Study Questions For Unit 9-12

While caring for a patient undergoing suctioning, the nurse suddenly insists on stopping the process of suctioning. Which parameter observed by the nurse supports this intervention? 1. Pulse oximetry of 90% 2. Body temperature of 99° F 3. Heart rate of 40 bpm 4. Respiratory rate of 20 breaths per minute

3

A patient who has atelectasis has a tracheostomy. While providing care, the nurse elevates the head of the patient's bed to 30 degrees and also changes the patient's body position frequently. What is the rationale behind the nurse's actions? 1. To prevent pulmonary aspiration 2. To maintain prolonged oral hygiene 3. To ensure an adequate sealing of the tube 4. To prevent the draining of the secretions from the tube

1

What should the nurse do when a patient with a tracheostomy tube experiences the signs and symptoms of respiratory distress? 1. Perform manual ventilation 2. Remove the outer cannula of the endotracheal tube 3. Remove secretions around the stoma 4. Seek the assistance of the nursing assistive personnel

1

While caring for a patient who has a chest tube, the nurse finds continuous bubbling in a water-seal chamber. Which intervention would be beneficial for the patient? 1. Unclamping the chest tube 2. Obtaining a large-gauge needle 3. Obtaining a flutter (Heimlich) valve 4. Determining that the chest tube is not occluded

1

While caring for a patient with respiratory disease, the nurse observes that the oxygen saturation drops from 94% to 85% when the patient ambulates. Which is the most appropriate nursing action? 1. Administer supplemental oxygen. 2. Obtain arterial blood gas (ABG) values to verify the oxygen saturation reading. 3. Continue to monitor the patient as this finding is a normal response to activity. 4. Move the oximetry probe from the finger to the earlobe for an accurate oxygen saturation measurement during activity

1

Why would the nurse request a humidification device while delivering oxygen to a patient in the home care setting? 1. Oxygen delivery greater than 4 L/minute 2. Storing oxygen delivery devices upright 3. Symptoms of hypoxia are noticed in the patient 4. Equipment is placed at least 8 ft from heat source

1

While caring for a patient who has hypoxia, the nurse finds that the patient's airway clearance is ineffective due to retention of thick pulmonary secretions. Which nursing interventions may be beneficial for the patient? Select all that apply. 1. Encouraging fluid intake 2. Teaching cascade cough 3. Administering antipyretic drugs 4. Administering intravenous antibiotics 5. Placing the patient in a low Fowler's position

1,2

The nurse is caring for a patient who has been diagnosed with pneumonia. The patient reports intermittent episodes of cough accompanied with thick yellow sputum. On auscultation, the nurse finds abnormal lung sounds (crackles) in the left base and both upper lobes. A chest x-ray reveals infiltrations in both upper lobes and the left lower lobe. Which instructions given by the nurse are appropriate for this patient? Select all that apply. 1. "Drink good quantities of warm water." 2. "Walk around as much as you can." 3. "Place a hot-water bag on your chest." 4. "Try to spend most of your time in prone position." 5. "Perform deep-breathing exercises once every 2 hours

1,2,5

The nurse is teaching a group of patients about respiratory disease. Which factors can affect the oxygen-carrying capacity of the blood? Select all that apply. 1. Anemia 2. Dysuria 3. Inhalation of toxins 4. Severe dehydration 5. Fracture of radius bone

1,3,4

A patient is admitted to a hospital with a myocardial infarction. Which common signs or symptoms should the nurse expect in this patient? Select all that apply. 1. The patient has a crushing or squeezing chest pain. 2. The pain does not last more than 20 minutes. 3. The pain is not ameliorated by rest or nitroglycerine. 4. There are convulsions and spasms of the extremities. 5. There may be shortness of breath along with chest pain

1,3,5

The nurse is caring for a patient who has been diagnosed with pneumonia. The blood gases report that was taken during admission indicates respiratory acidosis with mild hypoxemia. Repeated arterial blood gas (ABG) analysis reveals that hypoxemia is worsening. Presently, the PaO2 is 50 mm Hg and SpO2 is 70%. Which signs or symptoms consistent with decreased oxygen levels may the nurse find in the patient? Select all that apply 1. Tachypnea 2.Cough 3. Fever 4. Cyanosis 5. Tachycardia

1,4,5

The registered nurse instructs the nursing assistive person (NAP) to frequently reposition the elastic strap on the patient's oxygen mask. What is the rationale behind this? 1. To prevent epistaxis 2. To prevent skin breakdown 3. To prevent continued hypoxia 4. To prevent nasal mucosal dryness

2

Which nursing action is most appropriate during suctioning? 1. Picking up the connecting tubing with the dominant hand 2. Applying a clean glove to the dominant hand for oropharyngeal suctioning 3. Applying a sterile glove to the nondominant hand for artificial airway suctioning 4. Picking up a suction catheter with the nondominant hand and not letting the catheter touch nonsterile surfaces

2

Which position is appropriate in a patient who has a chest tube drainage system, in order to drain fluid from the chest? 1. Supine 2. High-Fowler's 3. Semi-Fowler's 4. Trendelenburg's

2

Which statement is true regarding chest tubes? 1. Chest tubes are routinely stripped to move clots. 2. Chest tubes are used in the treatment of pneumothorax. 3. Chest tube removal can be done without any patient preparation. 4. Chest tubes are catheters inserted through lungs to remove air from the pleural space

2

While caring for a patient who has a nasal cannula, the nurse loosens the elastic strap. Which unexpected patient outcome is responsible for the nurse's action? 1. Epistaxis 2. Skin irritation 3. Continuous hypoxia 4. Dry upper airway mucosa

2

During assessment, which finding indicates the presence of pneumothorax? 1. Absence of lung sounds on the affected side 2. Inability to auscultate tracheal breath sounds 3. Pleuritic pain that worsens on inspiration

3

The nurse is observing a patient's respiratory rate and depth. During which stage of the nursing process does this take place? 1. Planning 2. Evaluation 3. Assessment 4. Implementation

3

What is the consequence of using an artificial airway that is too large? 1. Hypotension 2. Thick secretions 3. Airway obstruction 4. Aspiration of gastric contents

3

Which type of oxygen mask is contraindicated for patients who have carbon dioxide retention? 1.Venturi mask 2. Nasal cannula 3.Simple face mask 4. Partial rebreather

3

he hemoglobin level of a patient who has pallor and looks weak is 8 g/dL. Upon assessment, the patient's heart rate is 110 bpm and respiratory rate is 30 breaths per minute. Which physiological factor is directly responsible for this condition? 1.Increased metabolic rate 2.Reduced circulating blood volume 3.Decreased oxygen-carrying capacity 4.Decreased inspired oxygen concentration

3

Which age-related changes in the older adult may result in decreased tissue oxygenation due to impaired chest expansion? Select all that apply. 1. Change in cough mechanism 2. Impairment of the immune system 3. Ossification of costal cartilage 4. Decreased intervertebral space 5. Diminished respiratory muscle strength

3, 4, 5

A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds? 1. Sonorous wheezes in the left lower lung 2. Rhonchi midsternum 3. Crackles only in apex of lungs 4. Inspiratory crackles in lung bases

4

A patient who has a history of chronic obstructive pulmonary disease (COPD) and diabetes mellitus develops hypoventilation. What does the nurse suspect is the cause of the hypoventilation? 1. Salicylate poisoning 2. Diabetic ketoacidosis 3. Amphetamine overdose 4. Overdose of oxygen therapy

4

A registered nurse evaluates the actions of a nursing student who is performing tracheal suctioning in a patient who has a history of respiratory distress. Which of the student's nursing actions indicates effective learning? 1. Applying the suction before the patient has coughed 2. Applying suction pressure while inserting the catheter 3. Continuing the press without allowing rests in between passes of the catheter 4. Maintaining the suction pressure between 120 and 150 mm Hg while withdrawing the catheter

4

The nurse is suctioning the tracheostomy in a patient. Which step in the nursing process is the nurse performing? 1. Planning 2. Evaluation 3. Assessmen 4. Implementation

4

What is the most serious complication of a tracheostomy? 1. Hypoxemia 2. Arrhythmia 3. Hypotension 4. Airway obstruction

4

What is the reason for heart failure after myocardial infarction (MI)? 1. Increased myocardial workload 2. Increased oxygen demands of the myocardium 3. Inability of the heart chambers to fill adequately 4. Impairment of the contractile function of the ventricle

4

A client with chronic obstructive pulmonary disease has a physician's prescription stating, "Adjust oxygen to keep SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN? A) Adjust the position of the oxygen tubing. B) Assess for signs and symptoms of hypoventilation. C) Change the O2 flow rate to keep SpO2 as prescribed. D) Choose which O2 delivery device should be used for the client.

A) The scope of a nursing assistant's work includes positioning of oxygen tubing for client comfort.

A client with asthma reports shortness of breath. What is the nurse assessing when auscultating this clients chest? A) Adventitious breath sounds B) Fremitus C) Oxygenation Status D) Respiratory excursion

A) Adventitious sounds are additional breath sounds superimposed on normal sounds. They indicate pathologic changes in the lung.

Which of the following skills can safely be delegated routinely to an NAP? A) Oropharyngeal suctioning B) Airway suctioning using a closed method C) Endotracheal tube care D) Tracheostomy care

A) Although an NAP may routinely handle oropharyngeal suctioning, the other skills require the training and judgment of an RN. The nurse is responsible for cardiopulmonary assessment and evaluation of the patient during the skill performance. Only in cases of a permanent tracheostomy or a well-established artificial airway in a stable patient may the skill of suctioning be delegated to an NAP.

Four clients are sent back to the emergency department from triage at the same time. Which client requires the nurse's immediate attention? A. Client with acute allergic reaction B. Client with dyspnea on exertion C. Client with lung cancer with cough D. Client with sinus infection with fever

A) An acute allergic reactions can lead to immediate respiratory distress. This is an emergent situation that requires the immediate attention of the nurse.

Which client has the most urgent need for frequent nursing assessment? A) An older adult client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year 2-pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask B) A young client who has had a tracheostomy for 1 week, who is on room air with SpO2 at percents in the upper 90's, who has been receiving antibiotic therapy for 16 hours, and who has foul-smelling drainage on the tracheostomy ties C) An older adult client who is anxious to go home with her new tank of oxygen and supply of nasal cannulas and is being discharged with a new prescription for home oxygen therapy D) A middle-aged client who was admitted yesterday with pneumonia and is receiving oxygen at 2 L/min through a nasal cannula

A) An older adult client with a long history of smoking and chronic lung disease who is receiving high-flow oxygen delivery is at elevated risk for respiratory depression owing to the hypoxic drive of respirations countered by high levels of oxygen. This client must be assessed frequently while receiving high-flow oxygen.

The RN has received report about all of these clients. Which client needs the most immediate assessment? A) Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry. B) Client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes C) Client with bronchogenic lung cancer who returned from bronchoscopy 3 hours ago D) Client with pleural effusion who has decreased breath sounds at the right base

A) An oxygen saturation level less than 91% indicates hypoxemia and requires immediate assessment and intervention to improve blood and tissue oxygenation

A client is admitted to the medical floor with a new diagnosis of lung cancer. How can the nurse assist the client initially with the anxiety associated with the new diagnosis? A) Encourage client to ask questions and verbalize concerns. B) Leave client alone to deal with his own feelings. C) Medicate client with diazepam (Valium) for anxiety every 8 hours. D) Provide journals about cancer treatment.

A) Anxiety causes increased oxygen consumption. Oxygen availability is limited in lung cancer. The availability of the nurse to answer questions and listen to the client's concerns will decrease anxiety.

In the older adult client, which respiratory change does not require further assessment by the nurse? A) Increased anteroposterior (AP) diameter B) Increased respiratory rate C) Shortness of breath D) Sputum production

A) Increased AP diameter is normal with aging

A patient is to be placed on a ventilator. Which nursing action has been found to be most effective in reducing ventilator-associated pneumonia? A) Performing mouth care at least four times a day B) Repositioning the patient every 2 to 3 hours C) Assessing lung sounds every shift D) Performing range-of-motion exercises three times a day

A) Studies have shown that frequent mouth care decreases the incidence of ventilator-associated pneumonia. The other procedures are important to do, but they do not affect the incidence of ventilator-associated pneumonia.

The peak pressure alarm is sounding on the ventilator of the client with a recent tracheostomy. What intervention should be done first? A) Assess the client's respiratory status. B) Decrease the sensitivity of the alarm. C) Ensure that the connecting tubing is not kinked. D) Suction the client.

A) The client must always be assessed before attention is turned to equipment.

For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube? A) Hyperoxygenate before and after suctioning. B) Repeat suctioning until the tube is clear. C) Apply suction during insertion of the tube. D) Suction for 30 seconds.

A) The client should be preoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning, the client should be hyperoxygenated for 1 to 5 minutes, or until the client's baseline heart rate and oxygen saturation are within normal limits.

The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? A) Appearance and behavior B) Measurement of vital signs C) Observing specific body systems D) Conducting a detailed health history

A) The nurse inspects appearance and behavior first as part of the nursing assessment. As the patient enters the room, the nurse can observe his or her appearance and behavior, noting any unusual choice of clothing or hygiene or any signs of confusion, anxiety, or happiness.

The low-pressure alarm has sounded on a patients ventilator. The nurse should check for which of the following situations? A) The ventilator circuit has a leak. B) The patient coughed during the inspiratory cycle. C) The airway needs suctioning. D) The patient is biting on the endotracheal tube.

A) The two most common causes for the low-pressure alarm sounding (indicating a sudden drop in pressure) are a leak in the ventilate circuit or the patient tube becoming disconnected from the ventilator. Patient coughing or biting on the ET tube may cause the high pressure alarm to sound. Secretions building up in the airway may cause a decrease in the pressure but not a sudden drop. Suctioning is the correct way to address that situation when identified.

A patient with pulmonary edema had BiPAP started 30 minutes ago. The nurse should inform the patient that he will undergo which diagnostic test shortly? A) Arterial blood gas B) Chest X-ray C) Pulmonary function test D) Pulse oximetry reading

A) When a patient is placed on noninvasive positive-pressure ventilation (BiPAP), it is necessary to evaluate the oxygenation and ventilation status of the patient. Although an arterial blood gas is an invasive procedure, it is important to know the patient's oxygen and carbon dioxide levels. Chest X-ray will provide information on fluid overload, and a pulmonary function test is inappropriate when a patient is acutely ill. A pulse oximetry reading would yield information on oxygenation

The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient? A) Nasal cannula B) Venturi mask C) Simple face mask without inflated reservoir bag D) Plastic face mask with inflated reservoir bag

A) A nasal cannula delivers precise, high-flow rates of oxygen.

The nurse auscultates popping, discontinuous sounds over the client's anterior chest. How does the nurse classify these sounds? A. Crackles B. Rhonchi C. Pleural friction rub D. Wheeze

A) Crackles are described as a popping, discontinuous sound cause be air moving into previously deflated airways. The airways have been deflated do the presence of fluids in the lung, and crackles should be considered to be a sign of fluid overload.

Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? A)Record the amount and continue to monitor drainage B)Notify the health care provider C)Strip the chest tube starting at the chest D) Increase the suction by 10 mm Hg

A) Dark-red drainage after surgery (50 to 200 mL per hour in first 3 hours) is expected, but be aware of sudden increases greater than 100 mL per hour after the first 3 hours, especially if it becomes bright red in color.

The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first? A) Raise the head of the bed to 45 degrees B) Take his oxygen saturation with a pulse oximeter. C) Take his blood pressure and respiratory rate. D) Notify the health care provider of his shortness of breath.

A) Raising the head of the bed brings the diaphragm down and allows for better chest expansion, thus improving ventilation.

A patient was admitted after a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax, which includes which of the following? A) Sharp pleuritic pain that worsens on inspiration B) Crackles over lung bases of affected lung C) Tracheal deviation toward the affected lung D) Increased diaphragmatic excursion on side of rib fractures

A) When the lung collapses, the thoracic space fills with air on each inspiration, and the atmospheric air irritates the parietal pleura, causing pain.

The nurse is caring for a patient who exhibits labored breathing and uses accessory muscles. The patient has crackles in both lung bases and diminished breath sounds. Which would be priority assessments for the nurse to perform? (Select all that apply.) A) SpO2 levels B) Amount of sputum production C) Change in respiratory rate and pattern D) Pain in lower calf area

A,B,C Pain in the lower calf area indicates vascular, not respiratory, status.

Which of the following are necessary to prepare the patient for postural drainage? (Select all that apply.) A) Encourage fluid intake of 1500 to 2000 mL B) Explain the procedure and positioning techniques. C) Schedule treatment 1 to 2 hours after meals. D) Coordinate treatments with other respiratory or

A,B,C,D Coordinating therapy around a patients meals and activities reduces the risks for aspiration, conflict with other therapies, and fatigue. In addition, adequate fluid intake helps to liquefy secretions so the patient can easily clear them. As always, informing patients of any therapy promotes cooperation and decreases anxiety.

Which of the following are signs and symptoms of a tension pneumothorax? (Select all that apply.) A) Distended neck veins B) Hypotension C) Hypertension D) Tachycardia

A,B,D Distended neck veins, hypotension, and tachycardia are cardinal signs of a tension pneumothorax. Option "C," hypertension, is not normally seen in a tension pneumothorax.

Which of these assessment findings will be of greatest concern when the nurse is assessing a client with emphysema? A) Barrel-shaped chest B) Bronchial breath sounds heard at the bases C) Hyperresonance to percussion of the chest D) Ribs lying horizontal

B) Bronchial breath sounds are not normally heard in the periphery and may indicate increased lung density, as in a tumor or an infective process such as pneumonia.

Which of the following statements by a new graduate nurse should be corrected by an experienced nurse? a. "Most older patients are ill and disabled. That's why we care for so many of them in the hospital." b. "Older adults are many times still interested in sexual relations." c. "Patients over age 65 are still lifelong learners." d. "Many older adult patients remain independent enough to live alone."

ANS: A Although many experience chronic conditions or have at least one disability that limits their performance of activities of daily living, in 2004, 37.4% of noninstitutionalized older adults assessed their health as excellent or very good. Older adults do report continued enjoyment of sexual relationships. Although changes in vision or hearing and reduced energy and endurance sometimes affect the process of learning, older adults are lifelong learners. Most older adults live in noninstitutional settings with family members or alone.

The client with a new tracheostomy has a soiled dressing. What is the best nursing intervention? A) Cut sterile 4 × 4 gauze to fit around the tracheostomy tube. B) Reinforce the dressing with sterile 4 × 4 gauze. C) Replace the dressing with clean, folded 4 × 4 gauze. D) Replace the dressing with sterile, folded 4 × 4 gauze.

D

Several theories on aging have been put forth, and the nurse should use these theories to a.Guide nursing care. b.Explain the stochastic view of genetically programmed physiological changes. c.Select one theory to guide nursing care for all geriatric patients. d.Understand the nonstochastic views of aging as the result of cellular damage.

ANS: A Although theories on aging are in various stages of development and have limitations, the nurse should use them to increase understanding of the phenomena affecting the health and well-being of older adults and to guide nursing care. Stochastic theories view aging as the result of random cellular damage occurring over time. No one single universally accepted theory predicts and explains the complexities of the aging process. Nonstochastic theories view aging as the result of genetically programmed physiological mechanisms within the body.

Which factors should the nurse assess to determine a patient's ability to learn? a. Developmental capabilities and physical capabilities b. Sociocultural background and motivation c. Psychosocial adaptation to illness and active participation d. Stage of grieving and overall physical health

ANS: A Developmental and physical capabilities reflect one's ability to learn. Sociocultural background and motivation are factors in readiness to learn. Psychosocial adaptation to illness and active participation are factors in readiness to learn. Readiness to learn is related to the stage of grieving. Overall physical health does reflect ability to learn; however, because it is paired here with stage of grieving (which is a readiness to learn factor), this is a wrong answer.

In caring for the patient's spiritual needs, the nurse understands that a. Establishing presence is part of the art of nursing. b. Presence involves "doing for" the patient. c. A caring presence involves listening to the patient's wishes only. d. The nurse must use her expertise to make decisions for the patient.

ANS: A Establishing presence is part of the art of nursing. Presence involves "being with" a patient versus "doing for" a patient. Demonstrate a caring presence by listening to the patient's concerns and willingly involving family in discussions about the patient's health. Show self-confidence when providing health instruction, and support patients as they make decisions about their health. 14

While preparing a teaching plan, the nurse described what the learner will be able to accomplish after the teaching session. Which action did the nurse complete? a. Developed learning objectives b. Provided positive reinforcement c. Implemented interpersonal communication d. Presented facts and knowledge

ANS: A Learning objectives describe what the learner will be able to do after successful instruction. Positive reinforcement follows feedback and involves the use of praise and acknowledgment of new attitudes, behaviors, or knowledge. Interpersonal communication is necessary for the teaching/learning process, but describing what the learner will be able to do after successful instruction constitutes learning objectives. Facts and knowledge will be presented in the teaching session.

During assessment of an older adult's skin integrity, expected findings include which of the following? a. Decreased elasticity b. Oily skin c. Increased facial hair in men d. Faster nail growth

ANS: A Loss of skin elasticity is a common finding in the older adult. Other common findings include pigmentation changes, glandular atrophy (oil, moisture, sweat glands), thinning hair (facial hair: decreased in men, increased in women), slower nail growth, and atrophy of epidermal arterioles.

Which of these findings, if identified in a patient on a gerontological unit, would be most surprising to a culturally sensitive nurse? a. The older person not being functionally independent b. Preferences in food, music, and religion c. Use of conventions of the handshake, silence, and eye contact d. Personal health practices and spiritual resources

ANS: A Most older people remain functionally independent despite the increasing prevalence of chronic disease. Examples of culturally competent nursing approaches to older adults include respect for preferences in food, music, and religion; appropriate use of conventions of the handshake, silence, and eye contact; use of interpreters; use of physical assessment norms appropriate for the ethnic group; and asking about personal health practices, family customs, lifestyle preferences, and spiritual resources.

A nurse provides teaching about coping with long-term impaired functions. Which situation serves as the best example? a. Teaching a family member to give medications through the patient's permanent gastric tube b. Teaching a woman who recently had a hysterectomy about her pathology reports c. Teaching expectant parents about physical and psychological changes in childbearing women d. Teaching a teenager with a broken leg how to use crutches

ANS: A Not all patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations. New knowledge and skills are often necessary for patients and/or family members to continue activities of daily living. Teaching family members to help the patient with health care management (e.g., giving medications through gastric tubes, doing passive range-of-motion exercises) is an example of coping with long-term impaired functions. Injured and ill patients need information and skills to help them regain or maintain their levels of health. Some examples of this include teaching a woman who recently had a hysterectomy about her pathology reports and expected length of recovery and teaching a teenager with a broken leg how to use crutches. In childbearing classes, you teach expectant parents about physical and psychological changes in the woman and about fetal development; this is part of health maintenance.

Which learning objective/outcome has the highest priority for a patient with life-threatening, severe food allergies that require an EpiPen (epinephrine)? a. The patient will administer epinephrine. b. The patient will identify the main ingredients in several foods. c. The patient will list the side effects of epinephrine. d. The patient will learn about food labels

ANS: A Once you assist in meeting patient needs related to basic survival (how to give epinephrine), you can discuss other topics, such as nutritional needs and side effects of medications. For example, a patient recently diagnosed with coronary artery disease has deficient knowledge related to the illness and its implications. The patient benefits most by first learning about the correct way to take nitroglycerin and how long to wait before calling for help when chest pain occurs. Thus, in this situation, the patient benefits most by first learning about the correct way to take epinephrine. "The patient will learn about food labels" is not objective and measurable and is not correctly written.

A patient had a stroke and must use a cane for support. A nurse is preparing to teach the patient about the cane. Which learning objective/outcome is most appropriate? a. The patient will walk to the bathroom and back to bed using a cane. b. The patient will understand the importance of using a cane. c. The patient will learn how to use a cane. d. The patient will know the correct use of a cane.

ANS: A Outcomes often describe a behavior that identifies the patient's ability to do something on completion of teaching such as will empty colostomy bag, or will administer an injection. Understand, learn, and know are not behaviors that can be observed or evaluated.

One of the greatest challenges for the nurse caring for older adults is ensuring safe medication use. One way to reduce the risks associated with medication usage is to a.Periodically review the patient's list of medications. b.Inform the patient that polypharmacy is to be avoided at all cost. c.Be aware that medication is absorbed the same way regardless of patient age. d.Focus only on prescribed medications.

ANS: A Periodic and thorough review of all medications is important to restrict the number of medications used to the fewest necessary to ensure the greatest therapeutic benefit with the least amount of harm. Although polypharmacy reflects inappropriate prescribing, the concurrent use of multiple medications is necessary in situations where an older adult has multiple acute and chronic conditions. Older adults are at risk for adverse drug effects because of age-related changes in the absorption, distribution, metabolism, and excretion of drugs. Work collaboratively with the older adult to ensure safe and appropriate use of all medications—both prescribed medications and over-the-counter medications.

The nurse correctly describes psychosocial theories on aging as theories that a. Describe role changes in behaviors in older adults. b. Emphasize that all adults age in similar ways. c. Stress the need for the aging to discontinue activities as they age. d. Describe behavior patterns for all aging adults as unpredictable.

ANS: A Psychosocial theories of aging explain changes in behaviors, roles, and relationships that come with aging. Although some theories generalize about aging, biologically and psychosocially each individual ages uniquely. The activity theory considers the continuation of activities performed during middle age as necessary for successful aging. The continuity theory states that personality remains the same and behavior becomes more predictable as people age.

11. When the nurse describes a patient's perceived ability to successfully complete a task, which term should the nurse use? a. Self-efficacy b. Motivation c. Attentional set d. Active participation

ANS: A Self-efficacy, a concept included in social learning theory, refers to a person's perceived ability to successfully complete a task. Motivation is a force that acts on or within a person (e.g., an idea, an emotion, a physical need) to cause the person to behave in a particular way. An attentional set is the mental state that allows the learner to focus on and comprehend a learning activity. Learning occurs when the patient is actively involved in the educational session.

In assessing the spiritual health of her patients, the nurse understands that a. Spiritual beliefs change as patients grow and develop. b. Spiritual health in older adults leads to peace and acceptance of others. c. Older adults often express spirituality by focusing on themselves. d. The basis of beliefs among older people is focused on one or two factors.

ANS: A Spiritual beliefs change as patients grow and develop. Health spirituality in older adults leads to peace and acceptance of self. However, older adults often express their spirituality by turning to important relationships and giving of themselves to others. Beliefs among older people vary based on many factors, such as gender, past experience, religion, economic status, and ethnic background.

A complex concept that is unique to each individual; is dependent upon a person's culture, development, life experiences, beliefs, and ideas about life; and is a unifying theme in peoples' lives is called a. Spirituality. b. Religion. c. Self-transcendence. d. Faith.

ANS: A Spirituality is a complex concept that is unique to each individual; is dependent upon a person's culture, development, life experiences, beliefs, and ideas about life; and is a unifying theme in peoples' lives. Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality. Self-transcendence is the belief that there is a force outside of and greater than the person. Faith allows people to have firm beliefs despite lack of physical evidence.

A patient with gradual, progressive cognitive impairment (dementia) is admitted to the nursing unit after hip replacement surgery. Which of the following is a nursing care principle for care of cognitively impaired older adults? a. Maintain physical health. b. Evaluate the patient's manifestations of standard symptoms. c. Assist patient with all ADLs. d. Isolate patients to protect others.

ANS: A The nurse works to monitor and maintain physical health. The nurse should also assess the person's unique manifestations of the disease as it progresses while facilitating independent performance of activities of daily living (ADLs). Social interaction based on the patient's abilities is to be promoted.

A patient has been taught how to cough and deep breathe. Which evaluation method is most appropriate? a. Return demonstration b. Computer instruction c. Verbalization of steps d. Cloze test

ANS: A To demonstrate mastery of the skill, have the patient perform a return demonstration under the same conditions that will be experienced at home or in the place where the skill is to be performed. Computer instruction is use of a programmed instruction format in which computers store response patterns for learners and select further lessons on the basis of these patterns (programs can be individualized). Computer instruction is a teaching tool, rather than an evaluation tool. Verbalization of steps can be an evaluation tool, but it is not as effective as a return demonstration when evaluating a psychomotor skill. The Cloze test, a test of reading comprehension, asks patients to fill in the blanks in a written paragraph.

Which of these assessments of an older adult, who has a urinary tract infection, requires an immediate nursing intervention? a.Presbycusis b.Confusion c.Death of a spouse 3 months ago d.Temperature of 97.6° F

ANS: B Confusion is a common manifestation in older adults with urinary tract infection; however, the cause requires further assessment. There may be another reason for the confusion. Confusion is not a normal finding in the older adult, even though it is commonly seen with concurrent infections. Difficulty hearing, presbycusis, is an expected finding in an older adult. Coping with the death of a spouse is a psychosocial concern to be addressed after the acute physiological concern in this case. Older adults tent to have lower temperatures, so the nurse needs to assess for slight elevations. A temperature of 97.6° F is within normal limits.

The word spirituality derives from the Latin word spiritus, which refers to breath or wind. Today, spirituality is a. Awareness of one's inner self and a sense of connection to a higher being. b. Less important than coping with the patient's illness. c. Patient centered and has no bearing on the nurse's belief patterns. d. Equated to formal religious practice and has a minor effect on health care.

ANS: A Today, spirituality is often defined as an awareness of one's inner self and a sense of connection to a higher being, to nature, or to some purpose greater than oneself. Spirituality is an important factor that helps individuals achieve the balance needed to maintain health and well-being and to cope with illness. It positively affects and enhances health, quality of life, health promotion behaviors, and disease prevention activities. Nurses need an awareness of their own spirituality to provide appropriate and relevant spiritual care to others. The concepts of spirituality and religion are often interchanged, but spirituality is a much broader and more unifying concept than religion. The human spirit is powerful, and spirituality has different meanings for different people.

When evaluating a patient's risk for spiritual crises, which of the following are part of the evaluation process? (Select all that apply.) a. Review the patient's self-perception regarding spiritual health. b. Review the patient's view of his/her purpose in life. c. Discuss with family and associates the patient's connectedness. d. Ask whether the patient's expectations are being met. e. Impress on the patient that spiritual health is permanent once obtained.

ANS: A, B, C, D One critical thinking model for spiritual health evaluation lists the evaluation process as including a review of the patient's self-perception regarding spiritual health, the patient's view of his/her purpose in life, discussion with the family and close associates about the patient's connectedness, and determining whether the patient's expectations are being met. Attainment of spiritual health is a lifelong goal.

Which statements by the nurse indicate a good understanding of patient education/teaching? (Select all that apply.) a. "Patient education is a standard for professional nursing practice." b. "Patient teaching falls within the scope of nursing practice." c. "Patient education is an essential component of safe, patient-centered care." d. "Patient education is not effective with children." e. "Patient teaching can increase health care costs." f. "Patient teaching should be documented in the chart."

ANS: A, B, C, F Patient education has long been a standard for professional nursing practice. All state Nurse Practice Acts acknowledge that patient teaching falls within the scope of nursing practice. Patient education is an essential component of providing safe, patient-centered care. It is important to document evidence of successful patient education in patients' medical records. Patient education is effective for children. Different techniques must be used with children. Creating a well-designed, comprehensive teaching plan that fits a patient's unique learning needs reduces health care costs, improves the quality of care, and ultimately changes behaviors to improve patient outcomes.

As the aging population in the United States increases, the nurse knows that the a. Baby boomer generation accounts for a very small percentage of this group. b. Extension of the average life span has also increased. c. Population segment over age 85 is decreasing. d. Diversity of this age group will certainly decrease.

ANS: B According to estimates, the number of older adults will increase to 72.1 million by 2030. Part of that increase is due to extension of the average life span. Two other factors that contribute to the projected increase in the number of older adults are the aging of the baby boom generation and the growth of the population segment over age 85. The baby boomers are the large group of adults born between 1946 and 1964.The diversity of the group over age 65 will also possibly increase.

22. A patient with heart failure is learning to reduce salt in the diet. When would be the best time for the nurse to address this topic? a. At bedtime, when the patient is relaxed b. At lunchtime while the nurse is preparing the food tray c. At bath time, when the nurse is cleaning the patient d. At medication time, when the nurse is administering patient medication

ANS: B Appropriate times to talk about food/diet changes during routine nursing care are at breakfast, lunch, and dinner times or when the patient is completing the menu. Many nurses find that they are able to teach more effectively while delivering nursing care. For example, while hanging blood, you explain to the patient why the blood is necessary and the symptoms of a transfusion reaction that need to be reported immediately. In this situation, because the teaching is about food, coordinating it with routine nursing care that involves food can be effective. At bedtime would be a good time to discuss routines that enhance sleep. At bath time would be a good time to describe skin care and how to prevent pressure ulcers. At medication time would be a good time to explain the purposes and side effects of the medication.

Which nursing action is most appropriate for assessing a patient's learning needs? a. Assess the patient's total health care needs. b. Assess the patient's health literacy. c. Assess all sources of patient data. d. Assess the goals of patient care

ANS: B Because health literacy influences how you deliver teaching strategies, it is critical for you to assess a patient's health literacy before providing instruction. The nursing process requires assessment of all sources of data to determine a patient's total health care needs. Evaluation of the teaching process involves determining outcomes of the teaching/learning process and the achievement of learning objectives, not patient care. Assessing the goal of meeting patient care is the evaluation component of the nursing process.

A student nurse learns that a normal adult heartbeat is 60 to 100 beats/minute. In which domain did learning take place? a. Kinesthetic b. Cognitive c. Affective d. Psychomotor

ANS: B Cognitive learning includes all intellectual behaviors and requires thinking. In the hierarchy of cognitive behaviors, the simplest behavior is acquiring knowledge. The student nurse acquired knowledge, which is cognitive. Kinesthetic is a type of learner who learns best with a hands-on approach. Affective learning deals with expression of feelings and acceptance of attitudes, opinions, or values. Psychomotor learning involves acquiring skills that require integration of mental and muscular activities, such as the ability to walk or to use an eating utensil.

As a patient ages, the nursing plan of care a. Should be standardized because all geriatric patients have the same needs. b. Needs to be individualized to the patient's unique needs. c. Should be based on chronological age alone. d. Focuses on the disabilities that all aging persons face.

ANS: B Every older adult is unique, and the nurse needs to approach each one as a unique individual. The nursing care of older adults poses special challenges because of great variation in their physiological, cognitive, and psychosocial health. Nurses need to take into account the cultural, ethnic, and racial diversity represented by these numbers (not just age) as they care for older adults from these groups. Aging does not inevitably lead to disability and dependence.

A nurse is teaching a patient about the Speak Up Initiatives. Which information should the nurse include? a. The nurse is the center of the health care team. b. If you still do not understand, ask again. c. Ask a nurse to be your advocate or supporter. d. Inappropriate medical tests are the most common mistakes.

ANS: B If you still do not understand, ask again is part of the S portion of the Speak Up Initiatives. Speak up if you have questions or concerns. You (the patient) are the center of the health care team, not the nurse. Ask a trusted family member or friend to be your advocate (advisor or supporter), not a nurse. Medication errors are the most common health care mistakes, not inappropriate medical tests

23. A nurse is teaching a patient who has low health literacy about chronic obstructive pulmonary disease (COPD) while giving COPD medications. Which technique is most appropriate for the nurse to use? a. Use complex analogies to describe COPD. b. Include the most important information on COPD at the beginning of the session. c. Ask for feedback to assess understanding of COPD at the end of the session. d. Offer pamphlets about COPD written at the eighth grade level with large type

ANS: B Include the most important information at the beginning of the session for illiterate patients or patients with a learning disability. Also, use visual cues and simple, not complex, analogies when appropriate. Another technique is to frequently ask patients for feedback to determine whether they comprehend the information. Additionally, provide teaching materials that reflect the reading level of the patient, with attention given to short words and sentences, large type, and simple format (generally, information written on a fifth grade reading level is recommended for adult learners).

Which action best indicates that learning has occurred? a. A nurse presents information about diabetes.' b. A patient demonstrates how to inject insulin. c. A family member listens to a lecture on diabetes. d. A primary care provider hands a diabetes pamphlet to the patient

ANS: B Learning is the purposeful acquisition of new knowledge, attitudes, behaviors, and skills. Complex patterns are required if the patient is to learn new skills, change existing attitudes, transfer learning to new situations, or solve problems. A new mother exhibits learning when she demonstrates how to bathe her newborn. A nurse presenting information and a primary care provider handing a pamphlet to a patient are examples of teaching. A family member listening to a lecture does not indicate that learning occurred; a change in knowledge, attitudes, behaviors, and/or skills must be evident.

An 80-year-old male is brought to the emergency department with an exacerbation of chronic obstructive pulmonary disease (COPD). He states that he quit smoking 30 years ago, so it can't be COPD. He argues, "It's just these colds I've been getting. They're just getting worse and worse." The nurse understands that a. These symptoms are more associated with normal aging than with disease. b. Older adults do not have to alter physical activity because of physical changes. c. The patient's age will require adjustment of lifestyle to one of inactivity. d. Older adults usually are aware and accepting of the aging process.

ANS: B Older adults face the necessity of adjustment to the physical changes that accompany aging. As body systems age, changes in appearance and functioning occur. These changes are not associated with a disease but are normal changes. The presence of disease sometimes alters the timing of the changes or their impact on daily life. Acceptance of personal aging does not mean retreat into inactivity, but it does require a realistic review of strengths and limitations. Some older adults find it difficult to accept that they are aging.

An outcome for an older adult patient living alone is to be free from falls. Which of these statements by a patient indicates that teaching on safety concerns has been effective? a. "I'll leave my throw rugs in place so that my feet won't touch the cold tile." b. "I'll take my time getting up from the bed or chair." c. "I should wear my favorite smooth bottom socks to protect my feet when walking around." d. "I will have my son dim the lighting outside to decrease the glare in my eyes."

ANS: B Older adults taking medications with adverse effects such as postural hypotension, dizziness, or sedation need to be aware of these potential effects and to take precautions such as changing position slowly or ambulating with assistance if unsteady. Household items that are easy to trip over, such as throw rugs, are a risk factor for falls. Other risk factors include wearing shoes in poor repair or slippery soles. Impaired vision and poor lighting are other risk factors.

A patient has been taught how to change a colostomy bag but is having trouble measuring and manipulating the equipment and has many questions. What is the nurse's next action? a. Refer to a mental health specialist. b. Refer to an ostomy specialist. c. Refer to a dietitian. d. Refer to a wound care specialist.

ANS: B Resources that specialize in a particular health need (e.g., wound care or ostomy specialists) are integral to successful patient education. A mental health specialist is helpful for emotional issues rather than for physical problems. A dietitian is a resource for nutritional needs. A wound care specialist provides complex wound care.

Which symptom is an expected cognitive change in the older adult patient? a. Disorientation b. Slower reaction time c. Poor judgment d. Loss of language skills

ANS: B Slower reaction time is a common change in the older adult owing to degeneration of nerve cells, decreased neurotransmitters, and decreased rate of conduction of impulses. Symptoms of cognitive impairment, such as disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are not normal aging changes and require further investigation of underlying causes.

The nurse is caring for a patient who claims that he does not believe in God, nor does he believe in an "ultimate reality." The nurse realizes that this patient a. Is devoid of spirituality. b. Is an atheist/agnostic. c. Finds no meaning through relationships with others. d. Believes that what he does is meaningless.

ANS: B Some individuals do not believe in the existence of God (atheist) or believe that there is no known ultimate reality (agnostic). This does not mean that spirituality is not an important concept for the atheist or the agnostic. Atheists search for meaning in life through their work and their relationships with others. Agnostics discover meaning in what they do or how they live because they find no ultimate meaning for the way things are. They believe that people bring meaning to what they do.

Which of the following statement about religion and spirituality is true? a. Religion is a unifying theme in people's lives. b. Spirituality is unique to the individual. c. Spirituality encompasses religion. d. Religion and spirituality are synonymous.

ANS: B Spirituality is a complex concept that is unique to each individual. Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality. People from different religions view spirituality differently. Although closely associated, spirituality and religion are not synonymous. Religious practices encompass spirituality, but spirituality does not need to include religious practice.

A nurse is asked about the goal of patient education. What is the nurse's best response? The goal of educating others is to help people a. Meet standards of the Nurse Practice Act. b. Achieve optimal levels of health. c. Become dependent on the health care team. d. Provide self-care only in the hospital.

ANS: B The goal of educating others about their health is to help individuals, families, or communities achieve optimal levels of health. Although all state Nurse Practice Acts acknowledge that patient teaching falls within the scope of nursing practice, this is the nurse's standard, not the goal of education. Patient education helps patients make informed decisions about their care and become healthier and more independent, not dependent. Nurses provide patients with information needed for self-care to ensure continuity of care from the hospital to the home.

A nurse is preparing to teach a patient about heart failure. Which environment is best for patient learning? a. A darkened, quiet room b. A well-lit, ventilated room c. A private room at 85° F temperature d. A group room for 10 to 12 patients with heart failure

ANS: B The ideal environment for learning is a room that is well lit and has good ventilation, appropriate furniture, and a comfortable temperature. Although quiet is appropriate, a darkened room interferes with the patient's ability to watch your actions, especially when you are demonstrating a skill or using visual aids such as posters or pamphlets. A room that is cold, hot, or stuffy makes the patient too uncomfortable to focus on the information being presented. Learning in a group of six or fewer is more effective than in larger groups and avoids outburst behaviors.

The nurse and the patient have the same religious affiliation. Because of this, the nurse a. Can assume that they have the same spiritual beliefs. b. Should not impose her personal values on the patient. c. Must use an assessment tool to assess the patient's beliefs. d. Can skip the spiritual belief assessment.

ANS: B The nurse can use an assessment tool or direct an assessment with questions based on principles of spirituality, but it is important not to impose personal value systems on the patient. This is particularly true when the patient's values and beliefs are similar to those of the nurse because it then becomes very easy to make false assumptions. It is important to conduct the spiritual belief assessment; conducting an assessment is therapeutic because it expresses a level of caring and support.

The nurse is caring for a patient who is terminally ill with very little time left to live. The patient states, "I always believed that there was life after death. Now, I'm not so sure. Do you think there is?" The nurse states, "I believe there is." The nurse has attempted to a. Strengthen the patient's religion. b. Provide hope. c. Support the patient's agnostic beliefs. d. Support the horizontal dimension of spiritual well-being.

ANS: B When a person has the attitude of something to look forward to, hope is present. Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality. This is not evident here. Agnostics believe that there is no known ultimatereality. This would indicate a lack of belief in life after death. The horizontal dimension of spiritual well-being describes positive relationships and connections people have with others. In this case, the patient is more concerned with the vertical dimension, which supports thetranscendent relationship with God or some other higher power

Which situation will cause the nurse to postpone a teaching session? (Select all that apply.) a. The patient is mildly anxious. b. The patient is fatigued. c. The patient is asking questions. d. The patient is hurting. e. The patient is febrile (high fever). f. The patient is in the acceptance phase.

ANS: B, D, E Any condition (e.g., pain, fatigue) that depletes a person's energy also impairs his or her ability to learn, so the session should be postponed until the pain is relieved and the patient is rested. Postpone teaching when an illness becomes aggravated by complications such as a high fever or respiratory difficulty. A mild level of anxiety motivates learning. When patients are ready to learn, they frequently ask questions. When the patient enters the stage of acceptance, the stage compatible with learning, introduce a teaching plan.

2A nurse has taught a patient about healthy eating habits. Which learning objective/outcome is most appropriate for the affective domain? a. The patient will state three facts about healthy eating. b. The patient will identify two foods for a healthy snack. c. The patient will verbalize the value of eating healthy. d. The patient will cook a meal with low-fat oil.

ANS: C Affective learning deals with expression of feelings and acceptance of attitudes, opinions, or values. Having the patient value healthy eating habits falls within the affective domain. Stating three facts or identifying two foods for a healthy snack falls within the cognitive domain. Cooking falls within the psychomotor domain.

A nurse wants the patient to begin to accept the chronic nature of diabetes. Which teaching technique should the nurse use to enhance learning? a. Lecture b. Demonstration c. Role play d. Question and answer session

ANS: C Affective learning deals with expression of feelings and acceptance of attitudes, opinions, or values. Role play and discussion (one-on-one and group) are effective teaching methods for the affective domain. Lecture and question and answer sessions are effective teaching methods for the cognitive domain. Demonstration is an effective teaching method for the psychomotor domain.

A nurse is teaching a group of healthy adults about the benefits of flu immunizations. Which purpose of patient education is the nurse fulfilling? a. Restoration of health b. Coping with impaired functions c. Promotion of health and illness prevention d. Health analogies

ANS: C As a nurse, you are a visible, competent resource for patients who want to improve their physical and psychological well-being. In the school, home, clinic, or workplace, you promote health and prevent illness by providing information and skills that enable patients to assume healthier behaviors. Injured and ill patients need information and skills to help them regain or maintain their level of health; this is referred to as restoration of health. Not all patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations; this is known as coping with impaired functions. Analogies supplement verbal instruction with familiar images that make complex information more real and understandable. For example, when explaining arterial blood pressure, use an analogy of the flow of water through a hose.

A nurse is teaching an older adult patient about strokes. Which teaching technique is most appropriate for the nurse to use? a. Use a pamphlet about strokes with large font in blues and greens. b. Speak in a high tone of voice to describe strokes. c. Begin and end each teaching session with the most important information about strokes. d. Provide specific information about strokes in frequent, large amounts.

ANS: C Begin and end each teaching session with the most important information when teaching older adult patients. Also, if using written material, assess the patient's ability to read and use information that is printed in large type and in a color that contrasts highly with the background (e.g., black 14-point print on buff-colored paper). Avoid blues and greens because they are more difficult to see. Speak in a low tone of voice (lower tones are easier to hear than higher tones). Provide specific information in frequent, small (not large) amounts for older adult patients

24. A nurse is teaching a culturally diverse patient about nutritional needs. What must the nurse do first before starting the teaching session? a. Obtain pictures of food. b. Get an interpreter. c. Establish a rapport. d. Refer to a dietitian.

ANS: C Establishing a rapport is important for all patients, especially culturally diverse patients, before starting teaching sessions. Obtaining pictures of food, getting an interpreter, and referring to a dietitian all occur after rapport is established.

Which situation indicates to the nurse that the patient is ready to learn? a. A patient has sufficient upper body strength to move from a bed to a wheelchair. b. A patient has the ability to grasp and apply the elastic bandage. c. A patient with a below-the-knee amputation is motivated about how to walk with assistive devices. d. A patient has normal eyesight to identify the markings on a syringe and coordination to handle a syringe.

ANS: C Motivation or readiness to learn sometimes results from social task mastery, or physical motives may be involved. Often patient motives are physical. Some patients are motivated to return to a level of physical normalcy. For example, a patient with a below-the-knee amputation is motivated to learn how to walk with assistive devices. Do not confuse readiness to learn with ability to learn. All the other answers are examples of ability to learn because this often depends on the patient's level of physical development and overall physical health. To learn psychomotor skills, a patient needs to possess a certain level of strength, coordination, and sensory acuity. For example, it is useless to teach a patient to transfer from a bed to a wheelchair if he or she has insufficient upper body strength. An older patient with poor eyesight or an inability to grasp objects tightly cannot learn to apply an elastic bandage or handle a syringe.

A 70-year-old patient who suffers from worsening dementia is no longer able to live alone. When discussing health care services and possible long-term living arrangements with the patient's only son, what should the nurse suggest? a. An apartment setting with neighbors close by b. Having the patient utilize weekly home health visits c. A nursing center because home care is no longer safe d. That placement is irrelevant because the patient is retreating to a place of inactivity

ANS: C Some family caregivers consider nursing center placement when in-home care becomes increasingly difficult, or when convalescence from hospitalization requires more assistance than the family is able to provide. An apartment setting and the use of home health visits are not appropriate because some older adults deny functional decline and refuse to ask for assistance with tasks that place their safety at great risk. Others avoid activities designed to benefit older adults such as senior health promotion activities (such as some health visits), and thus do not receive the benefits that these programs offer. Acceptance of personal aging does not mean a retreat into inactivity, but it does require a realistic review of strengths and limitations.

When comparing developmental tasks of middle-aged persons versus older adults, what should the nurse infer? a. Learning to cope with loss is most common during the middle adult years. b. After age 65, most older adults age both biologically and psychologically the same way. c. All older adults will need nursing assistance to deal with loss. d. Older adults fear and resent retirement as a disruption of their lifestyle.

ANS: C Some older adults deny their own aging in ways that are potentially problematic. For example, some older adults deny functional declines and refuse to ask for assistance with tasks that place their safety at great risk. The need to cope with loss is much greater in the older adult population. Most older adults cope with the death of a spouse. Some must cope with the death of adult children and grandchildren. All experience the death of friends. The ways that older adults adjust to the changes of aging are highly individualized. Many older adults welcome retirement as a time to pursue new interests and hobbies, participate in volunteer activities, continue their education, or start a new business career.

The nurse creates a referral to pastoral care when he/she realizes that the patient is in need of a. Psychiatric care. b. Return to religious affiliation. c. Spiritual care. d. Transfer to the psychiatric unit.

ANS: C Spiritual care helps people identify meaning and purpose in life, look beyond the present, and maintain personal relationships, as well as a relationship with a higher being or life force. The patient may need psychiatric care and may be transferred to the psychiatric unit, but referral to pastoral care will not provide that. Return to a religious affiliation may follow a return to spiritual health.

Which teaching strategy is best to utilize with older adult patients? a .Provide several topics of discussion at once to promote independence and making choices. b. Avoid uncomfortable silences after questions by helping patients complete their statements. c. Ask patients to recall past experiences that correspond with their interests. d. Speak in a high pitch to help patients hear better.

ANS: C Teaching strategies include the use of past experiences to connect new learning with previous knowledge, focusing on a single topic to help the patient concentrate, giving the patient enough time in which to respond because older adults' reaction times are longer than those of younger persons, and keeping the tone of voice low; older adults are able to hear low sounds better than high-frequency sounds

When caring for a terminally ill patient, the nurse should focus on the fact that a. Spiritual care is possibly the least important nursing intervention. b. Spiritual needs often need to be sacrificed for physical care priorities. c. The nurse's relationship with the patient allows for an understanding of patient priorities. d. Members of the church or synagogue play no part in the patient's plan of care.

ANS: C The nurse's relationship with the patient allows the nurse to understand the patient's priorities. Spiritual priorities do not need to be sacrificed for physical care priorities. When a patient is terminally ill, spiritual care is possibly the most important nursing intervention. If the patient participates in a formal religion, involve in the plan of care members of the clergy or members of the church, temple, mosque, or synagogue.

After a teaching session on taking blood pressures, the nurse tells the patient, "You took that blood pressure like an experienced nurse." What type of reinforcement did the nurse use? a. Material b. Activity c. Social d. Entrusting

ANS: C Three types of reinforcers are social, material, and activity. When a nurse works with a patient, most reinforcers are social and are used to acknowledge a learned behavior (e.g., smiles, compliments, words of encouragement). Examples of material reinforcers include food, toys, and music. Activity reinforcers rely on the principle that a person is motivated to engage in an activity if he or she has the opportunity to engage in a more desirable activity after completion of the task. The entrusting approach is a teaching approach that provides the patient the opportunity to manage self-care. It is not a type of reinforcement.

A nurse is going to teach a patient about hypertension. Which action should the nurse implement first? a. Set mutual goals for knowledge of hypertension. b. Teach what the patient wants to know about hypertension. c. Assess what the patient already knows about hypertension. d. Evaluate the outcomes of patient education for hypertension.

ANS: C Assessment is the first step of any teaching session, then diagnosing, planning, implementation, and evaluation. An effective assessment provides the basis for individualized patient teaching. Assessing what the adult patient currently knows improves the outcomes of patient education

A nurse is assessing the ability to learn of a patient who has recently experienced a stroke. Which question/statement will best assess the patient's ability to learn? a. "What do you want to know about strokes?" b. "On a scale from 1 to 10, tell me where you rank your desire to learn." c. "Do you feel strong enough to perform the tasks I will teach you?" d. "Please read this handout and tell me what it means."

ANS: D A patient's reading level affects ability to learn. Reading level is often difficult to assess because patients who are functionally illiterate are often able to conceal it by using excuses such as not having the time or not being able to see. One way to assess a patient's reading level and level of understanding is to ask the patient to read instructions from an educational handout and then explain their meaning. Asking patients what they want to know identifies previous learning and learning needs and preferences; it does not assess ability to learn. Motivation is related to readiness to learn, not ability to learn. Just asking a patient if they feel strong is not as effective as actually assessing the patient's strength.

What is the best suggestion a nurse could make to a family requesting help in selecting a local nursing center? a. Suggest choosing a nursing center that is as sanitary as possible. The closer the center is to hospital standards, the better. b. Have family members evaluate nursing home staff according to their ability to get tasks done efficiently. c. Make sure that nursing home staff members get patients out of bed every day for the entire day. d. Explain that it is probably best for the family to visit the center and inspect it personally.

ANS: D An important step in the process of selecting a nursing home is to visit the nursing home. The nursing home should not feel like a hospital. It is a home, a place where people live. Members of the nursing home staff should focus on the person, not the task. Residents should be out of bed and dressed according to their preferences, not staff preferences.

An older adult patient in no acute distress reports being less able to taste and smell. What is the nurse's best response to this information? a.Notify the physician immediately to rule out cranial nerve damage. b.Perform testing on the vestibulocochlear nerve and a hearing test. c.Schedule the patient for an appointment at a smell and taste disorders clinic. d.Explain to the patient that diminished senses are normal findings.

ANS: D Diminished taste and smell senses are common findings in older adults. Scheduling an appointment at a smell and taste disorders clinic, testing the vestibulocochlear nerve, or an attempt to rule out cranial nerve damage is unnecessary at this time per the information provided.

A nurse teaches a patient with heart failure healthy food choices. The patient states that eating yogurt is better than eating cake. In this situation, which element represents feedback? a. The nurse b. The patient c. The nurse teaching about healthy food choices d. The patient stating that eating yogurt is better than eating cake

ANS: D Feedback should show the success of the learner in achieving objectives (i.e., the learner verbalizes information or provides a return demonstration of skills learned). The nurse is the sender. The patient is the receiver. The teaching is the message

Which of these patient statements is the most reliable indicator that an older adult has the correct understanding of health promotion activities? a."I need to increase my fat intake and limit protein." b."I should discontinue my fitness club membership for safety reasons." c."I'm up to date on my immunizations, but at my age, I don't need the tetanus vaccine." d."I still keep my dentist appointments even though I have partials now."

ANS: D General preventive measures for the nurse to recommend to older adults include keeping periodic dental appointments to promote good oral hygiene, eating a low-fat, well-balanced diet, exercising regularly, and maintaining immunizations for influenza, pneumococcal pneumonia, and tetanus.

An older patient has fallen and broken his hip. As a consequence, the patient's family is concerned about his ability to care for himself, especially during his convalescence. What should the nurse do? a. Stress that older patients usually ask for help when needed. b. Inform the family that placement in a nursing center is a permanent solution. c. Tell the family to enroll the patient in a ceramics class to maintain his quality of life. d. Provide information and answer questions as family members make choices among care options.

ANS: D Nurses assist older adults and their families by providing information and answering questions as they make choices among care options. Some older adults deny functional declines and refuse to ask for assistance with tasks that place their safety at great risk. The decision to enter a nursing center is never final, and a nursing center resident sometimes is discharged to home or to another less-acute residence. What defines quality of life varies from person to person. Nurses must listen to what the older adult considers to be most important rather than making assumptions about the individual's priorities.

To promote physical well-being and socialization in an older adult, what should the nurse realize? a.Social isolationism is always a chosen behavior. b.Body image plays no role in decision making by the older adult. c.No community resources are focused on the older adult. d.Older adults may have a functional purpose in social arenas.

ANS: D Social service agencies in most communities welcome older adults as volunteers and provide the opportunity for older adults to serve while meeting their socialization or other needs. Although some older adults choose isolation or a lifelong pattern of reduced interaction with others, other older adults do not choose isolation but are vulnerable to its consequences. Some older adults withdraw from social interaction because of feelings of rejection. These older adults see themselves as unattractive and rejected because of changes in their personal appearance due to normal aging changes or because of body image changes. Many communities have outreach programs designed to make contact with isolated older adults.

Which statement indicates that the nurse has a good understanding of teaching/learning? a. "Teaching and learning can be separated." b. "Learning is an interactive process that promotes teaching." c. "Learning consists of a conscious, deliberate set of actions designed to help the teacher." d. "Teaching is most effective when it responds to the learner's needs."

ANS: D Teaching is most effective when it responds to the learner's needs. It is impossible to separate teaching from learning. Teaching is an interactive process that promotes learning. Teaching consists of a conscious, deliberate set of actions that help individuals gain new knowledge, change attitudes, adopt new behaviors, or perform new skills.

A 72-year-old woman was recently widowed. She worked as a teller at a bank for 40 years and has been retired for the past 5 years. She never learned how to drive. She lives in a rural area that does not have public transportation. Which of the following psychosocial changes does the nurse focus on as a priority? a.Sexuality b.Housing and environmentc. Retirementd. Social isolation

ANS: D The highest priority at this time is the potential for social isolation. This woman does not know how to drive and lives in a rural community that does not have public transportation. All of these factors contribute to her social isolation. Other possible changes she may be going through right now include sexuality related to her advanced age and recent death of her spouse; however, this is not the priority at this time. She has been retired for 5 years, so this is also not an immediate need. She may eventually experience needs related to housing and environment, but the data do not support this as an issue at this time.

A nurse is teaching the staff about nursing and teaching processes. Which information should the nurse include regarding the teaching process? During the teaching process, what should the nurse do? a. Assess all sources of data. b. Identify that it is the same as the nursing process. c. Perform nursing care therapies. d. Focus on a patient's learning needs

ANS: D The teaching process focuses on the patient's learning needs and willingness and capability to learn. Nursing and teaching processes are not the same. All the rest are components of the nursing process: Assess all sources of data and perform nursing care therapies

The nurse is admitting a patient to the hospital. The patient states that he is a very spiritual person but does not practice any specific religion. The nurse understands that these statements a. Are contradictory. b. Indicate a strong religious affiliation. c. Indicate a lack of faith. d. Are reasonable.

ANS: D These statements are reasonable and are not contradictory. Many people tend to use the terms spirituality and religion interchangeably. Although closely associated, these terms are not synonymous. Religious practices encompass spirituality, but spirituality does not need to include religious practice. When a person has the attitude of something to live for and look forward to, hope is present

While assessing the adult patients lungs, the nurse identifies the following assessment findings. Which finding should be reported to the the health care provider? A) Respiratory rate: 14 B) Pain reported when palpating posterior lower thorax C) Thorax rising and falling symmetrically for right and left lungs D) Vesicular breath sounds heard with auscultation of peripheral lung fields

B) Any areas of tenderness or pain over the posterior thorax could indicate injury such as a broken rib or disturbance of the integumentary system. Further palpation should be avoided until more assessment date are collected, either through further health history or diagnostic testing. All other finding are normal.

Several factors affect the volume and consistency of endotracheal secretions. Which of the following causes an increase in the amount and thickness of secretions? (Select all that apply.) A) Fluid intake B) Infection C) Respiratory rate D) Humidification

B) Patients with respiratory infection, such as pneumonia, are prone to increased secretions that are thicker and sometimes are more difficult to expectorate. Fluid intake increases the amount of secretions but will thin them. Humidity loosens secretions, facilitating airway suctioning when the patient cannot clear secretions effectively. Rate of respirations will not effect the amount or viscosity of secretions.

The client is admitted to the hospital for chronic obstructive pulmonary disease (COPD), and the physician requests a nasal cannula at 2 L/min. Within 30 minutes, the client's color improves. What does the nurse continue to monitor that may require immediate attention? A) Increasing carbon dioxide levels B) Decreasing respiratory rate C) Increasing adventitious breath sounds D) Increased coughing

B) Respiratory rate and depth should be monitored closely while the client receives oxygen, because hypoventilation is seen during the first 30 minutes of oxygen therapy in clients with hypoxic drive for respiration. The client's color will improve (from ashen or gray to pink) because of an increase in Pao2 level before apnea or respiratory arrest occurs from loss of the hypoxic drive.

The client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response? A) "But you know you need this to breathe, right?" B) "Do you have a pretty scarf or a large loose collar that you could place over it?" C) "Your family and friends probably won't even care." D) "It won't take you long to learn to manage."

B) Suggesting strategies to cover the tracheostomy recognizes client concerns and explores options for dealing with the effects of the procedure.

Where does gas change occur? A) Acinus B) Alveolus C) Bronchus D) Carina

B) The alveolus is the structural unit of the lung where gas exchange occurs

A client returns to the medical unit after a therapeutic bronchoscopy. Which intervention does the nurse apply first? A) Assess the puncture site for drainage B) Implement NPO C) Monitor for signs of anaphylaxis D) Perform aggressive chest physiotherapy

B) Until the client has a gag reflex and is fully alert, he should be maintained on NPO status to prevent aspiration

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy, not cyanotic, the nurse understands that the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following: A) Stimulates hyperventilation, causing respiratory alkalosis B) Forms a strong bond with hemoglobin, creating a functional anemia. C) Stimulates hypoventilation, causing respiratory acidosis D) Causes alveoli to overinflate, leading to atelectasis

B) Carbon monoxide strongly binds to hemoglobin, making it unavailable for oxygen binding and transport.

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion? A) Antibiotics B) Frequent change of position C) Oxygen humidification D) Chest physiotherapy

B) Movement not only mobilizes secretions but helps strengthen respiratory muscles by impacting the effectiveness of gas exchange processes.

A client had a thoracentesis 1 day ago. He calls the home health agency and tells the nurse that he is very short of breath and anxious. What is the major concern of the nurse? A) Abscess B)Pneumonia C) Pneumothorax D) Pulmonary embolism

C) A pneumothorax would be the complication of thoracentesis that causes the greatest concern, along with these symptoms.

A patient who started smoking in adolescence and continues to smoke 40 years late comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder? A) Alcoholism & hypertension B) Obesity & diabetes C) Stress-related illnesses D) Cardiopulmonary diseases and lung cancer

D) Cardiopulmonary diseases and lung cancer

You are a charge nurse on a surgical floor. The LPN/LVN informs you that a new client who had an earlier bronchoscopy has the following vital signs: heart rate 132, respiratory rate 26, and blood pressure 98/50. The client is anxious and his skin is cyanotic. What will be your first action? A) Call the Rapid Response Team. B) Give methylene blue 1% 1 to 2 mg/kg by IV injection C) Administer oxygen. D) Notify the physician immediately.

C) Administering oxygen and reassessing vital signs to observe for improvement is the first action. Administration of oxygen by itself may help relieve the client's anxiety.

A client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure. Which nursing action must be taken first? A) Suction as needed. B) Clean the tracheostomy inner cannula and stoma. C) Listen to lung sounds. D)Change the tracheostomy dressing as needed.

C) Assessment is the first phase of the nursing process. All other actions and procedures are driven by assessment findings. The first nursing action for a client following an airway procedure is to assess the client's respiratory status; this requires auscultation of the lungs.

A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What diagnostic test will the nurse teach the client about to help confirm the diagnosis? A) Bronchoscopy B) Chest x-ray C) Computed tomography (CT) scan D)Thoracoscopy

C) CT scans, especially spiral or helical CT scans, with injected contrast can detect pulmonary emboli.

Four clients arrive in the emergency department simultaneously with chest pain. The client with which type of chest pain requires immediate attention by the nurse? A) Client with pain on deep inspiration B) Client with pain on palpation C) Client with pain radiating to the shoulder D) Client with pain that is rubbing in nature

C) Chest pain radiating to the shoulder should be assumed to be cardiac in origin until proven otherwise; this requires the immediate attention of the nurse

Which value indicates clinical hypoxemia and the need to increase oxygen delivery? A) Hemoglobin of 22 g/dL B) PaCO2 of 30 mm Hg C) PaO2 of 65 mm Hg D) Oxygen saturation of 88%

C) Pao2 of 65 mm Hg indicates low levels of oxygen in the arterial blood; this is termed hypoxemia.

Use of noninvasive positive-pressure ventilation (CPAP or BiPAP) has the potential to cause carbon dioxide retention in selected patients. Patients with which of the following underlying diagnoses are at greatest risk for carbon dioxide retention? A) Heart failure B) Pulmonary fibrosis C) Chronic obstructive pulmonary disease D) Pulmonary edema

C) Patients diagnosed with COPD who have ventilatory failure are at risk to retain carbon dioxide. Patients with heart failure, pulmonary fibrosis, or pulmonary edema are at greatest risk for oxygen failure.

A client comes to the emergency department with a productive cough. Which symptom does the nurse look for that will require immediate attention? A) blood in the sputum B) Mucoid Sputum C) Pink frothy sputum D) Yellow sputum

C) Pink frothy sputum is common with pulmonary edema and requires immediate attention and intervention to prevent the clients condition from getting worse

Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient? A) Postural drainage B) Chest percussion C) Incentive spirometer D) Suctioning

C) An incentive spirometer is used to encourage deep breathing to inflate alveoli and open pores of Kohn. The rest are used to treat atelectasis and increased mucus production.

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? A) Coughing up thick sputum only occasionally B) Coughing up thin, watery sputum easily after nebulization C) Decreased independent ability to cough D) Lung sounds clear only after coughing

C) Impaired ability to cough up mucus caused by weakness or very thick secretions indicates a need for suctioning when you know the patient has pneumonia.

The nurse is working in an urgent clinic. Which of these four clients needs to be evaluated first by the nurse? A) Client who is short of breath after walking up two flights of stairs B)Client with soreness of the arm after receiving purified protein derivative (PPD) (Mantoux) skin test C) Client with sore throat and fever of 39° C oral D)Client who is speaking in three-word sentences and has SaO2 of 90% by pulse oximetry

D) A client should be able to speak in sentences of more than three words, and Sao2 of 90% indicates hypoxemia that requires intervention on the part of the

A client has returned to the postanesthesia care unit (PACU) after a bronchoscopy. Which of these nursing tasks is best for the charge nurse to delegate to the nursing assistant working in PACU? A) Assess breath sounds B) Check gag reflex C) Determine level of consciousness D) Monitor blood pressure & pulse

D) A nursing assistant working in the PACU would have experience in taking client vital signs after the client has had conscious sedation or anesthesia

Why is it important to assess a patient's understanding of a procedure? A) Encourages cooperation of the patient during and after the procedure B) Minimizes risks to the patient C) Identifies teaching needs D) All of the above

D) All of these outcomes are applicable to assessing patient knowledge of the procedure. If the patient understands what will happen to him during a procedure and why this is important for his health, he tends to cooperate during and after the procedure. If the patient understands the procedure and what he needs to do afterward to remain safe and free of complications, risks will be minimized. Also, by discussing the procedure with the patient, the nurse can identify teaching needs.

A client who smokes is being discharged home on oxygen. The client states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response? A) "You can quit when you are ready." B) "It's never too late to quit." C) "Just turn off your oxygen when you smoke." D) "You are right, the damage has been done. But let's talk about why smoking around oxygen is dangerous."

D) This is a great opening for the nurse to educate the client about the dangers of smoking in the presence of oxygen, as well as the benefits of quitting.

A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds? A) Sonorous wheezes in the left lower lung B) Rhonchi mid-sternum C) Crackles only in apex of lungs D) Inspiratory crackles in lung bases

D) Decreased effective contraction of left side of heart leads to back up of fluid in the lungs, increasing hydrostatic pressure and causing pulmonary edema, resulting in crackles in lung base

A patient has been newly diagnosed with emphysema. In discussing his condition with the nurse, which of his statements would indicate a need for further education? A) "I'll make sure that I rest between activities so I don't get so short of breath." B) "I'll rest for 30 minutes before I eat my meal." C) "If I have trouble breathing at night, I'll use two to three pillows to prop up." D) "If I get short of breath, I'll turn up my oxygen level to 6 L/min."

D) Hypoxia is the drive to breathe in a patient with chronic obstructive pulmonary disease who has become used to acidic pH and elevated CO2 levels. Turning up to 6 L/min increases the oxygen level, which turns off the drive to breathe.

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient's oxygen status? A. Increased breathlessness but increased activity tolerance B. Decreased breathlessness and decreased activity tolerance C. Increased activity tolerance and decreased breathlessness D. Decreased activity tolerance and increased breathlessness

D) Hypoxia occurs because of decreased circulating blood volume, which leads to decreased oxygen to muscles, causing fatigue, decreased activity tolerance, and a feeling of shortness of breath.

Which of the following statements made by a student nurse indicates the need for further teaching about suctioning a patient with an endotracheal tube? A)"Suctioning the patient requires sterile technique." B)"I'll apply suction while rotating and withdrawing the suction catheter." C)"I'll suction the mouth after I suction the endotracheal tube." D)"I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient."

D) Saline has been found to cause more side effects when suctioning and does not increase the amount of secretions removed.

If a patient is accidentally extubated, which of the following actions are appropriate? A) Remain with the patient. B) Assist respirations with bag-valve mask as needed. C) Assess patient for airway patency, spontaneous breathing, and vital signs. D) Prepare for reintubation. E) All of the above

E) All of the listed interventions are appropriate for unexpected extubation. The nurse should stay with the patient until assistance arrives to continually assess respiratory status and the need for any of the listed interventions.