N316- Final Exam Practice Q's

Male chauvinism

(assumption of male superiority) is common in many cultures and in healthcare settings.

Immigrants

(new member of a group or country) assume charecteristics of the new culture through a learning process.

Acculturation

A person who is acculturated accepts both his own and new culture, adopting elements of each.

The nurse has just been assigned to the clinical care of a newly admitted patient. To know how to best care for the patient, the nurse uses the nursing process. Which step would the nurse probably do first? 1)Assessment 2)Diagnosis 3)Plan outcomes 4)Plan interventions

ANS: 1 Assessment is the first step of the nursing process. The nursing diagnosis is derived from the data gathered during assessment, outcomes from the diagnosis, and interventions from the outcomes.

A patient who underwent a total abdominal hysterectomy is assisted out of bed as soon as her vital signs are stable. This intervention is most likely being directed by a 1)Critical pathway 2)Nursing care plan 3)Case manager 4)Traditional care model

ANS: 1 This patient's care is most likely being directed by a critical pathway. A critical pathway is a multidisciplinary approach to care that sequences interventions over a length of stay for a given case type, such as total abdominal hysterectomy. Using this model, the patient can be assisted out of bed as soon as her vital signs are stable. Using the traditional model, the nurse would have to obtain a physician's order to assist the patient out of bed after surgery. The nursing care plan guides nursing care but cannot specify when the patient can get out of bed postoperatively without a physician's order. When case management is used, care is coordinated by the case manager across the healthcare setting, but the case manager does not direct each care intervention. PTS:1DIF:ModerateREF:ESG, Chapter 1, "Healthcare Delivery Systems—Expanded Discussion," "Issues Related to Healthcare Reform"

_ 7. The ability of nurses to base their practice on professional standards of ethical conduct and to participate in ethical decision making is known as which of the following? 1) Ethical agency 2) Attitudes 3) Belief 4) Value neutrality

ANS: 1 Ethical agency Ethical agency is the ability of nurses to base their practice on professional standards of ethical conduct and to participate in ethical decision making. Attitudes are mental dispositions or feelings toward a person, object, or idea. A belief is something that one accepts as true. Value neutrality is when we attempt to understand our own values regarding an issue and to know when to put them aside, if necessary, to become nonjudgmental when providing care to clients.

The nurse is teaching a patient about the importance of reducing saturated fats in his diet. The nurse will recognize that learning has occurred if, upon questioning, the patient replies that he should read product labels to eliminate the intake of which saturated fat(s)? Choose all that apply. 1) Palm oil 2) Coconut oil 3) Canola oil 4) Peanut oil

ANS: 1, 2 Palm and coconut oils are sources of saturated fat that are contained in many processed foods. The patient should be encouraged to read product labels to eliminate them from his diet. Olive, canola, and peanut oils are unsaturated fats and should be substituted for saturated fats in the diet. PTS: 1 DIF: Moderate REF: p. 901 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Comprehension

Which statement by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply. 1)"I can wait until the end of the shift to document my care." 2)"Charting every 2 hours is the most appropriate way to document nursing care." 3)"I find it easier to chart before I go to lunch and then after my shift report." 4)"I should chart as soon as possible after nursing care is given."

ANS: 1, 2, 3 Documentation should be performed as soon as possible after the nurse makes an assessment or provides care. The longer the nurse waits, the less accurate the documentation will be. Leaving documentation until the end of the shift may cause important details to be omitted or mistaken. It is not necessary to complete documentation on a strict schedule, such as every 2 to 4 hours. Even waiting until lunch or reporting after the shift is over is too long of a period of time for accurate documentation. In addition, the objectivity of documentation might be influenced by the discussion that occurs during report.

_ 2. The nurses obligations in ethical decisions include which of the following? Choose all that apply. 1) Be a patient advocate. 2) Involve institutional ethics committees. 3) Improve ones own ethical decision making. 4) Respect patient confidentiality.

ANS: 1, 2, 3, 4 The nurses obligations in ethical decisions include being a patient advocate, using and participating in institutional ethics committees, and improving ethical decision making. Confidentiality is a basic patient right. The nurses role is to uphold that right.

Goals for Healthy People 2020 include which of the following? Choose all that apply. 1) Eliminate health disparities among various groups. 2) Decrease the cost of healthcare related to tobacco use. 3) Increase the quality and years of healthy life. 4) Decrease the number of inpatient days annually.

ANS: 1, 3 The four overarching goals of Healthy People 2020 are to (1) increase the quality and years of healthy life, free of disease, injury, and premature death; (2) eliminate health disparities and improve health for all groups of people; (3) create physical and social environments for people to live a healthy life; and (4) promote healthy development for people in all stages of life. PTS: 1 DIF: Moderate REF: p. 890 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Recall

A nurse with a large caseload of patients needs to delegate some assessment tasks to other members of the health team. The nurse is unsure which tasks can be delegated to nursing assistive personnel (NAP) and which are appropriate for a licensed practical nurse (LPN) or a registered nurse (RN). To which sources should the nurse turn for the answer to his question? Choose all that are appropriate. 1) The nurse practice act of his state 2) The American Medical Association guidelines 3) The Code of Ethics for Nurses 4) The American Nurses Association's Scope and Standards of Practice

ANS: 1, 4

Based only on Maslow's hierarchy of needs, which nursing diagnosis should have the highest priority? 1) Self-care Deficit 2) Risk for Aspiration 3) Impaired Physical Mobility 4) Disturbed Sensory Perception

ANS: 2

For which of the following purposes is a graphic flow sheet superior to other methods of recording data? 1) Easy documentation of routine vital signs 2) Seeing the patterns of a patient's fever 3) Describing the symptoms accompanying a rising temperature 4) Checking to make sure vital signs were taken

ANS: 2

A few nurses on a unit have proposed to the nurse manager that the process for documenting care on the unit be changed. They have described a completely new system. Why is it important for the nurse manager to have a critical attitude? It will help the manager to 1)Consider all the possible advantages and disadvantages 2)Maintain an open mind about the proposed change 3)Apply the nursing process to the situation 4)Make a decision based on past experience with documentation

ANS: 2 A critical attitude enables the person to think fairly and keep an open mind.

What do critical thinking and the nursing process have in common? 1)They are both linear processes used to guide one's thinking. 2)They are both thinking methods used to solve a problem. 3)They both use specific steps to solve a problem. 4)They both use similar steps to solve a problem.

ANS: 2 Critical thinking and the nursing process are ways of thinking that can be used in problem solving (although critical thinking can be used beyond problem-solving applications). Neither method of thinking is linear. The nursing process has specific steps; critical thinking does not.

Which of the following is considered a religious denomination within the tradition of Christianity? 1) Buddhism 2) Jehovah's Witnesses 3) Sikhism 4) Islam

ANS: 2 Jehovah's Witnesses is a religious denomination within Christianity. Buddhism, Sikhism, and Islam are all religious traditions outside of Christianity. PTS:1DIF:EasyREF:pp. 342-343; ESG, Chapter 16, "Supplemental Materials," "Major Religions: What Should I Know?" KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall

Which teaching strategy is typically most effective for presenting information to large groups? 1)Distributing printed materials 2)Lecturing using audiovisual format 3)Providing online sources of information 4)Role modeling

ANS: 2 Lecturing using audiovisual materials appeals to learners who best process information by hearing and seeing. From a practical point of view, a lecture format (traditional classroom or webinar) is efficient and effective with large groups. Although printed materials can help to reinforce information taught during a lecture, this can be problematic for auditory learners or those whose primary spoken language is not English. Online sources of information are ideal for learners who learn best by doing (kinesthetic learners). Role modeling is most effective for individuals or small groups of learners, especially when the relationship between the instructor and learner is meaningful. PTS:1DIF:EasyREF:p. 872

The nurse manager is devising a teaching schedule for the staff who are about to begin using a new type of patient bed in the ICU. Implementation is planned in 6 weeks. When is the best time for the manager to schedule the teaching sessions? 1)Immediately 2)One week before implementation 3)Two weeks before implementation 4)Four weeks before implementation

ANS: 2 People retain information better when they have the opportunity to use it soon after it is presented. Therefore, the nurse manager should schedule teaching sessions 1 week before implementation of the equipment. If classes are scheduled too early, the nurses might forget how to use the equipment before it is implemented. If the teaching is offered immediately prior to use with patients, there would not be an adequate opportunity to practice skills and ask appropriate questions regarding use of the new device. PTS:1DIF:ModerateREF:p. 858 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

The nurse is caring for a patient who emigrated from Puerto Rico. She can best care for this patient by learning about the 1)Practices of the patient's ethnic group 2)Patient's individual cultural beliefs 3)Values of her own culture 4)Spanish-speaking community

ANS: 2 The nurse cares for this patient by becoming familiar with the patient's individual cultural and ethnic beliefs and values. It is helpful to become familiar with the patient's ethnic group and the Spanish-speaking community; however, the nurse should not assume that the individual holds the same values, beliefs, and practices as his ethnic group or community. The nurse should explore her own culture but not assume that the patient holds those same beliefs and practices.

Which of the following is an example of theoretical knowledge? 1)A nurse uses sterile technique to catheterize a patient. 2)Room air has an oxygen concentration of 21%. 3)Glucose monitoring machines should be calibrated daily. 4)An irregular apical heart rate should be compared with the radial pulse.

ANS: 2 Theoretical knowledge consists of research findings, facts, principles, and theories. The oxygen concentration of room air is a scientific fact. The others are examples of practical knowledge—what to do and how to do it.

In an effort to promote health, the home health nurse opens the client's bedroom windows to let in fresh air and sunlight, washes her hands often, and teaches the patient and family about the importance of hygiene and cleanliness. This most closely illustrates the ideas of which of the following people? 1) Jean Watson 2) Jurgen Moltmann 3) Florence Nightingale 4) Robert Louis Stevenson

ANS: 3 Florence Nightingale believed that health was prevention of disease through the use of fresh air, pure water, efficient drainage, cleanliness, and light. Jean Watson believes that health has three elements: a high level of overall physical, mental, and social functioning; a general adaptive-maintenance level of daily functioning; and the absence of illness (or the presence of efforts that lead to its absence). Jurgen Moltmann believes that true health is the strength to live, the strength to suffer, and the strength to die. He also stated that health is not a condition of the body; it is the power of the soul to cope with the varying condition of that body. Robert Louis Stevenson wrote that health is not a matter of holding good cards; it is playing a poor hand well. PTS: 1 DIF: Easy REF: p. 222 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall

The client's weight is appropriate for his height. His laboratory values and other assessments reflect normal nutritional status. However, he has told the nurse, "I probably eat a little too much red meat. And what is this I hear about needing omega 3 oils in my diet? I don't like to take supplements, and I think I could really improve my nutrition." Which of the following nursing diagnoses should the nurse use? 1) Balanced Nutrition 2) Possible Imbalanced Nutrition: Less Than Body Requirements 3) Risk for Imbalanced Nutrition: Less Than Body Requirements 4) Readiness for Enhanced Nutrition

ANS: 4

What is the role of the Joint Commission in regard to patient assessment? The Joint Commission 1)States what assessments are collected by individuals with different credentials 2)Regulates the time frames for when assessments should be completed 3)Identifies how data are to be collected and documented 4)Sets standards for what and when to assess the patients

ANS: 4

Nursing codes of ethics support which of the following? 1)Patients can receive emergency treatment regardless of their ability to pay. 2)Nurses will educate patients about advance directives. 3)Nurses with HIV must disclose their condition to their employer. 4)Patients have the right to dignity, privacy, and safety.

ANS: 4 In the Patient Bill of Rights, patients have the right to dignity, privacy, and safety. Although they are not laws, nursing codes of ethics specify ethical duties of the nurse to the patient as related to corresponding patient rights. Although patients do have a right to receive emergency medical care regardless of their ability to pay, this is not part of the nursing code of ethics. Likewise, a nurse's role is to educate patients about advance directives; this is a goal supported by nursing organizations but is not part of the code of ethics

A patient has anemia. An appropriate goal for that the patient would be for him to increase his intake of which nutrient? 1) Calcium 2) Magnesium 3) Potassium 4) Iron

ANS: 4 Iron deficiency causes anemia; therefore, the nurse should encourage the patient with anemia to increase his intake of iron. Increasing calcium intake helps prevent osteoporosis. Magnesium supplementation may decrease the risk of hypertension and coronary artery disease in women. Potassium is essential for muscle contraction, acid-base balance, and blood pressure control. PTS:1DIF:EasyREF:p. 907 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

A patient of Japanese heritage avoids asking for narcotics for pain relief. The nurse writes a nursing diagnosis of "Pain related to reluctance to take medication secondary to cultural beliefs." If the cultural archetype is true for this particular patient, this probably means that the patient views pain as 1)A punishment for immoral behavior 2)A part of life 3)Best treated with herbal teas and prayer 4)A virtue and a matter of family honor

ANS: 4 Patients of Japanese heritage may view pain as a virtue and a matter of family honor. They may be more accepting of pain medications if the nurse reassures them that pain control enhances healing. Patients of Mexican heritage may view pain as punishment for immoral behavior. Those of Navajo Indian heritage commonly view pain as a part of life, whereas those of Puerto Rican heritage may feel that pain is best treated with herbal teas and prayer. Keep in mind that these are all archetypes and do not necessarily apply to all members of a cultural group.

Which one of the following important nursing actions is a hospitalized patient likely to experience on an emotional level and remember long after this hospitalization has ended? 1) Administering her medications according to schedule 2) Allowing flexible visitation by her family and friends 3) Explaining treatment options in terms she can understand 4) Providing a healing presence by listening and being attentive

ANS: 4 The nurse can contribute meaningfully to the patient's hospitalization by providing a healing presence. The nurse can do this by listening to the patient and being attentive. Administering medications according to schedule, allowing flexible visitation, and explaining treatment options are important contributions that the nurse can make, but they will not be most meaningful to the patient. Patients may be impressed, even amazed, by the healthcare technology used to diagnose and treat their illnesses. However, often what they remember, perhaps through the rest of their lives, is the people who connected with them in a personal way. PTS:1DIF:ModerateREF:p. 232 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension

When should the nurse collect evaluation data for this expected outcome: Patient will maintain urine output of at least 30 mL/hour? 1) At the end of the shift 2) Every 24 hours 3) Every 4 hours 4) Every hour

ANS: 4 The nurse should collect evaluation data as defined in the expected outcome. For instance, in this case, the nurse would check the patient's urine output every hour because the goal statement specifies an hourly rate (30 mL/hour). The unit of measurement in the goal guides how often the nurse would reassess the patient. PTS:1DIF:EasyREF: pp. 127-128 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application

A 76-year-old patient is admitted with an acute myocardial infarction (heart attack). The doctor tells the patient that an angioplasty is necessary. The patient agrees and signs the informed consent. This patient is experiencing which stage of illness behavior? 1) Sick-role behavior 2) Seeking professional care 3) Experiencing symptoms 4) Dependence on others

ANS: 4 This patient is experiencing the dependence-on-others stage of illness behavior; he has accepted the diagnosis and treatment of the healthcare provider. The patient entered the experiencing illness stage when he began having chest pain at home. He entered the sick-role behavior phase when he admitted to family that he was experiencing chest pain. When he decided to go to the emergency department for healthcare intervention, he entered the seeking-professional-care stage of illness. PTS:1DIF:ModerateREF:pp. 228-229 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis

Using Maslow's hierarchy of needs, rank the following nursing diagnoses in order of importance, beginning with the highest-priority diagnosis. 1) Anxiety 2) Risk for infection 3) Disturbed body image 4) Sleep deprivation

ANS: 4, 2, 1, 3

A clinic nurse is caring for a 40-year-old client who lives with his parents. The client's mother continues to do the client's laundry and provides spending money. Based on this situation, which family dynamic does the nurse recognize? A. Taking over B. Communicating indirectly C. Belittling feelings D. Making assumptions

ANS: A Taking over occurs when a family member fails to allow another member to develop a sense of responsibility and self-worth. By doing the client's laundry and managing finances, the mother is fostering the client's dependence. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Quasi-intentional torts

Breach of confidentiality: a nurse release a clients medical diagnosis to a member of the press Defamation of character: a nurse tells a coworker that se believes the client has been unfaithful to her partner

Personal value

a principle or standard that has meaning or worth to an individual. example is cleanliness

Cultural stereotype

a widely held but oversimplified and unsubstantiated belief that all people of a certain racial or ethnic group are alike in certain respects

An example of cultural universals?

all cultures celebrate the birth of a new baby in some way

clients rights

clients rights are legal privileges or powers a clients have when they receive health care services clients using the services of a health care institution retain their rights as individuals and citizens the American hospital association identifies patients' rights in health care settings nursing facilities that participate in medicare programs also follow resident rights statutes hat govern their operation

state laws

each state has enacted statues that define the parameters of nursing practice and give the authority to regulate the practice of nursing to its state board of nursing in turn, the boards of nursing have the authority to adopt rules and regulations that further regulate nursing practice. although the practice of nursing is similar among states, it is critical that nurses know the laws and rules governing nursing in the state in which they license Boards if nursing have the authority to issue and revoke a nursing license Boards also set standards for nursing programs and further delineate the scope of practice for RN's, practical nurses (PN's) and advanced practice nurses

what does reporting communicable disease allow?

ensure appropriate medical treatment of diseases (tuberculosis) monitor for common-source outbreaks (food borne, hep A) plan and evaluate control prevention plus (immunizations) identify outbreaks and epidemics determine public health priorities based on trends

common malpractice claims

failure to assess and diagnose failure to plan failure to implement a plan of care failure to evaluate

defamation of character

false statements published to a third part. slander is spoken and libel is written

negligence issues that prompt most malpractice suits include failure to :

follow professional and facility-established standards of care use equipment in a responsible and knowledgeable manner communicate effectively and throughly with clients document care the nurse provides notify the provider of a change in the clients condition

nurses can avoid liability for negligence by:

following standards of care giving competent care communicating with other health team members and clients developing a caring rapport with clients fully documenting assessments, interventions, and evaluations being failure with and following a facility's policies and procedures

Subcultures

groups within a larger culture or social system that have some characteristics (values, behaviors, ancestry, ways of living) that are different from those of the dominant culture

durable power of attorney for health care

is a document in which clients designate a health care proxy to make health care decisions for them if they are unable to do so. the proxy may be any competent adult the client chooses

informed consent

is legal process by which a client or the clients legally appointed designee has given written permission for procedure or treatment.

Ethnicity

is similar to culture in that it refers to groups whose members share a common social and cultural heritage that is passed down from generation to generation.

Dominant culture

is the group that has the most authority or power to control values and reward or punish behaviors.

statutory law

nurse practice acts describe and define the legal boundaries of nursing practice within each state.

Cultural assimilation

occurs when the new members gradually learn and take on the essential values, beliefs, and behaviors of the dominant culture.

organ donation

signed consent is necessary and consent may be given on a driver's license or state identification card

Belief

something one accepts as true "I believe germs cause disease"

standards of care (practice)

standards of care define and direct the level of care nurses should give, and they implicate nurses who did not follow theses standards of care. nurses should refuse to practice beyond the legal scope of practice or outside of their areas of competence regardless of reason (staffing shortage, lack of appropriate personnel) nurses should use the formal chain if command to verbalize concerns related to assignment in light of current legal scope of practice, job description, and area of competence

What are examples of subcultures?

street gangs, physicians, nurses, women, older adults, persons with disabilities, gays, and lesbians.

Sexism

the assumption that members of ones se are superior to those of the other sex.

the four elements and necessary to collect damages

the existence of a duty the breach of duty causation damages

Socialization

the process of learning to become a member of a society or a group. A person becomes socialized by learning social rules and roles.

Cultural specifics

this values, beliefs, and practices that are special or unique to a culture

the nurses responsibility in informed consent

witness informed consent: this means the nurse must: ensure that the provider gave the client the necessary information.ensure that the client understood the information and is competent to give informed consent. have the client sign the informed consent document notify the provider if the client has more questions or appears not to understand any of the information. the provider is then responsible for giving clarification. document questions the client has, notification of the provider, reinforcement of teaching, and use of an interpreter.

impaired coworkers

a nurse who suspects a coworker of any behavior that jeopardizes client care or could indicate a substance use disorder has a duty to report the coworker to the appropriate manager many facilities policies provide access to assistance programs that facilitate entry into a treatment program each state has laws and regulations that govern the disposition of nurses who have substance use disorders. criminal charges could apply

How does someone become assimilated?

a person becomes assimilated by learning to speak the dominant language; marrying a member from the new (host) culture; and making close, personal relationships with members of the new group.

duty to rescue

a person has to take reasonable steps to rescue a person in peril. ten states are duty to rescue states- Hawaii, Wisconsin, California, Rhode Island, Vermont, Washington, Massachusetts, Minnesota, Ohio, and Florida

Minority groups

made up of individuals who share race, religion, or ethnic heritage; however a minority group has fewer members than the majority group.

A patient of Scandinavian heritage is admitted for observation after sustaining injuries in a motor vehicle accident. The nurse expects that he may endure pain stoically, without grimacing or vocalizing. The nurse's thinking is an example of a/an 1)Archetype 2)Bias 3)Prejudice 4)Stereotype

ANS: 1 An archetype is an example of a person or thing—something that is recurrent—and it has its basis in facts. Therefore, it becomes a symbol for remembering some of the culture specifics and is usually not negative. A bias is the tendency to see only one side of an issue, a lack of impartiality. Prejudice refers to negative attitudes toward other people that are based on faulty and rigid stereotypes about race, gender, sexual orientation, and so on. A cultural stereotype is the unsubstantiated belief that all people of a certain racial or ethnic group are alike in certain respects. Similar to biases, a stereotype may be positive or negative.

Which instruction(s) should the nurse give to the patient complaining of constipation? Choose all that apply. 1) Drink at least eight glasses of water or non-caffeinated fluid per day. 2) Include a minimum of four servings of meat per day. 3) Consume a high-fiber diet. 4) Exercise as you feel necessary.

ANS: 1, 3 To prevent constipation, the nurse should instruct the patient to consume a high-fiber diet, drink at least eight glasses of water or non-caffeinated fluid per day, exercise regularly, and eat meals on a regular schedule. Caffeine can aggravate constipation. PTS:1DIF:ModerateREF:p. 929 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

The diagnostic label, or patient problem, is used primarily to suggest 1) Client goals 2) Cue clusters 3) Interventions 4) Etiology

ANS: 1

The nurse is interviewing a patient who has a recent onset of migraine headaches. The patient is highly anxious and cannot seem to focus on what the nurse is saying. Which of the following questions would be best for the nurse to use to begin gathering data about the headaches? 1) "When did your migraines begin?" 2) "Tell me about your family history of migraines." 3) "What are the types of things that trigger your headaches?" 4) "Describe what your headaches feel like."

ANS: 1

The patient verbalizes an overwhelming lack of energy. He says, "I still feel exhausted even after I sleep. I feel guilty when I can't keep up with my usual daily activities or sleep during the day. I've been a little depressed lately, too." The patient seems to have difficulty concentrating but has no apparent physical problems. Which of the following diagnoses best describes his health status? 1) Fatigue related to depression 2) Fatigue related to difficulty concentrating 3) Guilt related to lack of energy 4) Chronic confusion related to lack of energy

ANS: 1

What is wrong with the following diagnostic statement? "Impaired Physical Mobility related to laziness and not having appropriate shoes." The statement is 1) Judgmental 2) Too complex 3) Legally questionable 4) Without supportive data

ANS: 1

9. A patient has asked the nurse to explain her laboratory results. The nurse informs the patient that he must first assist another patient to the bathroom and then he will explain the results. The nurse assists the other patient to the bathroom and then returns to explain the results to the patient. What moral principle has the nurse displayed? 1) Nonmaleficence 2) Autonomy 3) Beneficence 4) Fedelity

Fidelity ANS: 4 Fidelity is the obligation to keep promises. Autonomy refers to a persons right to choose and his ability to act on that choice. Nonmaleficence is the twofold principle of doing no harm and preventing harm. Beneficence is the duty to do or promote good.

An example of culture specific?

celebrate birth rites in different way

federal regualtions

federal laws affecting nursing practice health insurance portability act (HIPPA) americans disability act (ADA) mental health parity act (MHPA) patient self determination act (PSDA)

federal laws

guiding nursing practice bill of rights, emergency medical treatment and active labor act, Americans with disabilities act, patient self determination act, and health insurance portability and accountability ace (HIPPA)

Good Samaritan law

limits liability of the healthcare professional and offers legal immunity if the nurse acts in a standard manner. it has been enacted in all states and the nurse is protected as long as they do not accept money for their actions

advance directives

the purpose of advance directives is to communicate a clients wishes regarding end-of-life care should the client become unable to do so. The PSDA requires asking all clients in admission to a heath care facility whether they have any advance directives staff should give clients who do have advance directives written information that outlines their rights related to health care decisions and how to formulate advance directives a health care representative should be available to help with this process

Match the nursing role listed on the left with the appropriate activity listed on the right. Each activity has only one correct answer. 1)Planning the unit's staffing schedule 2)Participating on a committee to develop a program to teach schoolchildren proper handwashing 3)Teaching the client about a scheduled test 4)Discussing new medication at a staff meeting 5)Discussing with the physician the client's reasons for not wanting the recommended surgery. ____ 1. Direct care provider ____ 2. Client advocate ____ 3. Manager ____ 4. Change agent

1.ANS:3PTS:1DIF:Moderate REF:p. 13; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application 2.ANS:5PTS:1DIF:Moderate REF:p. 13; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application 3.ANS:1PTS:1DIF:Moderate REF:p. 13; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application 4.ANS:2PTS:1DIF:Moderate REF:p. 13; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application

Match the nursing organization with its function in the nursing profession. 1)Responsible for setting and maintaining nursing education standards 2)Developed Code for Nurses and the Standards of Clinical Nursing Practice 3)Responsible for publishing the journal, Image 4)Honor society for nursing 5)Represents nursing and promotes nursing leadership worldwide ____ 11. American Nurses Association (ANA) ____ 12. National Student Nurses Association (NSNA) ____ 13. National League for Nursing (NLN) ____ 14. International Council of Nursing (ICN) ____ 15. Sigma Theta Tau International (STTI)

11. ANS: 2 PTS: 1 DIF: Moderate REF: p. 17 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 12. ANS: 3 PTS: 1 DIF: Moderate REF: p. 17 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 13. ANS: 1 PTS: 1 DIF: Moderate REF: p. 17 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 14. ANS: 5 PTS: 1 DIF: Moderate REF: p. 17 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 15. ANS: 4 PTS: 1 DIF: Moderate REF: p. 17 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall

Match the event with the appropriate year. Each item has only one correct answer. 1)Nursing programs become affiliated with religious groups 2)Start of public health nursing with the founding of the Henry Street Settlement 3)First formal nursing education in United States 4)First hospital 5)Establishment of the Army Nursing Service 6)Disassociation of nursing from religious orders 7)Florence Nightingale cared for the soldiers of the Crimean War ____ 5. 1st-century AD ____ 6. 15th to 19th century ____ 7. 1854 ____ 8. 1861 ____ 9. 1873 ____ 10. 1893

5.ANS:4PTS:1DIFgrinifficult REF: pp. 6-11; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 6.ANS:6PTS:1DIFgrinifficult REF: pp. 6-11; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 7.ANS:7PTS:1DIFgrinifficult REF: pp. 6-11; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 8.ANS:5PTS:1DIFgrinifficult REF: pp. 6-11; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 9.ANS:3PTS:1DIFgrinifficult REF: pp. 6-11; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 10.ANS:2PTS:1DIFgrinifficult REF: pp. 6-11; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall

What do the nursing assessment models have in common? 1) They assess and cluster data into model categories. 2) They organize assessment data according to body systems. 3) They specify use of the nursing process to collect data. 4) They are based on the ANA Standards of Care.

ANS: 1

What makes a nursing history different from a medical history? 1) A nursing history focuses on the patient's responses to the health problem. 2) The same information is gathered; the difference is in who obtains the information. 3) A nursing history is gathered using a specific format. 4) A medical history collects more in-depth information.

ANS: 1

Which of the following is a criticism of standardized nursing diagnoses developed by NANDA-I? 1) There is little research to support nursing diagnoses labels. 2) A perfect nursing diagnosis must be written for it to be useful. 3) They are not included in all states' nurse practice acts. 4) Other professions do not recognize nursing diagnoses.

ANS: 1

Which of the following is an example of a cluster of related cues? 1) Complains of nausea and stomach pain after eating 2) Has a productive cough and states stools are loose 3) Has a daily bowel movement and eats a high-fiber diet 4) Respiratory rate 20 breaths/min, heart rate 85 beats/min, blood pressure 136/84

ANS: 1

Which of the following is an example of an ongoing assessment? 1)Taking the patient's temperature 1 hour after giving acetaminophen (Tylenol) 2)Examining the patient's mouth at the time she complains of a sore throat 3)Requesting the patient to rate intensity on a pain scale with the first perception of pain 4)Asking the patient in detail how he will return to his normal exercise activities

ANS: 1

Which of the following nursing diagnoses is written in correct format? Assume the facts are correct in all of them. 1) Readiness for Enhanced Nutrition 2) Pain related to stating, "On a scale of 1 to 5, it's a 5." 3) Impaired Mobility related to pain A.M.B. hip fracture 4) Risk for Infection related to compromised immunity A.M.B. fever

ANS: 1

Which of the following nursing activities represent direct care? Choose all that apply. 1)Bathing a patient 2)Administering a medication 3)Documenting an assessment 4)Making work assignments for the shift

ANS: 1 Direct care involves personal interaction between the nurse and clients (e.g., giving medications, dressing a wound, or teaching a client about medicines or care). Nurses deliver indirect care when they work on behalf of an individual, group, family, or community to improve their health status (e.g., restocking the code blue cart [an emergency cart], ordering unit supplies, or arranging unit staffing).

A patient underwent surgery 3 days ago for colorectal cancer. The patient's critical pathway states that he should participate in a teaching session with the wound ostomy nurse to learn colostomy self-care. The patient appears depressed and refuses to look at the colostomy or even make eye contact. How should the nurse proceed? 1) Postpone the teaching session until the patient is more receptive. 2) Follow the critical pathway for patient teaching about ostomy care. 3) Administer a prescribed antidepressant and notify the physician. 4) Explain to the patient the importance of skin care around the ostomy site.

ANS: 1 A depressed affect and poor eye contact likely indicate that the client is having difficulty coping with the new colostomy. At this time, the client would not be physically and psychologically ready to obtain the most benefit from teaching pertaining to ostomy care. Therefore, the nurse should postpone the teaching session for this client until the client is receptive to receiving the information. The nurse should not perform the teaching session simply because the critical pathway indicates it is appropriate. Simply administering an antidepressant does not address the client's readiness to participate in a teaching session and ultimately self-care of the ostomy. The nurse should encourage the client to verbalize his feelings. Client education is not effective unless the client is receptive to the information. Readiness to learn is important. Proceeding with teaching when the client is struggling with coping is not sensitive to the client's individual needs. PTS:1DIF:ModerateREF:p. 120 KEY: Nursing process: Implementation | Client need: PHI | Cognitive level: Application

Which of the following is considered a "practice" (as opposed to a belief or value)? 1)Always drinking water after exercise 2)Thinking often about cleanliness 3)Emphasis on success 4)Maintaining youth

ANS: 1 A practice is a set of behaviors that one follows, such as always drinking water after exercise. Preoccupation with cleanliness, emphasis on success, and maintaining youth are examples of values that are dominant in United States culture.

The nurse administers heparin 5000 units subcutaneously at 2100 and documents in the medication administration record that the dose was administered. What other information is important for the nurse document? 1)Injection site 2)Previous site of administration 3)Patient response to medication 4)Heart rate prior to administration

ANS: 1 After administering an injection, the nurse must document the injection site to prevent the patient from receiving repeated injections in the same location. Heparin 5000 units subQ was prescribed for the patient. The previous route of administration is already documented on the MAR from the previous dose and would not be noted in the entry for the current dose. The patient's response to medication is recorded in the nurse's narrative note in the traditional paper for the electronic health record. When the nurse signs out that the drug was given in the medication administration record, she is validating that she administered the drug according to the physician's order. Heparin does not affect heart rate.

How are standardized (model) care plans similar to unit standards of care? Standardized (model) care plans 1) Describe the care needed by patients in defined situations 2) Include specific goals and nursing orders 3) Become a part of the patient's comprehensive care plan 4) Usually describe ideal nursing care

ANS: 1 All of the statements are true for standardized care plans, but only 1 is true of both standardized care plans and unit standards of care. Both describe care needed by patients in defined situations, although unit standards usually describe care for groups of patients (e.g., all women admitted to a labor unit), and standardized care plans are often organized around a particular or all nursing diagnoses commonly occurring with a particular medical diagnosis. Unit standards are more general and do not have goals for each patient. Unit standards are kept on file in a central place on the unit and do not become a part of the care plan. Unit standards describe minimal, not ideal, care. PTS: 1 DIF: Difficult REF: p. 87; requires analysis of text discussion. KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

How are NANDA-I problem labels and NOC outcome labels alike? Both describe 1) Health status in terms of human responses 2) Patient response before interventions are done 3) Patient response in positive terms 4) A pattern of related cues

ANS: 1 Both NANDA-I and NOC labels are stated as human responses. A NOC label can be used to describe patient responses both before and after intervention—NANDA-I before. NOC statements are neutral to allow for positive, negative, or no change in health status; NANDA-I diagnoses describe both problem responses and positive responses (wellness labels). NANDA-I labels are based on patterns of related cues; NOC labels are based on (linked to) NANDA-I labels. PTS: 1 DIF: Difficult REF: pp. 94; also information about NANDA-I diagnoses from Chapter 4 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

Which of the following is an example of what traditional medicine and complementary and alternative medicine therapies have in common? 1)Both can produce adverse effects in some patients. 2)Both use prescription medications. 3)Both are usually reimbursed by insurance programs. 4)Both are regulated by the FDA.

ANS: 1 Both traditional and complementary therapies can produce adverse effects in some patients. Many medications are derived from herbs, but the alternative treatments usually use the herbs, not prescription medication. Insurance programs do not necessarily reimburse alternative treatments, because many are not supported by sound scientific research methodology. Alternative medications are not regulated by the FDA. PTS:1DIF:ModerateREF:p. 20

Which definition best describes a critical pathway? 1) Standardized plan of care for frequently occurring conditions 2) Systematically developed statement to assist practitioners and patients in making decisions 3) Systematic review of clinical evidence for an intervention 4) Set of interrelated concepts that describes or explains something

ANS: 1 Critical pathways are standardized plans of care for commonly occurring health conditions (e.g., myocardial infarction) for which similar outcomes and interventions are appropriate for the majority of patients with the condition. Clinical practice guidelines are systematically developed statements to assist practitioners and patients in making decisions about appropriate healthcare for a particular disease or procedure. Evidence reports are systematic reviews on clinical topics for the purpose of providing evidence for guidelines, quality improvement, quality measures, and insurance coverage decisions. A theory is a set of interrelated concepts that describe or explain something. PTS:1DIF:EasyREF: p. 104 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall

Which statement accurately describes delegation? 1) Transferring authority to another person to perform a task in a selected situation 2) Collaborating with other caregivers to make decisions and plan care 3) Scheduling treatments and activities with other departments 4) Performing a planned intervention from a critical pathway

ANS: 1 Delegation is the transfer to another person of the authority to perform a task in a selected situation—the person delegating retains accountability for the outcome of the activity. Collaboration is described as working with other caregivers to plan, make decisions, and perform interventions. Coordination of care involves scheduling treatments and activities with other departments. Implementation is the process of performing planned interventions. PTS:1DIF:EasyREF: p. 122 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Knowledge

A client is admitted to a long-term care facility. The nurse knows that federal law requires the use of 1)The Minimum Data Set (MDS) for assessment 2)Situation-background-assessment-recommendation (SBAR) for reporting 3)Healthcare Financing Administration guidelines prior to surgery 4)Joint Commission guidelines for discharge planning

ANS: 1 Federal regulations require that a resident be evaluated using the Minimum Data Set (MDS) within 14 days of admission to a long-term care facility. SBAR is a technique used for communicating and organizing a hand-off report. HCFA guidelines govern home healthcare documentation. Joint Commission guidelines do apply to long-term care facilities, but only the MDS assessment is mandated by federal law.

What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident of a long-term care facility? 1)14 days 2)3 days 3)2 days 4)24 hours

ANS: 1 Federal regulations require that a resident be evaluated using the Minimum Data Set within 14 days of admission to a long-term care facility.

A patient who was prescribed furosemide (Lasix) is deficient in potassium. Which of the following is an appropriate goal for this patient? The patient will increase his consumption of: 1) Bananas, peaches, molasses, and potatoes. 2) Eggs, baking soda, and baking powder. 3) Wheat bran, chocolate, eggs, and sardines. 4) Egg yolks, nuts, and sardines.

ANS: 1 Foods rich in potassium include bananas, peaches, molasses, meats, avocados, milk, shellfish, dates, figs, and potatoes. Eggs, baking soda, and baking powder have high sodium content. Dairy products, beef, pork, beans, sardines, eggs, chicken, wheat bran, and chocolate are rich in phosphorus. Egg yolks, nuts, sardines, dairy products, broccoli, and legumes are rich in calcium. PTS:1DIF:ModerateREF:p. 908 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan? 1) Determine airway adequacy hourly and as needed. 2) Administer oxygen as needed. 3) Monitor arterial blood gas values. 4) Place the client in a high Fowler's position.

ANS: 1 For any acute respiratory problem, prior to implementing interventions, the nurse would assess breathing status of the patient by checking the respiratory rate and depth. When devising a plan of care for the client, nursing interventions should be listed according to priority. Airway always takes precedence, as ventilation, oxygenation, and positioning will be ineffective without a patent airway. PTS: 1 DIF: Difficult REF: p. 107 KEY: Nursing process: Planning | Client need: Physiological integrity | Cognitive level: Analysis

In caring for a patient with comorbidities, the nurse draws upon her knowledge of diabetes and skin integrity. In a spirit of inquiry, she looks up the latest guidelines for providing skin care and includes them in the plan of care. The nurse provides skin care according to the procedural guidelines and begins regular monitoring to evaluate the effectiveness of the interventions. These activities are best described as 1)Full-spectrum nursing 2)Critical thinking 3)Nursing process 4)Nursing knowledge

ANS: 1 Full-spectrum nursing (1) involves the use of critical thinking, nursing knowledge, nursing process, and patient situation. Although the other answers are important for planning and delivering nursing care, they do not reflect all the nurse has demonstrated.

When developing goals, which guideline should the nurse keep in mind? Goals should be 1) Realistic so that progress is recognized by the patient 2) Developed solely by the healthcare team 3) Developed without family input, to maintain confidentiality 4) Valued by the multidisciplinary care providers

ANS: 1 Goals should be realistic so that progress is recognized by the patient. They should be valued by both the patient and family. The nurse should develop goals with input from the patient and his family. PTS:1DIF:ModerateREF:p. 231 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension

Prior to discharge, a patient with diabetes needs to learn how to check a finger-stick blood sugar before taking insulin. Which action will best help the patient remember proper technique? 1)Encouraging the patient to check the blood sugar each time the nurse gives insulin 2)Providing feedback after the patient takes his blood sugar for the first time 3)Verbally instructing the patient about how to obtain a finger-stick blood sugar 4)Offering a brochure that describes the technique for checking blood sugar

ANS: 1 Having the patient check the finger-stick with the nurse each time insulin is administered is the best way to practice the correct technique and gain confidence prior to discharge. Repetition increases the likelihood that the patient will retain information and incorporate it into the daily management of his diabetes care. Although feedback is important, the patient might need it on more than one occasion. Verbal instructions for performing a new skill are most useful when the patient has an opportunity to perform the technique. A brochure is informative and useful for later reference; however, information about performing a new skill is best offered when the patient can see it demonstrated and has the opportunity to practice it with feedback from the nurse. PTS:1DIF:ModerateREF:p. 858

Health screening activities are designed to: 1) Detect disease at an early stage. 2) Determine treatment options. 3) Assess lifestyle habits. 4) Identify healthcare beliefs.

ANS: 1 Health screening activities are designed to detect disease at an early stage so that treatment can begin before there is an opportunity for disease to spread or become debilitating. PTS: 1 DIF: Moderate REF: p. 879 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension

The nurse is admitting a Roman Catholic adult patient who is critically ill. Based on her knowledge of the patient's religion, for which religious rite should she expect to notify the hospital chaplain? 1) Anointing of the Sick 2) Baptism 3) Eucharist 4) Sacrament of Reconciliation

ANS: 1 In Catholicism, those who are seriously ill might want to receive the sacrament of Anointing the Sick. The Sacrament of Reconciliation, which is performed by a priest, is used to gain forgiveness for past sins. The Eucharist, or communion, can be prepared and administered to a hospitalized patient, but it is not typically administered to someone who is critically ill. Baptism may be offered when infants or children of Christian parents are critically ill. PTS:1DIF:EasyREF:p. 342 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension

Which type of client-centered evaluation is performed at specific, scheduled times? 1) Intermittent 2) Ongoing 3) Terminal 4) Process

ANS: 1 Intermittent evaluation is performed at specific times; it enables the nurse to judge the progress toward goal achievement and to modify the plan of care as needed. Ongoing evaluation is performed while implementing, immediately after an intervention, or with each client contact; these are not necessarily scheduled events. Terminal evaluation is performed at the time of discharge. It describes the client's health status and progress toward goals at that time. Process evaluation focuses on the manner in which care is given. It may be performed at specific times, but it is not considered a client-centered evaluation. PTS:1DIF:EasyREF: p. 127 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Recall

A patient reports experiencing gas, abdominal bloating, and diarrhea after consuming milk or cheese. Lactose intolerance might immediately be suspected if the patient is of which heritage? 1)African American 2)Mexican American 3)European American 4)Arab American

ANS: 1 Lactose intolerance, caused by a deficiency of the enzyme lactase, is more commonly seen in African Americans than in the other cultural groups listed. Of course, one would assume lactose as the cause of the patient's symptoms, but it would be important to rule it out.

In the Leavell and Clark model of health protection, the chief distinction between the levels of prevention is: 1) The point in the disease process at which they occur. 2) Placement on the Wheels of Wellness. 3) The level of activity required to achieve them. 4) Placement in the Model of Change.

ANS: 1 Leavell and Clark identified three levels of activities for health protection: primary, secondary, and tertiary. Interventions are classified according to the point in the disease process in which they occur. PTS:1DIFgrinifficultREF:p. 879 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Analysis

A Muslim client has asked the nurse to pray with her. Which item should the nurse anticipate that the patient may request before praying? 1) Bathing water 2) Rosary beads 3) Mala beads 4) Prayer cloth

ANS: 1 Muslims may want water to wash the mouth, nostrils, and hands before praying. Roman Catholics may want to hold their rosary beads while praying. Some Buddhists and Hindus meditate with a set of beads, called a mala. Others may use a prayer cloth or other religious items. PTS:1DIF:ModerateREF:pp. 342-343, 350-351; ESG, Chapter 16, "Supplemental Materials," "Major Religions: What Should I Know?" KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension

When transferring a patient from a hospital to a long-term care facility, which of the following is most helpful in facilitating the patient's planning and emotional adjustment? 1) Notify the patient and family as much in advance of the transfer as possible. 2) Send a complete copy of the patient's medical records to the new facility. 3) Carefully coordinate the transfer with the long-term facility to keep it smooth. 4) Help arrange for transportation and accompany the patient to the transport vehicle.

ANS: 1 Notifying the patient and family well in advance of the transfer allows them time to adjust emotionally and to make any necessary plans. A copy of the records is usually sent, and the nurse does coordinate the transfer with the receiving facility; however, that does very little to assist with the patient's emotional status or planning. Someone from the hospital may accompany the patient to the car; or if the transfer is by ambulance, perhaps not. Either way, that will not help the patient and family to do the necessary planning for the transfer. PTS: 1 DIF: Moderate REF: p. 233 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

Nurses have the potential to be very influential in shaping healthcare policy. Which of the following factors contributes most to nurses' influence? 1)Nurses are the largest health professional group. 2)Nurses have a long history of serving the public. 3)Nurses have achieved some independence from physicians in recent years. 4)Political involvement has helped refute negative images portrayed in the media.

ANS: 1 Nurses are trusted professionals and the largest health professional group. As such, they have political power to effect changes. If nursing were a small group, there would be little potential for power in shaping policies, even if all the other answers were true. Serving the public, while positive, does not necessarily help nurses to be influential in establishing health policy. Independence from physicians, although positive, does not necessarily make nurses influential in establishing healthcare policy. Refuting negative media, although positive, does not necessarily make nurses influential in establishing healthcare policy. PTS: 1 DIF: Moderate REF: p. 21

The nursing instructor is teaching the student about occurrence reports. Which statement by the student indicates an understanding of the purpose of occurrence reports? 1)"Occurrence reports track problems and identify areas for quality improvement." 2)"Occurrence reports are required by the Food and Drug Administration to report drug errors." 3)"The Joint Commission requires occurrence reports for all client falls." 4)"Occurrence reports provide legal information should the patient seek legal action after an unusual occurrence."

ANS: 1 Occurrence reports are used to track problems and identify areas for quality improvement. Occurrence reports are not used to provide legal information should a patient seek legal action. As an internal communication and documentation tool, occurrence reports are not required to be reported to the FDA or Joint Commission.

The nurse is individualizing Mr. Wu's plan of care by writing a plan for his nursing diagnosis of Anxiety. Why does the nurse need to write goals/outcomes on the plan of care? Because outcomes describe 1) Desired changes in the patient's health status 2) Specific patient responses to medical interventions 3) Specific nursing behaviors to improve a patient's health 4) Criteria to evaluate the appropriateness of a nursing diagnosis

ANS: 1 Outcomes describe changes in the patient's health status in response to nursing, rather than medical, interventions. Outcomes relate to patient behavior, not nursing behaviors. Outcomes are a measure of the effectiveness of nursing care for a specific nursing diagnosis, not whether the nursing diagnosis is appropriate. PTS:1DIF:ModerateREF: p. 91 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension

A patient with attention deficit disorder is admitted to the hospital with type 1 diabetes. Which nursing diagnosis is commonly yet inappropriately used but should be avoided for this type of patient? Assume there are data to support all the diagnoses. 1)Deficient Knowledge (disease process) 2)Impaired ability to learn related to fear and anxiety 3)Difficulty learning related to cognitive developmental level 4)Lack of motivation to learn related to feelings of powerlessness

ANS: 1 Patients who have a learning disability should not have an identified nursing diagnosis of Deficient Knowledge; instead, they should have a diagnosis that accurately identifies their problem, such as Impaired Ability to Learn related to Fear and Anxiety; Difficulty Learning related to Delayed Cognitive Development; or Lack of Motivation to Learn related to Feelings of Powerlessness. Note that these are not NANDA-I diagnoses. PTS:1DIF:ModerateREF:pp. 864-865

The nurse notices that a patient has spoon-shaped, brittle nails. This suggests that the patient is experiencing Imbalanced Nutrition: Less Than Body Requirements related to deficiency of which of the following nutrients? 1) Iron 2) Vitamin A 3) Protein 4) Vitamin C

ANS: 1 Patients with iron deficiency may have spoon-shaped, brittle nails. Other abnormal nail findings include dull nails with transverse ridge (protein deficiency); pale, poor blanching, or mottled nails (vitamin A or C deficiency); splinter hemorrhages (vitamin C deficiency); and bruising or bleeding beneath nails (protein or caloric deficiency). PTS:1DIFgrinifficultREF:p. 920 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Comprehension

A Hispanic patient is frustrated because the healthcare team does not understand the importance of hot and cold therapies. Which nursing diagnosis is most appropriate for this patient? 1)Powerlessness 2)Impaired Verbal Communication 3)Spiritual Distress 4)Risk for Noncompliance

ANS: 1 Powerlessness is the best nursing diagnosis for the patient who is unable to make healthcare personnel understand the importance of his cultural beliefs. Impaired Verbal Communication can be used for patients who do not speak or understand the healthcare personnel's language. Spiritual Distress might occur because a treatment is not in agreement with the patient's religious beliefs. Risk for Noncompliance can be identified when a patient fails to follow a health-promoting or therapeutic plan the healthcare provider believes they agreed to.

How are short-term goals different from long-term goals? Short-term goals 1) Can be met within a few hours or a few days 2) Are developed from the problem side of the nursing diagnosis 3) Must have target times/dates 4) Specify desired client responses to interventions

ANS: 1 Short-term goals may be accomplished in hours or days; long-term goals usually are achieved over weeks, months, or even years. The other statements are true for both short-term and long-term goals. PTS:1DIF:ModerateREF: p. 91 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

A patient is brought to the emergency department experiencing leg cramps. He is irritable, his temperature is elevated, and his mucous membranes are dry. Based on these findings, the patient most likely has excess levels of which mineral? 1) Sodium 2) Potassium 3) Phosphorus 4) Magnesium

ANS: 1 Signs and symptoms associated with sodium excess include thirst, fever, dry and sticky tongue and mucous membranes, restlessness, irritability, and seizures. Findings associated with potassium excess include cardiac arrhythmias, weakness, abdominal cramps, diarrhea, anxiety, and paresthesia. Phosphorus excess leads to tetany and seizures. Magnesium excess causes weakness, nausea, and malaise. PTS:1DIFgrinifficultREF:p. 908 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

A 36-year-old mother of three small children has had nausea, vomiting, and extreme fatigue for the past 2 days. She calls her mother and tells her she is ill and asks if her mother can care for the children. Which stage of illness behavior is she experiencing? Choose all that apply. 1) Sick-role behavior 2) Dependence on others 3) Seeking professional care 4) Experiencing symptoms

ANS: 1 The 36-year-old mother is assuming sick-role behavior because she is identifying herself as ill. She is also in the stage of experiencing symptoms; she is experiencing symptoms and realizes that illness is starting, even though she has not yet entered the stages of dependence and seeking professional care. By telling her mother of the illness, she is relieved of her normal duties—caring for her children. Dependence on others occurs when the client accepts a diagnosis and treatment from the healthcare provider. Seeking professional care occurs after the sick-role behavior stage. During this stage, the client makes the decision that she is ill and that professional healthcare is needed. PTS:1DIF:ModerateREF:p. 228 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Application

Which individuals should receive annual lipid screening? 1) All overweight children 2) All adults 20 years and older 3) Persons with total cholesterol greater than 150 mg/dL 4) Persons with HDL less than 40 mg/dL

ANS: 1 The American Academy of Pediatrics takes a targeted approach, recommending that overweight children receive cholesterol screening, regardless of family history or other risk factors for cardiovascular disease. The American Heart Association recommends that all adults age 20 years or older have a fasting lipid panel at least once every 5 years. If total cholesterol is 200 mg/dL or greater—or HDL is less than 40 mg/dL—frequent monitoring is required. PTS: 1 DIF: Moderate REF: p. 888; Box 27-1 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application

A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. To develop a nursing diagnosis, the nurse must now 1)Analyze the assessment data 2)Consult standards of care 3)Decide which interventions are appropriate 4)Ask the client's perceptions of her health problem

ANS: 1 The basis of the nursing diagnosis is the assessment data. Standards of care are referred to when establishing nursing interventions. Customizing interventions personalizes nursing care. Asking the patient about her perceptions is a method to validate whether the nurse has chosen the correct nursing diagnosis and would probably have been done during the comprehensive assessment.

The nurse is using electronic care planning. He enters the patient's nursing diagnosis into the computer and chooses desired outcomes. He has validated his data, diagnosis, and goals. When he considers the list of interventions the program generates, he sees that none of them fit this patient's individual needs. What should the nurse do? 1) Reject them all and type in appropriate interventions. 2) Select the interventions from the program that are most suitable. 3) Ask another nurse to assess the patient and give her recommendation. 4) Restart the computer; it is probably a program malfunction.

ANS: 1 The nurse can reject all the suggested interventions if they do not address patient needs. Nearly all computer programs have a screen that allows you to type in interventions and nursing orders. It is the nurse's responsibility to choose interventions: He cannot abdicate this responsibility and let the computer "choose." As a professional, this nurse has already validated the data, nursing diagnosis, and goals, so he can feel reasonably certain that there is nothing wrong with the plan to that point. Although consultation with other nurses can be wise and prudent at times, the nurse caring for the patient would likely have the most familiarity with the healthcare needs and is in a better position to make sound judgments than another nurse who does not know the patient. Therefore, it might not be productive or efficient to consult another nurse or restart the computer. PTS:1DIF:ModerateREF:p. 108-109 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

The nurse is providing nutrition counseling for a patient planning pregnancy. The nurse should emphasize the importance of consuming which nutrient to prevent neural tube defects? 1) Folic acid 2) Calcium 3) Protein 4) Vitamin D

ANS: 1 The nurse should emphasize the importance of consuming folic acid even before conception to prevent neural tube defects from developing. Calcium and protein needs also increase during pregnancy; however, their consumption does not prevent neural tube defects. Vitamin D consumption does not prevent neural tube defects. PTS:1DIF:EasyREF:p. 913 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Comprehension

A mother brings her 4-month-old infant for a well-baby checkup. The mother tells the nurse that she would like to start bottle feeding her baby because she cannot keep up with the demands of breastfeeding since returning to work. Which response by the nurse is appropriate? 1) "Make sure you give your baby an iron-fortified formula to supplement any stored breast milk you have." 2) "You really need to continue breastfeeding your baby." 3) "Give your baby formula until he is 6 months old; then you can introduce whole milk." 4) "Your baby weighs 14 pounds, so he will require about 36 ounces of formula a day."

ANS: 1 The nurse should not make the mother feel guilty about her decision to stop breastfeeding. Instead, she should provide the mother with instruction about bottle feeding. She can give it to supplement any stored breast milk she might have in supply. She should emphasize the importance of giving the baby iron-fortified formula because fetal iron stores become depleted by 4 to 6 months of age. Infants younger than 1 year of age should not receive regular cow's milk because it may place a strain on the immature kidneys. Because the baby weighs 14 pounds, he will require about 21 ounces of formula a day (not 36 ounces), based on the nutritional recommendations that infants require 80 to 100 mL of formula or breast milk per kilogram of body weight per day. PTS:1DIF:ModerateREF:p. 912 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application

The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order? 1)Repeat the order to the prescriber even if she believes she understood the order correctly. 2)Immediately notify the pharmacy of the order and verify it with a pharmacist. 3)Ask the unit secretary to listen to the prescriber on the phone to verify the order. 4)Transcribe the order onto note paper and verify the dosage in a drug handbook.

ANS: 1 The nurse should repeat the order to the prescriber even if she believes she understood it entirely. If possible, she should have a second nurse (not the unit secretary) listen to the order to verify accuracy. Only the prescribing provider, not the pharmacist, can verify the order. The nurse should transcribe the order directly on the patient's chart. Transcribing it on a piece of paper and then copying it again introduces one more chance of error.

Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)? 1) Nurse who delegated the task 2) Licensed practical nurse working with the NAP 3) Unit nurse manager 4) Charge nurse for the shift

ANS: 1 The nurse who delegates the task is responsible for supervising and evaluating the outcomes of tasks performed by the NAP. Another registered nurse, such as a staff nurse, nurse manager, or charge nurse, can answer questions and provide help, if necessary. PTS:1DIF:EasyREF: p. 124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Recall

A 55-year-old patient returned to the medical-surgical unit after undergoing a right hemicolectomy (abdominal surgery) for colon cancer. Which of the following is an appropriate, correctly written nursing order for this patient? 1) 7/12/13 Encourage use of the incentive spirometer every hour while the client is awake—D. Goodman, RN 2) By 7/12/13, uses incentive spirometer 10 times every hour while awake to 1000 mL 3) Incentive spirometer hourly while awake 4) Offer incentive spirometer to the client—J. Smith, RN

ANS: 1 The option beginning with a date and ending with the RN's signature contains necessary information. It contains the date the order was written along with specific instruction for the nurse that is written in terms of nursing behavior. "Uses incentive spirometer 10 times . . ." is an example of an expected outcome. "Incentive spirometer hourly . . ." is an example of a medical order. Plus, the date and nurse's signature are missing. "Offer incentive spirometer . . ." does not provide the nurse with enough detailed instruction. Therefore, it is a poorly written nursing order. PTS:1DIF:ModerateREF:pp. 111-112 KEY: Nursing process: Planning | Client need: Physiological integrity | Cognitive level: Application

Which portion of a nutritional assessment must the registered nurse complete? 1) Analyzing the data 2) Obtaining intake and output 3) Weighing the patient 4) Obtaining the history

ANS: 1 The registered nurse should review and interpret (analyze) the data collected as part of a nutritional assessment. The registered nurse can delegate height, weight, and intake and output to nursing assistive personnel. History taking can be safely delegated to the licensed practical nurse. PTS:1DIF:ModerateREF:p. 925 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

Which healthcare worker should the nurse consult to counsel a patient about financial and family stressors affecting healthcare? 1)Social worker 2)Occupational therapist 3)Physician's assistant 4)Technologist

ANS: 1 The social worker coordinates services and counsels patients about financial, housing, marital, and family issues affecting healthcare. The occupational therapist helps patients regain function and independence for activities of daily living. Physician's assistants work under the physician's direction to diagnose certain diseases and injuries. Technologists provide a variety of specific functions in hospitals, diagnostic centers, and emergency care. For example, laboratory technologists aid in the diagnosis and treatment of patients by examining blood, urine, tissue, and body fluids. Radiology technologists perform x-rays and other diagnostic testing. PTS:1DIF:ModerateREF:ESG, Chapter 1, "Healthcare Delivery Systems—Expanded Discussion," "What Healthcare Providers Will You Work With?"

A registered nurse administers the wrong medication to a patient. She does not notify anyone of the error and documents that the correct medication was administered. The nurse was reported to the state board of nursing. Which of the following actions can the state board of nursing take against the nurse in this situation? 1)Disciplinary action against the nurse's license to practice 2)Criminal misdemeanor charges against the nurse 3)Medical malpractice lawsuit against the nurse 4)Employment release from the institution

ANS: 1 The state board of nursing is empowered to initiate disciplinary action against the nurse's license for professional misconduct. The board does not bring criminal charges or sentence the nurse to jail; that is the parameter of the state prosecutor and judge. A patient or the person harmed can bring medical malpractice lawsuits against the nurse.

During family therapy, to improve communication skills the nurse teaches family members to rehearse responses to situations involving interpersonal conflict. What is the primary drawback of using this teaching strategy? 1)Some people might have difficulty with an interactive approach when there is conflict among participants. 2)Nurses might rehearse responses that are not effective for resolving interpersonal conflict. 3)Nurses do not use the rehearsal technique because it is an inefficient use of time for participants. 4)This type of interactive teaching strategy is not as effective as dispersing information verbally or in print.

ANS: 1 The teaching strategy described is role-playing. Role-playing may cause participants to feel self-conscious; to be effective, participants must be willing to participate as an observer or role player, particularly in a situation where there is conflict among those involved in the exercise. With role-playing, the participant may be unaware that teaching is occurring. The strategy can therefore be a productive use of time while modeling effective responses and desired behavior. Rehearsing real-life situations common to family dynamics is typically more effective for conflict resolution than reading about the topic or discussing approaches for effective communication. PTS:1DIF:ModerateREF:ESG, Chapter 24, "General Teaching Strategies: Role Playing"

A patient tells the nurse, "I feel that God has abandoned me. I am so angry that I can't even pray." The patient refuses to see his clergyman when he calls. Which is the most appropriate nursing diagnosis for this patient? 1) Spiritual Distress 2) Risk for Spiritual Distress 3) Impaired Religiosity 4) Moral Distress

ANS: 1 This patient exhibits three defining characteristics for Spiritual Distress (feeling abandoned by God, inability to pray, refusing to see a religious leader). Therefore, the actual problem of Spiritual Distress exists, not the potential problem of Risk for Spiritual Distress. Impaired Religiosity is difficulty in exercising or impaired ability to exercise reliance on beliefs or to participate in rituals of a faith tradition (e.g., going to church). This patient is not unable to see the clergyman but chooses not to. Moral Distress occurs when a person makes a moral decision but is prevented from carrying out the chosen action. PTS:1DIF:ModerateREF:p. 348 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis

A 52-year-old man has a triceps skinfold thickness of 18 mm, and his weight exceeds the ideal body weight for his height by 23%. Which nursing diagnosis should the nurse identify for this patient? 1) Imbalanced Nutrition: More Than Body Requirements 2) Risk for Imbalanced Nutrition: More Than Body Requirements 3) Imbalanced Nutrition: Less Than Body Requirements 4) Readiness for Enhanced Nutrition

ANS: 1 This patient has defining characteristics for the nursing diagnosis Imbalanced Nutrition: More Than Body Requirements: triceps skinfold thickness more than 15 mm in men and weight that is 20% over ideal for height and frame. The patient does not have defining characteristics for the other nursing diagnoses. PTS:1DIF:ModerateREF:p. 929 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

Which type of medicine do those of Hindu faith typically practice? 1) Ayurvedic medicine 2) Western medicine 3) Chiropractic medicine 4) Qigong

ANS: 1 Those of Hindu faith typically practice Ayurvedic medicine, which encompasses all aspects of life, including diet, sleep, elimination, and hygiene. Some believe in the medicinal properties of "hot" and "cold" foods, which have nothing to do with temperature or degree of spiciness. People who practice Hinduism do not typically practice Western medicine, chiropractic medicine, or Qigong. Qigong, a form of Chinese martial arts, is used to achieve healing through focus on the body's energy centers. PTS:1DIF:ModerateREF:p. 343 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension

A preschool-age child is scheduled for a tonsillectomy. Which strategy might help lessen the child's anxiety before surgery? 1)Show the child a short, animated video (DVD) about the hospital visit and procedure. 2)Give the child a tour of the hospital a week before the surgery is scheduled. 3)Allow the child to use computer-assisted instruction to teach him about the procedure. 4)Provide one-to-one instruction about the care he will need after surgery.

ANS: 1 To reduce anxiety in a preschool-age child requiring surgery, show a short, animated video showing the area of the hospital where the child will be. The video should include a simple explanation of what is going to happen while he is in the hospital and afterward in a manner that is upbeat and friendly. A tour of the hospital with the sights and smells of sicker people might be more frightening to the young child. It is best to avoid exposure to pathogens before surgery, such as what could be acquired when touring the building. One-to-one instruction is a teaching strategy that is effective with adults and older children. PTS:1DIF:Moderate REF: p. 860 [Preoperational Stage]; answer not directly stated in text.

Which special consideration may the nurse need to make when caring for a female Rastafarian patient? 1) Allow the patient to wear her own clothing. 2) Provide a diet that is caffeine-free. 3) Allow the patient to wear jewelry with religious symbols. 4) Provide free-flowing water for bathing.

ANS: 1 Wearing secondhand clothes is taboo in the Rastafarian faith; therefore, the nurse should allow the patient to wear her own bedclothes instead of a hospital gown. Rastafarians typically consume tea, but some do not drink milk or coffee. Muslim women may wear a locket containing religious writing around the neck in a small leather bag. These are worn for protection and strength and should not be removed. Hindus prefer washing with free-flowing water for bathing, which should be provided when possible. PTS: 1 DIF: Moderate REF: ESG, Chapter 16, "Supplemental Materials," "Major Religions: What Should I Know?" KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

A family assessment should include the following areas. Choose all that apply. 1) Coping patterns 2) Health beliefs 3) Medical history 4) Physical exam

ANS: 1, 2 Conducting a family assessment includes identifying the following: data; family composition; family history and developmental stage; environmental data; family structure; family function; health beliefs, values, and behaviors; family stressors and coping; and abuse and violence within the family. The medical history and physical exam of individuals are only relevant to the family assessment if it affects other family members. PTS: 1 DIF: Moderate REF: pp. 308-311 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension

To promote wound healing, the nurse is teaching a patient about choosing foods containing protein. The nurse will evaluate that learning has occurred if the patient recognizes which food(s) as an incomplete protein that should be consumed with a complementary protein? Choose all that apply. 1) Whole grain bread 2) Peanut butter 3) Chicken 4) Eggs

ANS: 1, 2 Incomplete protein foods do not provide all of the essential amino acids necessary for protein synthesis. Therefore, the nurse should inform the patient that whole grain bread and peanut butter should be consumed with a complementary protein. For example, they could be eaten together as a peanut butter sandwich. PTS:1DIF:ModerateREF:p. 901 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Comprehension

Which action by the nurse breaches patient confidentiality? Select all that apply. 1)Leaving patient data displayed on a computer screen where others may view it 2)Remaining logged on to the computer system after documenting patient care 3)Faxing a patient report to the nurses' station where the patient is being transferred 4) Informing the nurse manager of a change in the patient's condition

ANS: 1, 2 Leaving patient data displayed on a computer screen where others may view them breaches patient confidentiality. The nurse should log off the computer immediately after use. Faxing a report to the nurses' station receiving a patient does not breach patient confidentiality because it is located at the nurses' station out of others' view. Anyone directly involved in the patient's care has the right to know about the patient's condition without breaching patient confidentiality.

In performing a hand-off report, the nurse should communicate information on which of the following? Select all that apply. 1)Teaching performed 2)Any change in client status 3)Treatments administered 4)Hygiene measures performed

ANS: 1, 2, 3 Hand-off reports include any client teaching done, therapies and treatments administered, and changes in the client's status. Hygiene care is routinely done in inpatient settings and is usually recorded on a flow sheet. Hand-off reports should be succinct and not contain routine information.

The nurse working in an ambulatory care program asks questions about the client's locus of control as a part of his assessment because of which of the following? Choose all that apply. 1) People who feel in charge of their own health are the easiest to motivate toward change. 2) People who feel powerless about preventing illness are least likely to engage in health promotion activities. 3) People who respond to direction from respected authorities often prefer a health promotion program supervised by a health provider. 4) People who feel in charge of their own health are less motivated by health promotion activities.

ANS: 1, 2, 3 Identifying a person's locus of control helps the nurse determine how to approach a client about health promotion. People who feel powerless about preventing illness are least likely to engage in health promotion activities. People who respond to direction from respected authorities often prefer a health promotion program that is supervised by a health provider. Clients who feel in charge of their own health are the easiest to motivate toward positive change. PTS:1DIFgrinifficultREF:p. 888 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension

Which of the following actions demonstrate how nurses promote health? 1) Role modeling 2) Educating patients and families 3) Counseling 4) Providing support

ANS: 1, 2, 3, 4 Nurses promote health by acting as role models, counseling, providing health education, and providing and facilitating support. PTS:1DIF:EasyREF:pp. 891-892 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Comprehension

The nurse is implementing a wellness program based on data gathered from a group of low-income seniors living in a housing project. He is using the Wheels of Wellness as a model for his planned interventions. Which of the following interventions would be appropriate based on this model? Choose all that apply. 1) Creating a weekly discussion group focused on contemporary news 2) Facilitating a relationship between local pastors and residents of subsidized housing 3) Coordinating a senior tutorial program for local children at the housing center 4) Establishing an on-site healthcare clinic operating one day per week

ANS: 1, 2, 3, 4 The Wheels of Wellness model identifies the following dimensions of health: emotional, intellectual, physical, spiritual, social/family, and occupational. A weekly discussion group stimulates intellectual health. A relationship between local pastors and those living in subsidized housing creates a climate for spiritual health. A tutorial program offered by seniors to local children will facilitate occupational health. An on-site healthcare clinic addresses physical health. PTS:1DIFgrinifficultREF:p. 881 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Analysis

Which of the following questions would be effective for obtaining information from a patient? Choose all that apply. 1) "How did this happen to you?" 2) "What was your first symptom?" 3) "Why didn't you seek healthcare earlier?" 4) "When did you start having symptoms?"

ANS: 1, 2, 4

The nurse who understands the electronic health record (EHR) can do which of the following? Select all that apply. 1)Facilitate evidence-based nursing practice 2)Promote efficient use of the nurse's documentation time 3)Reduce the opportunity for interdisciplinary collaboration 4)Ensure improved client safety and outcomes

ANS: 1, 2, 4 Electronic health records (EHR) have many advantages, including the facilitation of evidence-based nursing practice, efficient use of the nurse's documentation time, and improved client safety and outcomes. The EHR does not impair interdisciplinary collaboration; rather, the EHR fosters communication and collaboration among healthcare team members.

You are caring for a patient with renal failure. His morning laboratory results reveal an abnormal potassium level of 6.8. This value is more elevated than on the previous day, when the level was within normal limits. You page the patient's physician, but he does not return your call right away. You become busy with another patient and forget to notify the physician again and fail to mention the critical laboratory value to the oncoming nurse during shift report. Which of the following does this scenario illustrate? Choose all that apply. 1)Failure to implement a plan of care 2)Failure to evaluate 3)Malpractice 4)Failure to assess and diagnose

ANS: 1, 2, 4 Failure to implement a plan of care and failure to evaluate are two of the most common causes of nursing malpractice claims. The above scenario represents a failure to follow standards of care, failure to communicate, and failure to document, which are in the category of failure to implement a plan of care. It also represents a failure to assess and report a significant change in the patient's condition, which is part of the category of failure to evaluate. The nurse did assess the potassium level and recognize that it was too high.

Health promotion programs assist a person to advance toward optimal health. Which of the following activities might such programs include? Choose all that apply. 1) Disseminating information 2) Changing lifestyle and behavior 3) Prescribing medications to treat underlying disorders 4) Environmental control programs

ANS: 1, 2, 4 Health promotion programs may be categorized into four types: disseminating information, programs for changing lifestyle and behavior, environmental control programs, and wellness appraisal and health risk assessment programs. Prescribing medications to treat underlying disorders is an activity that fosters health focused at an individual level rather than at a group program level. PTS:1DIF:ModerateREF:p. 881 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Recall

Which of the following are examples of invasion of privacy by nurses? Choose all that apply. 1)Searching a patient's belongings without permission 2)Reviewing the plan for patient care in the lunchroom 3)Discussing healthcare issues for an unconscious patient with his power of attorney 4)Releasing patient health information to local newspaper reporters

ANS: 1, 2, 4 Invasion of privacy violates a person's right to be free from unwanted interference in her private affairs, such as occurs in discussing patient matters in a public setting; searching patients' private items without their permission; and releasing private information to the public. A durable power of attorney is a document empowering a person selected by the patient to make healthcare decisions in the event that the patient is unable to do so. It is permissible to discuss pertinent issues related to the welfare of the patient with the person holding a power of attorney.

Which aspects of healthcare are affected by a client's culture? Select all that apply. 1)How the clients views healthcare 2)How the client views illness 3)How the client will pay for healthcare services 4)The types of treatments the client will accept 5)When the client will seek healthcare services 6)The environment where the healthcare services are provided 7)The ease of accessibility of healthcare services

ANS: 1, 2, 4, 5 Culture affects clients' view of health and healthcare. It influences how they will define illness, when they will seek healthcare, and what treatments are acceptable in their culture. How services are paid for is related to economic status. Regardless of culture, anyone can be affected by previous healthcare experiences, the environment in which healthcare is provided, and accessibility of services.

What do negligence and malpractice have in common? Choose all that apply. 1)Negligence and malpractice are non-intentional torts. 2)Negligence and malpractice are felonies. 3)Malpractice is the professional form of negligence. 4)Negligence and malpractice involve the intent to do harm to a patient.

ANS: 1, 3 Negligence and malpractice are non-intentional torts—nurses can be negligent without intending to do harm. Negligence is simply the failure to use ordinary or reasonable care as dictated by the standards of practice and/or by what a reasonable and prudent nurse would do in the same or similar circumstances. Intent is not an element of negligence. When a nurse or other licensed professional healthcare provider is negligent and fails to exercise ordinary care, it is called malpractice. Malpractice is the professional form of negligence.

Which statement(s) about nursing interventions is/are true? Select all that apply. 1) The responsibility of writing nursing orders cannot be delegated to the LPN/LVN. 2) The best nursing interventions are based on tradition. 3) Nursing interventions should be individualized and culturally sensitive. 4) Standardized nursing interventions improve care for a specific client.

ANS: 1, 3 Some nursing interventions and activities can be delegated to the LPN/LVN or nursing assistive personnel (NAP); however, writing nursing orders is the responsibility of the registered nurse. Nursing interventions should always be individualized and culturally sensitive. Whenever possible, nursing interventions should be based on scientific evidence, not tradition. Standardized interventions are not customized to improve care for a specific client. PTS:1DIF:ModerateREF: pp. 103-104 KEY: Nursing process: Interventions | Client need: SASE | Cognitive level: Application

Which of the following are cues rather than inferences? Choose all correct answers. 1) Ate 50% of his meal 2) Patient feels better today 3) States, "I slept well" 4) White blood cell count 15,000/mm3

ANS: 1, 3, 4

Which statement(s) about culture is/are true? Choose all that apply. 1)Culture exists on both material and nonmaterial levels. 2)Culture mainly influences food choices and special holidays. 3)Cultural customs change over time at different rates. 4)Culture is learned through life experiences shared by other cultural members.

ANS: 1, 3, 4 Culture is learned through life experiences that are shared by other members of the culture, such as family members, those sharing similar religious beliefs, and people of similar cultural heritage in the same community. Culture exists at many levels that are both material and nonmaterial. Cultural customs, beliefs, attitudes, and practices are not static but change over time at different rates, depending on current events, other significant people, and social influences. Culture is all encompassing and affects everything its members think and do; it is not limited to food and holidays. Although those are visible manifestations of a culture, dietary practices and cultural calendars are not the essence of true and meaningful culture.

An 80-year-old resident in a long-term-care facility comes to the emergency department with dehydration. The nurse writes a diagnosis of Deficient Fluid Volume related to excessive fluid loss. An individualized nursing goal identified for this client is "The client will maintain urine output of at least 30 mL/hour." Which nursing interventions would directly help achieve or evaluate the stated goal? Choose all that are correct. 1) Measure and record urine output every hour; report an output of less than 30 mL/hour. 2) Monitor skin turgor and moistness of mucous membranes every shift. 3) Administer IV fluids as prescribed. 4) Keep oral fluids within the patient's reach, and encourage the patient to drink.

ANS: 1, 3, 4 Measuring and recording urine output allow for direct evaluation of the goal "urine output 30 mL/hour." Administering IV fluids adds fluid to correct dehydration, improve blood flow through the kidneys, and increase urine production. Intake of oral fluids has the same effect. Monitoring skin turgor and mucous membranes are ways to assess for dehydration, but it does not directly apply to the goal of maintaining urine output. It is an intervention aimed at the etiology of this nursing diagnosis, rather than the problem. PTS:1DIF:ModerateREF:p. 106-107; high-level question; answer not given verbatim KEY: Nursing process: Interventions | Client need: Physiological integrity | Cognitive level: Analysis

According to Pender's health promotion model, which variables must be considered when planning a health promotion program for a client? Choose all that apply. 1) Individual characteristics and experiences 2) Levels of prevention 3) Behavioral outcomes 4) Behavior-specific cognition and affect

ANS: 1, 3, 4 Pender identified three variables that affect health promotion: individual characteristics and experiences, behavior-specific cognition and affect, and behavioral outcomes. Levels of prevention were identified by Leavell and Clark; three levels relate to health protection. The levels differ based on their timing in the illness cycle. PTS: 1 DIF: Difficult REF: pp. 880-881 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension

Identify one or more choices that best complete the statement or answer the question. ____ 1. Which of the following is an example of whistle-blowing? Choose all that apply. 1) Reporting fraudulent billing practices 2) Reporting patients health status against the patients wishes 3) Reporting unsafe work practices 4) Reporting a coworker for working under the influence of drugs

ANS: 1, 3, 4 Reporting a patients health status against the patients wishes is a breach of patient confidentiality. Whistle-blowing is identifying incompetent, unethical, or illegal situations or actions of others in the workplace and reporting to someone who may be in a position to rectify the situation. Fraudulent billing practices are illegal and unethical; unsafe work practices are unethical and illegal; and a coworker under the influence of drugs is a risk to patients, as well acting in an illegal and unethical manner.

The nurse and nursing assistive personnel (NAP) are caring for a group of patients on the medical-surgical floor. For which of the following patients can the nurse delegate to the NAP the task of bathing? Choose all that apply. 1) 75-year-old patient newly admitted to the hospital with dehydration 2) 65-year-old patient hospitalized for a stroke, whose blood pressure is 188/90 mm Hg 3) 92-year-old patient with stable vital signs who was admitted with a urinary tract infection 4) 56-year-old patient with chronic renal failure who has vital signs within his normal range

ANS: 1, 3, 4 The nurse should not delegate bathing of a client newly diagnosed with a stroke whose blood pressure is unstable or otherwise abnormal. This client requires the keen assessment and critical thinking skills of a registered nurse. The nurse can safely delegate the care of stable clients, such as the client admitted with dehydration, the client admitted with a urinary tract infection, or the client with chronic renal failure. Any client who is very ill or who requires complex decision making should be cared for by a registered nurse. PTS: 1 DIF: Difficult REF: pp. 122-124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis

A nurse is caring for an 80-year-old patient of Chinese heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association standards for outcomes identification? Choose all that apply. 1) Developing culturally appropriate outcomes 2) Using the outcomes preprinted on the clinical pathway 3) Choosing the best outcome for the patient, regardless of the costs involved in bringing it about 4) Involving the patient and family in formulating the outcomes

ANS: 1, 4 ANA standard 3 includes "derives culturally appropriate expected outcomes from the diagnosis" and "involves the patient, family . . . in formulating expected outcomes. . . ." It is acceptable for the nurse to use outcomes on a clinical pathway, but these are not individualized; ANA standard 3 says that the nurse "identifies . . . outcomes for a plan individualized to the patient. . . ." The standard also says that the nurse should consider "associated risks, benefits, and costs. . . ." PTS:1DIF:ModerateREF: p. 82 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension

Which family function(s) is/are outlined in the structural-functional family theory? Select all that apply. 1) Meeting the emotional needs of family members 2) Reinforcing ethical and moral values 3) Promoting joint decision making among parents and children 4) Being productive members of society

ANS: 1, 4 Family functions outlined in the structural-functional family theory include being productive members of society, caring for elderly members, meeting physical and emotional needs of family members, and socialization of children. This model is more focused on the outcomes of family function than the process by which action occurs. Maintaining support for young adults as they leave the security of the family, reinforcing ethical and moral values, and promoting joint decision making among parents and children are examples of tasks outlined in family development theories. PTS:1DIF:ModerateREF:p. 302 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall

Which of the following are examples of a health-promotion activity? Select all that apply. 1)Helping a client develop a plan for a low-fat, low-cholesterol diet 2)Disinfecting an abraded knee after a child falls off a bicycle 3)Administering a tetanus vaccination after an injury from a car accident 4)Distributing educational brochures about the benefits of exercise

ANS: 1, 4 Health promotion includes strategies that promote positive lifestyle changes. Disinfecting an abraded knee is a treatment/intervention for an injury. Administering a vaccination is a disease-prevention and treatment activity. PTS: 1 DIF: Moderate REF: p. 18; high-level question, not directly stated in text KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Application

Which statement by the student nurse indicates an understanding of the nursing Kardex®? Choose all correct answers. 1)"The Kardex® pulls data from multiple areas of the patient's chart." 2)"The Kardex® is usually kept at the patient's bedside." 3)"The Kardex® is used to document patient response to interventions." 4)"The Kardex® summarizes the plan of care and guides nursing care."

ANS: 1, 4 The Kardex® is a tool that pulls data from multiple areas of the patient's health record and helps guide nursing care. Responses to interventions are documented on flow sheets and in nurses' notes. Kardexes® are paper forms that are kept together in a portable file at the nurses' station to allow all team members access to the summary information. The file is portable, so it could be carried to the bedside briefly; however, it is not stored there, as a general rule.

For a patient with Risk for Imbalanced Nutrition: Less Than Body Requirements related to Impaired Swallowing, which nursing interventions are appropriate? Choose all that apply. 1) Check inside the mouth for pocketing of food after eating. 2) Provide a full liquid diet that is easy to swallow. 3) Remind the patient to raise the chin slightly to prepare for swallowing. 4) Keep the head of the bed elevated for 30 to 45 minutes after feeding.

ANS: 1, 4 The nurse should check for pocketing of food that the patient has not been able to swallow, and should keep the head of the bed elevated for 30 to 45 minutes after feeding. Liquids should be avoided unless thickeners are added. The patient should flex the head forward (tuck the chin) in preparation for swallowing. PTS:1DIF:ModerateREF:pp. 927-928 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

A patient has left-sided weakness because of a recent stroke. Which type of special needs assessment would it be most important to perform? 1)Family 2)Functional 3)Community 4)Psychosocial

ANS: 2

How does a risk nursing diagnosis differ from a possible nursing diagnosis? 1) A risk diagnosis is based on data about the patient. 2) A possible diagnosis is based on partial (or incomplete) data. 3) Nurses collect the data to support risk diagnoses. 4) A possible diagnosis becomes an actual diagnosis when symptoms develop.

ANS: 2

The most obvious reason for using a framework when assessing a patient is to 1) Prioritize assessment data 2) Organize and cluster data 3) Separate subjective and objective data 4) Identify primary from secondary data

ANS: 2

What is wrong with the format of this diagnostic statement: Possible Risk for Constipation related to irregular defecation habits A.M.B. statement that "When I'm busy, I can't always take the time to go to the bathroom." 1) Possible nursing diagnoses do not have signs and symptoms. 2) A nursing diagnosis is either a possible risk or a risk, not both. 3) Constipation is a medical diagnosis. 4) The etiology is actually a defining characteristic.

ANS: 2

Which of the following is an example of the most basic motivation in Maslow's hierarchy of needs? 1)Experiencing loving relationships 2)Having adequate housing 3)Receiving education 4)Living in a crime-free neighborhood

ANS: 2

A patient who had surgery 8 hours ago has not voided. The nurse notifies the physician for an order to insert an indwelling urinary catheter. Which of the following statements should the nurse use to describe the procedure to the patient? 1)"I need to put a Foley in you because you haven't voided since your surgical procedure." 2)"I need to insert a tube into your bladder to drain the urine because you haven't urinated since surgery." 3)"I need to catheterize you because you haven't urinated since having your surgery." 4)"I need to place a catheter in your bladder because you haven't voided since surgery."

ANS: 2 "I need to insert a tube into your bladder . . ." best describes the procedure for the patient because the explanation is in terms most patients will understand. The other options contain medical jargon that could confuse the patient.

A patient refuses a dose of medication. How should the nurse document the event? 1)Patient is uncooperative and refuses the prescribed dose of digoxin. 2)Patient refuses the 0900 dose of digoxin. 3)Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin. 4)0900 dose of digoxin not given.

ANS: 2 "Patient refuses the 0900 dose of digoxin" objectively describes the event in which the patient refuses to take his 0900 dose of digoxin. "0900 dose of digoxin not given" provides no explanation as to why the medication was not given. The other two options offer judgmental information, which should be avoided when charting.

Which of the following is a client outcome criterion? 1) Central venous catheter site infection does not occur (90% of cases). 2) Client will sit out of bed in a chair for 20 minutes three times per day. 3) Postoperative phlebitis does not occur (95% of cases). 4) Falls will decrease by 2% between January 1 and March 30.

ANS: 2 A client outcome criterion states the client health status or behaviors one wishes to effect. "Client will sit out of bed . . ." is a client outcome criterion. The other options are examples of organizational criteria used to evaluate the quality of care throughout the institution. PTS:1DIF:ModerateREF: pp. 127-128 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application

Which of the following is the most valid criterion for determining the status of a patient's anxiety at discharge? The patient 1) Has a relaxed facial expression 2) States that he feels more relaxed today 3) Shows no physiological signs of anxiety (e.g., pallor) 4) Has no further questions about home care

ANS: 2 A criterion is considered valid when it measures what it is intended to measure. Because anxiety is subjective (perceived by the patient), the best measure of anxiety is what the patient says about it. A relaxed facial expression and other physiological signs might or might not show the level of anxiety. Relaxation might occur, for example, because the patient is sleeping or falling asleep. The fact that a patient is not asking questions about his surgery could mean that he has adequate knowledge about the topic; it would not indicate the presence or absence of anxiety. All of the options except what the patient states could be measuring something other than anxiety. PTS: 1 DIF: Difficult REF: p. 127 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application

An 80-year-old patient fell and fractured her hip and is in the hospital. Before the fall, she lived at home with her husband and managed their activities of daily living very well. The goal is for the patient to recover from the injury and return to her home. The hospital is ready to discharge her because she has exceeded the recommended length of stay in a hospital. However, she cannot walk or care for herself yet, and she will require lengthy physical therapy and further monitoring of her medications and her physical and mental status. To which type of facility should she be transferred? 1)Nursing home 2)Rehabilitation center 3)Outpatient therapy center 4)None of these; she should receive home healthcare

ANS: 2 A skilled nursing facility primarily provides skilled nursing care for patients who can be expected to improve with treatment. For example, a patient who no longer needs hospitalization may transfer to a skilled nursing facility to get skilled care until she is able to return home. A nursing home provides custodial care for people, like this patient, who cannot live on their own but who are not sick enough to require hospitalization. It provides a room, custodial care, and opportunity for recreation. This patient cannot ambulate or perform activities of daily living, so outpatient therapy and home care would not be appropriate. PTS:1DIF:ModerateREF:p. 18 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application

Of the following, the biggest disadvantage of having nursing assistive personnel (NAP) help nurses is that the nurse 1)Must know what aspects of care can legally and safely be delegated to the NAP 2)May rely too heavily on information gathered by the NAP when making patient care decisions 3)Is removed from many components of direct patient care that have been delegated to the NAP 4)Still maintains responsibility for the patient care given by the NAP

ANS: 2 All of the options may be disadvantages to using NAPs, but making decisions based on another's information is the greatest drawback because of the potential for negatively affecting patient care. Treatment decisions based on incorrect information may cause harm to the patient. PTS:1DIFgrinifficultREF:p. 20-21; students must conclude from content

A 4-year-old child is brought to the emergency department by his mother. He has a large bruise in his left chest and multiple contusions on his face. His mother tells you her boyfriend intentionally pushed the child down the stairs in anger. The child appears to be in a great deal of pain. Which of the following four items should the nurse do first? 1)Notify the nursing supervisor of the suspected physical abuse. 2)Complete a physical assessment of the child. 3)Obtain an order for pain medication. 4)Notify Child Protective Services of the suspected abuse.

ANS: 2 Although the nurse must report to designated authorities (Child Protective Services) suspected physical abuse, the primary responsibility of the nurse in this situation is to evaluate the patient's physical condition and extent of his injuries in order for appropriate medical treatment to be provided. Pain medication should not be administered prior to a thorough physical assessment. The nurse should always notify the nursing supervisor if any outside agencies may need to be contacted.

Which question helps the nurse to assess family structure? 1) "Where does your family live?" 2) "How are family decisions made?" 3) "With which religious affiliation is your family associated?" 4) "What is your ethnic background?"

ANS: 2 Asking how family decisions are made helps the nurse to assess family structure. Asking about religious affiliation, ethnic background, and where the family lives provides identifying data but does not reveal lines of authority and relationships among family members. PTS:1DIF:ModerateREF:p. 308 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application

A patient with trigeminal neuralgia is prescribed a mechanical soft diet. This diet places the patient at risk for which complication? 1) Dehydration 2) Constipation 3) Hyperglycemia 4) Diarrhea

ANS: 2 Because of its lack of fiber, a mechanical soft diet places the patient at risk for constipation. It does not place the patient at risk for dehydration, hyperglycemia, or diarrhea. PTS:1DIF:ModerateREF:p. 917 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

The nursing assistive personnel (NAP) informs the nurse that a patient has fallen out of bed and is in pain. The nurse assesses the patient and provides care. Identify the correct documentation of the fall. 1)Patient found on floor in pain after falling out of bed. 2)Patient found on floor after falling out of bed; found by NAP Smith. 3)Patient fell out of bed but is currently in bed. 4)Patient reminded to not climb OOB after falling.

ANS: 2 Charting must be accurate and succinct. Only chart what you observe. Do not chart what others have observed as your own observation. Avoid judging patients; instead, chart objectively.

The American Red Cross was established by 1)Louisa May Alcott 2)Clara Barton 3)Dorothea Dix 4)Harriet Tubman

ANS: 2 Clara Barton was an American teacher, nurse, and humanitarian who organized the American Red Cross after the Civil War. Louisa May Alcott was an American novelist who wrote Little Women in 1868. Dorothea Dix was an American activist who acted on behalf of the indigent population with mental illness. She was credited for establishing the first psychiatric institution. Harriet Tubman was an African American abolitionist and Union spy during the Civil War. After escaping captivity, she set up a network of antislavery activists, known as the Underground Railroad. PTS:1DIF:EasyREF:p. 10

The nurse works with the respiratory therapist to administer a patient's breathing treatments. He reports the patient's breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. This is an example of 1) Delegation 2) Collaboration 3) Coordination of care 4) Supervision of care

ANS: 2 Collaboration means working with other caregivers to plan, make decisions, and perform interventions. Delegation is the transfer to another person of the authority to perform a task in a selected situation. Coordination of care involves scheduling treatments and activities with other departments, putting together all the patient data to obtain the "big picture." Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity or task. PTS:1DIF:ModerateREF: pp. 122 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application

he nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone order for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order? 1)09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain. Kay Andrews, RN 2)09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews, RN 3)09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain V.O.: Dr. D. Kelly/Kay Andrews, RN 4)09/02/13 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RN

ANS: 2 Correct documentation of a telephone order is as follows: "09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews, RN" (date, time, medication, route, frequency of dose, circumstances under which it is to be given, prescriber's name and title, nurse's name and title.) The other options demonstrate incomplete documentation of a telephone order.

The nurse is developing a plan of care for a patient of Aleut descent who sustained a hip fracture. Which intervention by the nurse recognizes the patient's indigenous healthcare system and should be included in the plan of care? 1)Asking the family to bring in medals and amulets 2)Scheduling a visit from the shaman 3)Providing the patient with her favorite herbal tea 4)Requesting that the physician consult the patient's acupuncturist

ANS: 2 For the patient of Aleut descent, contacting the shaman and scheduling a visit with the patient might be helpful in recovery. Patients of Hispanic descent might benefit from herbal tea and medals and amulets brought in by the family. However, it is important to check with the physician before administering any herbal preparations that might interfere with prescribed medications. Asians and Pacific Islanders might benefit from a visit by the acupuncturist.

Which is one of the greatest concerns with heavy and chronic use of alcohol in teens and young adults? 1) Liver damage 2) Unintentional death 3) Tobacco use 4) Obesity

ANS: 2 Heavy and chronic use of alcohol and use of illicit drugs increase the risk of disease and injuries and intentional death (suicide and homicide). Although alcohol as a depressant slows metabolism, chronic alcohol use is more likely associated with poor nutrition, which may or may not lead to obesity. Chronic alcohol use causes damage to liver cells over time in the later years. Alcohol intake is often associated with tobacco and recreational drug use; however, the risk of unintentional injury, such as car accident, suicide, or violence, is more concerning than smoking. PTS:1DIF:EasyREF:p. 879 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension

What type of loss is most common among patients who are hospitalized for complex health conditions? 1) Privacy 2) Dignity 3) Functional 4) Identity

ANS: 2 Hospitalized patients commonly experience the loss of dignity. Wearing a hospital gown, having their body exposed, invasive procedures, loss of control over body functions—all of these contribute to loss of dignity, and all are very common among hospitalized patients. Healthcare providers have a duty to protect privacy and confidentiality of patients, even though it is certainly threatened by some situations during hospitalization. Some patients lose functioning and identity during hospitalization, but they are not common occurrences. PTS:1DIF:ModerateREF:p. 227 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension

A client arrives in the emergency department, pale and breathing rapidly. He immediately becomes unconscious and collapses to the floor. The nurse rapidly assesses the patient and decides the first series of actions that are needed. This scenario demonstrates 1) Formal planning 2) Informal planning 3) Ongoing planning 4) Initial planning

ANS: 2 Informal planning is performed while doing other nursing process steps and is not written; this nurse is forming a plan in her mind. The end product of formal planning is a holistic plan of care that addresses the patient's unique problems and strengths; this nurse has no time to create a holistic plan of care. Ongoing planning refers to changes made in the plan as you evaluate the patient's responses to care; no care has been given at this point. Initial planning does indeed begin with the first patient contact. However, it refers to the development of the initial comprehensive plan or care; this nurse does not have enough data for a comprehensive plan, nor does she have time to make such a plan at the moment. PTS:1DIF:EasyREF:p. 81 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

In which of the following circumstances might the nurse defer obtaining informed consent for care and treatment of a patient? 1)The patient is confused and cannot understand or sign the consent form. 2)The patient is brought to the emergency department in cardiac arrest; no family is present. 3)The surgeon requests that the patient be sent to the surgical suite before you get the consent form signed. 4)An unconscious patient is admitted to your unit; he is alone.

ANS: 2 Informed consent is the necessary authorization by the patient for any and all types of care and must be written and signed by the patient or the person legally responsible for the patient for hospital admission and for invasive or specialized treatments or diagnostic procedures. Written consent is not necessary in an emergency if experts agree that there was an immediate threat to life or health. The physician responsible for the care of the patient has the duty to obtain informed consent from the patient.

A client with a history of schizophrenia is diagnosed with a urinary tract infection. What is probably the most significant barrier this patient faces? 1) Chronic urinary incontinence 2) Stigma associated with mental illness 3) Risk for recurring infections 4) Auditory hallucinations ("hearing things")

ANS: 2 Mental illness is associated with a stigma that is usually a barrier, and even considered a debilitating handicap. Chronic urinary incontinence is not commonly associated with urinary tract infection, and nothing in the scenario suggests that the patient is incontinent. The patient is at risk for recurring urinary tract infections, but this is not considered a debilitating handicap. Auditory hallucinations are associated with schizophrenia but have not been described as the most debilitating handicap. PTS:1DIF:ModerateREF:p. 226 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Application

How is NOC different from the Omaha System? 1) NOC can be used to write health restoration outcomes. 2) NOC can be used in all specialty and practice areas. 3) NOC can be used for individuals, families, or groups. 4) NOC formulates goals based on nursing diagnoses.

ANS: 2 NOC was developed for all specialty and practice areas. The Omaha System was developed for community health nursing. Both address health restoration and can be used for individuals, family, or groups (community). Both base goals on nursing diagnoses, although Omaha does not use the NANDA-I taxonomy. PTS:1DIF:ModerateREF: p. 95; answer based on analysis of text discussion | V1, p. 98; answer based on analysis of text discussion KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

he surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM. Which action indicates that the nurse is following the surgeon's order? The nurse 1)Performs oral care 2)Assists the patient out of bed 3)Assists the patient with bathing 4)Changes the patient's operative dressings

ANS: 2 OOB is the abbreviation for "out of bed." The nurse is following the physician's order when she assists the patient out of bed in the morning. OOB does not indicate that the nurse should perform oral care, assist with bathing, or change the patient's postoperative dressings.

What is the purpose of completing an occurrence report? 1)Provide a legal defense should the patient seek legal action after an unusual occurrence 2)Track problems and identify areas for quality improvement 3)Report errors to the Food and Drug Administration 4)Report medical errors to the Joint Commission

ANS: 2 Occurrence reports are used to track problems and identify areas for quality improvement. Occurrence reports are not used to provide legal defense should a patient seek legal action or to report errors to the FDA or Joint Commission.

A middle-aged patient with a history of alcohol abuse is admitted with acute pancreatitis. This patient will most likely be deficient in which nutrients? 1) Iron 2) B vitamins 3) Calcium 4) Phosphorus

ANS: 2 Patients who regularly abuse alcohol may be deficient in many nutrients; however, they are commonly deficient in the B vitamins and folic acid. Vitamin A deficiency can be associated with night blindness in heavy drinkers; vitamin D deficiency leads to softening of the bones. Because some alcoholics are deficient in vitamins A, C, D, E, and K and the B vitamins, they experience delayed wound healing. In particular, because vitamin K, the vitamin needed for blood clotting, is commonly deficient in those who regularly abuse alcohol, those patients can have delayed clotting, resulting in excess bleeding. Deficiencies of other vitamins involved in brain function can cause severe neurological damage. PTS:1DIF:ModerateREF:p. 915 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

Many health providers define illness as pathology; however, people experience, rather than define, illness. Which of the following is how most people experience illness? 1) "Feeling lousy," a true sense of not being all right 2) A change in the way they feel or a disruption in their typical life 3) Something to be dreaded and avoided if at all possible 4) An experience that offers the potential for learning and spiritual growth

ANS: 2 People typically describe their illness in terms of how it makes them feel or the effect it has on day-to-day life. "Feeling lousy" is inappropriate as many people do not feel "lousy" when they are ill. For example, hypertension is an illness that may have no symptoms. Similarly, patients may have chronic disease that is well managed and therefore does not make them feel ill. "Something to be dreaded and avoided . . ." is also not accurate. If a person has an external locus of control, he may view illness as a consequence of actions taken. From this viewpoint, he may have little control over whether he can avoid illness. Finally, although some people do grow and learn in the face of illness, most people do not hold such a positive view about illness—and the question asks how people experience illness. PTS:1DIF:ModerateREF:p. 222 KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Recall

Which laboratory test result most accurately reflects a patient's nutritional status? 1) Albumin 2) Prealbumin 3) Transferrin 4) Hemoglobin

ANS: 2 Prealbumin levels fluctuate daily and give the best indication of the patient's immediate nutritional status. Albumin level is not as accurate because the half-life of albumin is 18 to 21 days, causing a delay in detection of nutritional problems. Transferrin, a protein that binds to iron, has a half-life of 8 to 9 days; therefore, it allows for faster detection of protein deficiency than does albumin. However, transferrin is not as fast as prealbumin. Hemoglobin level reflects iron intake or blood loss. PTS:1DIF:ModerateREF:p. 925 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall

Which of the following is considered a primary care service? 1)Providing wound care 2)Administering childhood immunizations 3)Providing drug rehabilitation 4)Outpatient hernia repair

ANS: 2 Primary care services focus on health promotion and disease prevention; administering childhood immunizations is one such service. Providing wound care and drug rehabilitation are examples of tertiary care services. Outpatient hernia repair surgery is an example of a secondary care service. PTS:1DIF:ModerateREF:ESG, Chapter 1, "Healthcare Delivery Systems—Expanded Discussion," "Categories of Healthcare?"

Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill? 1) Psychomotor 2) Interpersonal 3) Cognitive 4) Critical thinking

ANS: 2 Reassuring the client is an interpersonal skill. Inserting the nasogastric tube requires psychomotor skills. Checking catheter placement after insertion requires cognitive and psychomotor skills. Assessing whether there is an indication for the nasogastric tube requires critical thinking skills. PTS:1DIF:ModerateREF: p. 120 KEY: Nursing process: Implementation | Client need: PHI | Cognitive level: Comprehension

A mother of three young children is newly diagnosed with breast cancer. She is intensely committed to fighting the cancer. She believes she can control her cancer to some degree with a positive attitude and feelings of inner strength. Which of the following traits is she demonstrating that is linked to health and healing? 1) Invincibility 2) Hardiness 3) Baseline strength 4) Vulnerability

ANS: 2 Research has also demonstrated that in the face of difficult life events, some people develop hardiness rather than vulnerability. Hardiness is a quality in which an individual experiences high levels of stress yet does not fall ill. There are three general characteristics of the hardy person: control (belief in the ability to control the experience), commitment (feeling deeply involved in the activity producing stress), and challenge (the ability to view the change as a challenge to grow). These traits are associated with a strong resistance to negative feelings that occur under adverse circumstances. PTS:1DIF:ModerateREF:p. 887 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Application

The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient is obese. The nurse has been overweight at one time and works very hard now to maintain a healthy weight. She immediately thinks, "I know I tend to feel negatively about obese people; I figure if I can stop eating, they should be able to. I must remember how very difficult that is and be very careful not to be judgmental of this patient." This best illustrates 1)Theoretical knowledge 2)Self-knowledge 3)Using reliable resources 4)Use of the nursing process

ANS: 2 Self-knowledge is self-understanding—awareness of one's beliefs, values, biases, and so on. That best describes the nurse's awareness that her bias can affect her patient care. Theoretical knowledge consists of information, facts, principles, and theories in nursing and related disciplines; it consists of research findings and rationally constructed explanations of phenomena. Using reliable resources is a critical thinking skill. The nursing process is a problem-solving process consisting of the steps of assessing, diagnosing, planning outcomes, planning interventions, implementing, and evaluating. The nurse has not yet met this patient, so she could not have begun the nursing process.

When preparing a room to receive a newly admitted patient, which of the following should the nursing assistive personnel (NAP) do? 1) Mop the floor with an approved disinfecting solution. 2) Fold the top bed linens back to "open" the bed. 3) Hook up the suction machine and check to see that it is working. 4) Position the bed in its lowest position.

ANS: 2 The NAP should create an "open" bed. The housekeeping department is almost always responsible for cleaning the room between patients. The nurse is responsible for hooking up and checking special equipment such as suction. The nurse would need to tell the NAP whether the patient is to be admitted ambulatory, by wheelchair, or by stretcher to know whether to position the bed high or low. PTS:1DIF:ModerateREF:p. 233 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

Patients may be deficient in which vitamin during the winter months? 1) A 2) D 3) E 4) K

ANS: 2 The body can synthesize vitamin D from a cholesterol compound in the skin when exposed to adequate sunlight. People at risk for vitamin D deficiency are those who spend little time outdoors, older people, and people who live in an institution (e.g., a nursing home). The deficiency can also occur in the winter at northern and southern latitudes, in people who keep their bodies covered (e.g., traditional Muslim women), and in those who use sunscreen. Also, because breast milk contains only small amounts of vitamin D, breastfed infants who are not exposed to enough sunlight are at risk of the deficiency and rickets. There is no seasonal tie to deficiencies in the other fat-soluble vitamins, A, E, and K. PTS: 1 DIF: Easy REF: p. 905 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall

Which of the following best explains why it is difficult for the profession to develop a definition of nursing? 1)There are too many different and conflicting images of nurses. 2)There are constant changes in healthcare and the activities of nurses. 3)There is disagreement among the different nursing organizations. 4)There are different education pathways and levels of practice.

ANS: 2 The conflicting images of nursing make it more important to develop a definition; they may also make it more difficult, but not to the extent that constant change does. Healthcare is constantly changing and with it come changes in where, how, and what nursing care is delivered. Constant changes make it difficult to develop a definition. Although different nursing organizations have different definitions, they are similar in most ways. The different education pathways affect entry into practice, not the definition of nursing. PTS: 1 DIF: Moderate REF: p. 11; "How Is Nursing Defined?"

The nursing diagnosis is Impaired Memory related to fluid and electrolyte imbalances A.M.B. inability to recall recent events. Which of the following goals/outcomes must be included on the care plan? 1) Checks current medications for mind-altering side effects 2) Demonstrates use of techniques to help with memory loss 3) Drinks at least 1500 cc of fluid per day 4) Takes electrolyte supplements with meals

ANS: 2 The essential goal/outcome is aimed at the problem response Impaired Memory. The other goals in this question address the etiology. PTS:1DIF:ModerateREF: p. 93-94 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. She has made sure that nursing assistive personnel change the patient's position every 2 hours. In the evaluation phase of the nursing process, which of the following would the nurse do first? 1)Determine whether she has gathered enough assessment data. 2)Judge whether the interventions achieved the stated outcomes. 3)Follow up to verify that care for the nursing diagnosis was given. 4)Decide whether the nursing diagnosis was accurate for the patient's condition.

ANS: 2 The evaluation phase judges whether the interventions were effective in achieving the desired outcomes and helped to alleviate the nursing diagnosis. This must be done before examining the nursing process steps and revising the care plan.

Which statement best describes the health/illness continuum? 1) Health is the absence of disease; illness is the presence of disease. 2) Health and illness are along a continuum that cannot be divided. 3) Health is remission of disease; illness is exacerbation of disease. 4) Health is not having illness; illness is not having health.

ANS: 2 The health/illness continuum is best described as a graduated spectrum that cannot be divided. PTS:1DIF:ModerateREF:p. 223 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension

How can the nurse best provide teaching for a patient whose primary spoken language is not the same as hers? 1)Provide written materials in the patient's primary language. 2)Make arrangements to teach using an interpreter. 3)Provide a demonstration and request a return demonstration. 4)Use visual teaching aids to convey information.

ANS: 2 The nurse can best provide teaching for the patient whose primary spoken language is not the same as her own by requesting the aid of an interpreter. An interpreter can help the nurse to communicate clearly and accurately when assessing learning needs; dispersing the information; providing feedback to learners; and determining if teaching is effective. An interpreter also allows the patient to ask questions when necessary and the healthcare provider to respond with meaningful information. Written materials in the patient's primary language can help reinforce teaching. Demonstrating and requesting a return demonstration may be difficult if the patient does not understand the spoken language of the nurse. Visual aids may also be helpful for some learners, but they should not be the primary method for teaching because they do not offer an opportunity for the exchange of information through questions, demonstration, or discussion. PTS: 1 DIF: Moderate REF: p. 862

Which statement about the nursing process is correct? 1)It was developed from the ANA Standards of Care. 2)It is a problem-solving method to guide nursing activities. 3)It is a linear process with separate, distinct steps. 4)It involves care that only the nurse will give.

ANS: 2 The nursing process is a problem-solving process that guides nursing actions. The ANA organizes its Standards of Care around the nursing process, but the process was not developed from the standards. The nursing process is cyclical and involves care the nurses give or delegate to other members of the healthcare team.

A client is admitted to the hospital with an acute episode of chronic obstructive pulmonary (lung) disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations and has recorded the diagnosis and appropriate goals on the care plan. When selecting nursing interventions, what should the nurse do first? 1) Identify several interventions likely to achieve the desired outcomes. 2) Review the problem and etiology of the nursing diagnosis. 3) Choose the best interventions for the patient. 4) Review the goals she has written.

ANS: 2 The process of choosing interventions is review the nursing diagnosis, review the desired outcomes, identify several interventions or actions, choose the best interventions for the patient, and then individualize standardized interventions to meet the patient's unique needs. PTS:1DIF:ModerateREF: p. 106-107 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

For which patient is the nursing diagnosis Deficient Knowledge most appropriate? 1)Adolescent with Down syndrome and newly diagnosed with cardiac problem 2)Young adult admitted with acute renal failure who requires hemodialysis 3)Middle-aged woman with breast cancer receiving the last round of chemotherapy 4)Older adult with a long-standing history of type 1 diabetes admitted with a foot ulcer

ANS: 2 The young adult patient admitted with acute renal failure who needs hemodialysis will probably have Deficient Knowledge related to his treatment regimen. Patients with chronic illness, such as diabetes or cancer, are most likely to be knowledgeable about the disease and course of treatment; therefore, the nursing diagnosis Deficient Knowledge is less relevant than it is to a patient who is newly diagnosed. The adolescent patient with Down syndrome would have a nursing diagnosis of Impaired Ability to Learn. PTS:1DIFgrinifficultREF:pp. 864-865

A young adult with a severe episode of asthma bronchoconstriction comes to the emergency department with signs of respiratory distress. When the nurse performs the admission assessment, she notes that the patient is not able to say where she is or the time. Which nursing diagnosis is probably most suitable for this patient? 1) Chronic Confusion 2) Acute Confusion 3) Impaired Verbal Communication 4) Readiness for Enhanced Communication

ANS: 2 This patient is experiencing Acute Confusion caused by lack of oxygen related to his respiratory distress. As a young adult with an acute episode of asthma, this patient would not likely have a history of confusion; therefore, without more data, Chronic Confusion is not an appropriate diagnosis for this patient. Impaired Verbal Communication is an appropriate diagnosis for the patient with expressive or receptive aphasia, but not with confusion. Readiness for Enhanced Communication is appropriate when the patient expresses willingness to enhance communication. PTS:1DIFgrinifficultREF:p. 474 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis

Which of the following is particularly valuable in helping a patient with a terminal illness maintain a sense of self? 1) Family relationships 2) Spirituality 3) Nutrition 4) Sleep and rest

ANS: 2 When a patient is faced with a terminal illness, spirituality can help the patient maintain his sense of self. Family relationships can provide a loving, supportive source of comfort and reassurance but can sometimes cause the patient pain and a feeling of loneliness when faced with a terminal illness. Nutrition, sleep, and rest are healing but usually not as helpful to a patient with terminal illness as is spirituality. PTS:1DIFgrinifficultREF:p. 226 KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Recall

A resident in a long-term care facility receiving Medicare funds requires care for a stage 2 pressure ulcer. How often must the nurse document this patient's care? 1)Every 2 weeks 2)Every shift 3)Every week 4)Every 3 months

ANS: 2 When a patient requires Medicare-reimbursed services, such as wound care, documentation is required every shift. Those who require assistance with medications, nutrition, and activities of daily living must have a summary written by a registered nurse or licensed practical nurse every 2 weeks. A summary must also be recorded on a weekly basis for those who require wound care. The Minimum Data Set must be updated every 3 months.

_ 12. Nursing codes are: 1) Legally binding. 2) Not legally binding. 3) Legally binding in some circumstances. 4) Not admissible in court.

ANS: 2 Not legally binding. Codes of ethics are open to public scrutiny. The ethical aspects of nursing work, just like the technical aspects, are subject to review by professional groups and licensure boards, which may use sanctions to punish code violations. However, nursing codes are not legally binding.

13. An alert, oriented, and competent frail older adult man has been told that he is dying and has asked to have a DNAR order put on his chart. The patients family does not agree with his decision and asks the healthcare team to ignore the request. After a great deal of discussion among the physician, nurse, and family, they are no closer to resolution of the conflict. The nurse asks the hospital chaplain to come and help the family and the team understand each others opposing views. Which step of the MORAL model does this illustrate? 1) MMassage the dilemma 2) OOutline the options 3) RResolve the dilemma 4) LLook back and evaluate

ANS: 2 OOutline the options This illustrates the Outlining-options step. In Massaging the dilemma, the team would already have identified and defined the issues in the dilemma, and considered the values and options of all the major players. At the Outlining the options step, someone should delineate all of the options to all parties, including those that are less realistic and conflicting. In that step, someone often asks a member of the ethics committee or the hospital chaplain to help the parties understand the opposing viewpoints. Resolving the dilemma is the step in which all the options are reviewed and basic moral principles and frameworks are applied to arrive at a decision. Looking back to evaluate is done after a decision has been made and acted on. At that time, the entire process, including the consequences, is evaluated to determine how well it worked.

8. Identify the third step in the MORAL decision-making model. 1) Reassess the dilemma 2) Resolve the dilemma 3) Review the problem 4) Recall the history of the problem

ANS: 2 Resolve the dilemma MORAL is an acronym for the following steps: M, Massage the dilemma; O, Outline the options; R, Resolve the dilemma; A, Act by applying the chosen option; L, Look back and evaluate.

6. Which of the following consequentialist theories takes the position that the value of an action is determined by its usefulness? 1) Ethics of care 2) Utilitarianism 3) Deontology 4) Categorical imperative

ANS: 2 Utilitarianism Utilitarianism is a consequentialist theory that takes the position that the value of an action is determined by its usefulness. An ethics of care is a nursing philosophy that directs attention to the specific situations of individual patients viewed within the context of their life narrative. Deontology considers an action to be right or wrong independent of its consequences. A categorical imperative is a principle, established by Immanuel Kant, that states that one should act only if the action is based on a principle that is universal.

A patient has a nursing diagnosis of "Noncompliance with medication regimen related to a belief that God will heal her and that it would show a lack of faith to take the medications." The nurse and a clergyman have spent some time discussing spiritual and treatment issues with the patient. Which of the following would indicate that progress is being made toward achieving compliance with healthcare therapy? (Choose all that apply.) The patient says 1) "I will try to pray more often for stronger faith that God will heal me." 2) "Let me think about it until tomorrow; I may see my way to taking those pills then." 3) "You know, I've known some very holy people who were not cured by God." 4) "There is no confusion in my mind as to the right thing for me to do."

ANS: 2, 3 Agreeing to consider treatment ("think about it") and recognizing that sometimes faithful people are not cured both suggest that the patient is at least considering that it is all right for her to question her beliefs. Praying for stronger faith in God's healing suggests that she is holding strong in her belief that she will be healed if she only has enough faith. Having "no confusion" about the right thing to do would be evidence of problem resolution, provided the "right thing" to do is to take the medication. However, you need more information to know if that is what the patient means. It could just as easily mean that she is more sure than ever that she should not take the medication. PTS:1DIFgrinifficultREF:pp. 346-349; answer not stated in text; student must infer answer from question content KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application

Where in the body is glucose stored? Choose all that apply. 1) Brain 2) Liver 3) Skeletal muscles 4) Smooth muscles

ANS: 2, 3 Human beings store glucose in liver and skeletal muscle tissue as glycogen. Glycogen is converted back into glucose to meet energy needs. PTS:1DIF:ModerateREF:p. 902 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall

The nurse is caring for a patient of Japanese heritage who refuses pain medication despite the nurse's explaining its importance in the healing process. Which intervention(s) by the nurse is/are appropriate for this patient? Select all that apply. 1)Assess the patient's pain levels at less frequent intervals. 2)Document in the patient's record that the patient does not want to take opioids. 3)Utilize nonpharmacological measures to help control the patient's pain. 4)Notify the primary care provider of the patient's noncompliance.

ANS: 2, 3 Patients of Japanese heritage commonly avoid opioid use; however, they sometimes reconsider after healthcare personnel explain that they improve the healing process. When the patient continues to refuse pain medications despite explanation, the nurse should respect the patient's wishes and utilize nonpharmacological measures to control pain. The nurse should document that the patient wishes to avoid opioid use in the nurses' notes. The nurse should continue to assess pain levels in this patient at the same frequency as before. She should recognize and respect his cultural beliefs and not label him as noncompliant. Note that the same intervention would be appropriate for any patient in this situation, not just a Japanese patient.

Which of the following suggest that a family health problem may exist? Select all that apply. Family members 1) Respect each other's need for privacy 2) Enact decisions made by the most powerful member 3) Do not consider a conflict resolved until everyone agrees 4) Set boundaries between family members

ANS: 2, 3 Respect for privacy and clear boundaries between family members are characteristics of a healthy family. Boundaries define the responsibilities of adults that are clear and separate from responsibilities of growing children. In healthy families, there is typically egalitarian distribution of power. In healthy families, it is not always necessary for all members to agree; instead, they have the ability to compromise and members feel free to disagree. PTS: 1 DIF: Moderate REF: p. 310 KEY: Nursing process: Analysis/nursing diagnosis | Client need: PSI | Cognitive level: Analysis

The World Health Organization's definition of health includes which of the following? Choose all that apply. 1) Absence of disease 2) Physical well-being 3) Mental well-being 4) Social well-being

ANS: 2, 3, 4 The World Health Organization defines health as a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity. PTS:1DIF:EasyREF:p. 878 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall

Which of the following are cues? Select all that apply. 1) Taking a brisk walk five times a week 2) Using laxatives to have a bowel movement 3) Needing more sleep than usual 4) Decreasing the amount of fat in the diet 5) Weighing less than indicated by developmental norms

ANS: 2, 3, 5

A patient comes to the urgent care clinic because he stepped on a rusty nail. What type of assessment would the nurse perform? 1) Comprehensive 2) Ongoing 3) Initial focused 4) Special needs

ANS: 3

Nondirective interviewing is a useful technique because it 1) Allows the nurse to have control of the interview 2) Is an efficient way to interview a patient 3) Facilitates open communication 4) Helps focus patients who are anxious

ANS: 3

The patient shows the necessary defining characteristics, and the nurse has diagnosed Decisional Conflict related to unclear personal values and beliefs. What essential action should the nurse take to help ensure the accuracy of this diagnosis? 1) Ask a more experienced nurse to confirm it. 2) Have a social worker interview the patient. 3) Ask the patient to confirm the diagnosis. 4) Read about Decisional Conflict in the NANDA-I handbook.

ANS: 3

Which nursing diagnosis is written in the correct format when using the NANDA-I taxonomy? 1) Bowel Obstruction related to recent abdominal surgery A.M.B. nausea, vomiting, and abdominal pain 2) Inability to Ingest Food related to imbalanced nutrition: less than body requirements A.M.B. inadequate food intake, weight less than 20% under ideal body weight 3) Impaired Skin Integrity related to physical immobility A.M.B. skin tear over sacral area 4) Caregiver Role Strain related to alienation from family and friends A.M.B 24-hour care responsibilities

ANS: 3

Which nursing diagnosis is written in the correct format? 1) Imbalanced Nutrition: Less than Body Requirements related to body weight less than 20% under ideal weight 2) Ineffective Airway Clearance related to increased respiratory rate and irregular rhythm 3) Impaired Swallowing related to absent gag reflex 4) Excess Fluid Volume related to 3 lb weight gain in 24 hours

ANS: 3

Which of the following is an example of an active listening behavior? 1) Taking frequent notes 2) Asking for more details 3) Leaning toward the patient 4) Sitting with legs crossed

ANS: 3

Which of the following is an example of an open-ended question? 1)Have you had surgery before? 2)When was your last menstrual period? 3)What happens when you have a headache? 4)Do you have a family history of heart disease?

ANS: 3

Which of the following is the best approach to validate a clinical inference? 1) Have another nurse evaluate it. 2) Have the physician evaluate it. 3) Have sufficient supportive data. 4) Have the client's family confirm it.

ANS: 3

Which of the following most accurately describes nursing diagnoses? A nursing diagnosis 1) Supports the nurse's diagnostic reasoning 2) Supports the client's medical diagnosis 3) Identifies a client's response to a health problem 4) Identifies a client's health problem

ANS: 3

Which situation is the most conducive to conducting a successful interview of an elderly woman whose husband and two children are in the hospital room visiting and watching television? The woman is alert and oriented. 1) Provide enough chairs so the family and you are able to sit facing the client. 2) Introduce yourself and ask, "Dear, what name do you prefer to go by?" before asking any questions. 3) After the family leaves, ask the client if she is comfortable and willing to answer a few questions. 4) Ask the client if you can talk with her while her family is watching the television.

ANS: 3

A patient who underwent surgery 24 hours ago is prescribed a clear liquid diet. The patient asks for something to drink. Which item may the nurse provide for the patient? 1) Tea with cream 2) Orange juice 3) Gelatin 4) Skim milk

ANS: 3 A clear liquid diet consists of water; tea (without cream); coffee; broth; clear juices, such as apple, grape, or cranberry; popsicles; carbonated beverages; and gelatin. Skim milk, tea with cream, and orange juice are included in a full liquid diet. PTS:1DIF:EasyREF:p. 917 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

which of the following is a disadvantage of paper health records? 1)Assist collaboration 2)Provide cautionary reminders 3)Are sometimes illegible 4)Serve as a resource

ANS: 3 A disadvantage of paper documentation systems is that they are sometimes illegible. This increases the risk for medication administration and other errors, as well as taking nurses' time to decipher handwriting and call providers.

A registered nurse forgot to put the side rails up for a confused patient. The patient fell out of bed and fractured his hip. The patient sues and wins a judgment (award) for $2 million. The nurse has an occurrence policy with double limit coverage of $3 million/$10 million that covered the time period when the incident occurred. The statement that best describes the nurse's situation is that her insurance policy will: 1)Not cover her. 2)Pay $4 million. 3)Pay $2 million. 4)Pay 75% of the $2 million

ANS: 3 An occurrence policy will cover those claims that occurred during the time the policy was in effect. However, the policy will pay up to $3 million per claim; because the amount awarded does not exceed this, the nurse is covered.

An older adult patient who underwent bowel resection is recovering from surgery without complication. He ambulates in the hallway and requires little analgesia for pain. During the healthcare team's morning rounds, the surgeon informs the patient that the lesion removed was cancerous. Which factor will likely be the patient's most significant obstacle for learning? 1)The patient's baseline physical condition 2)A negative environmental influence 3)Anxiety associated with the new diagnosis 4)Reduced ability to understand the diagnosis

ANS: 3 Anxiety associated with the new diagnosis of cancer will most likely be a barrier to learning in this patient. Fear of the unknown, fear of pain, fear of physical discomfort with treatment options, fear of altered role in home or work life, and many other fears accompany the anxiety patients often experience when potentially life-threatening diagnoses are communicated. The patient has been ambulating and requiring minimal amount of pain medication; therefore, his physical condition is probably not the most significant barrier to learning. Simply because the patient is an older adult does not suggest he has reduced capacity to learn. PTS: 1 DIF: Difficult REF: pp. 857-858

During the day shift, a patient's temperature measures 97°F (36.1°C) orally. At 2000, the patient's temperature measures 102°F (38.9°C). What effect does this rise in temperature have on the patient's basal metabolic rate? 1) Increases the rate by 7% 2) Decreases the rate by 14% 3) Increases the rate by 35% 4) Decreases the rate by 28%

ANS: 3 Basal metabolic rate increases 7% for each degree Fahrenheit (0.56°C); therefore, this patient's temperature rise is an increase of 35%. PTS:1DIFgrinifficultREF:p. 910 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

A patient's 2:1 parenteral nutrition container infuses before the pharmacy prepares the next container. This places the patient at risk for which complication? 1) Sepsis 2) Pneumothorax 3) Hypoglycemia 4) Thrombophlebitis

ANS: 3 Because of the high glucose content of 2:1 parenteral nutrition, any interruption in therapy places the patient at risk for hypoglycemia. A PN of this type should not be discontinued abruptly, but rather over several (as many as 48) hours to prevent a sudden drop in blood sugar. Hypoglycemia is unlikely to occur with a 3:1 solution (containing lipids), as the final concentration of glucose is less than 10%. Sepsis is a complication that can occur if a break in aseptic technique occurs during therapy. Pneumothorax can occur as a result of central venous catheter insertion. Central venous catheters are typically employed for parenteral nutrition. Thrombophlebitis is a complication of central venous catheter use. PTS: 1 DIF: Difficult REF: pp. 959-960 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

How are critical pathways and standardized nursing care plans similar? Both 1) Specify daily, or even hourly, outcomes and interventions 2) Prescribe minimal care needed to meet recommended lengths of stay 3) Describe care common to all patients with a certain condition or situation 4) Emphasize medical problems and interventions

ANS: 3 Both critical pathways and standardized care plans are preplanned documents; they describe care common to all patients who have a certain condition (e.g., all patients who have a heart attack need some of the same interventions). The other statements are true of critical pathways but not of standardized nursing care plans. PTS:1DIFgrinifficultREF: pp. 86-87; high-level question, answer not given verbatim KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP) about delegating a task? 1) "Record how much the patient drinks today, please." 2) "Take the patient's vital signs every 2 hours today." 3) "Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C)." 4) "Assist the patient with all of her meals."

ANS: 3 Clear communication about a task (such as "Take the patient's temperature . . . ") tells the NAP exactly what the task is, the specific time it needs to be done, and the method for reporting the results to the registered nurse. The other options are vague and leave room for misinterpretation. PTS:1DIF:ModerateREF:p. 124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis

Which of the following is the most important reason for nurses to be critical thinkers? 1)Nurses need to follow policies and procedures. 2)Nurses work with other healthcare team members. 3)Nurses care for clients who have multiple health problems. 4)Nurses have to be flexible and work variable schedules.

ANS: 3 Critical thinking is essential for client care, particularly when the care is complex, involving numerous health issues. Following policies and procedures does not necessarily require critical thinking, and working with others or being flexible and working different schedules do not necessarily require critical thinking.

A client newly diagnosed with diabetes is admitted to the hospital because her diabetes is out of control. Which of the following is an appropriate direct-care intervention for this client during her stay? 1) Consulting the diabetic nurse educator for help with a teaching plan 2) Making arrangements for the client to join a diabetic support group 3) Demonstrating blood glucose monitoring and insulin administration to the client 4) Consulting with the dietician about the client's dietary concerns

ANS: 3 Demonstrating blood glucose monitoring and insulin administration is an appropriate direct-care intervention for this client. Direct-care interventions are performed through intervention with the client and include interventions such as physical care, emotional support, and client teaching. Indirect-care activities include consulting the diabetic nurse educator, making arrangements for the client to join a diabetic support group, and consulting with the dietitian about the client's dietary concerns. Indirect-care activities are performed away from but on behalf of the client. PTS:1DIF:ModerateREF:p. 103 KEY: Nursing process: Interventions | Client need: Physiological integrity | Cognitive level: Application

You are caring for an alert, oriented 47-year-old patient who is recovering from abdominal surgery. The patient becomes angry and upset and says, "I'm leaving this hospital. Remove my IV and surgical drains or I will do it myself." In order to keep him from removing his lines and leaving the hospital, you apply bilateral wrist restraints until you can contact the physician for an order for patient restraint. This is an example of which of the following? 1)Assault and battery 2)Felony 3)False imprisonment 4)Quasi-intentional tort

ANS: 3 False imprisonment involves an intentional or willful detention of a patient without consent or authority to do so. Restraining a patient without consent is another form of civil false imprisonment. Competent patients have a right to leave an institution, even if it is harmful to their health. Whenever possible, have the person sign a form stating that he is aware that he is leaving against medical advice.

The nurse is planning care for a patient. She is using a standardized care plan for Impaired Walking related to left-side weakness. Which of the following activities will the nurse perform when individualizing the plan for the patient? 1) Validate conflicting data with the patient. 2) Transcribe medical orders. 3) State the frequency for ambulation. 4) Perform a comprehensive assessment.

ANS: 3 Individualizing the care plan means identifying specific problems, outcomes, and interventions and the frequency of those interventions to meet the patient's needs. Validating data ensures your assessment is accurate. Transcribing orders is a part of developing and implementing the care plan but not of individualizing the plan. Performing an assessment is the beginning step to developing a care plan. Assessment helps you to know the ways in which a standardized plan needs to be individualized. PTS:1DIF:ModerateREF: p. 90 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

The nurse is teaching a clinic patient about hypertension. Which statement by the patient suggests that he is present oriented? 1)"I know I need to lose weight; I'll have to begin an exercise program right away." 2)"If I change my diet and begin exercising, maybe I can control my blood pressure without medications." 3)"I know I need to give up foods that contain a lot of salt, but with teenagers in the house it is very difficult." 4)"I will reduce the amount of calories, salt, and fat that I eat; I certainly do not want to have a stroke."

ANS: 3 Knowing an action is needed but giving reasons for not beginning it "just now" shows a focus on the present. The patient knows that he should reduce his sodium intake, but his present situation is preventing him from doing so. Therefore, he is disregarding the impact consuming sodium might have on his future. The other responses are future oriented because they indicate that the patient is planning lifestyle changes that will affect his future

The charge nurse in a progressive care unit assigns the care of a patient receiving hemodialysis to a newly hired licensed practical nurse (LPN) without checking to see that the nurse has been determined competent to care for hemodialysis patients. The LPN is in orientation and fails to inform the charge nurse that she does not have experience with this type of patient. The actions of the charge nurse would be considered to be which of the following? 1)Malpractice 2)Incompetence 3)Negligence 4)Abandonment

ANS: 3 Negligence is the failure to use ordinary or reasonable care or the failure to act in a reasonable and prudent (careful) manner. It is negligent to assign a nurse to care for a patient without verifying the nurse has training, experience, and clinical competence in caring for such patients.

The nurse is asking the patient reflective, clarifying questions to help the patient make a list of what is important and not important in life and the time commitment for each. Which standardized (NIC) nursing intervention does this action implement? 1) Spiritual Support 2) Self-Esteem Enhancement 3) Values Clarification 4) Hope Inspiration

ANS: 3 One of the steps of most values-clarification processes is to list values (what is important and not important in one's life) and the time commitment for each. The nurse facilitates this by asking reflective, clarifying questions of the patient. Values clarification does not necessarily directly enhance self-esteem, inspire hope, or provide spiritual support, although it can indirectly contribute to development of spiritual identity. PTS: 1 DIF: Moderate REF: ESG, Chapter 16, "Standardized Language," Table " Standardized Language: Using Selected NIC Interventions and Activities to Support Spirituality" KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

Which of the following is the best example of an outcome statement? The patient will 1) Use the incentive spirometer when awake 2) Walk two times during day and evening shifts 3) Maintain oxygen saturation above 92% while performing ADLs each morning 4) Tolerate 10 sets of range-of-motion exercises with physical therapy

ANS: 3 Outcome statements should have specific performance criteria and a target time; "maintain oxygen saturation" is the only one that meets those criteria. The incentive spirometer goal should say how many times the incentive spirometer should be used each hour as well as the volume. The walking goal should state how far the patient should walk. In the range-of-motion goal, tolerate is a vague word and is difficult to measure, and the outcome needs to specify how often. PTS:1DIF:ModerateREF: p. 91-92 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

A client who cannot manage a patient-controlled analgesia pump is prescribed morphine 4 mg intravenously q 1 hour PRN pain. When should the nurse administer the medication? 1)Every hour around-the-clock 2)Immediately after taking off the order 3)As needed, but not more than once per hour 4)1 hour after the last administered dose

ANS: 3 PRN is the abbreviation for "as needed." The nurse should administer the medication after assessing that the patient needs the medication or the patient requests it and at least 1 hour has elapsed since the last dose. STAT medications must be administered immediately.

Which nutritional goal is appropriate for a patient newly diagnosed with hypertension? The patient will: 1) Limit his intake of protein. 2) Avoid foods containing gluten. 3) Restrict his use of sodium. 4) Limit his intake of potassium-rich foods.

ANS: 3 Patients with hypertension should limit their intake of sodium. Those with liver disease should control their protein intake. Patients with renal disease must limit their intake of potassium-rich foods. Patients with celiac disease should avoid foods containing gluten. PTS: 1 DIF: Easy REF: p. 917 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

Which phrase is stated as a teaching goal (as compared with an objective) for a patient who had bowel resection with creation of a colostomy? The patient 1)empties the colostomy appliance when half filled. 2)performs skin care around the stoma site. 3)will perform ostomy self-care within 3 days after surgery. 4)applies a new ostomy appliance, making sure it adheres properly.

ANS: 3 Performing ostomy self-care is an appropriate goal for a patient who needs to learn colostomy self-care after surgery. Emptying the colostomy appliance demonstrates a behavioral learning objective, not a broad teaching goal. Performing skin care is also a desired skill stated by a learning objective. Applying an ostomy device is another observable learning objective. PTS:1DIFgrinifficultREF:p. 866

Which of the following is an example of practical knowledge? (Assume all are true.) 1)The tricuspid valve is between the right atrium and ventricle of the heart. 2)The pancreas does not produce enough insulin in type 1 diabetes. 3)When assessing the abdomen, you should auscultate before palpating. 4)Research shows pain medication given intravenously acts faster than by other routes.

ANS: 3 Practical knowledge is knowing what to do and how to do it, such as how to do an assessment. The others are examples of theoretical knowledge, anatomy (tricuspid valve), fact (type 1 diabetes), and research (IV pain medication).

Which type of managed care allows patients the greatest choice of providers, medications, and medical devices? 1)Health maintenance organization 2)Integrated delivery network 3)Preferred provider organization 4)Employment-based private insurance

ANS: 3 Preferred provider organizations are a form of managed care that allows the patient a greater choice of providers, medications, and medical devices within the designated list. Health maintenance organizations allow the patient to choose a primary care provider within the organization to coordinate his care. This type of program will only reimburse medical care when the patient has first obtained a referral from the primary provider. Integrated delivery networks combine providers, healthcare facilities, pharmaceuticals, and services into one system, and the patient must remain within the system to receive care. Employment-based private insurance is not a managed care organization. PTS:1DIF:EasyREF:ESG, Chapter 1, "Healthcare Delivery Systems, Expanded Discussion," "How Do Healthcare Policy and Reform Efforts Affect Care?"

A 55-year-old man suffered a myocardial infarction (heart attack) 3 months ago. During his hospitalization, he had stents inserted in two sites in the coronary arteries. He was also placed on a cholesterol-lowering agent and two antihypertensives. What type of care is he receiving? 1) Primary prevention 2) Secondary prevention 3) Tertiary prevention 4) Health promotion

ANS: 3 Primary prevention activities are designed to prevent or slow the onset of disease. Activities such as eating healthy foods, exercising, wearing sunscreen, obeying seat-belt laws, and getting immunizations are examples of primary-level interventions. Secondary prevention activities detect illness so it can be treated in the early stages. Tertiary prevention focuses on stopping the disease from progressing and returning the individual to the pre-illness phase. The patient has an established disease and is receiving care to stop the disease from progressing. PTS:1DIFgrinifficultREF:p. 879 KEY:Nursing process: Planning | Client need: PSI | Cognitive level: Application

Which factor is related to the increased risk of acquiring polio in the United States after the disease was thought to be eradicated? 1) Lack of health insurance 2) Bioterrorism 3) Reduced compliance with vaccinations 4) Drug resistance

ANS: 3 Reduced compliance with community immunization in the United States increases the risk for diseases, such as polio, that were thought to be eradicated. For vaccines to be effective, the population needs to receive them. Bioterrorism involves the introduction of a highly infectious microbe for which there is no protection to the population. Polio is not such a threat because immunization is available. Vaccinations are available through governmental programs for those who do not have health insurance. Drug resistance has led to the reemergence of tuberculosis, which was previously cured with antibiotics. PTS:1DIF:EasyREF:p. 306 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension

While addressing a community group, the nurse explains the importance of replacing saturated fats in the diet with mono- and polyunsaturated fats. She emphasizes that doing so greatly reduces the risk of which complication? 1) Kidney failure 2) Liver failure 3) Stroke 4) Lung cancer

ANS: 3 Replacing saturated fats in the diet with mono- and polyunsaturated fats reduces the risk of heart disease, atherosclerosis, and stroke, not kidney failure, liver failure, or lung cancer. PTS:1DIF:ModerateREF:p. 903 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application

Which of the following is an example of self-knowledge? The nurse thinks, "I know that I 1)Should take the client's apical pulse for 1 minute before giving digoxin" 2)Should follow the client's wishes even though it is not what I would want" 3)Have religious beliefs that may make it difficult to take care of some clients" 4)Need to honor the client's request not to discuss his health concern with the family"

ANS: 3 Self-knowledge is being aware of your religious and cultural beliefs and values. Taking the pulse is an example of practical knowledge. Following client wishes and honoring client requests are examples of ethical knowledge.

Which of the following provides evidence-based support for the contribution that advanced practice nurses (APNs) make within healthcare? 1)Reduced usage of diagnostics using advanced technology 2)Decreased number of unnecessary visits to the emergency department 3)Improved patient compliance with prescribed treatments 4)Increased usage of complementary alternative therapies

ANS: 3 Studies demonstrate that APNs have improved patient outcomes over those of physicians, including increased patient understanding and cooperation with treatments and decreased need for hospitalizations. No well-known, scientific studies support APNs' effect on the use of advanced technology. No well-known, scientific studies support APNs' effect on the frequency of emergency department visits. No well-known, scientific studies support APNs' effect on the use of alternative therapies. PTS:1DIF:ModerateREF:p. 20

It is a busy day on the medical-surgical floor, and the nurse must teach a patient ready for discharge about his medications. How can the nurse most efficiently utilize her time and provide this education? 1)Write down instructions so the patient can read them at home. 2)Discuss the information while assisting the patient with his bath. 3)Educate the patient about his medications as each one is given. 4)Follow up with the patient after discharge with a phone call.

ANS: 3 Teaching does not have to be performed in a formal session but is often most effective at a teachable moment when the information is perceived as most relevant, such as at the time the medication is given to the patient. Additionally, the information is more memorable when the patient can see the actual dose and identify it with the information presented. A teaching session about wound care would be appropriate during bathing but not medication teaching. Providing the patient written instructions without discussing the information does not allow the patient an opportunity to ask questions or the nurse to verify the patient understands the instruction. The patient should not be discharged without education about his prescribed medications, including what they are for, how to take them, instructions regarding dosing, what side effects can occur, and when to stop taking the medications. PTS:1DIF:ModerateREF:p. 859

Which set of topics makes up a hand-off report given in a recommended format? 1)Data-action-response 2)Subjective-objective-assessment-plan 3)Situation-background-assessment-recommendation 4)Patient-diagnosis-medications-activity

ANS: 3 The SBAR (situation-background-assessment-recommendation) technique is used as a mechanism to give a hand-off report by enabling a focused communication between healthcare team members. DAR is used in Focus Charting®, and SOAP is a method for documenting nursing care. The nursing admission assessment is completed and documented at the time of admission.

Nursing was described as a distinct occupation in the sacred books of which faith? 1)Buddhism 2)Christianity 3)Hinduism 4)Judaism

ANS: 3 The Vedas, the sacred books of the Hindu faith, described Indian healthcare practices and were the earliest writings of a distinct nursing occupation. PTS:1DIF:EasyREF:p. 7

Who is the primary decision maker when caring for healthy adult clients? 1) Physician 2) Family 3) Client 4) Nurse

ANS: 3 The client is the primary decision maker in the care of healthy clients. The nurse functions as a teacher and health counselor. The physician plays a role in health promotion and screening. The family may give input, but the client is the decision maker. PTS:1DIF:EasyREF: p. 110 KEY: Nursing process: Planning | Client need: Health promotion | Cognitive level: Comprehension

Which criterion might be used in structure evaluation? 1) Staff refrains from sharing computer password. 2) Healthcare provider washes hands with each client contact. 3) A defibrillator is accessible on each client care area. 4) Nurse verifies client identification before initiating care.

ANS: 3 The criterion that states "a defibrillator is present on each client care area" is associated with structure evaluation. "Refrains from sharing computer password," "washes hands before each client contact," and "verifies client identification before initiating care" are criteria associated with process evaluation. PTS:1DIF:ModerateREF: p. 127 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis

Which of the following is true for goals/outcomes for collaborative problems? 1) They are monitored only by other disciplines. 2) They are usually sensitive to nursing interventions. 3) They state that a complication will not occur. 4) They state only broad performance criteria.

ANS: 3 The goal for a collaborative problem is always that the complication will not occur. Other disciplines may be involved in helping to prevent the problem, but nurses still monitor for the complication. The outcomes to collaborative problems are not affected by nursing interventions alone. Goals for collaborative problems are specific to the medical condition/treatment. PTS:1DIF:ModerateREF: pp. 93 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

Dunn believes that an individual's state of health should be evaluated in the context of the person's environment. This approach illustrates that 1) An unhealthy physical environment, characterized by poor living conditions, always has a negative effect on an individual's health 2) Adequate income, food, and shelter create a healthful environment and always improve physical health status 3) Physical environment, family, and social support may help or hinder the health status of an individual 4) The environment that should always be assessed is the client's immediate surroundings; extended boundaries do not apply in an ill state

ANS: 3 The home environment, community, family, friends, and support system all influence health status. The balance among these variables has a net positive or negative effect on a client's health status. The effect of poor living conditions may be offset by the presence of loving family and friends. Poverty does not always have a negative effect on health. Similarly, the presence of food, shelter, and clothing does not always convey protective health, as loneliness and hopelessness may counteract these positive influences. When examining the client's environment, extended boundaries must be considered, especially when providing community-based care. PTS:1DIFgrinifficultREF:p. 223 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application

The nurse in the intensive care unit is providing care for only one patient, who was admitted in septic shock. Based on this information, which care delivery model can you infer that this nurse is following? 1)Functional 2)Primary 3)Case method 4)Team

ANS: 3 The nurse is following the case method model of nursing care. In this model, one nurse cares for one patient during a single shift. When the functional nursing model is employed, care is compartmentalized, and each task is assigned to a staff member with the appropriate knowledge and skills. In primary nursing, one nurse plans the care for a group of patients round-the-clock. The primary nurse assesses the patient and develops the plan of care. When he or she is working, he or she provides care for those patients that he or she is responsible for. In his or her absence, the associate nurses deliver care. Although the nurse in this case could possibly be a primary nurse, there are not enough data to confidently infer that. If the team nursing approach is utilized, a licensed nurse (RN or LVN) is paired with a nursing assistant. The pair is then assigned to a group of patients. PTS:1DIF:ModerateREF:ESG, Chapter 1, "Healthcare Delivery Systems—Expanded Discussion," "What Models of Care Are Used to Provide Nursing Care?"

The nurse makes a mistake while documenting in the patient's health record. Which action should the nurse take? 1)Use an opaque white fluid to cover the documentation error. 2)Completely cover the documentation error with black ink. 3)Draw a line through the error and initial the change. 4)Use correction tape to make the documentation correct.

ANS: 3 The nurse should draw a single line through the documentation error and place her initials next to the change. In some institutions, the nurse must also write the words "error" or "mistaken entry" above the error. The nurse should never use opaque cover-up liquid or correction tape. It is not acceptable to alter the patient's health record as though the error was not made. Making note of the correction in documentation makes it clear to others what happened.

When performing a spiritual assessment, who is the preferred source of information? 1) Durable power of attorney 2) Next of kin 3) Patient 4) Patient's clergyman

ANS: 3 The patient is the preferred source of information. In the event of an emergency admission or when a patient cannot give information, the nurse can consult the next of kin or the durable power of attorney for information about the patient's spirituality. Contacting the clergyman without the patient's permission is a breach of patient confidentiality. PTS:1DIF:ModerateREF:pp. 346-347; high-level question, not answered verbatim in text. KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis

A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery for colon cancer. Which integrated plan of care (IPOC) would be most appropriate for the nurse to implement? 1)Hypertension 2)Rheumatoid arthritis 3)Postoperative colon resection 4)Follow all three plans

ANS: 3 The postoperative colon resection integrated plan of care should be followed; however, modifications should be made to meet the patient's other health needs. Therefore, portions of the hypertension and rheumatoid arthritis integrated plan of care may be added to the postoperative colon resection plan of care.

At 1000 on 11/14/10, the nurse takes a telephone order for "metoprolol 5 mg intravenously now." What is the latest date and time the nurse will expect the prescriber to countersign the order? 1)11/14/13 at 1200 2)11/14/13 at 2200 3)11/15/13 at 1000 4)11/16/13 at 1000

ANS: 3 The prescriber must countersign all verbal and telephone orders within 24 hours.

An elderly patient tells the charge nurse that she wants another nurse to take care of her. When the charge nurse questions the patient, she states "I don't want a man taking care of me." Which cultural barrier is this patient exhibiting? 1)Ethnocentrism 2)Racism 3)Sexism 4)Chauvinism

ANS: 3 This patient is exhibiting sexism; she is objecting to the nurse merely because of his sex. Although we tend to think of sexism in a negative light, this woman may merely be reflecting a cultural attitude. The patient is in no position to actually discriminate against the nurse, in terms of employment, and so on. Therefore, her preferences should be respected. Ethnocentrism occurs when a person is positively biased toward their own culture. Racism is a form of prejudice and discrimination based on race. Chauvinism occurs when a person assumes that he is superior.

_ 10. The nurse is a member of the ethics committee. An alert, oriented, and competent 87-year-old man has asked to have a DNAR order put on his chart. The patients family does not agree with his decision and requests the ethics committee to intervene on their behalf. The ethics committee would most likely use which model in this patients case? 1) Social justice 2) Patient benefit 3) Autonomy 4) DNAR determination

ANS: 3 Autonomy The autonomy model is useful when the patient is competent to decide. This model emphasizes patient autonomy and choice as the highest values. The patient benefit model assists in decision making for the incompetent patient by using substituted judgment. The social justice model focuses more on broad social issues involving the entire institution rather than on a single patient issue. There is no DNAR determination model.

11. A 60-year-old patient with a treatable form of breast cancer has decided not to pursue radiation or chemotherapy. The nurse believes that the patient should be treated. She coerces her into receiving treatment by continuing to remind the patient about her responsibilities for raising her children. What type of behavior has the nurse displayed? 1) Nonmaleficence 2) Autonomy 3) Paternalism 4) Beneficence

ANS: 3 Paternalism Paternalistic behavior occurs when the nurse thinks she knows what is best for a competent patient and coerces the patient to act as she wishes rather than to act as the patient originally desired. Autonomy refers to a persons right to choose and his ability to act on that choice. Nonmaleficence is the twofold principle of doing no harm and preventing harm. Beneficence is the duty to do or promote good.

14. An alert, oriented, and competent frail older adult man has been told that he is dying, and has asked to have a DNAR order put on his chart. The patients family does not agree with his decision and asks the healthcare team to ignore the request. The healthcare team does not comply with the familys wishes, and after several days the family takes the matter to court. The court sides with the family and orders the healthcare team to remove the DNAR order. This is an example of which of the following? 1) An integrity-producing (good) compromise 2) An ethically sound compromise 3) Settlement of an issue by force 4) An effort to keep peace on the unit

ANS: 3 Settlement of an issue by force This is clearly an example of settling an issue by force, bringing in a more powerful entity (the court) to force the healthcare team to do what the family wants. It is not a compromiseof any sortbecause neither party backed away from its original position, and the action that was taken was not agreed on by both parties. This was not an effort to keep peace. The familys effort was to settle the disagreement in their favor. If the healthcare teams goal had been to keep peace on the unit, they would have acceded to the familys wishes without the need for court order.

Prioritize the following guidelines for nursing practice in order of specificity (1-4, with 4 being the most specific). 1) ____ State laws 2) ____ Institutional policies and procedures 3) ____ Federal laws 4) ____ State nurse practice acts

ANS: 3, 1, 4, 2 Institutional policies and procedures are usually more specific and detailed than standards set by professional organizations. State nurse practice acts identify the minimum level of nursing care for a specific patient in specific situations. Standards in nurse practice acts are set forth in statutes and enforced by authority granted by the state. Federal laws, both constitutional and statutory, affect nursing practice in the most general terms.

While you are admitting an adult patient, he asks you whether he should create an advance directive. To provide him adequate information to make an informed decision, you should tell the patient which of the following? Choose all that apply. 1)If he is unable to communicate, his family may make changes to his advance directive. 2)Once he signs an advance directive, no further care will be provided to him. 3)He may change his advance directive by telling his physician or by making changes in writing. 4)An advance directive will ensure he gets as much or as little care as he wishes.

ANS: 3, 4 Advance directives include living wills and durable powers of attorney. A living will establishes the patient's wishes regarding future healthcare should he become unable to give instructions. A patient may specify actions in a living will that are not supported by family members, such as a desire for a "do not resuscitate" order, or for as much or as little care as he wishes. A person may change or revoke an advance directive at any time. Changes and written revocation should be signed and dated and shared with the patient's physician. Even without an official written change, orally expressed direction to the physician generally has priority over any statement made in an advance directive as long as the patient is able to decide for himself and can communicate his wishes.

A nursing instructor asked his nursing students to discuss their experiences with charting assessment data. Which comment by the student indicates the need for further teaching? 1) "I find it difficult to avoid using phrases like, 'The patient tolerated the procedure well.'" 2) "It's confusing to have to remember which abbreviations this hospital allows." 3) "I need to work on charting assessments and interventions right after they are done." 4) "My patient was really quiet and didn't say much, so I charted that he acted depressed."

ANS: 4

A nursing instructor is guiding nursing students on best practices for interviewing patients. Which of the following comments by a student would indicate the need for further instruction? 1) "My patient is a young adult, so I plan to talk to her without her parents in the room." 2) "Because my patient is old enough to be my grandfather, I will call him 'Mr.'" 3) "When reading my patient's health record, I thought of a few questions to ask." 4) "When I give my patient his pain medication, I will have time to ask questions."

ANS: 4

Of the following recommended interviewing techniques, which one is the most basic? (That is, without that intervention, the others will all be less effective.) 1)Beginning with neutral topics 2)Individualizing your approach 3)Minimizing note taking 4)Using active listening

ANS: 4

When making a diagnosis using NANDA-I, which of the following provides support for the diagnostic label you choose? 1) Etiology 2) Related factors 3) Diagnostic label 4) Defining characteristics

ANS: 4

When should the nurse make systematic observations about a patient? 1)When the patient has specific complaints 2)With the first assessment of the shift 3)Each time the nurse gives medications to the patient 4)Each time the nurse interacts with the patient

ANS: 4

Which of the following describes the difference between a collaborative problem and a medical diagnosis? 1) A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem. 2) A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care. 3) A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes. 4) A collaborative problem requires intervention by the nurse and physician or other professional; a medical diagnosis requires intervention by a physician.

ANS: 4

Which of the following describes the most important use of nursing diagnosis? (All statements are true.) 1) Differentiates the nurse's role from that of the physician 2) Identifies a body of knowledge unique to nursing 3) Helps nursing develop a more professional image 4) Describes the client's needs for nursing care

ANS: 4

Why is it important to obtain information about nutritional and herbal supplements as well as about complementary and alternative therapies? 1) To determine what type of therapies are acceptable to the client 2) To identify whether the client has a nutrition deficiency 3) To help you to understand cultural and spiritual beliefs 4) To identify potential interaction with prescribed medication and therapies

ANS: 4

How does nursing diagnosis differ from a medical diagnosis? A nursing diagnosis is 1)Terminology for the client's disease or injury 2)A part of the client's medical diagnosis 3)The client's presenting signs and symptoms 4)A client's response to a health problem

ANS: 4 A nursing diagnosis is the client's response to actual or potential health problems.

During advanced cardiac life support (ACLS) training, a nurse performs defibrillation using a mannequin. Which teaching strategy is being employed? 1)One-to-one instruction 2)Computer-assisted instruction 3)Role modeling 4)Simulation

ANS: 4 ACLS training utilizes this strategy by creating a scenario using resuscitation mannequins and teaching healthcare workers to respond appropriately to life-threatening cardiopulmonary events. The nurse is demonstrating the skill of defibrillation. ACLS certification requires learners to perform the skill back to the examiner. With one-to-one instruction, one instructor orally presents information to one student. With ACLS training, the healthcare team is involved and not just individual nurses. In role modeling, the teacher teaches by example, demonstrating the behaviors (not skills) that need to be acquired by learners. PTS:1DIF:ModerateREF:p. 872

A client incorporates alternative healthcare into her regular health practices. For which alternative therapy should the patient visit a formally trained practitioner? 1)Use of herbs and roots 2)Application of oils and poultices 3)Burning of dried plants 4)Acupuncture

ANS: 4 Acupuncture requires a formally trained practitioner. Use of herbs and roots, the application of oils and poultices, and the burning of dried plants do not require formally trained practitioners. Patients should be advised to inform their traditional primary healthcare provider when using various herbal remedies, as they can interfere with other prescribed medication and cause untoward side effects.

The nurse is a Christian. She is caring for a Jewish patient who has asked her to offer a prayer at the bedside. The nurse feels comfortable doing so. Which of the following actions by the nurse is appropriate? 1) Offer a prayer for healing using the nurse's usual words and format. 2) Begin the prayer with "Jehovah God" as she always does while avoiding the name of Jesus. 3) Avoid saying any name for the Supreme Being while praying and quote an Old Testament Bible scripture as the prayer. 4) Say, "What name would you like for me to use to address the Supreme Being when I am praying for you?"

ANS: 4 Ask how the patient prefers to address the Divine. Some people prefer the use of parental language in their prayers; for example, Father God or Divine Mother. Some use the names Jehovah, Yahweh, or Allah. Hindus may address one or more of multiple gods, each of whom has several names. So seek direction from the patient in these matters: Most people are honored to be able to explain their beliefs and practices to someone who is open to the experience. The nurse should not assume that using the names Jesus and Jehovah God would be supportive to the patient, although they might not offend in any way. The nurse does not need to avoid addressing God by a name, but the most supportive way to do so is to find out the name the patient wishes to use. Furthermore, the nurse should not assume that the patient would find a New Testament Bible verse to be helpful spiritually. PTS:1DIF:ModerateREF:p. 350 KEY: Nursing process: Implementation | Client need: PSI | Cognitive level: Application

An older adult has type 1 diabetes. He can perform self-care activities but needs help with shopping and meal preparation as well as with blood glucose monitoring and insulin administration. Which type of healthcare facility would be most appropriate for him? 1)Acute care facility 2)Ambulatory care facility 3)Extended care facility 4)Assisted living facility

ANS: 4 Assisted living facilities are intended for those who are able to perform self-care activities but who require assistance with meals, housekeeping, or medications. Acute care facilities focus on preventing illnesses and treating acute problems. These facilities include physicians' offices, clinics, and diagnostic centers. Ambulatory care facilities provide outpatient care. Clients live at home or in nonhospital settings and come to the site for care. Ambulatory care facilities include private health and medical offices, clinics, surgery centers, and outpatient therapy centers. Extended care facilities typically provide long-term care, rehabilitation, wound care, and ongoing monitoring of patient conditions. PTS:1DIF:EasyREF:p. 18; ESG, Chapter 1, "Healthcare Delivery Systems—Expanded Discussion," "Where is Healthcare Provided?"

Which of the following interventions would help to prevent or relieve persistent nausea? 1) Assess for signs of dehydration. 2) Provide dietary supplements. 3) Have the patient sit in an upright position for 30 minutes after eating. 4) Immediately remove any food that the patient cannot eat

ANS: 4 Dehydration can occur as a result of continued nausea and vomiting, so the nurse should assess for it. However, this intervention does not prevent nausea. Dietary supplements might help to prevent malnutrition. However, they do not prevent nausea; in fact, they often cause nausea. Having the patient sit upright helps to prevent respiratory aspiration should the patient vomit; it does not prevent or relieve nausea. Odors (even pleasant ones) and even the sight of food can cause nausea, so any uneaten food should be removed immediately from the room. PTS:1DIFgrinifficultREF:p. 928 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan? 1) Teaching the client that he must lose weight to control his blood sugar 2) Informing the client he must exercise at least three times per week 3) Explaining to the client that he must come to the diabetic clinic weekly 4) Determining the client's main concerns about his diabetes

ANS: 4 Determining the client's main concerns promotes cooperation with the treatment regimen. For example, if the client is concerned about paying for diabetic monitoring equipment, he may disregard any teaching about the procedure. Although it is often important for a diabetic client to exercise and lose weight to control blood sugar levels, the client must want to do both. He will not exercise or lose weight simply because he is told to do so. The nurse must assess the client's support systems and resources, not just tell him he must come to the diabetic clinic weekly. Some clients do not have access to transportation and, therefore, could not come to the clinic without social service intervention. Remember that knowledge does not necessarily change behavior. PTS:1DIF:ModerateREF: p. 122 KEY: Nursing process: Planning interventions | Client need: PHSI | Cognitive level: Analysis

Some people readily become ill when under stress. Others are able to deal with tremendous stress and remain physically and mentally healthy. This disparity is affected by a person's level of hardiness. How can you apply this knowledge to your nursing care? 1) You cannot use this information at all. People are innately hardy or not. This is something that you must merely recognize. 2) You should encourage all people to develop some level of hardiness in order to get through difficult physical and emotional times. 3) You should assess for your own level of hardiness: If you are hardy, you will be a better nurse; if you are not, you can learn more about hardiness. 4) You can assess for hardiness in patients; you can encourage hardy patients to learn about their illness as a means for them to be more comfortable.

ANS: 4 Hardiness is a personality trait that helps many cope with stress and illness. As a personality trait, it is unlikely that you can teach or otherwise encourage this trait. Awareness of your own level of hardiness will help you understand your response to stress, but hardiness does not necessarily make you a better nurse. PTS:1DIFgrinifficultREF:p. 229 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

Which intervention depends almost entirely on the client's adhering to the therapy? 1) Inserting an IV catheter 2) Turning a client every 2 hours 3) Shortening a surgical drain 4) Following a low-fat, low-calorie diet

ANS: 4 Instituting and adhering to a low-fat, low-calorie diet is an intervention that depends almost entirely on the client's adhering to the therapy. Client cooperation is necessary for performing the other interventions, but the interventions do not depend on the client to the same extent. PTS:1DIF:EasyREF: p. 122 KEY: Nursing process: Planning interventions | Client need: SECE | Cognitive level: Analysis

The nurse administering pain medication every 4 hours is an example of which aspect of patient care? 1)Assessment data 2)Nursing diagnosis 3)Patient outcome 4)Nursing intervention

ANS: 4 Interventions are activities that will help the patient achieve a goal, such as administering pain-relieving medication. An example of assessment data might be, "Patient reports pain is a 5 on a 1 to 10 scale." The nursing diagnosis would be Pain. The nurse might define the patient outcome in this scenario as, "The patient will state the level of pain is less than 4."

A 62-year-old patient is admitted to the hospital with hypertension. Which question by the nurse is most important when performing the initial assessment interview? 1) "What medications do you take at home?" 2) "Do you have any environmental, food, or drug allergies?" 3) "Do you have an advance directive?" 4) "What is the greatest concern you are dealing with today?"

ANS: 4 It is most important for the nurse to ask the patient about his greatest concern. His concern can then be incorporated into the plan of care, making sure that his needs are met. Asking about medications, allergies, and an advance directive is also important but does not take priority over asking about the patient's greatest concern. PTS:1DIF:ModerateREF:p. 231 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis

After instructing a mother about nutrition for a preschool-age child, which statement by the mother would indicate correct understanding of the topic? 1) "I usually use dessert only as a reward for eating other foods." 2) "I will hide vegetables in casseroles and stews to get my child to eat them." 3) "I do not give my child snacks; they simply spoil his appetite for meals." 4) "I know that lifelong food habits are developed during this stage of life."

ANS: 4 Lifelong food habits are developed during the preschool stage of life. Therefore, the mother should widen the variety of foods she introduces to her child. Desserts should not be used as rewards for eating other foods. This practice can shape an attitude about food that can lead to eating disorders later in life. Preschool-age children often refuse combined foods such as casseroles and stews. Because they are active, preschoolers require nutritious between-meal snacks. PTS: 1 DIF: Moderate REF: p. 913 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application

Which of the following is the most important reason to develop a definition of nursing? 1)Recruit more informed people into the nursing profession 2)Evaluate the degree of role satisfaction 3)Dispel the stereotypical images of nurses and nursing 4)Differentiate nursing activities from those of other health professionals

ANS: 4 Nursing organization leaders think it is important to develop a definition of nursing to bring value and understanding to the profession, differentiate nursing activities from those of other health professionals, and help student nurses understand what is expected of them. A definition of nursing would not be likely to increase the number of informed people recruited into nursing. A definition of nursing would do little to improve the nurse's role satisfaction. Although a definition of nursing might contribute to fighting stereotypes of nursing, other, more powerful influences (e.g., media portrayals) exist to counteract it. PTS:1DIF:EasyREF:V1, pp. 11-13; students must infer from content

Which of the following outcome statements contains the best example of performance criteria? The patient will 1) Turn herself in bed frequently while awake 2) Understand how to use crutches by day 2 3) State that pain is decreased after being medicated 4) Eat 75% of each meal without complaint of nausea

ANS: 4 Performance criteria should be specific and measurable. "75% of each meal" is specific and measurable. "Frequently" is vague. You cannot observe whether someone "understands." "Decreased" is vague; a numerical pain rating would be better. PTS:1DIF:ModerateREF: p. 92 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

Which family member is most likely to be disabled? 1) 60-year-old African American male 2) 65-year-old Asian male 3) 70-year-old Caucasian female 4) 75-year-old Native American female

ANS: 4 Slightly more females (15.6%) than males (14.4%) reported a disability. In 2006, the prevalence of disability was lowest for persons ages 16 to 20 (6.9%) and highest for those 75 years and older (52.6%). Disability differs by ethnic group. Asians reported 6.3%, Caucasians 12.7%, African Americans 17.5%, Native Americans 21.7%, and persons of other ethnic backgrounds reported 11.9% disability. Therefore, the prevalence of disability would be highest in a female Native American who is 75 years or older. PTS:1DIFgrinifficultREF:p. 307 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application

Which of the following is a benefit of standardized care plans, as defined in your text? Standardized care plans 1) Apply to every patient on a particular unit 2) Include both medical and nursing orders 3) Specify patient outcomes for each day 4) Help ensure that important interventions are not overlooked

ANS: 4 Standardized care plans help promote consistency of care and ensure that important interventions are not forgotten. They are not likely to apply to every patient on a unit because they are usually single-problem plans or are used with a particular medical diagnosis. Unlike protocols, they do not include medical orders. Unlike critical pathways, they do not specify predicted patient outcomes for each day. PTS:1DIF:ModerateREF: p. 86 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Recall

ANS: 1 Wearing secondhand clothes is taboo in the Rastafarian faith; therefore, the nurse should allow the patient to wear her own bedclothes instead of a hospital gown. Rastafarians typically consume tea, but some do not drink milk or coffee. Muslim women may wear a locket containing religious writing around the neck in a small leather bag. These are worn for protection and strength and should not be removed. Hindus prefer washing with free-flowing water for bathing, which should be provided when possible. PTS: 1 DIF: Moderate REF: ESG, Chapter 16, "Supplemental Materials," "Major Religions: What Should I Know?" KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

ANS: 4 The nurse can best deliver spiritual care by developing a greater awareness of her own spirituality. This allows the nurse to be a better listener and provide better care for the patient. The nurse should avoid assuming that a patient who shares the same religious affiliation has the same beliefs. Moreover, the nurse should avoid trying to meet the patient's spiritual needs independently. A team approach to spirituality provides more comprehensive care. Also, unless asked, the nurse should avoid explaining her own religious beliefs, which might offend the patient. PTS: 1 DIF: Moderate REF: p. 345 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension

A client has been hospitalized for 6 weeks. All of the following interventions are good ones, but which intervention is specifically focused on helping the patient cope with the emotional responses to prolonged hospitalization? 1) Providing skin care every shift to prevent skin breakdown 2) Encouraging the patient to get up in a chair to eat meals 3) Assisting the patient to ambulate in the hallway for several minutes each day 4) Designating a corner of the patient's room to display personal mementos

ANS: 4 The patient's environment can help nourish wellness. Helping the patient designate a corner of the room to display personal mementos can be healing and help the patient cope with the prolonged hospitalization. The other interventions might be helpful to the patient but are not as helpful in specifically dealing with "hospitalization" as is designating a portion of the room that is uniquely hers. PTS:1DIF:ModerateREF:p. 226 KEY: Nursing process: Implementation | Client need: PSI | Cognitive level: Application

Because of religious beliefs, which of the following patients will most likely refuse a blood transfusion? One who is affiliated with 1) Islam 2) Baha'i 3) Hinduism 4) Jehovah's Witness

ANS: 4 Those of Jehovah's Witness faith believe that "taking blood into one's body" is morally wrong. Therefore, they will not consent to transfusions of whole blood or its components. Those of Islam, Baha'i, and Hindu faith will, as a rule, consent to blood transfusion. PTS:1DIF:EasyREF:p. 342 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall

Which member of the healthcare team typically serves as the case manager? 1)Occupational therapist 2)Physician 3)Physician's assistant 4)Registered nurse

ANS: 4 Typically, registered nurses serve as case managers for patients with specific diagnoses. Their role is coordinator of care across the healthcare system. The occupational therapist, physician, and physician's assistant all serve on the healthcare team and take direction from the case manager. PTS: 1 DIF: Easy REF: ESG, Chapter 1, "Healthcare Delivery Systems—Expanded Discussion," "What Healthcare Providers Will You Work With?"

An instructor is teaching about differentiated parent and adult child relationships. Students are instructed to give an example of a well-differentiated parent and adult child relationship. Which student example meets the instructor requirement? A. An adult child considers, but is not governed by, the advice of his or her parents. B. An adult child appears to listen, but ignores, the advice of his or her parents. C. An adult child respects and is governed by the wishes of his or her parents. D. An adult child never requests advice or feedback from his or her parents.

ANS: A The correct student example of a well-differentiated parent and adult child relationship is when an adult child considers, but is not governed by, the advice of his or her parent. The adult child should be differentiated enough not to be threatened by parental advice and should be able to consider the parental advice without feeling the advice must be followed. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A couple is in counseling related to their dysfunctional relationship. Their daughter has recently made a suicide gesture. The nurse should recognize that this might be an example of which family system concept? A. Triangulation B. Pseudohostility C. Double-bind communication D. Pseudomutuality

ANS: A Triangulation occurs when a relationship between two people is dysfunctional. A third person is brought into the relationship to help stabilize it. The couple is triangulating with their daughter. The threatened daughter draws attention from her parent's interpersonal conflicts by her own dysfunctional behavior. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

A nursing instructor is teaching about the importance of healthy family-member expectations for newly blended families. Which student statement indicates a need for further instruction? A. "Healthy family-member expectations should be flexible." B. "Healthy family-member expectations should be conforming." C. "Healthy family-member expectations should be individual." D. "Healthy family-member expectations should be realistic."

ANS: B Conforming is a behavior that interferes with adaptive functioning in terms of family member expectations. This student statement indicates a need for further instruction. Realism, flexibility, and individuality are all characteristics of healthy family-member expectations. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

During family counseling, a husband tells his wife to spend more time with the family, and she responds by stating, "Okay, I'll turn in my resignation tomorrow." The husband replies, "I knew it! You've always been a quitter!" How should the nurse interpret the husband's statement? A. The husband is expressing an emotional cutoff. B. The husband is expressing double-bind communication. C. The husband is expressing indirect messages. D. The husband is expressing avoidance behaviors.

ANS: B Double-bind communication sets up no-win situations. The husband has created a situation in which no matter what the wife does, she is wrong. KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Assessment | Client Need: Psychosocial Integrity

After hearing parents discuss divorce, a 5-year-old develops behavioral problems. Upon dealing with the child's behavioral issues, the marital relationship conflict decreases. The pediatric clinic nurse should recognize that this is an example of which family system concept? A. Differentiation of self B. Triangulation C. Fusion D. Emotional cutoff

ANS: B Triangulation occurs when a relationship between two people is dysfunctional so a third person is brought into the relationship to help stabilize it. The son and his behavioral problems redirect the focus from the couple's marital problems. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

During family counseling a child states, "I just want to surf like other kids. Mom says it's okay, but Dad says I'm too young." The mother allows surfing when the father is absent. In the structural model of family therapy, what family interactional pattern should the nurse recognize? A. Multigenerational transmission B. Disengagement C. Mother-child subsystem D. Emotional cutoff

ANS: C In this situation the mother and child have formed a subsystem in which they have aligned themselves against the father. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

An adolescent, his mother, and his soon-to-be stepfather have been in counseling with the nurse. Which statement by the nurse fosters positive relationships within this new family structure? A. "Stepchildren should be consistently disciplined by only one parent." B. "It is most important to give your full attention to the child's adjustment since it is most difficult for them." C. "Keeping the lines of communication open between everyone in the family is important in establishing healthy relationships." D. "Children need to decide who will be their disciplinarian because this new situation will be stressful."

ANS: C Open lines of communication are needed for newly forming families to begin their relationship together and establish a new family structure. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client is angry because her husband has forgotten their anniversary. The following week, the client is still unwilling to discuss this with her husband because she is afraid she will lose control. How should the nurse interpret this client's means of coping with anger? A. Coping by attacking B. Coping by surrendering C. Coping by avoiding D. Coping by belittling

ANS: C When coping by avoidance, differences are never acknowledged openly. The individual who disagrees avoids discussing it for fear that the other person will withdraw love or approval or become angry in response to the disagreement. Avoidance also occurs when an individual fears loss of control of his or her temper. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A 30-year-old client seeking therapy states, "My mom cries when she is not included in all my social activities and thinks of my friends as her own." How would the nurse describe the boundaries between this family's parent and child subsystems? A. The boundaries are rigid. B. The boundaries are restructured. C. The boundaries are enmeshed. D. The boundaries are disengaged.

ANS: C With enmeshed boundaries, family members lack individuation and experience exaggerated connectedness. The client's mother is trying to prevent independence by generating feelings of guilt. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |Client Need: Psychosocial Integrity

The physician prescribes a new drug with which the nurse is unfamiliar. She consults the hospital formulary to learn about the drug. Which learning domain is the nurse utilizing? ____________________

ANS: Cognitive Learning through the use of reading materials uses the cognitive domain of learning. Learning a skill through mental and physical activity uses the psychomotor domain. The affective domain involves changing feelings, beliefs, attitudes, and values. PTS:1DIF:ModerateREF:pp. 856-857 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application

A couple has been married for 20 years. They argue constantly, belittle feelings, and continuously contradict each other. During a therapy session, the nurse documents "Marital schism." What does the nurse mean by this documentation? A. The couple has a compatible marriage relationship. B. The husband has a dominant relationship over the wife. C. The couple has an enmeshed relationship. D. The couple has an incompatible marriage relationship.

ANS: D A marital schism is a state of chronic disequilibrium and discord. This describes this couple's marriage. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A nurse enters an inpatient room and finds the family disagreeing about the client's living arrangements after discharge. Which information should the nurse provide when teaching techniques to resolve family conflicts? A. All family members should use past incidents to make their point. B. One family member should act as a gatekeeper in order to avoid family confrontation. C. One family member should act as a compromiser to preserve harmony in the family system. D. All family members should respect differing opinions and use compromise and negotiation.

ANS: D Functional families allow and respect differences among members. They learn to handle differences and conflict through negotiation and compromise. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Health Promotion and Maintenance

During family counseling a husband states, "Every time my wife and I discuss child discipline, we get into shouting matches." The nurse instructs the couple to shout at each other for 2 weeks on Tuesdays and Thursdays for 30 minutes. What intervention is the nurse using? A. Reframing B. Restructuring the family C. Expressive psychotherapy D. Paradoxical intervention

ANS: D In a paradoxical intervention, the therapist requests the family to continue the maladaptive behavior. This removes control over the behavior from the family to the therapist. Clients are made more aware of the defeating behavior and this can lead to behavioral change. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A patient experiences expressive aphasia after a stroke. Which expected outcome is appropriate for this patient? 1) Uses alternative methods of communication 2) Communicates effectively using a translator 3) Interprets messages accurately 4) Follows commands when asked

ANS:1 An appropriate outcome for a patient with expressive aphasia is "uses alternative methods of communication." Expressive aphasia means the patient cannot verbalize his intended message, but the patient may be able to understand and to communicate in other ways. "Communicates effectively using a translator" is an appropriate outcome for a patient who is unfamiliar with the dominant language. "Interprets messages accurately" and "follows commands when asked" are appropriate outcomes for the patient with receptive, not expressive, aphasia. PTS:1DIF:ModerateREF:p. 475 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application

Which statement by the nurse manager demonstrates an assertive approach when communicating with the staff nurse about a patient care issue? 1) "You must assess and document pain status for every patient." 2) "Why haven't you been assessing and documenting pain for every patient?" 3) "Will you please assess and document pain status for every patient?" 4) "Explain why you haven't been assessing and documenting pain for every patient."

ANS:1 By stating that pain must be assessed and documented for every patient, the nurse manager is using an assertive approach. An assertive approach uses the statement of facts, not judgments. Asking why the nurse has not been assessing and documenting pain is judgmental and elicits a defensive response by the nurse. Asking the nurse whether she will assess and document pain for every patient invites a negative response and does not use an assertive approach. Asking the nurse to explain why she has not been assessing and documenting pain is also judgmental. PTS:1DIF:ModerateREF:pp. 470-471 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis

A patient comes to the emergency department complaining of severe, substernal chest pain. He is restless and anxious. Which statement by the nurse appropriately offers reassurance? 1) "I'll give you some medication to help relieve the pain." 2) "If you lie still and relax, you'll be fine in a little while." 3) "Please try not to think about the pain as best as you can." 4) "Don't worry; we're going to take good care of you."

ANS:1 By telling the patient that she is going to give him some medication to help relieve his pain, the nurse is offering him realistic reassurance. The other options offer false reassurance and minimize patient concerns. PTS:1DIF:ModerateREF:p. 479 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

.A patient who speaks little English is admitted to the hospital after experiencing severe abdominal pain. Which nursing diagnosis is preferred for this patient? 1) Impaired Communication 2) Readiness for Enhanced Communication 3) Impaired Verbal Communication 4) Sensory Alteration

ANS:1 Impaired Communication is the preferred nursing diagnosis when the patient is unfamiliar with the dominant language. Impaired Verbal Communication is an appropriate diagnosis for the patient with expressive or receptive aphasia. Readiness for Enhanced Communication is appropriate when the patient expresses willingness to enhance communication. Sensory Alteration is appropriate when there is a change in the characteristics of the patient's incoming stimuli. PTS:1DIFgrinifficultREF:p. 474 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis

The wife of an elderly patient begins crying after she is informed that he has a terminal illness. Which intervention by the nurse is best? 1) Sit quietly with the patient's wife while she composes her thoughts. 2) Inform his wife that a chaplain is available if she would like to speak to him. 3) Remind his wife that her husband has lived a long and happy life. 4) Tell his wife there are always options and suggest she not give up hope.

ANS:1 The nurse can intervene best by sitting quietly with the patient's wife, allowing her to compose her thoughts. Silence communicates acceptance. After processing the bad news, the wife can provide the nurse with further information, such as whether she would like to consult with a chaplain. Telling the wife there are always options offers false reassurance and would probably discourage her from further communication. PTS:1DIFgrinifficultREF:p. 476 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

.A health center that is interested in purchasing IV infusion pumps organizes a group of nurses to evaluate pumps provided by a variety of vendors. Which type of group has been organized? 1) Short term 2) Ongoing 3) Self-help 4) Work-related social support

ANS:1 The organized group is a short-term group. Short-term groups focus on the task at hand, which in this case is evaluating infusion pumps. Ongoing groups address issues that are recurrent. Self-help groups are voluntary organizations composed of people with a common need. Work-related social support groups assist members of a profession to cope with the stress associated with their work. PTS:1DIF:ModerateREF:p. 473 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension

Which statement about communication is true? (Choose all that apply.) Communication is 1) Used to meet physical and psychosocial needs 2) Most basically described as talking and listening 3) The process of sending and receiving information 4) The basis for forming relationships

ANS:1, 3, 4 People use communication to fulfill basic human needs at all levels: physical, psychosocial, emotional, and spiritual needs. Communication is a process of sending and receiving messages. It forms the basis for sharing meaning and building effective relationships among individuals, families, and the healthcare team. Communication involves more than just talking and listening. And simply because messages are verbalized does not mean listening and understanding are achieved. PTS:1DIF:EasyREF:pp. 463-464 KEY:Nursing process: N/A |Client need: PSI | Cognitive level: Recall

The nurse must insert a nasogastric (NG) tube into a patient with a bowel obstruction. Before inserting the tube, the nurse must explain the procedure to the patient. Which explanation by the nurse is best, assuming that all provide correct information? 1) "I'm going to insert an NG tube and connect it to low Gomco to keep your stomach empty." 2) "I'm going to insert a tube through your nose into your stomach to prevent you from vomiting." 3) "I'm going to insert an NG tube through your nares to suction your secretions and prevent emesis." 4) "Lie still, please; I need to elevate the head of the bed and insert this tube."

ANS:2 Because patients are typically confused by medical terminology, the nurse should use language that the patient can understand. "NG tube," "Gomco," "suction secretions," "nares," and "emesis" are all medical jargon that the patient might not understand. Moreover, the nurse should explain all procedures before performing them to help minimize the patient's anxiety. "Lie still, please . . . " offers no explanation of why the NG tube is being inserted, and it conveys that the nurse is impatient. PTS:1DIF:ModerateREF:p. 465 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

A patient newly diagnosed with breast cancer tells the nurse, "I'm worried I won't live to see my children grow up." Which response by the nurse best conveys concern and active listening? 1) "There have been many advances in breast cancer treatment; hope for the best." 2) "Breast cancer is a serious disease; I can understand why you're worried." 3) "You're strong and have youth on your side to fight the breast cancer." 4) "I'd be worried, too; I've seen a lot of patients die from breast cancer."

ANS:2 Restating the patient's concern by saying, "Breast cancer is a serious disease; I can understand why you're worried" conveys concern and active listening. Stating that there have been many advances in breast cancer treatment minimizes the patient's concern. Stating that the patient is young and should have no trouble surviving breast cancer minimizes the patient's concern and offers false reassurance. Stating that the nurse has seen a lot of patients die from breast cancer could frighten the patient and cause emotional harm. PTS:1DIF:ModerateREF:p. 476 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

When using the SBAR model to communicate with a physician, what information does the nurse offer first? 1) Statement of the problem and its probable cause 2) Nurse's name, patient's name, and reason for the communication 3) History of information related to and leading up to the situation 4) A solution to the problem or what is needed from the physician

ANS:2 SBAR is an acronym for Situation, Background, Assessment, and Recommendation. The nurse's name, and so forth, are part of the Situation. Statement of the problem and cause are the Assessment. History of the factors leading up to the current situation make up the Background. What the nurse thinks will correct the problem is categorized under Recommendation. PTS: 1 DIF: Difficult REF: p. 471 KEY:Nursing process: Implementation | Client need: PSI | Cognitive level: Application

A patient being admitted in hypertensive crisis informs the nurse that he stopped taking his blood pressure medication 3 weeks ago. Which response by the nurse is best? 1) "You're lucky you didn't have a stroke; you really need to take your medication." 2) "Tell me more about your experience with your high blood pressure medication." 3) "Why did you stop taking your high blood pressure medication?" 4) "It's very important to take your blood pressure medication."

ANS:2 The nurse can gather more information about the patient's reasons for stopping his blood pressure medication by asking him to tell her more about his experience with the medication. Telling the patient he is lucky he did not have a stroke suggests criticism. Asking the patient why he stopped taking his high blood pressure medication may cause the patient to become defensive and halt further communication. Telling the patient that it is very important to take his blood pressure medication is patronizing and also suggests criticism; at the very least, it fails to elicit more communication from the patient. PTS:1DIF:ModerateREF:pp. 477-478 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

Which statement by the nurse demonstrates that active listening has occurred? Choose all that apply. 1) "I listened to my patient while I was changing his IV site." 2) "I made eye contact and listened to my patient to find out his concerns." 3) "I took notes when I listened to my patient describe his symptoms." 4) "I sat with my patient and his wife to talk about their fears before the surgery."

ANS:2, 4 The nurse demonstrates active listening by facing the patient, making eye contact, and listening while he expresses concerns. Arranging time to sit with the patient and his wife to discuss fears about an upcoming surgery also indicates active listening. Listening to the patient while performing activities, such as hanging an IV infusion or bathing him, distracts the nurse from active listening. Although taking detailed notes can help the nurse to accurately recall the patient's words, this activity while listening to the patient speak can also be a distraction and could reduce eye contact and nonverbal cues of care and concern. PTS:1DIF:ModerateREF:p. 476 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application

A patient tells the nurse, "I'm having a lot of pain in my hip." Which response by the nurse is open-ended and would stimulate the patient to provide the most complete data? Choose all that are correct. 1) "Is your pain severe?" 2) "Tell me about your pain." 3) "When did you first notice this pain?" 4) "How would you describe your pain?"

ANS:2, 4 The responses "Tell me about your pain" and "How would you describe your pain?" are open-ended responses that stimulate conversation. Although it is important information, the question "Is your pain severe?" prompts a "yes" or "no" response. "When did you first notice this pain?"—also important information—is likely to stimulate a brief, factual answer. Such questions allow the nurse to control the patient's response. Limiting the response might lead to an incomplete assessment. PTS:1DIF:ModerateREF:p. 476; includes cross-reference to Chapter 3 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

Which of the following is a nonverbal behavior that enhances communication? 1) Keeping a neutral expression on the face 2) Maintaining a distance of 6 to 12 inches 3) Sitting down to speak with the patient 4) Asking mostly open-ended questions

ANS:3 Sitting down to speak with the patient enhances communication because it communicates a willingness to listen. A concerned expression, not a neutral one, demonstrates interest and attention. Maintaining a distance of 18 inches to 4 feet, not 6 to 12 inches, while speaking allows most patients to feel comfortable, thereby enhancing communication. When the interpersonal distance is too close, patients might feel uncomfortable. Asking open-ended questions is a verbal communication strategy, not a nonverbal behavior. PTS:1DIF:ModerateREF:p. 467 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Comprehension

A patient had surgery 6 hours ago. When the nurse enters the room to turn him, she notes that he is restless and grimacing. Considering the patient's nonverbal communication, what action should the nurse take first? 1) Administer pain medication to the patient. 2) Turn and reposition the patient. 3) Assess to determine the cause of the grimacing. 4) Leave the patient's room so he can rest quietly.

ANS:3 The nurse should assess the patient to determine whether he is having pain. The nurse should not assume by the patient's nonverbal communication that the patient is in pain and administer pain medication; the nurse should validate the message being sent. The nurse should not turn and reposition the patient without assessing him. Leaving the patient without addressing his nonverbal cues is neglectful. PTS:1DIF:ModerateREF:pp. 466-467 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis

A patient who speaks only French was admitted to the hospital after a motor vehicle accident. Assuming that the nurse does not speak French, what is the best way to communicate with this patient? 1) Use sign language for communicating. 2) Ask a family member to serve as a translator. 3) Request the services of a hospital translator. 4) Speak in English, but speak very slowly.

ANS:3 The nurse should request the services of a hospital translator to communicate with the patient who does not speak English. A family member should not be used as a translator unless there are no other options because it is often culturally unacceptable to have a family member ask personal questions. Also, considering the patient's right to confidentiality, it is not appropriate to share private information about the patient with family members unless permission is obtained. Using sign language can be an effective strategy for hearing-impaired persons. Speaking slowly in English is not useful if the patient does not understand the language. PTS:1DIF:ModerateREF:p. 475 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

.Which statement by the nurse indicates that the nurse-patient relationship is entering the termination phase? 1) "I'll be admitting you to our nursing unit as soon as I obtain your health history." 2) "You seem upset today. Would you like to talk about whatever is bothering you?" 3) "I'm leaving for the day. Is there anything I can do for you before I leave?" 4) "Hello. My name is Leslie, and I'm going to be your nurse today."

ANS:3 When the nurse states, "I'm leaving for the day. Is there anything I can do for you before I leave?" the nurse-patient relationship is entering the termination phase. The termination phase is the conclusion of the relationship, which can occur at the end of a nurse's shift. The pre-interaction phase occurs before the nurse meets the patient. The statement "I'll be admitting you to our floor as soon as I obtain your history" demonstrates the pre-interaction phase of the nurse-patient relationship. The nurse introduces herself to the patient during the orientation phase. During the working phase of the nurse-patient relationship, feelings are explored. This phase is demonstrated by the statement, "You seem upset today. Would you like to talk about whatever is bothering you?" PTS:1DIF:ModerateREF:p. 472 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

Which intervention by the nurse first helps to establish a trusting nurse-patient relationship? 1) Avoiding topics that may provoke emotional responses from the patient 2) Listening to the patient while performing care activities 3) Performing care interventions quietly and respectfully 4) Greeting the patient by name whenever entering the patient's room

ANS:4 The nurse can establish a trusting nurse-patient relationship by always greeting the patient by name, listening actively, responding honestly to the patient's concerns, providing explanations for care interventions, and providing care competently and consistently. PTS:1DIF:ModerateREF:p. 476 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

After a physician discusses cancer treatment options with a patient, the patient asks the nurse which treatment he should choose. Which response by the nurse is best? 1) "If I were you, I'd go with chemotherapy." 2) "What do you think about radiation therapy?" 3) "Why don't you see what your wife thinks." 4) "I'll give you some information about each option."

ANS:4 The nurse should avoid giving a personal opinion; instead offer the patient more information so he can make an informed decision. Responses such as, "If I were you, I'd go with chemotherapy" and "Why don't you see what your wife thinks" do not respect the patient's right to make his own decisions. "What do you think about radiation therapy," is leading the patient without exploring the other options. PTS:1DIF:EasyREF:pp. 478-479 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

.A nurse has sound, scientific evidence to support changing a procedure that would reduce catheter-related infections on the unit. The unit manager states, nevertheless, that she is unwilling to make the change because it would be too costly. Which response by the nurse represents assertive communication? 1) "This is a widely used practice. If you read more research, you'd probably wonder why we aren't already doing it." 2) "There is extensive evidence to support the new method, but I don't want to create an issue." 3) "Is the budget more important to the hospital than reducing infections and patient suffering?" 4) "I'd like to help gather information regarding the cost of new materials versus the savings in treating infections."

ANS:4 The statement pertaining to helping to gather information about of the cost of materials is an assertive response. It does not threaten the authority of the nurse manager and introduce another element preventing change that is unrelated to the procedure itself. It states the nurse's position and wishes clearly with an "I" statement, and it does not invite negative responses. The statement beginning with "This is a widely used practice" is aggressive and implies criticism and a judgment that the nurse manager does not read as much as she should. The statement ending with "I wouldn't want to create chaos" is passive and submissive. The statement beginning with "Is the budget more important . . ." is aggressive and judgmental. PTS:1DIF:ModerateREF:pp. 470-471 KEY: Nursing process: Implementation | Client need: PSI | Cognitive level: Application

A physician tells a patient that she has cancer and that she should have surgery as soon as possible. The patient is not certain she wants to pursue this treatment approach but responds by saying, "I'll do whatever you think I should do." Which communication style is this patient using? 1) Assertive 2) Aggressive 3) Passive aggressive 2 4) Passive

ANS:4 This patient is using a passive communication style to avoid conflict with others while allowing the other person to be in control. An aggressive approach forces others to relinquish control. The goal of the aggressive approach is to win and be in control. With assertive communication, the person expresses beliefs or feelings without infringing on another's rights. The passive aggressive approach uses a submissive style of communication but is aggressive in the sense that it manipulates the receiver to help the sender win. This allows the sender to be in control without conflict. PTS:1DIF:ModerateREF:p. 470 KEY: Nursing process: Analysis | Client need: PSI | Cognitive level: Application

Intentional torts

Assault: the conduct of one person makes another person fearful and apprehensive. a nurse threatens to place an NG tube in a client who is refusing to eat. Battery: intentional and wrongful physical contact with a person that involves an injury or offensive contact. A nurse restrains a client and administers an injection against her wishes. False imprisionment: a person is confined or restrained against his will. A nurse uses restraints on a competent client to prevent his leaving the health care facility.

The department of nursing at a local hospital is considering changing to charting by exception (CBE). Which statement provides a rationale to support making this change? CBE 1)Reduces the time nurses spend charting 2)Addresses the patient's concerns holistically 3)Establishes an ongoing care plan from admission 4)Is most useful when constructing a timeline of events

NS: 1 An advantage of CBE is that it reduces the amount of time that nurses must spend documenting. CBE assumes that unless a separate entry is made, all standards have been met with a normal response. Focus charting addresses the patient's concerns holistically. PIE charting establishes an ongoing care plan from admission. Narrative charting is especially useful when attempting to construct timelines of events.

Which of the following helps the body release growth hormone (growth hormone assists in tissue regeneration, synthesis of bone, and formation of red blood cells)? 1) A healthy diet 2) Physical activity 3) Restful sleep 4) Comfortable room temperature

NS: 3 During sleep, our bodies release the majority of our growth hormone, which assists in tissue regeneration, synthesis of bone, and formation of red blood cells. Consuming healthy foods helps prevent disease. Physical activity reduces the risk of chronic disease and promotes longevity. Keeping the body at a comfortable temperature helps maintain health but not release of growth hormone. PTS:1DIF:ModerateREF:p. 224 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Recall

he patient's health record contains the following provider's order: furosemide 40 mg intravenously STAT. If the nurse later needed to know when the medication had been given and the patient's response to the medication, where would he look? 1)Progress notes 2)Graphic record 3)Narrative notes 4)MAR

NS: 3 The nursing narrative note will contain documentation about the time the medication was administered and the patient's response to the medicine. In contrast, the MAR will only contain documentation about when the medication was given, not the patient's response. The physician's progress note contains documentation about why the furosemide was ordered. The graphic record will not contain charting about the medication but will contain information about the patient's output.

What do standardized nursing care plans and individualized care plans have in common? They both 1) Reflect critical thinking for a specific patient 2) Are preprinted to apply to needs common to a group of patients 3) Address a patient's individual needs 4) Provide detailed nursing interventions

NS: 4 They both provide detailed nursing interventions, although the individualized care plan is more specific to the patient's needs and reflects critical thinking, whereas standardized plans do not. It is not true of individual nursing care plans that they are preprinted and apply to a group. PTS: 1 DIF: Moderate REF: pp. 87 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

living will

a living will is a legal document that expresses the clients wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues most states laws include provisions that protect health care providers who follow a living will from liability

Practice

a set of behaviors that one follows "I always wash my hands before preparing food"

Cultural archetype

an example of person or. thing..something that is recurrent....and it has its basis in facts.

Communication

an exchange is an exchange of information, ideas and feelings. it includes verbal and nonverbal language.

culture of nursing

as the learned and transmitted lifeways, values, symbols, patterns and normative practices of members of the nursing profession that are not the same as those of the airstream culture

Territoriality

behavior and attitude that people exhibit about the area around them that they have claimed

regulatory law

federal and state regulatory organizations covering health care

the clients responsibility for informed consent

gives informed consent: to give informed consent the client must: give it voluntarily (no coercion involved) be competent and of legal age or an emancipated minor. when the client is unable to provide consent, another authorized person must give consent. receive information to make a decision based on an understanding of what t expect.

oregon

has the death with dignity act and is the only state where a physician assisted suicide is allowed by law

mandatory reporting

health care providers have a legal obligation to report their findings in accordance with the state law

Biological variations

include ways in which people are different genetically and physiologically

Cultural competence

is achieved on a continuum. ranging from incompetent to competent. It is a development process

nurses role in the informed consent

is to witness the clients signature or the informed consent form and to ensure that the provider has obtained the informed consent responsibly

common law

judicial court decisions when individual legal cases are decided

cultural sensitivity

more to do with personal attitudes and being careful not to say or do something that might be offensive to someone from a different culture

Clients rights

nurses are accountable for protecting the rights of clients. Examples include informed consent, refusal of treatment, advance directives, confidentiality, and informed security

standards of care (practice)

nurses base practice on established standards of care or legal guidelines for care such as the following: the nurse practice act of each state. published standards of nursing practice from professional organizations and specialty groups such as ANA the AACN and he AAOHN

nursing role in clients rights

nurses must ensure that clients understand their rights, and must protect their clients rights regardless of the clients age, nursing needs, or health care settings, the basic tenets are the same. the client has the right to: understand the aspects of care to be active in the decision-making process. accepts, refuse, or request modification of the plan of care receive care from competent individuals who treat the client with respect

Abuse

nurses must report any suspicion of abuse (child or elder abuse, domestic violence) following facility protocol

communicable diseases

nurses must report communicable diseases diagnosis to the local state or health department.

the providers responsibility for informed consent

obtains informed consent: the provider must give the client: the purpose of the procedure a complete description of the procedure a description of the professional who will perform and participate in the procedure a description of the potential harm, pain or discomfort that may occur. options for other treatments the option to refuse treatment and the consequences of doing so

who may grant consent for another person?

parent of a minor legal guardian court-specified representative an individual who has durable power of attorney for health care

nursing roles in advance directives

provide written information about the advance directive document the pts advance directives ensure that the advance directives reflect the pts current decisions inform all members of the health care teach of the pts advance directives

Environmental control

refers to a persons perception of his ability to plan activities that control nature or direct environmental factors.

Cultural awareness

refers to an appreciation of the external signs of diversity

Space

refers to an individuals personal space, or how the person relates toward the space around him

Multicultural

refers to many cultures and is used to describe groups rather than individuals.

the dying client

the legalities concerning the dying are debated almost every day. the uniform determination of death act defines death as the irreversible cessation of circulation nd respiratory functions or the irreversible cessation of all functions of the brain. in death, the body must be treated with dignity. abuse of a corpse could be class A or class D misdemeanor

consent is informed when a provider explains and the client understands:

the reason the client needs the treatment or procedure how the treatment or procedure will benefit the client the risks involved if the client chooses to receive the treatment or procedure other options to treat the problem, including not treating the problem

Ethnocentrism

the tendency to think that your own group (cultural, professional, ethnic, or social) is superior to others and to view behaviors and beliefs that differ greatly from your own as somehow wrong, strange, or unenlightened.

Cultural universals

the values, beliefs and practices that people from all culture share.

Time orientation

varies among people different cultures. some persons tend to be present or future oriented, whereas others are more rooted in the past

How can you recognize subcultures?

you may recognize subcultures by their speech patterns, dress, gestures eating habits, lifestyles, ad so on.

Licensure

you must have a valid license to practice nursing and every new nurse must take the NCLEX exam. Other states may apply for a reciprocity of licensure. the state boards of nursing regulate the practice of nursing and they own your license. they have the power and authority to suspend or revoke your license

All of the following are aspects of the full-spectrum nursing role. Which one is essential for the nurse to do in order to successfully carry out all the others? 1)Thinking and reasoning about the client's care 2)Providing hands-on client care 3)Carrying out physician orders 4)Delegating to assistive personnel

ANS: 1 A substantial portion of the nursing role involves using clinical judgment, critical thinking, and problem solving, which directly affect the care the client will actually receive. Providing hands-on care is important; however, clinical judgment, critical thinking, and problem solving are essential to do it successfully. Carrying out physician orders is a small part of a nurse's role; it, too, requires nursing assessment, planning, intervention, and evaluation. Many simple nursing tasks are being delegated to nursing assistive personnel; delegation requires careful analysis of patient status and the appropriateness of support personnel to deliver care. Another way to analyze this question is that none of the options of providing hands-on care, carrying out physician orders, and delegating to assistive personnel is required for the nurse to think and reason about a client's care; so the answer must be 1. PTS:1DIFgrinifficultREF: p. 11

What do initial, ongoing, and discharge planning have in common? 1) They are based on assessment and diagnosis. 2) They focus on the patient's perception of his needs. 3) They require input from a multidisciplinary team. 4) They have specific timelines in which to be completed.

ANS: 1 All planning is based on nursing assessment data and identified nursing diagnoses. The patient should have input, but the planning is based on the nursing assessment. The different types of planning are intertwined and may or may not be done at distinct, separate times. Discharge planning often requires a multidisciplinary team, but initial and ongoing planning may not. Initial planning is usually begun after the first patient contact, but there is no specified time for completion; ongoing planning is more or less continuous and is done as the need arises; discharge planning must be done before discharge. PTS:1DIF:ModerateREF: p. 81-82 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

The primary provider prescribes an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed? 1) Ask a colleague for help, because the nurse cannot safely perform the procedure alone. 2) Gather the equipment and prepare it before informing the client about the procedure. 3) Obtain an order to restrain the client before inserting the urinary catheter. 4) Inform the provider that the nurse cannot perform the procedure because the client is confused.

ANS: 1 Before the nurse begins a procedure, she should review the care plan and look at the orders critically. Because this client is confused, she should ask a colleague to assist with the procedure to prevent undue stress for the client and nurse. The client should be informed about the procedure before the nurse gathers the equipment. Gathering the equipment and bringing it into the room before explaining the procedure might cause the client anxiety. Restraining the client should be done only as a last resort and to prevent client injury. Informing the primary provider that the procedure cannot be performed because the client is confused is inappropriate because the procedure can very likely be done with assistance. PTS:1DIF:ModerateREF:p. 118 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis

Which food provides the body with no usable glucose? 1) Wheat germ 2) Apple 3) White bread 4) White rice

ANS: 1 Dietary fiber, such as wheat germ, contains no usable glucose. Apples, white bread, and white rice all contain carbohydrates, which provide usable glucose. PTS: 1 DIF: Easy REF: p. 902; does not specify wheat germ, just indicates that fiber provides no glucose. KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension

A patient who came from Central America is admitted with diabetes mellitus. The nurse is collecting biographical information. Which information provided by the patient represents his ethnicity? 1)Latino 2)Catholic 3)White 4)Teacher

ANS: 1 Ethnicity refers to groups whose members share a common cultural heritage. This patient came from a Spanish-speaking country in Central America; therefore, his ethnicity is considered Latino. Catholic is his religion, white is his race, and teacher is his occupation.

A 13-year-old girl is admitted to the adolescent unit with acute leukemia. The patient has a support system that includes her brother, sister, mother, father, and grandmother as well as members of her local community. Which component of her support system is considered a suprasystem? 1) The community 2) The parents 3) Her mother 4) Her sister

ANS: 1 Her surrounding community is considered a suprasystem because it is larger than the family system. Subsystems within the family include the parents, mother, siblings, sister, brother, father, and grandmother; they are smaller components that fit within the family system. PTS:1DIF:ModerateREF:p. 302 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis

Which of the following contributions of Florence Nightingale had an immediate impact on improving patients' health? 1)Providing a clean environment 2)Improving nursing education 3)Changing the delivery of care in hospitals 4)Establishing nursing as a distinct profession

ANS: 1 Improved sanitation (a clean environment) greatly and immediately reduced the rate of infection and mortality in hospitals. The other responses are all activities of Florence Nightingale that improved healthcare or nursing, but the impact is long range, not immediate. PTS: 1 DIF: Easy REF: V1, p. 3; student must infer from content | V1, p. 10; student must infer from content KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application

Which of the following examples includes both objective and subjective data? 1)The client's blood pressure is 132/68 and her heart rate is 88. 2)The client's cholesterol is elevated, and he states he likes fried food. 3)The client states she has trouble sleeping and that she drinks coffee in the evening. 4)The client states he gets frequent headaches and that he takes aspirin for the pain.

ANS: 2

Which of the following is an example of a problem that nurses can treat independently? 1) Hemorrhage 2) Nausea 3) Fracture 4) Infection

ANS: 2

Which of the following is known to be a healthy strategy for coping with stress? 1) Performing meaningful work 2) Consuming simple carbohydrates 3) Drinking three glasses of red wine each day 4) Weight training

ANS: 1 Many individuals find that meaningful work is a healthy way to cope with stressors. Consuming simple carbohydrates is not a healthy way to cope with stress. Drinking more than one glass of red wine each day is considered unhealthy. Weight training has been shown to increase bone density and reduce the risk of osteoporosis and heart disease but not necessarily to reduce stress. PTS:1DIF:ModerateREF:p. 225 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Application

Which standardized intervention vocabulary was designed specifically for community health nurses? 1) Omaha System 2) Clinical Care Classification 3) Nursing Interventions Classification 4) International Classification for Nursing Practice

ANS: 1 The Omaha System was designed specifically for community health nurses to use in caring for individuals, families, community groups, or entire communities. The Clinical Care Classification was developed for home healthcare. The Nursing Interventions Classification system is applicable in all settings, including home health and community nursing. The International Classification for Nursing Practice system was designed to describe nursing practice of individuals, families, and communities worldwide. PTS:1DIF:EasyREF: p. 110 KEY: Nursing process: Planning | Client need: SASE | Cognitive level: Recall

Which of the following characteristics do the various definitions of critical thinking have in common? Critical thinking 1)Requires reasoned thought 2)Asks the questions "why?" or "how?" 3)Is a hierarchical process 4)Demands specialized thinking skills

ANS: 1 The definitions listed in the text as well as definitions in Box 2-1 state that critical thinking requires reasoning or reasoned thinking. Critical thinking is neither linear nor hierarchical. That means that the steps involved in critical thinking are not necessarily sequential, where mastery of one step is necessary to proceed to the next. Critical thinking is a purposeful, dynamic, analytic process that contributes to reasoned decisions and sound contextual judgments.

A 65-year-old patient is admitted to the hospital with heart failure. The patient's best friend accompanies her on admission. They have been sharing a home since they each were widowed 3 years ago. Both women have grown children who live out of state. Using the family nursing approach, how can the nurse best intervene? 1) Involve the friend and children in the patient's care, discharge planning, and home care. 2) Encourage the friend to wait until discharge to provide care for the patient at home. 3) Explain to the friend that for confidentiality reasons she cannot be involved in the patient's care. 4) Encourage liberal visiting hours by the friend and the patient's children.

ANS: 1 The nurse can best intervene by involving the friend and the patient's children in the patient's care, discharge planning, and home care. The friend may or may not be able to care for the patient at home. But if planning to provide home care, the patient's friend should be informed of the patient's needs while in the hospital and have an opportunity to participate prior to discharge. The nurse can involve the friend with the patient's consent without infringing on the patient's privacy. Her name needs to be listed on the patient privacy (HIPAA) form. The nurse should also encourage liberal visiting hours by the friend and the patient's children if it is beneficial for the patient's recovery; however, comprehensive involvement in care is more inclusive than simply liberalizing visiting hours and therefore is the best answer. PTS:1DIF:ModerateREF:pp. 301-302 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

Which task can be delegated to nursing assistive personnel (NAP)? 1) Turn and reposition the client every 2 hours. 2) Assess the client's skin condition. 3) Change pressure ulcer dressings every shift. 4) Apply hydrocolloid dressing to the pressure ulcer.

ANS: 1 The nurse can delegate turning the client every 2 hours to the NAP. Assessing the client's skin condition, changing pressure ulcer dressings, and applying a hydrocolloid dressing to a pressure ulcer are all interventions that require nursing knowledge and judgment. PTS:1DIF:ModerateREF:pp. 122-124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application

The patient's medical record contains the following documentation: 06/05/05 0200 Received patient from the E.D. BP 80/52, HR 118, RR 24, temp 104°F. Arouses to verbal stimuli but drifts off to sleep. Normal saline infusing in left arm via18 gauge IV catheter at 250 mL/hr. Urinary catheter draining scant dark amber urine. Pt receiving O2 at 6 L/min via nasal cannula. Lungs with coarse crackles at the left base. Loose cough present. Pt unable to expectorate secretions.—Ann. Davids, RN Which type of charting has the nurse used? 1)Narrative 2)Focus 3)SOAP 4)PIE

ANS: 1 The nurse used narrative charting when documenting the condition of this newly admitted patient. This format is free text description of the patient status and nursing care. Focus charting highlights the patient's concerns, problems, and strengths in a three-column format. SOAP is an acronym for subjective data, objective data, assessment, and plan. This charting format is used to address single problems or to write summative notes. PIE is an acronym for problem, interventions, and evaluation. This charting method also addresses problems.

Which statement best describes theology? 1) Discussions and theories related to God and His relation to the world 2) Doctrines about the human soul and its relation to eternal life 3) A life-long journey involving accumulation of experience and understanding 4) Codes of conduct that integrate beliefs and values

ANS: 1 Theology is best described as discussions and theories related to God and His relation to the world. Eschatology includes doctrines about the human soul and its relation to death, judgment, and eternal life. Spirituality is considered a lifelong journey. Religion provides codes of conduct that integrate beliefs and values. PTS:1DIF:ModerateREF:p. 339 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall

_ 2. Which of the following terms refers to the ethical questions that arise out of nursing practice? 1) Nursing ethics 2) Bioethics 3) Ethical dilemma 4) Moral distress

ANS: 1 Nursing ethics Nursing ethics refers to ethical questions that arise out of nursing practice. Bioethics is a broader field that refers to the application of ethics to healthcare. An ethical dilemma occurs when a choice must be made between two equally undesirable actions, and there is no clearly right or wrong option. Moral distress occurs when someone is unable to carry out his or her moral decision.

The Joint Commission requires which type of assessment to be performed on all patients? 1)Functional ability 2)Pain 3)Cultural 4)Wellness

ANS: 2

For which patient would it be most important to perform a comprehensive discharge plan? 1) A teen who is a first-time mother, single, and lives with her parents 2) An older adult who has had a stroke affecting the left side of his body and lives alone 3) A middle-aged man who has had outpatient surgery on his knee and requires crutches 4) A young woman who was admitted to the hospital for observation following an accident

ANS: 2 A comprehensive discharge plan should be developed for older adults and anyone who has complex needs, including self-care deficits. The other patients do not have the complex needs of the older adult patient who has had a stroke that affects body function. PTS:1DIF:ModerateREF:p. 83 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis

Which patient is most likely experiencing positive nitrogen balance? A patient admitted: 1) With third-degree burns of his legs. 2) In the sixth month of a healthy pregnancy. 3) From a nursing home who has been refusing to eat. 4) With acute pancreatitis.

ANS: 2 A positive nitrogen balance typically exists during pregnancy when new tissues are being formed. Patients with burns, malnutrition, and serious illness commonly experience negative nitrogen balance because tissues are lost. PTS:1DIF:ModerateREF:p. 902 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

North American healthcare culture typically reflects which culture? 1)Asian 2)European American 3)Latino 4)African American

ANS: 2 Although the demographics are changing in this recent decade with increasing Hispanic and Asian inhabitants, North American healthcare culture typically reflects the dominant (European American) culture because most healthcare providers belong to that culture.

Which nursing intervention is considered an independent intervention? 1) Administering 1 L of dextrose 5% in normal saline solution at 100 mL/hour 2) Encouraging the postoperative client to perform coughing and deep breathing exercises 3) Explaining his diet to the client; then communicating the teaching with the dietitian 4) Administering morphine sulfate 2 mg IV to the client with postoperative pain

ANS: 2 Encouraging the postoperative client to perform coughing and deep breathing exercises is an independent nursing intervention. An independent intervention is one that nurses are licensed to prescribe, perform, or delegate based on their skills and knowledge. Administering IV fluid or morphine sulfate are dependent interventions; they require an order from a physician or advanced practice nurse but are carried out by the nurse. Explaining to the client how sodium intake affects his heart failure and then communicating the teaching with the dietitian is an interdependent intervention, one that is carried out in collaboration with other healthcare team members. PTS:1DIF:ModerateREF: p. 103 KEY: Nursing process: Interventions | Client need: SASE | Cognitive level: Application

Which family would most likely be helpful in encouraging the client to experience a high level of wellness? A family who 1) Controls feelings to avoid conflict 2) Teaches negotiation skills and independence 3) Encourages risk taking and adventure 4) Views themselves as helpless victims

ANS: 2 Families who promote independence and teach good negotiation skills enable family members to experience a high level of wellness by thinking for themselves. In contrast, families who tend to squelch personal feelings to avoid conflict may not allow a high level of wellness. Families who emphasize caution in new situations are more beneficial than those who encourage risk-taking. Families who view themselves as capable and successful are more advantageous than those who view themselves as helpless victims. PTS:1DIF:EasyREF:p. 225 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall

A patient with a diabetic foot ulcer will need to perform dressing changes after discharge. When should the nurse schedule the teaching session(s)? 1)Within 10 minutes after his next dose of oral pain medication 2)After the patient wakes up from a restful nap 3)Before the surgeon débrides the wound 4)Before the patient undergoes flow studies of his affected leg

ANS: 2 For learning to be most effective, teaching must occur when the patient is most ready. A patient's capacity to take in new information is reduced when he is anxious, in this example about testing or treatment, or is tired, or is experiencing pain. Therefore, the best time to teach this patient is when he is rested, such as after a restful nap. Ten minutes is not enough time for oral medication to take effect and relieve pain. PTS: 1 DIF: Difficult REF: pp. 857-858

Which statement pertaining to Benner's practice model for clinical competence is true? 1)Progression through the stages is constant, with most nurses reaching the proficient stage. 2)Progression through the stages involves continual development of thinking and technical skills. 3)The nurse must have experience in many areas before being considered an expert. 4)The nurse's progress through the stages is determined by years of experience and skills.

ANS: 2 Movement through the stages is not constant. Benner's model is based on integration of knowledge, technical skill, and intuition in the development of clinical wisdom. The model does not mention experience in many areas. The model does not mention years of experience. PTS:1DIF:ModerateREF:p. 15

A female patient tells the charge nurse that she does not want a male nurse caring for her. Which intervention by the charge nurse is best? 1) Explain that hospital policy does not allow nursing assignments based on the gender of the nurse. 2) Explore with the patient her beliefs and determine which might have caused her to make this statement. 3) Assure the patient that each nurse is capable of providing professional nursing care, regardless of their gender. 4) Comply with the patient's request and assign a female nurse to care for the patient.

ANS: 2 The charge nurse can best serve the patient and her staff by exploring the patient's beliefs that might prevent her from being cared for by a male. There are many reasons the woman may prefer a female nurse: she may be very modest, or she may be prejudiced against male nurses, for example. Hospital policy might state that, to prevent discrimination issues, nursing assignments should not be made based on the gender of the patient or nurse. However, even if this is so, before explaining this to the patient, the charge nurse should explore the patient's beliefs and make special arrangements with hospital administration to uphold the patient's beliefs, if possible. Telling the patient that each nurse is capable of providing care is not sensitive to the patient and her beliefs. Simply complying with the patient's wishes without further investigation may alienate the nursing staff. PTS: 1 DIF: Moderate REF: pp. 341-343, pp. 351-352 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

The nurse is caring for a 42-year-old Chinese American patient who underwent emergency coronary artery bypass graft surgery. He is self-employed and has no health insurance. Each day members of his family spend hours at his bedside. Which is the most important factor for the nurse to focus on when planning the patient's discharge? 1)Ethnic background 2)Family support 3)Employment status 4)Healthcare coverage

ANS: 2 The nurse should focus on the patient's strengths and resources for health restoration and self-care. In this case, that is the patient's family. His family can be a great support for him when he is discharged (e.g., preparing healthy meals, helping him manage exercise and treatment regimens). Although the patient's ethnic background is very important to his care, discharge planning should revolve around his available resources. Insurance should not be the focus at this time, although at some point the nurse has probably obtained data about these topics.

A patient and his wife are 2 years from retirement when he is diagnosed with lung cancer. Although with delayed childbearing, developmental stages can vary among families, which typical stage of family development is this couple likely experiencing? 1) Family launching young adults 2) Postparental family 3) Family with frail elderly 4) Family with teenagers and young adults

ANS: 2 This couple is most likely experiencing the postparental stage of family development. During this stage, the parents prepare for retirement and adjust to their children moving into phases of adulthood. In the stage of family launching young adults, the parents maintain support of young adults as they leave the security of family and the parents rediscover marriage. During the stage of family with teenagers and young adults, open communication is maintained among family members, ethical and moral values are reinforced, and there is a balance established between rules and independence among teens. PTS: 1 DIF: Moderate REF: p. 303 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application

Upon initial assessment of a 75-year-old patient, you identify bruises and scratches on the patient's arms, legs, and trunk in various stages of healing. You notify your supervisor when you suspect the patient may be a victim of physical abuse. You are complying with which of the following state laws? 1)Good Samaritan Law 2)Mandatory Reporting Law 3)Nurse Practice Act 4)Nursing Standards of Practice

ANS: 2 Under state mandatory reporting laws, nurses must report to designated authorities (e.g., Adult Protective Services) suspected physical, sexual, emotional, or verbal abuse or neglect by healthcare workers or family members. In general, nurses who fail to report suspected abuse or neglect may be held criminally or civilly liable.

The nurse is developing a teaching plan for an older adult patient with Alzheimer disease and her family. Which point should the nurse include in the teaching plan before discharge? 1) Importance of quitting smoking 2) Availability of community resources 3) Adherence to a low-fat diet 4) Importance of physical exercise

ANS: 2 When teaching the family of an older adult, the nurse should include information about community resources that are available, especially when caring for chronically ill, disabled, or elderly family members. Middle-age adults typically begin experiencing signs and symptoms associated with long-standing, unhealthy behaviors. Therefore, consuming a low-fat diet and limiting the intake of alcohol and tobacco are likely appropriate topics to include in the teaching plan for a middle-aged adult. Physical exercise and activity promote the quality of life. Careful planning is necessary to ensure safety and well-being for the family member with memory loss, confusion, and disorientation. PTS:1DIF:ModerateREF:p. 306 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

5. A 45-year-old patient is ventilator dependent after a high cervical neck injury. He is alert and oriented and, after giving it much thought, has decided that he wants to be removed from the ventilator. The nurse believes the patient intends suicide but supports his final decision. When the ventilator is removed, the nurse remains with the patient to support him. The nurses action demonstrates respect for what moral principle? 1) Nonmaleficence 2) Autonomy 3) Beneficence 4) Fidelity

ANS: 2 Autonomy Autonomy refers to a persons right to choose and his ability to act on that choice. In this case, the nurse respects the patients right to choose to die. Nonmaleficence is the twofold principle of doing no harm and preventing harm. Beneficence is the duty to do or promote good. Fidelity is the obligation to keep promises.

Which of the following explains why it is important to have the correct etiology for a nursing diagnosis? The etiology 1) Is the cause of the problem 2) Cannot always be observed 3) Directs nursing care 4) Is an inference

ANS: 3

A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system? 1)It involves a cooperative effort among various disciplines. 2)The system requires diligence in maintaining a current problem list. 3)Data may be fragmented and scattered throughout the chart. 4)It allows the nurse to provide information in an unorganized manner

ANS: 3 A major disadvantage of a source-oriented medical record is that data may be fragmented and scattered throughout the chart. The problem-oriented medical record requires a cooperative effort among disciplines and diligence in maintaining a current problem list. Narrative charting allows the nurse to provide information in a disorganized manner.

Which of the following is an example of an illness prevention activity? Select all that apply. 1)Encouraging the use of a food diary 2)Joining a cancer support group 3)Administering immunization for HPV 4)Teaching a diabetic patient about his diet

ANS: 3 Administering immunization for HPV is an example of illness prevention. Although cancer is a disease, it is assumed that a person joining a support group would already have the disease; therefore, this is not disease prevention but treatment. Illness-prevention activities focus on avoiding a specific disease. A food diary is a health-promotion activity. Teaching a diabetic patient about diet is a treatment for diabetes; the patient already has diabetes, so it cannot prevent diabetes. PTS: 1 DIF: Moderate REF: p. 18; high-level question, not directly stated in text KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Application

Which of the following nursing interventions is an indirect-care intervention? 1) Emotional support 2) Teaching 3) Consulting 4) Physical care

ANS: 3 An indirect-care intervention is an activity performed away from the client on behalf of the client. Indirect-care interventions include consulting with other healthcare team members, making referrals, advocacy, and managing the environment. Direct-care interventions include emotional support, patient teaching, and physical care. PTS:1DIF:EasyREF:pp. 103 KEY: Nursing process: Implementation | Client need: SASE | Cognitive level: Recall

The school nurse at a local elementary school is performing physical fitness assessments on the third-grade children. When assessing students' cardiorespiratory fitness, the most appropriate test is to have the students: 1) Step up and down on a 12-inch bench. 2) Perform the sit-and-reach test. 3) Run a mile without stopping, if they can. 4) Perform range-of-motion exercises.

ANS: 3 Field tests for running are good for children and can be utilized when assessing cardiorespiratory fitness. The step test is appropriate for adults. The 12-inch bench height is too high for young children. The sit-and-reach test as well as range-of-motion exercises would be appropriate when assessing flexibility. PTS:1DIF:ModerateREF:pp. 884-885 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application

Which polysaccharide is stored in the liver? 1) Insulin 2) Ketones 3) Glycogen 4) Glucose

ANS: 3 Humans store glucose in the liver as polysaccharides, known as glycogen. Glycogen can then be converted back into glucose to meet energy needs through a process known as glycogenolysis. If fats must be used for energy, they are converted directly into ketones. Insulin is a pancreatic hormone that promotes the movement of glucose into cells. PTS: 1 DIF: Moderate REF: p. 902 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Recall

A 26-year-old man of Mexican heritage is admitted for observation after sustaining injuries in a motor vehicle accident. When assessing this patient, the nurse must consider that he may possess which view of pain? 1)A belief in taboos against narcotic use to relieve pain 2)Expectation of immediate treatment for relief of pain 3)Endurance of pain longer and report it less frequently than some patients do 4)Use of herbal teas, heat application, and prayers to manage his pain

ANS: 3 In general, patients of Mexican heritage may endure pain longer and report it less frequently than some. Patients of Japanese heritage may have taboos against narcotic use to relieve pain. Patients of Puerto Rican heritage may use herbal teas, heat application, and prayers to manage pain. Remember that all of these are archetypes and are not necessarily true for all members of a cultural group.

The muscle strength of a woman weighing 132 pounds who is able to lift 72 pounds would be recorded as 0.55. The nurse explains this to the client as the 1) Ratio of weight lifted divided by body weight 2) Measure of weight pushed divided by BMI 3) Ability of a muscle to perform repeated movements 4) Ability to move a joint through its range of motion

ANS: 3 Muscle strength measures the amount of weight a muscle (or group of muscles) can move at one time. This is recorded as a ratio of weight pushed (or lifted) divided by body weight. A woman weighing 132 pounds who is able to lift 72 pounds has a ratio of 72 divided by 132, or 0.55. PTS:1DIF:ModerateREF:pp. 884-885 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application

A patient with morbid obesity was enrolled in a weight loss program last month and has attended four weekly meetings. But now he believes he no longer needs to attend meetings because he has "learned what to do." He informs the nurse facilitator about his decision to quit the program. What should the nurse tell him? 1) "By now you have successfully completed the steps of the change process. You should be able to successfully lose the rest of the weight on your own." 2) "Although you have learned some healthy habits, you will need at least another 6 weeks before you can quit the program and have success." 3) "You have done well in this program. However, it is important to continue in the program to learn how to maintain weight loss. Otherwise, you are likely to return to your previous lifestyle." 4) "You have entered the 'determination stage' and are ready to make positive changes that you can keep for the rest of your life. If you need additional help, you can come back at a later time."

ANS: 3 Prochaska and Diclemente identified four stages of change: the contemplation stage, the determination stage, the action stage, and the maintenance stage. This patient demonstrates behaviors typical of the action stage. If a participant exits a program before the end of the maintenance stage, relapse is likely to occur as the individual resumes his previous lifestyle. PTS:1DIF:ModerateREF:pp. 881-882 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

A patient tells you that chart entries made by the nurse from the previous day indicate he was uncooperative when asked to ambulate. He says this is not true and asks his record be corrected. You understand that, if what he says is accurate, he has the right to have the documentation error corrected based on which of the following regulations? 1)Americans with Disabilities Act (ADA) 2)Patient Self-Determination Act (PSDA) 3)Health Insurance Portability and Accountability Act (HIPAA) 4)Health Care Quality Improvement Act (HCQIA)

ANS: 3 The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule of 2004 provides comprehensive protection for the privacy of protected health information (confidentiality of patient records). In addition, patients have the right to see and copy their medical records and to reconcile incorrect information.

Which teaching technique is best for teaching a nursing assistant how to perform finger-stick glucose testing? 1)Provide a manufacturer's pamphlet with detailed instruction. 2)Explain the best technique for performing glucose testing. 3)Demonstrate the procedure; then ask for a return demonstration. 4)Suggest that the assistant watch a DVD showing the procedure.

ANS: 3 The best way to teach a psychomotor skill is to demonstrate the procedure and then ask for a return demonstration. Supplementary written information or DVD can also be supplied to the patient to reinforce learning. However, they are not the best method for teaching a psychomotor skill; enacting the procedure is more effective. PTS: 1 DIF: Moderate REF: pp. 871, 873

The nurse is beginning discharge planning for an older adult with left-side weakness. All of the following are important, but which action is most important in ensuring that the discharge plan is successful? 1) Start planning at admission. 2) Involve the family members. 3) Get patient input when making the plan. 4) Involve the multidisciplinary team.

ANS: 3 The discharge plan may be developed in a timely manner and involve the family and a multidisciplinary team, but if the patient does not agree with the plan, it will not be successful. PTS: 1 DIF: Moderate REF: pp. 83| p. 87 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

The nurse has just finished documenting that he removed a patient's nasogastric tube. Which is the next logical step in the nursing process? 1) Assessment 2) Planning 3) Evaluation 4) Diagnosis

ANS: 3 The implementation phase ends when you document nursing actions on the client's chart. Implementation evolves into the evaluation step when you document the client's response to your interventions. As a general rule, the steps in order are as follows: assessment diagnosis, planning outcomes, planning interventions, implementation, and evaluation. PTS:1DIF:EasyREF:p. 125 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Comprehension

The client is a 76-year-old man who is experiencing chronic illness. He has a genetic-linked anemia. He says he does not eat a balanced diet, as he prefers sweets to meat and vegetables. Which of the following dimensions of health can the nurse most likely influence by teaching and counseling him? 1) Age-related changes 2) Genetic anemia 3) Eating habits 4) Gender-related issues

ANS: 3 The nurse is most likely to influence the patient's eating habits because those are the dimension over which he has the most control and, therefore, has the most potential for changing. Although people consider biological factors when they describe themselves as well or ill, they are not entirely within our control. Biological factors include age and developmental stage, genetic makeup, and sex. PTS:1DIF:EasyREF:p. 224 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Application

The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not currently have any respiratory problems. The nurse's teaching plan includes coughing and deep breathing exercises. Which type of nursing intervention is the nurse performing? 1) Health promotion 2) Treatment 3) Prevention 4) Assessment

ANS: 3 The nurse is teaching the client coughing and deep breathing exercises, which help prevent postoperative pneumonia. Therefore, the nurse is utilizing a prevention intervention. Prevention interventions are used to help prevent complications, such as postoperative pneumonia. Health-promotion interventions promote a client's efforts to achieve a higher level of wellness. Treatment interventions treat disorders, relieve symptoms, and carry out medical orders. Assessment interventions detect changes in the client's condition and detect potential problems. PTS:1DIF:ModerateREF: p. 106 KEY: Nursing process: Interventions | Client need: Physiological integrity | Cognitive level: Application

A physician prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, and she cannot find it in the hospital formulary or other references. How should she proceed? 1) Administer the medication as prescribed. 2) Hold the medication and notify the prescriber. 3) Consult with a pharmacist before administering it. 4) Ask the patient's nurse for information about the medication.

ANS: 3 The nurse must recognize when she does not have the knowledge or skill needed to implement an order. Because the nurse is unfamiliar with the medication, that does not mean she should hold it and delay patient treatment. It is wisest to first consult with the pharmacist for information before administering the medication to ensure safe practice. Administering the medication as prescribed, without knowing its expected actions and side effects, at the least prevents adequate reassessment; at the most, it is dangerous. Holding the medication and notifying the prescriber prevents the client from receiving timely treatment—many drugs are less effective if a consistent schedule is not maintained. Asking another nurse to administer the medication is also unsafe because it cannot be assumed that the other nurse has the correct knowledge. In addition, the nurse caring for the client must assess for adverse reactions to the medication. PTS:1DIF:ModerateREF:p. 118 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis

Assume all of the following written instructions about digoxin provide correct information for patient care. Which one is best worded for patient understanding? 1)Obtain your radial pulse every morning before taking your digoxin dose. 2)Return to your healthcare provider for monthly laboratory studies of your digoxin levels. 3)Call your provider if you notice that objects look yellow or green. 4)Always take the same brand of medication because certain brands may not be interchangeable.

ANS: 3 The nurse should provide written instructions that contain short sentences and easy-to-read words. If instructions are written at too high a reading level, the patient may not understand and make a harmful error in dosing. Calling the provider when objects look yellow or green is the clearest statement for patient teaching because the instruction is short, concrete, and written with easy-to-understand words. Patient instructions must not contain words that require a higher level of reading or medical jargon. The instruction pertaining to being consistent with brand use is too wordy, especially for patients who are ill or for whom English is not a primary language. PTS:1DIFgrinifficultREF:p. 873

A 12-year-old patient's mother recently married a man who has a 13-year-old daughter. The nurse recognizes that the patient belongs to which type of family? 1) Extended 2) Traditional 3) Blended 4) Nuclear

ANS: 3 The patient belongs to a blended family; in which two single parents marry and raise their children together. An extended family may contain grandparents, aunts, uncles, cousins, and other biological relatives. A traditional, or nuclear, family contains a husband, wife, and their children. PTS:1DIF:EasyREF:p. 301 KEY: Nursing process: N/A | Client need: PSPI | Cognitive level: Application

A patient is admitted to the emergency department with a stroke. After being stabilized, the patient's needs are best met if the nurse documents a care plan that provides for 1)Acute interventions 2)Patient teaching 3)Discharge needs 4)Family health data

ANS: 3 The patient's potential discharge needs should be evaluated when the patient first enters the healthcare facility. After the patient is admitted, discharge needs should be continually reevaluated and documented throughout the patient's hospitalization.

A patient who moved to the United States from Italy comes to the clinic for medical care. The patient has been in this country for several years and has adopted some elements of her new country. Yet she still retains some customs from her homeland. This patient is experiencing 1)Assimilation 2)Socialization 3)Acculturation 4)Immigration

ANS: 3 This patient is experiencing acculturation; she has accepted both her own and the new culture and has incorporated elements of both into her life. Socialization is the process of learning to become a member of a society or group. Cultural assimilation occurs when the new member gradually learns and takes on, to a great extent, the dominant culture's values, beliefs, and behaviors. Immigration is the act of moving to a new country.

What is the most influential factor that has shaped the nursing profession? 1)Physicians' need for handmaidens 2)Societal need for healthcare outside the home 3)Military demand for nurses in the field 4)Germ theory influence on sanitation

ANS: 3 Throughout the centuries, stability of the government has been related to the success of the military to protect or extend its domain. As the survival and well-being of soldiers is critical, nurses provided healthcare to the sick and injured at the battle site. The physician's handmaiden was/is a nursing stereotype rather than an influence on nursing. Although there has been need for healthcare outside the home throughout history, this has more influence on the development of hospitals than on nursing; this need provided one more setting for nursing work. Germ theory and sanitation helped to improve healthcare but did not shape nursing. PTS: 1 DIF: Moderate REF: pp. 9-10 KEY: Nursing process: N/A Client need: N/A | Cognitive level: Recall

A pregnant 15-year-old girl presents to the emergency department (ED) of the local private hospital. She has been transported by her mother and appears to be in active labor. The girl is crying uncontrollably and says she is scared and experiencing painful contractions. Her mother states, "We don't have any money or insurance, but this hospital is closer than the public hospital, and she needs help now." What is the first step that the ED staff should take? 1)Arrange for an ambulance to transport her to the nearest public hospital. 2)Explain to the girl and her mother that the hospital only accepts patients who can pay the hospital bill. 3)Examine her to determine if her condition is stable or if she requires immediate medical attention. 4)Inform her mother that she will need to transport her daughter to the nearest public hospital.

ANS: 3 When a client comes to the ED requesting examination or treatment for an emergency medical condition (including labor), the hospital must provide stabilizing treatment; the client cannot be transferred until she is stable.

A patient with type 1 diabetes mellitus is admitted with hyperglycemia and associated acidosis. The presence of which alternative fuel in the body is responsible for the acidosis? 1) Glycogen 2) Insulin 3) Ketones 4) Proteins

ANS: 3 When fats are converted to ketones for use as alternative fuel, as in diabetic ketoacidosis when glucose cannot by used by the cells, the acidity of the blood rises, leading to the acidosis. Glycogen is converted to glucose to meet energy needs. Insulin, a pancreatic hormone, promotes the movement of glucose into cells for use. Proteins would not be used for fuel as long as fats were available. PTS:1DIFgrinifficultREF:pp. 902, 925 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehe

Chapter 42. Nursing Ethics Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. A 77-year-old woman with an inoperable brain tumor has been hospitalized for the past 5 days. Her daughter comes to visit her. The patient has asked that her daughter not be told her diagnosis. After visiting with her mother, the daughter asks to speak to the nurse. She says, My mother claims she has pneumonia, but I know she is not telling me the truth. The daughter asks the nurse to tell her what is truly wrong with her mother. The nurse should tell her that: 1) Her mother has an inoperable brain tumor, but does not wish anyone to know. 2) She needs to speak to the physician in charge of her mothers care. 3) Her mother has requested that her case not be discussed with anyone, not even family. 4) Her mother is very sick with a serious case of pneumonia that could lead to death.

ANS: 3 Her mother has requested that her case not be discussed with anyone, not even family. The nurses first allegiance is to the patient and her desire for confidentiality. Telling the daughter to speak to the physician would place the physician in the same position as the nurse. Telling her that her mother has pneumonia would be a lie. The nurse, of course, should inform the physician of the patients wishes so that he will be prepared if the daughter questions him about her mothers health condition.

4. A 45-year-old patient is ventilator dependent after a high cervical neck injury. He is conscious and competent and has decided that he wants to be removed from the ventilator. His family and the multidisciplinary team agree. The nurse believes the patient intends suicide and would prefer he choose differently but says nothing. The nurse remains at the bedside holding the patients hand. In this instance the nurse is displaying which of the following? 1) Value set 2) Value system 3) Value neutrality 4) Value awareness

ANS: 3 Value neutrality Value neutrality occurs when we put aside our own values regarding an issue in order to provide nonjudgmental care to clients. A value set is your list of values. A value system is your value set with the values ranked on a continuum from most important to least important.

Which of the following is an example of data that should be validated? 1)The client's weight measures 185 lb at the clinic. 2)The client's liver function test results are elevated. 3)The client's blood pressure is 160/94 mm Hg; he states that that is typical for him. 4)The client states she eats a low-sodium diet and reports eating processed food.

ANS: 4

A client informs the nurse that he has quit smoking because his father died from lung cancer 3 months ago. Based on his motivation, smoking cessation should be recognized as an example of which of the following? 1) Healthy living 2) Health promotion 3) Wellness behaviors 4) Health protection

ANS: 4 Although health promotion and health protection may involve the same activities, their difference lies in the motivation for action. Health protection is motivated by a desire to avoid illness. Health promotion is motivated by the desire to increase wellness. Smoking cessation may also be a wellness behavior and may be considered a step toward healthy living; however, neither of these addresses motivation for action. PTS:1DIF:ModerateREF:p. 879 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension

Which client has the greatest need for comprehensive discharge planning? 1) A woman who has just given birth to her second child and lives with her husband and 18-month-old daughter 2) A man who has been readmitted for exacerbation of his chronic obstructive pulmonary disease 3) A 12-year-old boy who had outpatient surgery on his knee and lives with his mother 4) A woman who was just diagnosed with renal failure and has started peritoneal dialysis

ANS: 4 Comprehensive discharge planning should be done for patients who have a newly diagnosed chronic disease or have complex needs. The other patients may require discharge planning but not as comprehensive as someone with a new diagnosis with complex treatment. PTS:1DIFgrinifficultREF: p. 83 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

Which factor is held in common by many of the world religions? 1) Strict health code, including dietary laws 2) Belief that one must submit to a god or gods 3) Rules prohibiting alcohol consumption 4) Sacred writings that reveal the nature of the Supreme Being

ANS: 4 Many of the world religions have sacred writings that are authoritative and reveal the nature of the Supreme Being. Mormons follow a strict health code, which advises healthful living. Islam means submission; therefore people of Islamic faith submit to Allah. Some religions, such as Mormon, Christian Science, Baha'i, and Sikhism, prohibit alcohol consumption, but many other religions permit it. PTS:1DIF:EasyREF:p. 339 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Recall

A patient of Orthodox Jewish faith is admitted to the hospital with heart failure on Yom Kippur. The physician prescribes digoxin 0.25 mg to be given orally for this patient. Based on the patient's religious affiliation, which of the following actions should the nurse take? 1) Administer the medication as prescribed. 2) Hold the medication until after Yom Kippur. 3) Explain the importance of taking the medication despite the holiday. 4) Ask the physician to change the route of administration.

ANS: 4 Orthodox Jews require an alternative to the oral route of drug administration on Yom Kippur to comply with their religious beliefs. Therefore, the nurse should ask the physician to change the route of administration. Administering the medication as prescribed breaks the patient's religious tradition on the holiest day of the Jewish calendar. Holding the medication until after Yom Kippur delays treatment and may cause harm to the patient; furthermore, it is not within the scope of nursing practice to hold medications that have been prescribed by a physician. The nurse should explain the importance of the medication in any case; but the nurse should not try to convince the patient to break away from his religious tradition when an alternative route of administration is available. PTS:1DIF:ModerateREF:p. 341 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

Which nursing intervention is best individualized to meet the needs of a specific client? 1) Suction the client every 2 hours per unit policy. 2) Use incentive spirometry every hour while awake per postoperative protocols. 3) Institute swallowing precautions. 4) Move client out of bed to the chair daily; client prefers to be out of bed for dinner.

ANS: 4 Positioning the client in the chair for meals considers the client's desire to be out of bed for dinner, so it is obviously individualized. An intervention performed according to unit policy or protocols is not necessarily individualized. "Institute swallowing precautions" does not provide instructions for the specific actions needed to do that for "this particular" client. PTS:1DIF:ModerateREF:p. 118; high-level question, answer not given verbatim KEY: Nursing process: Planning interventions | Client need: SECE | Cognitive level: Application

A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client's condition is getting worse; he is cyanotic (turning blue) with periods of labored breathing. What action should the nurse take first? 1)Study the discharge plan. 2)Check the graphic data for vital signs. 3)Examine the history and physical. 4)Look for an advance directive.

ANS: 4 The advance directive, which should be located in a special section of the patient's medical record, should be examined first because the patient's symptoms indicate that he may need to be resuscitated. The advanced directive contains information about the patient's wishes for intensity of care and actions that should be taken in the event of a life-threatening event. The discharge plan contains data from utilization review, case managers, or discharge planners on anticipated needs after discharge. Graphic data are to record assessment done frequently, such as vital signs. The history and physical provide a detailed summary of the patient's current problem, past medical and social history, medications taken by the patient, review of systems, and physical examination data.

Which organ relies almost exclusively on glucose for energy? 1) Liver 2) Heart 3) Pancreas 4) Brain

ANS: 4 The brain relies almost exclusively on glucose for energy. The heart and liver do not. The pancreas produces insulin for glucose utilization but does not use glucose. PTS:1DIF:Easy REF: p. 902; ESG, Chapter 28, Supplemental Materials, Dietary Reference Intake: Macronutrients KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall

For the patient with no healthcare coverage who is seeking medical care, the emergency department staff members decide whether to provide care or transport to a public facility based on which law, enacted by Congress in 1986 and updated in 2003? 1)Health Care Quality Improvement Act (HCQIA) 2)Patient Self-Determination Act (PSDA) 3)Newborns' and Mothers' Health Protection Act (NMHPA) 4)Emergency Medical Treatment and Active Labor Act (EMTALA)

ANS: 4 The intent of the Emergency Medical Treatment and Active Labor Act (EMTALA) is to ensure public access to emergency services regardless of ability to pay. The EMTALA prohibits "patient dumping," which is transferring indigent or uninsured patients from a private hospital to a public hospital without appropriate screening and stabilization. An exception is made if a hospital does not have the capability to stabilize a patient or if the patient requests a transfer.

A nurse makes a nursing diagnosis of Acute Pain related to the postoperative abdominal incision. She writes a nursing order to reposition the client in a comfortable position using pillows to splint or support the painful areas. What type of nursing intervention did the nurse write? 1) Collaborative 2) Interdependent 3) Dependent 4) Independent

ANS: 4 Writing an order to reposition the client in a comfortable position is an example of an independent nursing intervention, one that does not require a physician's order. The nurse is licensed to prescribe, perform, or delegate the intervention based on her knowledge and skills. A collaborative or interdependent intervention is one that is carried out in collaboration with other health team members, such as providing the client with a sodium-restricted diet. A dependent intervention is prescribed by a physician or advanced practice nurse; for example, administer oxygen at 2 L/min via nasal cannula. PTS:1DIF:ModerateREF: p. 103 KEY: Nursing process: Interventions | Client need: Physiological integrity | Cognitive level: Application

In defiance of parental wishes, a Japanese teenager succumbs to peer pressure and gets a tattoo. According to Bowen's family systems theory, how should the community health nurse interpret the teenager's action? A. The teenager is attempting to differentiate self. B. The teenager is triangulating self. C. The teenager is cutting self off emotionally. D. The teenager is exhibiting antisocial traits.

ANS: A The teenager is taking on some of the cultural values of peers and is beginning to develop a unique identity. This process is called differentiation and is a normal task of adolescence. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

In a family that is in the life cycle stage called "The Family with Adolescents," which changes must occur for the family to proceed developmentally? A. Making adjustments within the marital system to meet the responsibilities of parenthood B. Establishing a new identity as a couple by realigning relationships with extended family C. Redefining the level of dependence so that adolescents are provided with greater autonomy D. Reestablishing the bond of the dyadic marital relationship

ANS: C Stage IV of the family life cycle is described as "The Family with Adolescents." The task of this stage is to redefine the level of dependence so that adolescents are provided with greater autonomy while parents remain responsive to teenagers' dependency needs. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A home health nurse is visiting an Asian family. A married couple, their three children, and the maternal grandparents all live in the home. How should the nurse interpret the presence of the grandparents in the home? A. The parents have diffuse boundaries and have allowed the grandparental subsystem to be present. B. The grandparental subsystem is not successfully managing separation from the parental subsystem. C. Extended family living arrangements are common in some cultures. D. The nuclear family living arrangement is the preferred environment for childrearing.

ANS: C The Asian culture highly respects the elderly. Having the grandparents living in the home is not uncommon in this culture. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

A fatherless, 11-year-old African American girl lives with her grandmother after the death of her mother. Her older stepbrother is very involved in her life. How should the community health nurse view this family constellation, and why? A. Abnormal; the grandmother should be concerned with issues other than childrearing. B. Abnormal; a two-parent household is the most advantageous arrangement for parenting. C. Normal; cultural variations exist in the family life cycle. D. Normal; because of their wisdom, older adults make better parenting figures.

ANS: C The nurse should be aware that cultural differences and specific events may lead to variety in family constellations. This is normal. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A depressed 21-year-old client has lived with his mother ever since the death of his father 3 years ago. After the client received a college acceptance, the mother repeatedly states, "That's wonderful. I'll be fine all alone." How would the nurse interpret the mother's statements? A. The mother is withholding supportive messages. B. The mother is expressing denigrating remarks. C. The mother is communicating indirectly. D. The mother is using double-bind communication.

ANS: D The client's mother says she is fine with him going away to college but then tries to make him feel guilty about her being left alone. The client is in a no-win situation because his mother has given a mixed message—a double-bind communication. KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Analysis | Client Need: Psychosocial Integrity

Which intervention by the nurse would be best to motivate a patient newly diagnosed with hypertension to learn about the prescribed treatment plan? 1)Explain that when left untreated, hypertension may lead to stroke. 2)Ask the patient to let you know when he is ready to learn. 3)Encourage the patient to learn about various treatment options. 4)Reassure the patient that adhering to the treatment produces a good outcome.

ANS:1 A patient newly diagnosed with hypertension may not be motivated to learn because he most likely has not experienced physical symptoms or other outward complications. Therefore, the nurse should motivate the patient by pointing out serious risks to the quality of life if the blood pressure control is not achieved. Although readiness to learn is an important consideration, treatment might be delayed too long if the patient does not appropriately perceive the immediacy of the health risk. Simply encouraging a patient to learn about blood pressure and treatment options might not be suitable motivation to engage in active learning and to comply with prescribed treatment. Reassuring the patient and promising a good outcome by complying with medical treatment is not appropriate. Adhering to medical therapy reduces the risk for stroke and other complications; however, this cannot be guaranteed. PTS:1DIF:ModerateREF:pp. 856-857

The nurse is preparing a patient for a computed tomography (CT) scan of the abdomen. Which statement by the nurse is best (all contain correct information)? 1) "You will need to remain NPO for the 4 hours prior to your CT scan." 2) "You cannot have anything to eat or drink for 4 hours before your test." 3) "You will need to be NPO and drink this contrast media before your test." 4) "You may need to void before you go down to the department for your CT scan

ANS:2 Telling the patient that he cannot have anything to eat or drink for a specific time before his test is the best statement. It uses terms that the patient can understand. The other options use medical jargon that many patients may not understand. PTS:1DIF:ModerateREF:p. 465 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment? 1) Small group 2) Interpersonal 3) Group 4) Intrapersonal

ANS:2 The nurse uses interpersonal communication when interviewing the patient about his health history during the admission assessment. Small-group communication occurs when a person engages in an exchange of ideas with two or more people at the same time. Group communication is interaction that occurs among several people. Intrapersonal communication is conscious internal dialogue. PTS:1DIF:ModerateREF:p. 464 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension

The nurse manager of the medical intensive care unit formed a group to help her staff cope with stress more effectively. Which of the comments by group members will lead the manager to evaluate the group as successful? 1) "This was a good idea to form a group; I've been wanting to get to know some of the people working the other shifts." 2) "It really helps me to share feelings about how hard it is to see pain and suffering every day." 3) "I now have a group to help me when I need to work through situations in my own life causing me stress." 4) "It feels good to have a chance to get away from the unit and talk on a regular basis."

ANS:2 Work-related social support groups assist members of a profession to cope with the stress associated with their work. The focus of the group is to share feelings about the stress of the work environment. Although this may also be an opportunity to meet other staff members, get away from the unit, or share personal and family problems, these are not the primary focus of the group. PTS:1DIF:ModerateREF:p. 473 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application

The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows she should use touch cautiously, especially when communicating with which patient? 1) Middle-aged woman just diagnosed with terminal lung cancer 2) Middle-aged man experiencing the acute phase of myocardial infarction 3) Older adult with a history of dementia admitted for dehydration 4) Young adult in the rehabilitative phase after arthroscopic surgery

ANS:3 The nurse should use touch especially cautiously when communicating with a person who suffers from impaired mental health, such as dementia, because the patient may have difficulty interpreting the meaning of touch. In general, touch can be used with most patients, such as patients with cancer, an acute MI, or general orthopedic surgery, and with all age groups. However, the nurse should always be conscious of the situation, environment, and receptivity of the patient. PTS:1DIF:ModerateREF:p. 467 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis

During admission to the unit, a patient states, "I'm not worried about the results of my tests. I'm sure I'll be all right." As he observes the patient, the nurse notes that the patient is shaky and tearful and does not make eye contact. Unfortunately, the nurse is called away to an emergency before he has time to complete this discussion. Which of the following actions is most appropriate for the nurse to establish when returning to the patient? Patient will 1) Explain the reason for his incongruent statements 2) Engage in diversional activities to cope with stress 3) Express his concerns to his primary care provider 4) Discuss his concerns and fears with the nurse

ANS:4 The nurse has observed a mismatch between verbal and nonverbal communication. Unfortunately, an emergency has required the nurse to leave the patient. To resolve this mismatch, the nurse will set a goal to have the patient discuss his concerns and fears at their next interaction. It is inappropriate to ask the patient to explain why his verbal message did not match the nonverbal message because this will inhibit further conversation. It may be appropriate to have the patient discuss his concerns with his primary care provider; however, we do not have enough information to suggest this course of action. For example, if the patient is upset about some other matter, this action would not be appropriate. Similarly, it is not appropriate to suggest diversional activities until the reason for the mismatch between his words and behavior is identified. PTS: 1 DIF: Moderate REF: p. 476 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application

_ 3. A belief about the worth of something that serves as a principle or a standard that influences decision making is called which of the following? 1) Morals 2) Attitudes 3) Beliefs 4) Values

Values ANS: 4 A value is a belief you have about the worth of something that serves as a principle or a standard that influences decision making. Morals are private, personal, or group standards of right and wrong. Attitudes are mental dispositions or feelings toward a person, object, or idea. A belief is something that one accepts as true.

criminal and civil laws

criminal law is a subsection of public law and relates to the relationship between an individual and the government. A nurse who falsifies a record to cover up a series mistake can be guilty of breaking a criminal law cilvil laws protect individual rights one type of cilvil law that relates to the provision of nursing care is tort law

Biculture

describes a person who identifies with two cultures and integrates some of the values and lifestyles of each into his life.

Culture

it is both universal (everyone has it) and dynamic (active). Is what people in a group have in common, but it changes over time.

unintentional tortes

negligence: a nurse fails to implement safety measures for a client at risk for falls. malpractice (professional negligence): a nurse administers a large dose of medication due to a calculation error. the client has a cardiac arrest and dies

Licensure

nurses must have a current license in every state in which they practice. the states (about half of the) that have adopted the nurse licensure compact are exceptions. this model allows licensed nurses who reside in a compact state to practice in other compact states under a militate license. within the compact, nurses must practice in accordance with the statues and rules of the state in which they provide care

Religion

refers to an ordered system of beliefs regarding the cause, nature, and purpose of the universe, especially the beliefs related to the worship of god or gods.

Race

refers to the grouping of people based on biological similarities, such as skin color, blood type, or bone structure.