Fundamentals Final Exam Practice

A nurse is caring for an 80-year-old female patient who is living in a long-term care facility. To help this patient adapt to her present circumstances, the nurse is using reminiscence as therapy. Which question would encourage reminiscence? a. "Tell me about how you celebrated Christmas when you were young." b. "Tell me how you plan to spend your time this weekend." c. "Did you enjoy the choral group that performed here yesterday? d. "Why don't you want to talk about your feelings?"

a. Asking questions about events in the past can encourage the older adult to relive and restructure life experiences. Chapter 19

A nurse caring for older adults in a long-term care facility knows that several physical changes occur in the aging adult. Which characteristics best describe these changes? Select all that apply. a. Fatty tissue is redistributed. b. The skin is drier and wrinkles appear. c. Cardiac output increases. d. Muscle mass increases. e. Hormone production increases. f. Visual and hearing acuity diminishes.

a, b, f. Physical changes occurring with aging include these: fatty tissue is redistributed, the skin is drier and wrinkles appear, and visual and hearing acuity diminishes. Cardiac output decreases, muscle mass decreases, and hormone production decreases, causing menopause or andropause. Chapter 19

The nurse collects objective and subjective data when conducting patient assessments. Which patient conditions are examples of subjective data? Select all that apply. a. A patient tells the nurse that she is feeling nauseous. b. A patient's ankles are swollen. c. A patient tells the nurse that she is nervous about her test results. d. A patient complains of having a rash on her arm that is itchy. e. A patient rates his pain as a 7 on a scale of 1 to 10. f. A patient vomits after eating supper.

a, c, d, e. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, itchy, or chilly and experiencing pain. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Examples of objective data are an elevated temperature reading (e.g., 101°F), edema, and vomiting. Chapter 11

The student nurse learns that illnesses are classified as either acute or chronic. Which are examples of chronic illnesses? Select all that apply. a. Diabetes mellitus b. Bronchial pneumonia c. Rheumatoid arthritis d. Cystic fibrosis e. Fractured hip f. Otitis media

a, c, d. Diabetes, arthritis, and cystic fibrosis are chronic diseases because they are permanent changes caused by irreversible alterations in normal anatomy and physiology, and they require patient education along with a long period of care or support. Pneumonia, fractures, and otitis media are acute illnesses because they have a rapid onset of symptoms that last a relatively short time. Chapter 3

A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care? Select all that apply. a. The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. b. The nurse uses a binary decision tree for stepwise assessment and intervention. c. The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes. d. The nurse uses broad, research-based practice recommendations that may or may not have been tested in clinical practice. e. The nurse uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research. f. The nurse uses a decision tree that provides intense specificity and no provider flexibility.

a, c. A critical pathway represents a sequential, interdisciplinary, minimal practice standard for a specific patient population that provides flexibility to alter care to meet individualized patient needs. It also offers the ability to measure a cause-and-effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research. Chapter 13

During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of which characteristics of effective communication? Select all that apply. a. Group decision making b. Group leadership c. Group power d. Group identity e. Group patterns of interaction f. Group cohesiveness

a, d, e, f. Solving problems involves group decision making; ascertaining that the staff completes a task on time and that all members agree the task is important is a characteristic of group identity; group patterns of interaction involve honest communication and member support; and cohesiveness occurs when members generally trust each other, have a high commitment to the group, and a high degree of cooperation. Group leadership occurs when groups use effective styles of leadership to meet goals; with group power, sources of power are recognized and used appropriately to accomplish group outcomes. Chapter 20

A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply. a. The nurse carefully removes the bandages from a burn victim's arm. b. The nurse assesses a patient to check nutritional status. c. The nurse formulates a nursing diagnosis for a patient with epilepsy. d. The nurse turns a patient in bed every 2 hours to prevent pressure ulcers. e. The nurse checks a patient's insurance coverage at the initial interview. f. The nurse checks for community resources for a patient with dementia.

a, d, f. During the implementing step of the nursing process, nursing actions planned in the previous step are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient for nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing step. Chapter 14

The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all that apply. a. The nurse uses critical thinking skills to plan care for a patient. b. The nurse correctly administers IV saline to a patient who is dehydrated. c. The nurse assists a patient to fill out an informed consent form. d. The nurse learns the correct dosages for patient pain medications. e. The nurse comforts a mother whose baby was born with Down syndrome. f. The nurse uses the proper procedure to catheterize a female patient.

a, d. Using critical thinking and learning medication dosages are cognitive competencies. Performing procedures correctly is a technical skill, helping a patient with an informed consent form is a legal/ethical issue, and comforting a patient is an interpersonal skill. Chapter 10

A nurse is assessing a 15-year-old female patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: a. Clinical judgment b. Clinical reasoning c. Critical thinking d. Blended competencies

a. Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgment as it refers to the result or outcome of critical thinking or clinical reasoning—in this case the recommendation to meet with a nutritionist. Clinical reasoning usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems). Critical thinking is a broad term that includes reasoning both outside and inside of the clinical setting. Blended competencies are the cognitive, technical, interpersonal, and ethical/legal skills combined with the willingness to use them creatively and critically when working with patients. Chapter 10

The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. a. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." b. "It's hospital policy. I know it must be tiresome, but I will try to make this quick!" c. "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care." d. "We want to make sure that your responses to the medical exam are consistent and that all our data are accurate." e. "We need to check your health status and see what kind of nursing care you may need." f. "We need to see if you require a referral to a physician or other health care professional.

a, e, f. Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient's responses to health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgment about a patient's health status, the ability to manage his or her own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient's strengths and promotes optimum functioning, independence, and well-being, and enables the nurse to refer the patient to a physician or other health care professional, if indicated. The fact that this is hospital policy is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs a nursing history and exam. The assessment is not performed to check the accuracy of the medical examination. Chapter 11

A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs: (1) Disturbed Body Image (2) Ineffective Airway Clearance (3) Spiritual Distress (4) Impaired Social Interaction Which answer choice below lists the problems in order of highest priority to lowest priority based on Maslow's model? a. 2, 4, 1, 3 b. 3, 1, 4, 2 c. 2, 4, 3, 1 d. 3, 2, 4, 1

a. 2, 4, 1, 3. Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to Maslow's hierarchy: (1) physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self esteem needs, and (5) self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and belonging need, #1 is an example of a self-esteem need, and #3 is an example of a self-actualization need. Chapter 13

When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation." Which of the following comments is the nurse most likely to hear from the instructor? a. "Hold on a minute . . . Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue." b. "Job well done . . . you've identified this problem early and we can manage it before it becomes more acute." c. "Is this an actual or a possible diagnosis?" d. "This is a medical, not a nursing problem."

a. A data cluster is a grouping of patient data or cues that points to the existence of a patient health problem. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. There may be a reason for the lack of a bowel movement for 2 days, or it might be this individual's normal pattern. Chapter 12

A registered nurse assumes the role of nurse coach to provide teaching to patients who are recovering from strokes. One example of an intervention the nurse may provide related to this role is: a. The nurse uses discovery to identify the patients' personal goals and create an agenda that will result in change. b. The nurse is the expert in providing teaching and education strategies to provide dietary and activity modifications. c. The nurse becomes a mentor to the patients and encour- ages them to create their own fitness programs. d. The nurse assumes an authoritative role to design the structure of the coaching session and support the achieve- ment of patient goals.

a. A nurse coach establishes a partnership with a patient and, using discovery, facilitates the identification of the patient's personal goals and agenda to lead to change rather than using teaching and education strategies with the nurse as the expert. A nurse coach explores the patient's readiness for coaching, designs the structure of a coaching session, supports the achievement of the patient's desired goals, and with the patient determines how to evaluate the attainment of patient goals. Chapter 21

A nurse sees a patient walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. It is important that the nurse assess the patient for: a. Pain b. Anxiety c. Depression d. Fluid volume deficit

a. A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain. The nurse should clarify this nonverbal behavior. Chapter 20

To determine the significance of a blood pressure reading of 148/100, it is first necessary for the nurse to: a. Compare this reading to standards. b. Check the taxonomy of nursing diagnoses for a pertinent label. c. Check a medical text for the signs and symptoms of high blood pressure. d. Consult with colleagues.

a. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient's blood pressure reading, appropriate standards include normative values for the patient's age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis. Chapter 12

An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underlie the beginning nurse's response? a. Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. b. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. c. The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years; it's time to champion intuitive, creative thinking! d. It's simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers.

a. Beginning nurses must use nursing knowledge and scientific problem solving as the basis of care they give; intuitive problem solving comes with years of practice and observation. If the beginning nurse has an intuition about a patient, that information should be discussed with the faculty member, preceptor, or supervisor. Answer b is incorrect because there is a place for intuitive reasoning in nursing, but it will never replace logical, scientific reasoning. Critical thinking is contextual and changes depending on the circumstances, not on personal preference. Chapter 10

A nurse is preparing a clinical outcome for a 32-year-old female runner who is recovering from a stroke that caused right-sided paresis. An example of this type of outcome is: a. After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. b. By 8/15/15, patient will be able to use right arm to dress, comb hair, and feed herself. c. Following physical therapy, patient will begin to gradually participate in walking/running events. d. By 8/15/15, patient will verbalize feeling sufficiently prepared to participate in running events.

a. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describe the person's ability to function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key factors that affect someone's ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes. Chapter 13

A nurse is preparing to teach a 45-year-old male patient with asthma how to use his inhaler. Which teaching tool is one of the best methods to teach the patient this skill? a. Demonstration b. Lecture c. Discovery d. Panel session

a. Demonstration of techniques, procedures, exercises, and the use of special equipment is an effective patient teaching strategy for a skill. Lecture can be used to deliver information to a large group of patients but is more effective when the session is interactive; it is rarely used for individual instruc- tion, except in combination with other strategies. Discovery is a good method for teaching problem-solving techniques and independent thinking. Panel discussions can be used to impart factual material but are also effective for sharing experiences and emotions. Chapter 21

A nurse follows accepted guidelines for a healthy lifestyle. How can this promote health in others? a. By being a role model for healthy behaviors b. By not requiring sick days from work c. By never exposing others to any type of illness d. By spending less money on food

a. Good personal health enables the nurse to serve as a role model for patients and families. Chapter 3

A school nurse notices that a female adolescent student is losing weight and decides to perform a focused assessment of her nutritional status to determine if she has an eating disor- der. How should the nurse proceed? a. Perform the focused assessment. This is an independent nurse-initiated intervention. b. Request an order from Jill's physician since this is a physician-initiated intervention. c. Request an order from Jill's physician since this is a collaborative intervention. d. Request an order from the nutritionist since this is a collaborative intervention.

a. Performing a focused assessment is an independent nurse- initiated intervention, thus the nurse does not need an order from the physician or the nutritionist. Chapter 14

A student nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident with the procedure. What would be the student's best response? a. Tell the RN that he or she lacks the technical competencies to change the dressing independently. b. Assemble the equipment for the procedure and follow the steps in the procedure manual. c. Ask another student nurse to work collaboratively with him or her to change the dressing. d. Report the RN to his or her instructor for delegating a task that should not be assigned to student nurses.

a. Student nurses should notify their nursing instructor or nurse mentor if they believe they lack any competencies needed to safely implement the plan of care. It is within the realm of a student nurse to change a dressing if he or she is technically prepared to do so. Chapter 14

When interacting with a patient, the nurse answers, "I am sure everything will be fine. You have nothing to worry about." This is an example of what type of inappropriate com- munication technique? a. Cliché b. Giving advice c. Being judgmental d. Changing the subject

a. Telling a patient that everything is going to be all right is a cliché. This statement gives false assurance and gives the patient the impression that the nurse is not interested in the patient's condition. Chapter 20

A nurse is teaching first aid to counselors of a summer camp for children with asthma. This is an example of what aim of health teaching? a. Promoting health b. Preventing illness c. Restoring health d. Facilitating coping

b. Teaching first aid is a function of the goal to prevent ill- ness. Promoting health involves helping patients to value health and develop specific health practices that promote wellness. Restoring health occurs once a patient is ill, and teaching focuses on developing self-care practices that pro- mote recovery. When facilitating coping, nurses help patients come to terms with whatever lifestyle modification is needed for their recovery or to enable them to cope with permanent health alterations. Chapter 21

A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response? a. "You made an inference that she is fine because she has no complaints. How did you validate this?" b. "She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." c. "Sometimes everyone gets lucky. Why don't you try to help another patient?" d. "Maybe you should reassess the patient. She has to have a problem—why else would she be here?"

a. The instructor is most likely to challenge the inference that the patient is "fine" simply because she is telling you that she has no problems. It is appropriate for the instructor to ask how the student nurse validated this inference. Jumping to the conclusion that the patient does not trust the student nurse is premature and is an invalidated inference. Answer c is wrong because it accepts the invalidated inference. Answer d is wrong because it is possible that the condition is resolving. Chapter 11

The agent-host-environment model of health and illness is based on what concept? a. Risk factors b. Demographic variables c. Behaviors to promote health d. Stages of illness

a. The interaction of the agent, host, and environment creates risk factors that increase the probability of disease. Chapter 3

A public health nurse is leaving the home of a young mother who has a special needs baby. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's best response to the neighbor? a. "New mothers need support." b. "The lack of a father is difficult." c. "How are you today?" d. "It is a very sad situation."

a. The nurse must maintain confidentiality when providing care. The statement "New mothers need support" is a general statement that all new parents need help. The statement is not judgmental of the family's roles. Chapter 20

A nurse caring for a patient who is hospitalized following a double mastectomy is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship? a. Determining the progress made in achieving established goals b. Clarifying when the patient should take medications c. Reporting the progress made in teaching to the staff d. Including all family members in the teaching session

a. The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning coor- dinates with the termination phase of a helping relationship. The nurse should determine the progress made in achieving the goals related to the patient's care. Chapter 20

A nurse is using the SOAP format of documentation to docu- ment care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation? a. A patient problem list b. Notes describing the patient's condition c. Overall trends in patient status d. Planned interventions and patient outcomes

a. When using the SOAP format, the problem list at the front of the chart alerts all caregivers to patient priorities. Narra- tive notes allow nurses to describe a condition, situation, or response in their own terms. Abnormal status can be seen immediately when using charting by exception, and planned interventions and patient expected outcomes are the focus of the case management model. Chapter 16

The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? a. Comprehensive b. Initial c. Time-lapsed d. Quick priority

d. Quick priority assessments (QPA) are short, focused, prioritized assessments nurses do to gain the most important information they need to have first. The comprehensive initial assessment is performed shortly after the patient is admitted to a health care agency or service. The time-lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlier. Chapter 11

According to the Health Insurance Portability and Account- ability Act of 1996, if a health institution wants to release a patient's health information (PHI) for purposes other than treatment, payment, and routine health care operations, the patient must be asked to sign an authorization. The nurse is aware that there are exceptions to this requirement. In which of the following cases is an authorization form not needed? Select all that apply. a. News media are preparing a report on the condition of a public figure. b. Data are needed for the tracking and notification of disease outbreaks. c. Protected health information is needed by a coroner. d. Child abuse and neglect are suspected. e. Protected health information is needed to facilitate organ donation. f. The sister of a patient with Alzheimer's wants to help provide care.

b, c, d, e. Authorization is not required for tracking disease outbreaks, providing PHI to a coroner, reporting incidents of child abuse, or facilitating organ donations. Under no cir- cumstance can a nurse provide information to a news reporter without the patient's express authorization. An authorization form is still needed to provide PHI for a patient who has Alzheimer's disease. Chapter 16

Despite a national focus on health promotion, nurses working with patients in inner-city clinics continue to see disparities in health care for vulnerable populations. Which patients would be considered vulnerable populations? Select all that apply. a. A White male diagnosed with HIV b. An African American teenager who is 6 months pregnant c. A Hispanic male who has type II diabetes d. A low-income family living in rural America e. A middle-class teacher living in a large city f. A White baby who was born with cerebral palsy

b, c, d, f. National trends in the prevention of health disparities are focused on vulnerable populations, such as racial and ethnic minorities, those living in poverty, women, children, older adults, rural and inner-city residents, and people with disabilities and special health care needs. Chapter 3

A nurse is planning care for a male adolescent patient who is admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? Select all that apply. a. The nurse formulates nursing diagnoses. b. The nurse identifies expected patient outcomes. c. The nurse selects evidence-based nursing interventions. d. The nurse explains the nursing care plan to the patient. e. The nurse assesses the patient's mental status. f. The nurse evaluates the patient's outcome achievement.

b, c, d. During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to establish priorities, identify and write expected patient outcomes, select evidence-based nursing interventions, and communicate the plan of nursing care. Although all these steps may overlap, formulating and validating nursing diagnoses occurs most frequently during the diagnosing step of the nursing process. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process. Chapter 13

An RN working on a busy hospital unit delegates patient care to unlicensed assistive personnel (UAPs). Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply. a. Performing the initial patient assessments b. Making patient beds c. Giving patients bed baths d. Administering patient medications e. Ambulating patients f. Assisting patients with meals

b, c, e, f. Performing the initial patient assessment and administering medications are the responsibility of the registered nurse. In most cases, patient hygiene, bed-making, ambulating patients, and helping to feed patients can be delegated to a UAP. Chapter 14

A nurse uses critical thinking skills to focus on the care plan of an elderly patient who has dementia and needs placement in a long-term care facility. Which statements describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply. a. It functions independently of nursing standards, ethics, and state practice acts. b. It is based on the principles of the nursing process, problem solving, and the scientific method. c. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. d. It is not designed to compensate for problems created by human nature, such as medication errors. e. It is constantly re-evaluating, self-correcting, and striving for improvement. f. It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care.

b, c, e. Critical thinking applied to clinical reasoning and judgment in nursing practice is guided by standards, policies and procedures, and ethics codes. It is based on principles of nursing process, problem solving, and the scientific method. It carefully identifies the key problems, issues, and risks involved, and is driven by patient, family, and community needs, as well as nurses' needs to give competent, efficient care. It also calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly re evaluating, self-correcting, and striving to improve (Alfaro-LeFevre, 2014). Chapter 10

A nurse is caring for an older adult patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply. a. Bronchial pneumonia b. Impaired gas exchange c. Ineffective airway clearance d. Potential complication: sepsis e. Infection related to pneumonia f. Risk for septic shock

b, c, f. Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk for septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential complication: sepsis" is a collaborative problem. Chapter 12

Health promotion activities may occur on a primary, secondary, or tertiary level. Which activities are considered tertiary health promotion? Select all that apply. a. A nurse runs an immunization clinic in the inner city. b. A nurse teaches a patient with an amputation how to care for the residual limb. c. A nurse provides range-of-motion exercises for a paralyzed patient. d. A nurse teaches parents of toddlers how to childproof their homes. e. A school nurse provides screening for scoliosis for the students. f. A nurse teaches new parents how to choose and use an infant car seat.

b, c. Tertiary health promotion and disease prevention begins after an illness is diagnosed and treated to reduce disability and to help rehabilitate patients to a maximum level of functioning. These activities include providing ROM exercises and patient teaching for residual limb care. Providing immunizations and teaching parents how to childproof their homes and use an appropriate car seat are primary health promotion activities. Providing screenings is a secondary health promotion activity. Chapter 3

A nurse who is caring for older adults in a senior daycare center documents findings as related to which normal aging process? Select all that apply. a. A patient's increased skin elasticity causes wrinkles on the face and arms. b. Exposure to sun over the years causes a patient's skin to be pigmented. c. A patient's toenails have become thinner with a bluish tint to the nail beds. d. A patient experiences a hip fracture due to porous and brittle bones. e. Fragile blood vessels in the dermis allow for more easy bruising of a patient's forearm. f. Increased bladder capacity causes decreased voiding in an older patient.

b, d, e. Exposure to sun over the years can cause a patient's skin to be pigmented. Bone demineralization occurs with aging, causing bones to become porous and brittle, making fractures more common. The blood vessels in the dermis become more fragile, causing an increase in bruising and purpura. Wrinkling and sagging of skin occur with decreased skin elasticity. A patient's toenails may become thicker, with a yellowish tint to the nail beds. Bladder capacity decreases by 50%, making voiding more frequent; two or three times a night is usual. Chapter 19

A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply. a. A nurse sits down with a patient and prioritizes existing diagnoses. b. A nurse assesses a woman for postpartum depression during routine care. c. A nurse plans interventions for a patient who is diagnosed with epilepsy. d. A busy nurse takes time to speak to a patient who received bad news. e. A nurse reassesses a patient whose PRN pain medication is not working. f. A nurse coordinates the home care of a patient being discharged.

b, d, e. Informal planning is a link between identifying a patient's strength or problem and providing an appropriate nursing response. This occurs, for example, when a busy nurse first recognizes postpartum depression in a patient, takes time to assess a patient who received bad news about tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged. Chapter 13

A nurse is planning teaching strategies for patients addicted to alcohol, in the affective domain of learning. What are examples of strategies promoting behaviors in this domain? Select all that apply. a. The nurse prepares a lecture on the harmful long-term effects of alcohol on the body. b. The nurse explores the reasons alcoholics drink and pro- motes other methods of coping with problems. c. The nurse asks patients for a return demonstration for using relaxation exercises to relieve stress. d. The nurse helps patients to reaffirm their feelings of self- worth and relate this to their addiction problem. e. The nurse uses a pamphlet to discuss the tenants of the Alcoholics Anonymous program to patients. f. The nurse reinforces the mental benefits of gaining self- control over an addiction.

b, d, f. Affective learning includes changes in attitudes, values, and feelings (e.g., the patient expresses renewed self-confidence to be able to give up drinking). Cognitive learning involves the storing and recalling of new knowledge in the brain, such as the learning that occurs during a lecture or by using a pamphlet for teaching. Learning a physical skill involving the integration of mental and muscular activity is called psychomotor learning, which may involve a return demonstration of a skill. Chapter 21

Following a fall that left an elderly male patient temporarily bedridden, the nurse is using the SPICES assessment tool to evaluate him for cascade iatrogenesis. Which are correct aspects of this tool? Select all that apply. a. S - Senility b. P - Problems with feeding c. I - Irritableness d. C - Confusion e. E - Edema of the legs f. S - Skin breakdown

b, d, f. The SPICES acronym is used to identify common problems in older adults and stands for: S - Sleep disorders P - Problems with eating or feeding I - Incontinence C - Confusion E - Evidence of falls S - Skin breakdown (Fulmer & Wallace, 2012). Chapter 19

A registered nurse is writing a diagnosis for a 28-year-old male patient who is in traction due to multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. a. The nurse uses the nursing interview to collect patient data. b. The nurse analyzes data collected in the nursing assessment. c. The nurse develops a care plan for the patient. d. The nurse points out the patient's strengths. e. The nurse assesses the patient's mental status. f. The nurse identifies community resources to help his family cope.

b, d, f. The purposes of diagnosing are to identify how an individual, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use to resolve problems. The nurse assesses and collects patient data in the assessment step and develops a care plan in the planning step of the nursing process. Chapter 12

A nurse assesses patients in a physician's office who are experiencing different levels of health and illness. Which statements best define the concepts of health and illness? Select all that apply. a. Health and illness are the same for all people. b. Health and illness are individually defined by each person. c. People with acute illnesses are actually healthy. d. People with chronic illnesses have poor health beliefs. e. Health is more than the absence of illness. f. Illness is the response of a person to a disease.

b, e, f. Each person defines health and illness individually, based on a number of factors. Health is more than just the absence of illness; it is an active process in which a person moves toward one's maximum potential. An illness is the response of the person to a disease. Chapter 3

The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristic of the nursing process? a. Systematic b. Interpersonal c. Dynamic d. Universally applicable in nursing situations

b, interpersonal. All of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process. Chapter 10

A nurse writes nursing diagnoses for patients and their families visiting a community health clinic. Which nursing diagnoses are correctly written as three-part nursing diagnoses? (1) Disabled Family Coping related to lack of knowledge about home care of child on ventilator (2) Imbalanced Nutrition: Less Than Body Requirements related to inadequate caloric intake while striving to excel in gymnastics as evidenced by 20-pound weight loss since beginning the gymnastic program, and greatly less than ideal body weight when compared to standard height weight charts (3) Need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3-month hospital stay as evidenced by repeated comments "I cannot do this," "I know I'll harm her because I'm not a nurse," and "I can't do medical things" (4) Spiritual Distress related to inability to accept diagnosis of terminal illness as evidenced by multiple comments such as "How could God do this to me?," "I don't deserve this," "I don't understand. I've tried to live my life well," and "How could God make me suffer this way?" (5) Caregiver Role Strain related to failure of home health aides to appropriately diagnose needs of family caregivers and initiate a plan to facilitate coping as evidenced by caregiver's loss of weight and clinical depression a. (1) and (3) b. (2) and (4) c. (1), (2), and (3) d. All of the abo

b. (1) is a two-part diagnosis, (3) is written in terms of needs and not an unhealthy response, and (5) is a legally inadvisable statement. Chapter 12

A nurse makes a clinical judgment that an African American male patient in a stressful job is more vulnerable to developing hypertension than White male patients in the same or similar situation. The nurse has formulated what type of nursing diagnosis? a. Actual b. Risk c. Possible d. Wellness

b. A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is a Risk nursing diagnosis. Chapter 12

A nurse is collecting more patient data to confirm a diagnosis of emphysema for a 68-year-old male patient. What type of diagnosis does this intervention seek to confirm? a. Actual b. Possible c. Risk d. Collaborative

b. An intervention for a possible diagnosis is to collect more patient data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on reducing or eliminating risk factors, and interventions for collaborative problems focus on monitoring for changes in status and managing these changes with nurse and physician-prescribed interventions. Chapter 13

A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the first nursing action that should be taken prior to performing this care? a. Administer pain medication. b. Reassess the patient. c. Prepare the equipment. d. Explain the procedure to the patient.

b. Before implementing any nursing action, the nurse should reassess the patient to determine whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and if necessary administer pain medications. Chapter 14

A nurse in the rehabilitation division states to her head nurse, Mr. Tyler, "I need the day off and you didn't give it to me!" The head nurse replies, "Well, I wasn't aware you needed the day off, and it isn't possible since staffing is so inadequate." Instead of this exchange, what communication by the nurse would have been more effective? a. "Mr. Tyler, I placed a request to have August 8th off, but I'm working and I have a doctor's appointment." b. "Mr. Tyler, I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" c. "Mr. Tyler, I will need to call in on the 8th of August because I have a doctor's appointment." d. "Mr. Tyler, since you didn't give me the 8th of August off, will I need to find someone to work for me?"

b. Effective communication by the sender involves the imple- mentation of nonthreatening information by showing respect to the receiver. The nurse should identify the subject of the meeting and be sure it occurs at a mutually agreed upon time. Chapter 20

A nurse is performing an initial comprehensive assessment of an 84-year-old male patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following? a. Maslow's human needs b. Gordon's functional health patterns c. Human response patterns d. Body system model

b. Gordon's functional health patterns begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems. Chapter 11

Based on Erikson's theory, middle adults who do not achieve their developmental tasks may be considered to be in stagna- tion. Which statement is one example of this finding? a. "I am helping my parents move into an assisted-living facility." b. "I spend all of my time going to the doctor to be sure I am not sick." c. "I have enough money to help my son and his wife when they need it." d. "I earned this gray hair and I like it!"

b. Middle adults who do not reach generativity tend to become overly concerned about their own physical and emotional health needs. Chapter 19

A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply? a. "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!" b. "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." c. "No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient." d. "Don't worry about learning all of the questions to ask. Every agency has its own assessment form you must use."

b. Once you learn what constitutes the minimum data set, you can adapt this to any patient situation. It is not true that each assessment is the same even when you are using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person centered practice tailor their questions to the uniqueness of each patient and situation. Answer d is incorrect because relying solely on standard agency assessment tools does not allow for individualized patient care or critical thinking. Chapter 11

Nurses use the Nursing Interventions Classification Taxonomy structure as a resource when planning nursing care for patients. What information would be found in this structure? a. Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions b. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings c. A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention d. A complete list of reimbursable charges for each nursing intervention

b. The Nursing Interventions Classification Taxonomy lists nursing interventions, each with a label, a definition, a set of activities that a nurse performs to carry it out, and a short list of background readings. It does not contain case studies, diagnoses, or charges. Chapter 14

A nurse has taught a diabetic patient how to administer his daily insulin. The nurse should evaluate the teaching-learning process by: a. Determining the patient's motivation to learn b. Deciding if the learning outcomes have been achieved c. Allowing the patient to practice the skill he has just learned d. Documenting the teaching session in the patient's medical record

b. The nurse cannot assume that the patient has actually learned the content unless there is some type of proof of learning. The key to evaluation is meeting the learner out- comes stated in the teaching plan. Chapter 21

A nursing student is preparing to administer morning care to a patient. What is the most important question that the nurs- ing student should ask the patient about personal hygiene? a. "Would you prefer a bath or a shower?" b. "May I help you with a bed bath now or later this morning?" c. "I will be giving you your bath. Do you use soap or shower gel?" d. "I prefer a shower in the evening. When would you like your bath?"

b. The nurse should ask permission to assist the patient with a bath. This allows for consent to assist the patient with care that invades the patient's private zones. Chapter 20

A friend of a nurse calls and asks if she is still working at Memorial Hospital. The nurse replies, "Yes." The friend tells the nurse that his girlfriend's father was just admitted as a patient and he wants the nurse to find out how he is. The friend states, "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should make? a. "You shouldn't be asking me to do this. I could be fined or even lose my job for disclosing this information." b. "Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family mem- ber asks." c. "Because of the Health Insurance Portability and Account- ability Act, you shouldn't be asking for this information unless the patient has authorized you to receive it! This could get you in trouble!" d. "Why do you think Sue isn't talking about her worries?"

b. The nurse should immediately clarify what he or she can and cannot do. Since the primary reason for refusing to help is linked to the responsibility to protect patient privacy and confidentiality, the nurse should not begin by mention- ing the real penalties linked to abuses of privacy. Finally, it is appropriate to ask about Sue and her worries, but this should be done after the nurse clarifies what he or she is able to do. Chapter 16

A nurse is documenting the care given to a 56-year-old patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed was performed on the left leg. What would be the best action of the nurse to correct this documentation? a. Erase or use correcting fluid to completely delete the error. b. Draw a single line through the entry and rewrite it above or beside it. c. Use a permanent marker to block out the mistaken entry and rewrite it. d. Remove the page with the error and rewrite the data on that page correctly

b. The nurse should not use dittos, erasures, or correcting flu- ids. A single line should be drawn through an incorrect entry, and the words "mistaken entry" or "error in charting" should be printed above or beside the entry and signed. The entry should then be rewritten correctly. Chapter 16

A nurse is caring for an elderly male patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? a. Offer the patient 60 mL fluid every 2 hours while awake. b. During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL. c. Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/15 d. At the next visit, 12/23/15, the patient will know that he should drink at least 3 liters of water per day.

b. The outcomes in a and c make the error of expressing the patient goal as a nursing intervention. Incorrect: "Offer the patient 60 mL fluid every 2 hours while awake." Correct: "The patient will drink 60 mL fluid every 2 hours while awake, beginning 1/3/15." The outcome in d makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware." Chapter 13

A nurse is providing instruction to a patient regarding the procedure to change his colostomy bag. During the teach- ing session, he asks, "What type of foods should I avoid to prevent gas?" The patient's question allows for what type of communication? a. A closed-ended answer b. Information clarification c. The nurse to give advice d. Assertive behavior

b. The patient's question allows the nurse to clarify informa- tion that is new to the patient or that requires further explanation. Chapter 20

After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem? a. No problem b. Possible problem c. Actual nursing diagnosis d. Clinical problem other than nursing diagnosis

b. When a possible problem exists, such as situational low self-esteem related to effects of stroke, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion "no problem" means no nursing response is indicated. When an actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce, or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem. Chapter 12

A nurse's neighbor tells the nurse, "I have a high temperature, feel awful, and I am not going to work." What stage of illness behavior is the neighbor exhibiting? a. Experiencing symptoms b. Assuming the sick role c. Assuming a dependent role d. Achieving recovery and rehabilitation

b. When people assume the sick role, they define themselves as ill, seek validation of this experience from others, and give up normal activities. In stage 1: experiencing symptoms, the first indication of an illness usually is recognizing one or more symptoms that are incompatible with one's personal definition of health. The stage of assuming a dependent role is characterized by the patient's decision to accept the diagnosis and follow the prescribed treatment plan. In the achieving recovery and rehabilitation role, the person gives up the dependent role and resumes normal activities and responsibilities. Chapter 3

A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bedrest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? a. Risk for Impaired Skin Integrity b. Related to prescribed bedrest c. As evidenced by d. As evidenced by reddened areas of skin on the heels and back.

b."Related to prescribed bedrest" is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. "Risk for Impaired Skin Integrity" is the problem, and "as evidenced by reddened areas of skin on the heels and back" are the defining characteristics of the problem. Chapter 12

A nurse is teaching patients of all ages in a hospital setting. Which examples demonstrate teaching that is appropriately based on the patient's developmental level? Select all that apply. a. The nurse plans long teaching sessions to discuss diet modifications for an older adult diagnosed with type 2 diabetes. b. The nurse recognizes that a female adolescent diagnosed with anorexia is still dependent on her parents and includes them in all teaching sessions. c. The nurse designs an exercise program for a sedentary older adult male patient based on the activities he prefers. d. The nurse includes an 8-year-old patient in the teaching plan for managing cystic fibrosis. e. The nurse demonstrates how to use an inhaler to an 11-year-old male patient and includes his mother in the session to reinforce the teaching. f. The nurse continues a teaching session on STIs for a sexu- ally active male adolescent despite his protest that "I've heard enough already!"

c, d, e. Successful teaching plans for older adults incorpo- rate extra time, short teaching sessions, accommodation for sensory deficits, and reduction of environmental distractions. Older adults also benefit from instruction that relates new information to familiar activities or information. School- aged children are capable of logical reasoning and should be included in the teaching-learning process whenever possible; they are also open to new learning experiences but need learn- ing to be reinforced by either a parent or health care provider as they become more involved with their friends and school activities. Teaching strategies designed for an adolescent patient should recognize the adolescent's need for independ- ence, as well as the need to establish a trusting relationship that demonstrates respect for the adolescent's opinions. Chapter 21

During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after she communicates the plan of care. What would be appropriate nurse responses in this situation? Select all that apply. a. Fill the silence with lighter conversation directed at the patient. b. Use the time to perform the care that is needed uninter- rupted. c. Discuss the silence with the patient to ascertain its mean- ing. d. Allow the patient time to think and explore inner thoughts. e. Determine if the patient's culture requires pauses between conversation. f. Arrange for a counselor to help the patient cope with emotional issues.

c, d, e. The nurse can use silence appropriately by taking the time to wait for the patient to initiate or to continue speak- ing. During periods of silence, the nurse should reflect on what has already been shared and observe the patient without having to concentrate simultaneously on the spoken word. In due time, the nurse might discuss the silence with the patient in order to understand its meaning. Also, the patient's culture may require longer pauses between verbal communication. Fear of silence sometimes leads to too much talking by the nurse, and excessive talking tends to place the focus on the nurse rather than on the patient. The nurse should not assume silence requires a consult with a counselor. Chapter 20

A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply. a. A nurse administers 500 mg of ciprofloxacin to a patient with pneumonia. b. A nurse consults with a psychiatrist for a patient who abuses pain killers. c. A nurse checks the skin of bedridden patients for skin breakdown. d. A nurse orders a kosher meal for an orthodox Jewish patient. e. A nurse records the I&O of a patient as prescribed by his physician. f. A nurse prepares a patient for minor surgery according to facility protocol.

c, d, f. Nurse-initiated interventions, or independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing plan of care, as well as any other actions that nurses initiate without the direction or supervision of another health care professional. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a physician. Consulting with a psychiatrist is a collaborative intervention. Chapter 14

A nurse is documenting patient data in the medical record of a patient admitted to the hospital with a diagnosis of appen- dicitis. The physician has ordered 10 mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follows recommended guidelines? Select all that apply. a. 6/12/15 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN b. 6/12/15 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick, RN c. 6/12/15 0945 30 minutes following administration of mor- phine 10 mg IV patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN d. 6/12/15 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN e. 6/12/15 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 hours. M. Patrick, RN f. 6/12/15 0945 Patient states she does not want pain medica- tion despite return of pain. After discussing situation, patient agrees to medication administration.

c, d, f. The nurse should enter information in a complete, accurate, concise, current, and factual manner and indicate in each entry the date and both the time the entry was written and the time of pertinent observations and interventions. When charting, the nurse should avoid the use of stereotypes or derogatory terms as well as generalizations such as "seems comfortable today." The nurse should never document an intervention before carrying it out. Chapter 16

A nurse caring for adults in a physician's office notes that some patients age more rapidly that other patients of the same age. The nurse researches aging theories that attempt to describe how and why aging occurs. Which statements apply to the immunity theory of aging? Select all that apply. a. Chemical reactions in the body produce damage to the DNA. b. Free radicals have adverse effects on adjacent molecules. c. Decrease in size and function of the thymus causes infections. d. There is much interest in the role of vitamin supplementation. e. Lifespan depends on a great extent to genetic factors. f. Organisms wear out from increased metabolic functioning.

c, d. The immunity theory of aging focuses on the func- tions of the immune system and states that the immune response declines steadily after younger adulthood as the thymus loses size and function, causing more infec- tions. There is much interest in vitamin supplements (such as vitamin E) to improve immune function. In the cross-linkage theory, cross-linkage is a chemical reac- tion that produces damage to the DNA and cell death. The free radical theory states that free radicals, formed during cellular metabolism, are molecules with separated high-energy electrons, which can have adverse effects on adjacent molecules. The genetic theory of aging holds that lifespan depends to a great extent on genetic fac- tors. According to the wear-and-tear theory, organisms wear out from increased metabolic functioning, and cells become exhausted from continual energy depletion from adapting to stressors (Eliopoulos, 2010). Chapter 19

A nursing instructor teaching classes in gerontology to nurs- ing students discusses myths related to the aging of adults. Which statement is a myth about older adults? a. Most older adults live in their own homes. b. Healthy older adults enjoy sexual activity. c. Old age means mental deterioration. d. Older adults want to be attractive to others.

c. Although response time may be longer, intelligence does not normally decrease because of aging. Most older adults own their own homes, and although sexual activity may be less frequent, the ability to perform and enjoy sexual activity lasts well into the 90s in healthy older adults. Older adults want to be attractive to others. Chapter 19

What is the leading cause of cognitive impairment in old age? a. Stroke b. Malnutrition c. Alzheimer disease d. Loss of cardiac reserve

c. Alzheimer disease is the most common degenerative neurologic illness and the most common cause of cognitive impairment. It is irreversible, progressing from deficits in memory and thinking skills to an inability to perform even the simplest of tasks. Chapter 19

A nursing student is nervous and concerned about the work she is about to do at the clinical facility. To allay anxiety and be successful in her provision of care, it is most important for her to: a. Determine the established goals of the institution b. Be sure her verbal and nonverbal communication is congruent c. Engage in self-talk to plan her day and decrease her fear d. Speak with her fellow colleagues about how they feel

c. By engaging in self-talk, or intrapersonal communication, the nursing student can plan her day and enhance her clinical performance to decrease fear and anxiety. Chapter 20

A nurse has volunteered to give influenza immunizations at a local clinic. What level of care is the nurse demonstrating? a. Tertiary b. Secondary c. Primary d. Promotive

c. Giving influenza injections is an example of primary health promotion and illness prevention. Chapter 3

A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the physician's order sheet. The nurse's best response is: a. "Thank you for taking care of this!" b. Get a second nurse to listen to the order, and after writing the order on the physician order sheet, have both nurses sign it. c. "I am sorry, but verbal orders can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly." d. Try calling another resident for the order or wait until the next shift.

c. In most agencies, the only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency, when the physician/nurse practitioner is present but finds it impossible, due to the emergency situation, to write the order. Chapter 16

When helping a patient turn in bed, the nurse notices that his heels are reddened and plans to place him on precautions for skin breakdown. This is an example of what type of planning? a. Initial planning b. Standardized planning c. Ongoing planning d. Discharge planning

c. Ongoing planning is problem oriented and has as its purpose keeping the plan up to date as new actual or potential problems are identified. Initial planning addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. Standardized care plans are prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. During discharge planning, the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors competently at home. Chapter 13

A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a plan of care for this patient. Which QSEN competency does this action represent? a. Patient-centered care b. Evidence-based practice c. Quality improvement d. Informatics

c. Quality improvement involves routinely updating nursing policies and procedures. Providing patient centered care involves listening to the patient and demonstrating respect and compassion. Evidence-based practice is used when adhering to internal policies and standardized skills. The nurse is employing informatics by using information and technology to communicate, manage knowledge, and support decision making. Chapter 10

A 76-year-old patient states, "I have been experiencing com- plications of diabetes." The nurse needs to direct the patient to gain more information. What is the most appropriate com- ment or question to elicit additional information? a. "Do you take two injections of insulin to decrease the complications?" b. "Most physicians recommend diet and exercise to regulate blood sugar." c. "Most complications of diabetes are related to neuropathy." d. "What specific complications have you experienced?"

d. Requesting specific information regarding complications of diabetes will elicit specific information to guide the nurse in further interview questions and specific assessment techniques. Chapter 20

A female patient who is receiving chemotherapy for breast cancer tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm not going to come for my therapy anymore." The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process? a. The nurse judges whether the patient database is adequate to address the problem. b. The nurse considers whether or not to suggest a counseling session for the patient. c. The nurse reassesses the patient and decides how best to intervene in her care. d. The nurse identifies several options for intervening in the patient's care and critiques the merit of each option.

c. The first step when thinking critically about a situation is to identify the purpose or goal of your thinking. Reassessing the patient helps to discipline thinking by directing all thoughts toward the goal. Once the problem is addressed, it is important for the nurse to judge the adequacy of the knowledge, identify potential problems, use helpful resources, and critique the decision. Chapter 10

The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do? a. Inform the charge nurse b. Inform the surgeon c. Validate the finding d. Document the finding

c. The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate, thus all data should be validated before documentation if there are any doubts about accuracy. Chapter 11

A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response of the RN? a. Allow the UAPs to do the admission assessment and report the findings to the RN. b. Do his or her own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. c. Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. d. Contact his or her labor representative and complain about this practice.

c. The nurse should not delegate this nursing admission assessment because only nurses can perform this intervention. The nurse should seek clarification for this policy from the nursing administration. Chapter 14

Which clinic patient is most likely to have annual breast examinations and mammograms based on the physical human dimension? a. Jane, whose her best friend had a benign breast lump removed b. Sarah, who lives in a low-income neighborhood c. Tricia, who has a family history of breast cancer d. Nancy, whose family encourages regular physical examinations

c. The physical dimension includes genetic inheritance, age, developmental level, race, and gender. These components strongly influence the person's health status and health practices. A family history of breast cancer is a major risk factor. Chapter 3

A nurse is teaching a 50-year-old male patient how to care for his new ostomy appliance. Which teaching aid would be most appropriate to confirm that the patient has learned the information? a. Ask Me 3 b. Newest Vital Sign c. Teach-back tool d. TEACH acronym

c. The teach-back tool is a method of assessing literacy and confirming that the learner understands health informa- tion received from a health professional. The Ask Me 3 is a brief tool intended to promote understanding and improve communication between patients and their providers. The Newest Vital Sign (NVS) is a reliable screening tool to assess low health literacy, developed to improve communications between patients and providers. The TEACH acronym is used to maximize the effectiveness of patient teaching by tuning into the patient, editing patient information, acting on every teaching moment, clarifying often, and honoring the patient as a partner in the process. Chapter 21

A nurse develops a detailed plan of care for a 16-year-old female who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "We will be fine on our own. I don't need any more care." What would be the nurse's best response? a. "You know your personal situation better than I do, so I will respect your wishes." b. "If you don't accept these services, your baby's health will suffer." c. "Let's take a look at the plan again and see if we can adjust it to fit your needs." d. "I'm going to assign your case to a social worker who can explain the services better."

c. When a patient does not follow the plan of care despite your best efforts, it is time to reassess strategy. The first objective is to identify why the patient is not following the therapy. If the nurse determines, however, that the plan of care is adequate, the nurse must identify and remedy the factors contributing to the patient's noncompliance. Chapter 14

The nurse practices using critical thinking indicators (CTIs) when caring for patients in the hospital setting. The best description of CTIs is: a. Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice b. Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice d. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice

c. evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice. Chapter 10

A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a male patient who has been prescribed morphine via a patient- controlled analgesia pump (PCA) for pain related to pancre- atic cancer. Place the following nursing statements related to this call in the order in which they should be performed. a. "I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer." b. "Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump." c. "You want me to discontinue the PCA pump until you see him tonight at patient rounds." d. "I am Rosa Clark, an RN working on the second floor of South Street Hospital." e. "Mr. Sanchez was admitted two days ago following a diagnosis of pancreatic cancer." f. "I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered."

d, a, e, b, f, c. The order for ISBARR is: identity/introduction, situation, background, assessment, recommendation, and read-back. Chapter 16

A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response? a. "I'm sorry, but patients are not allowed to copy their medi- cal records." b. "I can make a copy of your record for you right now." c. "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules." d. "I will need to check with our records department to get you a copy."

d. According to HIPAA, patients have a right to see and copy their health record; update their health record; get a list of the disclosures a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations; request a restriction on certain uses or disclosures; and choose how to receive health information. The nurse should be aware of agency policies regarding the patient's right to access and copy records. Chapter 16

A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. An example of an affective outcome for this patient is: a. Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. b. By 6/12/15, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. c. By 6/19/15, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3″ to 2.5″). d. By 6/12/15, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

d. Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient's achievement of new skills. c is an outcome describing a physical change in the patient. Chapter 13

An experienced nurse tells a younger nurse who is working in a retirement home that older adults are different and do not have the same desires, needs, and concerns as other age groups. The nurse also comments that most older adults have "outlived their usefulness." What is the term for this type of prejudice? a. Harassment b. Whistle blowing c. Racism d. Ageism

d. Ageism is a form of prejudice in which older adults are stereotyped by characteristics found in only a few members of their age group. Harassment occurs when a dominant per- son takes advantage of or overpowers a less dominant person (may involve sexual harassment or power struggles). Whistle blowing involves reporting illegal or unethical behavior in the workplace. Racism is prejudice against other races and ethnic groups. Chapter 19

A student nurse is organizing clinical responsibilities for an 84-year-old female patient who is diabetic and is being treated for foot ulcers. The patient tells the student, "I need to have my hair washed before I can do anything else today; I'm ashamed of the way I look." The patient's needs include diagnostic testing, dressing changes, meal planning and coun- seling, and assistance with hygiene. How would the nurse best prioritize this patient's care? a. Explain to the patient that there is not enough time to wash her hair today because of her busy schedule. b. Schedule the testing and meal planning first and complete hygiene as time permits. c. Perform the dressing changes first, schedule the testing and counseling, and complete hygiene last. d. Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling.

d. As long as time constraints permit, the most important priorities when scheduling nursing care are priorities iden- tified by the patient as being most important. In this case, washing the patient's hair and assisting with hygiene puts the patient first and sets the tone for an effective nurse- patient partnership. Chapter 14

When providing health promotion classes, a nurse uses concepts from models of health. What do both the health-illness continuum and the high-level wellness models demonstrate? a. Illness as a fixed point in time b. The importance of family c. Wellness as a passive state d. Health as a constantly changing state

d. Both these models view health as a dynamic (constantly changing state). Chapter 3

A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which nursing diagnoses are correctly written as two-part nursing diagnoses? (1) Ineffective Coping related to inability to maintain marriage (2) Defensive Coping related to loss of job and economic security (3) Altered Thought Processes related to panic state (4) Decisional Conflict related to placement of parent in a long-term care facility a. (1) and (2) b. (3) and (4) c. (1), (2), and (3) d. All of the above

d. Each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology or cause. Chapter 12

Which of the following nursing diagnoses would be appropri- ate for many middle adults? a. Risk for Imbalanced Nutrition: Less Than Body Requirements b. Delayed Growth and Development c. Self-Care Deficit d. Caregiver Role Strain

d. Many middle adults help care for aging parents and have concerns about their own health and ability to continue to care for an older family member. Caregivers often face 24-hour care responsibilities for extended periods of time, which creates physical and emotional problems for the caregiver. Chapter 19

A nurse is counseling a 60-year-old female patient who refuses to look at or care for a new colostomy. She tells the nurse, "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? a. Collaborative problem b. Interdisciplinary problem c. Medical problem d. Nursing problem

d. Nursing Problem, because it describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studies. Chapter 12

A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication? a. Every three hours b. Every four hours c. Daily d. As needed

d. PRN means "as needed." Chapter 16

When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate? a. Correct the initial assessment form. b. Redo the initial assessment and document current findings. c. Conduct and document an emergency assessment. d. Perform and document a focused assessment of skin integrity.

d. Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone or corrected. This is not a life-threatening event; therefore, there is no need for an emergency assessment. Chapter 11

A nurse working in a long-term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes the theory of which theorist? a. Travelbee b. Watson c. Benner d. Swanson

d. Swanson (1991) identifies five caring processes and defines caring as "a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility. Travelbee (1971), an early nurse theorist, developed the Human-to-Human Relationship Model and defined nursing as an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering, and if necessary to find meaning in these experiences. Benner and Wrubel (1989) write that caring is a basic way of being in the world and that caring is central to human expertise, curing, and healing. Watson's theory is based on the belief that all humans are to be valued, cared for, respected, nurtured, understood, and assisted. Chapter 10

During rounds, a charge nurse hears the patient care techni- cian yelling loudly to a patient regarding a transfer from the bed to chair. When entering the room, what is the nurse's best response? a. "You need to speak to the patient quietly. You are disturbing the patient." b. "Let me help you with your transfer technique." c. "When you are finished, be sure to apologize for your rough demeanor." d. "When your patient is safe and comfortable, meet me at the desk."

d. The charge nurse should direct the patient care techni- cian to determine the patient's safety. Then the nurse should address any concerns regarding the patient care technician's communication techniques privately. The nurse should direct the patient care technician on aspects of therapeutic commu- nication. Chapter 20

A nurse enters a patient's room and examines the patient's IV fluids and cardiac monitor. The patient states, "Well, I haven't seen you before. Who are you?" What is the nurse's best response? a. "I'm just the IV therapist checking your IV." b. "I've been transferred to this division and will be caring for you." c. "I'm sorry, my name is John Smith and I am your nurse." d. "My name is John Smith, I am your nurse and I'll be caring for you until 11 p.m."

d. The nurse should identify himself, be sure the patient knows what will be happening, and the time period he will be with his patient. Chapter 20

When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. What should the nurse do? a. Introduce oneself and thank the wife for being present. b. Introduce oneself and ask the wife if she wants to remain. c. Introduce oneself and ask the wife to leave. d. Introduce oneself and ask the patient if he would like the wife to stay.

d. The patient has the right to indicate whom he would like to be present for the nursing history and exam. You should neither presume that he wants his wife there nor that he does not want her there. Similarly, the choice belongs to the patient, not the wife. Chapter 11

A 3-year-old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admis- sion interview, the nurse should implement which commu- nication techniques to elicit the most information from the parents? a. The use of reflective questions b. The use of closed questions c. The use of assertive questions d. The use of clarifying questions

d. The use of the clarifying question or comment allows the nurse to gain an understanding of a patient's comment. When used properly, this technique can avert possible misconcep- tions that could lead to an inappropriate nursing diagnosis. The reflective question technique involves repeating what the person has said or describing the person's feelings. Open- ended questions encourage free verbalization and expression of what the parents believe to be true. Assertive behavior is the ability to stand up for oneself and others using open, hon- est, and direct communication. Chapter 20

A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." Which statement is the most therapeutic? a. The nurse stands at the patient's bedside and states, "I understand how you feel. My mother said the same thing when she was ill." b. The nurse places a hand on the patient's arm and states, "You feel so alone." c. The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." d. The nurse holds the patient's hand and asks, "What makes you feel so alone?"

d. The use of touch conveys acceptance, and the implemen- tation of an open-ended question allows the patient time to verbalize freely. Chapter 20

A nurse is caring for a patient who is diagnosed with congestive heart failure. Which statement below is not an example of a well-stated nursing intervention? a. Offer patient 60 mL water or juice (prefers orange or cranberry juice) every 2 hours while awake for a total minimum PO intake of 500 mL. b. Teach patient the necessity of carefully monitoring fluid intake and output; remind patient each shift to mark off fluid intake on record at bedside. c. Walk with patient to bathroom for toileting every 2 hours (on even hours) while patient is awake. d. Manage patient's pain.

d. This statement lacks sufficient detail to effectively guide nursing intervention. The set of nursing interventions written to assist a patient to meet an outcome must be comprehensive. Comprehensive nursing interventions specify what observations (assessments) need to be made and how often, what nursing interventions need to be done and when they must be done, and what teaching, counseling, and advocacy needs patients and families may have. Chapter 13

A nurse is looking for trends in a postoperative patient's vital signs. Which documents would the nurse consult first? a. Admission sheet b. Admission nursing assessment c. Activity flow sheet d. Graphic record

d. While one recording of vital signs should appear on the admission nursing assessment, the best place to find sequen- tial recordings that show a pattern or trend is the graphic record. The admission sheet does not include vital sign docu- mentation, and neither does the activity flow sheet. Chapter 16