealed the presence of beta-hemolytic group A streptococcus. What would be the patient's stage of infection? Illness stage Convalescence Prodromal stage Incubation period

Illness stage The interval when a patient manifests signs and symptoms (such as a sore throat and pain while swallowing) that are specific to a type of infection is the illness stage. Convalescence is the interval when acute symptoms of infection disappear. The prodromal stage is the interval from the onset of nonspecific signs and symptoms to more specific symptoms. The incubation period is the first stage of the infection process. It is the interval between the entrance of a pathogen into body and the appearance of the first symptoms. p. 446

Which is a serious reportable event included in the National Quality Forum List? Immediate postoperative death Hypothermia due to severe cold conditions A fall associated with administration of diuretics Injury resulting from physical assault that occurred at a patient's home

Immediate postoperative death The National Quality Forum has compiled a list of serious reportable events that are the major focus of health care providers for patient safety initiatives. Events such as intraoperative or immediate postoperative death should be reported immediately because they are serious reportable events. Hypothermia due to severe conditions is not included on the list. Likewise, a fall associated with administration of diuretics is not listed as a serious reportable event. Injury due to physical assault in the health care facility, not at a patient's home, is a serious reportable event included on the National Quality Forum List. p. 379

A patient has accidently consumed kerosene. Which nursing intervention would further complicate the patient's condition? Inducing vomiting Maintaining the airway Administering oxygen Measuring oxygen saturation

Inducing vomiting Kerosene is a poisonous substance. Inducing vomiting in a patient who has consumed kerosene is dangerous, because it can cause aspiration. Maintaining the airway is the primary measure to reduce the risk of aspiration and is thus important in cases of kerosene poisoning. Oxygen administration is helpful in kerosene poisoning. Measuring oxygen saturation is an important intervention for this patient, because it helps to identify the need for intubation and other assistive measures. p. 390

According to the National Quality Forum, which event is included under patient-protection events? Abduction of a patient Infant discharge to the wrong person Disability associated with a medication error Surgery performed on the wrong body part

Infant discharge to the wrong person Infant discharge to the wrong person is included under patient-protection events. Events like the abduction of a patient are considered to be criminal events. Disability associated with a medication error is included under care-management events. Surgeries performed on the wrong body part are included under surgical events. p. 379

Which group is at the highest risk for lead poisoning? Adults Infants Adolescents Older adults

Infants Fetuses, infants, and children are at high risk for lead poisoning because their bodies absorb lead more easily and are more sensitive to the damaging effects of lead. Adults, older adults, and adolescents are less sensitive to lead exposure. p. 376

The nurse is assessing a group of patients in a health screening program. What should the nurse evaluate when assessing the infection risk in these patients? Inquire about diet and appetite. Compare monthly earnings. Assess immunization details. Inquire about travel history. Inquire about medication history.

Inquire about diet and appetite. Assess immunization details. Inquire about travel history. Inquire about medication history. A patient's nutritional health directly affects the patient's susceptibility to infection. Assessing immunization details is important to understand which vaccines have been given as preventive measures. The travel history can reveal important information regarding the risk of exposure to communicable diseases. The medication history will help to identify any medications that can increase the susceptibility of infections. Comparing monthly earnings is unrelated to assessment of risk for contracting an infection. pp. 449-450

A patient is admitted in the hospital with a diagnosis of meningococcal pneumonia. Which is the priority nursing intervention in this condition? Isolating the patient Performing oral hygiene Providing antimicrobial therapy Keeping the patient well hydrated

Isolating the patient Meningococcal pneumonia is an infectious droplet infection. Therefore, the patient should be isolated first to prevent the transmission of the disease. The nurse should isolate the patient before performing oral hygiene. The nurse should provide antimicrobial therapy after isolating the patient. The nurse should maintain adequate hydration to promote the patients' health and reduce the risk of infections. p. 459

The nurse is caring for an older adult in the home. The nurse is concerned about the risk of injury. Following an assessment, the nurse finds that the patient has visual impairment. Which actions should the nurse perform to reduce the risk of injury for this patient? Keep the home well lit. Keep the rooms ventilated. Keep clean eyeglasses at hand. Teach range-of-motion exercises. Perform a home hazard assessment.

Keep the home well lit. Keep clean eyeglasses at hand. Perform a home hazard assessment. Keeping the home well-lit will help the patient see objects without trouble. Clean and protected eyeglasses at hand will help the patient see clearly. During the home hazard assessment, the nurse should walk through the home with the patient and discuss how the patient normally conducts daily activities and whether the environment poses problems. Keeping the rooms ventilated may not help the patient in reducing risk of injury. Range-of-motion exercises may be performed by patients with altered mobility. p. 381

The nurse is changing the dressing of a patient with cellulitis who has been admitted to the hospital. Meanwhile, another health care provider in the same unit asks for the nurse's help with the blocked intravenous line of another patient. What should the nurse do? Leave the first patient, immediately flush the IV line and restore its patency. Inform the other health care provider to leave the IV line as it is. Complete the dressing and then go to the next patient. Leave the first patient, perform hand hygiene, and then ensure the patency of the IV line.

Leave the first patient, perform hand hygiene, and then ensure the patency of the IV line. Nurses should be aware of the routes through which transmission of infections can occur. During the procedure of changing a dressing, if the nurse handles the IV line of the other patient without performing hand hygiene, the infection is likely to spread to the other patient. Therefore, the nurse should perform hand hygiene before handling the IV line. Restoring the patency of the IV line requires the nurse to flush the IV line, which may increase the risk for contracting an infection if performed before hand hygiene. The IV line needs to be unblocked immediately, so the nurse should attend to the patient with the blocked IV line before completing the dressing of the patient with cellulitis. p. 448

The nurse cares for a patient with a history of tuberculosis who underwent surgery. Which laboratory parameters would indicate the absence of infection in the patient? Basophil count: 1% Monocyte count: 4% Neutrophil count: 80% Lymphocyte count: 10%

Monocyte count: 4% The normal range of monocytes is from 2 to 8%. A monocyte count of 4% indicates the absence of infection. Although the normal range of basophils is 0.5 to 1.5%, a reading of 1% may not indicate the absence of infection. The normal range of neutrophils is between 55 and 70%. This count may increase during acute suppurative infection. The normal range of lymphocytes is between 20 and 40%. This count may decrease in sepsis, which may occur postoperatively. p. 451

Which microorganism exits through a man's urethral meatus during sexual contact? Ebolavirus Clostridium difficile Neisseria gonorrhea Legionella pneumophila

Neisseria gonorrhea Neisseria gonorrhea exits through a man's urethral meatus or a woman's vaginal canal during sexual contact. Ebolavirus is transmitted through blood or body fluids. Clostridium difficile causes antibiotic-induced diarrhea. Legionella pneumophila grows only at certain temperatures. p. 445

A registered nurse teaches a nursing student about normal flora. Which statement of the nursing student indicates a need for further learning? Normal flora of the large intestine exist in large numbers. Normal flora maintain a sensitive balance with other microbes. A healthy person excretes trillions of microbes daily through the intestines. Normal flora may cause disease when residing in their usual area of the body.

Normal flora may cause disease when residing in their usual area of the body. Normal flora do not usually cause disease when they reside in their usual area of the body. Normal flora exist in large numbers in the large intestine without causing any illness. These flora maintain a sensitive balance with other microorganisms to prevent infection. A person normally excretes trillions of microbes daily through the intestines. p. 448

The home health nurse is assessing a patient with an uncoordinated and shuffling gait. The patient also has a stooping posture. Which assessment activities should the nurse perform on this patient? Observation of posture Checking visual acuity Observation of body alignment Measuring the range of motion Appraising the patient's home for hazards

Observation of posture Observation of body alignment Measuring the range of motion Appraising the patient's home for hazards Because of the uncoordinated, shuffling gait and stooping posture, this patient is at risk for falls. The appropriate assessment activities are observing the patient's posture, body alignment, and range of motion. A home hazard appraisal is required for patients at risk for falls. Poorly lit homes, rooms cluttered with small items, and rugs present hazards that could cause a patient to trip and fall. A visual acuity assessment is conducted with patients who have difficulty with night vision and people who trip over rugs and furniture. p. 380

A nurse instructs a patient to color code the hot water faucets and dials. What might be the possible age group of the patient? Young adult Older adult Adolescent Preschooler

Older adult Older adults are instructed to color code the hot water faucets and dials to prevent burns and scalds. The color coding makes it easier for an older adult to know which is hot and which is cold. Young adults and adolescents usually do not confuse hot and cold water, so this suggestion may not be helpful for them. Preschoolers usually need a parent's help taking baths and would not use hot-water faucets and dials. p. 388

The registered nurse is teaching a group of student nurses about various problems faced by older adults and effective interventions to overcome those problems. Which patient information provided by the registered nurse needs correction? Patient 1 Patient 2 Patient 3 Patient 4

Patient 1 Nocturia and incontinence are common problems in older adults. Interventions include instituting a regular toileting schedule with a recommended frequency of every 3 hours. Giving diuretics in the morning will also be beneficial in these patients. The nurse should provide adequate and meaningful stimuli when an older adult shows a reduced response to multiple stimuli. Older adults should be encouraged to engage in physical activity to increase their range of motion and strength. An older adult who has diminished memory may not take medications correctly. The nurse should encourage the use of medication organizers. Older adults are at a high risk for automobile accidents due to slowed reaction time. Therefore, the nurse should teach safety tips for avoiding automobile accidents. p. 387

A family member is providing care to a loved one who has an infected leg wound. What would you instruct the family member to do after providing care and handling contaminated equipment or organic material? Wear gloves before eating or handling food. Place any soiled materials into a bag and double bag them. Have the family member check with the doctor about the need for immunization. Perform hand hygiene before and after care and/or handling contaminated equipment or material.

Perform hand hygiene before and after care and/or handling contaminated equipment or material. Performing hand hygiene before and after care interrupts the transmission of microorganisms from family members. Hands should be washed before eating or handling food, but gloves are not necessary. In the home care setting, soiled materials should be placed in an impervious plastic or brown paper bag. Immunizations are important, but in this situation, they would not protect against a leg wound infection. pp. 458, 467

A patient is brought to the emergency room in an unconscious state. On taking the history the nurse finds that the patient had accidentally consumed agricultural pesticides. Which intervention will prevent the potential of aspiration in this patient? Avoiding the use of nasogastric tubes in the patient Positioning the patient with head turned Positioning the patient with head straight Making arrangements for suctioning of the secretions

Positioning the patient with head turned An unconscious patient is susceptible to aspirating the stomach contents into the bronchial tree. Positioning the patient with head turned prevents aspiration. Nasogastric tubes also prevent aspiration of secretions, because they do not allow the stomach contents to aspirate into the bronchial tree. If the patient's head is held straight, there is a higher chance of aspiration. Suctioning has no preventive role in aspiration, but it helps to remove active secretions of the lungs. p. 390

Which safety precaution should be followed by a patient infected with hepatitis A? Practicing hand hygiene Avoiding needle sharing Using a walker or cane Performing range-of-motion exercises

Practicing hand hygiene A patient with hepatitis A should practice hand hygiene so the pathogen is not transmitted to others. Needle sharing should be avoided in patients with hepatitis B because the infection is transmitted through blood. Walkers and canes should be used by the patients with osteoporosis to avoid the risk of falls. Range-of-motion exercises should be performed by patients with muscle weakness to avoid the risk of falls. p. 376

After performing a prescrub wash, a nurse dries his or her hands and forearms with a paper towel. What is the rationale behind this action? Preventing accidental contamination Eliminating transient microorganisms Ensuring complete antiseptic coverage Promoting a reduction in microorganisms

Promoting a reduction in microorganisms Drying the hands and forearms with a paper towel can promote a reduction in microorganisms on the hands and arms. Repeated drying and dropping the towel into a linen hamper after surgical hand scrub can prevent accidental contamination. Scrubbing the arm by dividing it into thirds can eliminate transient microorganisms and reduce the resident hand flora. Performing hand hygiene twice in a row ensures complete antiseptic coverage on all the surfaces of the hand. p. 478

A patient with a urinary tract infection is hospitalized due to severe discomfort. The primary health care provider advises the nurse to provide supportive therapy to the patient. Which actions of the nurse are included when providing supportive therapy? Provide adequate rest Provide adequate nutrition Maintain proper hand hygiene Monitor the patient's response to drug therapy Use standard precautions during therapy

Provide adequate rest Provide adequate nutrition Patients who require attentive care are provided with supportive therapy, which includes providing adequate rest and nutrition to the patient to improve the patient's defense mechanisms against infections. Maintaining proper hand hygiene, monitoring the patient's response to drug therapy, and the usage of standard precautions while handling patients during therapy are general responsibilities of the nurse while caring for a patient with exogenous or endogenous infections. p. 445

A patient is being provided artificial respiration through ventilators in an intensive care unit. Unfortunately there has been a fire on the unit. What should the nurse do in this situation? Provide manual respiration through a bag-valve-mask device. Make arrangements to shift the patient along with ventilators. Remove ventilator support and wait until the fire is under control. Make arrangements to provide oxygen until the fire is under control.

Provide manual respiration through a bag-valve-mask device. The most appropriate nursing action is to provide manual respiration through a bag-valve-mask device until the fire is brought under control. This would help to prevent hypoxia in the patient. It is difficult to shift the patient and ventilator setup during a fire. Taking the patient off ventilator support may prove fatal. Providing oxygen without ventilator support is not useful for patients who are on ventilators. p. 393

Which interventions are followed by the nurse to protect older adults in acute care settings? Providing bed rails for safety Keeping the environment free from clutter Explaining and demonstrating how to use the call light Responding quickly to call lights and bed/chair alarms Placing the call device close to the patient before a nurse-patient interaction

Providing bed rails for safety Keeping the environment free from clutter Explaining and demonstrating how to use the call light Responding quickly to call lights and bed/chair alarms The nurse should provide bed rails to prevent falls in older adults, keep the environment free from clutter, explain and demonstrate the use of call lights, and respond quickly to call lights and bed/chair alarms. The call devices are given to patients at the end of the nurse-patient interaction. p. 391

The nurse is using a chlorine compound at room temperature to clean surgical instruments contaminated by blood, pus, urine, and saliva. Which factors would reduce the efficacy of the disinfectant? Pus, blood, urine, and saliva were not rinsed off the instruments before application of the disinfectant. Soap and water were used to clean the instruments before application of the disinfectant. The instruments were thoroughly rinsed off with water before application of the disinfectant. The chlorine solution is diluted. The room where the instruments are being disinfected is at a normal temperature.

Pus, blood, urine, and saliva were not rinsed off the instruments before application of the disinfectant. Soap and water were used to clean the instruments before application of the disinfectant. The chlorine solution is diluted. Chlorine is a disinfectant and the nurse should be aware of all the factors influencing the efficacy of a disinfectant. Organic materials including blood, pus, saliva, and urine tend to reduce the efficacy of the disinfectant. Likewise, soap causes certain disinfectants to become less effective. Diluting a disinfectant also reduces its efficacy. For the disinfectant to work best, the instruments should be rinsed thoroughly in water before using the disinfectant. Disinfectants tend to work best at room temperature, so the room where the nurse is cleaning the instruments should be at a normal room temperature. p. 456

A patient has recovered from seizures in a postoperative ward. How should the nurse ensure continued safety of the patient? Raise the side rails of the bed. Place the patient in supine position. Keep the call light and intercom near the patient. Avoid the use of pillows. Place the bed in the lowest position.

Raise the side rails of the bed. Keep the call light and intercom near the patient. Place the bed in the lowest position. To ensure continued safety of a patient following seizures, the side rails of the bed should be raised to prevent a fall. Placing the call light and intercom within reach of the patient would help in receiving assistance, if needed. The bed should be lowered to the lowest position to prevent a fall and risk of injury. The patient should be positioned lying on the side, not in the supine position. Lying on the side prevents the tongue from falling back and obstructing the airway. A pillow should be used to support the head once the seizure is over. p. 394

Which nursing activity is involved in evaluation to determine patient safety? Identifying the patient's preparations of safety needs and risks Identifying the actual and potential threats to the patient's safety Determining the impact of the underlying illness on the patient's safety Reassessing the patient for the presence of physical, social, and environmental risks

Reassessing the patient for the presence of physical, social, and environmental risks The nurse reassesses a patient for the presence of physical, social, and environmental risks during evaluation. Identifying a patient's perceptions of safety needs and risks is involved in assessment. During assessment, the nurse also identifies the actual and potential threats to the patient's safety and determines the impact of the underlying illness on the patient's safety. p. 395

A patient was diagnosed with left-sided neglect after suffering a cerebrovascular accident. Which nursing intervention would be most effective to ensure the patient's safety? Teaching the patient to use a walker Reminding the patient to scan the environment while walking Encouraging the patient to see an ophthalmologist for visual assessment Teaching the patient to perform strengthening exercises on the left side of the body

Reminding the patient to scan the environment while walking The nurse should remind the patient to scan the environment when walking in the event of left-sided neglect after suffering a cerebrovascular accident, because the patient may fail to notice people or things approaching from the left. A patient with cerebrovascular accident-caused left-sided weakness should be educated regarding the use of a walker. Visiting an ophthalmologist is effective for those patients who have problems in seeing objects at a distance. The nurse should teach the patient with left sided weakness to perform strengthening exercises on the left side of the body. p. 385

The nurse has redressed a patient's wound and now plans to administer a medication to the patient. Which is the correct infection control procedure? Leave the gloves on to administer the medication. Remove gloves and administer the medication. Remove gloves and perform hand hygiene before administering the medication. Leave the medication on the bedside table to avoid having to remove gloves before leaving the patient's room.

Remove gloves and perform hand hygiene before administering the medication. Gloves need to be changed and hand hygiene performed to prevent transfer of microorganisms from one source (the wound) to another (the nurse's hands). Gloves are not a foolproof method of preventing contamination of the nurse's hands so it is necessary to perform hand hygiene according to approved protocol. Medications should never be left at the bedside. It is the nurse's responsibility to ensure that patients take their medications. pp. 459-460

While caring for a patient with testicular cancer in a health care setting, the nurse observes that the patient develops a urinary tract infection. Which actions of the nurse could be responsible for the development of this health care-associated infection? Repeated irrigation of the catheter The use of a contaminated antiseptic solution Improper specimen collection technique Improper care of the intravenous (IV) insertion site Improper disposal of respiratory exudates

Repeated irrigation of the catheter Improper specimen collection technique Health-care associated infections result from the delivery of health services in a health care facility. Repeated catheter irrigations or improper specimen collection techniques can cause urinary tract infections. The use of contaminated antiseptic solutions may cause surgical or traumatic wounds. The improper care of the intravenous (IV) insertion site may affect the patient's bloodstream. Improper disposal of respiratory exudates may cause respiratory tract infection. p. 448

There is a fire in a hospital. Which is the priority action of the nurse? Activating the fire alarms Confining the fire Extinguishing the fire Rescuing patients in immediate danger

Rescuing patients in immediate danger The nurse should use the mnemonic RACE to set priorities in case of a fire. When there is a fire in a hospital, the nurse's first and most important intervention is to Rescue and remove all patients who are in immediate danger. After those patients are removed, the nurse should Activate the fire alarm so that other patients and staff will know of the fire danger. After this the nurse should Confine the fire by closing all doors and windows and turning off oxygen and electrical equipment. Finally, the nurse may attempt to Extinguish the fire with the use of an appropriate fire extinguisher. Test-Taking Tip: Did you notice the acronym RACE in the choices? When the textbook has explained (or your instructor has taught) an acronym, look for it in the choices. It may have been shuffled out of order, but recognizing that it is there will provide a huge clue for the correct response. p. 392

A registered nurse teaches nursing students about nonspecific defense systems of the body to protect against infections. Which defense systems act as good examples to prevent infections? Saliva Blinking Erythrocytes Macrophages Thrombocytes

Saliva Blinking Macrophages Saliva, blinking, and macrophages are nonspecific body defense systems that help protect against infections. Saliva washes away particles containing microorganisms and reduces infection. Blinking reduces entry of particles containing pathogens, thus reducing the dose of organisms that cause infections. Macrophages engulf and destroy microorganisms that reach alveoli. Erythrocytes and thrombocytes are not associated with the body's defense systems. p. 447

After reviewing the laboratory reports of a patient, the nurse suspects that the patient has an acute suppurative infection. What would be the patient's neutrophil count? 60% 65% 70% 75%

75% The normal range of neutrophils in a healthy adult ranges from 55% to 70%. A high neutrophil count (such as 75%) would indicate an acute suppurative infection. p. 451

The head nurse is teaching student nurses about internal and external variables related to the development of a disease. Which factors are considered external variables? Emotional factors Spiritual factors Cultural background Employment status Family practices

Cultural background Employment status Family practices Both internal and external variables influence a person's health. External variables that affect the health of a person include socioeconomic factors such as cultural background, employment status, and family practices. Internal variables include developmental stage, intellectual background, emotional factors, and spiritual factors. pp. 69-70

Health literacy is defined as the cognitive and social skills that determine the motivation and ability of individuals to use information to promote and maintain good health. What individuals are most at risk of having low health literacy? Older adults Individuals living below the poverty level Minority adults White adults Individuals with higher secondary education

Older adults Individuals living below the poverty level Minority adults Older adults, individuals living in poverty, and minority adults are found to have very low health literacy scores. The white population and individuals with at least higher secondary education tend to have higher health literacy scores. pp. 344-345

Which factor increases the efficacy of disinfectants during the process of disinfection? Shortened exposure time The presence of pus at the time of disinfection The presence of soap at the time of disinfection Temperature maintained at room temperature

Temperature maintained at room temperature Disinfectants tend to work best at room temperature. Shortened exposure time decreases the efficacy of the disinfectants. The presence of pus and soap at the time of disinfection decreases the efficacy of disinfectants. p. 477

The nurse is planning to prepare a teaching plan on healthy nutrition. What are the factors that the nurse should consider before preparing the plan? . The patient's educational status The socioeconomic status of the patient The culture to which the patient belongs The consent of the healthcare provider The willingness of the patient to participate

The patient's educational status The socioeconomic status of the patient The culture to which the patient belongs The willingness of the patient to participate The teaching plan should be based on the patient's educational status so that the patient understands what is being taught. An important factor is the consideration of culture because there are many practices that are specific to certain cultures. If the patient experiences symptoms such as pain, the patient may not be receptive to the teaching. Therefore, the nurse should determine if the patient is willing to accept the teaching. Socioeconomic status should be considered to provide the most useful and helpful information to the patient regarding his or her current situation. It is the nurse's duty to inform the patient about his or her condition; the nurse does not need the consent of the healthcare provider to do so. pp. 345, 346

The nurse is teaching a patient with literacy problems about the steps to be taken before initiating prescribed hypertensive therapy. Which questions asked by the nurse help evaluate the effectiveness of the teaching? "Can you verbalize the information taught?" "Are you able to demonstrate the teaching?" "How does your illness affect your current lifestyle?" "What do you know about your illness and your treatment plan?" "How involved do you want a family member to be in the management of your illness?" "Which experiences have you had in the past that are similar to those you are experiencing now?"

"Can you verbalize the information taught?" "Are you able to demonstrate the teaching?" "How does your illness affect your current lifestyle?" "What do you know about your illness and your treatment plan?" Asking patients to verbalize understanding of information taught, observing and evaluating patient's ability to perform desired behaviors or demonstrate learned procedures helps to determine the patient's level of understanding. Asking questions about the effects of an illness on lifestyle is a nursing assessment for self-management. It allows the patient to verbalize potential barriers to therapy and thereby helps to evaluate the effectiveness of the therapy. Asking about the illness and the treatment plan also helps to evaluate the effectiveness of the teaching. Asking the patient about the involvement of his/her family member in the management of an illness, and asking about similar past experiences are nursing assessment questions to determine previous learning and identification of learning needs and preferences. pp. 351, 354

Which statement by a patient supports the nurse's conclusion that the patient follows a holistic approach of healing? "I am implementing changes in my behavior for better health." "I am following a perfect regimen of diet and exercise every day." "I am also using guided imagery and relaxation therapy for treatment." "I am following prescribed medical therapies to lower the risk of heart attack."

"I am also using guided imagery and relaxation therapy for treatment." A patient who follows a holistic approach to healing recognizes the natural healing abilities of the body and may prefer guided imagery and relaxation therapy. Traditional methods of healing may also be used. A patient who follows health promotion will practice healthy food habits and exercise to maintain proper health. A patient who follows the transtheoretical model of change will practice proper behavior habits to promote healing. Patients who follow the health belief model have their own perceptions about illness and try to take actions related to lifestyle changes to prevent the risk of illness. pp. 68-69

A patient with a 20-year history of diabetes mellitus had a lower leg amputation. Which statement made by the patient indicates that the patient is experiencing a problem with body image? "I just don't have any energy to get out of bed in the morning." "I've been attending church regularly with my wife since I got out of the hospital." "My wife has taken over paying the bills since I've been in the hospital." "I don't go out very much because everyone stares at me."

"I don't go out very much because everyone stares at me." The amputation resulted in a change in physical appearance that caused a change in body image. Reactions of patients and families to changes in body image depend on the type of changes (e.g., loss of a limb or an organ), their adaptive capacity, the rate at which changes take place, and the support services available. When a change in body image results from an event such as a leg amputation, the patient generally adjusts in the following phases: shock, withdrawal, acknowledgment, acceptance, and rehabilitation. The statement indicates that the patient is in the stage of withdrawal. p. 75

The registered nurse (RN) is teaching a patient's family members tips for protecting the patient during a seizure attack. Which statements made by a family member indicates the need for further teaching? "I should stay with the patient." "I should hold the limbs tightly." "I should position the patient safely." "I should note the time of the seizure." "I should lift the patient from the floor to the bed."

"I should hold the limbs tightly." "I should lift the patient from the floor to the bed." The patient's limbs should be held loosely if they are flailing, and clothing should be loosened. The patient should not be lifted from the bed while the seizure is in progress. Family members should stay with the patient during a seizure. The patient should be positioned safely to avoid injuries. The beginning time and duration of a seizure should be noted so the health care provider can be informed. p. 395

A registered nurse teaches a nursing student about preparing a patient for a sterile procedure. Which statements made by the nursing student indicate effective learning? "I should avoid explaining the surgical procedure to the patient." "I should inform the patient to avoid touching the sterile supplies and gown." "I should place a surgical mask on the patient before performing any surgery." "I should administer ordered analgesics half an hour before surgery begins if a patient is in pain." "I should inform the patient to avoid sudden movements of any parts of the body covered by sterile drapes."

"I should inform the patient to avoid touching the sterile supplies and gown." "I should administer ordered analgesics half an hour before surgery begins if a patient is in pain." "I should inform the patient to avoid sudden movements of any parts of the body covered by sterile drapes." The nurse should provide guidelines to the patient to avoid contamination while performing the surgery. The patient should avoid touching sterile supplies, drapes, and the nurse's gown and gloves to prevent contamination. If a patient is in pain, the nurse should administer ordered analgesics about half an hour before a sterile procedure begins. The patient should be informed to avoid sudden movements of any body parts that are covered by sterile drapes. The nurse should explain how the surgical procedure is being carried out and what can the patient do to avoid contaminating the sterile objects. The nurse should place a surgical mask on the patient in conditions such as respiratory infections, but this action is not necessary in all cases. p. 467

A registered nurse teaches a nursing student about precautions to be taken while pouring a sterile solution. Which statement made by the nursing student indicates a need for correction? "I should quickly pour the contents into the container." "I should pour fluids into the plastic molded sections." "I should verify the contents and expiration date." "I should remove the sterile seal and cap from the bottle in an upward motion." "I should make sure that a receptacle for a solution is located far away from the sterile work surface edge."

"I should quickly pour the contents into the container." "I should make sure that a receptacle for a solution is located far away from the sterile work surface edge." The nurse should slowly pour the contents to prevent splashing. The nurse should make sure that the receptacle for the solution is located near or on a sterile work surface edge to prevent reaching over the sterile field. The contents should be poured into cups or plastic molded sections in sterile kits. The nurse should verify the contents and expiration date of the solution to ensure that the solution is viable. The nurse should remove the sterile seal and cap from the bottle in an upward motion to prevent contamination of the bottle lip. p. 476

A registered nurse (RN) is teaching a parent about safety measures for a 5-year-old child. Which statement made by the parent indicates the need for further learning? "I should teach the child about bicycle safety." "I should teach the child about safety during specific sports." "I should teach the child how to operate electrical equipment." "I should teach the child about safe use of equipment for play and work."

"I should teach the child how to operate electrical equipment." Children should be taught not to operate electrical equipment, because an electrical mishap may occur. Bicycle safety should be taught to children to reduce injuries from falling. Safety during sports should be taught to children to protect them from injuries. The children should be taught about safe and appropriate used of equipment to avoid injuries. p. 387

A patient has a cold with mild fever and is advised to rest for 3 days. Which patient statements would be classified under illness behavior? "I shouldn't cook dinner for my husband. I don't want him to get sick, too." "I feel fine; I should go shopping." "It's really bad; I have to stay at home, and it's boring." "Maybe I can catch up on a few of my favorite movies." "Praying may help me feel better."

"I shouldn't cook dinner for my husband. I don't want him to get sick, too." "It's really bad; I have to stay at home, and it's boring." "Maybe I can catch up on a few of my favorite movies." "Praying may help me feel better." Illness behavior may include the disease and its effect on the well-being and level of functioning of the patient. Illness behavior includes the way people react to their diagnoses, interpret their symptoms, make decisions to cope, and use resources in the health care system. Exemption from cooking due to illness is an illness behavior. Feeling disappointed about staying home due to illness is an example of illness behavior. Planning to watch movies due to illness is an illness behavior. Planning to pray without fail to help treat the illness is also an illness behavior. Stating that one feels fine is not an illness behavior. pp. 73-74

Based on the transtheoretical model of change, which is the most appropriate response to a patient who states, "Me, exercise? I haven't done that since junior high gym class, and I hated it then!" "That's fine. I don't exercise either because I hate it, too, and I don't think it's helpful." "OI want you to walk 3 miles four times a week, and I'll see you in 1 month." "I understand. Can you think of one reason why being more active would be helpful for you?" "I'd like you to ride your bike three times this week and eat at least four fruits and vegetables every day."

"I understand. Can you think of one reason why being more active would be helpful for you?" The patient's response indicates that the patient is in the precontemplation stage and does not intend to change behavior in the next 6 months. In this stage the patient is not interested in information about the behavior and may be defensive when confronted with it. Asking an open-ended question may stimulate the patient to identify a reason to change behavior. Nurses are challenged to motivate and facilitate change in health behavior when working with individuals. STUDY TIP: In education, asking a question to stimulate students to think, instead of being didactic and telling them what they are not ready to hear is part of the Socratic approach. Consider this approach whenever you realize that a patient is in the precontemplation stage. p. 73

A registered nurse (RN) is teaching a patient about preventive measures for electrical shocks. Which statement by the patient indicates the need for further teaching? "I will not operate unfamiliar equipment." "I will keep the electrical items away from water." "I will grasp the plug, not the cord, while unplugging."

"I will use extension cords at all times." Extension cords are meant to be used as temporary power sources. They should be used only when necessary, not always. Unfamiliar equipment should not be operated to prevent electrical shocks. Electrical items should be kept away from water to prevent shocks. While unplugging, the plug should be grasped and not the cord. p. 390

The nurse is developing a health promotion program on healthy eating and exercise for high school students using the health belief model as a framework. Which statement is related to the perception of susceptibility to an illness? "I don't have time to exercise because I have to work after school every night." "I'm worried about becoming overweight and getting diabetes because my father has diabetes." "The statistics of how many teenagers are overweight is scary." "I've decided to start a walking club at school for interested students."

"I'm worried about becoming overweight and getting diabetes because my father has diabetes." The statement "I'm worried about becoming overweight and getting diabetes because my father has diabetes" indicates that the individual is concerned about developing diabetes and believes that there is a risk or susceptibility based on recognition of a familial link for the disease. Once this link is recognized, the individual may perceive the personal risk for diabetes. None of the other options recognizes a risk factor or susceptibility. pp. 66, 68

The registered nurse (RN) is teaching a nursing student about effective teaching. Which statements made by the nursing student about teaching indicates effective learning? "Teaching is most effective when it responds to the learner's needs." "Teaching is a process of both understanding and applying newly acquired concepts." "Teaching is the concept of imparting knowledge through a series of directed activities." "Teaching is the purposeful acquisition of new knowledge, attitudes, behaviors, and skills through an experience or external stimulus." "Teaching consists of a conscious, deliberate set of actions that help individuals gain new knowledge, change attitudes, adopt new behaviors, or perform new skills."

"Teaching is most effective when it responds to the learner's needs." "Teaching is the concept of imparting knowledge through a series of directed activities." "Teaching consists of a conscious, deliberate set of actions that help individuals gain new knowledge, change attitudes, adopt new behaviors, or perform new skills." Teaching is most effective when it responds to the learner's needs. The learner's needs are assessed by asking questions and determining learner's interest. Teaching is the concept of imparting knowledge through a series of directed activities. Effective teaching consists of a conscious, deliberate set of actions that help the learners to gain new knowledge, change attitudes, adopt new behaviors, or perform new skills. Learning, not teaching, is a process of both understanding and applying newly acquired concepts. Likewise, learning is purposeful attainment of new knowledge, attitudes, behaviors, and skills through an experience or external stimulus. p. 338

A registered nurse is teaching a student nurse about the various stages of infections. Which statement made by the student nurse indicates a need for additional teaching? "The incubation period for mumps is 1 to 5 days." "The acute symptoms of malaria will disappear during the convalescence stage." "Group A beta-hemolytic Streptococcus causes a sore throat, pain, and swelling at the illness stage." "Herpes simplex at the prodromal stage begins with itching at the site before the lesion appears."

"The incubation period for mumps is 1 to 5 days." The average incubation period for mumps is 16 to 18 days, but can range from 12-25 days. The recovery of the patient is noticed during the convalescence stage of malaria. Acute infections are noticed during the illness stage. Group A beta-hemolytic Streptococcus causes strep throat manifested by a sore throat, pain, and swelling. Herpetic whitlow is the infection caused by the herpes simplex virus. The nonspecific signs and symptoms, such as itching and tingling, develop during the prodromal stage at the site before the appearance of the lesions. p. 446

A patient comes to the local health clinic and states, "I've noticed how many people are out walking in my neighborhood. Is walking good for you?" Which is the best response to help the patient through the stages of change for exercise? "Walking is okay, but I really think running is better because it burns more calories." "Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?" "Yes, I want you to begin walking. Walk for 30 minutes every day and eat more fruits and vegetables." "They probably aren't walking fast enough or far enough. You need to spend at least 45 minutes if you are going to do any good."

"Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?" The patient's response indicates that the patient is in the contemplative state, possibly intending to make a behavior change within the next 6 months. The nurse's statement reinforces the behavior and provides a specific goal for the patient to begin a walking plan. p. 73

In the context of teaching an infant's mother about the child's developmental capacity, which statement(s) by the nurse would be most appropriate? "You should encourage learning through the use of pictures." "You should keep consistent routines of feeding and bathing." "You should use role play and imitation to make learning fun." "You should speak softly to convey a sense of trust to the baby." "You should use simple words to promote the child's understanding."

"You should keep consistent routines of feeding and bathing." "You should speak softly to convey a sense of trust to the baby." The nurse should implement teaching methods and actively involve the patient or caregiver in learning activities. The nurse should guide the infant's mother to keep consistent routines of feeding and bathing. The mother should also foster a sense of trust by speaking softly to her infant. The mother should encourage learning in a preschooler through pictures and short stories. The use of role play, imitation, and play would make the learning healthy and interesting for a preschooler. The mother of a toddler, not an infant, should use simple words while communicating. p. 343

A 62-year-old patient diagnosed with colorectal cancer underwent surgery for removal of the cancerous tissue. The nurse teaches the patient about medications, exercises, and self-care techniques. The patient interrupts the nurse saying that the teaching seems overwhelming and he needs rest. What should be the nurse's response? "Please listen for few more minutes, there isn't much more." "Let us discuss some other topics then return to this." "You should rest now. We can discuss this more in the evening." "I have not taught you anything until now. How can it be overwhelming?"

"You should rest now. We can discuss this more in the evening." The patient is an older adult who becomes weak after surgery. The patient's cognitive abilities may be reduced. The nurse should respect this and should stop any further teaching temporarily. Asking the patient to listen for a few more minutes would not be useful, because the patient is tired and will not be able to assimilate information. Because the patient has mentioned needing rest, it is not appropriate for the nurse to talk about some other subject. Telling the patient that nothing has been explained until that time and that the explanation should not be overwhelming is disrespecting the patient and his condition. pp. 341-342

In a hospital, a use of restraint is ordered and renewed every two hours. What might be the age of the patient? 8 years 15 years 21 years 35 years

15 years In hospital settings, each original restraint order and renewal is limited to 8 hours for adults, 2 hours for ages 9 to 17, and 1 hour for children under age 9. Therefore, a 15-year-old patient will require ordering and renewing of the restraint order every 2 hours. The 8-year-old child will require ordering and renewal every 1 hour. The 21-year-old and 35-year-old patients will require renewal every 8 hours. p. 393

The nurse works in a medical-surgical unit. Which patient should the nurse evaluate as the highest risk for health care-associated infections (HAIs)? A 20-year-old patient admitted with gastroenteritis A 24-year-old patient admitted with a fracture of the leg A 34-year-old patient admitted for appendectomy A 53-year-old diabetic patient admitted for herniorraphy

A 53-year-old diabetic patient admitted for herniorraphy Health care-associated infections (HAIs) are those that are acquired by patients in the hospital during their stays. People whose immunity is compromised are at risk of these infections. Those who are at greater risk include the elderly, the malnourished, or those who have some underlying conditions that compromise their immunity, such as diabetes or malignancies. Therefore, the 53-year-old diabetic patient is at increased risk of an HAI. Gastroenteritis, fracture, and appendectomy do not increase the risk of HAIs. Test-Taking Tip: Notice how the listings of the three incorrect choices do not include the descriptor of diabetic before patient. Sometimes the phrasing of the choice can be a clue—in addition to your knowledge of the susceptibility to infection of diabetic patients. p. 448

The nurse is briefing a group of nursing students about the Healthy People 2020 campaign. Which are goals of this campaign? Achieve health equity and eliminate disparities. Provide access to quality health services. Reduce alcohol and drug abuse. Attain high-quality longer lives free of preventable diseases. Create social and physical environments that promote good health for all.

Achieve health equity and eliminate disparities. Attain high-quality longer lives free of preventable diseases. Create social and physical environments that promote good health for all. Healthy People 2020 is a campaign that was approved in December 2010. The campaign focuses on promoting a society where all people live long and healthy lives. The goals of the campaign include achieving health equity and eliminating disparities; attaining high-quality longer lives free of preventable disease, disability, injury, and premature death; and creating social and physical environments that promote good health for all. Healthy People 2020 does not focus on providing health services; rather it focuses on prevention of disease. p. 66

A patient has joined a fitness club and attends aerobics class three nights a week. The patient is in what stage of behavioral change? Precontemplation Contemplation Preparation Action

Action The patient is in the action stage of behavioral change because the patient is actively engaged in strategies to change behavior. In precontemplation, the patient is not considering a change in behavior within the next 6 months. In contemplation, the patient is considering a change in 6 months, and in preparation, the patient makes small changes in anticipation of change that will occur in the next month. p. 73

The nurse is trying to convince a patient to go to physical therapy after a below-the-knee amputation. The patient finally agrees when the nurse tells him that he will be allowed to go to the gardens after each session. What kind of reinforcer did the nurse use to convince the patient? Social Material Physical Activity

Activity The nurse used the activity reinforcer. The patient is motivated to go to physical therapy when he is allowed to go the gardens after physical therapy sessions. Social reinforcers acknowledge learned behavior through smiles, compliments, and encouragement. Material reinforcers include toys, food, music, and so on, and work best when teaching children. Physical reinforcers include activities like giving a hug or a pat on the back. p. 348

A patient who had a hysterectomy 10 days ago has come for a follow-up visit. The patient is experiencing pain and itching at the incision site. After assessment, the health care provider suspects the incision site is infected. Which interventions would help control infection? Reduce water intake. Administer antibiotics. Administer anxiolytics. Provide adequate nutrition. Monitor response to drug therapy.

Administer antibiotics. Provide adequate nutrition. Monitor response to drug therapy. Antibiotics should be administered to control the wound infection. Adequate nutrition is a supportive therapy, which helps in wound healing and recovery from infection. The response to drug therapy should be monitored to plan further management. Reducing water intake is not advisable; instead adequate water intake should be encouraged. Administration of anxiolytics is only considered for anxious patients and not for wound infection. p. 445

While caring for a patient with mental illness, the nurse notices that the patient is actively participating in group activities verbally and nonverbally. Which domain of learning does the nurse recognize in this patient? Affective Cognitive Attentional Psychomotor

Affective The patient who participates in affective learning will exhibit good responding behavior. Verbal and nonverbal responses in group activities indicate affective learning development. The patient is not acquiring any knowledge about new factors or new facilities; instead, the patient is showing effective verbal and nonverbal communication. Therefore, the patent is not exhibiting cognitive learning. The attentional set is not a domain of learning; it is a mental state that allows a learner to focus on an activity. The patient is not using his or her mental or muscular activity to acquire a skill. Therefore, the patient is not exhibiting psychomotor development. p. 339

A student nurse is learning about preventive care. Which activities are included under tertiary prevention? Providing protection against occupational health hazards Taking measures to shorten a period of disability Providing services to limit disability and prevent death Aiding with rehabilitation for physically handicapped people

Aiding with rehabilitation for physically handicapped people Tertiary preventive measures are taken when permanent, irreversible damage has occurred as a result of a medical problem or accident. Aiding with rehabilitation for physically handicapped people is included under tertiary prevention. Providing facilities to limit disability and prevent death is a secondary preventive measure. Providing protection against occupational health hazards is a primary preventive measure. Taking measures to shorten the period of disability comes under secondary prevention. pp. 70-71

To which patients do standard precautions apply? All patients receiving care Patients with blood-borne infections Patients with infected, draining wounds Patients believed to have an infectious disease

All patients receiving care Standard precautions were implemented to provide safety for caregivers and patients regardless of infectious status. The answer choices concerning the use of standard precautions only for patients with blood-borne infections; those patients with infected, draining wounds; or patients believed to have infectious diseases are incorrect because they limit the scope of standard precautions that are used with certain populations. pp. 458-459

An older adult is being started on a new antihypertensive medication. In teaching the patient about the medication, what should the nurse do? Raise his or her voice and face the patient directly. Present the information once because of the older adult's short attention span. Expect the patient to understand the information quickly. Allow the patient time to express himself or herself and ask questions.

Allow the patient time to express himself or herself and ask questions. When teaching older adults, it is important to establish rapport, involve them in their care, and allow them to progress at their own pace. pp. 341-342

When the nurse is teaching a patient about how to administer an epinephrine injection in case of a severe allergic reaction, the nurse tells the patient to hold the injection like a dart. Which instructional method did the nurse use? Telling Analogy Demonstration Simulation

Analogy Analogies use familiar images to help explain complex information. p. 349

A nurse describes arterial blood pressure as "like water flowing through a hose." Which teaching technique does this exemplify? Analogy Role play Demonstration Simulation

Analogy Nurses may use analogies to explain difficult concepts with familiar images to make the concepts more real and understandable. Role play involves having the patient pretend to be him or herself or someone else in order to rehearse a desired behavior, for instance a parent rehearsing techniques for getting his or her child to take medicine. Demonstration is used to teach psychomotor skills such as preparing a syringe, bathing an infant, crutch walking, or taking a pulse. Simulation involves giving a patient a scenario and having him or her apply the learning to the situation; for instance, a nurse may give a heart patient a restaurant menu and ask him or her to select the most heart-healthy meal. p. 349

Which stage of cognitive learning involves the breakdown of information into organized parts? Applying Analyzing Evaluating Understanding

Analyzing The analyzing level of cognitive learning involves the ability to break information down into organized parts. Applying involves using learned concepts in real situations. The cognitive process of evaluation is the ability to judge the value of an action for a given purpose. Understanding is described as the ability to understand the meaning of learned material. p. 340

The nurse cares for a patient who is scheduled for surgery. Which objects would require high-level disinfection with phenolics? Stethoscopes Urinary catheters Surgical instruments Anesthesia equipment

Anesthesia equipment Phenolics are used for high-level disinfection. Semi-critical items such as anesthesia equipment, endoscopes, and endotracheal tubes require high-level disinfection or sterilization. Noncritical items such as stethoscopes require a disinfection of surfaces. Critical items such as urinary catheters and surgical instruments require sterilization. p. 456

The registered nurse (RN) is teaching a patient about The Joint Commission (TJC) Speak Up Initiatives. Which action taken by the patient indicates that the patient needs further teaching about these initiatives? Asking about the medication errors Asking the qualification of the primary health care provider Asking the purpose of medications given during the treatment Asking the primary health care provider to act as his or her advocate

Asking the primary health care provider to act as his or her advocate According to the TJC Speak Up Initiatives, the patient should ask a trusted family member or a friend to act as his or her advocate (advisor or supporter). The patient should know the medications and their purpose in the treatment, and medication errors that are most common health care mistakes. Patients should make sure that the treatment and medications they are getting are right and are provided by the right health care professionals. Therefore, the patient has a full right to ask about the qualification of the primary health care provider. The patient should have knowledge about the medications and their purpose in the treatment. p. 338

A patient who underwent bariatric surgery complains of serous exudate at the site of surgery. The primary health care provider diagnoses the patient with a health care-associated infection. Which microorganisms can cause exogenous infections? Yeast Aspergillus Streptococcus Staphylococcus Clostridium tetani

Aspergillus Clostridium tetani Microorganisms responsible for exogenous infections include Aspergillus and Clostridium tetani. Endogenous infections occur when the body's normal floras are altered. Yeast, streptococci,and staphylococci can cause endogenous infections. p. 448

Which teaching tool is beneficial for patients with reading comprehension problems and visual deficits? Graphs Physical objects Audiovisual materials Computer instruction

Audiovisual materials Audiovisual materials include slides, audiotapes, television, and videotapes used with printed material or discussion. This teaching tool is effective for patients with reading comprehension problems and visual deficits. Graphs are visual presentations of numerical data. They help learners grasp information quickly about single concepts. This teaching tool may not be beneficial to patients with visual deficits. Likewise, using physical objects such as actual equipment, objects, or models to teach concepts or skills may not be beneficial to the patients with visual deficits. The computer instruction method requires reading comprehension, psychomotor skills, and familiarity with computers. p. 353

A couple approaches the nurse for counseling. The body mass index (BMI) of the husband is 32 (obese). The BMI of the wife is 16 (underweight). Both are unemployed and need financial support. On interviewing, the nurse finds that the husband snores loudly, which disturbs the wife during sleep. Which internal variable has an influence on the woman's sleep? BMI of 32 Snoring Employment status BMI of 16

BMI of 16 The body mass index (BMI) of 16 shows that the woman is underweight. It shows her poor nutritional status. It is an internal variable that can have an influence on her health and sleep. The BMI of 32 is her husband's health indicator, so it is considered an external variable. Other external variables are snoring and employment status. pp. 69-70

A patient with chronic alcoholism is hospitalized in critical condition. The patient tells the nurse, "If God lets me live this time, I promise to quit drinking forever." Which stage of grieving does the patient demonstrate through this statement? Anger Resolution Bargaining Acceptance

Bargaining It is difficult for a patient to accept a temporary or permanent loss of health. The patient needs to grieve. This process of grieving provides time to adapt psychologically to the emotional and physical implications of the illness. In this scenario, the patient is offering to live better in exchange for the promise of better health, which indicates the bargaining stage of psychosocial adaptation to illness. A patient may place blame, complain, and direct anger towards the nurse or others in the anger stage. In the resolution stage, the patient may begin to express emotions openly. He or she realizes that the illness has created changes. When a patient is in the acceptance stage, he or she recognizes the reality of the condition, actively pursues information, and strives for independence. p. 342

The nurse is teaching juniors about the health promotion model (HPM). Which components belong to the health promotion model? Behavioral outcomes Individual characteristics and experiences Behavior-specific knowledge and affect Individual's perception of susceptibility to illness Likelihood that a person will take preventive action

Behavioral outcomes Individual characteristics and experiences Behavior-specific knowledge and affect The health promotion model (HPM) was proposed by Pender. According to this model, health is a positive, dynamic state, not merely the absence of disease. Health promotion activities are aimed at increasing the well-being of patients. The components of HPM include behavioral outcomes, individual characteristics and experiences, and behavior-specific knowledge and affect. The behavioral outcome as a result of health promotional activities is the end point in HPM. The individual characteristics and experiences determine the individual's response to health promotion activities. The behavior-specific knowledge and affect are important in understanding and implementing health promotion activities. The individual's perception of susceptibility to illness and the likelihood that a person will take preventive action do not affect HPM. These components belong to the health belief model. pp. 66-68

The nurse who is working in a postoperative unit realizes that there is chipped nail polish on her fingers. Another colleague who has artificial nails tells the nurse that it is not a concern. Which of them poses a greater risk for contracting an infection to the patients? There is no risk with either situation. The nurse with artificial nails has a higher risk. The nurse with chipped nail polish has a higher risk. Both nurses have an equal risk of causing infection.

Both nurses have an equal risk of causing infection. Research has shown that health care providers with chipped nail polish or with artificial nails have greater numbers of microorganisms, and therefore pose a greater risk to the patients. The Centers for Disease Control and Prevention's (CDC) hand hygiene guidelines recommend that artificial nails should not be worn by health care providers when working with high-risk patients. p. 469

A patient suffering from chronic obstructive pulmonary disease (COPD) refuses to meet anyone, including family members. Which impact of the illness is the patient showing? Illness symptom Coping Health prevention Changed self-concept Impact on family role

Changed self-concept Impact on family role The patient is experiencing an impact of illness on self-concept. A patient who refuses to interact with family members is also experiencing an illness reaction, which impacts the family role. Illness behaviors are a patient's reaction to the disease and a way of coping with the disease and its adversities. Behaviors are generally influenced by the way the patient perceives the illness to be, and adverse reactions are based on those perceptions. Refusing to meet anyone is not a symptom of chronic obstructive pulmonary disease (COPD). Health prevention is a way of preventing health problems from occurring. p. 75

The nurse has to teach a group of morbidly obese patients the significance of proper eating habits and exercise. Where would be an ideal setting to impart this teaching? Cafeteria Hospital lobby Gymnasium Classroom

Classroom An ideal setting for teaching would be a classroom, because patients would be able to sit comfortably, the room would have proper ventilation and light so that everyone could see and hear the teacher without distraction, and the patients would be able to observe one another during the teaching session. A cafeteria, hospital lobby, or noisy and busy places would have numerous distractions that could interfere with the teaching process. A gymnasium would not have comfortable seating arrangements for the patients to optimally concentrate on the teaching. p. 344

A patient who is on antibiotic therapy visits the primary health care provider with severe diarrhea. The primary health care provider diagnoses the patient with antibiotic-induced diarrhea. Which microorganism causes antibiotic-induced diarrhea? Bacteroides fragilis Clostridium difficile Staphylococcus aureus Legionella pneumophila

Clostridium difficile Clostridium difficile is a common spore-forming bacterium that causes antibiotic-induced diarrhea. Bacteroides fragilis are normal flora of the human colon that may cause infections when displaced into the bloodstream or tissues near the site of injury or surgery. Staphylococcus aureus can cause wound infection and pneumonia. Legionella pneumophila can grow in 25-degree to 42-degree water. This microorganism may not cause antibiotic-induced diarrhea. p. 444

Which teaching tool is most suitable for the patients who have strong reading comprehension and psychomotor skills? Physical objects Printed material Audiovisual materials Computer instruction

Computer instruction The computer instruction teaching tool requires reading comprehension, psychomotor skills, and familiarity with computers. Physical objects such as actual equipment, objects, or models are used to teach concepts or skills. This teaching tool for instruction may not require the patient to have strong reading comprehension skills. Using printed material as a teaching tool requires the patient to have good reading comprehension skills but would not require psychomotor skills. Audiovisual materials include slides, audiotapes, television, and videotapes used with printed material or discussion. This teaching tool is effective for patients with reading comprehension problems and visual deficits. p. 353

The nurse works in a psychiatric unit and understands that the use of restraints may be useful for ensuring patients' safety. Which complications should the nurse be aware of when using physical restraints? Constipation Incontinence Pressure ulcers Increased appetite Improved alertness

Constipation Incontinence Pressure ulcers Constipation can result from immobility. Incontinence can occur due to the inability to get out of bed on time to use the toilet. Pressure ulcers can result from pressure on bony prominences due to immobility. Increased appetite is generally not a complication and may not be related to use of restraints. Improved alertness is a good sign and is not a complication of the use of restraints. p. 391

A 76-year-old patient has come to a clinic for a regular check-up. During the assessment the nurse finds that the patient is a chronic smoker. The patient is not alcoholic but is allergic to milk and seafood. Considering the patient's age, screening tests for colon cancer are performed, and the patient is advised to begin a high-fiber diet. The patient complains of pain in the legs. The Doppler study of the lower extremities reveals peripheral vascular disease (PVD). The patient is advised to exercise regularly. Which suggested interventions are included in primary prevention? Counseling for smoking cessation Prescribing narcotic drugs for pain relief Encouraging the patient to exercise regularly Advising the patient to avoid milk products Advising a high-fiber diet to prevent colon cancer

Counseling for smoking cessation Advising the patient to avoid milk products Advising a high-fiber diet to prevent colon cancer In primary prevention, measures are taken before the occurrence of disease or dysfunction. In this case, activities for primary prevention include counseling for smoking cessation, advising the patient to avoid milk products, and advising a high-fiber diet. Prescription of narcotics for pain relief is a secondary prevention, which is done after diagnosis. Encouraging the patient to exercise is a tertiary prevention against complications and disabilities related to peripheral vascular disease. pp. 70-71

A head nurse is teaching cough etiquette to staff members at the hospital. What should the nurse include in the instructions? Cover the nose and mouth with a tissue when coughing. Dispose of any contaminated tissue promptly. Maintain a distance of at least 2 feet from persons with respiratory infections. Maintain a distance of greater than 3 feet from persons with respiratory infections. Place a surgical mask on a patient if it does not compromise respiratory function.

Cover the nose and mouth with a tissue when coughing. Dispose of any contaminated tissue promptly. Maintain a distance of greater than 3 feet from persons with respiratory infections. Place a surgical mask on a patient if it does not compromise respiratory function. Cough etiquette involves covering the nose and mouth with a tissue when coughing. It helps to prevent the spread of infections. Disposing of contaminated tissue promptly helps to contain the microbes. Spatial separation of greater than 3 feet from persons with respiratory infections helps to avoid contracting the infection through droplets. Placing a surgical mask on a patient if it does not compromise respiratory function helps to prevent infection in the patient. A distance of 2 feet is too close and promotes the spread of infection through droplets. pp. 457, 459

A patient who is hospitalized has just been diagnosed with diabetes. He is going to need to learn how to give himself injections. Which teaching method does the nurse use? Simulation Demonstration Group instruction One-on-one discussion

Demonstration Demonstration is used to help patients learn psychomotor skills. p. 339

The nurse needs to educate a patient on how to use a monitor to measure blood pressure at home. What is the best instructional method to accomplish this? One-on-one discussion Role-playing Demonstration Analogy

Demonstration Demonstration of a task is the best method to teach a person psychomotor skills. It can be combined with return demonstration, in which the patient performs the learned skill and the nurse is able to observe and give feedback. A one-on-one discussion is helpful when discussing health-related issues directly with the patient in an informal manner. Role-playing allows patients to play themselves or others and involves rehearsing a desired behavior. Analogies supplement verbal instruction with images that help with understanding of complex information. p. 349

A patient who underwent leg surgery is advised to use crutches to walk post discharge. Which teaching method would be most effective for the nurse to use? Simulation Demonstration Group instruction One-on-one discussion

Demonstration The demonstration method of teaching is used to teach psychomotor skills to patients, for example, preparing a syringe, bathing an infant, crutch walking, or taking a pulse. Simulation is a useful technique for teaching problem solving, application, and independent thinking. During individual or group discussion a pertinent problem or situation is posed for patients to solve. Group teaching is method in which a number of patients are taught at one time, and patients are able to interact with one another and learn from the experiences of others. During one-on-one discussions, information is usually given in an informal manner, allowing the patient to ask questions or share concerns. p. 350

The nurse assures a patient that the nurse is always available to talk. Which stage of grieving would most likely trigger this action of the nurse? Anger Resolution Bargaining Denial or disbelief

Denial or disbelief In the denial or disbelief stage of grieving, the patient is not prepared to deal with a problem. Therefore, the nurse should provide support and empathy and ensure the patient that he or she is always available for discussion. In the anger stage of grieving, the nurse should not argue with the patient and should calmly listen to patient's concerns. In the resolution stage of grieving, the nurse should encourage the patient to express his or her feelings. In bargaining stage of grieving, the nurse should convey only reality to the patient. p. 342

The nurse must teach discharge instructions to a postsurgical patient. Which learning principles should the nurse use to effectively educate the patient? Determine the extent to which the patient can perform skills. Assess the patient's physical condition before teaching. Refrain from asking the patient about cultural and spiritual influences about illness. If the patient is willing, involve the family member of the patient while teaching. Teach the patient in a location where he or she can easily interact with all the visitors.

Determine the extent to which the patient can perform skills. Assess the patient's physical condition before teaching. If the patient is willing, involve the family member of the patient while teaching. Determine the extent to which the patient can perform skills so the patient can easily perform the tasks given. Physical conditions such as body temperature, pain, and fatigue can interfere with the ability to maintain attention. Therefore, physical examination is necessary. If the patient desires, involving a family member can help speed recovery. The patient should be asked about his or her cultural and spiritual beliefs regarding the illness, because these influences might affect the learning process. The environment should be conducive to teaching. A quiet place away from distractions is also necessary. pp. 341-342, 350

A male patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce after 15 years of marriage and has been seeing his pastor to help him through this difficult time. He does not have a primary health care provider because he has never really been sick and his parents never took him to the physician when he was a child. Which external variables influence this patient's health practices? Difficulty paying bills Seeing his pastor as a means of support Family practice of not routinely seeing a health care provider Stress from the divorce and the loss of a job Family practice associated with the emotional aspects of seeing a health care provider

Difficulty paying bills Family practice of not routinely seeing a health care provider External factors impacting health practices include family beliefs and economic impact. How a patient's family uses health care services generally affects the patient's own health practices. Their perceptions of the serious nature of diseases and their history of preventive care behaviors (or lack of them) influence how patients will think about health. Economic variables may affect a patient's level of health by increasing the risk for disease and influencing how or at what point the patient enters the health care system. pp. 69-70

A patient is diagnosed with influenza. Which type of isolation precaution is most appropriate for this patient? Droplet precautions Contact precautions Airborne precautions Standard precautions

Droplet precautions Influenza is transmitted via droplets larger than 5 microns. Pneumonia causes deep chest pain with a cough that transmits the infection. Therefore, the nurse should follow droplet precautions to prevent the infection transmission. The nurse should follow contact precautions if the infection transmits by direct patient or environmental contact. Airborne precautions are used to prevent infections that transmit through droplet nuclei smaller than 5 microns. Standard precautions are used to prevent infections that may be caused by blood, blood products, body fluids, secretions, nonintact skin, and mucous membranes. p. 459

An 18-year-old patient is brought to the emergency department following a motor vehicle accident. Which are possible causes of a motor vehicle accident in this age group? Reduced vision Drunken driving Fast driving Carelessness regarding road hazards Improper driver's training

Drunken driving Fast driving Carelessness regarding road hazards Motor vehicle accidents are commonly seen in drivers between 16 to 19 years of age. In this age group, alcohol, drugs, and high speeds are the major causes of accidents. This age group does not always consider dangerous or hazardous situations. Reduced vision is a common cause of accidents in an older or elderly population. Proper training to drive is always provided before issuing a valid license. p. 374

The nurse is demonstrating the technique of self-administration of an insulin injection to a group of diabetic patients. What should the nurse keep in mind when teaching throughout the demonstration method? Encourage patients to ask questions. Set a timer to complete the demonstration. Perform the steps in the right sequence. Position the patients to provide a clear view of the skill being performed. When the demonstration is over, politely ask the patient to leave and to try the activity at home.

Encourage patients to ask questions. Perform the steps in the right sequence. Position the patients to provide a clear view of the skill being performed. While performing a demonstration, the nurse should encourage the patients to ask questions. The nurse should perform the steps of the activity in the right sequence so that the patients learn the right technique. The patients should be positioned in a way as to provide a clear view of the skill being performed. Repositioning would help the patients to view the whole procedure correctly and practice accordingly. The nurse should not rush to complete the demonstration and should give an ample amount of time for demonstrating each step. The nurse should encourage the patients to repeat the activity after the demonstration under the nurse's observation. p. 349

A patient's breast biopsy results return as positive for cancer. The patient says that there is some mistake and that she cannot have breast cancer. What actions should the nurse take to provide further information to this patient? Explain the situation to her relative or significant other. Explain carefully the significance and need for prompt tumor removal. Discuss chemotherapy treatment. Inform the patient about breast implants. Talk to the patient in a firm voice.

Explain the situation to her relative or significant other. Explain carefully the significance and need for prompt tumor removal. When the patient is in the denial stage secondary to a new diagnosis, the nurse should try to explain the situation to a relative or significant other, because the patient is not willing to accept the new condition or any other information regarding the same. The nurse should carefully and empathetically inform the patient about surgical treatment and the significance of the same. During the denial stage, discussion of detailed and future information such as chemotherapy and the possible necessity for breast implants should be avoided. The nurse should not use a firm voice while dealing with a patient in the denial stage of grieving. p. 341

The nurse has conducted a primary prevention program for school children less than 10 years of age. Which nursing intervention is considered primary prevention? Explaining the importance of a nutritious diet Supplying a nutritious diet to children with malnutrition Teaching disabled children to use their capacities to the fullest Conducting health examinations to identify children with malnutrition

Explaining the importance of a nutritious diet Primary prevention interventions are done before the development of a disease or disorder. Interventions can take the form of health education or nursing interventions such as immunizations. Primary prevention also includes a nutritious diet to maintain health and prevent illness. Teaching disabled children to use their capacities to the fullest would be considered tertiary prevention, because disability has already occurred. Conducting health examinations to identify children with malnutrition and supplying nutritious diets to children with malnutrition would be considered secondary prevention, because these measures are directed toward managing a disease that has already manifested. pp. 70-71

The nurse has been assigned to care for a 35-year-old patient who has developed new moles all over the body. On examination the nurse finds that the moles are different sizes and vary in color from brown to black. They are more commonly found on body parts exposed to sun. The nurse finds that the patient is a journalist. The patient's father died of melanoma many years back. What are the risk factors of melanoma in the patient? Age Exposure to sunlight Lifestyle Genetic factor Stressful workplace

Exposure to sunlight Genetic factor Excessive exposure to sun rays increases the likelihood of developing skin cancers such as melanoma. Genetic factors are an important cause of cancer, which increase the patient's susceptibility to the disease. Age is not a risk factor for cancer. Lifestyle factors such as stress in the workplace do not predispose a person to cancer. p. 72

The nurse understands that there are many variables that affect the health beliefs and practices of an individual. Which are examples of external variables? Family practices Socioeconomic factors Developmental stages Cultural beliefs Spiritual factors

Family practices Socioeconomic factors Cultural beliefs Family practices, socioeconomic factors, and cultural beliefs are all external variables. Family health practices have a huge impact on how a person thinks and acts. An individual tends to follow the same health practices that the family members follow. An individual usually seeks support and approval for the health practices and beliefs from social support systems. This social system includes spouse, neighbors, and peers. Cultural beliefs influence the way an individual seeks medical care and affect the personal health practices. Developmental stages and spiritual factors are internal variables, which influence a person's health and health care beliefs and practices. pp. 69-70

Stroke is a lifestyle disease. Which lifestyle factors may increase the risk of developing a stroke? Fast foods Physical inactivity Excessive sun exposure Tobacco use Lack of immunizations

Fast foods Physical inactivity Tobacco use Fast foods, physical inactivity, and use of tobacco could all increase the risk of stroke. Fast foods have high fat content and increase the risk of atherosclerosis, which in turn leads to stroke. Physical inactivity may lead to obesity, which again promotes deposition of fats in the blood vessels, thus increasing the risk of stroke. Tobacco use accelerates the process of atherosclerosis and also contributes to increasing the risk of stroke. Excessive sun exposure can cause cancer. A lack of immunizations may leave one susceptible to diseases such as influenza and hepatitis. p. 72

The nurse assesses the following risk factors for coronary artery disease (CAD) in a male patient. Which factors are classified as genetic or physiological? Sedentary lifestyle Father died from CAD at age 50 History of hypertension Diet high in sodium Elevated cholesterol level Age of 44 years

Father died from CAD at age 50 History of hypertension Elevated cholesterol level Genetic risk factors are related to heredity and the genetic predisposition to an illness; physiological factors involve the physical functioning of the body. Certain physical conditions such as being pregnant or overweight place increased stress on physiological systems (e.g., the circulatory system), increasing susceptibility to illness in these areas. A person with a family history of coronary artery disease is at risk for developing the disease later in life because of a hereditary and genetic predisposition to the disease. Age, diet and lifestyle are not genetic or physiological risk factors. p. 72

The nurse is caring for a patient who is quadriplegic. According to Maslow's hierarchy of needs, which patient needs should be given priority over others? Reassuring the patient Allowing the family members to visit Feeding the patient Ensuring adequate fluid intake Assisting with bladder or bowel elimination

Feeding the patient Ensuring adequate fluid intake Assisting with bladder or bowel elimination According to Maslow's hierarchy of needs, some human needs are more basic than other needs and should be met before other needs are met. Food, water, and elimination are basic needs and should be given priority over others. Reassurance helps to make the patient emotionally secure. A visit by family members makes the patient feel loved. Test-Taking Tip: Consider how you would feel if you were the patient and one type of care was offered before another. For instance, would you want a visit from a family member if you needed help with elimination at that time? pp. 67-68

The nurse understands that reinforcement requires using a stimulus that increases the probability of a response. Which examples are appropriate when teaching the reinforcement approach? Demonstrating how to bathe an infant Explaining to a patient about the need for an emergency diagnostic procedure Giving a child candy once the child has completed a given activity Allowing a diabetic patient to adjust his insulin dosage independently Asking a child to perform an activity and congratulate the child on performing the activity well

Giving a child candy once the child has completed a given activity Asking a child to perform an activity and congratulate the child on performing the activity well Reinforcement requires using a stimulus that increases the probability of a response. Giving a piece of candy is an example of material reinforcement and works best with children. Appreciating performance is an example of social reinforcement. Demonstrating an activity is the demonstration method of instruction. While preparing a patient for an emergency procedure, the nurse explains the procedure to the patient. Allowing a diabetic patient to adjust his insulin dosage independently is an entrusting approach to teaching. p. 348

While teaching pregnant women about nutrition and diet planning, the nurse randomly selects several women and gives them an opportunity to share their diet plans to correct mistakes and reinforce the correct information. Which method of teaching is the nurse following? Role play Group discussion Demonstration One-on-one discussion

Group discussion After a lecture, learners often need the opportunity to share ideas and seek clarification in the form of structured group discussion. Group discussions allow patients and families to learn from one another as they review common experiences. During role play, learners are asked to play themselves or someone else. Patients learn required skills and feel more confident in being able to perform them independently. Demonstrations are used to teach psychomotor skills such as preparing a syringe, bathing an infant, crutch walking, or taking a pulse. During one-on-one discussions, information is usually given in an informal manner, allowing the patient to ask questions or share concerns. p. 350

In a pediatric ward, one of the newborns died of sudden infant death syndrome (SIDS). Which nursing measure lowers the risk of death due to SIDS? Massaging the baby's heels Attaching pacifiers with a string around the baby's neck Gently rubbing the baby's back Having the baby sleep on his or her back

Having the baby sleep on his or her back Sudden infant death syndrome (SIDS) is a condition in which the infant dies due to an unexplained cause. The American Academy of Pediatrics recommends having the baby sleep on his or her back to reduce the risk of sudden infant death syndrome (SIDS). Massaging the heels helps in managing an apneic episode. Pacifiers should not be attached with a string around the neck, because this increases the risk of choking. Rubbing the baby's back is helpful in stimulating respiration in newborns. p. 385

Which disease can be transmitted when a nurse is drawing blood from a patient with an infection? Chickenpox Scarlet fever Tuberculosis Hepatitis B virus

Hepatitis B virus Vehicles such as blood may transmit the hepatitis B virus. Chickenpox, scarlet fever, and tuberculosis can be transmitted through the air or droplet nuclei. p. 445

An elderly patient is admitted to a hospital for management of depression. The patient asks the nurse for permission to do meditation and breathing exercises for 15 minutes in the evening. The nurse has given the permission to do so. Which health model is reflected in this situation? Health promotion model Health belief model Holistic health model Restoration and rehabilitation model

Holistic health model The holistic health model emphasizes that all dimensions of an individual should be considered, including emotional and spiritual well-being, for the total wellness of an individual. Therefore, the approach used in this case comes under the holistic health model. The health promotion model focuses on individual characteristics and experiences, behavior-specific knowledge and affect, and behavioral outcomes. The health belief model addresses the relationship between a person's beliefs and behavior. Restoration and rehabilitation fall under tertiary prevention. pp. 68-69

Which nursing activity is performed during the assessment of a patient? Selecting nursing interventions to promote safety Identifying patient perceptions safety needs and risks Consulting with occupational and physical therapists for assistive devices Selecting interventions that will improve the safety of the patient's home environment

Identifying patient perceptions safety needs and risks Identifying the patient's perceptions of safety needs and risks is involved in the critical thinking model for safety assessment. The critical thinking model for safety planning involves selecting nursing interventions to promote safety, consulting with occupational and physical therapists for assistive devices, and selecting interventions that will improve the safety of the patient's home environment. p. 381

Which is the first step in health promotion, wellness education, and illness prevention? Identifying risk factors Identifying vulnerable people Helping the patient improve health status Emphasizing wellness strategies

Identifying risk factors When caring for a patient, the nurse must identify the risk factors and discuss health issues following a comprehensive nursing assessment. Assessment is followed by identification of vulnerable groups. Following this, the nurse can help patients decide if they want to maintain or improve their health status by taking risk-reducing efforts. Based on the assessment and the patient's needs, the nurse can emphasize wellness strategies. p. 72

When illness occurs, different attitudes about the illness cause people to react in different ways. What do medical sociologists call this reaction to illness? Health belief Illness behavior Health promotion Illness prevention

Illness behavior Illness behavior involves how people monitor their bodies, define and interpret their symptoms, take remedial actions, and use the resources in the health care system. Personal history, social situations, social norms, and past experiences can affect illness behavior. Health beliefs are a person's ideas, convictions, and attitudes about health and illness. Positive health behaviors are activities related to maintaining, attaining, or regaining good health and preventing illness. Illness prevention motivates people to avoid a decline in health or functional levels. p. 74-75

A 76-year-old patient with peripheral vascular disease (PVD) developed gangrene of the left foot and underwent an amputation. After the amputation, the patient was given crutches, and an occupational therapist assisted the patient to walk with crutches. The patient is depressed due to the loss of the foot and has been prescribed antidepressants. Which tertiary preventive measures should be advised for this patient? Implanting a prosthetic foot in the left leg Referring the patient for vocational retraining Referring the patient to social support groups Advising the patient about measures to prevent accidents Prescribing antidepressant medications to the patient

Implanting a prosthetic foot in the left leg Referring the patient for vocational retraining Referring the patient to social support groups Tertiary measures are taken after permanent, irreversible disability and focus on rehabilitation. The tertiary preventive measures in this case would include implantation of a prosthetic foot, referring the patient for vocational retraining, and referring the patient to social support groups. Advising the patient about measures to prevent accidents is a primary prevention activity. Prescription of antidepressants is a secondary prevention activity. pp. 70-71

The nurse is teaching a group of student nurses about the three levels of prevention. Which activities are included in the secondary prevention of diseases? Use of specific immunizations Use of environmental sanitation Individual and mass screening activities Selective examinations to cure and prevent disease process Provision of facilities to limit disability and prevent death

Individual and mass screening activities Selective examinations to cure and prevent disease process Provision of facilities to limit disability and prevent death The activities of secondary prevention are aimed at early diagnosis, prompt treatment, and disability limitation. The activities include individual and mass screening and selective examination to diagnose diseases in early stages and provide timely treatment. Secondary prevention also includes provision of facilities to limit disabilities and prevent death. Use of specific immunizations and use of environmental sanitation are included in primary prevention. pp. 70-71

Which are components of the health belief model? Behavior-specific knowledge and affect Individual characteristics and experiences Individual's perception of susceptibility to an illness Individual's perception of the seriousness of an illness The likelihood that a person will take preventive action

Individual's perception of susceptibility to an illness Individual's perception of the seriousness of an illness The likelihood that a person will take preventive action The components of the health belief model include an individual's perception of susceptibility to an illness, perception of the seriousness of the illness, and the likelihood that a person will take preventive action. Individual characteristics and experiences, and behavior-specific knowledge and affect are components of the health promotion model, not the health belief model. p. 66-67

The nurse is teaching a group of student nurses about health belief models. Which components of the health belief model address the relationship between a person's beliefs and behaviors? Individual's perception of susceptibility to an illness Individual's perception of duration of an illness Individual's perception of management of an illness Likelihood that a person will take preventive action against a disease Individual's perception of the seriousness of an illness

Individual's perception of susceptibility to an illness Likelihood that a person will take preventive action against a disease Individual's perception of the seriousness of an illness The first component of the health belief model involves an individual's perception of susceptibility to an illness. Once individuals understand that they may be susceptible to a disease, they may be able to perceive the seriousness of the problem. The second component is an individual's perception of the seriousness of the illness. The third component is the likelihood that a person will take preventive action. Perception of duration and management of illness are not part of this model. p. 66-67

The nurse is explaining the health belief model to a group of student nurses. Which statements are true about this model? It was proposed by Pender in 1982 and revised in 1996. It addresses the relationship between a person's beliefs and behaviors. An individual's perception of susceptibility to an illness affects behavior. An individual's perception of the seriousness of the illness affects actions. The access to health care facilities determines whether an individual will take preventive action.

It addresses the relationship between a person's beliefs and behaviors. An individual's perception of susceptibility to an illness affects behavior. An individual's perception of the seriousness of the illness affects actions. The health belief model addresses the relationship between a person's beliefs and behaviors and the impact of those beliefs on health. The individual's perception of susceptibility to an illness affects behavior towards the illness. An individual who perceives an increased susceptibility to an illness may take preventive action against the illness. An individual who perceives that the illness is serious may seek medical advice. The health belief model was proposed by Rosenstoch and Becker and Maiman. The access to health care facilities may affect the types of health care received but does not affect the preventive measures taken by the individual. p. 66-67

The nurse is learning about the holistic health model of nursing. Which statements are true about this model? It attempts to create conditions for optimal health. It recognizes the natural healing abilities of the body. It incorporates complementary and alternative therapies into nursing care. It is used to understand the relationships of basic human needs. It is based on the belief that certain human needs are more basic than others.

It attempts to create conditions for optimal health. It recognizes the natural healing abilities of the body. It incorporates complementary and alternative therapies into nursing care. The holistic health model attempts to create conditions for optimal health. It recognizes that the human body possesses a natural healing ability. These abilities can be used in patient care by incorporating complementary and alternative therapies such as music therapy and relaxation therapy. Maslow's hierarchy model helps to understand the relationships of basic human needs. It is based on the belief that certain human needs are more basic and need to be met before others. pp. 68-69

The nurse attends to a group of patients with depression. The nurse conducts a group discussion with the patients to teach them effective learning skills. How will the group discussion help the patients? It will allow patients to receive support from other patients in the group. It will allow patients to express concerns. It will allow patients to discuss personal and sensitive things. It will help patients to learn from others' experiences. It will help promote responsiveness, valuing others, and organization.

It will allow patients to receive support from other patients in the group. It will help patients to learn from others' experiences. It will help promote responsiveness, valuing others, and organization. If patients with depression sit in a group and interact with other patients who have similar symptoms, they receive support from other patients in the group. The group discussion helps them learn from the experiences of others and promotes responsiveness, valuing others, and organization. However, patients may not speak of their concerns or about sensitive topics in a group. For that, the nurse will need to have a one-on-one conversation. p. 349

A nursing student performs surgical hand asepsis after assisting a registered nurse in a surgical procedure. Which action made by the nursing student needs correction? Keeping the hands below the waist level Turning off the faucet using the knees Using a continuous motion to rinse from the fingertips to the elbows Using a rotary motion to move the towel from the fingers to the elbows

Keeping the hands below the waist level Because the area below the waist level is considered unsterile, the nurse should keep his or her hands above the waist. The faucet should be closed by using the knees to prevent contamination of the hands. The nurse should use a continuous motion to rinse from the fingertips to the elbows, allowing water to run off at the elbows. The nurse should use a rotary motion to move the towel from the fingers to the elbows during drying to dry the skin from the hands to the elbows. p. 478

A 45-year-old diabetic non-English-speaking woman, whose husband died 12 years ago, was found unconscious at her home. Her neighbors brought her to the hospital. The patient was diagnosed with diabetic ketoacidosis (DKA). After initial interventions, the patient regained consciousness. Which internal variables may influence the health of the patient? Language Help from neighbors Location of the patient Location of the hospital The patient's age and gender

Language The patient's age and gender Internal variables include a person's developmental stage, intellectual background, perception of functioning, and emotional and spiritual factors. These factors may affect the health of a person. In this case the patient's language, age, and gender are internal variables. Factors such as help from neighbors, location of the hospital, and location of the patient are external variables. p. 69

The registered nurse (RN) is preparing to teach a nursing student about the process of learning in nursing practice. Which information should the RN include in the nursing plan? Learning involves setting an appropriate pace. It requires the educator to be knowledgeable about subject matter. Learning includes both understanding and applying newly acquired concepts. Learning involves imparting knowledge through a series of directed activities. It is the acquisition of new knowledge, behaviors, and skills through an experience.

Learning includes both understanding and applying newly acquired concepts. It is the acquisition of new knowledge, behaviors, and skills through an experience. Learning is a process that includes both understanding and application of newly acquired concepts. It is the purposeful acquisition of new knowledge, behaviors, and skills through an experience. Teaching involves the educator or guide pacing the learning process appropriately. The educator should be knowledgeable about the subject matter in the process of teaching. Teaching imparts knowledge through a series of directed activities. p. 338

While assessing the behavior of a patient with a drug addiction, the nurse observes that the patient has abstained from taking drugs for the past 6 months and has been practicing healthy eating habits. Which stage of behavior change does the patient exhibit? Action Preparation Maintenance Contemplative

Maintenance A patient who has abstained from drug use for the past 6 months and is following a proper health regimen is in the maintenance stage of behavior change. A patient in the action stage of behavior change will actively engage in change. A patient in the preparation stage will begin to change habits. A patient in the contemplative stage will consider making lifestyle changes for the next 6 months. pp. 72-73

The nurse is teaching dietary modifications to a group of people with heart disease. Which actions by the nurse would maintain the attention and participation of the class? Making eye contact Using gestures Being stationary Asking questions Using a monotone voice

Making eye contact Using gestures Asking questions Active participation and attention is essential for learning to happen. The nurse should make eye contact with the listeners to increase their interest. Using gestures and engaging the listeners by asking questions help maintain the attention level of the participants. Being stationary and using a single tone while talking decreases the interest and attention of the listeners. pp. 340-341

A patient approaches the nurse to learn about complementary and alternative interventions for a headache. Which complementary and alternative interventions should the nurse suggest to the patient to help attain a good outcome? Drug therapy Music therapy Therapeutic touch Relaxation therapy Radiation therapy

Music therapy Therapeutic touch Relaxation therapy Complementary and alternative therapies can be incorporated into the nursing care model for providing holistic care. These therapies promote the natural healing abilities of the body. Music therapy helps to provide a soothing environment. Therapeutic touch helps in relieving anxiety. Relaxation therapy helps to relax the body and mind. Drug therapy and radiation therapy are not alternative interventions. pp. 68-69

Which action is performed by the nurse in the given image? Opening of the last and innermost flap Opening of the first side flap and pulling aside Opening of the second side flap and pulling it aside Opening of the outermost flap of the sterile kit away from body

Opening of the outermost flap of the sterile kit away from body The nurse is opening the outermost flap of the sterile kit away from the body to avoid microbial contamination. This is the first step of opening a sterile kit. The first side flap is opened and pulled aside in the second step. The second side flap is opened and pulled aside in the third step. The last and the innermost flap are opened in the last step. p. 473

What is the major reservoir of the microbe that causes gas gangrene? Water Oxygen Organic matter Undigested food in the bowel

Organic matter Clostridium perfringens causes gas gangrene; it thrives mostly on organic matter. Some bacterial forms, such as spores, live on a water surface for long periods of time. Aerobic organisms such as Staphylococcus aureus require oxygen for survival and multiplication sufficient to cause disease. Escherichia coli consumes undigested food in the bowel. p. 443

The nurse is assessing a group of patients in a health screening program. A patient complains of itching and irritation under the right arm and the nurse suspects a localized infection. What assessments should be done on this patient? Examine for paleness of skin. Palpate the area for tenderness. Inquire about pain and tightness. Inspect the area for redness and swelling. Inquire about gastrointestinal disturbances.

Palpate the area for tenderness. Inquire about pain and tightness. Inspect the area for redness and swelling. Gentle palpation of the infected area may reveal some degree of local tenderness due to inflammation. Inquiring about pain and tightness is important, because they may be caused by edema. Infected areas generally appear red and swollen due to inflammation. Paleness of skin is not a manifestation of infection. Gastrointestinal disturbances are not related to localized infection and may sometimes be found in systemic infections. p. 450

During a follow-up visit for a regular checkup, a patient who is on long-term antihypertensive medication exhibits a blood pressure of 180/100 mm Hg. The primary health care provider prescribes diuretics. Which teaching approach is most suitable to the patient? Telling Entrusting Reinforcing Participating

Participating With the participating approach to teaching, the nurse and patient set objectives and become involved in the learning process together. If the patient is already on long-term antihypertensive medications and still has high blood pressure, it likely means that he or she is not complying with the treatment. Hence, the participating approach helps the patient set objectives to meet the goal. The telling approach is used when the nurse is teaching limited information to a patient, such as when preparing a patient for an emergent diagnostic procedure. The entrusting approach provides a patient the opportunity to manage self care. With this approach, the patient accepts responsibility, performs tasks correctly and consistently, and is allowed to adjust the dose of medication. Reinforcing requires the use of a stimulus to increase the probability of a desired response. p. 349

A nurse reviews the data of patients with various infections. Which patient is at highest risk of transmitting infection to others? Patient A Patient B Patient C Patient D

Patient A While all the illnesses are potentially contagious, the nurse must analyze the data and prioritize which patient is most contagious. Mumps is a viral infection that is most contagious at least 5 days after salivary glands begin to swell. Strep throat is a bacterial infection that is usually no longer contagious after the patient has taken antibiotics for 24 hours. The patient diagnosed with influenza is able to infect others beginning 1 day before symptoms develop and up to 5 to 7 days after becoming sick. The transmission of infection for pneumonia varies depending on the cause. Most viral pneumonias resolve within 1 - 3 weeks but can result in a persistent cough for weeks after a person is no longer contagious. p. 446

The nurse has provided teaching for four patients separately. Which patient is most likely to understand the teaching if the real equipment cannot be used for a demonstration? Patient A (Computer Instruction) Patient B (Printed Material) Patient C (Graphs) Patient D (Models)

Patient D (Models) Nurses may use actual equipment, objects, or models to teach concepts or skills. Models are useful when real objects are too small, large, or complicated, or are unavailable. Computer instruction uses programmed instruction, in which the computer stores response patterns for learners and selects further lessons on the basis of these patterns. Computer instruction is not a substitute for a demonstration using real equipment.Printed material and online materials are written teaching tools available in print or online as pamphlets, booklets, or brochures. This method is ideal for understanding complex concepts and relationships, but is not a substitute for a demonstration using real equipment. Graphs are visual presentations of numerical data. They are represented as bar, circle, or line graphs. Graphs help learners to grasp the information quickly about single concept, but are not a substitute for a demonstration using real equipment. p. 353

The senior nurse is discussing with student nurses the serious reportable events included in the list of the National Quality Forum (NQF). Which environmental events must be discussed? Physical assault of the patient Patient death due to burns from facility equipment Patient death associated with falls Sexual assault of the patient Patient death due to electrocution

Patient death due to burns from facility equipment Patient death associated with falls Patient death due to electrocution According to the National Quality Forum (NQF), the death or serious illness of a patient incurred from burns, falls, or electric shock during care in a health care facility are considered environmental events. Physical assault and sexual assault are criminal events that need to be reported. Test-Taking Tip: When you read the question carefully, you will note that it only asks for environmental events. You examine the choices and realize that only the choices related to facility equipment, falls, or electrocution are environmental events. p. 378

Which patient is suspected to have an electrolyte imbalance? Patient with risk of falls Patient exposed to carbon monoxide Patient with lower extremity weakness Patient exposed to heat for an extended period

Patient exposed to heat for an extended period A patient exposed to extreme heat experiences changes in the electrolyte balance of the body and a rise in core temperature that results in heatstroke or heat exhaustion. Risk of falls, exposure to carbon monoxide, and lower extremity weakness are not associated with electrolyte imbalance. p. 375

Which basic step of the nursing process includes setting priorities based on the patient's immediate needs? Planning Evaluation Assessment Implementation

Planning In the planning phase of the nursing process, priorities are identified based on patient's needs and expected outcomes. Evaluation involves identifying success or failure in meeting desired outcomes and goals. Assessment involves collecting data about the patient's physical, psychosocial, and spiritual needs. In implementation, the nurse performs nursing care therapies. pp. 344, 347

The nurse is attending to patients in a postoperative unit. Based on the holistic model of care, which activities should the nurse encourage the patients to perform? Praying with family Breathing exercises Relaxation therapy Fulfilling psychosocial need Maintaining proper body image

Praying with family Breathing exercises Relaxation therapy In the holistic method, the nurse recognizes the natural healing ability of the body. The nurse combines conventional medicine along with complementary and alternative therapies, which are effective, economical, and noninvasive. Prayers with family members, breathing exercises, and relaxation therapy are techniques that help in healing the patient naturally using the body's own ability. Fulfilling the psychosocial need of the patient comes under Maslow's hierarchy model. Maintaining proper body image is not included in the holistic model. pp. 68-69

A 45-year-old non-English-speaking woman who has diabetes was found unconscious at home. Her neighbors brought her to the hospital 38 miles away. The patient was diagnosed with diabetic ketoacidosis (DKA). After recovery, the patient informs the nurse that she has been drinking alcohol regularly for the past 15 years and often skips meals. The nurse tries to advise the patient about lifestyle changes, but she shows no interest. After a couple of days, the patient agrees to implement the lifestyle changes. Which stages of the transtheoretical model of behavior change does the patient exhibit? Preparation stage Contemplation stage Action stage Maintenance stage Precontemplation stage

Preparation stage Precontemplation stage According to the transtheoretical model, a patient goes through five stages during behavior change. At first, the patient showed no interest in a lifestyle change; this is called the precontemplation stage. Later, she agreed to make changes in her lifestyle to improve her health. This is the preparation stage. The contemplation stage involves considering a change within the next 6 months. Actively engaging in strategies to change behavior is the action stage. The maintenance stage involves activities that maintain a changed behavior. p. 73

A nursing student is giving preparatory instructions to a patient undergoing an unfamiliar test. Which preparatory approach by the nursing student indicates the need for further learning? Describing physical sensations during a procedure Ensuring that the patients know when the results of their tests will be available Preparing patients for aspects of the experience that are rarely experienced Describing the cause of the sensation to prevent misinterpretation of the experience

Preparing patients for aspects of the experience that are rarely experienced The nurse should prepare the patients only for aspects of the experience that others have commonly noticed, such as a tight tourniquet causing a person's hand to tingle and feel numb. The nurse should describe the physical sensations experienced during a procedure, such as the sticking sensation caused as the needle punctures the skin. The nurse should be sure that the patient knows when the results will be available and who will give them the results of their tests. The nurse should describe the cause of the sensation to prevent misinterpretation of the experience. For example, the nurse should explain that a needle stick burns because the alcohol used to clean the skin enters the puncture site. p. 350

The nurse includes role play, imitation, and play in the teaching method to make learning fun. The nurse is teaching to which age group of children? Infant Adolescent School-aged Preschooler

Preschooler The nurse uses role play, imitation, and play to make learning fun for a preschooler. For an infant, the nurse would maintain routines; however, an infant would be unable to engage in role pay and imitation. The nurse uses problem solving to help adolescents make choices but would not engage them in play. The nurse teaches a school-aged child psychomotor skills required to maintain health. p. 343

An older adult is being started on a new anti-asthmatic medication. Which interventions should the nurse follow while teaching the patient about medication? Speak loudly. Present the information all at once. Present only the most significant information. Use blue and green in visual aids for instruction. Establish personalized, realistic short-term learning goals.

Present only the most significant information. Establish personalized, realistic short-term learning goals. When teaching an older adult, the nurse should present only the most significant information to avoid overwhelming of the learner. Repetition to reinforce content also helps the learner retain the information. Establishing personalized, realistic short-term learning goals is a strategy to facilitate learning when providing patient education to the older adults. Learning in an older adult can be facilitated by creating a casual and relaxed learning environment; it is not necessary to speak loudly, and doing so may contribute to the patient's anxiety. While giving instructions or teaching a new skill to older adult, give concise step-by-step directions instead of presenting the information at once. When teaching older adults using visual aids, avoid blues and greens, because these colors can become more difficult to be distinguished with age. p. 353

The nurse has conducted an immunization program for physically challenged children in a rehabilitation center. Pneumonia vaccine was administered to the children as a part of the program. Which level of prevention is this? Primary Tertiary Secondary Early diagnosis

Primary Primary prevention includes measures taken before the occurrence of a medical problem. For example, vaccinations are given to children or adults to prevent a disease from occurring; thus, vaccinations come under the realm of primary prevention. Tertiary prevention is required when there is a permanent disability. Secondary prevention includes early diagnosis, treatment, and disability limitation. pp. 70-71

The nurse is participating at a health fair at the local mall giving influenza vaccines to senior citizens. Which level of prevention is the nurse practicing? Primary Secondary Tertiary Quaternary

Primary Primary prevention is aimed at health promotion and includes health-education programs, immunizations, and physical and nutritional fitness activities. It can be provided to an individual and includes activities that focus on maintaining or improving the general health of individuals, families, and communities. It also includes specific protection such as immunization for influenza. Secondary prevention is diagnosing and treating an illness and limiting disabilities. Tertiary prevention includes restoration and rehabilitation. Quaternary prevention doesn't exist. p. 71

The nurse is providing information to a group of adolescents about contraception and the risk of human immunodeficiency virus (HIV) infection. What is the nurse teaching in this instance? Primary prevention Secondary prevention The health belief model The holistic approach model

Primary prevention The nurse is teaching the adolescents the measures that should be taken to prevent human immunodeficiency virus (HIV) infection and unplanned pregnancy; therefore, the nurse is providing primary prevention. When providing secondary prevention, the nurse educates the patient about screening techniques available for specific diseases. The nurse respects the patient's cultural practices while following the health belief model of treatment. The nurse provides a traditional method of healing while providing a holistic approach to treatment. However, neither the health belief model nor the holistic approach are considered preventive care. p. 72

A patient who is infected with herpes simplex complains of itching and tingling. There are no visible lesions found on examination. To which stage of herpes simplex infection does this patient belong? Illness stage Incubation stage Prodromal stage Convalescence stage

Prodromal stage The prodromal stage is defined as the interval from onset of nonspecific signs and symptoms to more specific symptoms related to the type of infection or disease. In this stage the microorganisms grow and multiply. Itching and tingling sensations are nonspecific symptoms of herpes simplex that occur before the lesions appear. In the illness stage, the patient actually develops the signs and symptoms specific to the type of infection. The incubation period is an interval between entrance of the pathogen into body and appearance of the first symptoms. In the convalescence stage, acute symptoms of infection will disappear. Study Tip: Although the prefix pro often means "favoring" or "supporting;" it can also mean "before" in time or in place, just like the prefix pre. The suffix drome means "running," as in syndrome, which means (symptoms that) "run together." Thus, prodrome means "running before"; so prodromal refers to the time before specific symptoms appear. p. 446

A patient needs to learn to use a walker. Which domain is required for learning this skill? Affective domain Cognitive domain Attentional domain Psychomotor domain

Psychomotor domain Using a walker requires the integration of mental and muscular activity. Test-Taking Tip: If you cannot recall the meanings of terms in a question or choices, take the word apart in your mind and examine the word roots. In the choice "Psychomotor domain," you see psycho and motor. You know psych is the word root for mind, that motor indicates motion, and that both mind and body are important in learning a physical skill, so you have the answer. p. 341

In a trauma unit a patient who was injured in a traffic accident begins having seizures. How should the nurse position this patient to prevent traumatic injury due to seizures? Place a pillow under the head. Avoid placing a pad under the head. Raise the side rails of the bed. Shift the patient to a bed during seizures. Clear the surrounding area of all furniture.

Raise the side rails of the bed. Clear the surrounding area of all furniture. A patient who is having seizures may sustain trauma due to unsafe surroundings. If the patient is in a bed, the side rails should be raised to prevent the patient from falling off the bed. If the seizures are occurring while the patient is on the floor, then the floor must be cleared of all furniture to prevent injury. Pillows usually cause suffocation; therefore, they should not be used. The nurse should support the patient's head either on the lap or by using a pad. During active seizures, the patient should not be shifted to a bed, because it may further increase the risk of injury to the patient. p. 394

A patient who has unilateral neglect related to brain injury from a cerebrovascular accident is unable to eat food on the left side of the plate. Which nursing intervention is followed in this situation? Remind the patient to eat food on the left side of the plate. Teach the patient to use a walker and cane around the home. Help the patient identify actions he or she can adapt to the left side. Teach the patient how to perform range-of-motion exercises on the left side.

Remind the patient to eat food on the left side of the plate. The nurse should remind the patient to eat food on the left side of the plate in the event of unilateral neglect related to brain injury from a cerebrovascular accident. When the patient has anxiety related to fear of falling, the nurse should help the patient identify actions he or she can adapt to the left side. When the patient is physically impaired related to left-sided weakness, the nurse should teach the patient how to use a walker and cane around the home. The nurse should teach the patient how to perform range-of-motion exercises if the patient has impaired physical mobility related to left-sided weakness. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. p. 385

At which stage of the grieving process does the patient begin to express emotions openly? Anger Resolution Bargaining Acceptance

Resolution In the resolution stage of grieving, the patient starts expressing emotions openly. In the anger stage, the patient may avoid discussion of the illness. In the bargaining stage, the patient may offer to live a better life in exchange for the promise of better health. In the acceptance stage, the patient recognizes the reality of the situation. p. 342

A patient who was hospitalized due to a smoking-related illness tells the nurse, "I am ready to accept responsibility for learning and I need your help." Which stage of psychosocial grief is reflected in this statement? Anger Disbelief Resolution Bargaining

Resolution It is difficult for a patient to accept a temporary or permanent loss of health. The process of grieving provides time to adapt psychologically to the emotional and physical implications of their illnesses. In the resolution stage, the patient begins to sense a need for help, is ready to accept responsibility for learning, and begins to express his or her emotions openly. The stage of anger is reflected when the patient direct anger towards the nurse or others. The stage of disbelief would be characterized by the patient avoiding discussions about illness. The bargaining stage would be indicated by the patient offering to live a better life in exchange for the promise of better health. p. 342

What is the portal of exit of the influenza virus? Blood Respiratory tract Reproductive tract Skin and mucous membrane

Respiratory tract The influenza virus is released from the body via the respiratory tract when an infected person sneezes or coughs. Organisms that cause communicable disease such as Hepatitis B and HIV exit from wounds and bloody stool. Organisms such as Neisseria gonorrheae and HIV exit through the reproductive tract during sexual contact. Any break in the skin and mucous membranes allows pathogens to exit the body; the influenza virus does not exit through the skin. p. 444

A patient presents with incapacitating lower back pain. The patient's activities of daily living are greatly altered, and the patient cannot work. The nurse diagnoses the problem as a lumbar sprain/strain injury and outlines a treatment plan including medications, proper exercise, and rest. What would be the best motive for this patient to learn exercises? Return to physical normalcy. Restrict certain foods. Rest for a longer period. Stop working and be unemployed.

Return to physical normalcy. The physical motive for this patient to return to a normal activity level would lead the patient to learn exercises. The patient's condition would not be affected by a food restriction. Rest and unemployment also would not be sufficient for the patient to start exercising. p. 340

During a teaching session, a parent approaches the nurse for advice about managing a child's temper tantrums. The nurse enacts the role of the child to evaluate the parent's response to the child's behavior. Which instructional method is the nurse using to teach the parent? Role play Analogies Simulation Demonstration

Role play During role play, people are asked to play themselves or someone else. Patients learn required skills and feel more confident in being able to perform them independently. Analogies supplement verbal instruction with familiar images that make complex information more real and understandable. Simulation is a useful technique for teaching problem solving, application, and independent thinking. During individual or group discussion, the nurse poses a pertinent problem or situation for patients to solve. Demonstration is used when teaching psychomotor skills, such as preparing a syringe, bathing an infant, crutch walking, or taking a pulse. p. 350

The nurse allows a patient to actively apply knowledge in controlled situations. Which teaching technique is the nurse is applying in this scenario? Role play Discussion Independent project Question and answer session

Role play In the role play method of teaching the nurse allows the patient to actively apply knowledge in controlled situations. This method promotes the synthesis of information and problem solving skills. The discussion method promotes the patient's active participation and focuses on topics of interest to the patient. An independent project allows a patient to assume responsibility for completing learning activities at his or her own pace. Question and answer sessions help address the patient's specific concerns. p. 340

The nurse is teaching the parents of a school-aged child about the risks of physical and sexual abuse and methods necessary to educate the child about them. Which level of Maslow's hierarchy of needs is the nurse addressing? Self-esteem Safety and security Love and belonging Physiological needs

Safety and security The nurse is instructing the parents to teach the child about physical and sexual abuse to ensure the child's physical and psychological safety. Therefore, the nurse is addressing the safety and security level of Maslow's hierarchy of needs. The nurse addresses the child's need to feel love and belonging when instructing the parents to behave politely and provide protection. The nurse addresses the physiological needs of Maslow's hierarchy when instructing the parents to provide proper nutrition and shelter for their child. The nurse addresses self-esteem when patients are undergoing major psychological setbacks in life or are depressed. pp. 67-68

The nurse is conducting a home visit with an older adult couple. She assesses that the lighting in the home is poor and there are throw rugs throughout the home and a low footstool in the living room. She discusses removing the rugs and footstool and improving the lighting with the couple. Which level of need is the nurse addressing, according to Maslow? Physiological Safety and security Love and belonging Self-actualization

Safety and security The teaching addresses the need for safety and security. The throw rugs, low lighting, and low stool are hazards that can cause falls in the elderly. Preventing falls is a priority safety issue for older adults. Physiological needs refer to the need for food, fluid, elimination, and so forth. Love and belonging refers to the need for relationships, and self-actualization is the need to feel fulfilled in life. pp. 67-68

A professor at a nursing school asks students to give examples of secondary prevention. Which examples would the professor expect from the students? Screening techniques of diseases Treating diseases at an early stage Wellness education activities Rehabilitation activities Immunization for influenza

Screening techniques of diseases Treating diseases at an early stage Secondary prevention focuses on individuals who are experiencing health problems or illnesses and are at risk for developing complications or worsening conditions. It includes screening techniques and treating early stages of a disease to limit disability by averting or delaying the consequences of advanced disease. Primary prevention aimed at health promotion includes health education programs, immunizations, and physical and nutritional fitness activities. Tertiary prevention occurs when a defect or disability is permanent and irreversible. Activities are directed at rehabilitation rather than diagnosis and treatment. pp. 70-71

The nurse works in a special care unit for children with severe immunology problems and is caring for a 3-year-old boy from Greece. The boy's father is with him while his mother and sister are back in Greece. The nurse is having difficulty communicating with the father. Which action should the nurse take? Care for the boy using hand gestures as if he were from the local community. Ask the manager to talk with the father and keep him out of the unit. Have another nurse care for the boy because maybe that nurse will do better with the father. Search for help with language interpretation and develop an understanding of the cultural differences.

Search for help with language interpretation and develop an understanding of the cultural differences. The nurse needs to understand how the Greek culture impacts the father's health beliefs and communication with health care providers. Cultural variables must be incorporated into the child's plan of care. Cultural background influences beliefs, values, and customs. It influences the approach to the health care system, personal health practices, and the nurse-patient relationship. Cultural background may also influence an individual's beliefs about causes of illness and remedies or practices to restore health. Utilizing hand gestures is not a genuine way to communicate with a patient from another culture. Parents are integral components in the health and healing of their children. It is not appropriate to pass the child to another nurse unless that nurse has a better understanding of the Greek language and culture. p. 70

In a health fair, a woman with diabetes was diagnosed with high blood pressure. She was advised to follow a low-salt diet. The woman followed the dietary restrictions and noted improvement in her blood pressure after 6 months. Which level of prevention does this case illustrate? Primary Tertiary Secondary Specific

Secondary Patients with health problems or who are at risk for developing complications need medical interventions. Early diagnosis and treatment can limit further damage and help patients recover from their illness. This patient has been diagnosed with high blood pressure and advised to eat a low-salt diet to control blood pressure. Thus, this intervention is considered secondary prevention. Primary prevention occurs before development of a medical problem. Tertiary prevention is required for patients who need rehabilitation. Specific protection is a form of primary prevention. pp. 70-71

The nurse is conducting a health fair in a rural area to teach the importance of health promotion and illness prevention. Which topics and objectives should the nurse include in this session, according to Healthy People 2020? Dental hygiene Sexually transmitted diseases Injury and violence prevention Mental health and mental disorders Immunization and infectious disease

Sexually transmitted diseases Injury and violence prevention Mental health and mental disorders Immunization and infectious disease Healthy People 2020 identifies goals set by the U.S. Department of Health and Human Services (USDHHS) to achieve a high quality of health for all and to create a safe environment. The initiative focuses on health topics and objectives that the nurse should include in the session. These include sexually transmitted diseases, injury and violence prevention, mental health and mental disorders, and immunization and infectious disease. The list also includes adolescent health, tobacco use, substance abuse, environmental health, and access to health care. Dental hygiene is not included in this list. pp. 65-66

Which factors responsible for cerebrovascular disease are classified as lifestyle choices? Smoking five times a day A sedentary lifestyle A history of diabetes Thromboembolic disease. Eating pizza for dinner every night

Smoking five times a day A sedentary lifestyle Eating pizza for dinner every night Tobacco use increases the risk of cardiovascular disease. Therefore, a patient who smokes regularly will have a higher risk of cerebrovascular disease. A patient who has a sedentary lifestyle and does not walk frequently or do any physical activity will have a high risk of cerebrovascular disease. A sedentary lifestyle is a lifestyle choice and can be changed. A patient who eats pizza and foods with poor nutritional value may have a risk for cerebrovascular disease. Eating habits are also considered to be lifestyle factors. Although a patient with a history of diabetes will have a risk of cerebrovascular disease due to abnormal glucose regulation that affects the cerebrovascular system, this is a genetic and physiological factor. Likewise, a patient with thromboembolic disease will have inadequate blood circulation, which may cause cerebrovascular disease, but this is a physiological factor responsible for cerebrovascular disease, not a lifestyle choice. p. 72

Which mnemonic should a patient follow if his or her clothing or skin is burning? PASS RACE Back to sleep Stop, drop, and roll

Stop, drop, and roll All patients, even young children, should follow the mnemonic "stop, drop, and roll" if his or clothing or skin is burning. PASS is the mnemonic applied for correct usage of fire extinguisher. The mnemonic RACE is used to set priorities in case of a fire. The parents should teach the mnemonic "back to sleep" to have the infants sleep on their back. p. 390

The nurse uses droplet precautions with a patient who is admitted to the infectious care unit. Which disease might a patient have? Measles Herpes simplex Varicella zoster Streptococcal pharyngitis

Streptococcal pharyngitis Streptococcal pharyngitis is a droplet infection caused by droplets larger than 5 microns. Therefore, the nurse should take droplet precautions. Measles is an airborne infection; therefore, the nurse should take airborne precautions. Herpes simplex and varicella-zoster are transmitted by direct contact; therefore, the nurse should take contact precautions. p. 459

The nurse is advising the mother of a 4-month-old infant to remove plastic bags from the home. Which risk is the nurse addressing? Choking Poisoning Head injury Suffocation

Suffocation Plastic bags from the cleaners or grocery store may cause an infant to suffocate. Choking can be prevented by avoiding the use of toys with small parts like buttons. Poisoning may occur due to toxic or poisonous substances, including plants. Head injury may be caused by falls. p. 387

For a patient who has wrist and ankle restraints, which position will place the patient at risk of aspiration? Sitting Supine Lateral Sleeping

Supine A patient with wrist and ankle restraints will be at a risk for aspiration if he or she is positioned in the supine position. The sitting position would be appropriate for a patient who needs belt restraints. Placing the patient in a lateral position or with the head of the bed elevated will prevent the risk of aspiration. The sleeping position would not place the patient at risk for aspiration. p. 402

A patient diagnosed with coronary heart disease(CAD) has deficient knowledge related to the illness and its implications. Which teaching is a priority for the patient? Teaching about exercises Teaching about dietary changes Teaching how to take medication Teaching how to care for self at home Teaching what to do if chest pain occurs

Teaching how to take medication Teaching how to care for self at home Teaching what to do if chest pain occurs The nurse should set priorities for patient education based on the patient's needs. When the patient has deficient knowledge about the illness and its implications, the nurse teaches the patient how to take the medication, because this is an immediate need. Teaching about exercises, dietary changes, and home care can be performed after teaching about the illness and the medication. p. 347

The nurse has to inform a patient about an emergency appendectomy to be performed for acute abdominal pain and the postoperative recovery. Which teaching approach would be most effective? Telling Participating Entrusting Reinforcement

Telling The telling approach should be used for teaching when limited information is to be taught. It is more effective when the patient is having anxiety. Participating involves the nurse and patient working together to achieve learning objectives. Entrusting gives the patient the opportunity to manage self-care, and the patient accepts the responsibility. Reinforcement is using some stimulus to increase the probability of a response. p. 348

The nurse is caring for a patient who is undergoing a colonoscopy. Which method of teaching is most suitable to the patient? Telling Entrusting Reinforcing Participating

Telling When preparing a patient for an emergent diagnostic procedure such as colonoscopy, the educator should use the telling approach to teaching, because it requires teaching limited information. The entrusting approach provides a patient the opportunity to manage self care. With this approach, the patient accepts responsibility and performs tasks correctly and consistently. Reinforcement requires the use of a stimulus to increase the probability of a desired response. A learner who receives reinforcement before or after a desired learning behavior is more likely to repeat that behavior. With the participating approach, a nurse and patient set objectives and become involved in the learning process together. With this method, there is opportunity for discussion, feedback, mutual goal setting, and revision of the teaching plan. p. 349

A pregnant patient reports abdominal pain. The nurse takes the patient for an emergency fetal fibronectin diagnostic test. Which teaching approach does the nurse use in this situation? Telling Entrusting Reinforcing Participating

Telling When using the telling approach, the nurse provides limited information to the patient while preparing the patient for an emergency diagnostic procedure. The entrusting approach provides the patient the opportunity to manage self-care. However, the nurse does not use this approach, because the patient does not have knowledge about the test she will be undergoing. The nurse uses the reinforcement approach whenever a desired response from the patient is needed. In this situation, the nurse does not require any desired response from the patient. The participating approach is used when the nurse and the patient set objectives and become involved in the learning process together; this approach is not appropriate for an emergency. p. 348

A patient experienced a myocardial infarction 4 weeks ago and is currently participating in the daily cardiac rehabilitation sessions at the local fitness center. In which level of prevention is the patient participating? Primary Secondary Tertiary Quaternary

Tertiary Tertiary prevention involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration following myocardial infarction. Tertiary prevention activities are directed at restoration and rehabilitation. Care at this level aims to help patients achieve as high a level of functioning as possible, despite the limitations caused by illness or impairment. This level of care is called preventive care because it involves preventing further disability or reduced functioning. Primary prevention is aimed at health promotion and includes health-education programs, immunizations, and physical and nutritional fitness activities. Secondary prevention includes diagnosing and treating an illness and limiting disabilities. Tertiary prevention includes restoration and rehabilitation. p. 71

Which statement regarding health care-associated infections requires correction? The costs of health care-associated infections are reimbursed. Health care-associated infections can significantly increase the cost of health care. The length of hospitalization influences the risk of health care-associated infections. Health care-associated infections result from the delivery of health services in a healthcare facility.

The costs of health care-associated infections are reimbursed. The costs of health care-associated infections (HAIs) are not reimbursed; therefore, the prevention of HAIs plays an important role in the managed care of health care systems. HAIs can increase the cost of health care because they increase infections in patients. The invasive procedure involved, the therapies received, and the length of hospitalization can influence the risk of HAIs in patients. HAIs can be caused by invasive procedures performed during the delivery of health services in a health care facility. p. 447

Which nursing action is an example of teaching to a patient's cognitive learning style? The nurse gives patients examples of other patients' experiences. The nurse orally explains to the patient how to use the wheelchair. The nurse asks the patient to demonstrate the use of the wheelchair after teaching. The nurse shows the patient how to use the wheelchair.

The nurse orally explains to the patient how to use the wheelchair. The cognitive domain of learning involves discussion of specific patient concerns. Therefore, the action of the nurse teaching the patient orally about the use of the wheelchair is an example of the cognitive domain of teaching. In the affective domain of teaching, the nurse will allow the patient to learn from others' experiences. Psychomotor teaching enables the patients to perform skills as observed. Therefore, showing the patient how to use the wheelchair and asking the patient to demonstrate its use is an example of psychomotor teaching. p. 339

A patient who smokes is in the precontemplation stage to quit smoking. What does this indicate, according to the transtheoretical model? The patient intends to quit smoking in the next 6 months. The patient has started making lifestyle changes. The patient has actively taken measures to quit smoking. The patient does not intend to quit smoking in the next 6 months.

The patient does not intend to quit smoking in the next 6 months. According to the transtheoretical model, there are five stages in health behavior change that a person may go through while trying to change habits. These stages include precontemplation, contemplation, preparation, action, and maintenance. In the precontemplation stage, a person has no intention of making any changes in the next 6 months. In the contemplation stage, the patient indicates the intention to quit in the next 6 months. The patient starts making lifestyle changes in the preparation stage. In the action stage the patient employs active measures to quit smoking. p. 73

A 62-year-old patient is diagnosed with colorectal cancer and is scheduled for surgery. Following the surgery, the healthcare provider informs the patient the surgery was successful. However, the patient is told that she needs chemotherapy, because the cancer had spread to other organs. The patient asks the nurse whether the spread of cancer will stop if she stops smoking and consuming alcohol. Which stage of grieving is the patient experiencing? The stage of denial The stage of anger The stage of bargaining The stage of resolution

The stage of bargaining The patient is experiencing the bargaining stage of grief. In this stage, the patient offers to live a healthier life in exchange for better health. The stage of denial indicates that the patient is unable to accept illness or disability. In the stage of anger, the patient tends to blame himself or herself and others for the condition. The anger is often directed toward the nurse and the family members. In the stage of resolution, the patient starts accepting the illness and asks questions related to the illness and care. Study Tip: Memorize the stages of grief with a mnemonic such as DABRA: denial, anger, bargaining, resolution, and acceptance. p. 341

A 45-year-old diabetic non-English-speaking woman whose husband died 12 years ago was found unconscious at home. Her neighbors brought her to the hospital 38 miles away. The patient was diagnosed with diabetic ketoacidosis (DKA). After initial interventions, the patient regained consciousness. She refuses to take insulin because it is against her religion. She is very upset and asks to see a chaplain. What should the nurse do to ensure the best care for the patient? Try to arrange a chaplain per the patient's request. Give insulin, because only this can improve the patient's blood sugar level. Inform the patient about the advantages and disadvantages of insulin. Withhold insulin at this time, because it is against the patient's religious belief. Arrange a language interpreter for better communication.

Try to arrange a chaplain per the patient's request. Inform the patient about the advantages and disadvantages of insulin. Withhold insulin at this time, because it is against the patient's religious belief. Arrange a language interpreter for better communication. The nurse should take measures to address the internal variables of the patient to ensure she receives the best care. The nurse should arrange for a chaplain to visit to give the patient emotional and spiritual support. The nurse should explain the advantages and the disadvantages of insulin to the patient. This information will help the patient reconsider her decision. A language interpreter would improve communication and help the nurse better understand the patient's needs. The nurse should not decide whether or not to administer insulin without the patient's consent. However, insulin is needed to manage the patient's blood sugar level, so the nurse should explain the consequences of not taking insulin. p. 70

The nurse is teaching hand washing to a group of preschoolers. Which teaching interventions would facilitate learning in this group? Teach psychomotor skills needed to maintain health. Use role-playing, imitation, and play to make learning fun. Provide information regarding the health problem to the child. Allow the preschooler to make decisions about health and health promotion. Encourage learning together through pictures and short stories about how to perform hygiene.

Use role-playing, imitation, and play to make learning fun. Encourage learning together through pictures and short stories about how to perform hygiene. To facilitate learning in a preschooler, the teaching aids should be developmentally appropriate. Therefore, role-playing, imitation, and play would be appropriate methods of teaching. The preschoolers should be encouraged to learn together through pictures and short stories. Teaching psychomotor skills, providing information regarding health problems, and allowing the preschoolers to make decisions about health and health promotion are not appropriate interventions for a preschooler as understanding these would require more maturity. p. 342

Which teaching method should the nurse include for a toddler? Having the toddler touch different textures Speaking softly to convey a sense of trust Using play to teach procedures and activities Using pictures to teach how to perform hygiene

Using play to teach procedures and activities For a toddler, the nurse uses play to teach procedures and activities. The nurse would have an infant touch different textures. The nurse speaks softly to an infant to convey a sense of trust. For a preschooler, the nurse uses pictures to teach how to perform hygiene. p. 343

A nurse cares for a patient who is diagnosed with tuberculosis. Which nursing interventions would be most appropriate to reduce the risk of transmission? Wearing an N95 respirator Maintaining a positive airflow in the room Wearing a surgical mask when the patient is 5 feet away or less Wearing a mask while outside of the patient's room Wearing gloves while performing a physical examination of the patient

Wearing an N95 respirator Wearing gloves while performing a physical examination of the patient Diseases such as tuberculosis are transmitted by small droplets that remain in the air for longer periods of time. The nurse should wear an N95 respirator whenever entering the patient's room. The nurse should also wear gloves while performing a physical examination to reduce the transmission of infection by direct contact. A specially equipped room with a negative airflow is referred to as an airborne infection isolation room; this room is used to reduce the risk of airborne transmission. Positive airflow is used with patients with allogeneic hematopoietic stem cell transplants as a protective environment precaution. A surgical mask is applied when the patient is 3 feet away or less to reduce the risk of transmission through larger droplet nuclei. The patient, not the nurse, should wear a mask when he or she is outside of his or her room as a protective environment precaution. p. 460

A patient comes to a rheumatology clinic with acute osteoarthritis. The patient's height is 167 cm (5 ft 5 in) and weight is 75kg (165 lb). The patient's body mass index (BMI) exceeds the average level. The nurse understands that the patient needs a tertiary level of preventive care. Which should the nurse suggest to the patient? Immunizations Weight reduction Continuing medication Physical exercise Diagnostic tests

Weight reduction Continuing medication Physical exercise The nurse should suggest that the patient reduce weight. This would help to prevent putting more pressure on the affected joints. Continuation of medicine is important, because this will reduce the pain of osteoarthritis and prevent progression of the disease. Physical exercise helps to maintain movement of joints, because stiffness of joints is a common problem experienced by patients with osteoarthritis. Immunizations are considered primary prevention. Diagnostic tests are secondary prevention. pp. 70-71

The nurse is planning to teach a patient about the importance of exercise. When is the best time for teaching to occur? When there are visitors in the room When the patient's pain medications are working Just before lunch, when the patient is most awake and alert When the patient is talking about current stressors in his or her life In the evening, when the patient is tired but the floor is quiet

When the patient's pain medications are working Just before lunch, when the patient is most awake and alert Plan teaching when the patient is most attentive, receptive, alert, and comfortable. p. 346

The nurse suspects the exit of an infectious organism through a purulent skin discharge. What would be the components of this discharge? Serum Platelets Red blood cells White blood cells

White blood cells A break in the integrity of the skin and mucous membranes may allow pathogens to exit the body, which may be exhibited by the presence of a purulent drainage. This purulent discharge contains white blood cells and bacteria. Serous exudates may contain serum. Platelets may not be present in any exudates. Sanguineous exudates may contain red blood cells. p. 446

The nurse is trying to assess the health literacy status of a patient in a clinic. What screening tools can be used to test literacy? The Joint Commission's Speak Up Initiatives Wide Range Achievement Test (WRAT) 3 National Assessment of Adult Literacy Survey (NAALS) Cloze test Rapid Estimate of Adult Literacy in Medicine (REALM)

Wide Range Achievement Test (WRAT) 3 Cloze test Rapid Estimate of Adult Literacy in Medicine (REALM) The WRAT 3, Cloze test, and REALM tools can be used to test literacy. The WRAT 3 evaluates reading, spelling, and arithmetic skills. The Cloze test is a test for reading comprehension. The REALM tool determines reading levels by using pronunciation of health care terms. TJC's Speak Up Initiatives help patients to understand their rights when receiving health care but do not test health literacy. The NAALS is a survey conducted to assess the extent of health literacy in America. p. 345