Exam 3 N266

A nurse is teaching an older adult patient about ways to detect a melanoma. Which of the following are age-appropriate teaching techniques for this patient? (Select all that apply.) 1. Speak in a low tone. 2. Begin and end the session with the most important information regarding melanoma. 3. Provide a pamphlet about melanoma with large font in blues and greens. 4. Provide specific information in frequent, small amounts for older adult patients. 5. Speak quickly so that you do not take up much of the patient's time.

Answer: 1, 2, 4. Lower tones are easier for patients with hearing deficits to hear. Reinforce important information at the beginning and end of each teaching session to enhance understanding. Providing information in small amounts helps the older adult understand information better. A pamphlet should be written in a color that contrasts with the background (e.g., black 14-point print on matte white paper). Blues and greens are hard to distinguish. Take your time with an older adult. Speaking quickly can easily lead to misunderstanding. Chapter 25

A nurse works with a patient using therapeutic communication and the phases of the therapeutic relationship. Place the nurse's statements in order according to these phases. 1. The nurse states, "Let's work on learning injection techniques." 2. The nurse is mindful of his/her own biases and knowledge in working with the patient with B12 deficiency. 3. The nurse summarizes progress made during the nursing relationship. 4. After providing introductions, the nurse defines the scope and purpose of the nurse-patient relationship.

2, 4, 1, 3. In the therapeutic relationship the nurse begins by understanding the self (preinteraction), then provides introductions, followed by a working phase and finally termination and summarization. Chapter 24

The nurse applying effective communication skills throughout the nursing process should: (Place the following interventions in the correct order.) 1. Validate health care needs through verbal discussion with the patient. 2. Compare actual and expected patient care outcomes with the patient. 3. Provide support through therapeutic communication techniques. 4. Complete a nursing history using verbal communication techniques.

4, 1, 3, 2. The correct order for the nurse to communicate with the patient is to first complete the history (part of assessment), then corroborate findings through a validation process. After this, the nurse would use therapeutic communication to address needs, and finally would complete an evaluation process to see whether the actual outcomes matched the expected outcome Chapter 24

While assessing an older woman who is recently widowed, the nurse suspects that this woman is experiencing a developmental crisis. Which questions provide information about the impact of this crisis? (Select all that apply.) 1. With whom do you talk on a routine basis? 2. What do you do when you feel lonely? 3. Tell me what your husband was like. 4. I know this must be hard for you. Let me tell you what might help. 5. Have you experienced any changes in lifestyle habits, such as sleeping, eating, smoking, or drinking?

Answer: 1, 2, 5. A developmental crisis occurs as a person moves through the stages of life, including widowhood. It is important to gather information about how this crisis affects the woman's interactions, how she is currently coping with loneliness, and any changes in her lifestyle habits. Although losing her husband is a source of stress, discussing him now does not focus on her current situation. Saying "I know this must be hard for you. Let me tell you what might help" is unacceptable because the purpose of assessment is to gather data and let the patient tell his or her story Chapter 37

A patient has just learned she has been diagnosed with a malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. The nurse has been caring for her for only 2 hours but has a good relationship with her. What is the most appropriate intervention for support of her spiritual well-being at this time? 1. Make a referral to a professional spiritual care adviser. 2. Sit down and talk with the patient; have her discuss her feelings and listen attentively. 3. Move the patient's Bible from her bedside cabinet drawer to the top of the over-bed table. 4. Ask the patient whether she would like to learn more about the implications of having this type of tumor.

Answer: 2. Establishing presence contributes to a patient's sense of well-being. It helps to prevent emotional and environmental isolation. Automatically making a referral to a spiritual care adviser might not be the patient's wish. She may not see an adviser as a resource. Reading a Bible can be an important ritual, but at this time the patient needs to make a connection with someone who can help minimize loneliness and powerlessness. Providing instruction will be important, but the patient is unlikely to be receptive at this time. Chapter 35

dition and receives several new orders for the patient over the phone. When documenting telephone orders in the electronic health record, most hospitals require a nurse to do which of the following? 1. Print out a copy of all telephone orders entered into the electronic health record in order to keep them in personal records for legal purposes. 2. "Read back" all telephone orders to the provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the electronic health record. 3. Record telephone orders in the electronic health record, but wait to implement the order(s) until they are electronically signed by the health care provider who gave them. 4. Implement telephone order(s) immediately, but insist that the health care provider come to the patient care unit to personally enter the order(s) into the electronic health record within the next 24 hours

Answer: 2. Guidelines from TJC require a "read-back" on all telephone (and verbal) orders. The nurse reads a telephone order back word for word and receives confirmation that the order is correct from the health care provider who gave the order Chapter 26

The nurse is gathering a history from a 72-year-old male patient being admitted to a nursing home. The patient requests a private room. The nurse understands that: 1. The patient cannot be sexually active since he is moving into a nursing home. 2. The patient may be requesting a private room to facilitate an intimate relationship with his partner. 3. There is no need to take a sexual history since most older adults are uncomfortable discussing intimate details of their lives. 4. Older adults in nursing homes usually do not participate in sexual activity

Answer: 2. Studies have shown an increase in sexual dysfunction with aging but no decrease in sexual activity or interest. Sometimes sexual health is not addressed by the nurse, but it is important to include a sexual history as a routine aspect of assessment to communicate that sexual activity is normal. Long-term care facilities need to make arrangements to allow for continuation of sexual experiences of residents as long as no health risks are involved. Chapter 34

A patient suddenly experiences a severe headache with numbness and decreased movement in the left arm. The emergency room physician suspects a stroke and is going to have the patient undergo an emergent angiogram to remove the clot. Which teaching approach is most appropriate? 1. Selling approach 2. Telling approach 3. Entrusting approach 4. Participating approach

Answer: 2. Telling is the best approach when there is limited time for teaching information. Chapter 25

The nurse works at an agency where military time is used for documentation, and needs to document that a patient was transported to the operating room for an emergency procedure at 8 in the evening. Point to the area on the clockface below that indicates 8 in the evening in military time:

Answer: 2000. The military clock begins at 1 minute after midnight as 0001 and ends with midnight at 2400. Noon is 1200. 1 pm is 1300, 2 pm is 1400, 3 pm is 1500, and so on. Chapter 26

A patient asks a nurse to provide instruction on how to perform a breast self-exam. Which domains are required to learn this skill? (Select all that apply.) 1. Affective domain 2. Sensory domain 3. Cognitive domain 4. Attentional domain 5. Psychomotor domain

Answer: 3 and 5. For a patient to perform a breast self-exam it will be necessary to understand the purpose of the exam and why it is performed the way it is. Cognitive learning in this scenario involves a patient acquiring information to further develop his or her understanding and thinking processes so that the patient can make a decision based on a self-exam finding. Psychomotor learning in this case involves actual use of the hands to palpate in symmetrical areas of the breast correctly. Affective domain does not apply unless the nurse decides the patient's values prevent self-exam adherence. There are no attentional or sensory learning domains. Chapter 25

The nurse is interviewing a patient in the community clinic and gathers the following information about her: she is intermittently homeless, a single parent with two children who have developmental delays. She has had asthma since she was a teenager. She does not laugh or smile, does not volunteer any information, and at times appears close to tears. She has no support system and does not work. She is experiencing an allostatic load. As a result, which of the following would be present during complete patient assessment? (Select all that apply.) 1. Post-traumatic stress disorder 2. Rising hormone levels 3. Chronic illness 4. Insomnia 5. Depression

Answer: 3, 4, 5. An increased allopathic load can result in longterm physiological and psychological problems such as chronic illness, depression, sleep deprivation, chronic fatigue syndrome, and autoimmune disorders. Post-traumatic stress disorder results from a single traumatic event. Hormone levels rise in the alarm stage. Chapter 37

A nursing student is developing a plan of care for a 74-year-old-female patient who has spiritual distress over losing a spouse. As the nurse develops appropriate interventions, which characteristics of older adults should be considered? (Select all that apply.) 1. Older adults do not routinely use complementary medicine to cope with illness. 2. Older adults dislike discussing the afterlife and what might have happened to people who have passed on. 3. Older adults achieve spiritual resilience through frequent expressions of gratitude. 4. Have the patient determine whether her husband left a legacy behind. 5. Offer the patient her choice of rituals or participation in exercise

Answer: 3, 4, 5. Older-adult patients achieve spiritual resiliency in expressing gratitude and finding ways to maintain purpose in life. Leaving legacies maintains a connection between the person left behind and the lost loved one. Older adults frequently use complementary medicine, rituals, and exercise to cope with illness and pain. Belief in the afterlife grows with aging Chapter 35

A nurse who recently graduated from nursing school is providing discharge instructions to a patient who suffered a myocardial infarction (MI). The nurse knows that sexual issues are common after an MI but feels uncomfortable bringing up this topic. What is the best way for the nurse to handle this situation? (Select all that apply.) 1. Instruct the patient to discuss any sexual concerns with his or her partner after discharge. 2. Avoid discussing the topic unless the patient brings it up. 3. Ask a more experienced nurse to cover this with the patient and learn from the example. 4. Plan to attend conferences or training soon on how to discuss such issues. 5. Encourage the patient to discuss any personal concerns with the cardiologist.

Answer: 3, 4. Nurses often avoid discussing sexual issues with patients because they are uncomfortable, lack knowledge, or have personal values in conflict with the patients' values. Nurses who have difficulty addressing sexual issues need to seek education and experiences to increase knowledge and explore their personal values. Chapter 34

The nurse is evaluating how well a patient newly diagnosed with multiple sclerosis and psychomotor impairment is coping. Which statements indicate that the patient is beginning to cope with the diagnosis? (Select all that apply.) 1. "I'm going to learn to drive a car, so I can be more independent." 2. "My sister says she feels better when she goes shopping, so I'll go shopping." 3. "I'm going to let the occupational therapist assess my home to improve efficiency." 4. "I've always felt better when I go for a long walk. I'll do that when I get home." 5. "I'm going to attend a support group to learn more about multiple sclerosis."

Answer: 3, 5. Inviting the occupational therapist into the patient's home and attending support groups are early indicators that the patient is recognizing some of the challenges of the disease and participating in positive realistic activities to cope with the stressors related to changes in physical functioning. The other options relate to independence and other coping strategies but do not address coping with the specific challenges of the disease. Chapter 37

The nurse is administering a dose of metoprolol to a patient, and is completing the steps of bar code medication administration within the EHR. As the bar code information on the medication is scanned, an alert that states "Do not administer dose if apical heart rate (HR) is <60 beats/minute or systolic blood pressure (SBP) is <90 mm Hg" appears on the computer screen. The alert that appeared on the computer screen is an example of what type of system? 1. Electronic health record (EHR) 2. Charting by exception 3. Clinical decision support system (CDSS) 4. Computerized physician order entry (CPOE)

Answer: 3. Computer decision supportsystems(CDSS) are computerized programs that prompt health care providers with clinical knowledge and relevant patient information that assistswith clinical decision making. A nursing CDSS uses a complex system of rules to analyze data and provide alertsto support clinical decisions made by nurses. Chapter 26

A nurse is caring for a patient who is Muslim and has diabetes. Which of the following items does the nurse need to remove from the meal tray when it is delivered to the patient? 1. Small container of vanilla ice cream 2. A dozen red grapes 3. Bacon and eggs 4. Garden salad with ranch dressing

Answer: 3. Islam prohibits the consumption of pork Chapter 35

When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, what is the first assessment the nurse conducts? 1. The amount of family support 2. A 3-day diet recall 3. A thorough physical assessment 4. Threats to safety in her home

Answer: 3. Stress often causes symptoms similar to physical illnesses. Physical causes for problems need to be investigated and treated before treatment for stress-related symptoms can be initiated. Chapter 37

A 16-year-old female tells the school nurse that she doesn't need the human papillomavirus (HPV) vaccine since her partner always uses condoms. The best response by the nurse to this statement is: 1. "Latex condoms are the most effective way to eliminate the risk of HPV transmission." 2. "Your parents may not want you to receive the HPV vaccine since it has been shown to increase sexual risk taking and sexual activity." 3. "The HPV 9-valent vaccine is recommended for males and females even if they use condoms because it targets the specific viruses that cause cancer and genital warts." 4. "You are past the recommended age to receive the vaccine."

Answer: 3. An HPV vaccine that protects both men and women against the types of HPV that cause serious health issues is available and recommended for individuals ages 11 to 26. The use of latex condoms reduces the risk of contracting a sexually transmitted infection (STI), but abstinence is the only practice that eliminates the risk. Longitudinal research indicates that vaccination does not increase sexual risk-taking behaviors among youths and is safe Chapter 34

When documenting an assessment of a patient's cardiac system in an electronic health record, the nurse uses the computer mouse to select the "WNL" statement to document the following findings: "Heart sounds S1 & S2 auscultated. Heart rate between 80-100 beats per minute, and regular. Denies chest pain." This is an example of using which of the following documentation formats? 1. Focus charting incorporating "Data, Action & Response" (DAR) 2. Problem-intervention-evaluation (PIE) 3. Charting-by-exception (CBE) 4. Narrative documentation

Answer: 3. Charting-by-exception (CBE) is a unique documentation format designed with the philosophy that all standards are met unless otherwise documented. Many computerized nursing documentation systems have incorporated a CBE design. Exception-based documentation systems incorporate clearly defined criteria for nursing assessment and documentation of "normal" findings. Predefined statements used to document "normal" assessment of body systems are called "within defined limits" (WDL) or "within normal limits" (WNL) definitions. They consist of written criteria for a "normal" assessment for each body system. Automated documentation within a computerized documentation system allows nurses to select a WNL (or WDL) statement or to choose other statements from a drop-down menu. Chapter 26

A nurse is preparing to teach a patient who has sleep apnea how to use a CPAP machine at night. Which action is most appropriate for the nurse to perform first? 1. Allow patient to manipulate machine and look at parts. 2. Provide a teach-back session. 3. Set mutual goals for the education session. 4. Discuss the purpose of the machine and how it works

Answer: 3. Planning should occur before any form of implementation or evaluation. The nurse should build from simple to more complex information. Learning about the purpose of the machine and how it works is basic information needed for the patient to understand and be motivated to use it. Allowing the patient to manipulate the machine will precede instruction on its actual use. Teach-back will inform the nurse as to the patient's level of learning Chapter 25

A patient recovering from open heart surgery is taught how to cough and deep breathe using a pillow to support or splint the chest incision. Following the teaching session, which of the following is the best way for the nurse to evaluate whether learning has taken place? 1. Verbalization of steps to use in splinting 2. Selecting from a series of flash cards the images showing the correct technique 3. Return demonstration 4. Cloze test

Answer: 3. Return demonstration permits a patient to perform a skill as the nurse observes. It provides excellent feedback and reinforcement. Chapter 25

A nurse used spiritual rituals as an intervention in a patient's care. Which of the following questions is most appropriate to evaluate its efficacy? 1. Do you feel the need to forgive your wife over your loss? 2. What can I do to help you feel more at peace? 3. Did either prayer or meditation prove helpful to you? 4. Should we plan on having your family try to visit you more often in the hospital?

Answer: 3. Rituals include participation in worship, prayer, sacraments (e.g., baptism, Holy Eucharist), fasting, singing, meditating, scripture reading, and making offerings or sacrifices. When you include the use of rituals in a patient's plan of care, evaluate whether the patient perceived these activities as useful. If not, other interventions will be necessary. Chapter 35

A 63-year-old woman is a family caregiver for her 88-year-old mother who has dementia. The caregiver asked the home health nurse how to manage her mother when she becomes confused and violent. The best instructional method a nurse can use for this situation is: 1. Demonstration 2. Preparatory instruction 3. Role-playing 4. Group instruction with other family caregiver

Answer: 3. Role-playing is effective in teaching a person how to respond to another person's behavior. The technique involves rehearsing a desired behavior. Preparatory instruction is for an individual who is about to undergo a procedure that typically causes anxiety. Demonstration is used when psychomotor skills are being taught. Group instruction would be useful as a way for the caregiver to discuss problems confronted during caregiving but is less effective for responding to a specific behavior. Chapter 25

When providing postmortem care, which actions are necessary for the nurse to complete? 1. Locating the patient's clothing 2. Calling the funeral home 3. Providing culturally and religiously sensitive care in body preparation 4. Providing postmortem care to protect the family of the deceased from having to view the body

Answer: 3. A deceased person's body deserves the same respect and dignity as that of a living person and needs to be prepared in a manner consistent with the patient's cultural and religious beliefs. Chapter 36

The nurse assesses pain and redness at a vascular access device (VAD) site. Which action is taken first? 1. Apply a warm, moist compress. 2. Aspirate the infusing fluid from the VAD. 3. Report the situation to the health care provider. 4. Discontinue the intravenous infusion.

Answer: 4. Pain and redness at a VAD site are indicators of phlebitis. When phlebitis occurs, the infusion must be stopped and the VAD removed as the highest priority Chapter 42

A 34-year-old single father who is anxious, tearful, and tired from caring for his three young children tells the nurse that he feels depressed and doesn't see how he can go on much longer. Which statement would be the nurse's best response? 1. "Are you thinking of suicide?" 2. "You've been doing a good job raising your children. You can do it!" 3. "Is there someone who can help you during the evenings and weekends?" 4. "Tell me what you mean when you say you can't go on any longer."

Answer: 4. You need to get information about what the gentleman means when he says he can't go on any longer. He might be thinking of turning his children over to a grandparent or seeking other child-care arrangements. Asking about suicide initially might be premature. Asking "Are you thinking of suicide?" prematurely might shut the patient down entirely. If the patient talks about suicide, for safety reasons it is very important to further discuss his suicidal thoughts and refer to the appropriate health care professional. Asking the open-ended question provides an opportunity to understand what the person is thinking and open lines of communication. Chapter 37

lowing surgical complications. The patient has had limited activity but is now finally ordered to begin a mobility program. The patient just returned from several diagnostic tests and tells the nurse he is feeling quite fatigued. The nurse prepares to instruct the patient on the mobility program protocol. Which of the following learning principles will likely be affected by this patient's condition? 1. Motivation to learn 2. Developmental stage 3. Stage of grief 4. Readiness to learn

Answer: 4. A patient's readiness to learn is affected by his or her attentional set. Physical discomfort, fatigue, anxiety, confusion, and environmental distractions influence the ability to concentrate and learn. Chapter 25

The nurse is discussing the advantages of using computerized provider order entry (CPOE) with a nursing colleague. Which statement best describes the major advantage of a CPOE system within an electronic health record? 1. CPOE reduces the time necessary for health care providers to write orders. 2. CPOE reduces the time needed for nurses to communicate with health care providers. 3. Nurses do not need to acknowledge orders entered by CPOE in an electronic health record. 4. CPOE

Answer: 4. Although the other answers loosely describe some positive aspects of CPOE, option 4 provides the best description of the major advantage CPOE offers—the reduction of transcription errors, which reduces medical errors and creates a safer patient care environment. Chapter 26

Which statement made by a patient who is recovering after recently experiencing third-degree burns shows connectedness? 1. "My pain medicine helps me feel better." 2. "I know I will get better if I just keep trying." 3. "I see God's grace and become relaxed when I watch the sun set at night." 4. "I feel so much closer to God after I read my Bible and pray

Answer: 4. Connectedness is a dimension of spirituality that is related to the human need of belonging. Individuals can be connected to themselves, others, God or another Supreme Being, or nature. Individuals often stay connected to God through prayer Chapter 35

The nurse is reviewing health care provider orders that were handwritten on paper when all computers were down during a system upgrade. Which of the following orders contain an inappropriate abbreviation included on The Joint Commission's "Do Not Use" list and should be clarified with the health care provider? 1. Change open midline abdominal incision daily using wet-tomoist normal saline and gauze. 2. Lorazepam 0.5 mg PO every 4 hours prn anxiety 3. Morphine sulfate 1 mg IVP every 2 hours prn severe pain 4. Insulin aspart 8u SQ every morning before breakfast

Answer: 4. In option 4, the word "unit(s)" should be written out because the letter "u" can be mistaken for "0," the number "4," or "cc." The other orders are written appropriately Chapter 26

The nurse is changing the dressing over the midline incision of a patient who had surgery. Assessment of the incision reveals changes from what was documented by the previous nurse. After documenting the current wound assessment, the nurse contacts the surgeon (Dr. Oakman) by telephone to discuss changes in the incision that are of concern. Which of the following illustrates the most appropriate way for the nurse to document this conversation? 1. Health care provider notified about change in assessment of abdominal incision. T. Wright, RN 2. 09-3-18: Notified Dr. Oakman by phone that there is a new area of redness around the patient's incision. T. Wright, RN 3. 1015: Contacted Dr. Oakman and notified about changes in abdominal incision. T. Wright, RN 4. 09-3-18 (1015): Dr. Oakman contacted by phone. Notified about new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN

Answer: 4. This statement includes the date and time the health care providerwas contacted, the specific name of the health care provider, descriptive details of the changes of concern noted in the patient assessment,whether any orderswere received, and the name and credentials of the nurse who contacted the health care provider. Chapter 26

A nurse prepares to contact a patient's physician about a change in the patient's condition. Put the following statements in the correct order using SBAR (Situation, Background, Assessment, and Recommendation) communication. 1. "She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on levofloxacin at 5 pm yesterday. She states she has a poor appetite; her weight has remained stable over the past 2 days." 2. "The patient reported feeling very nauseated after her dose of levofloxacin an hour ago." 3. "Is it possible to make a change in antibiotics, or could we give her a nutritional supplement before her medication?" 4. "The patient started to complain of nausea yesterday evening and has vomited several times during the night."

Answer: 4S, 1B, 2A, 3R. The nurse describes the patient's complaint of nausea and vomiting to the physician (Situation). Specific patient demographic information and reason for admission with current symptomology are provided (Background). The physician is informed of the patient's complaint of nausea after receiving levofloxacin (Assessment). Physician is asked if he or she would like to make a change in the antibiotic or provide a nutritional supplement before medication administration (Recommendation) Chapter 24

A nurse has the responsibility of managing a patient's postmortem care. What is the proper order for postmortem care when there is no autopsy ordered? 1. Bathe the body of the deceased. 2. Collect any needed specimens. 3. Remove all tubes and indwelling lines. 4. Position the body for family viewing. 5. Speak to the family members about their possible participation. 6. Ensure that the request for organ/tissue donation and/or autopsy was completed. 7. Notify support person (e.g., spiritual care provider, bereavement specialist) for the family. 8. Accurately tag the body, including the identity of the deceased and safety issues regarding infection control. 9. Elevate the head of the bed

Answer: 6, 9, 2, 5, 7, 3, 1, 4, 8. This order provides dignity to the deceased and ensures that the nurse is adhering to all policies and laws concerning autopsies, organ donation, or an investigation. Chapter 36

1. Mrs. Yang says to Mattie, "Where is my hula? This isn't my hula!" Mattie replies, "I'm not sure I understand. Your hula? Perhaps do you mean your house? You don't know where your house is? Did you mean house but mistakenly said hula?" Mrs. Yang snaps, "Yes! My house. That's what I meant. The right word wouldn't come." Mattie uses the communication technique of clarifying to explain further what Mrs. Yang is trying to say. A. True B. False

Answer: A Rationale: Alzheimer's patients typically confuse words. Clarifying by giving an example of what the patient means helps resolve any confusion and improves communication between the nurse and patient. Case Study, Chapter 24

Mr. Matt Wexler is being admitted to the psychiatric unit at the Veteran's Affairs (VA) hospital for violent behavior. He is a 28-year-old soldier who has just returned from three tours in Afghanistan. His girlfriend stated that he tried to strangle her when he confused her with an undercover Afghani secret agent. Marlene is the nursing student assigned to Mr. Wexler. She reviews his intake forms and health care provider's orders. His diagnoses are posttraumatic stress disorder (PTSD), paranoia, and psychosis. 1. Marlene talks with Mr. Wexler about his diagnoses and care plan. She explains to him that he is experiencing both situational and adventitious crises as a result of his experience in the Middle East. The frame of reference for Mr. Wexler's crises is which of the following? A. Mr. Wexler's point of view B. Mr. Wexler's medical history C. Mr. Wexler's girlfriend's point of view D. Mr. Wexler's care plan

Answer: A Rationale: The view of the person experiencing the crisis is the frame of reference for the crisis Case Study, Chapter 37

1. Boris takes Mr. Scalini's vital signs at 0800. When should Boris chart Mr. Scalini's vital signs? A. At the time of occurrence B. At the end of shift C. Before the lunch break At 1200

Answer: A Rationale: Vital signs; pain assessment; administration of medications and treatments; preparation for diagnostic tests or surgery; changes in the patient's status and who was notified; treatment for a sudden change in the patient's status; the patient's response to treatment or intervention; and admission, transfer, discharge, or death of a patient should be documented at the time of occurrence. Case Study Chapter 26

1. Michelle sits in on a counseling session with her nursing mentor and a childless couple. The choices for infertile couples include which of the following? (Select all that apply.) A. Pursuing adoption B. Remaining childless C. Undergoing fertilization treatment D. Medicating with St. John's wort

Answer: A, B, C Rationale: Choices for the infertile couple include pursuit of adoption, medical assistance with fertilization, or adapting to the probability of remaining childless. St. John's wort is an herbal treatment used for depression management Case Study, Chapter 34

1. Mr. Smith tells Margaret that he doesn't think he can hold the spoon on his own and feed himself. Mr. Smith lacks self-efficacy. Self-efficacy comes from which of the following sources? (Select all that apply.) A. Enactive mastery experiences B. Vicarious experiences C. Auditory persuasion D. Physiological states

Answer: A, B, D Rationale: Self-efficacy, which is the person's perceived ability to successfully complete a task, comes from four sources: enactive mastery experiences, vicarious experiences, verbal persuasion, and physiological and affective states. Case Study, Chapter 25

1. Marlene teaches Mr. Wexler how to interpret the impact of his military experience and violent act toward his girlfriend. She is teaching him how to take an ________________ of himself.

Answer: Appraisal Rationale: Appraisal is how people interpret the impact of the stressor on themselves or on what is happening and what they are able to do about it. Chapter 37

1. Marlene teaches Mr. Wexler about crisis management. Most crises are resolved within 2 weeks. A. True B. False

Answer: B Rationale: A crisis is generally resolved in some way within approximately 6 weeks, with the goal of crisis intervention and management being to return the person to a precrisis level of functioning. Chapter 37

1. Sara further explores the concept of grief. Suicide is a risk for people who experience masked grief. A. True False

Answer: B Rationale: Suicide is a risk for people who experience exaggerated grief in which self-destructive or maladaptive behaviors are present. Case Study Chapter 36

1. Boris charts Mr. Scalini's pain assessment in Mr. Scalini's chart. Which of the following is a correct example of charting as it appears in the chart? A. "Patient appears to be free from pain." B. "Patient states a 0 on a pain-rating scale of 1 to 10." C. "Patient seems to be resting comfortably." D. "Patient seems to have pain at the incision site."

Answer: B Rationale: A factual record such as a patient chart should include descriptive, objective information about what a nurse sees, hears, feels, and smells. Vague terms such as appears and seems state an opinion and not fact. The patient's complaint of pain using the pain-rating scale is a descriptive piece of subjective information that is permissible in the patient's chart Case Study, Chapter 26

1. Mr. Smith becomes agitated as Margaret tries to retrain him in his use of eating utensils. Margaret knows that, as his anxiety increases, his ability to pay attention also increases. A. True B. False

Answer: B Rationale: As anxiety increases, the patient's ability to pay attention often decreases, not increases. Case Study, Chapter 25

1. Boris charts Mr. Scanlini's vital signs and intake and output on a flow sheet. Documenting on a flow sheet ensures duplication of data as required by The Joint Commission. A. True B. False

Answer: B Rationale: Documenting on a flow sheet prevents duplication of data. The Joint Commission does not require duplication of data Case Study Chapter 26

Michelle is a nursing student who has always been interested in the creation of life, the process of conception, and newborns. Because of this interest, she volunteers at a fertility clinic one afternoon a week. She enjoys working with singles and couples who wish to have children; she finds great satisfaction in helping her patients' dreams come true. 1. Michelle knows that infertility is the inability to conceive after 6 months of unprotected intercourse. A. True False

Answer: B Rationale: Infertility is the inability to conceive after 1 year of unprotected intercourse. Case Study, Chapter 34

1. During the counseling session with Michelle, the nursing mentor, and the childless couple, sexual dysfunction is discussed. Sexual dysfunction is higher in men than in women. A. True False

Answer: B Rationale: The general incidence of sexual dysfunction in the general population is estimated to be as high as 40% in men and 45% in women. Case Study, Chapter 34

1. Which of the following nursing assessment questions posed by Max to Mrs. Gupta will help him develop her plan of care? (Select all that apply.) A. "How long have you been a Hindu?" B. "How happy are you with your life?" C. "How does your faith help you cope?" D. "How has your illness changed your life?" E. "Do you pray?"

Answer: B, C, D, E Rationale: Asking the patient about happiness, faith, life changes, and prayer offer insight into her needs. Asking how long she has been Hindu is not effective since most people ascribe to their religion as children because of familial and cultural influences. Chapter 35

1. Sara teaches the bereavement group Kübler-Ross' five stages of dying. Rank them in order. A. Bargaining B. Denial C. Depression D. Acceptance Anger

Answer: B, E, A, C, D Rationale: The five stages of dying as defined by Kübler-Ross are denial, anger, bargaining, depression, and acceptance Case Study, Chapter 36

Sara is in her last semester of nursing school. She works as a student nurse twice a week with the local hospice to fulfill her community health rotation course requirement. Hospice offers bereavement counseling to the family members of deceased patients. The hospice director asks Sara to prepare an educational lesson to present at the next bereavement group meeting. 1. Sara plans to teach the bereavement group about the different kinds of grief. A gay man's grief over the loss of his partner to acquired immunodeficiency syndrome (AIDS) signifies which type of grief? A. Normal grief B. Anticipatory grief C. Disenfranchised grief Ambiguous grief

Answer: C Rationale: Disenfranchised grief is known as marginal or unsupported grief when the relationship to the deceased person is not socially sanctioned, cannot be shared openly, or seems of lesser significance because it does not meet the norms of society. A gay relationship may be viewed by some as disenfranchised grief. Case Study Chapter 36

Mrs. Anna Gupta is a 54-year-old Hindu woman admitted to the medical-surgical unit for recovery from a total hysterectomy. The hysterectomy was required because she suffered from heavy bleeding secondary to fibroid tumors. She is in her room surrounded by family, including her husband, two sons, and a daughter. Max is the nursing student assigned to Mrs. Gupta. Max reviews her surgical record, laboratory results, and medication orders before entering her room to perform an admission history and physical examination. He notes that Mrs. Gupta is Hindu; therefore he plans to ask about her cultural and spiritual preferences during the patient interview. 1. Max asks Mrs. Gupta to explain her medical history, including the decision to undergo a hysterectomy. Which of the following statements made by Mrs. Gupta is a reflection of her religious beliefs? A. "I can only have a female nurse examine me." B. "My fibroids were caused by nonhuman spirits that invaded my body." C. "My past sins are responsible for my fibroid tumors." D. "Singing will help me heal faster."

Answer: C Rationale: Hindus believe that past sins cause illness. Case Study, Chapter 35

Margaret is a first-semester nursing student who is doing her clinical rotation in an assisted-living care facility. She is assigned to Mr. Alfred Smith, an 81-year-old African-American male who has dementia. Mr. Smith's family could no longer take care of him at home because he became combative in the evenings as a result of the effects of sundowner's syndrome. to preserve his safety, Mr. Smith now lives on the locked unit at the assisted-living facility where one or more members of his immediate and extended family come to visit every day. In addition, Mr. Smith's great niece, Harriet, works at the same facility and checks on Mr. Smith during each of her shifts. 1. Because of Mr. Smith's progressing dementia, he has difficulty feeding himself. When Margaret prompts him to eat his oatmeal at breakfast, he just stares at his spoon. Margaret picks up his spoon and wraps his hand around the handle. For which psychomotor learning skill is Margaret trying to retrain Mr. Smith? A. Set B. Mechanism C. Perception D. Guided response

Answer: C Rationale: Perception is the simplest behavior, which requires being aware of objects or qualities through the use of sense organs. Margaret tries to retrain Mr. Smith's perceptions by having him hold his spoon. Case Study, Chapter 25

Mrs. Elaine Yang is an 82-year-old Chinese woman who lives in a long-term care facility. She has early-onset Alzheimer's disease, which causes her to not always be oriented to person, time, and place. She used to smoke 1.5 packs of cigarettes per day, but she quit smoking 10 years ago. Other than having an occasional headache, she is healthy and does not require any medication except acetaminophen for the headaches. Mattie is the nursing student assigned to Mrs. Yang. Mattie's priorities in caring for Mrs. Yang are to maintain safety and help orient Mrs. Yang when she becomes confused. 1. Mrs. Yang is very stoic and never asks for help. Mattie has learned this and thus pretends that she is running an errand on the other side of the building to secretly assist Mrs. Yang to the dining room to ensure that she arrives safely to lunch. Mattie gently touches Mrs. Yang's shoulder as they walk along the hallway. Which zone of touch is Mattie exhibiting? A. Consent zone B. Intimate zone C. Social zone D. Vulnerable zone

Answer: C Rationale: The social zone of touch includes the hands, arms, shoulders, and back; permission is not required to touch these areas Case Study Chapter 24

1. Sara teaches the bereavement group the Grief Tasks Model by Worden. Rank in order the tasks of this grief theory. A. Emotionally relocate the deceased and move on with life. B. Experience the pain of grief. C. Accept the reality of the loss. D. Adjust to a world in which the deceased is missing.

Answer: C, B, D, A Rationale: The tasks of Worden's Grief Tasks Mode in order are: accept the reality of the loss; experience the pain of grief; adjust to a world in which the deceased is missing; and emotionally relocate the deceased and move on with life. Case Study , Chapter 36

1. Mrs. Yang tells Mattie that she has something important to tell her. Mattie uses the active listening techniques of SOLER when communicating with Mrs. Yang. Which of the following are techniques of SOLER? (Select all that apply.) A. Listen to the patient. B. Establish constant eye contact. C. Sit facing the patient. D. Observe an open posture. E. Reiterate the patient's statements.

Answer: C, D Rationale: The techniques of SOLER are: sit facing the patient; observe an open posture; lean toward the patient; establish and maintain intermittent eye contact; and relax. Case Study, Chapter 24

Boris is a nursing student on the medical-surgical unit who is assigned a new admission from the postanesthesia care unit (PACU), Mr. Rudolpho Scalini. Mr. Scalini is 54 years old and status post-right total hip replacement (THR). He is an owner of a local Italian restaurant chain and is 5'6" and 220 pounds. Mr. Scalini's hip replacement was precipitated by his obesity and refusal to engage in a regular exercise program. Boris conducts his admission assessment of Mr. Scalini and charts his findings in the electronic health record (EHR). 1. Boris completes Mr. Scalini's admission paperwork. Which of the following establishes reimbursement to the hospital for Mr. Scalini's care? A. Patient care plan B. Joint Commission standards C. Nanda diagnoses D. Diagnosis-related groups

Answer: D Rationale: Diagnosis-related groups enable hospitals to be reimbursed a predetermined dollar amount by Medicare. Case Study Chapter 26

1. Mr. Smith constantly denies that he has dementia by stating, "I'm old. A little forgetfulness is normal." Mr. Smith is in the _________ or _________ stage of grieving.

Answer: Denial or disbelief Rationale: Patients in the denial or disbelief stage of grieving do not acknowledge that their health has changed, and they are not prepared to deal with the problem. Case Study, Chapter 25

As Max concludes his assessment and patient interview, Mrs. Gupta states, "You are very kind...a good boy. You make me feel better. Good things will come to you." Max took the time to develop a holistic view of Mrs. Gupta and her care. Therefore he created a ____________ relationship with her.

Answer: Healing Rationale: A healing relationship between the nurse and the patient involves taking a holistic view of the patient's care. It mobilizes hope for the nurse and patient; finds an interpretation or understanding of the illness, pain, anxiety, or other stressful emotion that is acceptable to the patient; and helps the patient use social, emotional, and spiritual resources Case Study, Chapter 35

The nurse is writing a narrative progress note. Identify each of the following statements as subjective data (S) or objective data (O): 1. April 24, 2019 (0900) 2. Repositioned patient on left side. 3. Medicated with hydrocodone-acetaminophen 5/325 mg, 2 tablets PO. 4. "The pain in my incision increases every time I try to turn on my right side." 5. S. Eastman, RN 6. Surgical incision right lower quadrant, 3 inches in length, well approximated, sutures intact, no drainage 7. Rates pain 7/10 at location of surgical incision

Answer: O: 1, 2, 3, 5, 6, 7. S: 4. Statement 4 is the only example of a subjective statement. All other statements in the list are objective data. Logical order for placement of these statements includes "1, 4, 6, 7, 3, 2, and 5." The date and time of a narrative note are recorded first, followed by information from the patient that informs clinical decisions, followed by assessment data, and interventions made. A narrative note is closed with the nurse's signature (first initial, last name, credentials) Chapter 26

1. Mattie says to Mrs. Yang, "You look wonderful today, Mrs. Yang. You seem very rested. And what a beautiful scarf! Did that come from China?" Mattie is sharing ___________ with Mrs. Yang.

Answer: Observations Rationale: Nurses make observations by commenting on how the other person looks, sounds, or acts. Stating observations often helps the patient communicate with the need for excessive questioning, focusing, or clarification. Case Study, Chapter 24

When assessing a young woman who was a victim of a home invasion 3 months earlier, the nurse learns that the woman has vivid images of the event whenever she hears loud yelling or a sudden noise. The nurse recognizes this as ____________.

Answer: Post-traumatic stress disorder (PTSD). PTSD originates with a person's experiencing or witnessing a traumatic event and responding with intense fear or helplessness. The home break-in is the traumatic event that is causing intense fear and/or flashbacks when the noises of the break-in are replicated. Chapter 37

1. Mr. Wexler says to Marlene, "I'm worried about how my hospital stay and illness affects the rest of my life. How am I supposed to support myself and my girlfriend if I'm in the hospital?" The uncertainty associated with hospitalization and illness is a _______________ factor.

Answer: Situational Rationale: Situational factors lead to situational stress, which arises from changes such as being hospitalized and unable to work. Case Study, Chapter 37

Max uses the SWB scale to assess Mrs. Gupta's spirituality. What does SWB stand for?

Answer: Spiritual well-being Rationale: The SWB scale is a 20-item tool that that assesses the individual's view of life and relationship with a higher power. Case Study, Chapter 35

The nurse who works at the local hospital is transferring a patient to an acute rehabilitation center in another town. To complete the transfer, information from the patient's electronic health record must be printed and faxed to the acute rehabilitation center. Which of the following actions is most appropriate for the nurse to take to maintain privacy and confidentiality of the patient's information when faxing this information? (Select all that apply.) 1. Confirm that the fax number for the acute rehabilitation center is correct before sending the fax. 2. Use the encryption feature on the fax machine to encode the information and make it impossible for staff at the acute rehabilitation center to read the information unless they have the encryption key. 3. Fax the patient's information without a cover sheet so that the person receiving the information at the acute rehabilitation center can identify it more quickly. 4. After sending the fax, place the information that was printed out in a standard trash can after ripping it into several pieces. 5. After sending the fax, place the information that was printed out in a secure canister marked for shredding

Answers: 1, 2, 5. Nurses have the legal and ethical obligation to safeguard any patient information that is printed or extracted from the electronic (or paper) health record. Best practice is to use all measures to fax information securely, and to shred any printed health record material after it has been used for the purpose intended. Chapter 26

The nurse is providing education on sexually transmitted infections (STIs) to a group of older adults. The nurse knows that further teaching is needed when the participants make which statements? (Select all that apply.) 1. "I don't need to use condoms since there is no risk for pregnancy." 2. "I should be screened for an STI each time I'm with a new partner." 3. "I know I'm not infected because I don't have discharge or sores." 4. "I was tested for STIs last year, so I know I'm not infected." 5. "The infection rate in older adults is low because most are not sexually active."

Answer: 1, 3, 4, 5. One of the challenges in reducing the incidence of STIs is that most STIs have few symptoms in males or females. Asymptomatic STIs can be diagnosed during a physical examination with appropriate laboratory tests. Older adults may engage in risky sexual behaviors because of lack of knowledge about STIs and condom usage. Research indicates that older adults are remaining sexually active longer than previously believed and the incidence of STI and human immunodeficiency virus (HIV) infections has steadily increased for the past 12 years. Screening after each new sex partner is the most effective method to detect and manage STIs, so this statement shows understanding of the teaching by the patient. Chapter 34

Which actions by the nurse help grieving families? (Select all that apply.) 1. Encourage involvement in nonthreatening group social activities. 2. Follow up with the family in their home. 3. Remind them that feelings of sadness or pain can return around anniversaries. 4. Encourage survivors to ask for help. 5. Look for overuse of alcohol, sleeping aids, or street drugs.

Answer: 1, 3, 4, 5. Providing education, encouraging, and monitoring for healthy and unhealthy coping responses during grief are ways to support and help families grieve. Encouraging survivors to seek available resources helps survivors cope with grief. Chapter 36

When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply.) 1. Check for needed adaptive equipment. 2. Exaggerate lip movements to help the patient lip-read. 3. Give the patient time to respond to questions. 4. Keep communication short and to the point. 5. Communicate only through written information.

Answer: 1, 3, 4. Chapter 24

A crisis intervention nurse is working with a mother whose child with Down syndrome has been hospitalized with pneumonia and who has lost her child's disability payment while the child is hospitalized. The mother worries that her daughter will fall behind in her classes during hospitalization. Which strategies are effective in helping this mother cope with these stressors? (Select all that apply.) 1. Referral to social service process reestablishing the child's disability payment 2. Sending the child home in 72 hours and having the child return to school 3. Coordinating hospital-based and home-based schooling with the child's teacher 4. Teaching the mother signs and symptoms of a respiratory tract infection 5. Telling the mother that the stress will decrease in 6 weeks when everything is back to normal

Answer: 1, 3, 4. The stressors for this parent are her child's illness, missing school, and loss of disability payments. Obtaining resources to resolve these stressors will reduce the mother's stress load and allow her to focus on helping her child improve and on preventing another respiratory tract infection. Discharging the child in 72 hours with a return to school may not be best for the child's physical condition and may make the situation worse. Giving the mother a 6-week time frame is unrealistic because everyone's time frame is different. The mother may also need to adjust. Chapter 37

The school nurse is counseling an adolescent male who is returning to school after attempting suicide. He denies substance abuse and has no history of treatment for depression. He says he has no friends or family who understand him. Critical thinking encourages the nurse to consider all possibilities, including which of the following? (Select all that apply.) 1. Adolescents often explore their sexual identity and expose themselves to complications such as sexually transmitted infections (STIs) or unplanned pregnancy. 2. Peer approval and acceptance are not important in this agegroup. 3. Lesbian, gay, bisexual, and transgender (LGBTQ+) youth often experience stress from identification with a sexual minority group. 4. Knowledge about normal changes associated with puberty and sexuality can decrease stress and anxiety. 5. Adolescence is a time of emotional stability and self-acceptance

Answer: 1, 3, 4. Adolescents are establishing their identity and exploring their sexual preference. Those who identify with a sexual minority group often experience stress and isolation from peers. They need clear and accurate information about physiological and emotional changes occurring in their body. Peer influence is high during this time, but support from family and health care professionals is equally important to adolescents. Chapter 34

The nurse is working in an agency that has recently implemented an electronic health record. Which of the following are acceptable practices for maintaining the security and confidentiality of electronic health record information? (Select all that apply.) 1. Using a strong password and changing your password frequently according to agency policy 2. Allowing a temporary staff member to use your computer user name and password to access the electronic record 3. Ensuring that work lists (and any other data that must be printed from the electronic health record) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed 4. Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other health care providers who are not involved in that patient's care 5. Remaining logged in to a computer to save time if you only need to step away to administer a medication

Answer: 1, 3, 4. Mechanisms to protect the privacy and confidentiality of protected health information in the electronic health record include: not sharing passwords, not leaving computers with open electronic health records unattended, and preventing those not involved with a patient's care from seeing information displayed on a monitor. Chapter 26

The nurse is providing community education about how the sexual response changes with age. Which statement made by one of the adults indicates the need for further information? 1. "Health problems such as diabetes, chronic obstructive pulmonary disease, and hypertension have little effect on sexual functioning and desire." 2. "It usually takes longer for both sexes to reach an orgasm." 3. "Most of the normal changes in function are related to alteration in circulation and hormone levels." 4. "Many medications can interfere with sexual function."

Answer: 1. Pathological processes can interfere with sexual function and desire. Changes in circulation, neurological pathways, and hormone levels account for many of the normal physiological changes that occur with the aging process. Common medications such as diuretics, antihypertensives, antianxiety medications, and antidepressants can contribute to sexual dysfunction. Older males and females take longer to reach orgasm, and the refractory period lengthens Chapter 34

The nurse is caring for a patient who has just had a near-death experience (NDE) following a cardiac arrest. Which intervention by the nurse best promotes the spiritual well-being of the patient after the NDE? 1. Allowing the patient to discuss the experience 2. Referring the patient to pastoral care 3. Having the patient talk to another patient who had an NDE 4. Offering to pray for the patient

Answer: 1. Patients who have a near death experience (NDE) are often reluctant to speak of the experience. Allowing the patient to discuss the NDE helps the patient find acceptance of and meaning from the event. It also allows the patient to explore what happened and promotes spiritual well-being Chapter 35

A patient's cultural background affects the motivation for learning. Using the ACCESS model, match the nursing approach with the correct model component. ACCESS model component 1. Assessment 2. Communication 3. Cultural 4. Establishment 5. Sensitivity 6. Safety Nursing Approach A. Help patients feel culturally secure and able to maintain their cultural identity. B. Remain aware of verbal and nonverbal responses. C. Be aware of how patients from diverse backgrounds perceive their care needs. D. Become aware of your patient's culture and your own cultural biases. E. Learn about the patient's health beliefs and practices. F. Show respect by creating a caring rapport.

Answer: 1E, 2B, 3D, 4F, 5C, 6A. Chapter 25

The nurse is caring for a patient who is very depressed and decides to complete a spiritual assessment using the FICA tool. Using the FICA assessment tool, match the criteria on the left with the appropriate assessment question on the right. 1. F—Faith ___ 2. I—Importance of spirituality ___ 3. C—Community ___ 4. A—Interventions to address spiritual needs ___ a. Tell me if you have a higher power or authority that helps you act on your beliefs b. Describe which activities give you comfort spiritually c. To whom do you go for support in times of difficulty? d. Your illness has kept you from attending church. Is that a problem for you?

Answer: 1a, 2d, 3c, 4b. Chapter 35

The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following? (Select all that apply.) 1. Loss of autonomy caused by health problems 2. Physical appearance and body image 3. Accepting one's personal identity 4. Separation from family 5. Taking tests in school

Answer: 2, 3, 4, 5. As adolescents search for identity with peer groups and separate from their families, they also experience stress. In addition, they face stressful questions about sex, jobs, school, career choices, and using mind-altering substances. During this stage of development, stress can occur because of a preoccupation with appearance and body image. A loss of autonomy caused by health problems usually applies to the older adult. Chapter 37

The nurse therapeutically responds to an adult patient who is anxious by: (Select all that apply.) 1. Matching the rate of speech to be the same as that of the patient 2. Providing good eye contact 3. Demonstrating a calm presence 4. Spending time attentively with the patient 5. Assuring the patient that all will be well

Answer: 2, 3, 4. Chapter 24

Nurses must communicate effectively with the health care team for which of the following reasons? (Select all that apply.) 1. To improve the nurse's status with the health team members 2. To reduce the risk of errors to the patient 3. To provide an optimum level of patient care 4. To improve patient outcomes 5. To prevent issues that need to be reported to outside agencies

Answer: 2, 3, 4. Effective communication in health care has been linked to a decrease in medical errors and an improvement in quality of care and patient outcomes. The status of the nurse or the prevention of reportable issues is not the focus of communication with patients. Chapter 24

A nurse is caring for a young patient who has been told he has multiple sclerosis. The nurse has planned time to conduct a teaching session that will focus on the disease and principles of management. The nurse chooses to use the EDUCATE model to proceed with instruction. Which of the following are components of the model? (Select all that apply.) 1. State goals of the session for the patient. 2. Repeat the most important information. 3. Practice empathetic skills. 4. Be aware of nonverbal messages. 5. Use a standard question list for the chosen topic

Answer: 2, 3, 4. Repetition of important information, using empathetic skills, and being aware of nonverbal messages are all a part of the EDUCATE model. The nurse is not the source of the goals for a teaching session. Ask patients to state their goals of care to begin a discussion. A standard list of questions may not be relevant to a patient. A more patient-centered approach is to use a question list that includes questions patients can ask so that providers can answer them Chapter 25

Which interventions does a nurse implement to help a patient at the end of life maintain autonomy while in a hospital? (Select all that apply.) 1. Use therapeutic techniques when communicating with the patient. 2. Allow the patient to determine timing and scheduling of interventions. 3. Allow patients to have visitors at any time. 4. Provide the patient with a private room close to the nurses' station. 5. Encourage the patient to eat whenever he or she is hungry

Answer: 2, 3, 5. Allowing patients to make choices about their care and end-of-life experience provides opportunities for them to maintain their autonomy Chapter 36

A nurse is preparing to teach an older adult who has chronic arthritis how to practice meditation. Which of the following strategies are appropriate? (Select all that apply.) 1. Encourage family members to participate in the exercise. 2. Have patient identify a quiet room in the home that has minimal interruptions. 3. Suggest the use of a quiet fan running in the room. 4. Explain that it is best to meditate about 5 minutes 4 times a day. 5. Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer

Answer: 2, 3, 5. A quiet room with no distractions is conducive to meditation. The low buzz of a fan also blocks distractive noises. A patient should relax comfortably during meditation. Meditation is usually recommended 10 to 20 minutes twice a day. The activity should be conducted alone without distraction Chapter 35

A 44-year-old male patient has just been told that his wife and child were killed in an auto accident while coming to visit him in the hospital. Which of the following statements are assessment findings that support a nursing diagnosis of Spiritual Distress related to loss of family members? (Select all that apply.) 1. "I need to call my sister for support." 2. "I have nothing to live for now." 3. "Why would my God do this to me?" 4. "I need to pray for a miracle." 5. "I want to be more involved in my church

Answer: 2, 3. Patients most likely to have a diagnosis of Spiritual Distress are facing loss or terminal or serious illness and have poor personal relationships. Indicating that there is nothing to live for now and wondering why God would do this to him reflect dispiritedness (e.g., expressing lack of hope, meaning, or purpose in life; anger toward God). The other responses show a potential for enhancement of spiritual well-being. Chapter 35

The nurse uses silence as a therapeutic communication technique. What are the purposes of the nurse's silence? (Select all that apply.) 1. Allows the nurse time to focus and avoid saying the wrong thing 2. Prompts the patient to talk when he or she is ready 3. Allows the patient time to think and gain insight 4. Allows time for the patient to drift off to sleep 5. Determines whether the patient would prefer to talk with another staff member

Answer: 2, 3. Silence can provide that patient an opportunity to think and gain insight. Often the patient feels compelled to break the silence and is prompted to talk. Chapter 24

Which comments to a patient by a new nurse regarding palliative care needs are correct? (Select all that apply.) 1. "Even though you're continuing treatment, palliative care is something we might want to talk about." 2. "Palliative care is appropriate for people with any diagnosis." 3. "Only people who are dying can receive palliative care." 4. "Children are able to receive palliative care." 5. Palliative care is only for people with uncontrolled pain

Answer: 1, 2, 4. Palliative care is available to all patients regardless of age, diagnosis, and prognosis. Chapter 36

The nurse recognizes that which factors influence a person's approach to death? (Select all that apply.) 1. Culture 2. Spirituality 3. Personal beliefs 4. Previous experiences with death 5. Gender 6. Level of education

Answer: 1, 2, 3, 4. Culture, spirituality, personal beliefs and values, and previous experiences with death influence how a person approaches death. Chapter 36

To best assist a patient in the grieving process, which factors are most important for the nurse to assess? (Select all that apply.) 1. Previous experiences with grief and loss 2. Religious affiliation and denomination 3. Ethnic background and cultural practices 4. Current financial status 5. Current medications

Answer: 1, 2, 3. Previous experiences, religious affiliation, and cultural practices help individuals develop coping and can be a source of support at the end of life Chapter 36

When planning care for a dying patient, which interventions promote the patient's dignity? (Select all that apply.) 1. Providing respect 2. Viewing the patient as a whole 3. Providing symptom management 4. Showing interest 5. Being present 6. Inserting a straight catheter when the patient has difficulty voiding

Answer: 1, 2, 4, 5. A sense of dignity includes a person's positive self-regard, the ability to find meaning in life, to feel valued by others, and by how one is treated by caregivers. Chapter 36

An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.) 1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 3. Roller clamp wide open 4. Tubing kinked in bedrails 5. Circulatory overload

Answer: 1, 2, 4. Factors that could slow an IV infusion even if the infusion pump is set correctly include increased pressure at the outflow site (e.g., infiltration) and compression of the tubing lumen (e.g., patient lying on the tubing or tubing kinked in bedrails). Chapter 42

An adolescent who is pregnant for the first time is at her initial prenatal visit. The women's health nurse practitioner (WHNP) informs the patient that she will be screening her for sexually transmitted infections (STIs). The patient replies, "I know I don't have an STI because I don't have any symptoms." Which responses by the WHNP would be appropriate? (Select all that apply.) 1. "Untreated STIs can cause serious complications in pregnancy, so we routinely screen pregnant women." 2. "Bacterial STIs don't usually cause symptoms, or you could have an asymptomatic viral STI." 3. "Chlamydia screening is recommended for all sexually active women up to age 25 even if asymptomatic." 4. "People between the ages of 15 and 24 are often asymptomatic and have the highest incidence of STIs." 5. "There is no need to screen for infection since you aren't having any problems or symptoms."

Answer: 1, 3, 4. Serious complications can result from untreated STIs in pregnancy, complications such as preterm labor, rupture of membranes, and premature delivery of the newborn. The risk of untreated STIs in any female is pelvic inflammatory disease, which, if untreated, can cause serious problems such as infertility. Routine screening for chlamydia is recommended for all sexually active women up to age 25. Many people do not know they are infected because they do not experience symptoms. Bacterial STIs are more likely to cause symptoms, whereas viral STIs are often asymptomatic Chapter 34

Motivational interviewing (MI) is a technique that applies understanding a patient's values and goals in helping the patient make behavioral changes. When using motivational interviewing, what outcomes does the nurse expect? (Select all that apply.) 1. Gaining an understanding of the patient's motivations 2. Directing the patient to avoid poor health choices 3. Recognizing the patient's strengths and supporting his or her efforts 4. Providing assessment data that can be shared with families to promote change 5. Identifying differences in patient's health goals and current behaviors

Answer: 1, 3, 5. Motivational interviewing is a technique used to promote an understanding of the patient's motivations, health goals, and current behaviors in a nonjudgmental environment while focusing on the patient's strengths and efforts. The nurse provides a supportive approach to assist the patient in establishing and promoting positive health care changes. Chapter 24

The patient states, "I don't have confidence in my doctor. She looks so young." The nurse therapeutically responds: (Select all that apply.) 1. Tell me more about your concern. 2. You have nothing to worry about. Your doctor is perfectly competent. 3. You are worried about your care? 4. You can go online and see how others have rated your doctor. I do that. 5. You should ask your doctor to tell you her background

Answer: 1, 3. The nurse responding to the patient's concern about the physician's age would not disagree with the patient by simply claiming the doctor was competent but would rather ask questions to elicit more information about the area of concern, such as asking a broader question about concerns. Telling the patient to look the physician up online or advising the patient to query the physician directly are ways that the nurse unhelpfully gives advice to the patient Chapter 24

The nurse is caring for a 50-year-old woman visiting the outpatient medicine clinic. The patient has had type 1 diabetes since age 13. She has numerous complications from her disease, including reduced vision, heart disease, and severe numbness and tingling of the extremities. Knowing that spirituality helps patients cope with chronic illness, which of the following principles should the nurse apply in practice? (Select all that apply.) 1. Pay attention to the patient's spiritual identity throughout the course of her illness. 2. Select interventions that you know scientifically support spiritual well-being. 3. Listen to the patient's story each visit to the clinic, and offer a compassionate presence. 4. When the patient questions the reason for her long-time suffering, try to provide answers. 5. Consult with a spiritual care adviser, and have the adviser recommend useful interventions.

Answer: 1, 3. A person's spiritual well-being can change over time; therefore, it is important to pay attention to it over the course of his or her illness. Listening is a powerful way to support a patient's spirituality. Evidence-based interventions are preferred, but they must be agreed on by the patient and tailored to his or her perspectives and not just those of the nurse. Patients are not looking for answers. What is spoken as a spiritual question is most often an expression of spiritual pain. Using spiritual care advisers is a valuable resource but should be selected by the patient, not independently by the nurse, and any interventions should be mutually agreed on among nurse, patient, and adviser. Chapter 35

Which strategies should a nurse use to facilitate a safe transition of care during a patient's transfer from the hospital to a skilled nursing facility? (Select all that apply.) 1. Collaboration between staff members from sending and receiving departments 2. Requiring that the patient visit the facility before a transfer is arranged 3. Using a standardized transfer policy and transfer tool 4. Arranging all patient transfers during the same time each day 5. Relying on family members to share information with the new facility

Answer: 1, 3. Providing a standardized process, policy, and tool can assist in a predictable, safe transfer of important patient information between health care facilities. Communication and collaboration between the sender and receiver of information enable the staff to validate that the information was received and understood. Requiring a patient visit is not always necessary, and relying on family members to share information does not release staff from their responsibilities. Doing patient transfers on the same day and time has no effect on creating a safe patient transfer Chapter 24

The nurse is gathering a sexual health history on a patient being admitted to the hospital for surgery. Which question demonstrates a nonjudgmental attitude? 1. Can you tell me your sexual orientation? 2. How do you and your wife feel about intimacy? 3. Do you have sex with men, women, or both? 4. Do you have sexual intercourse at your age?

Answer: 1. A nonjudgmental attitude facilitates trust and open communication between the nurse and patient. Using a term such as sexual orientation and asking about preferred pronouns allows the patient to identify his or her unique sexuality and sexual health needs. Chapter 34

A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1c, a measure of blood sugar control over the past 90 days, has increased by saying, "The hemoglobin A1c is wrong. My blood sugar levels have been excellent for the last 6 months." Which defense mechanism is the patient using? 1. Denial 2. Conversion 3. Dissociation 4. Displacement

Answer: 1. Denial is avoiding emotional stress by refusing to consciously acknowledge anything that causes intolerable anxiety. This patient's statements reflect denial about poorly controlled blood sugars. Chapter 37

A 10-year-old girl was playing on a slide at a playground during a summer camp. She fell and broke her arm. The camp notified the parents and took the child to the emergency department according to the camp protocol for injuries. The parents arrive at the emergency department and are stressed and frantic. The 10-yearold is happy in the treatment room, eating a Popsicle and picking out the color of her cast. List in order of priority what the nurse should say to the parents. 1. "Can I contact someone to help you?" 2. "Your daughter is happy in the treatment room, eating a Popsicle and picking out the color of her cast." 3. "I'll have the doctor come out and talk to you as soon as possible." 4. "I want to be sure you are ok. Let's talk about what your concerns are about your daughter before we go see her."

Answer: 2, 4, 3, 1. First and most important the parents need to know the immediate status of their daughter. Letting them know the situation will help to relieve their immediate stress. Second, helping the parents discuss their concerns will reduce their stress and will allow them to see their daughter without increasing the 10-year-old's anxiety. Third, let the parents know that you recognize their need to talk to the doctor as soon as possible and that you will act as their advocate to get that accomplished. Last, but also important, you want to ask whether there is anyone you can call to help. There may be children who need to be picked up from camp/ day care, for example, and a neighbor or grandparent may be able to assist. Chapter 37

A 53-year-old female being treated for breast cancer tells the nurse that she has no interest in sex since her surgery 2 months ago. The nurse is aware that: (Select all that apply.) 1. Sexual issues are expected in a woman this age. Copyright 2021 © by Elsevier, Inc. All rights reserved. 2. Women experience sexual dysfunction more frequently than men. 3. Hypoactive sexual desire disorder (HSDD) occurs in women over 65 years of age. 4. Medical conditions such as cancer often contribute to HSDD

Answer: 2, 4, 5. Women of all ages (not just older women) can experience reduced sexual desire or libido. Biological, organic, or psychosocial factors; pain; depression; and body image concerns can result in sexual problems in men and women. Sexual dysfunction is common in men and women, but it occurs more frequently in women. Self-concept issues, including changes in body image, identity, and role performance, can impact self-esteem and sexual functioning Chapter 34

A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks whether the patient is dying and now in "hospice." What does the nurse tell the family member about palliative care? (Select all that apply.) 1. Palliative care and hospice are the same thing. 2. Palliative care is for any patient, any time, any disease, in any setting. 3. Palliative care strategies are primarily designed to treat the patient's illness. 4. Palliative care relieves the symptoms of illness and treatment. 5. Palliative care selects home health care services

Answer: 2, 4. Palliative care and hospice care are different. Palliative care is available to all patients regardless of age, diagnosis, and prognosis. The focus of palliative care is on management of symptoms Chapter 36

The nurse reviews the health history of a 48-year-old man and notes that he was started on medications for elevated blood pressure and depression at his last annual physical. He tells the nurse that over the past 6 months he is having difficulty sustaining an erection. The nurse understands that: (Select all that apply.) 1. Nurses are not expected to discuss sexual issues with male patients and the physician should address this. 2. Sexual function can be affected by some medications. 3. Sexually transmitted infections (STIs) can cause complications such as erectile dysfunction and screening should be done. 4. Some men with health issues experience erectile dysfunction. 5. Medications used to treat hypertension and depression seldom interfere with sexual function.

Answer: 2, 4. Nurses should complete a holistic assessment on all patients to be able to personalize a plan of care. Nurses who are uncomfortable discussing sexual concerns of patients should seek out training and resources to develop this skill. Many drugs and illnesses can affect sexual function. Antidepressants can alter sexual functioning by blocking neurotransmitters. Antihypertensives can affect sexual function by altering circulation. Erectile dysfunction occurs more frequently in older men but can occur in men as young as 40. STIs may affect sexual functioning but are less likely than medications or illness to be the cause of erectile dysfunction. Chapter 34

Which of the following scenarios demonstrate that learning has taken place? (Select all that apply.) 1. A patient listens to a nurse's review of the warning signs of a stroke. 2. A patient describes how to set up a pill organizer for newly ordered medicines. 3. A patient attends a spinal cord injury support group. 4. A patient demonstrates how to take his blood pressure at home. 5. A patient reviews written information about resources for cancer survivors.

Answer: 2, 4. Steps 2 and 4 are examples of patients exhibiting behaviors that demonstrate learning. The other three steps are examples of patient involvement in instruction. Chapter 25

What are the physical circulatory changes that occur as death approaches? 1. Skin irritation 2. Mottling 3. Increased urine output 4. Weakness

Answer: 2. Patients experience circulatory changes resulting in mottling. Weakness, skin irritation, and incontinence are some of the physical changes that occur as death nears but are not related to circulatory changes. Chapter 36

When delegating input and output (I&O) measurement to assistive personnel, the nurse instructs them to record what information for ice chips? 1. Two-thirds of the volume 2. One-half of the volume 3. One-quarter of the volume 4. Two times the volume

Answer: 2. When ice chips melt, their water volume is one-half the volume of the ice chips. The water volume should be recorded as intake. Chapter 42