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TEST BANK for Timby's Fundamental Nursing Skills and Concepts 12th Edition by Loretta A Donnelly-Moreno, Chapters 1 - 38 Complete

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Table of contents

• Chapter 1 Nursing Foundations
• Chapter 2 Nursing Process
• Chapter 3 Laws and Ethics
• Chapter 4 Health and Illness
• Chapter 5 Homeostasis, Adaptation, and Stress
• Chapter 6 Culture and Ethnicity
• Chapter 7 The Nurse–Client Relationship
• Chapter 8 Client Teaching
• Chapter 9 Recording and Reporting
• Chapter 10 Asepsis
• Chapter 11 Admission, Discharge, Transfer, and Referrals
• Chapter 12 Vital Signs
• Chapter 13 Physical Assessment
• Chapter 14 Special Examinations and Tests
• Chapter 15 Nutrition
• Chapter 16 Fluid and Chemical Balance
• Chapter 17 Hygiene
• Chapter 18 Comfort, Rest, and Sleep
• Chapter 19 Safety
• Chapter 20 Pain Management
• Chapter 21 Oxygenation
• Chapter 22 Infection Control
• Chapter 23 Body Mechanics, Positioning, and Moving
• Chapter 24 Fitness and Therapeutic Exercise
• Chapter 25 Mechanical Immobilization
• Chapter 26 Ambulatory Aids
• Chapter 27 Perioperative Care
• Chapter 28 Wound Care
• Chapter 29 Gastrointestinal Intubation
• Chapter 30 Urinary Elimination
• Chapter 31 Bowel Elimination
• Chapter 32 Oral Medications
• Chapter 33 Topical and Inhalant Medications
• Chapter 34 Parenteral Medications
• Chapter 35 Intravenous Medications
• Chapter 36 Airway Management
• Chapter 37 Resuscitation
• Chapter 38 End-of-Life Care

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Chapter 1 Nursing Foundations

MULTIPLE CHOICE

1. Florence Nightingales contributions to nursing practice and education:

• are historically important but have no validity for nursing today.

• were neither recognized nor appreciated in her own time.

• were a major factor in reducing the death rate in the Crimean War.

• were limited only to the care of severe traumatic wounds.

ANSWER: C

By improving sanitation, nutrition ventilation, and handwashing techniques, Florence Nightingales nurses dramatically reduced the death rate from injuries in the Crimean War.DIF: Cognitive Level: Knowledge REF: dm 2 OBJ: Theory #1 TOP: Nursing History KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

2. Early nursing education and care in the United States:

• were directed at community health.

• provided independence for women through education and employment.

• were an educational model based in institutions of higher learning.

• have continued to be entirely focused on hospital nursing.

ANSWER: B

Because of the influence of early nursing leaders, nursing education became more formalized through apprenticeships in Nightingale schools that offered independence to women through education and employment.DIF: Cognitive Level: Knowledge REF: dm 2 OBJ: Theory #4 TOP: Nursing History KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

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• In order to fulfill the common goals defined by nursing theorists (promote wellness, prevent

illness, facilitate coping, and restore health), the LPN must take on the roles of:

• caregiver, educator, and collaborator.

• nursing assistant, delegator, and environmental specialist.

• medication dispenser, collaborator, and transporter.

• dietitian, manager, and housekeeper.

ANSWER: A

In order for the LPN to apply the common goals of nursing, he or she must assume the roles of caregiver, educator, collaborator, manager, and advocate.DIF: Cognitive Level: Comprehension REF: dm 4 OBJ: Theory #2 TOP: Art and Science of Nursing KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

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• Although nursing theories differ in their attempts to define nursing, all of them base their

beliefs on common concepts concerning:

• self-actualization, fundamental needs, and belonging.

• stress reduction, self-care, and a systems model.

• curative care, restorative care, and terminal care.

• human relationships, the environment, and health.

ANSWER: D

Although nursing theories differ, they all base their beliefs on human relationships, the environment, and health.DIF: Cognitive Level: Comprehension REF: dm 4 OBJ: Theory #2 TOP: Nursing Theories KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

• Standards of care for the nursing practice of the LPN are established by the:
• Boards of Nursing Examiners in each state.

• National Council of States Boards of Nursing (NCSBN).

• American Nurses Association (ANA).

• National Federation of Licensed Practical Nurses.

ANSWER: D

The National Federation of Licensed Practical Nurses modified the standards published by the ANA in 2004 to better fit the role of the LPN.DIF: Cognitive Level: Comprehension REF: dm 5 OBJ: Theory #2 TOP: Standards of Care KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

6. The LPN demonstrates an evidence-based practice by:

• using a drug manual to check compatibility of drugs.

• using scientific information to guide decision making.

• using medical history of a patient to direct nursing interventions.

• basing nursing care on advice from an experienced nurse.

ANSWER: B

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The use of scientific information from high-quality research to guide nursing decisions is reflective of the application of evidence-based practice.DIF: Cognitive Level: Knowledge REF: dm 5 OBJ: Theory #3 TOP: Evidence Based Practice KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

• Lillian Wald and Mary Brewster established the Henry Street Settlement Service in New York

in 1893 in order to:

• offer a shelter to injured war veterans.

• found a nursing apprenticeship.

• provide health care to poor persons living in tenements.

• offer better housing to low-income families.

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ANSWER: C

Henry Street Settlement Service brought the provision of community health care to the poor people living in tenements.DIF: Cognitive Level: Comprehension REF: dm 2 OBJ: Theory #4 TOP: Growth of Nursing KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

8. An p educational p pathway p for p an p LPN p refers p to p an p LPN:

• learning p on p the p job p and p being p promoted p to p a p higher p level p of p responsibility.

• moving p from p a p maternity p unit p to p a p more p complicated p surgical p unit.

• obtaining p additional p education p to p move p from p one p level p of p nursing p to p another.

• learning p that p advancement p requires p consistent p work p and p

commitment. p ANSWER: p C

By p broadening p the p educational p base, p an p LPN p may p advance p and p build p a p nursing p career. p DIF: p Cognitive p Level: p Knowledge p REF: p dm p 6 p OBJ: p Theory p #7 TOP: p Nursing p Education p Pathways p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• When p diagnosis-related p groups p (DRGs) p were p established p by p Medicare p in p 1983, p

the p purpose p was p to:

• put p patients p with p the p same p diagnosis p on p the p same p unit.

• attempt p to p contain p the p costs p of p health p care.

• increase p availability p of p medical p care p to p the p elderly.

• identify p a p patients p condition p more p

quickly. p ANSWER: p B

The p purpose p of p instituting p DRGs p was p to p contain p skyrocketing p costs p of p health p care. p DIF: p Cognitive p Level: p Knowledge p REF: p dm p 8 p OBJ: p Theory p #10 TOP: p Health p Care p Delivery p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p advent p of p diagnosis-related p groups p (DRGs) p required p that p nurses p working p in p

health p care p agencies:

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• record p supportive p documentation p to p confirm p a p patients p need p for p care p in p order p to p qualify

p for p reimburs

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• use p the p DRG p rather p than p their p own p observations p for p patient p assessment.

• be p aware p of p the p specific p drugs p related p to p the p diagnosis.

• acquire p cross-training p to p make p staffing p more p

flexible. p ANSWER: p A

DRGs p required p that p nurses p provide p more p supportive p documentation p of p their p assessments p and p identified p patient p needs p to p qualify p the p facility p for p Medicare p reimbursement. p Observant p assessment p might p also p indicate p another p DRG p classification p and p consequently p more p reimbursement p for p the p facility.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 8 p OBJ: p Theory p #10 p TOP: p Managed p Care p KEY: p Nursing p Process p

Step: p N/A

MSC: p NCLEX: p N/A

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• If p a p member p of p a p health p maintenance p organization p (HMO) p is p having p

respiratory p problems p such p as p fever, p cough, p and p fatigue p for p several p days p and p wants

p to p see p a p specialist, p the p person p is p required p to p go:

• directly p to p an p emergency p room p for p treatment.

• to p any p general p practitioner p of p choice.

• directly p to p a p respiratory p specialist.

• to p a p primary p care p physician p for p a p

referral. p ANSWER: p D

Participants p in p an p HMO p must p see p their p primary p physician p to p receive p a p referral p for p a p specialist p in p order p for p the p HMO p to p pay p for p the p care.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 9 p OBJ: p Theory p #11 p TOP: p Managed p Care p KEY: p Nursing p Process p

Step: p N/A

MSC: p NCLEX: p N/A

• An p advantage p of p preferred p provider p organizations p (PPOs) p is p that:
• they p make p insurance p coverage p of p employees p less p expensive p to p employers.

• there p are p fewer p physicians p to p choose p from p than p in p an p HMO.

• long-term p relationships p with p physicians p are p more p likely.

• patients p may p go p directly p to p a p specialist p

for p care. p ANSWER: p A

The p use p of p PPOs p allows p insurance p companies p to p keep p their p premiums p low p and p in p turn p makes p insurance p coverage p less p expensive p for p the p employers. p There p are p usually p more p physicians p from p which p to p choose p than p from p a p HMO, p but p long-term p relationships p between p physician p and p patient p cannot p be p established p easily. p Patients p still p must p see p their p primary p physician p before p being p referred p to p other p specialties.DIF: p Cognitive p Level: p Knowledge p REF: p dm p 6 p OBJ: p Theory p #11 TOP: p Preferred p Provider p Organizations p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• After p passing p the p National p Council p Licensure p Examination p for p Practical p Nurses p

(NCLEX- p PN), p the p nurse p is p qualified p to p take p an p additional p certification p in p the p

field p of:

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• pharmacology.

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• care p of p infants p and p children.

• operating p room p technology.

• community p

health. p ANSWER: p A

After p becoming p an p LPN, p the p nurse p may p apply p for p additional p certification p in p pharmacology p or p long-term p care.DIF: p Cognitive p Level: p Knowledge p REF: p dm p 6 p OBJ: p Theory p #6 p TOP: p Educational p Opportunities p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

14. Nursing p interventions p are p best p defined p as p activities p that:

• are p taken p to p improve p the p patients p health.

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• involve p researching p methods p to p maintain p asepsis.

• include p the p family p in p nursing p care.

• review p guidelines p for p handling p infectious p

wastes. p ANSWER: p A

Interventions p are p actions p taken p to p improve, p maintain, p or p restore p health. p DIF: p Cognitive p Level: p Comprehension p REF: p dm p 4 p OBJ: p Theory p #2 p TOP: p Art p and p Science p of p Nursing p KEY: p

Nursing p Process p Step: p Planning

MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• Nurse p Practice p Acts p define p the p legal p scope p of p an p LPNs p practice, p which p are

p written p and p enforced p by:

• the p American p Nurses p Association.

• the p National p Council p Licensure p Examiners.

• each p state.

• each p health p care p

agency. p ANSWER: p C

Each p state p writes p and p enforces p the p Nurse p Practice p Act, p which p defines p the p legal p scope p of p nursing p practice.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 5 p OBJ: p Theory p #3 p TOP: p Nurse p Practice p Act p KEY: p Nursing p Process

p Step: p N/A

MSC: p NCLEX: p N/A

• Women p volunteers p were p organized p to p give p nursing p care p to p the p wounded p soldiers

p during p the p Civil p War p by:

• Florence p Nightingale.

• Dorothea p Dix.

• Clara p Barton.

• Lillian p

Wald.

ANSWER: p B

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The p Union p government p appointed p Dorothea p Dix, p a p social p worker, p to p organize p women p volunteers p to p provide p nursing p care p for p the p soldiers p during p the p Civil p War.

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DIF: p Cognitive p Level: p Knowledge p REF: p dm p 2 p OBJ: p Theory p #4 p TOP: p Nursing p History p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p nursing p theory p presented p by p Sister p Calista p Roy p is p based p on:
• reduction p of p stress.

• achievement p of p maximum p level p of p wellness.

• relief p of p self-care p deficit.

• adaptation p

modes. p ANSWER: p D

Adaptation p modes p (physiologic, p psychological, p sociologic, p and p independence) p are p the p basis p of p the p nursing p theory p of p Sister p Calista p Roy.

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DIF: p Cognitive p Level: p Knowledge p REF: p dm p 4, p Table p 1-1 OBJ: p Theory p #2 p TOP: p Nursing p Theories p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

18. The p founding p of p the p Red p Cross p is p attributed p to:

• Lillian p Wald.

• Dorothea p Dix.

• Florence p Nightingale.

• Clara p

Barton. p ANSWER: p D

Clara p Barton p founded p the p Red p Cross.DIF: p Cognitive p Level: p Knowledge p REF: p dm p 2 p OBJ: p Theory p #4 p TOP: p Nursing p History p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p nursing p theorist p whose p practice p framework p is p based p on p 14 p fundamental p needs p is:
• Dorothy p Johnson.

• Jean p Watson.

• Virginia p Henderson.

• Martha p

Rogers. p ANSWER: p C

Virginia p Hendersons p nursing p theory p framework p is p based p on p 14 p fundamental p needs. p DIF: p Cognitive p Level: p Knowledge p REF: p dm p 4, p Table p 1-1 OBJ: p Theory p #2 p TOP: p Nursing p Theorists p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p nursing p theory p that p uses p seven p behavioral p subsystems p in p an p adaptation p model p is:
• Betty p Neumann.

• Sister p Calista p Roy.

• Dorothy p Johnson.

• Patricia p

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Benner. p ANSWER: p C

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Dorothy p Johnsons p practice p framework p is p based p on p seven p behavioral p subsystems p in p an p adaptation p model.DIF: p Cognitive p Level: p Knowledge p REF: p dm p 4, p Table p 1-1 OBJ: p Theory p #2 p TOP: p Nursing p Theorists p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p Standards p of p Clinical p Nursing p Practice p are p designed p to p direct p LPNs p to:
• advance p their p nursing p career.

• seek p a p scientific p basis p for p their p interventions.

• deliver p safe, p knowledgeable p care.

• a p leadership p

role. p ANSWER: p C

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The p Standards p of p Clinical p Nursing p Practice p are p designed p to p guide p the p LPN p to p deliver p safe, p knowledgeable p care.DIF: p Cognitive p Level: p Knowledge p REF: p dm p 5 p OBJ: p Theory p #2 p TOP: p Nursing p Standards p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p Safe p Effective p Care p Environment

22. A p states p Nurse p Practice p Act p is p designed p to p protect p the:

• physician.

• nurse.

• public.

• hospital.

p ANSWER: p C

Nurse p Practice p Acts p are p designed p to p protect p the p public.DIF: p Cognitive p Level: p Knowledge p REF: p dm p 6 p OBJ: p Theory p #5 p TOP: p Nurse p Practice p Act p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• It p is p appropriate p for p practical p nurses p to p provide p direct p patient p care p to p persons p

in p a p hospital p under p the p supervision p of p a:

• physicians p assistant.

• registered p nurse p on p the p unit.

• supervising p nurse p who p is p responsible p for p care p on p several p units.

• more p experienced p LPN p on p the p

unit. p ANSWER: p B

Practical p nurses p provide p direct p patient p care p under p the p direct p supervision p of p a p registered p nurse, p physician, p or p dentist.DIF: p Cognitive p Level: p Knowledge p REF: p dm p 6 p OBJ: p Theory p #9 p TOP: p Scope p of p Practice p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• An p example p of p tertiary p health p care p is care.
• hospice

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• restorative

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• emergency

• home p

health p ANSWER: p A

Tertiary p health p care p includes p extended p care, p chronic p disease p management, p medical p homes, p in- p home p personal p care, p and p hospice p care.

Chapter p 2 p Nursing p Process MULTIPLE p CHOICE

• The p nurse p is p aware p that p any p description p of p health p would p include p the p concept p that:
• health p is p the p absence p of p illness, p and p illness p is p the p presence p of p chronic p disease.

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• culture, p education, p and p socioeconomic p status p influence p ones p definition p of p health p or p

illness.

• illness p is p a p biologic p malfunction, p and p health p is p biologic p soundness.

• lifestyle p factors p are p the p major p determinant p of p health p or

p illness. p ANSWER: p B

The p concept p of p health p is p influenced p by p culture, p education, p and p socioeconomic p factors. p DIF: p Cognitive p Level: p Comprehension p REF: p dm p 15 p

OBJ: p Theory p #1

TOP: p Views p of p Health p and p Illness p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• The p nurse p takes p into p consideration p that p the p patient p with p an p admitting p

diagnosis p of p type p 2 p diabetes p mellitus p and p influenza p is p described p as p having:

• two p chronic p illnesses.

• two p acute p illnesses.

• one p chronic p and p one p acute p illness.

• one p acute p and p one p infectious p

illness. p ANSWER: p C

Chronic p illnesses p are p those p that p develop p slowly p over p a p long p period p and p last p throughout p a p lifetime. p Acute p illnesses p develop p suddenly p and p resolve p in p a p short p time. p Type p 2 p diabetes p mellitus p would p be p considered p chronic, p whereas p influenza p would p be p considered p acute.DIF: p Cognitive p Level: p Application p REF: p dm p 15 p OBJ: p Theory p #1 TOP: p Classification p of p Illnesses p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

3. The p nurse p explains p that p an p idiopathic p disease p is p one p that:

• is p caused p by p inherited p characteristics.

• develops p suddenly, p related p to p new p viruses.

• results p from p injury p during p labor p or p delivery.

• has p an p unknown p

cause. p ANSWER: p D

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Idiopathic p disease p is p defined p as p disease p whose p cause p is p unknown. p DIF: p Cognitive p Level: p Knowledge p REF: p dm p 13 p

OBJ: p Theory p #1

TOP: p Classification p of p Illnesses p KEY: p Nursing p Process p Step: p Implementation

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MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

4. The p nurse p assesses p a p terminal p illness p in p a:

• 76 p year p old p admitted p to p a p nursing p home p with p Alzheimers p disease p who p is p pacing p and p

asking p to p go p ho

• 43 p year p old p with p Lou p Gehrigs p disease p who p is p refusing p food p and p fluid.
• 2 p year p old p child p who p burned p her p esophagus p by p drinking p drain p cleaner p and p who p is p

being p fed p by p a p tub p 52 p year p old p diagnosed p with p lung p cancer p who p had p part p of p one p lung p removed p and p has p a p closed p chest p dr d.

ANSW

ER: p B

place.A p terminal p illness p is p defined p as p one p in p which p a p person p will p live p only p a p few p months, p weeks, p or p days. p A p person p who p refuses p food p and p hydration p will p generally p not p live p more p than p a p few p days.

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DIF: p Cognitive p Level: p Comprehension p REF: p dm p 13 p OBJ: p Theory p #1 p TOP: p Stages p of p Illness p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p clarifies p to p a p patient p who p now p has p an p abscess p following p a p ruptured p

appendix p that p the p abscess p is p considered p to p be:

• a p secondary p illness.

• a p life p threatening p complication.

• an p expected p event p following p any p surgery.

• a p disorder p easily p treated p with p

antibiotics. p ANSWER: p A

A p secondary p illness p is p an p illness p that p arises p from p a p primary p disorder. p DIF: p Cognitive p Level: p Comprehension p REF:

p dm p 13 p OBJ: p Theory p #1

TOP: p Views p of p Health p and p Illness p KEY: p Nursing p Process p Step: p Intervention p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p uses p a p diagram p to p demonstrate p how p Dunns p theory p of p health p and p

illness p can p be p compared p with p a:

• plant p that p grows p from p a p seed, p blossoms, p wilts, p and p dies.

continuum, p with p peak p wellness p and p death p at p opposite p ends; p the p person p moves p back p and p forth p in p a p dy

• change.

• ladder; p from p birth p to p death p the p individual p moves p progressively p downward p a p ladder p to p

eventual p death

• state p of p mind p dependent p on p the p individual p perception p of p their p own p

health p or p illness. p ANSWER: p B

Dunns p theory p of p a p health p continuum p shows p how p an p individual p moves p between p peak p wellness p and p death p in p a p constant p process.DIF: p Cognitive p Level: p Knowledge p REF: p dm p 14 p OBJ: p Theory p #1 TOP: p Views p of p Health p and p Illness p KEY: p Nursing p Process p Step: p

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Intervention p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• A p patient p has p been p advised p by p the p physician p to p take p medication p for p high p

cholesterol p and p to p change p eating p habits p after p discharge p home. p The p home p health p nurse p discovered p that p the p patient p refused p to p follow p the p medical p and p nutritional p directions. p The p nurses p best p initial p response p to p this

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situation p is p to:

• emphasize p to p the p patient p how p important p it p is p to p follow p the p doctors p advice.

determine p whether p any p cultural, p socioeconomic, p or p religious p values p conflict, p thus p interfering p with p th

• compliance.

• explain p that p without p diet p and p medication p the p condition p will p worsen p and p serious p

problems p will p devel

• inform p the p physician p that p the p patient p is p unable p to p understand p the p

instructions. p ANSWER: p B

The p patient p may p have p cultural, p socioeconomic, p or p religious p values p that p cause p conflicts p that p prevent p her p from p following p the p doctors p instructions.DIF: p Cognitive p Level: p Application p REF: p dm p 15 p OBJ: p

Theory p #5 p TOP: p Concepts p of p Health p and p Illness p | p

Cultural p Influences p KEY: p Nursing p Process p Step: p Assessment

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MSC: p NCLEX: p Psychological p Integrity: p coping p and p adaptation

• A p nurse p practicing p a p holistic p approach p to p nursing p care p must:
• recognize p that p a p change p in p one p aspect p of p the p persons p life p can p alter p the p whole p of p that p

persons p life.

• take p responsibility p for p health p care p decisions.

• promote p state p of p the p art p technology.

• discourage p the p use p of p more p natural p remedies p and p alternative p methods p of p

health p care. p ANSWER: p A

Holistic p nursing p requires p that p the p nurse p recognize p that p a p change p in p one p aspect p of p the p patients p life p (biological, p sociological, p psychological, p and p spiritual) p will p bring p about p changes p in p that p patients p whole p life.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 17 p OBJ: p Theory p #6 TOP: p Holistic p Approach p to p Caring p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p N/A

• According p to p Maslows p hierarchy, p physiological p needs p are p those p that:
• nurture p intimacy.

• foster p independence.

• encourage p social p interaction.

• are p essential p to p human p

life. p ANSWER: p D

Physiological p needs p are p those p that p are p essential p to p human p life, p such p as p oxygenation, p nutrition, p and p elimination.DIF: p Cognitive p Level: p Application p REF: p dm p 17 p OBJ: p Theory p #7 p TOP: p Maslows p Hierarchy p of p Needs p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p factors p involved p in p assessing p the p importance p the p patient p attaches p to p

the p relief p of p a p particular p deficit p include:

• needs p that p the p nurse p must p assess p to p prioritize p care, p because p they p may p be p different p from

p person p to p per

• ordering p needs p according p to p Maslows p hierarchy, p with p lower p level p needs p being p least p

compelling. p needs p based p on p a p hierarchy p in p which p higher p level p needs p are p more p

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prominent p and p demand p attention p b

• needs.

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• needs p that p are p usually p not p known p to p the p patient p and p that p must p be p determined

p by p the p nurse. p ANSWER: p A

A p persons p concern p relative p to p a p needs p deficit p must p be p assessed p by p the p nurse p to p meet p the p needs p of p each p patient. p Needs p are p viewed p differently p from p one p person p to p the p next.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 17 p OBJ: p Theory p #7 TOP: p Maslows p Hierarchy p of p Needs p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p believes p that p teaching p a p patient p how p to p give p insulin p and p monitor p blood p glucose

levels p will p improve p the p level p of p the p patients:

• physiological p well p being.

• security, p by p providing p psychological p comfort.

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• self p esteem, p by p promoting p independence p and p learning.

• self p actualization, p by p seeking p knowledge p and p

truth. p ANSWER: p C

Teaching p activities p to p a p patient p that p are p to p be p used p after p discharge p enhances p independence p and p promotes p self p esteem.DIF: p Cognitive p Level: p Application p REF: p dm p 19 p OBJ: p Theory p #7 TOP: p Maslows p Hierarchy p of p Needs p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p psychosocial p adaptation

12. Homeostasis p can p be p described p as:

• the p unchanging p steady p condition p of p humans p in p a p changing p external p environment.
• a p tendency p of p biological p systems p toward p stability p of p the p internal p environment p by p

continuously p adjus p biological p wellness p that p comes p from p the p ability p of p the p body p to p change p and p respond p to p physical p chang

• environment.

• a p response p to p stress p that p results p from p a p persons p choice p of p coping p mechanisms p to p deal p

with p the p stress. p ANSWER: p B

Homeostasis p results p from p the p constant p adjustment p of p the p internal p environment p in p response p to p change; p it p is p mental, p emotional, p and p biological, p as p well p as p conscious p and p unconscious.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 20 p OBJ: p Theory p #8 TOP: p Homeostasis p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p N/A

• A p patient p admitted p for p diagnostic p tests p is p frightened p of p hospital p procedures p and

p is p nervous p about p the p possible p outcome p of p the p tests. p She p states p that p her p mouth p is p dry p and p her p heart p is p pounding. p Her p blood p pressure p is p 168/78 p mm p Hg p (her p usual p blood p pressure p is p 140/80 p mm p Hg), p pulse p is p 112 p beats/min, p and p respirations p are p 22 p breaths/min. p The p nurse p will p recognize p that p these p signs p and p symptoms p are:

• indicative p of p serious, p acute p health p problems p and p should p be p reported p to p the p physician p

immediately.

• most p likely p related p to p the p disease p for p which p the p patient p is p admitted p to p the p hospital.

• the p effects p of p the p parasympathetic p nervous p system p and p can p be p ignored.

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• the p effects p of p the p sympathetic p nervous p system p that p can p negatively p affect p the p

patients p health. p ANSWER: p D

Fear p stimulates p the p sympathetic p nervous p system p to p produce p the p symptoms p identified p in p the

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question. p If p prolonged, p they p negatively p affect p a p persons p health. p DIF: p Cognitive p Level: p Analysis p REF: p dm p 22, p Table p 2-2 OBJ: p Theory p #10 p TOP: p Stress p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• According p to p Hans p Selyes p general p adaptation p syndrome p (GAS), p a p person

p who p has p experienced p excessive p and p prolonged p stress p is p likely p to:

• develop p an p illness p or p disease p such p as p allergy, p arthritis, p or p asthma.

• become p resistant p to p biological p methods p of p treatment.

• seek p treatment p for p imagined p illnesses p and p nonexistent p symptoms.

• be p admitted p to p the p hospital p during p the p alarm

p stage. p ANSWER: p A

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Many p diseases p are p known p to p be p caused p or p exacerbated p by p prolonged p stress. p Seyle p concluded p that p stress p induced p illnesses p respond p to p biological p methods p of p treatment.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 22, p Box p 2-2 OBJ: p Theory p #10 p TOP: p Adaptation p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p is p aware p that p a p stressor p as p experienced p by p an p individual p is p usually p perceived:
• as p a p negative p event p or p stimulus p that p affects p homeostasis p in p maladaptive p ways.

• in p different p ways p based p on p previous p experience p and p personality p traits.

• as p an p opportunity p for p growth p and p learning.

• in p similar p ways p if p age p and p education p are p

similar. p ANSWER: p B

Stressors p are p not p perceived p the p same p way p by p different p people p or p even p by p the p same p person p at p different p times. p The p experience p of p a p stressor p depends p on p previous p experience p and p personality, p as p well p as p factors p such p as p physical p or p emotional p conditions, p age, p and p education.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 22 p OBJ: p Theory p #9 TOP: p General p Adaptation p Syndrome p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Psychological p Integrity: p psychosocial p adaptation

• In p 1946, p the p World p Health p Organization p redefined p health p as p the:
• absence p of p disease p or p infirmity.

• state p of p complete p physical, p mental, p and p social p well p being.

• presence p of p disease p or p infirmity.

• state p of p incomplete p physical, p mental, p and p social p well

p being. p ANSWER: p B

In p 1946, p the p World p Health p Organization p redefined p health p as p the p state p of p complete p physical, p mental, p and p social p well p being p and p not p merely p the p absence p of p disease p or p infirmity.DIF: p Cognitive p Level: p Knowledge p REF: p dm p 13 p OBJ: p Theory p #1 p TOP: p Views p of p Health p and p Illness p KEY: p

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Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p nurse p assesses p that p a p person p is p in p the p acceptance p stage p of p illness p when p the p patient:
• looks p to p home p remedies p to p become p well.

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• reassumes p usual p responsibilities p and p roles.

• assumes p the p sick p role.

• rejects p medical p

treatment. p ANSWER: p C

When p a p person p enters p the p acceptance p stage p of p illness, p he p or p she p assumes p the p sick p role p and p withdraws p from p usual p responsibilities p and p will p frequently p seek p medical p treatment p at p this p time. p DIF: p Cognitive p Level: p Comprehension p REF: p dm p 13

p OBJ: p Theory p #1

TOP: p Acceptance p Stage p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p instructs p a p patient p that p according p to p Selyes p GAS p theory, p when p

stress p is p strong p enough p and p occurs p over p a p long p enough p period, p the p patient p will p

enter p the p stage p of:

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• convalescence.

• alarm.

• transition.

• exhaustion.

p ANSWER: p D

The p exhaustion p stage p in p the p GAS p occurs p when p the p stressor p has p been p present p for p such p a p period p that p the p patient p will p deplete p the p bodys p resources p for p adaption.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 18 p OBJ: p Theory p #1 p TOP: p Exhaustion p Stage p of p GAS p KEY: p Nursing p Process p Step: p Intervention p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p explains p defense p mechanisms p as p a p patients p attempt p to:
• justify p the p patients p assumption p of p the p sick p role.

• reduce p anxiety.

• problem p solve.

• increase p

dependence. p ANSWER: p B

Defense p mechanisms p are p unconscious p strategies p to p reduce p anxiety. p DIF: p Cognitive p Level: p Knowledge p REF: p dm p 22, p Table p 2-3 OBJ: p Theory p #9 p TOP: p Defense p Mechanisms p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychological p Integrity: p coping p and p adaptation

• In p giving p nursing p care p to p persons p of p Asian p origin, p the p nurse p should:
• keep p the p room p warm p and p free p of p drafts.

• look p the p patient p directly p in p the p eye.

• ask p permission p before p touching p the p patient.

• warmly p clasp p the p patients p hand p in p

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greeting. p ANSWER: p C

Seek p permission p before p touching p persons p of p Asian p extraction p because p they p may p be p sensitive p to p physical p personal p contact.

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DIF: p Cognitive p Level: p Application p REF: p dm p 16, p Table p 2-1 p OBJ: p Theory p #4 p TOP: p Cultural p Sensitivity KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychological p Integrity: p coping p and p adaptation

• Sickle p cell p anemia p is p an p example p of p a p biological p trait p found p primarily p in populations.
• Asian

• African

• American p Indian

• Hispanic

p ANSWER: p B

Sickle p cell p anemia p is p a p biological p variation p found p predominantly p in p people p of p African p descent.

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DIF: p Cognitive p Level: p Knowledge p REF: p dm p 16, p Table p 2-1 OBJ: p Theory p #5 p TOP: p Cultural p Influences p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• When p a p young p family p man p hospitalized p after p a p breaking p his p leg p confides p to p the p

nurse p that p he p is p concerned p about p the p well p being p of p his p family p and p financial p stress, p

the p nurse p can p best p support p his p sense p of p security p by:

• reassuring p him p that p his p leg p will p heal p quickly.

• actively p listening p to p his p concerns.

• encouraging p family p to p make p frequent p visits.

• distracting p him p from p his p concerns p by p

socialization. p ANSWER: p B

A p nurses p ability p to p use p active p listening p will p enhance p the p sense p of p security p when p patients p feel p that p their p needs p are p perceived p accurately.DIF: p Cognitive p Level: p Application p REF: p dm p 19 p OBJ: p Theory p #7 TOP: p Maslows p Hierarchy p of p Needs p KEY: p Nursing p Process p Step: p Intervention p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p assesses p successful p adaptation p in p a p post p stroke p patient p when p the p patient:
• learns p to p walk p and p maintain p balance p with p the p aid p of p a p walker.

• consistently p takes p antihypertensive p drugs.

• attempts p to p get p out p of p bed p unassisted.

• refuses p assistance p with p

feeding. p ANSWER: p A

Adaptation p is p a p readjustment p in p habits p to p limitations p and p disabilities. p Learning p to p walk p and p maintain p balance p with p the p aid p of p a p walker p is p an p example p of p this.DIF: p Cognitive p Level: p Application p REF: p dm p 20 p OBJ: p Theory p #1 p TOP: p Adaptation p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p takes p into p consideration p that p in p the p stage p of p resistance p in p Selyes p GAS, p the p patient:

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• regresses p to p a p dependent p state.

• continues p to p battle p for p equilibrium.

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• becomes p maladaptive.

• begins p to p develop p stress p related p

disorders. p ANSWER: p B

The p resistance p stage p is p the p second p stage p in p the p GAS p when p a p patient p is p still p attempting p to p find p equilibrium.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 22 p OBJ: p Theory p #10 p TOP: p Selyes p GAS p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• A p patient p states, p I p am p not p obese. p My p entire p family p is p large. p The p nurse p assesses p that p the p

patient

is p using p the p defense p mechanism p of:

• sublimation.

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• projection.

• denial.

• displacement.

p ANSWER: p C

Denial p is p a p defense p mechanism p that p allows p a p person p to p live p as p though p an p unwanted p piece p of p information p or p reality p does p not p exist. p There p is p a p persistent p refusal p to p be p swayed p by p the p evidence. p DIF: p Cognitive p Level: p Application p REF: p dm p 25, p Table p 2-3 OBJ: p Theory p #8 p TOP: p Defense p

Mechanisms p KEY: p Nursing p Process p

Step: p Assessment

MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p child p who p has p just p been p scolded p by p her p mother p proceeds p to p hit p her p doll p

with p a p hairbrush. p The p nurse p recognizes p the p childs p actions p are p characteristic p of:

• denial.

• displacement.

• rationalization.

• repression.

p ANSWER: p B

Displacement p is p a p defense p mechanism p that p characterizes p discharging p intense p feelings p for p one p person p onto p an p object p or p another p person p who p is p less p threatening, p thereby p satisfying p an p impulse p with p a p substitute p object.DIF: p Cognitive p Level: p Application p REF: p dm p 25, p Table p 2-3 p OBJ: p Theory p #8 p TOP: p Defense p Mechanisms KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p encourages p a p patient p to p participate p in p health p maintenance p by p

maintaining p an p ideal p body p weight p as p a p method p of prevention.

• primary

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• secondary

• tertiary

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• simple

ANSWER: p A

Primary p prevention p avoids p or p delays p occurrence p of p a p specific p disease p or p disorder. p DIF: p Cognitive p Level: p Comprehension p REF: p dm p 26 p OBJ: p Theory p #1 TOP: p Primary p Prevention p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• A p nurse p clarifies p that p methods p of p tertiary p prevention p are p designed p for:
• rehabilitation.

• delay p of p the p development p of p a p disorder.

• screening p for p early p detection p of p disease.

• using p an p established p protocol p of p therapy p for p a p specific p disease.

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ANSWER: p A

Tertiary p prevention p consists p of p rehabilitation p measures p after p the p disease p or p disorder p has p stabilized. p Latent p prevention p does p not p exist.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 26 p OBJ: p Theory p #1 p TOP: p Tertiary p Prevention p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• When p a p new p admission p to p an p extended p care p facility p wanders p about p listlessly, p eats p

only p a p small p amount p of p each p meal, p and p keeps p himself p isolated, p the p nurse p can p

intervene p by:

• assisting p with p feeding p at p each p meal.

• reminding p him p that p he p is p in p a p safe p and p secure p area.

• socializing p with p him p in p the p privacy p of p his p room.

• supporting p him p to p interact p with p an p exercise p

group. p ANSWER: p D

The p membership p and p social p interaction p in p a p group p may p provide p a p means p for p a p sense p of p belonging. p DIF: p Cognitive p Level: p Application p REF: p dm p 19 p OBJ: p Theory p #11 TOP: p Love p and p Belonging p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p psychosocial p adaptation p COMPLETION

• Exercise p can p reduce p stress p and p anxiety p by p the p release p of .

p ANSWER:

endorphins The p release p of p endorphins p induces p a p feeling p of p well p being p and p tranquility. p DIF: p Cognitive p Level: p Knowledge p REF: p dm p 24 p OBJ: p Theory p #11 TOP: p Views p of p Health p and p Illness p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p N/A

• Adequate is p necessary p in p the p communication p between p nurse p and p patient

p in p order p to p meet p the p higher p basic p needs p of p security, p love, p belonging, p and p self p esteem.

ANSWER:

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feedback Adequate p feedback p and p clarification p are p essential p in p assisting p the p patient p meet p the p higher p level p needs.

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DIF: p Cognitive p Level: p Comprehension p REF: p dm p 20 p OBJ: p Theory p #7 p TOP: p Communication p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p N/A MULTIPLE p RESPONSE

• When p the p brain p perceives p a p situation p as p threatening, p the p sympathetic p nervous p

system p reacts p by p stimulating p which p of p the p following p physiological p functions? p (Select p all p that p apply.)

• Constriction p of p the p pupils

• Dilation p of p the p bronchial p tubes

• Decreased p heart p rate

• Dilation p of p the p

pupils p ANSWER: p B, p D

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Activation p of p the p sympathetic p nervous p system p causes p the p pupils p and p bronchial p tubes p to p dilate. p It p also p causes p the p heart p rate p to p increase.DIF: p Cognitive p Level: p Analysis p REF: p dm p 22, p Table p 2-3 p OBJ: p Theory p #11 p TOP: p Sympathetic p Nervous p System KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p N/A

• The p nurse p describes p behaviors p of p the p transition p stage p of p illness, p which p are: p

(Select p all p that p apply.)

• awareness p of p vague p symptoms.

• denial p of p feeling p ill.

• resorts p to p self p medication.

• withdrawal p from p roles p and p responsibilities.

• recovery p from p illness p

begins. p ANSWER: p A, p B, p C

The p transition p stage p (onset) p of p illness p is p demonstrated p by p the p patients p awareness p of p vague p symptoms, p denial p of p feeling p ill, p and p initiation p of p self p medication; p however, p he p or p she p still p fulfils p the p roles p and p responsibilities p of p life.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 13 p OBJ: p Theory p #1 p TOP: p Stages p of p Illness p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• Which p defines p the p holistic p approach p to p caring p for p the p sick p and p promoting p

wellness? p (Select p all p that p apply.)

• The p nurses p focus p is p specific p to p the p disease p or p injury.

• The p nurse p realizes p that p each p person p has p a p responsibility p for p his p or p her p own p health.

• Health p care p providers p are p required p to p intervene p on p behalf p of p all p persons p to p ensure p that

p health p goals p a

• Providers p combine p traditional p methods p of p health p care p with p relaxation p techniques p for p pain p

manageme

• A p change p in p one p aspect p of p a p persons p life p may p or p may p not p alter p the p

person p as p a p whole. p ANSWER: p B, p C, p D, p E

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The p holistic p approach p to p medicine p treats p the p patient p as p a p whole p and p may p use p a p mix p of p traditional p medicine p and p alternative p medicine. p Any p change p in p one p aspect p of p the p whole p may p change p the p entire p whole.

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Chapter p 3 p Laws p and p Ethics MULTIPLE p CHOICE

1. A p student p nurse p who p is p not p yet p licensed:

• may p not p perform p nursing p actions p until p he p or p she p has p passed p the p licensing p examination.

• is p not p responsible p for p his p or p her p actions p as p a p student p under p the p state p licensing p law.

• may p perform p nursing p actions p only p under p the p supervision p of p a p licensed p nurse.

• must p apply p for p a p temporary p student p nurse p permit p to p practice p as

p a p student. p ANSWER: p C

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Students p may p perform p nursing p actions p before p they p are p licensed p but p only p under p the p supervision p of p a p licensed p nurse. p The p student p is p responsible p for p his p or p her p own p actions; p however, p the p supervising p nurse p may p also p be p responsible, p depending p on p the p situation. p No p special p permit p is p required p to p practice p as p a p student p in p an p approved p school p of p nursing.DIF: p Cognitive p Level: p Knowledge p REF: p dm p 30 p OBJ: p Theory p #1 TOP: p Practice p Regulations p for p the p Student p Nurse p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• During p an p employment p interview, p the p interviewer p asks p the p nurse p applicant p about p

HIV p status. p The p nurse p applicant p can p legally p respond:

• No, p even p though p he p or p she p has p a p positive p HIV p test.

• I p dont p know, p but p I p would p be p willing p to p be p tested.

• I p dont p know, p and p I p refuse p to p be p tested.

• You p do p not p have p a p right p to p ask p me p that p

question. p ANSWER: p D

In p employment p practice, p it p is p illegal p to p discriminate p against p people p with p certain p diseases p or p conditions. p Asking p a p question p about p health p status, p especially p HIV p or p AIDS p infection, p is p illegal. p DIF: p Cognitive p Level: p Application p REF: p dm p 31 p OBJ: p Clinical p Practice p #1 TOP: p Discrimination p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• An p example p of p a p violation p of p criminal p law p by p a p nurse p is:
• taking p a p controlled p substance p from p agency p supply p for p personal p use.

• accidentally p administering p a p drug p to p the p wrong p patient, p who p then p has p a p serious p reaction.

• advising p a p patient p to p sue p the p doctor p for p a p supposed p mistake p the p doctor p made.

• writing p a p letter p to p the p newspaper p outlining p questionable p or p unsafe p hospital

p practices. p ANSWER: p A

Theft p of p a p controlled p substance p is p a p federal p crime p and p consequently p a p crime p against p society. p DIF: p Cognitive p Level: p Application p REF: p dm p 30 p OBJ: p Theory p #2 TOP: p Criminal p Law p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

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• The p LPN p (LVN) p assigns p part p of p the p care p for p her p patients p to p a p nursing p assistant. p The p LPN p is

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legally p required p to p perform p which p of p the p following p for p the p residents p assigned p to p the p assistant?

• Toilet p the p residents p every p 2 p hours p and p as p needed.

• Feed p breakfast p to p one p of p the p residents p who p needs p assistance.

• Give p medications p to p the p residents p at p the p prescribed p times.

• Transport p the p residents p to p the p physical p therapy p

department. p ANSWER: p C

Toileting, p feeding, p and p transporting p residents p or p patients p are p tasks p that p can p be p legally p assigned p to p a p nurses p aide. p Administering p medications p is p a p nursing p act p that p can p be p performed p only p by p a p licensed p nurse p or p by p a p student p nurse p under p the p supervision p of p a p licensed p nurse.DIF: p Cognitive p Level: p Application p REF: p dm p 31 p OBJ: p Theory p #3 p TOP: p Delegation p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Safe p Effective p Care p

Environment: p coordinated p care

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• If p a p nurse p is p reported p to p a p state p board p of p nursing p for p repeatedly p making p

medication p errors, p it p is p most p likely p that:

• the p nurse p will p immediately p have p his p or p her p license p revoked.

• the p nurse p will p have p to p take p the p licensing p examination p again.

• a p course p in p legal p aspects p of p nursing p care p will p be p required.

• there p will p be p a p hearing p to p determine p whether p the p charges

p are p true. p ANSWER: p D

The p nurse p may p have p his p or p her p license p revoked p or p be p required p to p take p a p refresher p course, p but p this p would p be p based p on p the p evidence p presented p at p a p hearing. p The p licensing p examination p is p not p usually p required p as p a p correction p of p the p situation p as p described.DIF: p Cognitive p Level: p Knowledge p REF: p dm p 31 p OBJ: p Theory p #3 p TOP: p Professional p Discipline p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• A p nurse p co-worker p arrives p at p work p 30 p minutes p late, p smelling p strongly p of p alcohol.

p The p fellow p nurses p legal p course p of p action p is p to:

• have p the p nurse p lie p down p in p the p nurses p lounge p and p sleep p while p others p do p the p work.

• state p that, p if p this p happens p again, p it p will p be p reported.

• report p the p condition p of p the p nurse p to p the p nursing p supervisor.

• offer p a p breath p mint p and p instruct p the p nurse p co-worker p

to p work. p ANSWER: p C

Nurses p must p report p the p condition. p It p is p a p nurses p legal p and p ethical p duty p to p protect p patients p from p impaired p or p incompetent p workers. p Allowing p the p impaired p nurse p to p sleep p enables p the p impaired p nurse p to p avoid p the p consequences p of p his p or p her p actions p and p to p continue p the p risky p behavior.Threatening p to p report p the p next p time p continues p to p place p patients p at p risk, p as p does p masking p the p signs p of p impairment p with p breath p mints.DIF: p Cognitive p Level: p Application p REF: p dm p 31 p OBJ: p Theory p #3 p TOP: p Professional p Discipline p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• When p a p student p nurse p performs p a p nursing p skill, p it p is p expected p that p the p student:

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• perform p the p skill p as p quickly p as p the p licensed p nurse.

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• achieve p the p same p result p as p the p licensed p nurse.

• not p be p held p to p the p same p standard p as p the p licensed p nurse.

• always p be p directly p supervised p by p an p

instructor. p ANSWER: p B

Students p are p not p expected p to p perform p skills p as p quickly p or p as p smoothly p as p experienced p nurses, p but p students p must p achieve p the p same p result p in p a p safe p manner.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 30 p OBJ: p Theory p #1 TOP: p Practice p Regulations p for p the p Student p Nurse p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• If p a p nurse p receives p unwelcome p sexual p advances p from p a p nursing p supervisor, p the p

first p step p the p nurse p should p take p is p to:

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• send p an p anonymous p letter p to p the p nursing p administration p to p alert p them p to p the p situation.

tell p the p nursing p supervisor p that p she p is p uncomfortable p with p the p sexual p advances p and p ask p the p superviso

• behavior.

• report p the p nursing p supervisor p to p the p state p board p for p nursing.

• resign p and p seek p employment p in p a p more p comfortable p

environment. p ANSWER: p B

The p first p step p in p dealing p with p sexual p harassment p in p the p workplace p is p to p indicate p to p the p person p that p the p actions p or p conversations p are p offensive p and p ask p the p person p to p stop. p If p the p actions p continue, p then p reporting p the p occurrence p to p the p supervisor p or p the p offenders p supervisor p is p indicated.DIF: p Cognitive p Level: p Application p REF: p dm p 32 p OBJ: p Clinical p Practice p #1 p TOP: p Sexual p Harassment p KEY: p Nursing p Process p Step: p N/A MSC: p NCLEX: p N/A

• A p person p who p has p been p brought p to p the p emergency p room p after p being p struck p by p

a p car p insists p on p leaving, p although p the p doctor p has p advised p him p to p be p hospitalized p

overnight. p The p nurse p caring p for p this p patient p should:

• have p him p sign p a p Leave p Against p Medical p Advice p (AMA) p form.

• tell p him p that p he p cannot p leave p until p the p doctor p releases p him.

• immediately p begin p the p process p of p involuntary p committal.

• contact p the p persons p health p care p proxy p to p assist p in p the p decision-

making p process. p ANSWER: p A

A p person p has p the p right p to p refuse p medical p care, p and p agencies p use p the p Leave p AMA p to p document p the p medical p advice p given p and p the p patients p informed p choice p to p leave p against p that p advice.DIF: p Cognitive p Level: p Application p REF: p dm p 38 p OBJ: p Clinical p Practice p #3 p TOP: p Patients p Rights p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p N/A

10. The p information p in p a p patients p chart p may p legally p be:

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• copied p by p students p for p use p in p school p reports p or p case p studies.

• provided p to p lawyers p or p insurers p without p the p patients p permission.

• shared p with p other p health p care p providers p at p the p patients p request.

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• withheld p from p the p patient, p because p it p is p the p property p of p the p doctor

p or p agency. p ANSWER: p C

A p release p or p consent p is p required p to p provide p information p from p a p patients p chart p to p anyone p not p directly p caring p for p that p patient. p The p patient p must p provide p consent p to p provide p information p to p insurers, p lawyers, p or p other p health p care p agencies p or p providers.p The p patient p has p the p right p to p access p the p information p in p his p or p her p chart p (copies), p but p the p agency p or p doctor p retains p ownership p of p the p document.DIF: p Cognitive p Level: p Application p REF: p dm p 34 p OBJ: p Theory p #5 p TOP: p Legal p Documents p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• If p a p patient p indicates p that p he p is p unsure p if p he p needs p the p surgery p he p is p

scheduled p for p later p that p morning, p the p nurse p would p best p reply:

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• Your p doctor p explained p all p of p that p yesterday p when p you p signed p the p consent.

• Your p doctor p is p in p the p operating p room; p she p cant p talk p to p you p now.

• You p should p have p the p surgery; p your p doctor p recommended p that p you p have p it.

• I p will p call p the p doctor p to p speak p with p you p before p you p go p to p the p

operating p room. p ANSWER: p D

A p consent p can p be p withdrawn p at p any p time p before p the p treatment p or p procedure p has p been p started. p The p physician p should p be p notified p by p the p supervising p nursing p staff p of p the p unit.DIF: p Cognitive p Level: p Application p REF: p dm p 36 p OBJ: p Clinical p Practice p #4 p TOP: p Informed p Consent p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p 16-year-old p boy p is p admitted p to p the p emergency p room p after p fracturing p his p arm

p from p falling p off p his p bike p while p visiting p with p his p stepfather p who p is p not p the p custodial p parent. p The p nurse p is p preparing p him p to p go p to p the p operating p room p but p

must p obtain p a p valid p informed p consent p by:

• having p the p patient p sign p the p consent p for p surgery.

• obtaining p the p signature p of p his p stepfather p for p the p surgery.

• declaring p the p patient p to p be p an p emancipated p minor.

• obtaining p permission p of p the p custodial p parent p for p the p

surgery. p ANSWER: p D

The p patient p is p a p minor p and p cannot p legally p sign p his p own p consent p unless p he p is p an p emancipated p minor; p the p guardian p for p this p patient p is p the p custodial p parent. p A p step- parent p is p not p a p legal p guardian p for p a p minor p unless p the p child p has p been p adopted p by p the p step-parent. p The p hospital p does p not p have p the p authority p to p declare p the p patient p an p emancipated p minor.DIF: p Cognitive p Level: p Application p REF: p dm p 36 p OBJ: p Clinical p Practice p #3 p TOP: p Consent p KEY: p Nursing p Process p Step: p Intervention MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

• A p patient p has p advance p directives p spelled p out p in p a p durable p power p of p

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attorney, p with p the p appointment p of p his p daughter p as p his p health p care p agent. p The p

daughter p will p be p responsible p for:

• paying p all p the p medical p bills p associated p with p the p fathers p illness.

• making p all p informed p consent p decisions p for p her p father.

• making p all p choices p about p her p fathers p health p care p if p the p father p is p unable.

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• paying p only p for p those p health p care p decisions p based p on p the p advance p

directives. p ANSWER: p C

A p health p care p agent p makes p decisions p for p the p patient p only p when p a p patient p is p unable, p according p to p the p wishes p made p known p by p the p patient p in p advance p directives. p A p health p care p agent p is p not p responsible p for p financial p decisions p or p payments.DIF: p Cognitive p Level: p Application p REF: p dm p 36 p OBJ: p Clinical p Practice p #5 p TOP: p Advance p Directives p KEY: p Nursing p Process p Step: p N/A MSC: p NCLEX: p N/A

• A p patient p has p signed p a p do-not-resuscitate p (DNR) p order. p If p a p nurse p performs p

cardiopulmonary p resuscitation p (CPR) p when p the p patient p stops p breathing p and p then p

successfully p revives p the p patient, p the:

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• nurse p could p be p found p guilty p of p battery.

• patient p would p have p no p grounds p for p legal p action.

• patient p could p charge p the p nurse p with p false p imprisonment.

• nurse p could p be p found p guilty p of p

assault. p ANSWER: p A

A p nurse p who p attempts p CPR p on p a p patient p who p had p a p doctors p order p for p a p DNR p could p be p found p guilty p of p battery.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 9 p | p dm p 36 p OBJ: p Clinical p Practice p #3 p TOP: p DNR p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• A p patient p refuses p to p take p his p medications p or p to p eat p his p breakfast. p He p is p

alert, p mentally p competent, p and p fairly p comfortable. p The p nurse p should:

• give p the p medications p by p injection p if p the p patient p will p not p take p them p orally.

• respect p the p patients p right p to p refuse p medications p or p food, p because p he p is p competent.

• tell p the p patient p that p he p must p cooperate p with p his p care.

• contact p the p doctor p to p insert p a p feeding p tube p to p supply p both p

medicine p and p food. p ANSWER: p B

The p competent p patient p has p the p right p to p refuse p medicine, p food, p treatments, p and p procedures. p Giving p (or p threatening p to p give) p medications p by p injection p over p the p patients p objections p is p considered p battery. p Threatening p the p patient p or p overriding p the p patients p wishes p is p a p violation p of p the p patients p bill p of p rights p and p constitutes p assault p or p battery.DIF: p Cognitive p Level: p Application p REF: p dm p 38 p OBJ: p Clinical p Practice p #3 p TOP: p Patients p Rights p KEY: p Nursing p Process p Step: p N/A MSC: p NCLEX: p N/A

• A p nurse p remarks p to p several p people p that p Dr. p X p must p be p getting p senile p because p

she p makes p so p many p mistakes. p If p that p remark p results p in p some p of p Dr. p Xs p patients p changing p to p another p doctor, p Dr. p X p would p have p grounds p to p sue p the p nurse p for:

• slander.

• libel.

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• invasion p of p privacy.

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• negligence.

p ANSWER: p A

A p person p who p makes p untrue, p malicious, p or p harmful p remarks p that p damage p a p persons p reputation p and p cause p injury p (loss p of p business) p is p guilty p of p defamation p and p slander. p Libel p is p defamation p that p is p written.DIF: p Cognitive p Level: p Application p REF: p dm p 38 p OBJ: p Clinical p Practice p #5 p TOP: p Defamation/Slander p KEY: p Nursing p Process p Step: p N/A MSC: p NCLEX: p N/A

• A p licensed p nurse p is p liable p for p charges p of p malpractice p when p she:
• does p not p show p up p for p work p and p fails p to p call p to p notify p the p agency.

• clocks p in p for p another p nurse p to p prevent p that p nurse p from p having p pay p docked.

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• falsifies p data, p causing p the p patient p to p suffer p problems p resulting p in p death.

• assists p in p performing p CPR p that p is p unsuccessful, p and p the p

patient p dies. p ANSWER: p C

Malpractice p is p professional p negligence p or, p in p this p case, p doing p (falsifying) p something p the p reasonable p and p prudent p nurse p would p not p do. p It p is p the p proximate p cause p of p the p patient p injury. p This p is p a p case p of p causation.DIF: p Cognitive p Level: p Application p REF: p dm p 37, p Box p 3-6 OBJ: p Theory p #5 p TOP: p Negligence p and p Malpractice p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• A p postoperative p patient p in p the p intensive p care p unit p (ICU) p is p so p confused p and p

agitated p that p staff p have p not p been p able p to p safely p care p for p him. p He p has p pulled p out p his p central p line p once, p and p he p slides p to p the p bottom p of p the p bed, p where p he p attempts p to p climb p out, p pulling p and p disrupting p the p various p tubes p and p monitors. p The p nurses p best p

course p of p action p is p to:

• place p him p in p a p protective p vest p device.

• use p a p sheet p to p tie p him p in p a p chair p at p the p nurses p station.

• request p that p the p doctor p write p an p order p for p a p protective p device p and/or p medication.

• call p a p family p member p to p stay p with p the p

patient. p ANSWER: p C

A p protective p device p may p not p be p used p (except p in p an p emergency) p without p a p doctors p order, p and p it p is p used p only p when p other p less p restrictive p means p do p not p provide p safety p for p the p patient.DIF: p Cognitive p Level: p Application p REF: p dm p 39 p OBJ: p Clinical p Practice p #3 p TOP: p False p Imprisonment p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Safe p Effective p Care p Environment: p safety p and p infection p control

• An p elderly, p slightly p confused p patient p sustains p an p injury p from p a p heating p pad p that p

was p wrongly p applied p by p the p nurse. p The p nurse p should:

• pretend p to p be p unaware p of p the p injury p to p the p patient.

• report p the p incident p to p the p risk p management p team p via p an p incident p report.

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• document p in p the p patients p chart p that p an p incident p report p was p filled p out.

• not p chart p anything p about p the p injury p in p the p

patients p chart. p ANSWER: p B

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When p an p incident p occurs p that p has p potential p for p a p future p lawsuit, p the p risk p management p team p should p be p aware p of p it p as p soon p as p possible. p An p incident p report p should p be p filled p out, p and p the p patient p chart p should p be p documented p to p describe p the p injury. p No p mention p of p the p incident p report p is p usually p made p in p the p patient p chart. p Honesty p and p a p forthright p explanation p to p the p patient p reduce p the p risk p of p lawsuits.DIF: p Cognitive p Level: p Application p REF: p dm p 40 p OBJ: p Theory p #5 p TOP: p Incident p Reports p KEY: p Nursing p Process p

Step: p N/A

MSC: p NCLEX: p N/A

• Nursing p liability p insurance p is p a p policy p purchased p and p put p into p effect p by p the p nurse p for p the

purpose p of:

• providing p protection p against p being p sued.

• reducing p the p chance p of p litigation.

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• paying p attorney p fees p and p any p award p won p by p the p plaintiff.

• providing p the p hospital p with p added p

protection. p ANSWER: p C

Nursing p liability p pays p attorney p fees p and p any p award p won p by p the p plaintiff. p DIF: p Cognitive p Level: p Comprehension p REF: p dm p 40 p OBJ: p Theory p #5 p TOP: p Nursing p Ethics p KEY: p Nursing p

Process p Step: p N/A

MSC: p NCLEX: p N/A

• Ethics p and p law p are p different p from p each p other p in p that p ethics:
• bear p a p penalty p if p violated.

• are p voluntary.

• rarely p change.

• can p always p direct p all p

decisions. p ANSWER: p B

Ethics p are p voluntary p and p are p based p on p values. p Ethics p may p change p as p parameters p of p health p care p change. p There p is p no p penalty p for p violation.DIF: p Cognitive p Level: p Analysis p REF: p dm p 40 p OBJ: p Theory p #6 p TOP: p Nursing p Ethics p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• To p best p protect p himself p or p herself p from p being p sued, p the p nurse p should:
• continue p to p do p procedures p as p taught p in p school.

• purchase p malpractice p insurance.

• maintain p competency.

• use p evidence-based p

practice. p ANSWER: p C

Keeping p up p with p continuing p education, p maintaining p competency, p and p seeking p to p improve p ones p own p practice p by p self-evaluation p will p best p protect p the p nurse.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 39, p Box p 3-7 OBJ: p Theory p #5 p TOP: p Avoiding p Lawsuits p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

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• The p Health p Insurance p Portability p and p Accountability p Acts p (HIPAA) p main p focus p is p in p keeping:

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• patients p safe p from p harm.

• patient p information p in p a p secure p office p area.

• medications p in p a p locked p area.

• hospital p infections p under p

control. p ANSWER: p B

HIPAA p regulates p the p way p patient p information p is p conveyed p and p stored. p DIF: p Cognitive p Level: p Comprehension p REF: p dm p 34, p Box p 3-4 OBJ: p Clinical p Practice p #1 p TOP: p HIPAA p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• When p a p patient p asks p a p nurse p to p witness p the p signing p of p a p will, p the p nurse p should p

refer p the p request p to p the:

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• nurse p supervisor.

• hospital p legal p department.

• notary p public p for p the p hospital.

• nurses p

attorney. p ANSWER: p C

Although p witnessing p a p legal p document p for p a p patient p is p not p illegal, p most p agencies p have p a p policy p regarding p the p proper p course p of p action p by p referring p the p patient p to p the p notary p public.DIF: p Cognitive p Level: p Application p REF: p dm p 36 p OBJ: p

Theory p #1 p TOP: p Witnessing p Wills p and p Other p Legal p

Documents KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Safe p Effective p Care p Environment: p safety p and p infection p control

• Criteria p that p justify p becoming p an p emancipated p minor p and p able p to p sign p a p

medical p consent p include p all p of p the p following p except:

• independence p established p through p a p court p order.

• service p in p the p armed p forces.

• a p 14-year-old p whose p parents p are p dead.

• a p 17-year-old p pregnant p

female. p ANSWER: p C

Criteria p are p that p the p minor p be p independent p by p court p order, p be p a p member p of p the p military, p be p pregnant, p or p be p married.DIF: p Cognitive p Level: p Application p REF: p dm p 36 p OBJ: p Clinical p Practice p #33 p TOP: p Emancipated p Minor p KEY: p Nursing p Process p

Step: p N/A

MSC: p NCLEX: p N/A

• A p written p statement p expressing p the p wishes p of p a p patient p regarding p future p consent p

for p or p refusal p of p treatment p in p case p the p patient p is p incapable p of p participating p in p decision

p making p is p an p example p of:

• a p privileged p relationship.

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• a p health p care p agent.

• an p advance p directive.

• witnessed p will.

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ANSWER: p C

An p advance p directive p makes p the p patients p wishes p known p regarding p medical p decisions p and p consent p in p the p event p that p he p or p she p is p unable p to p participate p in p decision p making.DIF: p Cognitive p Level: p Knowledge p REF: p dm p 36 p OBJ: p Clinical p Practice p #5 p TOP: p Legal p Terms p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• A p nurse p is p caring p for p an p unmarried p 16-year-old p patient p who p has p just p given p birth p

to p a p baby p boy. p The p nurse p will p get p the p consent p to p perform p a p circumcision p on p the p

patients p son p from p the:

• patients p father.

• patients p physician.

• patients p mother.

• 16-year-old p patient.

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ANSWER: p D

Pregnancy p qualifies p as p the p basis p for p the p 16-year-old p to p be p treated p as p an p emancipated p minor. p DIF: p Cognitive p Level: p Application p REF: p dm p 36 p OBJ: p Clinical p Practice p #3 TOP: p Patients p Rights p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p N/A

• A p 48-year-old p man p refuses p to p take p a p medication p ordered p for p the p control p of p his p

blood p pressure. p The p nurses p most p effective p response p would p be:

• Your p doctor p expects p you p to p be p compliant.

• You p have p the p right p to p refuse. p This p medication p keeps p your p blood p pressure p under p control.

• Fine. p I p will p document p that p you p are p refusing p this p drug.

• Are p you p aware p that p you p could p have p a p

stroke? p ANSWER: p B

Patients p have p the p right p to p refuse p medication, p but p it p is p the p nurses p responsibility p to p explain p the p reason p for p the p particular p drug.DIF: p Cognitive p Level: p Application p REF: p dm p 37 p OBJ: p Theory p #1 p TOP: p Legal p Standards p KEY: p Nursing p Process p

Step: p Implementation

MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• The p Occupational p Safety p and p Health p Act p includes p all p of p the p following p except:
• regulations p for p handling p infectious p materials.

• radiation p and p electrical p equipment p safeguards.

• staffing p ratios p and p delegation p criteria.

• regulations p for p handling p toxic p

materials. p ANSWER: p C

The p Occupational p Safety p and p Health p Act p was p passed p in p 1970 p to p improve p the p work p environment p in p areas p that p affect p workers p health p or p safety. p It p includes p regulations p for p handling p infectious p or p toxic p materials, p radiation p safeguards, p and p the p use p of p electrical p equipment.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 31 p OBJ: p N/A p TOP: p OSHA p KEY: p Nursing p Process p Step: p N/A p MSC: p

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NCLEX: p N/A

• The p most p frequently p cited p cause p of p a p sentinel p event p by p the p Joint p Commission p is p a p problem p in:
• applying p physical p restraints.

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• methods p of p patient p transportation.

• medication p errors.

• inadequate p

communication. p ANSWER: p D

The p most p frequently p cited p cause p of p a p sentinel p event p by p the p Joint p Commission p is p communication. p During p handoff p communication, p there p is p a p risk p that p critical p patient p care p information p might p be p lost p due p to p lack p of p communication.DIF: p Cognitive p Level: p Knowledge p REF: p dm p 33 p OBJ: p Clinical p Practice p #2 p TOP: p Communication p KEY: p Nursing p Process p Step: p N/A MSC: p NCLEX: p N/A

• The p acronym p SBAR p is p a p method p to p communicate p with p a p physician p that p

clarifies p a p situation p that p may p result p in p litigation. p The p acronym p stands p for:

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• situation, p background, p alterations, p results.

• subjective, p believable, p actual, p recommendation.

• situation, p background, p assessment, p recommendation.

• situation, p basis, p assessment, p

recommendation. p ANSWER: p C

SBAR p is p an p acronym p that p stands p for p situation, p background, p assessment, p and p recommendation. p This p undetailed p analysis p clarifies p the p situation p in p a p manner p that p is p concise p yet p complete.DIF: p Cognitive p Level: p Knowledge p REF: p dm p 33 p OBJ: p Theory p #5 p TOP: p SBAR p Reporting p KEY: p Nursing p Process p

Step: p N/A

MSC: p NCLEX: p N/A

• The p patient p who p cannot p legally p sign p his p or p her p own p surgical p consent p is p a(n):
• 17-year-old p who p is p serving p in p the p armed p forces.

• 16-year-old p who p is p legally p married.

• 17-year-old p emancipated p minor.

• 18-year-old p who p received p a p narcotic p 30 p

minutes p ago. p ANSWER: p D

The p person p giving p the p consent p must p be p able p to p take p part p in p the p decision p making. p A p sedated p person p does p not p have p this p ability.DIF: p Cognitive p Level: p Application p REF: p dm p 36 p OBJ: p Clinical p Practice p #3 p TOP: p Patients p Rights p KEY: p Nursing p Process p Step: p N/A MSC: p NCLEX: p N/A

• The p nurse p who p may p be p liable p for p invasion p of p privacy p would p be p the p nurse p who p is:
• refusing p to p give p patient p information p to p a p relative p over p the p phone.

• firmly p closing p the p door p prior p to p bathing p the p patient.

• discussing p her p patients p with p a p fellow p nurse.

• reporting p the p patient p as p a p possible p victim p of p

elder p abuse. p ANSWER: p C

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Discussing p a p patient p with p anyone, p even p another p health p professional, p who p is p not p involved p in p the p patients p care p can p put p a p nurse p at p risk p for p invasion p of p privacy.

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DIF: p Cognitive p Level: p Application p REF: p dm p 38 p OBJ: p Clinical p Practice p #3 p TOP: p Patients p Rights p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p N/A

34. A p characteristic p of p an p advance p directive p is p that:

• advance p directives p do p not p expire.

• only p some p states p recognize p advance p directives.

• advance p directives p can p be p non-verbal.

• advance p directives p from p one p state p are p recognized p by p

another. p ANSWER: p A

An p advance p directive p is p a p written p statement p expressing p the p wishes p of p the p patient p regarding p future p consent p for p or p refusal p of p treatment p if p the p patient p is p incapable p of p participating p in p decision p making,

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and p they p do p not p expire. p All p states p recognize p advance p directives, p but p each p state p regulates p advance p directives p differently, p and p an p advance p directive p from p one p state p may p not p be p recognized p in p another. p DIF: p Cognitive p Level: p Comprehension p REF: p dm p

36 p OBJ: p Clinical p Practice p #5

TOP: p Advance p Directives p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• A p patient p who p is p refusing p to p take p his p medication p is p threatened p that p he p will p be p

held p down p and p forced p to p take p the p dose. p This p is p an p example p of:

• battery.

• defamation.

• assault.

• invasion p of p

privacy. p ANSWER: p C

Assault p is p the p threat p to p harm p another p or p even p to p touch p another p without p that p persons p permission. p The p person p being p threatened p must p believe p that p the p nurse p has p the p ability p to p carry p out p the p threat. p DIF: p Cognitive p Level: p Comprehension p REF: p

dm p 37 p OBJ: p Theory p #3

TOP: p Legal p Terms p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p nurse p explains p that p a p sentinel p event p is p a p situation p in p which p a p patient:
• refuses p care.

• is p accidentally p exposed.

• leaves p the p hospital p against p medical p advice.

• comes p to p

harm.

ANSWER: p D

A p sentinel p event p is p an p unexpected p situation p in p which p the p patient p comes p to p harm. p DIF: p Cognitive p Level: p Comprehension p REF: p dm p 33 p

OBJ: p Theory p #5

TOP: p Legal p Terms p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

COMPLETION

• In p 2003, p the p Patients p Bill p of p Rights p was p revised p to p become p the :

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p Understanding p Expectations, p Rights, p and p Responsibilities.

ANSWER:

Patient p Care p Partnership

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The p Patient p Care p Partnership p addresses p patient p rights p and p the p responsibility p of p health p care p facilities.DIF: p Cognitive p Level: p Knowledge p REF: p dm p 32 p OBJ: p Clinical p Practice p #3 p TOP: p Patients p Rights p KEY: p Nursing p Process p Step: p N/A MSC: p NCLEX: p N/A

• CAPTA, p passed p in p 1973, p is p a p law p regarding p the p safety p of p minors. p It p is p the and

p .

p ANSWER:

Child p Abuse p Prevention; p Treatment p Act This p is p a p law p that p requires p mandated p reporting p and p defines p who p is p a p mandated p reporter. p DIF: p Cognitive p Level: p Knowledge p REF: p dm p 32 p OBJ: p Theory p #1 TOP: p Professional p Accountability p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

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MULTIPLE p RESPONSE

39. Professional p accountability p includes: p (Select p all p that p apply.)

• understanding p theory.

• adhering p to p the p dress p code p of p the p facility.

• asking p for p assistance p when p unsure p of p a p procedure p or p physician p order.

• participating p in p continuing p education p classes.

• meeting p the p health p care p needs p of p the p patient.

• reporting p patient p health p status p changes p to p all p family p

members. p ANSWER: p A, p C, p D, p E

Professional p accountability p is p a p nurses p responsibility p to p meet p the p health p care p needs p of p the p patient p in p a p safe p and p caring p application p of p nursing p skills p and p understanding p of p human p needs.DIF: p Cognitive p Level: p Analysis p REF: p dm p 39 p OBJ: p Theory p #3 TOP: p Professional p Accountability p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• A p nurse p arrives p at p the p scene p of p a p motor p vehicle p accident. p A p person p in p the p

vehicle p mumbles p incoherently p when p asked p his p name. p Which p actions p are p not p covered p by p the p Good p Samaritan p Act? p (Select p all p that p apply.)

• Using p two p magazines p and p a p bandana p to p splint p a p broken p arm

• Applying p a p tourniquet p to p a p lacerated p leg p while p awaiting p emergency p personnel

• Pulling p the p individual p from p the p surface p of p the p highway

• Initiating p an p emergency p tracheotomy p when p the p individual p goes p into p respiratory p arrest

• Compressing p a p bleeding p wound p with p a p soiled

p shirt p ANSWER: p D

The p Good p Samaritan p Act p covers p care p given p in p an p emergency, p but p only p within the p scope p of p ones p practice, p and p care p that p does p not p cause p harm p resulting p from p negligence. p DIF: p Cognitive p Level: p Comprehension p REF: p dm p 32 p OBJ: p Theory p #5 TOP: p Legal p Scope p of p Practice p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p Safe p Effective p Care p

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Environment

• The p Ethics p Committee p of p a p facility p has p the p responsibility p to: p (Select p all p that p apply.)

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• develop p policies.

• address p issues p in p their p facility.

• modify p the p established p codes p of p ethics p as p suits p the p situation.

• create p a p master p plan p for p decision p making p to p be p followed p in p ethical p dilemmas.

• help p to p find p a p better p understanding p of p ethical p dilemmas p from p different p

standpoints. p ANSWER: p A, p B, p E

An p Ethics p Committee p of p an p institution p has p representatives p from p various p fields p to p formulate, p address, p and p help p clarify p ethical p problems p that p present p themselves p in p their p facility.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 42 p OBJ: p Theory p #6 p TOP: p Ethics p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

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• The p commonalities p of p The p Codes p of p Ethics p of p the p National p Association p for p

Practical p Education p and p Service p (NAPNES) p and p The p National p Federation p of p Licensed p Practical p Nurses p (NFLPN) p include: p (Select p all p that p apply.)

• commitment p to p continuing p education.

• respect p for p human p dignity.

• maintenance p of p competence.

• requirement p for p membership p in p a p national p organization.

• preserving p the p confidentiality p of p the p nursepatient p

relationship. p ANSWER: p A, p B, p C, p E

Both p Codes p of p Ethics p support p maintenance p of p competency, p preservation p of p confidentiality p of p the p nursepatient p relationship, p commitment p to p continuing p education, p and p respect p for p human p dignity.

Chapter p 4 p Health p and p Illness MULTIPLE p CHOICE

• The p rehabilitation p nurse p describes p a p patient p who p is p blind, p works p full p time p as p a p

Spanish p interpreter, p and p lives p with p his p wife p in p a p downtown p apartment. p The p nurse p

classifies p this p person p as:

• impaired.

• disabled.

• handicapped.

• dependent.

p ANSWER: p A

The p blindness p is p an p impairment p of p vision p that p does p not p inhibit p the p patient p from p performing p his p job p or p enjoying p a p normal p life.DIF: p Cognitive p Level: p Application p REF: p 177 p OBJ: p 1 p (theory) TOP: p Concepts p of p Rehabilitation p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p Physiological p Adaptation

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• A p resident p with p advanced p Parkinsons p disease p stays p in p his p wheelchair p all p day p

because p it p is p too p tiring p to p walk p and p he p is p fearful p of p falling. p In p order p to p increase p

mobility, p the p best p intervention p would p be p to:

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• instruct p the p resident p in p crutch p walking.

• assist p the p resident p to p walk p in p the p hallway p with p a p gait p belt.

• encourage p the p resident p to p rock p back p and p forth p in p his p wheelchair p to p off p load p weight.

• arrange p for p a p walking p

cane. p ANSWER: p B

Walking p is p the p best p exercise p to p prevent p problems p associated p with p immobility. p The p gait p belt p will p make p the p resident p more p secure. p Canes p and p crutches p do p not p diminish p the p weakness p or p the p fear p of p falling.DIF: p Cognitive p Level: p Application p REF: p 184 p | p Box p 9-5 p OBJ: p 2 p (theory) p TOP: p Preventing p Problems p of p Immobility KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Health p Promotion p and p Maintenance

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• The p obese p resident p who p lies p on p her p back p because p it p is p difficult p to p turn p due p to p

her p weight p has p a p pressure p ulcer p on p her p coccyx p that p is p covered p with p a p dressing. p

The p most p effective p intervention p to p encourage p independence p is:

• have p staff p turn p the p resident p every p 2 p hours.

• turn p the p patient p on p her p side p and p use p pillows p to p stabilize p her.

• arrange p for p short p side p rails p to p be p used p for p positioning.

• arrange p for p a p trapeze p so p the p patient p can p assist p with p

positioning. p ANSWER: p D

The p trapeze p allows p for p self-positioning p and p is p less p confining p than p are p bed p rails. p The p other p options p do p not p foster p independence.DIF: p Cognitive p Level: p Application p REF: p 186-187 p OBJ: p 2 p

(theory) p TOP: p Preventing p Problems p of p Immobility

KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Health p Promotion p and p Maintenance

• When p the p nurse p assesses p reddened p heels p on p the p bed-bound p stroke p patient, p the p

nurse p modifies p the p care p plan p to p include p which p intervention?

• Massage p heels p briskly.

• Apply p socks p to p feet.

• Swab p heels p with p alcohol.

• Elevate p feet p on p

pillows. p ANSWER: p D

Elevation p of p the p feet p gets p the p weight p off p the p heels p and p will p allow p them p to p heal. p All p other p options p are p not p helpful p to p damaged p skin. p Brisk p massage p may p promote p damage p to p the p skin. p Alcohol p can p be p irritating p and p may p further p damage p heel p skin.DIF: p Cognitive p Level: p Application p REF: p 180 p | p Nursing p Care p Plan p 9-1 p OBJ: p 2 p (theory) p TOP: p Preventing p Problems p of p Immobility KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Health p Promotion p and p Maintenance

• The p nurse p cautions p the p 70-year-old p patient p who p just p had p the p cast p removed p from p

a p broken p arm p that p the p immobility p during p the p time p he p was p in p a p cast p can p cause:

• arthritis.

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• phlebitis.

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• frozen p shoulder.

• painful p

swelling. p ANSWER: p C

Immobility p can p cause p loss p of p strength p and p flexibility p in p the p older p adult. p DIF: p Cognitive p Level: p Knowledge p REF: p 178 p | p 180 p | p Table p 9-1 OBJ: p 3 p (theory) p TOP: p Effects p of p Immobility: p Joint p Stiffness p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Health p Promotion p and p Maintenance

• The p nurse p assessing p an p 85-year-old p patient p who p has p been p on p bed p rest p for p a p

fractured p hip p finds p the p patient p flushed p with p a p temperature p of p 100 p F, p pulse p of p 100, p and p respiration p rate p of p 24. p The p next p intervention p should p be p to p assess:

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• BP.

• breath p sounds.

• abdominal p distention.

• amount p of p urinary p

output. p ANSWER: p B

The p initial p assessments p are p the p cardinal p signs p of p pneumonia. p The p breath p sounds p should p be p assessed p next p to p determine p the p presence p of p any p adventitious p breath p sounds. p BP p will p also p need p to p be p assessed, p but p the p breath p sounds p are p more p important p with p the p signs p and p symptoms p present.Abdominal p distention p is p indicative p of p a p gastrointestinal p problem. p Amount p of p urinary p output p is p important p to p an p ongoing p assessment p but p not p a p priority p in p the p present p circumstances.DIF: p Cognitive p Level: p Analysis p REF: p 179 p | p Table p 9-1 OBJ: p 3 p (theory) p TOP: p Effects p of p Immobility: p Hypostatic p Pneumonia KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Health p Promotion p and p Maintenance

• The p 76-year-old p stroke p patient p in p a p long-term p care p facility p has p sent p his p food p

tray p back p to p the p kitchen p untouched p for p the p second p time p today. p The p most p effective

p intervention p to p increase p nutrition p would p be p to:

• take p the p tray p back p and p offer p to p feed p the p patient.

• request p the p dietitian p to p talk p with p the p patient p about p food p preferences.

• take p a p high-protein p drink p to p the p patient.

• sit p with p the p patient p during p

meals. p ANSWER: p C

Taking p the p high-energy p drink p meets p the p immediate p challenge p of p inadequate p nutritional p intake. p Referral p to p the p dietitian p and p sitting p with p the p patient p may p be p helpful. p Offering p to p feed p from p a p rejected p tray p is p not p supportive.DIF: p Cognitive p Level: p Analysis p REF: p 190-191 p OBJ: p 2 p (theory) TOP: p Effects p of p Immobility: p Anorexia p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Health p Promotion p and p Maintenance

• When p the p nurse p is p assessing p a p bed-bound p resident, p a p reddened p area p over p the p

coccyx p that p does p not p blanch p is p discovered. p The p best p intervention p to p prevent p further p

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skin p damage p is p to:

• cover p with p a p transparent p film p dressing.

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• apply p warm p compress.

• turn p the p patient p every p 2 p hours.

• continue p to p monitor p the p

area. p ANSWER: p A

Since p this p appears p to p be p a p stage p 1 p pressure p area, p the p transparent p film p ensures p the p proper p amount p of p moisture p is p present p for p healing p while p allowing p monitoring p of p the p area. p A p warm p compress p is p not p warranted. p This p patient p will p need p to p be p turned p every p hour. p Monitoring p of p the p area p should p continue p but p does p not p meet p the p immediate p need.DIF: p Cognitive p Level: p Analysis p REF: p 180 p | p Nursing p Care p Plan p 9-1 p OBJ: p 3 p (theory) p TOP: p Effects p of p Immobility: p Impaired p Circulation KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Health p Promotion p and p Maintenance

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• The p LPN/LVN p making p care p assignments p to p nursing p assistants p would p not p assign p a p

patient p who p has:

• manipulative p behavior.

• an p unstable p condition.

• a p draining p wound.

• a p communicable p

disease. p ANSWER: p B

Nursing p assistants p are p not p assigned p to p patients p who p have p an p unstable p condition.p Care p of p an p unstable p patient p does p not p fall p into p the p scope p of p practice p of p the p unlicensed p personnel.DIF: p Cognitive p Level: p Comprehension p REF: p 183 p | p Assignment p Considerations p OBJ: p 5 p (theory) p TOP: p Assigning p Personnel KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Safe, p Effective p Care p Environment: p Coordinated p Care

10. The p chief p goal p of p a p long-term p care p facility p is p to:

• offer p restorative p services.

• promote p individual p independence.

• facilitate p achievement p of p complete p autonomy.

• manage p medication p

protocols. p ANSWER: p B

Promotion p of p independence p is p the p chief p goal, p not p complete p autonomy. p Other p options p are p services p directed p at p achieving p increased p independence.DIF: p Cognitive p Level: p Comprehension p REF: p 183 p OBJ: p 4 p (theory) TOP: p Goal p of p Long-Term p Care p Facilities p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Health p Promotion p and p Maintenance

• The p nurse p reminds p the p nursing p assistant p that p the p purpose p of p locking p the p

wheels p of p a p wheelchair p is p to:

• supply p a p stable p support p for p a p patient p to p lift p self.

• keep p patient p in p a p position p at p a p table p or p bedside.

• prevent p falls.

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• keep p the p patient p from p moving p

self. p ANSWER: p C

Fall p prevention p is p the p purpose p of p locking p the p wheels p of p a p wheelchair. p DIF: p Cognitive p Level: p Comprehension p REF: p 184 p | p Box p 9-5 OBJ: p 2 p (clinical) p TOP: p Fall p Prevention p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Safe, p Effective p Care p Environment: p Safety p and p Infection p Control

• To p decrease p the p incidence p of p falls, p the p nurse p will p arrange p for p the p replacement p of:
• canes p with p 4 p feet p with p a p single-footed p cane.

• hard-soled p shoes p with p soft-soled p bedroom p slippers.

• area p rugs p with p a p nonslip p pad.

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• plain p carpet p with p a p highly p patterned p

carpet. p ANSWER: p C

Loose p area p rugs p should p be p replaced p with p nonslip p carpets. p DIF: p Cognitive p Level: p Knowledge p REF: p 184 p | p Box p 9-5 p OBJ: p 2 p (clinical) p TOP: p Fall p Prevention KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Safe, p Effective p Care p Environment: p Safety p and p Infection p Control

• The p nurse p instructing p a p family p in p the p selection p of p a p chair p for p an p older p adult p

with p Parkinsons p disease p would p stress p selecting p a p chair p that:

• is p very p wide p to p allow p for p position p changes.

• has p sturdy p arms p to p aid p in p rising.

• is p low p to p prevent p falls.

• is p soft p and p deep p for p added p

comfort. p ANSWER: p B

Sturdy p arms p assist p in p rising p and p sitting. p Soft, p low, p and p wide p chairs p cause p a p person p to p lean p forward p to p rise p and p to p fall p into p the p chair p to p be p seated.DIF: p Cognitive p Level: p Comprehension p REF: p 184 p | p Box p 9-5 p OBJ: p 2 p (clinical) p TOP: p Fall p Prevention KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Safe, p Effective p Care p Environment: p Safety p and p Infection p Control

• The p charge p nurse p instructs p the p nursing p assistants p to p answer p the p call p lights p

promptly, p especially p for p patients p who p are p receiving:

• diuretics p for p fluid p reduction.

• antibiotics p for p infection.

• proton p pump p medications p for p gastric p reflux.

• NSAIDs p for p

arthritis. p ANSWER: p A

People p taking p diuretics p need p to p go p to p the p bathroom p frequently, p and p oftentimes p urgently. p Prompt p attention p to p call p lights p will p reduce p the p probability p of p the p patient p

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getting p up p unassisted. p Diuretics p may p also p cause p orthostatic p hypotension, p which p increases p the p risk p for p falling.

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DIF: p Cognitive p Level: p Comprehension p REF: p 184 p | p Box p 9-5 p OBJ: p 2 p (clinical) p TOP: p Fall p Prevention KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Safe, p Effective p Care p Environment: p Safety p and p Infection p Control

• The p nurse p is p caring p for p a p resident p who p has p a p security p device p for p safety p

purposes. p What p intervention p must p the p nurse p include p in p the p plan p of p care?

• Visually p check p the p resident p every p hour.

• Turn p and p reposition p the p resident p every p hour.

• Assess p condition p of p the p skin p every p 4 p hours.

• Reassess p the p need p for p the p security p device p every p 4 p to

p 8 p hours. p ANSWER: p D

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The p need p for p continuing p the p use p of p the p security p device p must p be p assessed p every p 4 p to p 8 p hours. p The p patient p should p be p visually p checked p every p 30 p minutes, p and p turned p and p skin p assessed p every p 2 p hours. p DIF: p Cognitive p Level: p Application p REF: p 184 p | p Box p 9-5 OBJ: p 2 p (clinical) p TOP: p Use p of p Security p Devices p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Safe, p Effective p Care p Environment: p Safety p and p Infection p Control

• When p the p confused p resident p pours p his p cereal p in p a p cup p and p drinks p it, p the p nurse p should:
• put p his p cereal p back p in p the p bowl p and p hand p the p resident p a p spoon.

• discard p the p cup p with p his p cereal p and p bring p fresh p cereal p in p a p bowl.

• calmly p instruct p the p resident p that p cereal p is p to p be p eaten p from p a p bowl.

• not p interrupt p the p

behavior. p ANSWER: p D

The p nurse p should p leave p the p resident p alone p to p feed p himself p independently. p Staff p should p refrain p from p doing p what p the p resident p can p do p for p himself.DIF: p Cognitive p Level: p Application p REF: p 186 p OBJ: p 4 p (theory) p TOP: p Long-Term p Care p Facility p Goals: p Autonomy KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity

• The p nurse p planning p a p group p TV p activity p in p a p long-term p care p facility p would p

choose p a p channel p that p offers p a(n):

• cartoon.

• travel p documentary.

• dramatic p two-part p mini-series.

• opera p

performance. p ANSWER: p B

Travel p documentaries p are p colorful p and p do p not p have p a p plot p to p follow. p Cartoons p are p juvenile, p opera p does p not p have p universal p appeal, p and p the p two-part p drama p would p

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require p long p attention p spans p and p good p short-term p memory.DIF: p Cognitive p Level: p Application p REF: p 187 p OBJ: p 4 p (theory) p TOP: p Long-Term p Care p Facility p Goals: p Autonomy

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KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Psychosocial p Integrity

• To p motivate p a p frustrated p stroke p patient p who p is p learning p to p walk p again, p the p

most p effective p motivational p intervention p the p rehabilitation p nurse p could p make p is p to:

• show p short p movies p on p ambulation p techniques.

• observe p the p patient p while p in p physical p therapy.

• arrange p a p visit p with p another p stroke p victim p who p has p learned p to p ambulate.

• encourage p a p 1-week p break p from p therapy, p which p will p help p the p resident p come p

back p refreshed. p ANSWER: p C

Talking p with p someone p who p can p truly p understand p the p frustration p is p helpful. p Showing p a p short p movie p on p ambulation p techniques p may p be p an p effective p teaching p tool, p but p it p is p not p a p motivational p tool.Observing p the p resident p is p necessary p but p does p not p provide p motivation. p A p 1- week p break p will p interrupt p progress p that p has p been p made, p thus p decreasing p motivation.

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DIF: p Cognitive p Level: p Application p REF: p 188 p | p Elder p Care p Points p OBJ: p 4 p (theory) p TOP: p Goals p for p

Rehabilitation: p Motivation

KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Psychosocial p Integrity

• The p nurse p caring p for p the p resident p who p is p disoriented p can p provide p the p best p

care p with p which p intervention?

• Ensuring p activities p are p scheduled p for p the p same p time p each p day

• Changing p care p assignments p for p assistive p personnel p frequently p to p prevent p burnout

• Encouraging p autonomy p by p allowing p the p resident p to p choose p clothes p from p the p closet

• Administering p sedatives p to p calm p the p

patient p ANSWER: p A

Keeping p a p routine p leads p to p less p confusion. p Changing p assistive p personnel p care p assignments p frequently p is p confusing p for p the p resident. p Choosing p clothing p from p an p entire p closet p is p overwhelming p for p the p confused p resident; p rather, p giving p the p resident p a p few p items p to p choose p from p encourages p autonomy p without p increasing p confusion. p Sedatives p should p not p be p given p to p treat p confusion.DIF: p Cognitive p Level: p Application p REF: p 185-186 p OBJ: p 4 p

(theory) p TOP: p Managing p Confusion p and p Disorientation

KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity p MULTIPLE p

RESPONSE

• Treatment p resources p that p focus p on p restorative p care p for p people p with p chronic p

illness p and p disabilities p are: p (Select p all p that p apply.)

• outpatient p clinics.

• long-term p health p care p facilities.

• home p care.

• rehabilitation p agencies.

• hospice p

agencies. p ANSWER: p A, p B, p

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C, p D Outpatient p clinics, p long-term p care p facilities, p home p care, p and p rehabilitation p agencies p are p sources p of p rehabilitation p for p people p with p chronic p illness p or p disability. p Hospice p agencies p focus p on p care p of p the p dying p patient.

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DIF: p Cognitive p Level: p Knowledge p REF: p 179 p OBJ: p 1 p (theory) TOP: p Locus p of p Treatment p for p Chronic p Illness p KEY: p Nursing p Process p Step: p NA p MSC: p NCLEX: p Health p Promotion p and p Maintenance

• The p nurse p reinforces p that p the p multifocused p goal p of p rehabilitation p is p to: p (Select p all p that p apply.)
• promote p new p coping p skills.

• teach p adaptive p living p skills.

• focus p on p self-care p for p increased p independence.

• improve p quality p of p life.

• restore p former p level p of p

function. p ANSWER: p A, p B, p C, p D

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Restoring p former p level p of p function p is p not p a p goal p of p rehabilitation p because p this p may p an p impossible p goal. p New p coping p and p adaptive p skills, p and p self-care p skills p that p improve p the p quality p of p life p are p all p goals p of p rehabilitation.DIF: p Cognitive p Level: p Application p REF: p 187 p OBJ: p 7 p (theory) TOP: p Goals p of p Rehabilitation p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p Physiological p Adaptation

• The p patient p who p has p been p in p traction p for p bilateral p femur p fractures p complains p of p

constipation. p To p stimulate p bowel p action, p the p nurse p will: p (Select p all p that p apply.)

• provide p prune p juice p from p the p snack p cart.

• increase p fluid p intake.

• arrange p for p high-fiber p foods p such p as p cauliflower p and p broccoli.

• give p prescribed p stool p softeners.

• encourage p milk p

products. p ANSWER: p A, p B, p C, p D

Milk p products p are p constipating. p Prune p juice, p extra p fluid, p high-fiber p foods, p and p stool p softeners p will p combat p constipation.DIF: p Cognitive p Level: p Application p REF: p 180-181 p OBJ: p 2 p

(theory) p TOP: p Preventing p Problems p of p Immobility

KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Health p Promotion p and p Maintenance

• The p rehabilitation p nurse p outlines p the p impact p of p disability, p which p includes: p

(Select p all p that p apply.)

• unchanged p family p roles.

• life p patterns p centered p around p treatment p or p rehabilitation.

• grief p over p what p has p been p lost.

• spiritual p distress.

• sense p of p

powerlessness. p ANSWER: p B, p C, p

D, p E Family p roles p often p change p as p a p result p of p a p disability. p Life p patterns p will p center p

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around p treatment p and p rehabilitation p for p at p least p the p initial p phase p of p incurring p the p disability, p as p well p as p grief, p spiritual p distress, p and p powerlessness.

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DIF: p Cognitive p Level: p Application p REF: p 177-178 p OBJ: p 4 p (theory) p TOP: p Impact p of p Disability p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity

• Long-term p health p care p facilities p are p the p center p of p treatment p for p people p who p are: p

(Select p all p that p apply.)

• recovering p after p the p most p acute p phase p of p their p illness p is p over.

• receiving p rehabilitation p after p a p joint p replacement.

• too p weak p from p primary p illness p to p care p for p themselves p presently.

• in p need p of p a p permanent p home p because p of p effects p of p a p chronic p condition.

• under p treatment p for p substance p abuse.

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ANSWER: p A, p B, p C, p D

Long-term p health p care p facilities p do p not p offer p active p treatment p to p substance p abusers.p Recovery p from p an p acute p illness, p joint p replacement p rehabilitation, p weakness p from p illness, p and p a p permanent p home p for p a p chronic p illness p are p common p reasons p individuals p seek p care p from p long-term p care p facilities.DIF: p Cognitive p Level: p Application p REF: p 179 p | p 183 p OBJ: p 4 p (theory) TOP: p Purpose p of p Long-Term p Health p Care p Facilities p KEY: p Nursing p Process p Step: p NA p MSC: p NCLEX: p Health p Promotion p and p Maintenance

• The p LPN/LVN p in p a p long-term p health p care p facility p may p perform p in p the p roles p of: p

(Select p all p that p apply.)

• charge p nurse.

• designer p of p nursing p care p plans.

• administrator p of p medications.

• administrator p of p wound p care.

• assignment p

delegator. p ANSWER: p A, p C, p D,

p E The p LPN/LVN p does p not p design p the p nursing p care p plan p but p may p contribute p to p the p care p plan. p This p is p the p responsibility p of p the p RN. p The p LPN/LVN p may p act p in p the p role p of p charge p nurse p while p under p the p supervision p of p an p RN. p Administration p of p medications p and p wound p care p and p delegation p of p care p are p commonly p the p LPN/LVNs p responsibility.DIF: p Cognitive p Level: p Comprehension p REF: p 189 p OBJ: p 5 p (theory) TOP: p LPN/LVN p Role p in p Long-Term p Health p Care p Facility p KEY: p Nursing p Process p Step: p NA p MSC: p NCLEX: p Health p Promotion p and p Maintenance

• When p delegating p care p to p a p nursing p assistant, p the p LPN/LVN p should: p (Select p all p that p apply.)
• give p specific p instruction p as p to p what p is p to p be p done.

• instruct p how p the p task p is p to p be p done.

• list p information p that p needs p to p be p reported.

• be p aware p that p the p nurse p is p responsible p for p outcome p of p delegated p care.

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• insist p that p the p nursing p assistant p accept p the p

responsibility. p ANSWER: p A, p B, p C, p D

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In p delegating p to p unlicensed p assistive p personnel, p the p LPN/LVN p should p first p inquire p if p the p nursing p assistant p is p willing p to p take p responsibility p for p the p care p assigned.DIF: p Cognitive p Level: p Comprehension p REF: p 183 p | p Assignment p Considerations p OBJ: p 5 p (theory) p TOP: p Delegation p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Safe, p Effective p Care p

Environment: p Coordinated p Care

• The p LPN/LVN p can p apply p a p physical p restraint p to p a p resident p in p a p long-term p care p

facility p when: p (Select p all p that p apply.)

• an p order p for p the p restraint p is p obtained p within p 12 p hours p of p application.

• all p other p measures p have p been p attempted p and p failed.

• documentation p is p made p on p all p failed p attempts.

• the p family p is p unable p to p stay p with p the p resident.

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• the p least p restrictive p device p is p

chosen. p ANSWER: p B, p C, p D, p E

The p order p for p the p restraint p must p be p obtained p within p 24 p to p 48 p hours p after p application p of p the p device. p The p LPN/LVN p who p applies p a p physical p restraint p must p have p satisfied p all p of p the p other p options.DIF: p Cognitive p Level: p Application p REF: p 184-185 p OBJ: p 2 p (clinical) p TOP: p Use p of p Restraints p KEY: p Nursing p Process p

Step: p Planning

MSC: p NCLEX: p Safe, p Effective p Care p Environment: p Safety p and p Infection p Control

• The p student p nurse p is p becoming p familiar p with p Healthy p People p 2020 p goals p

related p to p rehabilitation. p The p student p nurse p demonstrates p an p understanding p of p the p goals p when p identifying p which p of p the p following p as p goals? p (Select p all p that p apply.)

• Increase p the p proportion p of p adults p with p disabilities p who p participate p in p social p activities.

• Increase p the p proportion p of p adults p with p disabilities p who p report p satisfaction p with p life.
• Increase p the p proportion p of p people p with p disabilities p who p report p not p having p the p assistive p

devices p and p t p Reduce p the p proportion p of p adults p with p disabilities p who p report p feelings p such p as p sadness, p unhappiness,

• prevent p them p from p being p active.

Reduce p the p proportion p of p people p with p disabilities p who p report p environmental p barriers p to p participation

• work, p or p community p

activities. p ANSWER: p A, p B, p D, p E

One p of p the p goals p of p Healthy p People p 2020 p is p to p reduce p rather p than p increase p the p proportion p of people p with p disabilities p who p report p not p having p the p assistive p devices p and p technology p needed. p All p other p options p are p included p as p goals.DIF: p Cognitive p Level: p Comprehension p REF: p 187 p OBJ: p 7 p (theory) TOP: p Healthy p People p 2020 p Goals p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Health p Promotion p and p Maintenance

COMPLETION

• The p rehabilitation p nurse p makes p the p point p that p a p dysfunction p of p a p specific p body p part p is p termed

p .

p ANSWER:

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impairment An p impairment p is p a p dysfunction p of p an p organ p or p body p part.DIF: p Cognitive p Level: p Comprehension p REF: p 177 p OBJ: p 1 p (theory)

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TOP: p Concepts p of p Rehabilitation p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p Physiological p Adaptation

• The p nurse p working p in p a p long-term p care p facility p is p aware p that p in p order p to p comply p

with p Medicare p guidelines, p documentation p of p assessment p findings p which p measure p physical, p psychological, p and p psychosocial p functioning p are p necessary p using p the .

ANSWER:

Minimum p Data p Set p minimum p data p set p MDS The p Minimum p Data p Set p (MDS) p is p a p primary p screening p and p assessment p tool p that p is p standard p for p all p Medicare p and p Medicaid p residents p in p a p long-term p care p facility.

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Chapter p 5 p Homeostasis, p Adaptation, p and p Stress MULTIPLE p CHOICE

• An p 82-year-old p man p is p alert p and p oriented p and p in p good p physical p health p except p for p

some p arthritic p pain p that p slows p me p down, p but p I p just p keep p moving. p He p lives p alone p in p an p apartment p in p a p senior p citizen p complex p but p enjoys p the p company p of p other p residents p and p takes p part p in p the p social p activities p there. p His p lifestyle p is p an p example p

of:

• an p exception p to p the p expected p norm.

• the p disengagement p theory.

• the p activity p theory.

• the p biologic p

theory. p ANSWER: p C

The p activity p theory p states p that p persons p who p remain p active p and p interested p in p outside p activities p live p longer.DIF: p Cognitive p Level: p Analysis p REF: p dm p 165 p OBJ: p Theory p #3 p TOP: p Theories p of p Aging p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Psychosocial p

Integrity: p psychosocial p adaptation

• The p nurse p understands p that p the p best p explanation p of p why p a p particular p person p lives p

into p his p 90s p in p relatively p good p health p is p that p the p person:

• had p healthy p parents p who p passed p on p to p him p good p genes p and p no p hereditary p diseases.

• has p lived p a p healthful p lifestyle, p which p has p included p preventative p care, p good p nutrition, p

exercise, p and p a

• has p treated p illness p with p old-fashioned p home p remedies p while p avoiding p the p use p of p many p

prescription p d

• reads p a p lot p about p the p newest p advances p in p health p care p and p tries p these p approaches p as p

soon p as p they p are p p p ANSWER: p B

Lifestyle p and p personality p together p probably p contribute p to p longevity p more p than p genetics, p new p medical p approaches, p or p old-fashioned p home p remedies, p although p those p may p contribute p in p important p ways. p A p healthy p lifestyle p decreases p the p risk p of p disease p and p its p sequelae.

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DIF: p Cognitive p Level: p Comprehension p REF: p dm p 165 p OBJ: p Theory p #3 p TOP: p Longevity p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• An p 85-year-old p widow p who p lives p alone p has p fallen p several p times p in p the p last p month p and p has p been

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noted p by p her p children p to p be p confused p about p her p medications p and p to p frequently p forget p what p is p cooking p on p the p stove p until p it p is p burned. p These p observations p

indicate p that:

• she p needs p to p be p hospitalized p to p determine p the p cause p of p her p confusion p and p falls.

• home p delivery p of p a p hot p meal p each p day p would p solve p her p cooking p risk.

• nursing p home p placement p would p be p the p best p solution p to p her p problems p of p aging.

• further p assessment p is p needed p to p evaluate p an p increased p level p of p

assistance. p ANSWER: p D

The p widow p is p showing p signs p of p needing p additional p assistance. p It p might p include p home- p delivered p meals p or p nursing p home-placement, p but p further p assessment p needs p to p be p performed. p Acute p care p hospitalization p is p not p indicated p in p this p situation.DIF: p Cognitive p Level: p Analysis p REF: p dm p 172 p OBJ: p Clinical p Practice p #5 p TOP: p Aging p Parents p KEY: p Nursing p Process p Step: p Planning

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MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p clarifies p that p the p immune p system p failure p theory p states p that:
• the p elderly p lose p their p ability p to p effectively p respond p to p infections p and p are p more p likely p to p

die p from p them

• the p body p no p longer p recognizes p itself p and p begins p to p attack p itself, p causing p illness.

• toxins p and p harmful p chemicals p (free p radicals) p in p the p environment p cause p damage p to p body p

cells.

• the p diminished p activity p of p the p elderly p make p them p susceptible p

to p illness. p ANSWER: p A

With p advancing p age, p the p immune p system p of p the p elderly p has p less p ability p to p fight p infections. p DIF: p Cognitive p Level: p Knowledge p REF: p dm p 165 p OBJ: p Theory p #1 TOP: p Theories p of p Aging p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p seeks p out p residents p with p whom p they p reminisce p in p an p interview p

regarding p the p residents p life p story. p The p value p of p this p activity p is p that:

• it p gives p the p staff p more p time p to p care p for p other p residents p and p perform p routine p care.

• it p can p affirm p the p positives p of p the p residents p life p and p lead p to p ego p integrity p for p the p

resident.

• nursing p home p residents p have p long p days p to p pass, p and p any p activity p helps p the p time p pass p

more p quickly.

• students p learn p about p the p good p old p days p and p better p appreciate p the p modern p conveniences p

available p tod p ANSWER: p B

Eriksons p psychosocial p task p for p older p adults p is p ego p integrity, p which p can p be p assisted p by p life p review p and p reminiscence.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 170 p OBJ: p Theory p #6 TOP: p Psychological p Aspects p of p Aging p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p psychosocial p adaptation

• The p home p health p aide p who p visits p an p older p adult p reports p to p the p nurse p that p the p

patient p has p many p new p bruises p on p her p arms p and p face. p The p patient p states p that p her p

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daughter p has p a p temper p and p got p mad p when p she p visited p the p day p before. p The p nurse p

should:

• call p the p daughter p for p clarification.

• notify p her p nursing p supervisor p to p report p the p incident p to p the p authorities.

• tell p the p aide p to p report p it p to p the p nursing p supervisor.

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• plan p to p visit p the p patient p when p the p daughter p will p be

p present. p ANSWER: p B

It p is p a p legal p requirement p for p licensed p health p care p personnel p to p report p suspected p elder p abuse p to p protect p the p public p (patient). p An p LPN p should p report p to p the p RN p supervisor p first. p The p aide p is p supervised p by p the p nurse p and p thus p the p nurse p is p responsible. p It p is p not p the p nurses p responsibility p to p determine p whether p the p daughter p is p abusing p the p patient p but p only p to p report p it p so p that p it p can p be p investigated p by p the p proper p agency.DIF: p Cognitive p Level: p Analysis p REF: p dm p 170 p OBJ: p Theory p #4 TOP: p Family p Relationships p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Safe p Effective p Care p Environment: p safety p and p infection p control

• A p 76-year-old p neighbor p confides p to p the p nurse p that p she p is p having p to p get p up p in p

the p middle p of p the p night p to p void p and p often p wets p herself p before p she p can p get p to p the p bathroom p during p the p day. p The p nurses p best p explanation p would p be:

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• As p you p get p older, p your p bladder p muscle p loses p tone p and p you p can p hold p less p urine.

• You p are p probably p drinking p too p much p during p the p day p and p especially p before p bedtime.

• You p probably p have p a p bladder p infection p that p should p be p treated p with p antibiotics.

• With p age, p the p urine p becomes p very p concentrated p and p causes p the p bladder p to p empty p

spontaneously. p ANSWER: p A

Physiologic p changes p of p aging p include p decreased p bladder p and p sphincter p tone, p resulting p in p stress p incontinence p and p more p frequent p voiding.DIF: p Cognitive p Level: p Application p REF: p dm p 166, p Table p 13-1 p OBJ: p Clinical p Practice p #1 p TOP: p Physical p Changes KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• A p nurse p making p a p home p visit p to p a p 75-year-old p woman p discovers p that p the p patient p

stays p in p bed p or p on p the p couch p most p of p the p time p because p she p is p afraid p of p falling. p

The p nurse p should p arrange p for p a:

• sitter p to p stay p with p the p woman p during p the p day.

• wheelchair p to p increase p mobility.

• physical p therapist p to p teach p resistance p training.

• special p cushion p for p the p chair p and p bed p to p reduce p the p risk p

of p decubiti. p ANSWER: p C

A p physical p therapist p can p teach p resistance p and p balance p training p to p help p prevent p falls. p DIF: p Cognitive p Level: p Analysis p REF: p dm p 167 p OBJ: p Theory p #4 TOP: p Physical p Health p Concerns p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p home p health p nurse p assesses p an p 80-year-old p who p has p fallen p twice p in p the p last p

10 p days. p The p nurse p discovers p that p the p patient p uses p a p cane p for p ambulation p stability, p drinks p up p to p 6 p cups p of p coffee p a p day, p has p altered p depth p perception p because p of p cataracts, p and p has p recently p carpeted p her p home p with p a p smooth p tight p weave p carpet. p The

p nurse p suspects p the p cause p of p her p recent p falls p to p be p the:

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• use p of p the p cane.

• new p carpet.

• large p intake p of p caffeine.

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• altered p depth p

perception. p ANSWER: p D

Altered p depth p perception, p changes p in p gait, p and p slow p reaction p times p may p cause p falls p in p the p elderly. p The p cane p helps p with p stability, p and p the p smooth p tight p weave p carpet p should p not p cause p falls.DIF: p Cognitive p Level: p Analysis p REF: p dm p 167 p OBJ: p Theory p #4 p TOP: p Fall p Prevention p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• A p 70-year-old p widower p continues p to p work p part p time p in p a p demanding p business, p

while p traveling p in p his p free p time p with p a p 68-year-old p widow p to p visit p longtime p friends p and p relatives. p He p remains p an p active p member p of p several p community p organizations. p

His p life p is p an p example p of p a p person p who:

• is p acting p like p a p younger p person p to p prove p to p himself p that p he p is p not p old.

• is p adjusting p well p to p the p changes p of p benign p senescence.

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• should p slow p down p and p enjoy p retirement p while p he p is p still p healthy.

• is p avoiding p the p psychosocial p tasks p of p aging p such p as p retirement p and p

slowing p down. p ANSWER: p B

Benign p senescence p is p the p normal p changes p of p aging, p and p many p healthy p people p at p 70 p years p of p age p do p not p fit p the p stereotype p of p old p but p are p more p like p older p adults p of p 45 p to p 70 p years.DIF: p Cognitive p Level: p Analysis p REF: p dm p 166, p Table p 13-1 p OBJ: p Theory p #3 p TOP: p Cognitive p Aspects p of p Aging KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Health p Promotion p and p Maintenance

• A p 78-year-old p man p is p admitted p to p the p hospital p after p a p fall p from p his p bed p at p home

p that p resulted p in p a p fractured p hip p and p several p fractured p ribs. p He p states, p I p dont p know p how p I p broke p so p many p bones. p I p only p fell p out p of p bed. p The p nurse p can p explain p that:

• loss p of p calcium p from p bone p occurs p in p older p adults p and p can p result p in p fractures p from p

minor p trauma.

• it p is p likely p that p an p underlying p disease p made p him p more p susceptible p to p fractures.

• the p bedside p table p near p the p bed p added p to p his p injuries.

• the p height p of p the p bed p will p need p to p be p lowered p when p he p goes p home p to p prevent p

further p injuries. p ANSWER: p A

A p physiologic p change p of p aging p is p loss p of p calcium p from p bone, p resulting p in p osteoporosis p and p greater p likelihood p of p fractures.DIF: p Cognitive p Level: p Application p REF: p dm p 166, p Table p 13-1 p OBJ: p Theory p #4 p TOP: p Physical p Changes p of p Aging KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• An p 84-year-old p patient p who p is p hospitalized p for p pneumonia p says p to p the p nurse, p I p

dont p know p why p Ive p lived p so p long. p All p my p friends p are p gone, p my p children p and p grandchildren p are p all p independent p and p successfulnobody p needs p me p anymore. p An p

appropriate p response p by p the p nurse p is:

• You p have p a p lot p to p live p for. p Your p children p and p grandchildren p really p love p you.

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• You p must p have p inherited p good p genes. p You p should p be p thankful p youre p still p alive.

• Tell p me p about p your p children p and p what p it p was p like p when p you p were p raising p them.

• The p pneumonia p has p made p you p feel p morbid. p Things p will p

look p up! p ANSWER: p C

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Encouraging p reminiscing p helps p the p older p adult p put p her p life p in p perspective p and p acquire p a p sense p of p ego.DIF: p Cognitive p Level: p Application p REF: p dm p 170 p OBJ: p Clinical p Practice p #4 TOP: p Psychosocial p Aspects p of p Aging p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• An p 80-year-old p man p has p no p chronic p diseases p and p is p alert, p oriented, p and p

physically p active. p Which p of p the p following p nursing p diagnoses p is p likely p to p be p present p as p a p result p of p the p normal p aging p process?

• Poisoning, p risk p for, p related p to p the p many p medications p an p older p person p must p take.

• Suffocation, p risk p for, p related p to p declining p respiratory p function.

• Hopelessness, p related p to p recognition p of p the p end p of p life p drawing p near.

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• Constipation, p related p to p slowed p

peristalsis. p ANSWER: p D

Constipation p is p a p common p nursing p diagnosis p for p older p adults p in p otherwise p good p health. p In p addition p to p peristalsis p slowing, p most p older p adults p experience p decreased p taste p and p smell p resulting p in p decreased p appetite p and p food p intake, p as p well p as p decreased p physical p mobility.DIF: p Cognitive p Level: p Analysis p REF: p dm p 166, p Table p 13-1 p OBJ: p Theory p #4 p TOP: p Physical p Changes KEY: p Nursing p Process p Step: p Diagnosis p MSC: p NCLEX: p Health p Promotion p and p Maintenance

• The p nurse p warns p that p infection p after p exposure p to p respiratory p illness p in p the p older p adult:
• is p more p likely p to p result p in p serious p lower p respiratory p infection p related p to p weakened p

respiratory p muscle

• is p likely p to p be p fatal p due p to p the p older p persons p low p resistance.

• results p in p rates p of p infection p similar p to p those p in p the p younger p adult.

• can p be p easily p prevented p with p the p use p of p antibiotics p when p the p adult p

is p exposed. p ANSWER: p A

Changes p in p the p older p adult p respiratory p system p make p older p adults p more p susceptible p to p infections p that p can p be p very p serious. p Although p some p infections p are p life p threatening, p most p are p not.DIF: p Cognitive p Level: p Comprehension p REF: p dm p 166, p Table p 13-1 p OBJ: p Theory p #4 p TOP: p Physical p Changes KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• When p the p nurse p is p conducting p a p class p for p senior p citizens p at p a p local p assisted p

living p facility, p to p enhance p physical p health, p he p encourages p the p older p residents p to p

engage p in p some p form p of p exercise p for p at p least:

• 1 p hour p every p other p day.

• 10 p minutes p at p a p time p several p times p a p day.

• 30 p minutes p a p day, p five p times p a p week.

• 1 p hour p every p

morning. p ANSWER: p C

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Exercise p for p as p little p as p 30 p minutes p a p day p 5 p days p a p week p is p beneficial.DIF: p Cognitive p Level: p Application p REF: p d. ... 169 p OBJ: p Clinical p Practice p #2

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TOP: p Physical p Health p Promotion p

Behaviors p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p points p out p that p there p are p many p myths p about p the p elderly p that p are

p not p true. p The p statement p that p reflects p the p most p accuracy p about p the p elderly p is:

• most p old p people p live p in p nursing p homes.

• genetics p is p the p main p factor p in p longevity.

• the p optimistic, p happy p person p generally p lives p longer.

• most p old p people p are p isolated p from p their p

families. p ANSWER: p C

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Myths p about p old p people p include: p most p old p people p live p in p nursing p homes, p genetics p is p the p main p factor p in p longevity, p and p most p old p people p are p isolated p from p their p families. p It p is p true p that p a p major p contributor p to p longer p life p is p that p the p optimistic, p happy p person p generally p lives p longer.DIF: p Cognitive p Level: p Comprehension p REF: p d. ... 171 p OBJ: p Theory p #3 TOP: p Theories p of p Aging p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p psychosocial p adaptation

• When p the p 75-year-old p patient p tells p the p nurse p that p he p has p had p a p good p and p

rewarding p life p and p has p enjoyed p every p minute p of p it, p the p nurse p is p aware p that p the p

patient p has p attained p the p Eriksonian p stage p of:

• generativity.

• autonomy.

• integrity.

• intimacy.

p ANSWER: p C

Erik p Eriksons p psychosocial p development p theory p includes p the p stage p of p ego p integrity p vs. p despair, p which p is p characterized p by p reflection p on p ones p life p and p ones p achievements. p A p sense p of p pride p or p despair p is p developed p regarding p the p accomplishments p in p life p that p have p been p made p or p were p lost. p DIF: p Cognitive p Level: p Comprehension p REF: p d. ........................................... 170 p OBJ: p Theory p #3 TOP: p Theorists p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Health p Promotion p and p Maintenance: p growth p and p development

• When p a p 68-year-old p recent p retiree p confides p in p the p health p clinic p nurse p that

p he p has p felt p depressed p and p withdrawn p since p retirement, p the p nurse p suggests p

that p he:

• talk p with p the p physician p about p anti-depression p medication.

• arrange p his p day p so p that p he p is p able p to p take p a p nap p in p the p afternoon.

• set p a p small p goal p for p himself p to p be p met p every p day.

• eat p three p regular p meals p as p he p did p when p he p was p

employed. p ANSWER: p C

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Setting p a p small p goal p to p be p met p allows p for p direction p in p the p day. p Many p recent p retirees p miss p the p regulation p of p employment.DIF: p Cognitive p Level: p Application p REF: p d. ... 169 p OBJ: p Theory p #3

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TOP: p Theorists p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Psychosocial p Integrity: p psychosocial p adaptation

COMPLETION

• An p 85-year-old p has p been p increasingly p confused p and p disoriented p to p place p and p time p

over p the p last p several p months. p He p also p has p difficulty p remembering p what p he p ate, p who p visited, p and p where p the p recreation p room p is. p This p behavior p is p indicative p of .

ANSWER:

dementia Confusion, p memory p loss, p and p disordered p thinking p are p early p signs p of p dementia. p Causes p of p dementia p include p malnutrition, p medications, p mini-strokes, p and p Alzheimers p disease.DIF: p Cognitive p Level: p Analysis p REF: p d. .... 169, p Table p 13-2 OBJ: p Clinical p Practice p #4 p TOP: p Physical p Health p Concerns p KEY: p Nursing p Process p Step: p Assessment

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MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• A p 67-year-old p submitted p a p job p application p at p a p local p gas p station. p The p station p

manager p said, p Arent p you p retired? p I p cant p hire p you. p Youre p too p old p to p be p working! p This p is p an p example p of p .

p ANSWER:

ageism Ageism p is p defined p as p any p discrimination p related p to p age, p including p job p discrimination. p DIF: p Cognitive p Level: p Analysis p REF: p d. 169 p OBJ: p Theory p #2 TOP: p Employment p and p Retirement p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p home p health p nurse p assesses p the p older p patients p in p her p case p load p for p signs p

of p abuse. p The p nurse p is p aware p that p the p primary p incidence p of p abuse p is .

ANSWER:

neglect In p patients p over p the p age p of p 80 p who p suffer p abuse, p the p primary p type p of p abuse p is p neglect. p DIF: p Cognitive p Level: p Knowledge p REF: p d. 170 p OBJ: p Theory p #4 TOP: p Elder p Abuse p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort p MULTIPLE p RESPONSE

• To p promote p cognitive p health p for p a p 79-year-old, p the p nursing p student p should p

encourage p the p patient p to p do p which p of p the p following? p (Select p all p that p apply.)

• Read p the p newspaper.

• Put p together p puzzles.

• Take p naps p when p tired.

• Write p letters.

• Toilet p

independently. p ANSWER: p A, p B,

p D

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Mental p stimulation p such p as p these p activities p maintains p active p and p healthy p neural p connections, p which p promotes p cognitive p health.DIF: p Cognitive p Level: p Application p REF: p d. ... 169 p OBJ: p Clinical p Practice p #3

TOP: p Cognitive p Health p Promotion p Behaviors

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KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• A p 76-year-old p recently p lost p her p spouse. p They p lived p in p a p large p house p with p a p

yard p that p they p managed p well p until p her p spouses p sudden p death. p She p is p in p good p health p and p stays p active p but p is p becoming p concerned p about p her p ability p to p maintain p the p large p house p by p herself. p The p nurses p most p helpful p suggestion p would p be p to: p (Select p all p that p apply.)

• recommend p living p with p her p daughter p who p lives p 2 p hours p away.

• encourage p her p to p investigate p apartment p rentals.

• encourage p her p to p check p herself p into p a p skilled p nursing p facility.

• hire p a p gardener p and p a p housekeeper p to p maintain p the p property.

• encourage p her p to p involve p family p in p any p decisions p related p to p her p living p arrangements.

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ANSWER: p B, p E

Many p older p adults p choose p to p rent p an p apartment p when p they p cannot p maintain p a p house p and p yard. p Including p family p members p in p important p decisions p keeps p communication p lines p open. p Family p members p can p offer p support p and p recommendations p to p their p parent(s), p easing p the p decision-making p process.DIF: p Cognitive p Level: p Analysis p REF: p pp. p 170-171 p OBJ: p Clinical p

Practice p #5 p TOP: p Psychosocial p Health p Promotion p Behaviors

KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Psychosocial p Integrity

• An p 82-year-old p patient p expresses p concern p of p always p being p cold. p Based p on p

knowledge p of p the p physical p changes p associated p with p aging, p the p nurse p could p

appropriately p respond: p (Select p all p that p apply.)

• Wrap p up p warmly, p because p the p cold p feeling p is p a p result p of p decreased p bone p calcium p that p

occurs p with p ag

• Chronic p constipation p can p lead p to p a p sense p of p cold p because p of p the p reduced p peristalsis.

• Subcutaneous p fat p is p reduced p as p part p of p aging. p This p fat p that p helps p to p keep p you p warm p

decreases.

• A p low p level p of p thyroid p hormone p causes p you p to p feel p cold.

• Eat p more p protein p foods p to p help p your p body p

generate p heat. p ANSWER: p C, p D

Decreased p subcutaneous p fat p and p slowed p thyroid p production p contribute p to p older p people p feeling p cold.DIF: p Cognitive p Level: p Application p REF: p d. p 166, p Table p 13-1 OBJ: p Theory p #4 p TOP: p Physical p Changes p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p Physiological p Integrity

• The p nurse p points p out p elements p in p our p culture p that p support p longevity p in p older p

people, p which p include: p (Select p all p that p apply.)

• reducing p stress p from p regular p exercise p on p the p body p in p younger p years.

• being p actively p involved p in p their p own p health p care.

• taking p of p antibiotics p through p their p lifetime.

• increasing p education p about p health p matters.

• avoiding p the p eating p of p red p

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meat. p ANSWER: p B, p D

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Active p participation p in p ones p own p health p care, p being p better p educated p about p illness, p and p illness p prevention p are p elements p in p attaining p a p longer p life p span.

Chapter p 6 p Culture p and p Ethnicity Test p Bank p MULTIPLE p

CHOICE

• A p nurses p neighbor p confides p that p she p has p been p treating p a p health p problem p through p

a p faith p healer p in p her p religion p but p is p worried p because p the p condition p seems p to p be p worsening. p She p asks p the p nurse p what p she p should p do. p The p nurses p best p response p

would p be:

Faith p healing, p although p frequently p effective, p makes p a p disease p more p difficult p or p even p impossible p to p tr

• medicine.

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Many p people p use p medical p treatment p along p with p faith p healing. p Is p there p anything p in p your p religion p that

• treatment?

• Faith p healing p may p take p longer p than p medical p treatment p to p work. p Are p you p doing p exactly p

as p your p healer

• You p should p see p a p physician p or p your p faith p healer, p but

p not p both. p ANSWER: p B

A p persons p health p care p choices p are p influenced p by p religious p beliefs p and p culture. p Many p people p use p religious p or p folk p medicine p in p addition p to p modern p medicine.DIF: p Cognitive p Level: p Application p REF: p d. p 183, p Table p 14-3 p OBJ: p Theory p #1 p TOP: p Religious p

Influence p in p Health p Care p KEY: p Nursing p Process p

Step: p Implementation

MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p most p culturally p sensitive p and p useful p question p the p admitting p nurse p should p ask

p the p Jewish p patient p would p be:

• Do p you p follow p any p dietary p restrictions p or p will p you p eat p hospital p food p as p it p is p prepared p

here?

• Are p there p any p medications p or p treatments p your p religion p does p not p allow p in p your p medical p

treatment?

• Would p you p like p me p to p notify p your p rabbi p so p that p he p can p make p visits p to p you p during p

your p stay?

• Tell p me p about p any p religious p practices p you p observe p that p we p need p to p incorporate p

into p your p care. p ANSWER: p D

The p response p to p the p general p question p requesting p any p special p concerns p would p include p information p relative p to p food, p prayer, p and p rabbinical p visitation. p The p other p questions p do p have p importance, p but p the p general p question p will p allow p the p nurse p to p hear p what p is p most p significant p to p the p patient.DIF: p Cognitive p Level: p Application p REF: p d. p 183, p Table p 14-3 p OBJ: p Theory p #7 p TOP: p Religion p and p Health p Care KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

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• A p nurse p referring p to p an p elderly p Asian p man p says, p He p probably p uses p acupuncture p

and p believes p in p yin p and p yang. p This p remark p is p an p example p of:

• stereotyping p of p the p patient.

• ethnocentrism p of p the p patient.

• cultural p sensitivity p on p the p part p of p the p nurse.

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• a p worldview p of p the p

nurse. p ANSWER: p A

Stereotyping p occurs p when p common p characteristics p of p a p cultural p group p are p applied p to p an p individual p with p no p attention p to p the p individuals p characteristics.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 180 p OBJ: p Clinical p Practice p #5 p TOP: p Stereotyping p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p Roman p Catholic p patient p going p to p surgery p for p an p emergency p cesarean p delivery p

is p afraid p the p baby p may p not p survive, p and p because p she p is p Roman p Catholic, p she p asks p you p to p be p sure p that p the p baby p is p baptized p when p it p is p born. p Your p response p to p her p

should p be:

• There p wont p be p time p to p baptize p the p baby p in p the p operating p room.

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• I p will p call p your p priest p to p come p in, p but p if p he p is p unable p to p be p there, p Ill p be p sure p the p

baby p is p baptized.

Baptisms p are p not p usually p done p in p the p hospital, p and p certainly p not p in p the p operating p room, p but p I p will p tell

• your p concerns.

• You p need p to p think p positively. p Both p you p and p the p baby p are p going p to

p be p just p fine. p ANSWER: p B

Baptism p is p very p important p to p practicing p Roman p Catholic p patients, p and p even p stillborns p are p baptized. p Baptism p should p be p performed p by p the p priest, p but p any p believer p can p baptize p in p an p emergency.DIF: p Cognitive p Level: p Application p REF: p d. p 176, p Box p 14-1 p OBJ: p Theory p #6 p TOP: p Religious p Characteristics KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p 76-year-old p Hispanic p woman p is p in p the p skilled p nursing p facility p where p she p is p to p

participate p in p a p rehabilitation p program p following p a p hip p replacement. p She p is p alert, p oriented, p and p cooperative p but p speaks p only p Spanish; p her p adult p children p interpret p for p her p when p they p are p present. p The p nurse p plans p the p most p effective p way p to p

communicate p with p this p patient p is p to:

• communicate p with p the p patient p when p the p children p are p present p and p can p translate.

• arrange p to p have p one p of p the p children p present p at p all p times.

• create p a p translation p guide p with p commonly p used p Spanish p and p English p words p and p phrases.

• call p on p the p facility p translator p for p every p interaction p with p the

p resident. p ANSWER: p C

A p simple p translation p guide p can p be p used p with p a p cooperative p patient p in p this p nonacute p setting. p The p other p solutions p are p unworkable p and p unrealistic.DIF: p Cognitive p Level: p Application p REF: p d. p 181 p OBJ: p Clinical p Practice p #3 p TOP: p Communication p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p person p who p believes p and p practices p the p Christian p Science p religion p is p most p likely p to:

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• seek p the p latest p technological p medical p and p surgical p care p available.

• use p medicinal p herbs p and p drugs p rather p than p surgery p to p treat p illness p and p disease.

• use p prayer p and p altered p thinking p to p correct p the p causes p of p illness p and p disease.

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• require p the p dead p to p be p buried p within p 24 p hours p of p

the p death. p ANSWER: p C

A p person p of p the p Christian p Science p belief p does p not p normally p seek p traditional p health p care p and p uses p prayer p for p healing.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 176, p Box p 14-1 OBJ: p Theory p #6 p TOP: p Religious p Characteristics p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• A p woman p who p is p part p of p a p traditional p Muslim p family p is p hospitalized p after p an p accident. p It p is

most p important p for p the p nurse p to p include p in p the p care p to:

• provide p privacy p when p the p priest p comes p to p administer p the p sacrament p of p the p sick.

• respect p her p need p for p modesty p in p keeping p her p body p covered.

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• keep p her p hair p covered p at p all p times.

• refrain p from p touching p the p soles p of p

her p feet. p ANSWER: p B

Traditional p Muslim p women p are p extremely p modest p and p keep p their p bodies p covered. p DIF: p Cognitive p Level: p Comprehension p REF: p d. p 178, p Box p 14-2 OBJ: p Theory p #6 p TOP: p Religious p Characteristics p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p is p aware p that p when p an p Orthodox p Jewish p family p has p a p baby p boy, p it p

is p expected p that p the:

• baby p will p be p circumcised p by p the p physician p as p soon p as p possible p after p the p birth.

• husband p of p the p woman p will p provide p the p physical p care p she p needs.

• naming p of p the p baby p will p be p done p by p the p mother p before p she p leaves p the p hospital.

• baby p will p be p circumcised p on p the p eighth p day p of p life p when p

he p is p named. p ANSWER: p D

Male p Orthodox p Jewish p children p are p named p and p circumcised p by p the p mohel p on p the p eighth p day p of p life.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 178, p Box p 14-2 p OBJ: p Theory p #6 p TOP: p Religious p Practices KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Psychosocial p Integrity: p psychosocial p adaptation

• A p single p African-American p working p mother p of p three p children p who p is p in p a p state p of p

poverty p often p misses p appointments p for p the p childrens p immunizations p or p well p child p check-ups. p The p nurse p understands p that p the p likely p reason p for p this p could p be p that p she: is p more p concerned p with p surviving p day-to-day p problems p than p with p taking p a p child p to p a p clinic p when p the

• illness.

• would p rather p enjoy p her p time p off p in p leisure p activities p than p taking p the p children p to p a p

clinic.

• is p from p a p culture p that p values p nontraditional p medical p care p from p curanderos p and p faith p

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healers.

• belongs p to p a p religious p group p that p is p opposed p to p immunizations p and p medical

p treatment. p ANSWER: p A

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People p who p live p in p poverty p are p often p focused p on p day-to-day p living. p Preventative p medicine p is p future p oriented.DIF: p Cognitive p Level: p Application p REF: p d. p 179 p OBJ: p Theory p #2 p TOP: p Low-Income p Families p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Psychosocial p Integrity: p psychosocial p adaptation

• The p nurse p is p aware p that p Muslims p and p Orthodox p Jews p have p similar p dietary p

restrictions p in p that p both p groups p require p that p their p followers:

• remain p mainly p vegetarians.

• avoid p milk p and p meat p at p the p same p meal.

• eat p only p meat p that p has p been p slaughtered p according p to p their p religious p law.

• avoid p shellfish.

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ANSWER: p C

Muslim p and p Jewish p followers p require p food p to p be p prepared p according p to p religious p law. p In p the p Jewish p faith, p it p is p called p kosher, p which p also p requires p the p separation p of p milk p and p meat.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 178, p Box p 14-2 p OBJ: p Theory p #4 p TOP: p Dietary p Restrictions KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Psychosocial p Integrity: p psychosocial p adaptation

• A p resident p in p a p skilled p nursing p facility p indicates p that p she p is p an p agnostic p and p is p

afraid p of p what p will p happen p to p her p when p she p dies. p An p appropriate p nursing p

intervention p for p this p patient p is p to:

• request p the p physician p to p order p an p anxiety-reducing p medication.

• ask p the p patient p whether p she p would p like p to p talk p to p the p facility p social p worker p or p

chaplain p to p address p her

• offer p reassurance p to p the p patient p that p God p will p understand p her p confusion.

• share p your p religious p belief p with p the p

patient. p ANSWER: p B

Exploring p spiritual p (meaning p of p life p and p death) p issues p with p a p social p worker p or p spiritual p care p person p is p appropriate p to p address p spiritual p distress p as p demonstrated p by p the p patients p anxiety p over p her p impending p death.DIF: p Cognitive p Level: p Application p REF: p d. p 179 p OBJ: p Clinical p Practice p #4 p TOP: p Spiritual p Distress p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p is p sensitive p to p the p fact p that p Hispanics p believe p that p some p foods p and p

fluids p have p hot p and p cold p properties p that p affect p their p health p by:

• destroying p the p pathogen p causing p the p disease.

• restoring p equilibrium p to p the p body.

• strengthening p the p mind p to p dispel p an p evil p spirit.

• ensuring p

healing. p ANSWER: p B

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Hispanics p believe p that p certain p foods p through p their p hot p or p cold p properties p can p restore p the p bodys p equilibrium.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 183, p Table p 14-3

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OBJ: p Theory p #6 p TOP: p Nutrition p and p Religion p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p patient p who p is p Native p American p and p visiting p a p health p care p clinic p for p the p first p

time p keeps p his p eyes p on p the p floor p and p seldom p makes p eye p contact p with p the p nurse. p

The p nurse p would p be p correct p in p thinking p that p the p patient:

• is p depressed p and p concerned p about p his p health p status.

• would p be p more p comfortable p with p an p elder p from p his p tribe p present.

• is p uncomfortable p talking p about p health p issues p with p a p woman.

• finds p direct p or p sustained p eye p contact p rude p or p

disrespectful. p ANSWER: p D

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Native p Americans p do p not p usually p sustain p eye p contact p in p the p same p way p as p European p Americans p do p because p they p consider p it p rude.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 181 p OBJ: p Theory p #5 p TOP: p Cultural p Behaviors p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• When p a p devout p Muslim p dies, p the p nurse p makes p arrangements p to:
• notify p a p family p member p to p come p bathe p the p patient.

• extinguish p all p light p and p leave p the p room p in p darkness.

• cover p the p body p with p the p patients p prayer p rug.

• place p an p open p Koran p over p the p patients p

heart. p ANSWER: p A

A p family p member p must p bathe p the p deceased p person p before p anybody p else p touches p the p body. p DIF: p Cognitive p Level: p Application p REF: p d. p 178, p Box p 14-2 OBJ: p Theory p #6 p TOP: p Muslim p Death KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p nurse p who p practices p in p a p culturally p competent p manner p is p one p who p

is p able p to:

• work p in p a p large p facility p where p there p are p a p variety p of p diverse p

cultures.

• assist p a p patient p from p another p culture p to p change p and p adapt p to p the p medical p culture.

• look p at p the p world p through p the p eyes p of p the p culturally p diverse p patient.

• recognize p which p cultural p traits p are p harmful p in p the p health p

care p culture. p ANSWER: p C

Cultural p competence p is p attained p when p the p nurse p makes p a p conscious p attempt p to p learn p about p people p of p diverse p cultures p and p look p at p the p world p through p their p perspective.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 179 p OBJ: p Clinical p Practice p #2 p TOP: p Transcultural p Competence p KEY: p Nursing p Process p

Step: p N/A

MSC: p NCLEX: p N/A

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• A p young p African-American p man p is p admitted p to p the p hospital p in p sickle p cell p

crisis. p He p is p unmarried p and p lives p with p an p extended p family p headed p by p his p grandmother. p The p nurse p takes p into p consideration p that p this p type p of p family p

arrangement p is:

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• egalitarian.

• patriarchal.

• matriarchal.

• transcultural.

p ANSWER: p C

Matriarchal p families p are p headed p by p women p (mother) p and p are p commonly p seen p in p African- p American p families.DIF: p Cognitive p Level: p Knowledge p REF: p d. p 181 p OBJ: p Clinical p Practice p #2 p TOP: p Family p Types p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p must p be p alert p to p non-verbal p expressions p to p assess p pain p in p patients p

from p a(n) p p p background.

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• Hispanic

• Pacific p Islander

• European

• African p

American p ANSWER: p B

Pacific p Islanders p are p reluctant p to p express p emotion p to p others p and p are p stoic p about p pain. p DIF: p Cognitive p Level: p Comprehension p REF: p d. p 183, p Table p 14- 3 OBJ: p Theory p #4 p TOP: p Cultural p Sensitivity p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p desired p outcome p for p a p patient p with p a p nursing p diagnosis p of p spiritual p

distress p is p that p the p patient p expresses:

• acceptance p that p she p is p not p being p punished p by p God p with p illness.

• concern p about p the p meaning p and p importance p of p her p life.

• continued p anger p at p God p for p afflicting p her p with p the p illness.

• refusal p to p participate p in p religious p rituals p that p have p no p meaning p for

p her p now. p ANSWER: p A

Spiritual p distress p is p often p caused p by p a p belief p that p illness p is p a p punishment p for p wrongdoing p or p sin. p DIF: p Cognitive p Level: p Application p REF: p d. p 185 p OBJ: p Clinical p Practice p #4 TOP: p Spiritual p Distress p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p understands p that p when p an p Asian p patient p refers p to p yin, p the p patient p is p

referring p to p a p balancing p force p that p is p represented p by:

• light.

• a p masculine p force.

• cold p and p feminine p elements.

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• harmony.

p ANSWER: p C

Yin p is p the p balancing p force p to p yang p that p is p represented p by p elements p that p are p dark, p cold, p and

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feminine.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 183, p Table p 14-3 p OBJ: p Theory p #7 p TOP: p Nutritional p Practices KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p understands p that p acupuncture p and p acupressure p are p alternative p therapies p based p on:
• healing p through p meditation p and p prayer.

• concepts p of p hot p and p cold p and p balancing p those p against p the p illness.

• the p power p of p suggestion p and p autohypnosis.

• interrupting p or p changing p the p flow p of p energy p fields p in p

the p body. p ANSWER: p D

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Acupressure, p massage, p and p acupuncture p all p are p based p on p theories p of p energy p flow p in p the p body p that p can p be p manipulated p to p affect p health.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 183, p Table p 14-3 p OBJ: p Theory p #5 p TOP: p Alternative p Treatments KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p nurse p is p caring p for p a p Catholic p patient p who p has p just p given p birth p to p a p

nonviable p fetus. p When p considering p the p religion p of p this p patient, p the p nurse p should:

• discourage p baptism p since p the p fetus p is p nonviable.

• baptize p the p fetus p if p a p priest p is p not p immediately p available.

• encourage p the p mother p to p consider p tubal p ligation.

• discuss p hormonal p contraception p with p the p

mother. p ANSWER: p B

Within p the p Catholic p religion, p infants p must p be p baptized p soon p after p birth p because p of p the p belief p that p babies p not p baptized p will p not p go p to p Heaven. p Even p aborted p fetuses p must p be p baptized. p If p a p priest p is p not p immediately p available, p the p nurse p may p baptize p by p pouring p holy p water p on p the p head p and p saying, p I p baptize p you p in p the p name p of p the p Father, p of p the p Son, p and p of p the p Holy p Spirit.DIF: p Cognitive p Level: p Application p REF: p d. p 176, p Box p 14-1 p OBJ: p Clinical p Practice p #6 p TOP: p Spiritual p Distress KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p nurse p caring p for p a p patient p who p is p a p practicing p Jehovahs p Witness p and p who p

has p had p surgery p confirms p that is p on p hand p to p be p infused.

• frozen p packed p cells

• Dextran

• 5% p glucose p in p water

• normal p

saline p ANSWER: p B

Jehovahs p Witnesses p are p not p permitted p to p take p blood p into p their p bodies, p but p blood p

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expanders p such p as p Dextran p can p be p infused.

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DIF: p Cognitive p Level: p Application p REF: p d. p 176, p Box p 14-1 OBJ: p Clinical p Practice p #1 p TOP: p Religious p Influence p in p Health p Care p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p practicing p member p of p the p Church p of p Jesus p Christ p of p Latter p Day p Saints p is p

being p prepared p for p surgery p on p his p left p knee. p The p nurse p should p remove p all p the p

personal p possessions p with p the p exception p of:

• the p wedding p ring.

• the p religious p medallion p around p the p neck.

• undergarments.

• linen p

socks. p ANSWER: p C

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Members p of p the p Church p of p Jesus p Christ p of p Latter-Day p Saints p may p wear p sacred p undergarments p that p should p only p be p removed p in p an p emergency. p If p removed, p the p undergarments p should p be p put p back p on p as p soon p as p possible.DIF: p Cognitive p Level: p Application p REF: p d. p 183, p Table p 14-1 OBJ: p Clinical p Practice p #1 p TOP: p Religious p Influence p in p Health p Care p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p nurse p is p caring p for p a p patient p of p the p Muslim p faith. p The p nurse p would p send p the

p food p tray p back p if p it p contains:

• pork p chops p and p sweet p potatoes.

• beef p patty p with p mushroom p sauce.

• liver p and p mashed p potatoes.

• crab p cakes p and p rice p with p

almonds. p ANSWER: p A

Practicing p Muslims p do p not p consume p pork p or p alcoholic p beverages. p They p also p forbid p cremation. p DIF: p Cognitive p Level: p Application p REF: p d. p 178, p Box p 14-2 OBJ: p Clinical p Practice p #1 p TOP: p Religious p Influence p in p Health p Care p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p nurse p is p caring p for p a p postpartum p patient p who p adheres p to p the p beliefs p of p

Orthodox p Judaism. p The p question p that p would p be p the p most p culturally p sensitive p would p

be:

• Would p you p like p crab p cakes p for p your p lunch?

• Would p you p like p your p husband p to p give p you p a p back p rub?

• Has p your p husband p decided p on p a p name p for p your p new p baby?

• Will p your p doctor p circumcise p your p baby p

tomorrow? p ANSWER: p C

Practicing p members p of p Orthodox p Judaism p name p their p male p children p 8 p days p after p being p born, p when p circumcision p is p performed. p Babies p are p named p by p the p father. p The p Orthodox p Jewish p man p cannot p touch p the p woman p until p after p the p ritual p bath p (mikvah). p Jewish p persons p are p discouraged p from p eating p shellfish.

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DIF: p Cognitive p Level: p Application p REF: p d. p 178, p Box p 14-2 OBJ: p Clinical p Practice p #1 p TOP: p Religious p Influence p in p Health p Care p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p supervisor p becomes p concerned p when p observing p the p nurse p caring p for p

an p Orthodox p Jewish p patient p preparing p to p trim p the p patients p beard p with p a(n):

• pair p of p scissors.

• electric p razor.

• razor p blade.

• barbers p straight p

razor. p ANSWER: p C

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Practicing p members p of p Orthodox p Judaism p view p the p beard p as p a p sign p of p holiness, p and p no p blade p must p touch p the p skin. p Scissors p or p an p electric p razor p may p be p used.DIF: p Cognitive p Level: p Application p REF: p d. p 183, p Table p 14-3 OBJ: p Clinical p Practice p #1 p TOP: p Religious p Influence p in p Health p Care p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity

• A p young p Hindu p woman p who p is p part p of p a p traditional p Hindu p family p is p in p a p coma

p and p is p going p to p be p transferred p to p the p ICU. p The p family p member p whom p the p nurse p

should p consult p about p this p health p matter p would p be p the:

• eldest p woman p in p the p family.

• family p council.

• patients p husband.

• the p older p

siblings. p ANSWER: p A

Traditional p Hindu p families p consider p the p eldest p woman p in p the p family p to p be p the p authority p on p health p and p healing p matters. p She p should p be p consulted p and p included p in p any p patient p teaching.DIF: p Cognitive p Level: p Application p REF: p d. p 178 p OBJ: p Clinical p Practice p #1 TOP: p Religious p Influence p in p Health p Care p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

28. An p example p of p an p ethnocentric p remark p would p be:

• I p think p Catholics p should p have p as p many p children p as p they p want.

• I p dont p see p why p Muslims p cant p pray p in p church p like p we p Protestants p do.

• You p have p to p admire p the p Asian p immigrants p for p keeping p all p their p eastern p traditions.

• It p seems p that p Hispanics p have p taken p over p this p

country. p ANSWER: p B

Ethnocentrism p is p the p tendency p of p human p beings p to p think p that p their p way p of p thinking, p believing, p and p doing p things p is p the p only p way p or p the p only p right p way. p Beliefs p that p greatly p differ p from p ones p own p are p seen p as p strange p and p are p therefore p considered p wrong.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 180 p OBJ: p Clinical p

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Practice p #5 p TOP: p Ethnocentrism p KEY: p Nursing p Process p Step: p N/A

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MSC: p NCLEX: p N/A

• A p nursing p instructor p is p teaching p a p group p of p nursing p students p about p cultural p values p

practiced p by p Arab p Americans. p The p nursing p instructor p would p recognize p the p need p for p

further p teaching p if p a p nursing p student p states, p I p will:

• offer p Arab-American p patients p items p using p my p left p hand.

• make p sure p all p females p are p cared p for p by p females.

• refrain p from p sitting p with p the p sole p of p my p shoe p visible.

• refrain p from p offering p Arab-American p patients p

pork. p ANSWER: p A

Arab p Americans p do p not p eat p pork p or p drink p alcohol. p It p is p considered p rude p to p pass p things p with p the p left p hand p because p it p is p considered p unclean. p It p is p considered p rude p to p sit p with p the p sole p of p the p shoe p within p view p of p someone. p Arab p women p are p uncomfortable p with p care p performed p by p males.

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DIF: p Cognitive p Level: p Comprehension p REF: p d. p 183, p Table p 14-3 p OBJ: p Clinical p Practice p #1 p TOP: p Religious p Influence p in p Health p Care p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p psychosocial p adaptation

• A p nurse p caring p for p a p newborn p of p Eastern p European p Jewish p ancestry p is p aware p

that p this p patient p is p predisposed p to:

• Tay-Sachs p disease.

• sickle p cell p anemia.

• diabetes p mellitus.

• sickle p cell p

trait. p ANSWER: p A

People p of p Eastern p European p Jewish p ancestry p may p carry p the p trait p for p a p fatal p neurologic p disorder p of p infancy p called p Tay-Sachs p disease.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 184 p OBJ: p Clinical p Practice p #1 TOP: p Religious p Influence p in p Health p Care p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• A p home p health p nurse p caring p for p a p patient p of p American p Indian p ancestry p will p

be p particularly p alert p to p symptoms p of because p of p a p genetic p predisposition p to p that p illness.

• diabetes p mellitus

• Tay-Sachs p disease

• sickle p cell p anemia

• sickle p cell p

trait p ANSWER: p A

Diabetes p is p more p common p among p the p Hispanic p and p American p Indian p populations p because p of p a p genetic p susceptibility.DIF: p Cognitive p Level: p Knowledge p REF: p d. p 184 p OBJ: p Clinical p Practice p #1 TOP: p Religious p Influence p in p Health p Care p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

COMPLETION

• Persons p of p African p extraction p are p predisposed p to p the p three p disorders p of , ,

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and .

p ANSWER:

sickle p cell p anemia; p sarcoidosis; p keloids People p of p African p or p Mediterranean p heritage p are p prone p to p sickle p cell p anemia p and p trait, p sarcoidosis, p and p keloids.DIF: p Cognitive p Level: p Knowledge p REF: p d. p 184 p OBJ: p Theory p #1 p TOP: p Racial p Predisposition p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p term p developed p to p describe p care p that p recognizes p cultural p diversity p and p that p is

p sensitive p to p the p cultural p needs p of p the p patient p is .

ANSWER:

transcultural p nursing

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Recognizing p the p need p for p culturally p diverse p capabilities p in p nursing p is p a p growing p aspect p of p health p care, p especially p in p our p global p community.DIF: p Cognitive p Level: p Knowledge p REF: p d. p 179 p OBJ: p Theory p #1 p TOP: p Transcultural p Nursing p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p concept p of described p by p Dr. p Madeline p Leininger p is p the p force p

that p allows p people p to p grow, p remain p well, p and p avoid p or p face p death.

ANSWER:

human p caring Dr. p Leininger p described p human p caring p as p the p force p that p allows p people p to p grow, p remain p well, p avoid p illness, p and p face p or p survive p death.DIF: p Cognitive p Level: p Knowledge p REF: p d. p 179 p OBJ: p Theory p #2 p TOP: p Human p Caring p KEY: p Nursing p Process p

Step: p N/A

MSC: p NCLEX: p N/A MULTIPLE p RESPONSE

• Although p the p words p spirituality p and p religion p are p often p used p interchangeably, p

spirituality p actually p refers p to p which p of p the p following? p (Select p all p that p apply.)

• Concerns p of p the p spirit

• Formalized p system p of p beliefs

• Understanding p ones p place p in p the p world

• An p element p of p religion

• Belief p in p a p higher p power p or p creative

p force p ANSWER: p A, p C, p D, p E

Spirituality p and p religion p are p similar, p but p both p must p be p addressed p for p the p patients p psychosocial p integrity p to p improve.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 175 p OBJ: p Theory p #1 p TOP: p Spirituality p and p Religion p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p nurse p takes p into p consideration p that p culture p and p religion p influence p life p

choices p that p include: p (Select p all p that p apply.)

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• smoking.

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• drug p use.

• frequency p of p intercourse.

• nutrition.

• reading p material.

• use p of p

caffeine.

ANSWER: p A, p B, p D, p E,

p F The p use p of p drugs p (including p caffeine, p tobacco, p and p alcohol), p nutritional p choices, p and p food p preparation p are p influenced p by p culture.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 174 p OBJ: p

Theory p #1 p TOP: p Cultural p Influences p on p Life p Choices

KEY: p Nursing p Process p Step: p Planning

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MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p is p aware p that p cultural p influences p shape p the p worldview p of p all p people, p

which p define p for p each p person p the p concepts p of p the: p (Select p all p that p apply.)

• meaning p of p lifes p events.

• basis p of p a p value p system.

• rational p explanation p of p lifes p mysteries.

• meaningful p employment.

• difference p between p good p and p

evil. p ANSWER: p A, p B, p C, p E

The p worldview p of p an p individual p shapes p his p or p her p value p system, p defines p right p and p wrong, p and p helps p to p explain p lifes p events p and p mysteries. p Significance p of p employment p is p not p included p in p a p worldview.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 175 p OBJ: p Theory p #1 p TOP: p Worldview p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• Protestant p denominations p that p use p their p own p holy p books p in p addition p to p the p

Bible p include: p (Select p all p that p apply.)

• Baptists.

• Christian p Scientists.

• Mormons.

• Lutherans.

• Episcopalians.

p ANSWER: p B, p C

Protestant p denominations p that p use p another p holy p book p in p addition p to p the p Bible p are p Christian p Scientists, p Mormons, p Jehovahs p Witnesses, p and p the p Unification p Church.

Chapter p 7 p The p Nurse–Client p Relationship

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MULTIPLE p CHOICE

• The p nurse p can p best p ensure p that p communication p is p understood p by:

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• speaking p slowly p and p clearly p in p the p patients p native p language.

• asking p the p family p members p whether p the p patient p understands.

• obtaining p feedback p from p the p patient p that p indicates p accurate p comprehension.

• checking p for p signs p of p hearing p loss p or p aphasia p before p

communicating. p ANSWER: p C

The p best p way p to p determine p understanding p is p to p ask p the p patient. p Factors p such p as p anxiety, p hearing p acuity, p language, p aphasia, p or p lack p of p familiarity p with p medical p jargon p or p routines p can p all p contribute p to p misunderstanding.DIF: p Cognitive p Level: p Comprehension p REF: p pp. p 100-101 p OBJ: p Theory p #1 p TOP: p Feedback p KEY: p Nursing p Process p Step: p Evaluation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

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2. The p nurse p recognizes p a p verbal p response p when p the p patient:

• nods p her p head p when p asked p whether p she p wants p juice.

• writes p the p answer p to p a p question p asked p by p the p nurse.

• begins p sobbing p uncontrollably p when p asked p about p her p daughter.

• is p moaning p and p restless p and p appears p to p be p

in p pain. p ANSWER: p B

Verbal p communication p involves p words, p either p written p or p spoken. p Nodding, p sobbing, p and p moaning p are p nonverbal p communication.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 99 p OBJ: p Theory p #1 TOP: p Verbal p Communication p Feedback p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p recognizes p the p patient p who p demonstrates p communication p congruency p

when p the p patient:

• smiles p and p laughs p while p speaking p of p feeling p lonely p and p depressed.

• wrings p her p hands p and p paces p around p the p room p while p denying p that p she p is p upset.

• is p tearful p and p slow p in p speech p when p talking p about p her p husbands p death.

• states p she p is p comfortable p while p she p frowns p and p her p teeth p are

p clenched. p ANSWER: p C

Congruent p communication p is p the p agreement p of p verbal p and p nonverbal p messages. p DIF: p Cognitive p Level: p Comprehension p REF: p d. p 99 p OBJ: p Theory p #1 TOP: p Congruence p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p Hispanic p patient p approaches p the p Asian p nurse p and, p standing p very p close, p touches

p the p nurses p shoulder p during p their p conversation. p The p nurse p begins p to p step p back p to p 18 p to p 24 p inches, p while p smiling p and p nodding p to p the p patient. p This p situation p is p

most p likely p an p example p of:

• the p nurses p need p to p maintain p a p professional p role p rather p than p a p social p role.

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• a p patients p attempt p to p keep p the p nurses p attention.

• a p nurses p need p to p establish p a p more p appropriate p location p for p conversation.

• a p difference p in p culturally p learned p personal p space p of p the p nurse p and p the p patient.

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ANSWER: p D

Personal p space p between p people p is p a p culturally p learned p behavior; p Asians, p North p American p natives, p and p Northern p European p people p generally p prefer p more p personal p space p than p people p of p Hispanic, p Southern p European, p or p Middle p Eastern p cultures.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 100 p OBJ: p Theory p #2 p TOP: p Cultural p Differences p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p nurse p says p to p a p patient, p I p am p going p to p take p your p TPR, p and p then p Ill p check p to p see p whether p

you can p have p a p PRN p analgesic. p In p considering p factors p that p affect p communication, p the p nurse p has:

• used p terminology p to p clearly p inform p the p patient p of p what p she p is p doing.

• given p information p that p is p unnecessary p for p the p patient p to p know.

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• used p medical p jargon, p which p might p not p be p understood p by p the p patient.

• taken p into p consideration p the p patients p need p to p know p what p is p

happening. p ANSWER: p C

Medical p jargon p such p as p abbreviations p or p medical p terminology p is p often p misunderstood, p even p by p well-educated p people.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 101 p OBJ: p Theory p #3 TOP: p Blocks p to p Communication p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

6. A p nurse p using p active p listening p techniques p would:

use p nonverbal p cues p such p as p leaning p forward, p focusing p on p the p speakers p face, p and p slightly p nodding p to p i

• message p has p been p heard.
• avoid p the p use p of p eye p contact p to p allow p the p patient p to p express p herself p without p feeling p

stared p at p or p deme p anticipate p what p the p speaker p is p trying p to p say p and p help p the p patient p express p herself p when p she p has p difficu

• sentence.

• ask p probing p questions p to p direct p the p conversation p and p obtain p the p information p needed p as p

efficiently p as p ANSWER: p A

Eye p contact p is p a p culturally p learned p behavior p and p in p some p cases p may p not p be p appropriate. p Probing p questions p or p finishing p the p patients p sentence p is p not p part p of p active p listening p and p is p detrimental p to p an p interview.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 101 p OBJ: p Theory p #3 p TOP: p Active p Listening p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• When p the p patient p says, p I p dont p want p to p go p home, p the p nurses p best p therapeutic p

verbal p response p would p be:

• Im p sure p everything p will p be p fine p once p you p get p home.

• You p dont p want p to p go p home?

• Doesnt p your p family p want p you p to p come p home?

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• I p felt p like p that p when p I p had p surgery p

last p year. p ANSWER: p B

The p use p of p reflecting p encourages p the p patient p to p expand p on p his p or p her p feelings p or p thoughts.

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DIF: p Cognitive p Level: p Application p REF: p d. p 103, p Table p 8-1 p OBJ: p Theory p #3 p TOP: p Communication p Techniques KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• To p begin p talking p with p a p newly p admitted p patient p about p pain p management, p the p nurse

p would p most p appropriately p state:

• You p look p pretty p comfortable. p Are p you p having p any p pain?

• Tell p me p about p the p pain p youve p been p having.

• Is p this p pain p the p same p as p the p pain p you p had p yesterday?

• Dont p worry; p this p pain p wont p last p

forever. p ANSWER: p B

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An p open-ended p question p allows p the p patient p to p express p his p or p her p feelings p or p needs. p DIF: p Cognitive p Level: p Application p REF: p d. p 103, p Table p 8-1 OBJ: p Theory p #3 p TOP: p Communication p Techniques p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• When p a p patient p begins p crying p during p a p conversation p with p the p nurse p about p

the p patients p upcoming p surgery p for p possible p malignancy, p the p nurses p most p

therapeutic p response p would p be:

• Your p surgeon p is p excellent, p and p I p know p hell p do p a p great p job.

• Oh, p dear, p your p gown p is p way p too p big, p let p me p get p you p another p one.

• Dont p cry; p think p about p something p else p and p youll p feel p better.

• Here p is p a p tissue. p Id p like p to p sit p here p for p a p while p if p you

p want p to p talk. p ANSWER: p D

Offering p self, p or p presence, p and p accepting p a p patients p need p to p cry p is p supportive. p DIF: p Cognitive p Level: p Application p REF: p d. p 103, p Table p 8- 1 OBJ: p Theory p #3 p TOP: p Therapeutic p Techniques p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• To p enhance p the p establishment p of p rapport p with p a p patient, p the p nurse p should:
• identify p himself p by p name p and p title p each p time p he p introduces p himself.

• share p his p own p personal p experiences p so p that p the p patient p gets p to p know p him p as p a p friend.

• act p in p a p trustworthy p and p reliable p manner; p respect p the p individuality p of p the p patient.

• share p information p with p the p patient p about p other p patients p and p why p they p are p

hospitalized. p ANSWER: p C

Trust p and p reliability, p as p well p as p conveying p respect p for p the p individual, p all p promote p rapport. p Identifying p oneself p is p important p but p in p itself p does p not p promote p rapport. p Sharing p personal p experiences p or p divulging p the p confidential p nature p of p other p patients p

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conditions p is p not p appropriate p in p the p nursepatient p relationship.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 107 p OBJ: p Clinical p Practice p #2 p TOP: p Rapport p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

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• The p nurse p explains p that p the p therapeutic p nursepatient p relationship p differs p from p

the p social p relationship p because:

• a p social p relationship p does p not p have p goals p or p needs p to p be p met.

• the p nursepatient p relationship p ends p when p the p patient p is p discharged.

• the p focus p is p mainly p on p the p nurse p in p the p nursepatient p relationship.

• a p social p relationship p does p not p require p trust p or p sharing p of p life p

experiences. p ANSWER: p B

The p nursepatient p relationship p is p limited p to p the p patients p stay p in p the p facility p and p is p focused p on p the p patient. p A p social p relationship p may p have p goals p or p needs p and p does p require p trust p and p sharing p of p life p experiences.DIF: p Cognitive p Level: p Comprehension p REF: p pp. p 106-107 p OBJ: p Theory p #4 p TOP: p Relationships p KEY: p Nursing p Process p Step: p Implementation

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MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p has p selected p an p outcome p for p the p patient p to p eat p all p of p the p food p on p

the p breakfast p tray p each p day. p Assessing p that p the p patient p has p eaten p all p of p the p

breakfast, p the p nurse p would p give p positive p feedback p by p saying:

• Wow! p That p breakfast p must p have p been p pretty p good.

• I p like p pancakes p too. p Everyone p on p the p hall p seemed p to p enjoy p them.

• I p hope p you p can p keep p all p that p breakfast p down.

• Hurray! p You p finished p your p whole p meal! p What p would p you p like p for p

tomorrow? p ANSWER: p D

Giving p positive p feedback p increases p the p likelihood p of p the p desired p behavior p to p be p repeated. p Commenting p on p the p tastiness p of p the p food p or p the p fact p that p others p liked p it p is p not p responding p directly p to p the p patients p having p eaten p the p whole p meal.DIF: p Cognitive p Level: p Application p REF: p d. p 100 p OBJ: p Theory p #9 p TOP: p Positive p Feedback p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p 67-year-old p woman p had p major p abdominal p surgery p yesterday. p She p has p IV p lines,

p a p urinary p catheter, p and p an p abdominal p wound p dressing, p and p she p is p receiving p PRN p pain p medication. p The p end- p of-shift p report p that p best p conveys p the p patient p status p is:

• Doing p great, p was p up p in p the p chair p most p of p the p day. p No p complaints p of p pain p or p

discomfort. p Voiding p ade

Abdominal p surgery p yesterday, p dressing p is p dry p and p intact, p her p IVs p are p on p time p and p shes p had p pain p med b.

c.

d.

ANSW

ER: p C

stable.

Abdominal p dressing p dry, p IVs800 p mL p left p in p #6; p NS p running p at p 125 p mL/hr; p urine p output p 800 p mL p this p 15 p mg p for p pain p at p 8:00 p AM p and p at p 1:30 p PM. p Shes p comfortable p now. p Vital p signs p are p stable, p no p fever.Unchanged p since p this p morning. p She p wanted p to p know p how p soon p she p can p have p something p to p eat, p so p m p check p with p her p doctor p this p evening. p Her p husband p has p been p visiting p all p day p and p will p let p you p know p if p s This p brief p clear p report p addresses p the p major p concerns p of p the p abdominal p dressing, p the p

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status p of p the p IV p fluids, p vital p signs, p and p analgesia p needs.DIF: p Cognitive p Level: p Application p REF: p pp. p 109-110 p OBJ: p Clinical p Practice p #4 p TOP: p Shift p Report p KEY: p Nursing p Process p Step: p Implementation

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MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

• An p aspect p of p computer p use p in p patient p care p in p which p the p LPN p may p need p to

p be p proficient p includes:

• input p of p data p such p as p requests p for p radiographs p or p laboratory p services.

• programming p the p computer p to p record p data p from p physicians p and p other p health p care p

workers.

teaching p patients p how p to p use p hospital p computers p to p access p information p such p as p discharge p instruction

• relative p to p specific p medications.

• scheduling p admissions, p discharges, p and p nurse p staffing p to p keep p the p unit p at p the p best p

occupancy p and p uti p ANSWER: p A

Many p facilities p use p computers p for p data p entry p relative p to p requesting p radiograph p or p lab p services p and p physical p assessment p and p medication p administration. p Programming p such p computers p is p not p a

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nursing p task, p and p patients p need p to p have p individualized p information p about p discharge p and p medications.DIF: p Cognitive p Level: p Knowledge p REF: p pp. p 110-111 p OBJ: p Theory p #8 p TOP: p Computer p Use p KEY: p Nursing p Process p Step: p N/A MSC: p NCLEX: p N/A

• A p patient p with p a p nursing p diagnosis p of p Sensory p perception, p disturbed p auditory, p

would p most p appropriately p require p the p nurse p to:

• obtain p a p sign p language p interpreter p when p a p family p member p is p unavailable.

• speak p slowly p and p distinctly, p but p not p shout.

• provide p bright p lighting p without p glare p and p orient p frequently.

• reorient p frequently p to p time, p place, p staff, p and p

events. p ANSWER: p B

A p patient p with p disturbed p auditory p perception p cannot p hear p well p (or p at p all); p therefore, p speaking p slowly p and p distinctly p without p shouting p increases p patient p comprehension.DIF: p Cognitive p Level: p Application p REF: p pp. p 107-108 p OBJ: p Clinical p

Practice p #3 p TOP: p Hearing-Impaired p Patient p Communication

KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• When p an p office p nurse p asks p the p patient p to p repeat p information p that p he p has p

just p given p to p the p patient p over p the p telephone, p the p nurse p is:

• testing p the p patients p intelligence p and p memory.

• acting p in p a p cautious p way p to p avoid p charges p of p negligence.

• verifying p that p the p patient p understands p the p information.

• saving p the p extra p time p it p would p take p to p mail p the p

information. p ANSWER: p C

Obtaining p feedback p from p a p patient p to p ascertain p that p the p patient p understands p instructions p is p an p important p part p of p the p communication p process, p especially p over p the p phone, p when p the p nurse p does p not p have p nonverbal p cues.DIF: p Cognitive p Level: p Comprehension p REF: p pp. p 100-101 p OBJ: p Theory p #3 p TOP: p Telephonic p Communication p KEY: p Nursing p Process p Step: p

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Implementation

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MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p 36-year-old p woman p who p is p in p traction p for p a p fractured p femur p that p she p

received p in p an p auto p accident p is p found p crying p quietly. p The p nurse p can p best p address p

this p situation p by p saying:

• Whats p the p matter? p Why p are p you p crying? p Are p you p in p pain?

• Stop p crying p and p tell p me p what p your p problem p is.

• This p could p have p been p much p worse. p Youre p lucky p no p one p was p killed.

• You p are p upset. p Can p you p tell p me p whats p

wrong? p ANSWER: p D

The p nurse p offers p a p general p lead p as p to p what p is p causing p the p distress. p The p other p options p are p judgmental p or p clichs p or p offer p no p opportunity p for p the p patient p to p express p feelings.DIF: p Cognitive p Level: p Application p REF: p d. p 103, p Table p 8-1 p OBJ: p Theory p #3 p TOP: p Reflecting p Observations

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KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• When p the p nurse p is p giving p direction p to p a p nursing p assistant p who p is p being p

delegated p part p of p the p patient p care, p the p nurses p most p effective p direction p would p be:

• Do p the p morning p care p first p on p the p patients p in p 205 p and p 206 p who p cant p get p out p of p bed.

• You p take p care p of p all p the p patients p in p 205 p and p 206. p Let p me p know p how p youre p doing p

and p whether p you p ne

• Give p the p patient p in p 204A p a p shower p after p breakfast, p and p call p me p to p check p her p feet p

before p you p get p her p d

• Take p the p vital p signs p on p all p the p patients p in p the p lounge p and p tell p me p whether p

there p are p problems. p ANSWER: p C

The p clarity p and p brevity p of p the p direction p makes p the p delegated p task p clear p and p leaves p the p responsibility p of p assessment p to p the p nurse.DIF: p Cognitive p Level: p Application p REF: p d. p 110 p OBJ: p Theory p #7 p TOP: p Delegation p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

• When p the p patient p says, p I p get p so p anxious p just p lying p here p in p this p hospital p bed. p I

p have p a p million p things p I p should p be p doing p at p home, p the p most p empathetic p response p

would p be:

• Id p feel p the p same p way p you p do. p I p know p just p what p youre p going p through.

• It p sounds p like p youre p having p a p tough p time p dealing p with p this p situation.

• Its p always p darkest p before p the p dawn. p Hang p in p there; p it p will p get p better.

• You p sound p pretty p sorry p for p yourself. p Why p dont p you p look p at p the

p positives? p ANSWER: p B

Empathy p recognizes p a p patients p situation p and p encourages p expression p of p feelings. p DIF: p Cognitive p Level: p Application p REF: p d. p 107 p OBJ: p Theory p #3 TOP: p Empathy p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

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• A p patient p asks p the p nurse, p What p would p you p do p if p you p had p cancer p and p had p to p

choose p between p surgery p and p chemotherapy? p The p reply p that p can p best p help p the p

patient p is:

• If p I p were p you, p I p would p choose p surgery p and p then p consider p chemo p afterward.

• What p solutions p have p you p considered?

• I p would p talk p it p over p with p my p friends p first.

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• I p dont p know. p Im p glad p it p isnt p my p

decision. p ANSWER: p B

Nurses p can p help p by p reminding p patients p of p alternatives p open p to p them p and p should p refrain p from p giving p advice p but p can p encourage p the p patient p to p consider p options. p The p nurse p may p be p glad p not p to p face p a p decision p a p patient p must, p but p it p is p not p helpful p to p the p patient p to p say p this.DIF: p Cognitive p Level: p Application p REF: p d. p 103, p Table p 8-1 p OBJ: p Theory p #3 p TOP: p Offering p Alternatives KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p chooses p to p use p touch p in p the p nursepatient p relationship p because p touch:
• can p convey p caring p and p support p when p words p are p difficult.

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• should p be p avoided p because p of p problems p of p cultural p misinterpretation.

• is p appropriate p only p in p special p circumstances, p such p as p with p young p children.

• is p a p nursing p intervention p of p choice p in p almost p all p

situations. p ANSWER: p A

Touch p is p a p powerful p and p supportive p nonverbal p communication p in p many p situations. p It p is p appropriate p for p all p ages, p but p not p in p some p situations. p Careful p assessment p of p the p patients p situation p and p cultural p values p should p determine p its p use, p but p it p should p not p be p avoided p because p of p stereotypes. p DIF: p Cognitive p Level: p Comprehension p REF: p d. p 103 p

OBJ: p Theory p #4

TOP: p Caring p Touch p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• When p the p nurse p makes p the p statement, p We p can p come p back p to p that p laterright p

now p I p need p to p know p about p when p your p symptoms p started, p the p nurse p is:

• letting p the p patient p know p that p topic p of p conversation p was p inappropriate.

• setting p limits p on p the p expression p of p feelings.

• refocusing p the p patient p to p the p issue p at p hand p when p the p conversation p has p wandered.

• closing p off p the p conversation p by p quickly p getting p to p the p point p of p the

p interview. p ANSWER: p C

Refocusing p is p often p necessary p to p accomplish p data p collection. p It p does p not p block p communication p and p is p not p used p to p close p a p conversation p or p stop p an p inappropriate p topic.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 102 p OBJ: p Theory p #3 TOP: p Refocusing p Communication p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p patient p who p has p had p a p stroke p is p unable p to p speak p clearly p and p has p right-sided p

hemiplegia. p The p nurse p will p design p the p approach p to p the p assessment p interview p by:

• asking p questions p and p explaining p procedures p to p the p patients p daughter.

• speaking p slowly p and p giving p the p patient p time p to p respond.

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• telling p the p patient p he p will p get p all p necessary p information p from p the p daughter.

• prompting p the p answers p and p finishing p the p sentences p for p the

p patient. p ANSWER: p B

Speaking p slowly p recognizes p that p the p patient p may p process p (if p able) p information p more p slowly.

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DIF: p Cognitive p Level: p Application p REF: p d. p 103, p Table p 8-1 p OBJ: p Clinical p Practice p #3 p TOP: p Impaired p Communication p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• When p a p nurse p is p conducting p an p assessment p interview, p the p most p efficient p technique p would p be:
• explaining p the p purpose p of p the p interview.

• excluding p relatives p and p friends p from p the p interaction.

• telling p the p patient p what p data p are p already p available.

• asking p closed p questions p to p obtain p essential p

information. p ANSWER: p D

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Closed p questions p have p a p definite p place p when p the p nurse p wants p to p obtain p specific p essential p data. p Closed p questions p force p the p patient p to p stick p to p the p topic.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 102 p OBJ: p Clinical p Practice p #1 p TOP: p Interview p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• While p interviewing p a p Native p American p man p for p the p admission p history, p the p

nurse p should p expect p to:

• wait p patiently p through p long p pauses p in p the p conversation.

• maintain p eye p contact p with p the p patient.

• give p the p patient p permission p to p speak.

• have p another p family p member p speak p for p the p

patient. p ANSWER: p A

Native p Americans p use p long p pauses p in p their p conversation p to p better p consider p their p answer p and p consider p the p question. p The p culturally p sensitive p nurse p would p wait p quietly p through p the p pauses. p DIF: p Cognitive p Level: p Comprehension p REF: p d. p 102 p

OBJ: p Clinical p Practice p #1

TOP: p Cultural p Considerations p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p is p aware p that p the p purpose p of p therapeutic p communication p is p to:
• gather p as p much p information p as p possible p about p the p patients p problem.

• direct p the p patient p to p communicate p about p his p deepest p concerns.

• focus p on p the p patient p and p the p patient p needs p to p facilitate p interaction.

• gain p specific p medical p information p and p history p of p

illness. p ANSWER: p C

Therapeutic p communication p is p a p conversation p that p is p focused p on p the p patient p and p promotes p understanding p between p the p sender p and p the p receiver.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 102 p OBJ: p Theory p #4 p TOP: p Therapeutic p Communication p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Psychosocial p Integrity: p

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coping p and p adaptation

• The p practical p nursing p student p who p is p engaged p in p a p therapeutic p communication p

with p a p patient p will p have p the p most p difficulty p with p the p technique p of:

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• closed p questions.

• restating.

• using p general p leads.

• silence.

p ANSWER: p D

The p use p of p silence p is p the p hardest p for p most p students p to p develop p because p it p makes p them p uncomfortable, p so p they p tend p to p end p it p prematurely.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 102 p OBJ: p Theory p #31 p TOP: p Silence p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• To p convey p the p intervention p of p active p listening, p the p nurse p would:

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• maintain p eye p contact p by p staring p at p the p patient.

• prompt p the p patient p when p the p patient p stops p talking p for p a p moment.

• make p a p conscious p effort p to p block p out p other p sounds p in p the p immediate p environment.

• write p down p remarks p on p a p clipboard p to p facilitate p later p topics p of p

conversation. p ANSWER: p C

An p active p listener p maintains p eye p contact p without p staring, p gives p the p patient p full p attention, p and p makes p a p conscious p effort p to p block p out p other p sounds p and p distractions.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 101 p OBJ: p Theory p #3 p TOP: p Active p Listening p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• When p the p nurse p enters p the p room, p the p patient p is p laughing p out p loud p at p something p

on p TV. p The p patient p stops p and p apologizes p for p the p laughter, p saying, p I p guess p I p ought p not p be p laughing p at p all p since p I p am p stuck p here p with p two p broken p legs. p The p nurse p can p

use p evidence-based p information p when p she p responds:

• Laughter p is p nearly p always p a p cover-up p for p anxiety p when p facing p a p long p rehabilitation.

• Long p periods p of p laughter p decrease p the p amount p of p oxygen p available p to p your p body p for p

healing.

• Laughter p in p a p hospital p is p often p distracting p and p depressing p to p other p patients p nearby.

• Laughter p truly p is p the p best p medicine p as p it p has p a p positive p effect p on p the p

immune p system. p ANSWER: p D

Hasen p and p Hasen p (2009) p found p that p laughter p and p appropriate p use p of p humor p decreased p stress p and p anxiety p and p had p a p positive p effect p on p the p immune p system.DIF: p Cognitive p Level: p Application p REF: p d. p 101 p OBJ: p Clinical p Practice p #2 p TOP: p Use p of p Laughter p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• When p interacting p with p an p elderly p patient, p the p nurse p would p enhance p communication p by:
• speaking p slowly p in p order p to p allow p the p patient p to p process p the p message.

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• addressing p him p by p his p first p name p to p encourage p a p therapeutic p relationship.

• standing p in p the p doorway p rather p than p entering p the p room p to p give p the p elderly p patient p more

p privacy.

• speaking p in p simple p sentences, p as p if p to p a p child.

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ANSWER: p A

When p interacting p with p an p elderly p person, p the p nurse p should p try p not p to p speak p too p quickly p or p expect p an p immediate p answer p because p the p elderly p take p more p time p to p process p the p message. p Do p not p use p baby p talk p or p speak p to p them p as p if p they p were p children.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 101 p OBJ: p Theory p #2 p TOP: p Communication p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• When p the p nurse p observes p a p resident p in p a p long-term p facility p pounding p his p fists p

on p his p legs p and p grinding p his p teeth, p the p nurse p will p validate p her p perception p of p the p

patients p non-verbal p expression p of p anger p by:

• documenting p that p the p patient p was p agitated p and p appeared p angry.

• asking p the p male p nursing p assistant p if p it p is p his p perception p that p the p patient p appears p angry.

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• accessing p the p nursing p care p plan p to p ascertain p if p there p is p a p nursing p diagnosis p relative p to p

anger.

• sitting p down p near p the p patient p and p saying, p You p seem p

upsetcan p I p help? p ANSWER: p D

All p perceptions p based p on p the p observation p of p non-verbal p behavior p should p be p validated p by p consulting p the p patient.DIF: p Cognitive p Level: p Application p REF: p d. p 100 p OBJ: p

Theory p #9 p TOP: p Validating p Perceptions

KEY: p Nursing p Process p Step: p Assessment p | p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• When p a p patient p states, p I p dont p feel p like p walking p today, p the p nurses p most p

therapeutic p verbal p response p would p be:

• You p have p to p walk p today.

• You p dont p want p to p walk p today?

• I p dont p feel p like p walking p today p either.

• Why p dont p you p want p to p walk p

today? p ANSWER: p B

Reflection p is p a p way p to p restate p the p message. p The p idea p is p simply p reflected p back p to p the p speaker p in p a p statement p to p encourage p continued p dialogue p on p the p topic.DIF: p Cognitive p Level: p Application p REF: p d. p 103, p Table p 8-1 p OBJ: p Theory p #3 p TOP: p Communication p Techniques KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• When p a p patient p states, p My p son p hasnt p been p to p see p me p in p months, p the p

nurses p best p verbal p response p is:

• Dont p worry; p Im p sure p your p son p will p visit.

• Your p son p hasnt p been p around p much p lately?

• My p son p doesnt p come p to p visit p me p either.

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• How p terrible p that p he p doesnt p visit

p you. p ANSWER: p B

Restating p in p different p words p what p the p patient p said p encourages p further p communication p on p that

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topic.DIF: p Cognitive p Level: p Application p REF: p d. p 103, p Table p 8-1 p OBJ: p Theory p #3 p TOP: p Communication p Techniques KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• An p example p of p a p nurse p communicating p with p a p patient p using p open-ended p questions p would p be:
• Is p your p pain p less p today p than p it p was p yesterday?

• Did p you p sleep p all p night p without p waking?

• How p many p bowel p movements p have p you p had p today?

• What p was p your p daughters p reaction p to p your p desire p for p

hospice? p ANSWER: p D

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An p open-ended p question p is p broad, p indicating p only p the p topic, p and p it p requires p an p answer p of p more p than p a p word p or p two. p Use p of p an p open-ended p question p or p statement p allows p the p patient p to p elaborate p on p a p subject p or p to p choose p aspects p of p the p subject p to p be p discussed. p Open-ended p questions p or p statements p are p helpful p to p open p up p the p conversation p or p to p proceed p to p a p new p topic. p They p usually p cannot p be p answered p with p one p word p or p just p yes p or p no.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 103, p Table p 8-1 p OBJ: p Theory p #3 p TOP: p Communication p Techniques KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p tells p a p patient, p For p the p last p 2 p days p we p have p talked p about p whether p to

p notify p your p daughter p of p your p upcoming p surgery p in p 2 p days. p You p have p indicated p you p do p not p want p to p be p a p burden p to p her, p but p you p also p would p like p to p have p her p here. p You p may p have p to p decide p rather p quickly p because p of p the p time p constraint. p The p nurse p is p

using p the p technique p of:

• focusing.

• reflection.

• restatement.

• summarizing.

p ANSWER: p D

Summarizing p presents p the p problem p and p possible p solutions p with p the p attendant p difficulties. p This p technique p unclutters p the p problem p and p presents p it p back p to p the p patient p for p his p or p her p choice p of p a p solution.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 104 p OBJ: p Theory p #3 TOP: p Communication p Techniques p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p is p caring p for p a p patient p who p states, p I p tossed p and p turned p last p night. p The

p nurse p responds p to p the p patient, p You p feel p like p you p were p awake p all p night? p This p is p an p

example p of:

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• an p open-ended p question.

• restatement.

• reflection.

• offering p self.

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ANSWER: p B

Restatement p is p a p therapeutic p communication p technique p in p which p the p nurse p restates p in p different p words p what p the p patient p said. p This p encourages p further p communication p on p that p topic.DIF: p Cognitive p Level: p Comprehension p REF: p pp. p 102-103 p OBJ: p Theory p #3 p TOP: p Restatement p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p is p caring p for p a p patient p who p has p just p had p a p mastectomy p (breast p

removal). p The p patient p expresses p concern p that p her p husband p will p no p longer p find p her p attractive p because p of p her p mastectomy. p The p nurse p appropriately p responds:

• Youre p concerned p your p husband p will p find p you p unattractive p because p of p your p mastectomy?

• Youre p a p beautiful p woman; p of p course p your p husband p will p find p you p attractive p after p your p

mastectomy.

• Dont p worry; p when p I p had p my p mastectomy, p my p husband p still p found p me p very p attractive.

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• You p should p leave p your p husband p immediately p if p he p thinks p youre p unattractive p after p a p

mastectomy. p ANSWER: p A

This p is p an p example p of p restatement, p which p allows p the p patient p to p know p her p message p was p understood p and p encourages p the p patient p to p continue p about p her p concerns p on p the p topic.DIF: p Cognitive p Level: p Application p REF: p pp. p 102-103 p OBJ: p Theory p #3 p TOP: p Restatement/Reflection p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p patient p states, p Im p so p worried p that p I p might p have p cancer. p The p nurse p responds,

p It p is p time p for p you p to p eat p breakfast. p The p nurses p response p is p an p example p of:

• using p clichs.

• judgmental p response.

• changing p the p subject.

• giving p false p

reassurance. p ANSWER: p C

Changing p the p subject p is p a p block p to p effective p communication p in p which p the p patient p is p deprived p of p the p chance p to p verbalize p concerns.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 104 p OBJ: p Theory p #3 p TOP: p Changing p the p Subject p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p is p aware p that p the p use p of p false p reassurance p is p harmful p to p the

p nursepatient p relationship, p because p this p communication p block:

• discounts p the p patients p stated p concerns.

• shows p a p judgmental p attitude p on p the p part p of p the p nurse.

• summarizes p the p patients p concerns p and p closes p communication.

• confuses p the p patient p by p giving p

information. p ANSWER: p A

Giving p false p reassurance p is p a p block p to p effective p communication p in p which p the p patients

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p feelings p are p negated p and p in p which p the p patient p may p be p given p false p hope, p which, p if p things p turn p out p differently, p can p destroy p trust p in p the p nurse.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 104 p OBJ: p Theory p #3

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TOP: p False p Reassurance p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p home p health p patient p with p a p bleeding p ulcer p informs p the p nurse p that p she p ate p

a p bowl p of p chili p with p jalapenos. p An p inappropriate p communication p block p with p a p

judgmental p tone p by p the p nurse p would p be:

• Well, p you p have p had p this p problem p long p enough p to p know p what p will p happenyou p certainly p

cant p blame p m

• I p dont p think p that p was p a p smart p thing p for p you p to p do p considering p your p ulcer.

• Well, p you p better p watch p your p stool p for p evidence p of p blood p so p you p can p notify p your p

physician.

• Oh, p poo! p A p bowl p of p chili p every p now p and p then p wont p make p a p lot p of p

difference p to p your p ulcer. p ANSWER: p B

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Judgmental p response p is p a p block p to p effective p communication p in p which p the p nurse p is p judging p the p patients p action. p It p implies p that p the p patient p must p take p on p the p nurses p values p and p is p demeaning p to p the p patient.DIF: p Cognitive p Level: p Analysis p REF: p d. p 105, p Table p 8-2 p OBJ: p Theory p #3 p TOP: p Judgmental p Response KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p patient p tells p the p nurse p that p she p dislikes p the p food p that p is p served p in p the p

hospital. p The p nurse p responds, p Our p cooks p work p very p hard; p the p food p that p is p served p is p very p good. p The p nurses p response p is p an p example p of p the p communication p block p of:

• judgmental p response.

• giving p advice.

• defensive p response.

• using p

clichs. p ANSWER: p C

Defensive p response p is p a p block p to p effective p communication p in p which p the p nurse p responds p by p defending p the p hospital p food. p This p prevents p the p patient p from p feeling p that p she p is p free p to p express p her p feelings.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 105 p OBJ: p Theory p #3 p TOP: p Defensive p Response p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p nurse p caring p for p a p patient p who p fell p off p the p roof p while p he p was p intoxicated p

asks p the p patient, p Why p in p the p world p were p you p on p the p roof p when p you p had p been p drinking? p The p nurses p statement p is p an p example p of p which p type p of p communication?

• Changing p the p subject

• Defensive p response

• Inattentive p listening

• Asking p probing p

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questions p ANSWER: p D

Asking p probing p questions p is p a p block p to p effective p communication p in p which p the p nurse p pries p into p the

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patients p motives p and p therefore p invades p privacy.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 105 p OBJ: p Theory p #3 p TOP: p Probing p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p caring p for p a p patient p who p is p concerned p about p her p 10-pound p weight p

loss p relative p to p her p chemotherapy p tells p the p patient, p Lucky p you! p Every p cloud p has p a p silver p lining. p The p nurses p statement p is p an p example p of p which p type p of p communication p block?

• Defensive p response

• Asking p probing p questions

• Using p clichs

• Changing p the p

subject p ANSWER: p C

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Using p clichs p is p a p block p to p effective p communication p in p which p the p patients p individual p situation p is p negated, p and p the p patient p is p stereotyped. p This p type p of p response p sounds p flippant p and p prevents p the p building p of p trust p between p the p patient p and p the p nurse.DIF: p Cognitive p Level: p Comprehension p REF: p pp. p 105-106 p OBJ: p Theory p #3 p TOP: p Clichs p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p is p caring p for p a p patient p with p a p diagnosis p of p lung p cancer. p The p nurse p

states, p If p I p were p you, p I p would p have p radiation p therapy. p The p nurses p statement p is p an p example p of p which p type p of p communication p block?

• Inattentive p listening

• Giving p advice

• Using p clichs

• Defensive p

response p ANSWER: p B

Giving p advice p is p a p block p to p effective p communication p and p tends p to p be p controlling p and p diminishes p patients p responsibility p for p taking p charge p of p their p own p health.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 105, p Table p 8-2 p OBJ: p Theory p #3 p TOP: p Giving p Advice KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p is p caring p for p a p patient p who p is p concerned p about p living p alone. p The p

best p response p by p the p nurse p is:

• Where p have p you p considered p living?

• Why p dont p you p live p with p your p family?

• I p think p you p should p live p with p your p family.

• If p you p were p my p mom, p Id p have p you p live p

with p me. p ANSWER: p A

Rephrasing p will p help p the p patient p explore p various p alternatives. p The p nurse p should p not p use p phrases p such p as p Why p dont p you, p When p that p happened p to p me, p I p did, p or p I p think

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p you p should. p Rephrasing, p for p example, p Have p you p thought p of p your p options? p or p You p might p want p to p think p about, p or p Have p you

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considered? p will p help p the p patient p explore p various p alternatives. p DIF: p Cognitive p Level: p Application p REF: p d. p

104 p OBJ: p Theory p #3

TOP: p Offering p Alternatives p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p characteristic p that p is p representative p of p the p nursepatient p relationship p is

p that p this p relationship:

• focuses p on p the p nurses p ability p to p build p rapport.

• continues p after p discharge.

• does p not p include p humor.

• focuses p on p the p assessed p patient p health p

problems. p ANSWER: p D

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The p nursepatient p relationship p focuses p on p the p patient, p has p goals, p and p is p defined p by p specific p boundaries. p The p relationship p takes p place p in p the p health p care p setting, p and p boundaries p are p defined p by p the p patients p problems, p the p help p needed, p and p the p nurses p professional p role. p When p the p patient p is p discharged, p the p relationship p ends.DIF: p Cognitive p Level: p Knowledge p REF: p pp. p 106-107 p OBJ: p Theory p #4 p TOP: p NursePatient p Relationship p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• When p communicating p with p an p aphasic p patient, p the p nurse p appropriately:
• speaks p quickly p and p shouts p so p the p patient p can p hear.

• assumes p the p patient p can p understand p what p is p heard.

• speaks p to p the p patients p caregiver p about p the p patient.

• assumes p the p patient p cannot p understand p what p is p

heard. p ANSWER: p B

When p communicating p with p an p aphasic p patient, p the p nurse p assumes p the p patient p can p understand p what p is p heard p even p though p speech p is p jargon p or p the p person p is p mute, p unless p deafness p has p been p diagnosed. p The p nurse p should p talk p to p the p patient, p and p not p talk p to p someone p else p in p the p room p about p the p patient.The p nurse p should p speak p slowly p and p distinctly p and p should p not p shout. p DIF: p Cognitive p Level: p Comprehension p REF: p d. p 108, p Box p 8-1 OBJ: p Clinical p Practice p #3 p TOP: p Impaired p Communication p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• When p communicating p with p a p hearing-impaired p patient, p the p nurse p appropriately:
• shouts p repeatedly p at p the p patient.

• speaks p directly p into p the p patients p ear.

• uses p long, p complex p sentences.

• uses p short, p simple p

sentences. p ANSWER: p D

When p communicating p with p a p hearing-impaired p patient, p the p nurse p appropriately p uses p

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short, p simple p sentences. p The p nurse p should p not p shout p because p this p can p distort p speech p and p does p not p make p the p message p any p clearer. p The p nurse p should p never p speak p directly p into p the p persons p ear. p This p can p distort

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the p message p and p hide p all p visual p cues.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 108, p Box p 8-1 p OBJ: p Clinical p Practice p #3 p TOP: p Impaired p Communication p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

49. When p communicating p with p a p preschooler, p the p nurse p should:

• use p abstract p explanations.

• use p unfamiliar p language.

• use p long, p complex p sentences.

• consider p the p developmental p level, p using p familiar p

words. p ANSWER: p D

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When p interacting p with p a p toddler p or p a p preschooler, p the p nurse p should p focus p on p the p childs p needs p and p concerns. p The p nurse p should p also p use p simple, p short p sentences p and p concrete p explanations p with p familiar p words.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 109 p OBJ: p Clinical p Practice p #3 p TOP: p Communication p with p Children p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• When p communicating p with p an p adolescent, p the p nurse p should p be p very p sensitive p to p avoid:
• asking p embarrassing p questions.

• offering p advice.

• interrupting p frequently.

• using p active p

listening. p ANSWER: p C

An p adolescent p needs p time p to p talk. p The p nurse p should p use p active p listening, p avoid p interrupting, p and p show p acceptance. p The p nurse p should p try p not p to p give p advice.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 109 p OBJ: p Clinical p Practice p #3 p TOP: p Communication p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p physician p informs p the p student p nurse p that p he p would p like p to p give p a p

telephone p order. p The p best p response p by p the p student p is:

• document p the p telephone p order p on p the p physicians p orders.

• ask p another p student p to p listen p as p a p witness p to p the p telephone p order.

• tape-record p the p physician p giving p the p order p to p the p student p nurse.

• ask p the p registered p nurse p to p take p the p telephone

p order. p ANSWER: p D

The p student p nurse p should p have p an p instructor p or p another p registered p nurse p standing p by p to p take p the p new p orders p from p the p physician p because p students p cannot p legally p take p telephone p orders.DIF: p Cognitive p Level: p Application p REF: p d. p 110 p OBJ: p Theory p #6 p TOP: p Telephone p Orders p KEY: p Nursing p

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Process p Step: p N/A p MSC: p NCLEX: p N/A

• A p nurse p is p delegating p to p a p nursing p assistant. p The p most p appropriate p form p of p this p type p of

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communication p would p be:

• Let p me p know p if p Mr. p Jones p temperature p is p high.

• I p need p to p know p if p Mr. p Jones p blood p pressure p is p elevated.

• Come p and p get p me p if p Mr. p Jones p has p a p high p heart p rate.

• If p Mr. p Jones p heart p rate p is p greater p than p 100, p let p

me p know. p ANSWER: p D

It p is p important p to p communicate p well p in p order p to p assign p tasks p and p delegate p to p others p effectively. p The p nurse p should p give p clear, p concise p messages p that p include p the p desired p results.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 110 p OBJ: p Theory p #7 p TOP: p Delegation p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Safe p Effective p Care p

Environment: p coordinated p care

• In p order p to p safeguard p patient p information p when p using p a p computer, p the p nurse p should:

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• only p use p the p computer p located p in p the p nurses p station.

• wait p until p the p end p of p the p shift p and p chart p all p information p at p one p time.

• use p personal p code p words p and p abbreviations p to p disguise p information.

• change p the p computer p password p

frequently. p ANSWER: p D

Computerized p patient p information p requires p extra p vigilance p by p the p nurse p to p safeguard p confidentiality. p Changing p personal p passwords p frequently p helps p safeguard p information. p When p using p the p computer p at p a p health p care p facility, p the p nurse p must p remember p not p to p leave p a p computer p screen p open p when p he p or p she p is p finished. p The p nurse p should p always p log p out p so p that p someone p else p cannot p access p information p using p his p or p her p password p and p must p not p share p his p or p her p password p with p others. p Computers p in p the p nurses p station p are p not p as p convenient p as p those p at p the p bedside p or p in p the p hall. p Personal p codes p and p abbreviations p are p not p useful.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 111 p OBJ: p Theory p #8 p TOP: p Patient p Information p Safety p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

COMPLETION

• Pain p is p often p conveyed p through p non-verbal p communication. p Two p other p common, p

non-verbally p expressed p emotions p are and .

ANSWER:

anxiety; p fear p fear; p anxiety Anxiety p and p fear p can p be p expressed p non-verbally p by p such p behaviors p as p restlessness p and p picking p at p the p bed p covers.DIF: p Cognitive p Level: p Knowledge p REF: p d. p 100 p OBJ: p Theory p #1 p TOP: p Nonverbal p Communication p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• To p elicit p more p information p from p a p patient, p the p nurse p should p ask p questions p that p

require p more p than p a p one-word p answer. p This p type p of p question p is p called .

ANSWER:

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open-ended Open-ended p questions p provide p more p information p than p can p be p gathered p from p closed p questions.

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DIF: p Cognitive p Level: p Knowledge p REF: p d. p 102 p OBJ: p Theory p #1 TOP: p Open-Ended p Questions p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p communication p technique p of gives p the p caregiver p the p opportunity p to p

ask p and p respond p to p questions.

ANSWER:

ISBAR-R

ISBAR-R p format p allows p the p opportunity p to p ask p and p respond p to p questions p concerning p patient p care p during p the p end p of p shift p report. p The p initials p stand p for p introduction, p situation, p background, p assessment, p recommendation, p and p readback.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 110 p OBJ: p Theory p #9 p TOP: p ISBAR-R p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Safe p Effective p Care p

Environment: p coordinated p care p MULTIPLE p RESPONSE

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• The p nurse p is p alert p to p avoid p using p blocks p to p effective p communication p that p

include: p (Select p all p that p apply.)

• changing p the p subject.

• using p non-judgmental p remarks.

• giving p advice.

• asking p probing p questions.

• offering p hope.

• using p

clichs. p ANSWER: p A, p

C, p D, p F Such p behavior p as p changing p the p subject, p giving p advice, p asking p probing p questions p that p probe p into p a p patients p motive, p and p using p clichs p all p block p communication. p Offering p hope p and p giving p remarks p that p are p non-judgmental p are p appropriate p forms p of p communication.DIF: p Cognitive p Level: p Comprehension p REF: p pp. p 104-106 p OBJ: p Theory p #3 p TOP: p Effective p Communication p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• During p the p initial p interview p of p a p patient, p the p nurse p should: p (Select p all p that p apply.)
• assess p the p language p capabilities p of p the p patient.

• use p open-ended p questions.

• limit p the p interview p to p approximately p 30 p minutes.

• assess p comprehension p abilities p of p the p patient.

• make p the p patient p as p comfortable p as p possible.

• obtain p the p patients p medical p history p from p the p

physician. p ANSWER: p A, p C, p D, p E

During p the p initial p assessment, p the p patient p should p be p comfortable p and p the p nurse p should p ask p closed p questions p to p elicit p specific p information. p The p interview p should p last p approximately p 30 p minutes, p and p the p nurse p needs p to p evaluate p the p language p and p

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comprehension p skills p of p the p patient p to p ensure p effective p communication.DIF: p Cognitive p Level: p Comprehension p REF: p pp. p 107-108 p OBJ: p Clinical p Practice p #1 p TOP: p Interview p Skills p KEY: p Nursing p Process p Step: p Implementation

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MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• When p using p the p telephone p to p communicate p with p a p physician p about p a p patient, p the p

student p nurse p should p have p ready: p (Select p all p that p apply.)

• current p information p relative p to p patients p condition p change.

• assessment p of p vital p signs.

• information p on p urinary p output.

• patients p social p security p number p or p hospital p identification p number.

• medications p

received. p ANSWER: p A, p B, p C, p

E

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As p a p rule p the p physician p does p not p need p to p have p the p social p security p number p or p the p hospital p identification p number, p but p does p need p information p on p the p patients p condition, p vital p signs, p urinary p output, p and p medications p received.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 110 p OBJ: p

Theory p #6 p TOP: p Telephone p Communication p with p a p Physician

KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

• The p nurse p will p appropriately p and p deliberately p use p the p closed p question p technique

p when p the p patient p is: p (Select p all p that p apply.)

• being p asked p for p specific p information.

• extremely p anxious p and p unfocused.

• having p difficulty p expressing p feelings.

• confused.

• angry p and p ranting p about p his p lack p of p

medical p care. p ANSWER: p A, p B, p D

Closed p questions p are p useful p for p gaining p specific p information p such p as p age, p address, p and p listing p of p allergies. p Closed p questions p help p the p anxious, p confused, p and p unfocused p patient p to p respond. p Patients p who p are p having p difficulty p expressing p feelings p are p not p aided p by p closed p questions. p Angry p patients p need p to p be p helped p by p silence p or p general p leads.DIF: p Cognitive p Level: p Application p REF: p d. p 102 p OBJ: p Theory p #3 p TOP: p Closed p Questions p KEY: p Nursing p Process p Step: p Intervention p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• Behaviors p that p indicate p to p the p patient p that p the p nurse p is p inattentive p to p the p patients

p concerns p are p such p activities p as: p (Select p all p that p apply.)

• turning p back p to p straighten p the p bedside p table p while p the p patient p is p talking.

• tapping p feet p or p fingers.

• sitting p down p in p a p chair p near p the p bed p with p arms p crossed.

• leaving p a p hand p on p the p door p to p go p out.

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• nodding p and p asking p for p

elaboration. p ANSWER: p A, p B, p C, p D

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Turning p from p the p patient, p tapping p the p feet p or p fingers, p sitting p with p arms p crossed, p and p leaving p the p patient p all p indicate p to p the p patient p that p his p or p her p concerns p are p not p important p and p the p information p is p boring p to p the p nurse. p Nodding p and p asking p for p elaboration p indicate p that p the p nurse p is p attentive p and p focused p on p his p or p her p concerns.

Chapter p 8 p Client p Teaching MULTIPLE p CHOICE

• Before p beginning p to p teach p a p patient p to p give p himself p insulin, p the p nurse p asks, p Have p you p ever

known p anyone p who p gave p himself p insulin p injections? p This p question p is p primarily p designed p to:

• assess p the p patients p learning p needs.

• stimulate p the p patient p to p focus p on p the p teaching p goal.

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• reduce p the p patients p anxiety p relative p to p insulin p injection.

• reduce p the p amount p of p information p the p nurse p has p to p

provide. p ANSWER: p A

Assessing p a p patients p previous p experience p (as p well p as p education, p learning p mode, p and p motivation) p gives p the p nurse p valuable p information p in p developing p a p teaching p plan p tailored p to p the p individual. p It p may p reduce p the p amount p of p information p needed, p or p it p may p increase p it p if p some p of p what p the p patient p knows p is p erroneous.DIF: p Cognitive p Level: p Analysis p REF: p d. p 119 p OBJ: p Theory p #3 TOP: p Assessing p Learning p Needs p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p uses p a p syringe p and p vial p of p insulin p to p show p how p to p draw p up p the p

correct p dose p while p she p explains p the p procedure p to p the p patient. p To p best p promote p

learning, p her p next p step p should p be p to:

• give p the p patient p written p materials p to p study p and p learn p the p procedure.

• have p the p patient p explain p the p procedure p to p the p nurse p to p assess p understanding.

• give p the p patient p a p day p to p allow p him p to p process p and p absorb p the p information.

• have p the p patient p practice p the p procedure p with p the p nurse p

helping. p ANSWER: p D

Kinesthetic, p or p hands-on, p learning p reinforces p the p visual p demonstration. p Immediate p handling p of p the p materials p reduces p anxiety. p Giving p the p patient p reading p materials p or p asking p the p patient p to p explain p verbally p will p not p be p as p effective p as p the p kinesthetic p application.DIF: p Cognitive p Level: p Application p REF: p d. p 116 p OBJ: p Theory p #3 TOP: p Modes p of p Learning p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• In p teaching p an p 82-year-old p patient p to p perform p a p dressing p change p to p be p done p

at p home p after p discharge, p the p nurse p would p adjust p the p teaching p session p to:

• include p another p person p in p the p instruction p because p an p 82-year-old p person p will p be p unable p

to p master p the

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• slow p the p pace p and p frequently p ask p questions p to p assess p comprehension.

• speed p through p the p details p because p age p and p experience p will p shorten p learning p time.

• provide p written p material p and p diagrams p

alone. p ANSWER: p B

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The p older p patient p needs p to p have p the p pace p slowed p and p have p time p to p ask p questions p to p confirm p comprehension. p The p inclusion p of p written p materials p to p reinforce p teaching p is p also p good, p but p should p not p be p the p only p method p of p instruction.DIF: p Cognitive p Level: p Application p REF: p d. p 118 p OBJ: p Theory p #5 TOP: p Factors p Affecting p Learning p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• An p 80-year-old p patient p is p to p be p taught p the p process p of p colostomy p irrigation p and p reattachment p of

the p colostomy p bag. p The p nurses p initial p assessment p prior p to p instruction p should p address p the p patients:

• understanding p of p the p process p of p irrigation.

• familiarity p with p the p irrigation p materials.

• manual p dexterity.

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• motivation p to p

learn. p ANSWER: p D

The p patients p motivation p to p learn p a p new p skill p is p essential p to p the p success p of p the p instruction. p Some p patients p need p to p see p the p advantage p of p independence p to p motivate p them p to p learn. p Manual p dexterity p and p basic p understanding p of p materials p and p process p are p important, p but p initially p the p motivation p needs p to p be p assessed.DIF: p Cognitive p Level: p Analysis p REF: p d. p 119 p OBJ: p Clinical p Practice p #1 p TOP: p Motivation p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p can p assess p her p patients p ability p to p read p and p comprehend p written p

instructions p by p doing p which p of p the p following?

• Asking p the p patient, p Did p you p graduate p from p high p school?

Giving p the p patient p a p printed p instruction p sheet p and p saying, p Some p people p have p difficulty p with p written p i

• find p them p helpful. p Would p these p be p helpful p to p you?

• Asking p the p patient, p Are p you p able p to p read?

Giving p the p patient p some p printed p materials p and p saying, p After p you p have p read p this, p Ill p ask p you p some p qu d.

ANSW

ER: p B

in p them, p to p see p if p youve p learned p it.Graduation p from p high p school p does p not p guarantee p reading p comprehension. p Actually p reading p allows p the p nurse p to p know p if p the p patient p can p read p as p well p as p comprehend.DIF: p Cognitive p Level: p Application p REF: p d. p 119 p OBJ: p Theory p #3 p TOP: p Assessing p Literacy p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p patient p being p assessed p for p pre-operative p learning p needs p says p his p mother p

had p the p same p surgery p by p the p same p surgeon p 3 p years p ago. p The p nurse p should p

design p the p teaching p plan p to:

• do p a p brief p review p of p the p preoperative p teaching, p because p the p patient p is p already p familiar p

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with p the p proce

• teach p thoroughly p as p the p procedure p may p have p changed.

• simply p give p the p patient p a p written p list p of p preoperative p instructions.

• explore p with p the p patient p what p he p knows p about p the p proposed p surgery p and p add p or p correct

p where p necess p ANSWER: p D

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Assessing p a p patients p experience p and p knowledge p allows p the p nurse p to p tailor p the p teaching p to p the p individual. p The p nurse p should p never p assume p that p a p patient p knows p what p he p is p supposed p to p know p and p that p teaching p again p what p the p patient p already p knows p is p a p waste p of p time p or p insults p the p patients p intelligence p and p experience. p Giving p a p list p of p preoperative p instructions p is p simply p impossible.DIF: p Cognitive p Level: p Analysis p REF: p d. p 119 p OBJ: p Theory p #4 TOP: p Assessing p Learning p Needs p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p is p aware p that p the p knowledge p deficit p of p a p postpartum p patient p with p her p first p child p that

can p be p safely p addressed p by p the p community p nurse p after p discharge p is:

• weaning p the p child p from p breast-feeding.

• care p of p the p patients p surgical p incision.

• feeding p the p baby p by p breast p or p bottle.

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• recognizing p signs p or p symptoms p of p

infection. p ANSWER: p A

Priority p teaching p needs p prior p to p discharge p are p those p that p have p to p do p with p physiologic p or p safety p needs. p Thus p feeding p the p baby, p care p of p the p incision p (prevent p infection), p and p recognition p of p signs p that p affect p safety p must p be p addressed p before p discharge. p Weaning p will p not p occur p until p much p later p and p can p be p addressed p safely p by p the p home p health p nurse.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 116 p OBJ: p Theory p #8 p TOP: p Prioritizing p Learning p Needs p KEY: p Nursing p

Process p Step: p Planning

MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• The p nurse p evaluates p the p effectiveness p of p teaching p relative p to p how p to p use p an p eye p

shield p after p eye p surgery p is p to:

• have p the p patient p tell p the p nurse p what p he p is p going p to p do.

• have p the p patient p demonstrate p that p he p can p secure p the p eye p shield.

• ask p the p patient p if p he p has p any p questions p related p to p the p use p of p the p shield.

• call p the p patient p at p home p in p 3 p days p and p ask p if p he p has p been p

wearing p the p shield. p ANSWER: p B

A p return p demonstration p and p explanation p by p the p patient p will p evaluate p whether p the p patients p learning p needs p are p met. p Having p the p patient p describe p the p process p and p ask p questions p might p be p helpful p but p does p not p show p that p the p patient p can p place p the p shield p correctly p (a p psychomotor p skill). p Evaluation p of p teaching p should p be p done p to p allow p time p to p revise p the p teaching p plan p if p the p patient p is p unable p to p meet p the p behavioral p objectives. p Calling p after p discharge p is p too p late p to p correct p problems.DIF: p Cognitive p Level: p Application p REF: p d. p 120 p OBJ: p Theory p #2 p TOP: p Evaluation p of p Learning p KEY: p Nursing p Process p Step: p Evaluation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p will p choose p the p best p time p to p continue p postoperative p teaching p regarding p

wound p care p and p dressings, p which p would p be:

• immediately p after p the p patient p has p been p medicated p for p pain.

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• just p before p the p patient p is p discharged, p so p the p information p is p current.

• when p the p patient p is p comfortable p and p receptive p to p the p teaching.

• the p last p thing p in p the p evening, p after p visitors p have p left, p before p bedtime.

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ANSWER: p C

A p patient p who p is p in p pain, p sedated p from p pain p medication, p or p fatigued p at p the p end p of p the p day p after p visitors p leave p will p not p be p receptive p to p teaching. p Teaching p should p begin p before p discharge p to p improve p learning.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 119 p OBJ: p Theory p #3 p TOP: p Readiness p to p Learn p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p nurse p plans p to p teach p a p 4-year-old p about p what p to p expect p after p his p broken p arm p has p been p

casted

by:

p bringing p a p doll p and p casting p materials p to p the p room, p showing p the p casting p materials p and p actually p casting

• explaining p the p purpose p of p the p cast.

• telling p the p child p that p while p he p is p asleep, p the p doctor p will p take p off p his p arm p and p wrap p it

p up.

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• breaking p up p the p teaching p sessions p into p two p separate p 5-minute p sessions.

• being p treated p as p an p adult p because p this p approach p helps p the p child p to p

feel p grown p up. p ANSWER: p C

Children p benefit p from p teaching p that p is p geared p toward p their p age p and p level p of p understanding. p Teaching p in p short p sessions, p allowing p for p the p childs p brief p attention p span, p will p enhance p teaching. p Children p are p very p literal p and p improbable p stories p will p be p believed.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 118 p OBJ: p Theory p #5 p TOP: p Teaching p a p Child p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p best p way p for p a p nurse p to p reinforce p learning p during p a p return p demonstration p by

p the p patient p is p for p the p nurse p to:

give p recognition p and p praise p for p the p parts p the p patient p does p well p and p to p assist p or p teach p when p the p patient

• or p forgetful.

• watch p quietly p until p the p return p demonstration p is p finished p and p then p list p the p errors.

• instruct p the p patient p to p read p the p written p material p again p when p an p error p is p made.

• stop p the p patient p each p time p he p makes p a p mistake p and p have p him p start p again p after p the p

nurse p reviews p the p p p ANSWER: p A

Praise p and p walking p through p the p procedure p reinforces p learning. p DIF: p Cognitive p Level: p Application p REF: p d. p 117

p OBJ: p Theory p #3

TOP: p Teaching p Methods p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p patient p states, p I p dont p think p Ill p ever p be p able p to p give p myself p an p injection. p The p

best p reply p by p the p nurse p is:

• Everyone p feels p like p that p at p first. p Youll p get p over p it.

• Dont p be p afraid. p Its p an p easy p skill p for p anyone p to p learn.

• What p bothers p you p most p about p the p idea p of p giving p yourself p an p injection?

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• I p know p just p how p you p feel. p I p would p have p trouble p giving p myself p

an p injection. p ANSWER: p C

When p a p patient p lacks p self-confidence, p the p nurse p needs p to p explore p the p patients p feelings. p DIF: p Cognitive p Level: p Application p REF: p d. p 117 p OBJ: p Theory p #4

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TOP: p Confidence p and p Abilities p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p takes p into p consideration p that p when p using p printed p material p for p teaching

p a p 65-year- p old p Middle-Eastern p patient p who p speaks p perfect p English, p the p nurse p

should:

• use p teaching p material p printed p in p English.

• determine p if p the p patient p can p read p English.

• engage p a p translator p to p read p the p English p material p to p the p patient.

• use p English p material p that p is p printed p in p bold p type p on p

white p paper. p ANSWER: p B

Determine p if p the p patient p is p literate p in p English. p If p not, p a p translator p may p be p able p to p rewrite p the p instructions p in p the p preferred p language. p Simply p reading p the p English p version p is p not p helpful p if p the

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patient p is p to p refer p to p the p material p after p discharge. p Bold p print p will p not p help p a p person p who p does p not p read p English.DIF: p Cognitive p Level: p Application p REF: p d. p 119 p OBJ: p Theory p #3 TOP: p Using p Printed p Materials p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• Because p a p person p may p learn p best p in p a p particular p manner, p to p improve p patient p

teaching, p the p nurse p should:

• ask p the p patient p whether p he p learns p best p visually, p aurally, p or p kinesthetically.

• use p a p hands-on p approach, p because p it p works p best p for p most p people.

• test p the p patients p reading p comprehension p before p using p visual p handouts.

• use p a p combination p of p the p three p modes p of p learning p to p enhance

p learning. p ANSWER: p D

Many p people p do p not p know p which p mode p of p learning p is p their p dominant p one, p and p most p people p learn p best p with p a p combination p of p teaching/learning p techniques.DIF: p Cognitive p Level: p Knowledge p REF: p d. p 116 p OBJ: p Theory p #3 TOP: p Learning p Modalities p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• Once p a p teaching p plan p is p formulated p and p placed p in p the p nursing p care p plan p for p

a p hospitalized p patient:

• one p nurse p will p be p designated p to p teach p the p plan p on p a p priority p basis.

• behavioral p objectives p are p used p to p identify p expected p outcomes.

• it p is p printed p and p given p to p the p patient p as p a p guide p for p learning.

• it p outlines p all p that p will p be p taught p before p the p patient p is p

discharged. p ANSWER: p B

Behavioral p objectives p identify p actions p that p can p be p measured; p thus p they p serve p as p evaluation p tools p of p expected p outcomes. p Many p people p are p involved p in p a p teaching p plan, p with p responsibility p designated p in p the p plan. p Not p all p of p the p teaching p plan p may p be p accomplished p during p the p hospital p stay. p Priorities p identify p which p learning p needs p are p most p important p to p teach p before p discharge p and p which p can p be p taught p by p the p

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community p nurse p after p discharge.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 119 p OBJ: p Clinical p Practice p #2

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TOP: p Behavioral p Objectives p KEY: p Nursing p Process p Step: p N/A MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• In p a p skilled p nursing p home, p a p newly p admitted p resident p becomes p terminally p ill p

following p a p cerebrovascular p accident p (CVA). p To p diminish p the p familys p anxiety, p the p nurse p teaches p the p family p members p about p activities p that p are p being p performed p to p provide p care p and p comfort p to p their p loved p one. p This p teaching p is p provided p in p order p to:

• reduce p the p likelihood p of p a p lawsuit p over p the p anticipated p death.

• decrease p the p familys p needs p in p the p expression p of p their p grief.

• increase p the p familys p comfort p in p their p affective p domain.

• enable p the p family p to p be p better p prepared p for p the p

approaching p death. p ANSWER: p C

Teaching p that p addresses p a p persons p feelings, p beliefs, p or p values p addresses p the p affective p domain.

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DIF: p Cognitive p Level: p Comprehension p REF: p d. p 116 p OBJ: p Theory p #3 p TOP: p Affective p Domain p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p designing p a p teaching p plan p for p a p patient p admitted p to p the p hospital p for p

treatment p of p a p heart p problem p after p years p of p treating p the p ailment p at p home p with p herbal p remedies p and p practices p common p in p his p cultural p group p should:

• help p the p patient p to p see p that p using p herbal p remedies p has p not p worked p in p the p past.

• explain p that p cultural p remedies p may p conflict p with p conventional p medicine.

• help p the p patient p to p identify p optimum p outcomes p that p can p be p achieved p through p education p

and p comprom

• ask p family p members p to p intervene p for p the p cessation p of p the p use p of p

cultural p remedies. p ANSWER: p C

A p persons p cultural p values p must p be p considered p in p formulating p a p nursing p care p plan. p Working p with p the p patient p to p identify p what p is p of p value p to p the p patient p can p assist p the p nurse p to p plan p care p that p meets p the p patients p needs p for p education.DIF: p Cognitive p Level: p Application p REF: p d. p 117 p OBJ: p Theory p #4 TOP: p Cultural p Values p and p Expectations p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p recognizes p the p American p Indians p need p for p the p intervention p of p a p

shaman p in p dealing p with p illness p because p the p shaman p helps p the p patient p in p seeking:

• a p sense p of p peace p and p harmony p with p nature.

• a p spiritual p route p to p healing.

• healing p through p the p domination p over p evil.

• support p from p deceased p

ancestors. p ANSWER: p B

The p American p Indian p has p a p strong p belief p that p spiritual p healing p is p essential p to p physical p health. p DIF: p Cognitive p Level: p Knowledge p REF: p d. p 117 p OBJ: p Clinical p Practice p #2 TOP: p Cultural p Values p and p Expectations p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

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19. The p nurse p appropriately p begins p discharge p planning p when:

• the p physician p writes p orders p to p discharge p the p patient.

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• the p patient p feels p ready p to p be p discharged p home.

• it p is p anticipated p the p patient p will p be p discharged p in p 8 p hours.

• the p patient p is p admitted p to p the p health p care p

facility. p ANSWER: p D

Discharge p planning p requires p looking p ahead p in p order p to p meet p the p patients p ongoing p needs p at p home. p It p is p a p process p that p begins p at p the p time p of p admission.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 119 p OBJ: p Theory p #1 p TOP: p Discharge p Planning p KEY: p Nursing p Process p

Step: p Implementation

MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• A p nurse p is p showing p a p diabetic p patient p how p to p draw p insulin p out p of p a p

syringe. p The p mode p of p learning p that p the p nurse p is p using p is learning.

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• auditory

• visual

• kinesthetic

• oral

ANSWER: p B

Visual p learning p is p based p on p learning p through p what p the p learner p sees. p DIF: p Cognitive p Level: p Comprehension p REF: p d. p 116 p OBJ: p Theory p #3 p TOP: p Modes p of p Learning p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p

Integrity: p basic p care p and p comfort

• The p nurse p will p plan p to p offer p the p teaching p session p in p a p quiet p area p in p order p to:
• ensure p that p the p patient p can p hear p what p the p nurse p says.

• reduce p distractions.

• provide p absolute p privacy.

• make p the p environment p more p like p a p

classroom. p ANSWER: p B

Teaching p sessions p are p best p done p in p a p quiet p environment p to p reduce p distractions. p DIF: p Cognitive p Level: p Comprehension p REF: p d. p 119 p OBJ: p Theory p #4 TOP: p Enhancing p Learning p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• When p a p nurse p is p talking p through p a p procedure p or p assisting p the p patient p to p

learn, p the p nurse p encourages p the p patient p to:

• close p her p eyes p and p envision p the p process.

• read p the p listed p steps p written p on p a p poster p board p on p the p wall.

• write p down p the p steps p as p she p performs p them.

• verbalize p each p step p until p the p steps p are p

memorized. p ANSWER: p C

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Writing p down p the p steps p as p they p are p performed p provides p a p guide p in p the p patients p own p words p that p can p be p followed p independently.DIF: p Cognitive p Level: p Application p REF: p d. p 120 p OBJ: p Theory p #3

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TOP: p Modes p of p Learning p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p nurse p who p is p communicating p with p a p school-age p child p about p receiving p

anesthesia p for p surgery p later p this p afternoon p would p best p describe p the p process p by p

saying:

• The p doctor p who p will p be p wearing p a p mask p will p put p a p needle p in p your p arm p and p then p

you p go p to p sleep p for p a

• You p will p just p float p off p to p dreamland p and p after p you p come p back p your p tonsils p will p have

p been p cut p out. p After p the p doctor p puts p medicine p in p your p arm, p you p will p ride p on p a p pony p to p where p fairies p will p take p out p yo c.

d.

ANSW

ER: p D

will p ride p right p back p here.

You p will p be p given p a p ride p on p a p special p bed p to p a p big p room p where p the p doctor p will p give p you p some p medici p you p very p sleepy.

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Children p interpret p language p literally, p so p avoid p idioms p or p stories p that p might p be p frightening p because p they p can p be p easily p misunderstood. p Language p should p be p tailored p to p the p childs p understanding.DIF: p Cognitive p Level: p Application p REF: p d. p 118 p OBJ: p

Theory p #5 p TOP: p Communication p with p School-Age p Child

KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• When p teaching p an p elderly p patient p about p changing p his p dressing, p the p nurse p

would p most p appropriately:

• be p certain p the p patient p is p wearing p his p glasses p and/or p hearing p aid.

• talk p through p the p process p rapidly p to p keep p the p patient p from p becoming p tired.

• wait p for p the p patient p to p ask p any p questions p about p the p procedure.

• point p out p each p mistake p during p the p return p

demonstration. p ANSWER: p A

Special p considerations p when p teaching p the p elderly p include p being p certain p the p patient p is p wearing p glasses p and/or p a p hearing p aid p that p is p turned p on p and p adjusted, p if p needed. p Short p sentences p should p be p used, p and p the p nurse p should p speak p slowly. p Pointing p out p mistakes p without p any p praise p can p diminish p the p confidence p of p the p patient.DIF: p Cognitive p Level: p Application p REF: p d. p 118 p OBJ: p Theory p #5 TOP: p Communication p with p the p Elderly p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p would p identify p an p opportunity p for p a p teachable p moment p in p the p situation

p of p a p patient p who:

• has p just p been p told p of p the p malignancy p of p his p tumor.

• says, p How p will p I p remember p all p the p things p about p my p new p diet?

• has p just p returned p from p surgery p for p a p deviated p septum.

• is p packing p belongings p in p preparation p for p

discharge. p ANSWER: p B

The p teachable p moment p occurs p when p the p patient p is p at p an p optimal p level p of p readiness p to p learn p and p shows p a p willingness p to p apply p that p information.

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DIF: p Cognitive p Level: p Application p REF: p d. p 115 p OBJ: p Theory p #4

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TOP: p Teachable p Moment p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort p MULTIPLE p RESPONSE

• Continuous p learning p needs p for p the p patient p upon p discharge p should p be p

communicated p to p the: p (Select p all p that p apply.)

• visiting p nurse.

• family.

• primary p care p physician.

• pharmacy p or p medical p supply p facility.

• home p health p

aide. p ANSWER: p A, p B, p C

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Health p care p entities p that p need p to p be p aware p of p post-discharge p continuous p learning p needs p include p the p visiting p home p health p nurse, p the p family, p and p the p primary p care p physician. p Pharmacies p and p medical p supply p facilities p are p not p notified. p The p home p health p aide p will p not p be p instructed p by p the p home p health p nurse.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 115 p OBJ: p

Theory p #8 p TOP: p Continued p Teaching p After p Discharge

KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• The p nurse p reminds p the p patient p that p health p instruction p supports p the p goals p of p

Healthy p People p 2020, p which p include: p (Select p all p that p apply.)

• promoting p healthy p behavior.

• increasing p the p life p span.

• providing p equipment p for p self-care.

• ensuring p access p to p adequate p health p care.

• strengthening p community p

relationships. p ANSWER: p A, p D, p E

Health p instruction p supports p the p goals p of p Healthy p People p 2020, p which p include p promoting p healthy p behaviors, p protecting p health, p ensuring p access p to p quality p health p care, p and p strengthening p community p health p promotion p programs.DIF: p Cognitive p Level: p Knowledge p REF: p d. p 115 p OBJ: p Theory p #2 TOP: p Healthy p People p 2020 p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• The p nurse p is p aware p that p the p major p modes p of p learning p are: p (Select p all p that p apply.)
• oral.

• tactile.

• auditory.

• kinesthetic.

• gustatory.

• visual.

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ANSWER: p C, p D, p F

Kinesthetic, p auditory, p and p visual p are p the p major p modes p of p learning. p DIF: p Cognitive p Level: p Knowledge p REF: p d. p 116 p OBJ: p Theory p #3 p TOP: p Modes p of p Learning p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p

Physiological p Integrity: p basic p care p and p comfort

• The p LPN/LVN p is p qualified p to p give p patient p teaching p on p information p relative p to: p

(Select p all p that p apply.)

• disease p process.

• postoperative p care.

• prognosis.

• rehabilitation.

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• disaster p

preparedness. p ANSWER: p A, p B, p

D, p E LPNs p and p LVNs p are p qualified p to p give p teaching p on p topics p relative p to p disease p process, p postoperative p care, p rehabilitation, p and p disaster p preparedness. p Information p on p prognosis p is p not p appropriate.

Chapter p 9 p Recording p and p Reporting Test p Bank p MULTIPLE p

CHOICE

• The p nurse p with p a p patient p who p complains p of p severe p pain p documents p every p 15 p

minutes p about p the p steps p taken p to p try p to p relieve p the p pain p (without p success). p The p nurse p also p documents p the p time p and p content p of p two p calls p made p to p the p patients p physician p requesting p that p the p physician p examine p the p patient p for p unexpected p

complications. p This p documentation p by p the p nurse p is p likely p to:

• cause p the p physician p to p come p to p the p attention p of p the p hospital p administration.

• be p questioned p by p the p nurses p supervisor p for p time p inefficiency.

• be p used p against p the p nurse p if p a p lawsuit p results, p because p it p proves p the p nurse p was p not p

able p to p relieve p the

• justify p insurance p reimbursement p for p an p extended p duration p of p hospitalization p for p

the p patient. p ANSWER: p D

Documentation p of p complications p or p a p patients p changing p condition p is p used p by p insurance p companies p to p justify p payments p for p hospitalization. p Documentation p also p serves p as p evidence p of p standards p of p care p in p a p court p of p law.DIF: p Cognitive p Level: p Application p REF: p d. p 81 p OBJ: p Theory p #4 TOP: p Purposes p of p Documentation p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p patient p who p is p very p angry p and p is p leaving p the p hospital p against p medical p

advice p (AMA) p demands p to p have p the p medical p chart p to p take, p because p it p is p her p

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personal p property. p An p appropriate p response p would p be:

• Certainly. p This p hospital p doesnt p need p to p keep p it p if p you p are p leaving p and p will p not p be p

returning p here.

You p are p entitled p to p the p information p in p your p chart, p but p the p chart p is p the p property p of p the p hospital. p I p will

• copy p made p for p you.

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• The p information p in p your p chart p is p confidential, p and p you p cannot p leave p this p facility p with p

it.

• Because p you p are p leaving p against p the p medical p advice p of p your p physician, p you p may p not p

have p the p chart. p ANSWER: p B

The p chart p is p the p property p of p the p facility, p but p the p patient p has p a p legal p right p to p the p information p in p it p even p if p she p is p leaving p AMA.DIF: p Cognitive p Level: p Application p REF: p d. p 83 p OBJ: p Theory p #3 p TOP: p The p Medical p Record p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• A p student p nurse p is p assigned p to p a p clinical p unit p on p which p one p of p the p patients p is p a p

nationally p known p celebrity. p The p student p reads p the p chart p to p find p out p why p the p celebrity p is p being p treated. p The p student p who p is p not p the p assigned p caregiver p is:

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motivated p to p learn p about p the p health p problem p of p this p patient p and p is p appropriately p seeking p knowledge

• experience.

• doing p appropriate p research p about p nursing p care p as p long p as p information p is p not p divulged.

• violating p the p confidentiality p of p the p patients p record.

neglecting p the p assigned p patient p load p and p should p read p the p unassigned p patients p chart p only p after p his p assi d.

ANSW

ER: p C

completed.A p person p reading p a p patients p chart p who p is p not p involved p in p the p patients p care p is p in p violation p of p confidentiality. p Protecting p the p patients p privacy p is p of p prime p importance.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 83 p OBJ: p Theory p #3 p TOP: p The p Medical p Record p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• A p patient p with p a p nursing p diagnosis p of p Skin p integrity, p impaired, p related p to p surgery p

as p evidenced p by p disruption p of p skin p surface p has p the p following p nursing p documentation: p Incision p clean, p dry, p intact. p No p pain p or p tenderness. p Instructed p to p keep p area p dry, p may p wear p light p dressing p to p protect p from p clothing. p Verbalizes p understanding p of p wound p care p and p ability p to p manage p at p home. p Wound p healing p without p complication. p This p

documentation p is:

• an p example p of p charting p by p exception.

• evidence p of p the p use p of p the p nursing p process.

• using p the p problem-oriented p medical p record p (POMR) p format.

• usually p entered p on p a p flow p sheet p for p treatments p and p

vital p signs. p ANSWER: p B

The p nursing p process p is p evident p in p this p documentation. p Assessment, p interventions, p and p evaluation p are p all p noted.DIF: p Cognitive p Level: p Analysis p REF: p d. p 83 p OBJ: p Theory p #2 TOP: p Methods p of p Charting p KEY: p Nursing p Process p Step: p

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Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• Which p nursing p assessment p is p an p example p of p brevity p and p clarity p while p meeting p legal p guidelines?
• 4 p cm p reddened p area p over p sacrum. p Skin p intact, p warm, p and p dry.

• Taking p fluids p poorly, p but p more p than p yesterday.

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• Apparently p comfortable p all p night. p Offers p no p complaints p of p pain.

• Patient p says p she p is p still p slightly p nauseated, p would p like p to p try p some p

toast p and p tea. p ANSWER: p A

Provision p of p specific p objective p datasize, p location, p and p characteristics p of p the p patients p skinis p clear p and p brief p and p informative.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 92 p OBJ: p Clinical p Practice p #2 p TOP: p The p Charting p Process p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p nurse p enters p a p notation p in p a p patients p chart p but p then p discovers p that p the p

notation p was p made p in p the p wrong p chart. p The p nurse p correctly:

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draws p a p single p line p through p the p notation p so p that p it p is p still p readable p and p writes p mistaken p entry, p his p sign

• and p time.

• removes p the p page p on p which p the p error p is p written p and p rewrites p the p other p correct p notes.

blacks p out p the p note p to p protect p the p confidentiality p of p the p patient p about p whom p it p was p written p and p writes

• wrong p patient, p his p signature, p and p the p date p and p time.

• whites p out p the p wrong p entry p and p writes p the p note p in p the p chart p of p the p

correct p patient. p ANSWER: p A

When p an p error p is p made, p no p attempt p to p hide p or p obliterate p the p error p should p be p made, p because p this p may p be p questioned p in p a p court p of p law.DIF: p Cognitive p Level: p Application p REF: p d. p 96, p Box p 7-4 p OBJ: p Theory p #6 p TOP: p Charting p Error p Corrections p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p resident p in p a p skilled p nursing p facility p for p a p short-term p rehabilitation p following p a

p hip p replacement p says p to p the p nurse, p I p dont p want p to p have p you p draw p any p more p blood p for p those p useless p tests. p When p the p nurse p fails p to p convince p the p patient p to p have p

the p blood p drawn, p the p most p appropriate p documentation p would p be:

• Refuses p to p have p blood p drawn. p Doctor p notified.

• Refuses p to p have p blood p drawn; p says p tests p are p useless. p Doctor p notified.

• Doctor p notified p of p failure p to p draw p ordered p blood p work.

• Blood p not p drawn p because p tests p are p no p longer p desired p

by p patient. p ANSWER: p B

When p a p patient p refuses p a p treatment, p the p nurse p should p document p the p exact p words p of p the p patient p regarding p why p the p patient p is p refusing p care.DIF: p Cognitive p Level: p Application p REF: p d. p 96, p Box p 7-4 p OBJ: p Clinical p Practice p #2 p TOP: p What p to p Document p KEY: p Nursing p Process p Step: p Implementation

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MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p clinic p nurse p is p documenting p in p a p patient p chart p about p the p pain p that p brought p the p

patient p to p seek p medical p attention. p The p best p description p is:

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• Abdominal p pain, p unrelieved p by p antacids. p Had p spaghetti, p salad, p coffee, p and p ice p cream p

cake p for p lunch.

• Severe p pain p around p umbilicus, p unable p to p sleep p because p of p pain. p Started p approximately p 2

p hours p after

• Pain p at p level p of p 7 p to p 8. p Nothing p has p relieved p or p lessened p pain, p it p just p keeps p getting p

worse.

• Peri-umbilical p sharp p pain p at p pain p level p of p 7 p to p 8 p for p last p 3 p hours, p started p 2 p hours p

after p lunch. p No p relie p ANSWER: p D

When p charting p a p sign p or p symptom, p the p nurse p should p include p the p quality p (level p 7 p to p 8), p chronology p (after p lunch, p last p 3 p hours), p and p aggravating p or p alleviating p factors, p as p well p as p associated p symptoms. p DIF: p Cognitive p Level: p Application p REF: p d. p 95, p Box p 7-2 OBJ: p Clinical p Practice p #2 p TOP: p The p Charting p Process p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

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• In p a p chart p for p a p patient p who p has p had p an p allergic p reaction p to p a p drug p and p an p

associated p nursing p diagnosis p of p Skin p integrity, p impaired, p related p to p allergic p reaction p as p evidenced p by p rash p and p hives, p the p nurse p charts p Subjective: p denies p itching. p Happy p with p improvement p in p skin. p Objective: p rash p fading p on p face, p chest, p and p back; p no p hives p visible p on p skin. p Skin p warm, p dry, p and p intact. p Assessment: p skin p integrity p improving. p Plan: p check p rash p daily p until p discharge. p This p type p of p charting p is p an p example p of:

• charting p by p exception.

• narrative p style.

• a p problem-oriented p medical p record p (POMR).

• the p case p management p

system. p ANSWER: p C

The p POMR p focuses p on p a p patient p problem p or p nursing p diagnosis p and p typically p uses p the p SOAP p (subjective, p objective, p assessment, p plan) p format p as p shown p here.DIF: p Cognitive p Level: p Application p REF: p d. p 83 p OBJ: p Theory p #4 p TOP: p Methods p of p Charting p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• In p an p agency p that p uses p specific p protocols p (Standard p Procedures) p and p charting p by p

exception, p an p advantage p compared p with p using p traditional p (narrative p or p problem-oriented)

p charting p is p that p charting p by p exception:

• is p well p suited p to p defending p nursing p actions p in p court.

• contains p important p data p certain p to p be p noted p in p the p narrative p sections.

• allows p staff p to p learn p the p system p quickly p and p easily.

• highlights p abnormal p data p and p patient p

trends. p ANSWER: p D

Charting p by p exception p enables p staff p to p see p notation p of p changes p in p a p patients p condition p at p a p glance. p DIF: p Cognitive p Level: p Comprehension p REF: p d. p 83 p OBJ: p Theory p #4 TOP: p Methods p of p Charting p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• If p an p agency p is p using p computer-assisted p charting, p the p nurse p is p responsible p for:

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• learning p the p passwords p of p the p staff p nurses p and p physicians p so p that p they p can p

communicate p with p one p an

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• guarding p the p confidentiality p of p the p patient p record p by p not p leaving p the p patient p screen p on p

if p he p leaves p th p teaching p the p patient p to p input p information p about p herself, p such p as p intake p and p output p or p symptoms p the p p

• experience.

• choosing p whether p he p will p use p the p computer p to p help p in p charting p or p continue p to p use p

traditional p paper p d p ANSWER: p B

Confidentiality p of p computer p records p is p as p important p as p that p of p the p paper p chart. p Nurses p must p also p be p protective p of p their p user p passwords.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 90, p Box p 7-1 p OBJ: p Theory p #4 p TOP: p Methods p of p Charting KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

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• A p nurse p begins p the p shift p caring p for p a p patient p who p has p just p returned p from p the p

recovery p room p after p surgery. p It p is p most p important p to p document:

• at p the p end p of p the p shift p so p that p the p nurse p can p give p his p full p attention p and p time p to p the p

patients p needs p duri

• a p nursing p care p plan p in p the p chart p before p assessing p the p patient p so p that p the p nurse p can p

identify p priorities.

• at p least p three p times p during p the p shift: p at p the p beginning, p in p the p middle, p at p the p end, p and p

as p needed.

• an p initial p assessment p of p the p patient p and p a p plan p based p on p the p needs p of p the p patient p as p

assessed p at p the p be p ANSWER: p D

An p initial p assessment p should p be p performed p at p the p beginning p of p the p shift p and p promptly p documented. p It p will p determine p the p plan p and p priorities. p Charting p should p be p done p as p close p to p the p time p of p occurrence p as p possible.DIF: p Cognitive p Level: p Application p REF: p d. p 96, p Box p 7-4 p OBJ: p Theory p #1 p TOP: p The p Charting p Process KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p uses p the p flow p sheet p in p patient p care p documentation p primarily:
• to p track p routine p assessments, p treatments, p and p frequently p given p care.

• to p eliminate p written p narratives p and p to p save p time.

• in p computer-assisted p charting p to p create p visual p graphs p showing p change.

• to p improve p continuity p of p care p and p exchange p of p information p among p

disciplines. p ANSWER: p A

Flow p sheets p are p a p time p saver p but p do p not p eliminate p narrative p charting. p They p are p used p to p document p information p that p is p routine p and p that p would p be p lost p in p a p narrative p note.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 83 p OBJ: p Theory p #4 p TOP: p Flow p Sheets p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• In p a p skilled p nursing p facility, p if p all p of p the p following p are p available, p the p best p

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way p for p the p new p nurse p to p obtain p current p information p about p the p needs p and p abilities p

of p his p patients p would p be p to p use p the:

• physicians p order p sheets.

• nurses p admission p history p and p physical.

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• nursing p Kardex.

• most p recent p nurses p

notes. p ANSWER: p C

A p nursing p Kardex p is p a p 1-page p summary p of p the p patients p diagnosis p and p current p orders, p treatments, p and p care p needs.DIF: p Cognitive p Level: p Knowledge p REF: p d. p 93 p OBJ: p Clinical p Practice p #2 p TOP: p Nursing p Kardex p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

• When p the p nurse p charts p in p narrative p or p source-oriented p format p about p the p patients p condition p and

the p nursing p care p provided, p it p is p appropriate p for p him p to p record:

• Patient p will p go p to p physical p therapy p after p lunch.

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• Diabetes p in p excellent p control. p Continue p with p current p insulin p schedule.

• I p gave p the p patient p a p thorough p bath p and p cut p her p fingernails.

d. To p x-ray p by p wheelchair p @ p 10:30 p AM p IV p infusing p in

p left p arm. p ANSWER: p D

Documentation p that p includes p specific p information p regarding p time, p method p of p travel, p destination, p and p current p status p (that p an p IV p medication p is p infusing) p is p a p clear p example p of p source-oriented p charting.DIF: p Cognitive p Level: p Application p REF: p d. p 83 p OBJ: p Theory p #4 TOP: p Source p Oriented p Charting p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

• The p nurse p understands p that p a p face p sheet p contains p information p pertaining p to:
• serial p measurements p and p observations, p such p as p temperature, p pulse, p respiration, p blood p

pressure, p and

• plan p of p care p for p the p patient, p including p nursing p diagnoses, p goals/expected p outcomes, p and p

nursing p inte

• written p report p of p the p nursing p process, p record p of p interventions p implemented, p and p the p

patients p respons

• patient p data, p including p patients p name, p address, p phone p number, p insurance p company, p and p

admitting p di p ANSWER: p D

The p type p of p information p contained p on p a p face p sheet p includes p patient p data, p including p the p patients p name, p address, p phone p number, p next p of p kin, p hospital p identification p number, p religious p preference, p place p of p employment, p insurance p company, p occupation, p name p of p admitting p physician, p and p admitting p diagnosis.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 82, p Table p 7-1 p OBJ: p Theory p #4 p TOP: p Documentation p Forms KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

• A p nurse p understands p that p the p physicians p directives p for p patient p care p are p also p referred p to p as p the:
• history p and p physical.

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• physicians p orders.

• progress p notes.
• face p

sheet. p ANSWER: p B

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The p physicians p directives p for p patient p care p are p the p same p as p the p physicians p orders. p DIF: p Cognitive p Level: p Knowledge p REF: p d. p 82, p Table p 7-1 OBJ: p Clinical p Practice p #4 p TOP: p The p Medical p Record p KEY: p Nursing p Process p Step: p N/A p MSC:

p NCLEX: p N/A

• A p nurse p tells p her p neighbor p personal p information p about p a p hospitalized p patient. p Telling p her

neighbor p about p this p indicates p that p the:

p nurse p is p actively p promoting p nursing p as p a p profession, p and p it p is p important p to p share p information p that p mi

• to p pursue p a p nursing p career.

actions p of p the p nurse p are p appropriate p since p his p neighbor p is p his p confidante, p and p the p neighbor p has p assure

• information p provided p will p not p be p shared.

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nurse p has p violated p the p confidentiality p of p the p patient p by p discussing p personal p information p about p the p pa

• neighbor.

nurse p has p not p violated p the p confidentiality p of p the p patient p because p the p patient p is p terminal; p sharing p this p i d.

ANSW

ER: p C

harm p the p patient.As p a p legal p record, p the p contents p of p the p chart p must p be p kept p confidential p and p can p be p given p out p only p with p the p patients p written p consent p because p it p contains p personal p information p regarding p the p patient. p Only p those p health p professionals p caring p directly p for p the p patient, p or p those p involved p in p research p or p teaching, p should p have p access p to p the p chart. p Protecting p the p privacy p of p the p patient p is p of p prime p importance. p Patient p information p is p not p discussed p with p others p who p are p not p directly p involved p in p the p patients p care.DIF: p Cognitive p Level: p Application p REF: p d. p 83 p OBJ: p Theory p #3 p TOP: p Patient p Confidentiality p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p Quality p and p Safety p Education p for p Nurses p (QSEN) p project p has p

identified p the p most p important p pre-licensing p skills p for p nurses p as:

• effective p communication.

• informatics.

• familiarity p with p medical p terms.

• writing p nursing p care p

plans. p ANSWER: p B

The p Quality p and p Safety p Education p for p Nurses p (QSEN) p project p has p identified p informatics p as p an p important p pre-licensing p skill.DIF: p Cognitive p Level: p Knowledge p REF: p d. p 87 p OBJ: p Theory p #4 TOP: p Informatics p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• Advantages p of p source-oriented p or p narrative p charting p include p all p of p the p following p

except p that p it:

• encourages p documentation p of p normal p and p abnormal p findings.

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• gives p information p on p the p patients p condition p and p care p in p chronological p order.

• indicates p the p patients p baseline p condition p for p each p shift.

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• includes p aspects p of p all p steps p of p the p nursing p

process. p ANSWER: p A

A p disadvantage p of p source-oriented, p or p narrative, p charting p is p that p it p encourages p documentation p of p both p normal p and p abnormal p findings, p making p it p difficult p to p separate p pertinent p from p irrelevant p information.DIF: p Cognitive p Level: p Comprehension p REF: p pp. p 83-84 p OBJ: p Theory p #4 p TOP: p The p Charting p Process p KEY: p Nursing p Process p

Step: p N/A

MSC: p NCLEX: p N/A

• Which p examples p of p documentation p would p be p most p informative p to p transcribe p to p the p patients

medical p record?

• Patient p consumed p two p slices p of p bread p and p a p cup p of p coffee p at p breakfast.

• Patient p does p not p appear p to p be p hungry p after p consuming p breakfast.

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• Patient p ate p a p small p amount p of p bread p and p drank p a p little p coffee p for p breakfast.

• Patient p ate p well p for p breakfast, p lunch, p and p dinner p and p seems

p content. p ANSWER: p A

Use p of p the p words p appears p to p or p seems p in p phrases p such p as p appears p to p be p resting p should p be p avoided. p Chart p the p behavior; p the p patient p either p is p or p is p not p resting. p Words p that p have p ambiguous p meanings p and p slang p should p not p be p used p in p charting. p For p example, p how p much p is p a p little, p a p small p amount, p or p a p large p amount? p What p do p phrases p such p as p ate p well p and p taking p fluids p poorly p mean? p Although p such p words p give p a p general p idea p of p what p is p meant, p they p are p not p specific.DIF: p Cognitive p Level: p Application p REF: p d. p 92 p OBJ: p Theory p #4 TOP: p Source p Oriented p Charting p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care p COMPLETION

• Charting p that p follows p the p nursing p process p and p uses p nursing p diagnoses p while p

placing p the p plan p of p care p within p the p nurses p progress p notes p is charting.

ANSWER:

PIE problem p identification, p intervention, p and p evaluation p The p nurse p needs p to p be p able p to p define p PIE p charting.DIF: p Cognitive p Level: p Knowledge p REF: p d. p 86 p OBJ: p Theory p #2 p TOP: p Documentation p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Safe p Effective p Care p

Environment: p coordinated p care

• Health p care p professionals p assigned p to p a p patient p require p access p to p the p chart p to p

review p information p and p to p document p care p given. p All p contents p of p the p chart p must p be p kept . p The p contents p of p the p chart p should p not p be p discussed p with p persons p who p are p not p involved p in p the p care p of p the p patient.

ANSWER:

confidential The p nurse p needs p to p be p able p to p identify p what p

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confidentiality p entails. p DIF: p Cognitive p Level: p Knowledge p REF: p d. p 83 p OBJ: p Theory p #3 p TOP: p Confidentiality p KEY: p

Nursing p Process p Step: p N/A

MSC: p NCLEX: p N/A

• The p nurse p explains p that p should p a p patient p return p to p the p hospital p for p treatment p within p p

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years, p the p medical p chart p can p be p retrieved p from p medical p records p

for p review. p ANSWER:

10 ten Medical p records p are p kept p in p the p health p information p department p of p a p hospital p for p a p period p of p 10 p years.DIF: p Cognitive p Level: p Knowledge p REF: p d. p 83 p OBJ: p Theory p #3 TOP: p Storage p of p Medical p Records p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

• When p using p a p case p management p system p of p charting p a(n) , p an p unexpected p event

p in p the p patients p condition p is p documented p on p the p back p of p the p pathway p sheets.

ANSWER:

variance

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A p variance p is p an p unexpected p event p in p the p patients p course p of p care. p An p example p would p be p a p healing p wound p that p was p complicated p by p an p infection.DIF: p Cognitive p Level: p Knowledge p REF: p d. p 83, p Figure p 7-10 OBJ: p Theory p #4 p TOP: p Variances p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A MULTIPLE p RESPONSE

• Advantages p of p the p problem-oriented p medical p record p (POMR) p are p that p this p method p

of p charting: p (Select p all p that p apply.)

• promotes p the p problem-solving p approach.

• formats p charting p into p chronological p order.

• makes p tracking p trends p in p patient p care p easy.

• allows p for p easy p auditing p of p patient p records p to p evaluate p staff p performance.

• reinforces p application p of p the p nursing p

process. p ANSWER: p A, p D, p E

POMR p promotes p problem p solving p with p the p reinforcement p of p the p nursing p process. p This p method p allows p for p easy p auditing p of p patient p records.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 85 p OBJ: p Theory p #4 p TOP: p Problem p Oriented p Charting p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p method p of p computer-assisted p charting: p (Select p all p that p apply.)
• improves p communication p between p departments.

• is p less p costly p to p educate p personnel p to p the p method.

• speeds p reimbursement p for p services.

• allows p electronic p records p to p be p retrieved p more p quickly.

• allows p entries p to p be p made p at p point p

of p care. p ANSWER: p A, p C, p D, p E

Computerized p charting p improves p communication p between p departments, p speeds p reimbursement p for p services p and p retrieval p of p records, p and p allows p entries p to p be p made p quickly p at p the p point p of p care. p It p is p more p expensive p to p educate p personnel p in p the p use p of p computers p than p in p other p forms p of p documentation.

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DIF: p Cognitive p Level: p Knowledge p REF: p pp. p 89-90 p OBJ: p Theory p #4 p TOP: p Documentation p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p N/A

• Helpful p cultural p information p the p nurse p should p include p on p the p admission p note p is:

p (Select p all p that p apply.)

• primary p language p spoken.

• number p of p children p in p the p immediate p household.

• beliefs p about p causality p of p illness.

• level p of p English p literacy.

• dietary p concerns.

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ANSWER: p A, p C, p D, p E

Information p relative p to p primary p language, p beliefs p about p cause p of p illness, p level p of p English p literacy, p and p dietary p concerns p are p helpful p items p to p include p on p the p admission p note.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 91 p OBJ: p Theory p #1

Chapter p 10 p Admission, p Discharge, p Transfer, p and p Referrals Test p Bank p MULTIPLE p

CHOICE

• The p nurse p is p aware p that p patients p who p are p admitted p to p the p hospital p as p a p routine p

admission p under p a p managed p care p plan p must:

• have p Medicare.

• be p pre-approved.

• be p able p to p pay p the p deductible.

• be p admitted p several p days p prior p to p the p

procedure. p ANSWER: p B

Managed p care p insurance p programs p require p that p all p routine p admissions p be p pre-approved.p Often p the p patient p is p required p to p come p to p the p hospital p several p days p prior p to p the p admission p to p complete p paperwork p or p lab p procedures.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 392 p OBJ: p Theory p #1 p TOP: p Managed p Care p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

• A p patient p is p scheduled p to p have p a p diagnostic p procedure p performed p on p an p

outpatient p basis p at p 9:00 p AM. p The p nurse p will p advise p the p patient p to:

• arrive p 2 p hours p before p the p scheduled p procedure.

• wear p comfortable p clothing.

• read p printed p materials p about p the p procedure.

• be p prepared p to p pay p at p least p 10% p of p the p predicted p cost p of p the p

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hospitalization. p ANSWER: p A

Patients p are p usually p required p to p arrive p 1 p to p 2 p hours p before p a p scheduled p procedure p to p complete p the p necessary p paperwork. p The p patient p may p be p requested p to p pay p a p co p pay p or p a p deductible, p but p there p is

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no p set p amount.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 392 p OBJ: p Theory p #1 p TOP: p Outpatient p Admission p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Safe p Effective p Care p

Environment: p coordinated p care

• If p there p is p a p prior p authorization p for p hospitalization p required p for p a p routine p

admission, p the p nurse p explains p that p the p notification p to p the p insurance p company p is p the p

responsibility p of p the:

• patient.

• admissions p department p of p the p health p facility.

• patient, p physician, p and p the p admissions p department.

• office p of p the p admitting p

physician. p ANSWER: p D

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The p office p of p the p admitting p physician p is p the p usual p agent p to p get p prior p approval p for p a p hospitalization. p The p admissions p department p confirms p that p all p pre-admission p requirements p are p met.DIF: p Cognitive p Level: p Knowledge p REF: p d. p 392 p OBJ: p Theory p #1 TOP: p Admission p Procedures p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

• The p nurse p orienting p a p new p patient p to p the p unit p would p include:
• expected p cost p of p the p room p per p day.

• location p of p call p bell p and p how p to p use p it.

• calling p the p patient p by p their p first p name p for p less p formality.

• times p of p the p shift p

changes. p ANSWER: p B

Newly p admitted p patients p should p be p treated p with p respect p without p familiarity. p The p physical p arrangement p of p the p room p and p bath, p how p to p work p all p controls, p such p as p the p call p bell, p and p the p names p of p the p nurses p who p will p be p giving p care p should p be p included p in p the p orientation.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 392 p OBJ: p Clinical p Practice p #1 p TOP: p Admission p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p patient p admitted p to p the p hospital p through p the p emergency p department p has p jewelry p

and p a p large p amount p of p money. p The p most p efficient p intervention p about p these p valuables

p would p be:

• send p them p home p with p a p family p member.

• put p them p away p quickly p in p the p patients p closet.

• lock p them p in p the p narcotics p cabinet p on p the p nursing p unit.

• place p them p in p a p valuables p envelope p and p have p them p locked p in p the p

agency p safe. p ANSWER: p A

Valuables p such p as p credit p cards, p money, p or p jewelry p should p be p sent p home p with p a p family p member. p DIF: p Cognitive p Level: p Application p REF: p d. p 393 p OBJ: p Clinical p

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Practice p #1 TOP: p Admission p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• While p admitting p a p patient p from p home p to p the p skilled p nursing p facility, p the p nurse p

notes p that p the p patient p has p brought p medications p that p are p not p included p on p the p physicians p medication p order p sheet.

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The p nurses p best p initial p action p is p to:

• send p the p medications p home p with p a p family p member.

• seal p the p medications p in p an p envelope p and p lock p it p in p the p medicine p cart.

• administer p the p medications p with p the p ordered p medications.

• notify p the p physician p about p the p medications p the p patient p has p

been p taking. p ANSWER: p D

It p is p important p to p notify p the p physician p of p any p medications p the p patient p has p been p taking p at p home p that p are p not p included p in p the p present p orders.DIF: p Cognitive p Level: p Application p REF: p d. p 393 p OBJ: p Clinical p Practice p #1 p TOP: p Admission p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Safe p Effective p Care p Environment: p safety p and p infection p control

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• New p orders p have p been p written p by p the p attending p physician p for p a p patient p admitted

p to p a p skilled p nursing p facility. p After p transcription, p the p orders p will p be p verified p by p

the:

• unit p secretary.

• administrative p RN.

• LPN/LVN p in p charge.

• director p of p

nurses. p ANSWER: p C

In p most p skilled p nursing p facilities, p verification p of p orders p (checking p and p signing p them) p is p performed p by p the p LPN/LVN.DIF: p Cognitive p Level: p Application p REF: p d. p 393 p OBJ: p Clinical p Practice p #1 TOP: p Orders p in p Skilled p Nursing p Facility p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

• When p the p nurse p discovers p that p the p patients p consent p form p for p an p invasive p procedure

p is p incorrect, p the p nurse p should:

• cross p out p the p incorrect p information p and p write p error, p and p then p write p in p the p correct p

information.

• destroy p the p incorrect p form p and p write p a p new p one p correctly.

• cross p out p the p entire p form, p but p leave p it p in p the p chart p as p a p permanent p record.

• notify p the p physician p of p the p error p and p clarify p what p the p physician p prefers p

to p be p done. p ANSWER: p B

The p consent p form p is p considered p a p legal p document p and p should p be p transcribed p accurately p to p prevent p errors; p the p incorrect p one p should p be p destroyed.DIF: p Cognitive p Level: p Application p REF: p d. p 393 p OBJ: p Clinical p Practice p #1 p TOP: p Consent p Forms p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

• A p patients p condition p warrants p a p transfer p from p Intensive p Care p to p a p regular p nursing

p unit p in p the p same p hospital. p Before p assisting p with p the p patients p move, p the p nurse p notes

p that p the p transfer p has p been p authorized p by p the:

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• patient.

• charge p nurse.

• physician.

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• family.

p ANSWER: p C

In p general, p transfers p from p one p nursing p area p to p another p require p a p specific p order p by p the p attending p physician. p The p charge p nurse p of p the p receiving p unit p should p be p notified p as p well p as p the p patient p and p family.DIF: p Cognitive p Level: p Application p REF: p d. p 395 p OBJ: p Clinical p Practice p #3 p TOP: p Transfer p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

• A p newly p admitted p patient p has p his p own p walker p that p he p wishes p to p use p during p this p hospital p stay.

The p responsibility p of p the p nurse p to p this p piece p of p durable p equipment p is p to:

• write p the p patients p name p on p a p wide p piece p of p tape p and p affix p it p to p the p walker.

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• list p the p walker p as p part p of p the p patients p personal p belongings p and p place p the p list p in p his p

chart.

• tell p the p patient p that p personal p walkers p cannot p be p used p in p the p hospital p for p safety p reasons.

• write p a p note p in p the p nursing p care p plan p that p the p patient p has p his p

own p walker. p ANSWER: p A

All p equipment p brought p to p the p hospital p by p the p patient p should p be p clearly p labeled, p usually p with p a p wide p piece p of p tape p on p which p the p patients p name p is p written p in p large p letters.DIF: p Cognitive p Level: p Application p REF: p d. p 395 p OBJ: p Theory p #3 p TOP: p Admission p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p helping p to p organize p the p transfer p of p an p elderly p patient p from p the p acute p

care p facility p to p an p extended p care p facility p will p be p sure p to:

• check p drawers p and p shelves p for p personal p items.

• give p unused p medications p to p the p patient.

• ask p the p business p office p to p send p stored p valuables p to p the p receiving p facility.

• send p a p small p snack p with p the p

patient. p ANSWER: p A

Checking p drawers p and p shelves p for p personal p items p prior p to p a p transfer p is p helpful p in p preventing p loss. p DIF: p Cognitive p Level: p Knowledge p REF: p d. p 395 p OBJ: p Clinical p Practice p #3 TOP: p Transfer p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

• As p a p member p of p the p health p care p team, p the p LPN/LVN p understands p that p discharge p

planning p for p the p hospitalized p patient p begins:

• the p day p before p discharge.

• at p the p time p of p admission.

• immediately p following p diagnostic p procedures p or p surgery.

• as p soon p as p a p family p meeting p is p

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scheduled. p ANSWER: p B

Discharge p planning p begins p at p admission, p especially p if p the p diagnosis p indicates p that p the p patient p will p need p rehabilitation p or p long-term p assistance.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 395 p OBJ: p Theory p #5

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TOP: p Discharge p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

• A p patient p who p is p scheduled p for p discharge p has p items p that p were p stored p in p the p

hospital p safe. p After p retrieving p them, p the p nurse p should p document p their p return p to p the p

patient p by:

• making p an p entry p in p the p physician p progress p notes.

• writing p a p note p to p the p charge p nurse.

• having p the p patient p sign p for p them p as p per p policy.

• asking p the p unit p secretary p to p place p a p note p in p

the p chart. p ANSWER: p C

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Retrieve p any p valuables p stored p in p the p hospital p safe p before p discharge p and p have p the p patient p sign p according p to p policy p and p procedure.DIF: p Cognitive p Level: p Application p REF: p d. p 395 p OBJ: p Theory p #5 p TOP: p Discharge p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Safe p Effective p Care p

Environment: p coordinated p care

• A p patient p has p a p hospital p discharge p order p for p later p that p day. p The p LPN/LVN p

understands p that p part p of p the p discharge p process p to p be p performed p by p the p registered p

nurse p is:

• packing p the p patients p personal p belongings.

• writing p the p discharge p instructions.

• assisting p the p patient p to p get p dressed.

• accompanying p the p patient p to p the p hospital p

entrance. p ANSWER: p B

Written p discharge p instructions p are p prepared p by p the p RN. p The p remaining p duties p can p be p performed p by p the p LPN/LVN.DIF: p Cognitive p Level: p Application p REF: p d. p 396 p OBJ: p Theory p #5 p TOP: p Discharge p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Safe p Effective p Care p

Environment: p coordinated p care

• A p patient p who p has p questions p about p the p availability p of p home p health p services p

after p hospital p discharge p should p be p referred p to p the:

• physician.

• registered p nurse.

• occupational p therapist.

• medical p social p worker p

(MSW). p ANSWER: p D

An p MSW p can p provide p information p about p long-term p planning, p financial p assistance, p and p community p services p available p after p discharge.DIF: p Cognitive p Level: p Application p REF: p d. p 396 p OBJ: p Clinical p Practice p #5 p TOP: p Discharge p KEY: p Nursing p Process p Step: p

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Planning MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

• A p hospitalized p patient p tells p the p nurse p that p he p intends p to p leave p the p hospital, p against p medical

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advice. p The p nurses p initial p action(s) p should p be p to:

• listen p to p the p patient, p answer p questions, p and p offer p to p have p the p supervisor p or p physician p

speak p with p the

• advise p the p patient p that p this p may p mean p that p insurance p would p not p pay p for p this p

hospitalization.

• obtain p a p written p explanation p of p the p reasons p from p the p patient p and p have p the p patient p sign p

at p the p bottom

• call p both p the p supervisor p and p a p family p member p to p try p to p get p the p patient p

to p reconsider. p ANSWER: p A

It p is p the p responsibility p of p the p health p team p to p help p patients p understand p the p significance p of p leaving p against p medical p advice. p Listen p to p what p the p patient p has p to p say p and p offer p to p help p get p the p problem p resolved p without p resorting p to p a p discharge. p If p the p ultimate p decision p is p to p leave, p the p physician p is p notified p and p the p patient p is p asked p to p sign p a p form p indicating p that p he p or p she p is p leaving p against p medical p advice.DIF: p Cognitive p Level: p Application p REF: p d. p 396 p OBJ: p Theory p #5

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TOP: p Discharge p Against p Medical p Advice p

(AMA) p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p patient p is p near p death p and p the p family p is p upset p and p disorganized. p The p

most p helpful p intervention p for p the p patient p and p the p family p would p be p for p the p

nurse p to:

• ask p the p family p the p name p of p their p mortician.

• offer p to p call p the p spiritual p advisor p (e.g., p priest, p minister, p or p rabbi).

• encourage p the p family p to p perform p their p rituals.

• encourage p the p family p to p visit p the p

chapel. p ANSWER: p B

If p death p is p anticipated, p many p people p derive p significant p comfort p from p spiritual p or p religious p beliefs p or p practices.DIF: p Cognitive p Level: p Application p REF: p d. p 397 p OBJ: p Clinical p Practice p #6 p TOP: p Death p of p a p Patient p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• For p the p nurse p to p provide p support p to p families p of p patients p who p have p died, p it p is p most p important p

to:

• have p an p understanding p that p all p people p deal p with p death p in p due p time.

• read p a p number p of p articles p about p death p and p dying.

• have p a p personal p experience p of p a p similar p nature.

• deal p with p personal p feelings p about p death p and p

dying. p ANSWER: p D

Before p someone p can p be p a p support p person p to p someone p who p has p lost p a p loved p one, p he p or p she p must p have p dealt p with p personal p feelings p about p death.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 397 p OBJ: p Clinical p Practice p #6 p TOP: p Death p of p a p Patient p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p psychosocial p adaptation

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• A p nurse p who p was p present p at p the p time p of p the p death p of p a p patient p should p document:
• time p of p death.

• time p at p which p life p signs p ceased.

• notification p of p the p mortuary.

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• which p family p members p were p

notified. p ANSWER: p B

It p is p still p required p in p most p states p for p a p physician p to p pronounce p death. p The p nurse p should p document p when p all p signs p of p life p ceased. p The p name p of p the p person p making p the p pronouncement p and p the p time p should p be p documented.DIF: p Cognitive p Level: p Knowledge p REF: p d. p 397 p OBJ: p Theory p #6 p TOP: p Pronouncement p of p Death p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Safe p Effective p Care p

Environment: p coordinated p care

• A p young p patient p has p died p in p the p emergency p department p after p suffering p severe p trauma. p The

nurse p understands p that p this p patients p family p may p take p comfort p from p the p opportunity p to:

• allow p donation p of p the p patients p organs.

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• view p all p of p the p injuries p to p the p patients p body.

• plan p the p funeral p before p leaving p the p hospital.

• donate p the p patients p belongings p to p

charity. p ANSWER: p A

When p handled p sensitively, p requests p for p organ p donation p can p be p an p opportunity p for p the p family p to p allow p something p good p to p come p out p of p a p personal p tragedy.DIF: p Cognitive p Level: p Application p REF: p d. p 397 p OBJ: p Clinical p Practice p #6 p TOP: p Organ p Donation p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• A p blind, p elderly p patient p is p admitted p to p the p hospital p for p dehydration p and p

weakness. p The p nurse p can p make p the p admission p process p less p stressful p by:

• sending p all p personal p belongings p home p with p family p members.

• performing p the p initial p assessment p in p a p non-hurried p manner.

• providing p a p printed p orientation p handout p regarding p hospital p policy.

• performing p a p quick p assessment p before p orienting p the p patient p to p

the p unit. p ANSWER: p B

Elderly p patients p need p time p and p support p in p adjusting p to p a p hospital p stay. p An p unhurried p manner p will p show p support p and p give p the p patient p a p little p more p time p to p adjust p to p the p change.DIF: p Cognitive p Level: p Application p REF: p d. p 393, p Elder p Care p OBJ: p Clinical p Practice p #3 p TOP: p Admission KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• It p is p determined p that p a p patient p is p brain p dead p after p suffering p a p massive p

cerebral p bleed. p The p physician p has p just p talked p to p the p family p about p removing p the p

patient p from p life p support. p The p nurse p would p anticipate:

• calling p the p coroners p office.

• calling p the p insurance p company.

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• contacting p the p organ p donation p team.

• asking p about p an p

autopsy. p ANSWER: p C

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Requests p for p organ p donation p are p usually p done p by p a p physician p or p a p nurse p trained p for p making p such p requests.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 397 p OBJ: p Clinical p Practice p #6 p TOP: p Organ p Donation p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity

• The p nurse p recognizes p that p an p autopsy p must p be p performed p when p the p patient:
• is p over p 52.

• died p of p unknown p causes.

• has p requested p it p on p admission.

• has p died p in p an p industrial p accident.

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ANSWER: p B

Autopsies p are p required p when p a p patient p has p died p of p unknown p causes. p A p family p may p request p an p autopsy, p but p the p request p must p be p signed p by p the p next p of p kin.DIF: p Cognitive p Level: p Knowledge p REF: p d. p 397 p OBJ: p Theory p #2 p TOP: p Autopsy p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

• The p nurse p is p performing p an p initial p assessment p on p a p patient p with p respiratory p

difficulty. p The p nurse p would p anticipate p documenting p signs p and p symptoms p such p as:

• alteration p in p sensation.

• use p of p accessory p muscles.

• regular p respiratory p pattern.

• excessive p

dryness. p ANSWER: p B

An p example p of p signs p found p in p a p patient p with p respiratory p difficulty p is p use p of p accessory p muscles p of p respiration.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 394, p Table p 23-1 p OBJ: p Clinical p Practice p #2 p TOP: p Assessment KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p is p assisting p with p an p admission p assessment p of p a p patient p with p

hypertension. p While p the p nurse p is p preparing p to p weigh p the p patient, p the p patient p states, p It p is p not p necessary p to p weigh p me, p because p I p weighed p 130 p pounds p last p week. p What p would p be p the p nurses p best p response?

• Are p you p sure p that p your p weight p has p not p changed?

• I p will p write p down p your p stated p weight.

• It p is p important p to p get p a p more p recent p weight.

• Dont p worry; p your p weight p is p

confidential. p ANSWER: p C

The p patient p should p be p weighed p and p measured p rather p than p the p stated p height p and p weight p being p accepted.

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DIF: p Cognitive p Level: p Application p REF: p d. p 394, p Table p 23-1

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OBJ: p Clinical p Practice p #2 p TOP: p Assessment p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p reminds p a p patient p that p if p enrolled p in p a p managed p care p program, p some p

procedures p will p not p be p approved p for p payment, p such p as:

• cosmetic p surgery p to p repair p a p scar p from p an p accident.

• breast p augmentation.

• emergency p admission p for p shortness p of p breath.

• post-mastectomy p breast p

implants. p ANSWER: p B

Elective p cosmetic p surgeries p are p not p covered p by p managed p care p companies. p DIF: p Cognitive p Level: p Comprehension p REF: p d. p 392 p

OBJ: p Theory p #1

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TOP: p Non-payment p for p Procedures p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

27. When p the p orders p have p been p verified, p the p nurse:

• draws p a p line p below p the p orders p and p signs p his p or p her p name p and p the p date.

• signs p his p or p her p name p in p red p immediately p below p the p physicians p signature.

c. writes: p transcribed p by p A p Nurse p at p 0900.

• draws p a p line p down p the p left p margin; p then p signs, p dates, p and p times p the p

transcription. p ANSWER: p D

After p the p verification p of p the p order, p the p nurse p draws p a p line p down p the p left-hand p margin; p then p the p nurse p signs, p dates, p and p times p the p transcription.DIF: p Cognitive p Level: p Application p REF: p d. p 294, p Skill p 19-1 p OBJ: p Clinical p Practice p #2 p TOP: p Documentation KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Safe p Effective p Care p Environment: p coordinated p care

COMPLETION

• An p examination p of p the p remains p of p a p body p by p a p pathologist p to p determine p the p

cause p of p death p is p a(n) .

ANSWER:

autopsy An p autopsy p is p an p examination p of p the p remains p by p a p pathologist p to p determine p the p cause p of p death. p An p autopsy p is p usually p performed p when p the p patient p has p died p of p unknown p causes, p has p died p at p the p hands p of p another, p or p has p not p been p seen p within p a p specific p period p of p time p by p a p physician.DIF: p Cognitive p Level: p Knowledge p REF: p d. p 297 p OBJ: p Theory p #6 p TOP: p Post p Mortem p KEY: p Nursing p Process p

Step: p N/A

MSC: p NCLEX: p N/A MULTIPLE p RESPONSE

• The p nurse p is p orienting p an p elderly p patient p newly p admitted p to p the p nursing p

unit. p Which p are p appropriate p interventions p to p apply p to p alleviate p the p patients p

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anxiety? p (Select p all p that p apply.)

• Call p the p patient p by p his p first p name.

• Instruct p the p patient p on p the p use p of p the p call p light.

• Encourage p the p patient p to p ask p questions p regarding p admission.

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• Allow p extra p time p for p the p patient p to p process p any p new p information.

• Lock p all p patient p valuables p in p the p facilitys p safe p

storage. p ANSWER: p B, p C, p D

Respectful p and p proper p communication, p especially p during p orientation p of p the p patient p to p the p facility, p alleviates p anxiety. p It p is p best p to p orient p the p patient p to p the p room, p including p the p use p of p the p call p light, p and p to p allow p the p patient p time p to p process p information p and p ask p questions.DIF: p Cognitive p Level: p Application p REF: p pp. p 392-393 p OBJ: p Theory p #3 p TOP: p Health p Education p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Health p Promotion p and p Maintenance

• A p patient p dies p after p suffering p a p severe p cerebrovascular p accident p (CVA). p The p

family p members p are p informed p of p his p demise p and p are p at p the p bedside. p What p documentation p should p be p noted p in p the p patients p chart? p (Select p all p that p apply.)

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• Results p of p the p autopsy

• Who p pronounced p the p patient

• Official p time p of p death

• Time p vital p signs p ceased

• Why p the p patient p

died p ANSWER: p B, p C, p D

Death p must p be p accurately p noted p in p the p medical p record p and p should p include p who p pronounced p the p patients p death, p the p time p vital p signs p ceased, p and p the p official p time p of p death.DIF: p Cognitive p Level: p Application p REF: p d. p 397 p OBJ: p Clinical p Practice p #6 p TOP: p Pronouncement p of p Death p KEY: p Nursing p Process

p Step: p N/A

MSC: p NCLEX: p Physiological p Integrity

• The p nurse p appreciates p that p a p routine p hospital p admission p differs p from p an p emergency

p admission p in p that p a p routine p admission: p (Select p all p that p apply.)

• is p scheduled p in p advance.

• is p not p stressful.

• is p completely p covered p by p insurance.

• has p a p predictable p outcome.

• allows p time p to p arrange p for p disruptions p in p

routine. p ANSWER: p A, p E

Routine p admissions p are p scheduled p in p advance p with p the p full p knowledge p and p permission p of p the p third-party p payer. p Routine p admissions p allow p for p time p to p arrange p for p disruptions p in p a p familys p routine. p All p hospital p admissions p can p be p stressful p and p potentially p have p unpredictable p outcomes. p Insurance p may p not p completely p cover p the p expense.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 391 p OBJ: p Theory p #1 p TOP: p Routine p Admissions p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Safe p Effective p Care p

Environment: p coordinated p care

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• The p nurse p explains p that p the p Admitting p Department p of p the p acute p care p facility p has p

a p number p of p significant p duties, p which p include: p (Select p all p that p apply.)

• arranging p for p pre-admission p lab p work p and p radiographs.

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• notifying p the p patients p spiritual p counselor p of p the p admission.

• confirming p that p all p admission p criteria p are p met.

• arranging p for p special p diets.

• making p arrangements p for p co-pays p and p

deductibles. p ANSWER: p C, p E

The p Admitting p Department p handles p all p the p paperwork p necessary p for p hospitalization p prior p to p the p actual p admission. p They p confirm p that p all p pre-admission p studies p have p been p done p and p the p insurance p company p is p in p accordance p with p the p admission. p They p will p also p keep p track p of p co-pays p and p deductibles p of p the p patients p insurance.

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Chapter p 11 p Vital p Signs p Test p Bank p MULTIPLE p

CHOICE

• The p nurse p would p anticipate p a p patient p diagnosed p with p damage p to p the p

hypothalamus p after p suffering p a p head p injury p from p a p fall p to p exhibit:

• a p blood p pressure p elevation.

• a p temperature p abnormality.

• a p decrease p in p pulse p rate.

• depressed p

respirations. p ANSWER: p B

The p hypothalamus, p which p is p located p between p the p cerebral p hemispheres, p controls p body p temperature. p Any p damage p to p the p hypothalamus p prevents p the p body p from p regulating p its p temperature.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 335 p OBJ: p Theory p #1 p TOP: p Vital p Signs: p Temperature p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p documents p vital p signs p on p a p newly p admitted p patient p as: p blood p pressure p

is p 148/94 p mm p Hg, p the p pulse p is p 80 p beats/min, p and p the p respirations p are p 16 p breaths/min. p The p nurse p would p record the p pulse p pr essure p as mm p Hg.

• 14
• 54
• 64

d.

ANSWE

R: p B

80 In p calculating p pulse p pressure, p take p the p difference p between p the p systolic p and p diastolic p pressures p (i.e., p 148 p 94 p = p 54).DIF: p Cognitive p Level: p Analysis p REF: p d. p 356 p OBJ: p Clinical p

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Practice p #4 p TOP: p Vital p Signs: p Blood p Pressure p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• A p patient p has p been p admitted p with p hypothermia p after p lying p unconscious p overnight p in

p an p unheated p apartment. p The p most p appropriate p route p to p assess p the p patients p core p

temperature p would p be:

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• rectal.

• tympanic p arterial p thermometer.

• axillary.

• tympanic.

p ANSWER: p D

The p same p blood p vessels p serve p the p hypothalamus p and p the p tympanic p membrane, p so p the p tympanic p temperature p is p an p excellent p indicator p of p core p body p temperature, p although p it p can p be p affected p by p ear p wax.DIF: p Cognitive p Level: p Application p REF: p d. p 339 OBJ: p Theory p #3 p | p Clinical p Practice p #1 p TOP: p Vital p Signs: p Temperature p KEY: p Nursing p Process p Step: p Implementation

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MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p would p document p a p patient p as p being p febrile p if p the p patients p temperature p was p over

p F.

• 99.5
• 99.8
• 100

d.

ANSWE

R: p D

100.5 A p patient p with p a p temperature p above p the p normal p range p (100.2 p F) p is p called p febrile. p DIF: p Cognitive p Level: p Knowledge p REF: p d. p 339 p OBJ: p Theory p #3 TOP: p Vital p Signs: p Temperature p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• To p ensure p an p accurate p reading p when p using p a p glass p oral p thermometer, p it p is p necessary p to:
• rinse p the p thermometer p with p water.

• wipe p the p thermometer p with p alcohol.

• shake p down p the p galinstan p alloy p to p below p normal.

• dry p the p thermometer p with p a p dry p

cotton p ball. p ANSWER: p C

Oral p thermometers p remain p at p the p last p reading p until p they p are p shaken p down; p therefore, p for p accuracy, p the p thermometer p must p be p below p normal p range p before p using.DIF: p Cognitive p Level: p Application p REF: p d. p 342 p OBJ: p Clinical p Practice p #1 p TOP: p Vital p Signs: p Temperature p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p taking p an p apical p pulse p would p place p the p stethoscope p at:
• the p left p of p the p sternum p at p the p third p intercostal p space.

• directly p below p the p sternum.

• slightly p above p the p left p nipple.

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• the p left p midclavicular p line p at p the p fifth p intercostal

p space. p ANSWER: p D

The p apical p pulse p is p determined p by p placing p a p stethoscope p on p a p point p midway p between p the

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imaginary p line p running p from p the p midclavicle p through p the p left p nipple p in p the p fifth p intercostal p space. p DIF: p Cognitive p Level: p Application p REF: p d. p 350, p Skill p 21-4 OBJ: p Theory p #2 p | p Clinical p Practice p #2 p TOP: p Vital p Signs: p Pulse p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p would p record p a p pulse p as p bradycardic p if p the p rate p were beats/min.
• 64
• 62
• 60
• 59

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ANSWER: p D

Bradycardia p indicates p a p slow p pulse p that p is p less p than p 60 p beats/min. p DIF: p Cognitive p Level: p Comprehension p REF: p d. p 349 p OBJ: p Theory p #3 p TOP: p Vital p Signs: p Pulse p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p

Integrity: p basic p care p and p comfort

• The p nurse p is p aware p that p the p use p of p an p oral p glass p thermometer p would p be p contraindicated p in p a:
• 5-year-old p with p a p facial p laceration.

• 12-year-old p patient p with p a p recent p seizure.

• 15-year-old p with p an p abscessed p tooth.

• 20-year-old p with p severe p

dehydration. p ANSWER: p B

The p rectal p method p is p best p for p patients p who p have p seizure p activity p so p as p not p to p put p them p at p risk p for p biting p and p breaking p the p thermometer.DIF: p Cognitive p Level: p Application p REF: p d. p 339 p OBJ: p Clinical p Practice p #1 p TOP: p Vital p Signs: p Temperature p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p anticipates p that p if p the p stroke p volume p of p a p patient p is p reduced, p the p pulse p will p be:
• stronger.

• weaker.

• bradycardic.

• irregular.

p ANSWER: p B

A p weak p pulse p will p result p if p the p stroke p volume p is p reduced, p because p this p decreases p circulating p volume.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 337 p OBJ: p Theory p #2 p TOP: p Vital p Signs: p Pulse p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• When p caring p for p a p victim p with p a p gunshot p wound p to p the p abdomen p who p has p

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lost p a p significant p amount p of p blood, p the p nurse p would p anticipate p the p vital p signs p to p

reflect:

• increase p in p temperature.

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• decrease p in p blood p pressure.

• decrease p in p pulse.

• decrease p in p

respirations. p ANSWER: p B

If p blood p volume p decreases, p as p with p bleeding, p blood p pressure p decreases. p DIF: p Cognitive p Level: p Analysis p REF: p d. p 351, p Table p 21-2 OBJ: p Theory p #2 p TOP: p Vital p Signs: p Blood p Pressure p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• When p a p frail p 83-year-old p patient p whose p temperature p was p 96.8 p F p at p 8:00 p

AM p shows p a p temperature p of p 98.6 p F p at p 4:00 p PM, p the p nurse p is:

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• pleased p that p the p temperature p has p come p up p to p normal.

• satisfied p that p the p patient p is p warm p enough.

• concerned p about p the p evidence p of p fever.

• relieved p that p the p patient p is p

improving. p ANSWER: p C

In p older p patients p who p have p a p frail p frame, p the p normal p temperature p is p often p 97.2 p F. p An p elevation p of p 2 p F p is p indicative p of p fever.DIF: p Cognitive p Level: p Application p REF: p d. p 340, p Elder p Care p OBJ: p Theory p #4 p TOP: p Vital p Signs p in p the p Elderly KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• A p patient p who p is p terminally p ill p is p described p during p shift p report p as p having p

Cheyne-Stokes p breathing. p On p assessment, p the p nurse p anticipates p finding:

• a p breathing p pattern p of p dyspnea p followed p by p a p short p period p of p apnea.

• rapid p wheezing p respirations p for p two p or p three p breaths p with p short p periods p of p apnea.

• quick p shallow p respirations p with p long p periods p of p apnea.

• respirations p gradually p decreasing p in p rate p and p

depth. p ANSWER: p A

Cheyne-Stokes p respirations p are p faster p and p deeper p rather p than p slower p and p are p followed p by p a p period p of p no p breathing.DIF: p Cognitive p Level: p Analysis p REF: p pp. p 354-355 p OBJ: p Theory p #5 p TOP: p Vital p Signs: p Respirations p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p explains p to p a p patient p that p the p pulse p oximeter p can p measure p the p arterial p oxygen p by:
• assessing p the p amount p of p blood p passing p through p the p sensor.

• assessing p the p relative p warmth p of p the p skin p on p the p monitored p part.

• measuring p the p oxygenated p hemoglobin p through p a p capillary p bed.

• measuring p the p respirations p to p the p blood p pressure p via p

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infrared p rays. p ANSWER: p C

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The p pulse p oximeter p measures p oxygen p saturation p by p means p of p a p sensor/probe p attached p to p peripheral p digits, p an p earlobe, p the p nose, p or p the p forehead p as p it p passes p through p the p capillary p bed. p Oxygenated p blood p absorbs p more p infrared p than p red p light.DIF: p Cognitive p Level: p Comprehension p REF: p d. p 355 p OBJ: p Theory p #5 p TOP: p Vital p Signs: p Pulse p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• Because p the p elderly p have p non-elastic p blood p vessels, p they p are p prone p to p orthostatic p hypotension.

A p priority p intervention p for p a p patient p with p orthostatic p hypotension p is p to:

• keep p the p patient p in p bed p in p a p high p Fowlers p position.

• allow p the p patient p to p sit p on p the p side p of p the p bed p for p a p minute p before p standing.

• instruct p the p patient p to p use p the p wheelchair p for p all p mobility p activity.

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• help p the p patient p to p rise p quickly p and p support p the p patient p for

p a p minute. p ANSWER: p B

The p elderly p often p experience p orthostatic p hypotension p and p are p at p risk p for p falls p and p should p be p encouraged p to p sit p on p the p side p of p the p bed p a p minute p before p standing. p These p patients p also p benefit p from p the p use p of p elastic p stockings.DIF: p Cognitive p Level: p Application p REF: p d. p 361, p Elder p Care p OBJ: p Theory p #2 p TOP: p Orthostatic p Hypotension KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Safe p Effective p Care p Environment: p safety p and p infection p control

• An p elderly p patient p has p a p tympanic p temperature p of p 96.2 p F p (35.7 p C). p What p nursing

p intervention p would p best p meet p this p patients p need?

• Take p the p patients p vital p signs p every p 4 p hours, p including p temperature.

• Provide p fluids p to p increase p circulation.

• Increase p room p temperature p to p 72 p F p (22.2 p C) p and p add p blankets p to p the p bed.

• Check p the p temperature p orally p to p confirm p the p accuracy p of p the

p reading. p ANSWER: p C

Nursing p interventions p for p treating p hypothermia p should p focus p on p reducing p heat p loss p and p supplying p additional p warmth, p such p as p increasing p the p room p temperature p and p adding p blankets p to p the p bed.DIF: p Cognitive p Level: p Application p REF: p d. p 341 p OBJ: p Theory p #3 TOP: p Vital p Signs: p Temperature p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p using p either p a p regular p or p an p electronic p sphygmomanometer p would p

ensure p that p the p cuff p is p the p correct p size p by:

• using p a p narrow p cuff p for p an p obese p patient.

• making p sure p the p width p of p the p bladder p is p at p least p 3 p inches.

• confirming p that p the p bladder p goes p around p three p fourths p of p the p arm.

• always p using p a p wide p

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cuff. p ANSWER: p C

For p accuracy p in p a p BP p reading, p the p cuff p of p the p sphygmomanometer p should p have p a p bladder p that p goes p around p three p fourths p of p the p arm.

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DIF: p Cognitive p Level: p Comprehension p REF: p d p 358, p Skill p 21-6 p OBJ: p Clinical p Practice p #4 p TOP: p Vital p Signs: p Blood p Pressure p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• For p the p nurse p to p assess p the p most p accurate p respiration p count, p the p nurse p should:
• inform p the p patient p about p his p respirations p and p ask p him p to p breathe p normally.

• count p each p inhalation p and p expiration p for p 1 p full p minute.

• watch p the p patients p chest p rise p and p fall p from p a p distance.

• continue p to p hold p the p patients p radial p pulse, p and p count p the p respirations p for p 30 p seconds p

and p multiply p the p ANSWER: p D

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The p respirations p should p be p counted p for p 30 p seconds p and p multiplied p by p 2 p if p they p are p regular. p If p the p patient p knows p the p nurse p is p assessing p the p respiration, p he p or p she p may p alter p breathing.DIF: p Cognitive p Level: p Application p REF: p d p 350, p Skill p 21-5 p OBJ: p Clinical p Practice p #3 p TOP: p Vital p Signs: p Respirations p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• Elderly p patients p with p hypertension p may p have p an p auscultatory p gap p in p their p Korotkoff

p sounds. p It p is p important p when p taking p their p blood p pressure p measurement p to:

• continue p to p listen p until p the p cuff p is p deflated.

• pump p up p the p cuff p until p no p sound p is p heard p and p then p let p the p air p out.

• make p sure p the p bell p of p the p stethoscope p is p placed p firmly p over p the p artery.

• stop p midway p and p begin p to p inflate p

again. p ANSWER: p A

Many p older p adults p with p hypertension p have p an p auscultatory p gap p in p their p Korotkoff p sounds, p making p it p important p to p listen p until p the p cuff p is p deflated p to p avoid p mistaking p the p auscultatory p gap p as p the p Korotkoff p sound.DIF: p Cognitive p Level: p Application p REF: p d p 360 p OBJ: p Theory p #6 TOP: p Vital p Signs p in p the p Elderly p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• Regarding p the p blood p pressure p in p children, p the p diastolic p pressure p is p

assessed p by p the p auscultation p of p a:

• clear p tapping p that p gradually p grows p louder.

• murmur p or p swishing p sound p that p increases p with p depression p of p the p cuff.

• sudden p change p or p muffling p of p the p sound.

• louder p knocking p sound p that p occurs p with p each p

heartbeat. p ANSWER: p C

A p sudden p change p or p muffling p sound p (Phase p IV) p indicates p the p diastolic p pressure p in p children p and p in p some p adults.

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DIF: p Cognitive p Level: p Application p REF: p d p 360 p OBJ: p Clinical p Practice p #4 p TOP: p Vital p Signs p in p Children p KEY: p Nursing p Process

p Step: p Assessment

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MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p covers p a p newborn p babys p head p with p a p cap, p because p the p head:
• is p wet p and p needs p to p be p dried.

• has p large p fontanels.

• allows p loss p of p body p heat.

• can p be p reshaped p more p

quickly. p ANSWER: p C

Infants p lose p considerable p body p heat p through p the p scalp; p therefore p a p cap p helps p prevent p heat p loss. p DIF: p Cognitive p Level: p Application p REF: p d p 341, p Elder p Care OBJ: p Theory p #3 p TOP: p Vital p Signs: p Infant p Temperature p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

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• The p nurse p is p caring p for p a p patient p who p had p a p cardiac p catheterization p 2 p hours p

ago p and p has p a p pressure p dressing p to p his p left p groin. p In p addition p to p taking p routine p

vital p signs, p the p nurse p should p also p check p the:

• strength p of p the p femoral p pulse.

• presence p of p the p pedal p pulse.

• temperature p of p the p right p foot.

• ability p to p move p the p left p

toes. p ANSWER: p B

Pedal p pulses p are p checked p to p determine p whether p there p is p any p blockage p in p the p artery p following p a p cardiac p catheterization.DIF: p Cognitive p Level: p Application p REF: p d p 351 p OBJ: p Clinical p Practice p #7 p TOP: p Pedal p Pulse p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p accuracy p in p measuring p the p apical p pulse p is p enhanced p when p the p nurse:
• counts p the p radial p pulse p at p the p same p time.

• counts p the p beats p for p one p minute.

• keeps p the p patient p warm.

• uses p the p bell p of p the p

stethoscope. p ANSWER: p B

Using p the p diaphragm p of p the p stethoscope, p the p nurse p counts p the p beats p for p 1 p full p minute. p DIF: p Cognitive p Level: p Application p REF: p d p 350, p Skill p 21-4 OBJ: p Clinical p Practice p #2 p TOP: p Counting p Apical p Pulse p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p 45-year-old p patient p who p is p alert p and p oriented p has p a p blood p pressure p of p 98/66 p

mm p Hg, p radial p pulse p of p 76 p beats/min p (irregular), p and p respirations p of p 18 p breaths/min p

(regular). p The p best p nursing p intervention p is p to:

• notify p the p charge p nurse p of p the p hypotension.

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• notify p the p doctor p of p the p bradycardia.

• check p medications p that p might p be p the p cause p of p the p irregularity.

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• check p the p patients p record p to p determine p his p baseline p blood p

pressure. p ANSWER: p D

Check p to p see p what p the p patients p baseline p vital p signs p indicate p regarding p the p cardiac p arrhythmia. p DIF: p Cognitive p Level: p Application p REF: p d p 350, p Skill p 21-4 OBJ: p Clinical p Practice p #6 p TOP: p Vital p Signs p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p nurse p is p caring p for p a p patient p with p a p cardiac p disease p history. p When p measuring p vital p signs, p the

nurse p finds p that p the p radial p pulse p is p 102 p beats/min p and p irregular. p The p nurse p correctly:

• listens p to p the p apical p pulse p for p 1 p full p minute.

• takes p the p pulse p for p 30 p seconds p on p the p other p wrist.

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• records p the p findings p on p the p graphic p sheet.

• takes p the p pulse p for p 1 p full p minute p on p the p

other p wrist. p ANSWER: p A

An p apical p pulse p is p measured p whenever p the p radial p pulse p is p irregular p or p when p the p patient p has p a p cardiac p disease p history.DIF: p Cognitive p Level: p Application p REF: p d p 358, p Skill p 21-6 p OBJ: p Clinical p Practice p #2 p TOP: p Vital p

Signs: p Pulse

KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p caring p for p a p 30-year-old p postsurgical p patient p would p assess p that p the p

patient p is p in p pain p as p indicated p by:

• a p temperature p of p 102 p F.

• respirations p of p 16 p breaths/min.

• a p pulse p rate p of p 120 p beats/min.

• blood p pressure p of p 128/86 p mm p

Hg. p ANSWER: p C

Pain p increases p the p pulse p rate.DIF: p Cognitive p Level: p Application p REF: p d p 351, p Table p 21-2 OBJ: p Theory p #2 p TOP: p Vital p Signs p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p explains p that p one p method p of p environmental p heat p loss p is p

convection, p which p is p exemplified p by p body p heat p being p reduced p by:

• being p transferred p to p ice p packs.

• production p of p sweat.

• being p removed p by p fast p air p currents p from p a p fan.

• exposure p to p a p cool p

environment. p ANSWER: p C

Heat p loss p through p convection p can p be p accomplished p by p the p use p of p a p fan, p which p

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produces p fast p air p currents.DIF: p Cognitive p Level: p Comprehension p REF: p d p 335 p OBJ: p Theory p #1

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TOP: p Heat p Loss p by p Convection p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p home p health p nurse p is p instructing p a p caregiver p about p caring p for p a p patient p with p

hypothermia. p The p nurse p recognizes p that p further p instruction p is p warranted p when p the p

caregiver p states, p I p will:

• offer p warm p fluids p to p the p patient, p if p permitted.

• instruct p the p patient p to p remain p on p strict p bed p rest.

• provide p the p patient p with p additional p blankets.

• encourage p the p patient p to p increase p his p muscle p

activity. p ANSWER: p B

Nursing p activities p for p treating p the p patient p with p a p below-normal p body p temperature p should p focus p on p reducing p heat p loss p and p supplying p additional p warmth. p These p activities p may p include p (1) p providing

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additional p clothing p or p blankets p for p warmth p (an p electric p blanket p is p most p effective p for p raising p temperature); p (2) p giving p warm p fluids, p if p permitted; p (3) p adjusting p the p temperature p of p the p room p to p 72 p F p or p higher; p (4) p eliminating p drafts; p and p (5) p increasing p the p patients p muscle p activity.DIF: p Cognitive p Level: p Analysis p REF: p d p 341 p OBJ: p Theory p #3 TOP: p Vital p Signs: p Hypothermia p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort p COMPLETION

• The p nurse p clarifies p the p average p cardiac p output p in p the p adult p is p about

L/minute. p ANSWER:

5 five The p average p cardiac p output p of p the p normal p adult p is p about p 5 p L/minute. p DIF: p Cognitive p Level: p Knowledge p REF: p d p 337 p OBJ: p Theory p #2 p TOP: p Cardiac p Output p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p

Integrity: p physiological p adaptation

• The p nurse p converts p the p Fahrenheit p temperature p of p 99.2 p to p a p Celsius p reading

p of . p ANSWER:

37.3 To p convert p Fahrenheit p to p Celsius: p subtract p 32 p from p the p Fahrenheit p reading p and p

multiply p by p 5/9: p 99.2 p 32 p = p 67.2 p 5 p = p 336 p / p 9 p = p 37.3.

DIF: p Cognitive p Level: p Analysis p REF: p d p 338, p Table p 21-1 OBJ: p Clinical p Practice p #1 p TOP: p Conversion p of p Fahrenheit p to p Celsius p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort MULTIPLE p RESPONSE

• Standards p of p the p Joint p Commission p state p that p pain p is p the p fifth p vital p sign p

and p should p be p documented p by p assessments p of: p (Select p all p that p apply.)

• location.

• duration.

• usual p methods p of p relief.

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• character.

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• intensity.

p ANSWER: p A, p B, p

D, p E Pain p should p be p monitored p when p vital p signs p are p monitored, p to p closely p assess p for p any p cardiac p changes. p Pain p is p documented p by p assessments p relative p to p location, p intensity, p character, p frequency, p and p duration.DIF: p Cognitive p Level: p Application p REF: p d p 362 p OBJ: p Theory p #7 p TOP: p Pain p Assessment p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p would p refrain p from p applying p a p blood p pressure p cuff p on p the p affected p arm p of p a p patient

who p has p a: p (Select p all p that p apply.)

• previous p mastectomy.

• patent p IV p line.

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• injured p hand.

• 2-year-old p hand p amputation.

• dialysis p

shunt. p ANSWER: p A, p B, p

E Arms p affected p by p previous p mastectomies, p patent p IVs, p or p dialysis p shunts p should p not p be p used p to p assess p the p blood p pressure p using p an p inflatable p cuff.DIF: p Cognitive p Level: p Application p REF: p d p 358, p

Skill p 21-6 p OBJ: p Clinical p Practice p #4

TOP: p Contraindications p for p Blood p Pressure p Cuff p

Application p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p assesses p that p the p 86-year-old p patient p is p experiencing p orthostatic p

hypotension p when p assessments p indicate: p (Select p all p that p apply.)

• dizziness p upon p rising p to p a p standing p position.

• a p drop p of p 15 p to p 20 p mm p Hg p from p baseline p when p changing p position.

• nausea.

• syncope.

• blurred p

vision.

ANSWER: p A, p B, p D, p E

Assessment p of p dizziness, p drop p in p up p to p 20 p mm p Hg p from p baseline p BP, p syncope, p and p blurred p vision p are p all p indicative p of p orthostatic p hypotension.

Chapter p 12 p Physical p Assessment MULTIPLE p CHOICE

• When p the p patient p complains p of p nausea p and p dizziness, p the p nurse p recognizes p these p complaints p as

p data.

• objective

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• medical

• subjective

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• adjunct

p ANSWER: p C

Subjective p data p are p symptoms p that p only p the p patient p can p identify. p DIF: p Cognitive p Level: p Application p REF: p d p 55 p OBJ: p Theory p #3 p TOP: p Assessment p Data p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p

Integrity: p basic p care p and p comfort

• The p major p goal p of p the p admission p interview p (usually p performed p by p the p RN) p is p to:
• establish p rapport.

• help p the p patient p understand p the p objectives p of p care.

• identify p the p patients p major p complaints.

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• initiate p nursing p care p plan p

forms. p ANSWER: p C

The p interview p is p used p as p part p of p the p assessment p process p to p elicit p information p about p the p patients p physical, p emotional, p and p spiritual p health.DIF: p Cognitive p Level: p Comprehension p REF: p d p 55 p OBJ: p Theory p #1 p TOP: p Interview p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• An p example p of p a p structured p format p for p gathering p data p that p aids p in p forming p a p database p is:
• North p American p Nursing p Diagnosis p AssociationInternational p (NANDA-I).

• Maslows p hierarchy.

• following p the p information p in p the p history p and p physical.

• Gordons p 11 p Health p

Patterns. p ANSWER: p D

Mary p Gordons p assessment p guide p is p a p guided p path p to p cover p 11 p health p points. p Although p Maslow p may p be p used, p it p is p not p structured.DIF: p Cognitive p Level: p Knowledge p REF: p d p 55 p OBJ: p Theory p #2 p TOP: p Gordons p 11 p Health p Patterns p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• During p the p assessment p phase p of p the p nursing p process, p the p nurse
• develops p a p care p plan p to p meet p the p patients p nursing p needs.

• begins p to p formulate p plans p for p providing p nursing p intervention.

• establishes p a p nursing p diagnosis p for p the p nursing p care p plan.

• gathers, p organizes, p and p documents p data p in p a p logical p

database. p ANSWER: p D

Gathering p and p organizing p data p is p the p first p step p in p the p assessment p phase p of p the p nursing p process. p DIF: p Cognitive p Level: p Comprehension p REF: p d p 58 p OBJ: p Theory p #1 TOP: p Data p Collection p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• After p the p admission p assessment p is p completed, p on p subsequent p shifts p or p days, p the p nurse:
• does p not p assess p the p patient p again p unless p the p condition p changes.

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• refers p only p to p the p admission p assessment p during p the p hospitalization.

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• performs p a p complete p physical p examination p every p day.

• assesses p the p patient p briefly p in p the p first p hour p of p

the p shift. p ANSWER: p D

The p patient p should p be p briefly p assessed p at p the p beginning p of p each p shift p and p more p thoroughly p if p his p or p her p condition p changes p or p as p per p the p plan p of p care.DIF: p Cognitive p Level: p Comprehension p REF: p d p 59 p OBJ: p Theory p #1 p TOP: p Physical p Assessment p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p performing p an p admission p interview p on p an p elderly p person p should:
• rush p through p the p interview p to p avoid p tiring p the p patient.

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• direct p questions p to p the p family p rather p than p the p patient.

• allow p more p time p for p a p response p to p questions.

• prompt p the p patient p to p speed p

recall. p ANSWER: p C

When p interviewing p an p elderly p person, p allow p more p time p because p the p person p will p probably p have p a p more p extensive p history p and p may p take p a p little p longer p to p recall p the p needed p information.DIF: p Cognitive p Level: p Application p REF: p d p 58 p OBJ: p Theory p #5 TOP: p Admission p Interview p KEY: p Nursing p Process p Step: p Intervention p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

7. A p nursing p diagnosis p consists p of:

• the p physicians p medical p diagnosis p listed p as p the p nursing p diagnosis.

• diagnostic p labels p formulated p by p the p North p American p Nursing p Diagnosis p

AssociationInternational p (N

• the p patients p explanation p of p his p or p her p chief p complaint p or p current p complaint.

• the p results p of p the p nursing p assessment p without p consideration p of p

doctors p orders. p ANSWER: p B

NANDA-I p has p formulated p an p official p list p of p nursing p diagnoses p to p identify p patient p problems p and p problems p that p patients p are p at p risk p of p developing. p A p nursing p diagnosis p is p independent p of p a p medical p diagnosis.DIF: p Cognitive p Level: p Comprehension p REF: p d p 61 p OBJ: p Theory p #5 p TOP: p Nursing p Diagnosis p KEY: p Nursing p Process p

Step: p N/A

MSC: p NCLEX: p N/A

• An p elderly p patient p with p a p medical p diagnosis p of p chronic p lung p disease p has p developed

p pneumonia. p She p is p coughing p frequently p and p expectorating p thick, p sticky p secretions. p She p is p very p short p of p breath, p even p with p oxygen p running, p and p she p is p exhausted p and p says p she p cant p breathe. p Based p on p this p information, p an p appropriately p worded p nursing p diagnosis p for p this p patient p is

• Airway p clearance, p ineffective, p related p to p lung p secretions p as p evidenced p by p cough p and p

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shortness p of p bre

• Pneumonia, p cough, p and p shortness p of p breath p related p to p chronic p lung p disease.

• Difficulty p breathing p not p relieved p by p oxygen p and p evidenced p by p shortness p of p breath.

• Cough p and p shortness p of p breath p caused p by p pneumonia, p chronic p lung p disease, p advanced p

age, p and p exha p ANSWER: p A

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The p nursing p diagnosis p from p the p NANDA p list p is p complete p with p a p cause p and p signs p and p symptoms. p DIF: p Cognitive p Level: p Analysis p REF: p d p 63, p Box p 5-4 OBJ: p Theory p #5 p TOP: p Nursing p Diagnosis p KEY: p Nursing p Process p Step: p Diagnosis MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• If p a p patient p has p several p nursing p diagnoses, p the p nurse p will p first:
• consult p with p the p doctor p regarding p which p diagnosis p is p most p important.

• devise p nursing p interventions p for p the p most p quickly p solved p problems.

• prioritize p the p nursing p problems p according p to p Maslows p hierarchy p of p needs.

• review p the p patients p medical p prescriptions p and p other p drugs p being p taken.

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ANSWER: p C

Nursing p diagnoses p (and p thus p their p interventions) p must p be p prioritized p to p identify p the p order p of p importance p based p on p Maslows p hierarchy.DIF: p Cognitive p Level: p Analysis p REF: p d p 63, p Box p 5-4 OBJ: p Clinical p Practice p #4 p TOP: p Prioritizing p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• A p patient p has p a p nursing p diagnosis p of p Imbalanced p nutrition: p less p than p body p

requirements, p related p to p mental p impairment p and p decreased p intake, p as p evidenced p by p increasing p confusion p and p weight p loss p of p more p than p 30-pounds p over p the p last p 6 p months. p An p appropriate p short-term p goal p for p this p patient p is p to:

• eat p 50% p of p six p small p meals p each p day p by p the p end p of p 1 p week.

• demonstrate p progressive p weight p gain p over p 6 p months.

• eat p all p of p the p meals p prepared p during p admission.

• verbalize p understanding p of p caloric p needs p and p intention p

to p eat. p ANSWER: p A

Short-term p goals p should p be p realistic p and p attainable p and p should p have p a p time p line p of p 7 p to p 10 p days p before p discharge.DIF: p Cognitive p Level: p Application p REF: p d p 63 p OBJ: p Clinical p Practice p #6 p TOP: p Expected p Outcomes p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

11. The p nursing p diagnoses p that p has p the p highest p priority p is:

• Mobility, p impaired p physical, p related p to p muscular p weakness p as p evidenced p by p the p inability

p to p walk p wi

Communication, p impaired p verbal, p related p to p neuromuscular p weakness p as p evidenced p by p facial p weakn

• speak.

Imbalanced p nutrition: p less p than p body p requirements, p related p to p difficulty p swallowing p and p inadequate

• evidenced p by p weight p loss p of p 10 p pounds.

• Airway p clearance, p ineffective, p related p to p neuromuscular p disorder p as p evidenced p by p choking

p and p coug p ANSWER: p D

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Choking p and p aspiration p are p life-threatening p events p and p take p priority p over p problems p such p as p weakness, p inability p to p speak, p or p weight p loss.

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DIF: p Cognitive p Level: p Analysis p REF: p d p 62 p OBJ: p Clinical p Practice p #4 p TOP: p Prioritizing p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• A p patient p with p visual p impairment p is p identified p as p at p risk p for p falls p related p to p

blindness. p An p appropriate p intervention p would p be p to:

• assist p the p patient p with p feeding p herself p at p the p end p of p the p meal.

• arrange p furnishings p in p room p to p provide p clear p pathways p and p orient p the p patient p to p these.

• take p the p patients p blood p pressure p before p she p gets p up p in p the p morning.

• report p any p falls p immediately p to p the p charge p nurse p and p

the p doctor. p ANSWER: p B

Providing p clear p pathways p directly p reduces p the p risk p of p patient p falls. p DIF: p Cognitive p Level: p Analysis p REF: p d p 59 p OBJ: p Clinical p Practice p #6 p TOP: p Clinical p Planning p KEY: p

Nursing p Process p Step: p Planning

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MSC: p NCLEX: p Safe p Effective p Care p Environment: p safety p and p infection p control

• The p North p American p Nursing p Diagnosis p AssociationI p (NANDA-I) p list p is p revised p

and p updated p every:

• year.

• 2 p years.

• 3 p years.

• 5 p

years. p ANSWER: p B

NANDA-I p meets p every p 2 p years p to p revise p and p update p the p list. p DIF: p Cognitive p Level: p Knowledge p REF: p d p 61

p OBJ: p Theory p #5

TOP: p NANDA-I p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

14. A p nursing p care p plan p consists p of:

• nursing p orders p for p individualized p interventions p to p assist p the p patient p to p meet p expected p

outcomes.

• orders p for p diagnostic p and p therapeutic p procedures p such p as p laboratory p tests p or p radiographs.

• the p physicians p history p and p physical p examination, p as p well p as p medical p diagnoses.

• laboratory p and p radiograph p reports, p pathology p reports, p and p the p medication

p record. p ANSWER: p A

The p nursing p care p plan p consists p of p the p nursing p orders p for p interventions p to p address p problems p and p establish p outcomes p by p which p the p plan p can p be p evaluated.DIF: p Cognitive p Level: p Comprehension p REF: p d p 65 p OBJ: p Clinical p Practice p #5 p TOP: p Nursing p Care p Plan p KEY: p Nursing p Process p Step: p N/A MSC: p NCLEX: p N/A

• In p an p acute p care p facility, p a p nursing p care p plan p is p usually p reviewed p and p updated:
• every p shift.

• every p 24 p hours.

• once p every p 3 p days.

• on p admission p and p

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discharge. p ANSWER: p B

Ongoing p assessment, p intervention, p and p evaluation p lead p to p attainment p or p modification p of p the

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original p plan p for p the p patient p who p is p acutely p ill. p The p nursing p care p plan p must p be p updated p daily p to p reflect p these p changes.DIF: p Cognitive p Level: p Knowledge p REF: p d p 65 p OBJ: p Clinical p Practice p #6 p TOP: p Nursing p Care p Plan p KEY: p Nursing p Process p

Step: p N/A

MSC: p NCLEX: p N/A

• The p nurse p takes p into p consideration p that p the p difference p between p a p sign p and p a p

symptom p is p that p a p sign p is:

• subjective p data.

• unreliable p because p it p depends p on p translation.

• can p be p verified p by p examination.

• something p a p patient p reports p that p is p verified p by p a p relative.

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ANSWER: p C

Signs p are p objective p data p that p can p be p confirmed p by p examination, p assessment, p or p observation. p Signs p are p reliable p research-based p data.DIF: p Cognitive p Level: p Comprehension p REF: p d p 62 p OBJ: p Theory p #2 TOP: p Assessment p (Data p Collection) p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

17. The p nurse p clarifies p that p nursing p orders p are p also p called:

• goals.

• qualifiers.

• interventions.

• measurement p

criteria. p ANSWER: p C

Nursing p orders p are p also p called p nursing p interventions p and p follow p the p same p requirements p when p placed p in p a p nursing p care p plan.DIF: p Cognitive p Level: p Knowledge p REF: p d p 65 p OBJ: p Theory p #2 p TOP: p Nursing p Orders p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p nurse p designs p the p goals p for p patients p in p long-term p facilities p to p be:
• conditional.

• open p ended.

• based p on p behavioral p norms.

• long-term.

p ANSWER: p D

Long-term p goals p are p more p appropriate p for p patients p in p long-term p facilities p because p they p will p be p there p for p an p extended p period p and p many p of p their p health p problems p are p chronic.DIF: p Cognitive p Level: p Comprehension p REF: p d p 65 p OBJ: p Theory p #7 p TOP: p Long-Term p Goals p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Physiological p Integrity: p

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basic p care p and p comfort

19. Standardized p Nursing p Care p Plans p can:

• be p documented p without p alteration.

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• have p items p altered p or p deleted.

• become p part p of p the p record p without p documentation.

• help p the p family p understand p the p concept p of p Nursing p

Care p Plans. p ANSWER: p B

Standardized p Nursing p Care p Plans p are p generic p and p need p to p be p altered p to p become p individualized. p They p must p be p documented.DIF: p Cognitive p Level: p Comprehension p REF: p d p 65 p OBJ: p Theory p #7 p TOP: p Assessment p (Data p Collection) p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• A p nurse p is p caring p for p a p patient p with p a p medical p diagnosis p of p right p lower p lobe p

pneumonia. p The p patient p is p expectorating p thick p green p mucus, p has p an p oxygen p saturation p level p of p 90%, p and p has p audible p crackles p in p the p base p of p the p right p lung. p An

p appropriate p nursing p diagnosis p for p this p patient p is:

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Airway p clearance, p ineffective, p related p to p retained p secretions p as p evidenced p by p expectoration p of p thick

• saturation p level p of p 90%, p and p audible p crackles p in p the p base p of p the p right p lung.

Airway p clearance, p ineffective, p related p to p right p lower p lobe p pneumonia p as p evidenced p by p expectoration

• mucus, p oxygen p saturation p level p of p 90%, p and p audible p crackles p in p the p base p of p the p right p

lung.

Right p lower p lobe p pneumonia, p related p to p airway p clearance, p ineffective, p as p evidenced p by p expectoration c.

d.

ANSW

ER: p A

mucus, p oxygen p saturation p level p of p 90%, p and p audible p crackles p in p the p base p of p the p right p lung.

Expectoration p of p thick p green p mucus, p oxygen p saturation p level p of p 90%, p and p audible p crackles p in p the p ba p related p to p right p lower p lobe p pneumonia p as p evidenced p by p airway p clearance.The p nursing p diagnosis p is p from p the p NANDA-I p list p and p is p complete p with p a p cause p and p signs p and p symptoms. p The p other p answers p contain p a p medical p diagnosis p of p pneumonia, p which p is p inappropriate. p DIF: p Cognitive p Level: p Analysis p REF: p d p 61 p OBJ: p Theory p #7 TOP: p Nursing p Diagnosis p KEY: p Nursing p Process p Step: p Diagnosis p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort p COMPLETION

• Conclusions p that p have p been p made p based p on p observed p data p are .

p ANSWER:

inferences Inferences p are p conclusions p made p based p on p observed p data. p DIF: p Cognitive p Level: p Knowledge p REF: p d p 61 p

OBJ: p Theory p #6

TOP: p Inferences p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A MULTIPLE p RESPONSE

• The p nurse p understands p that p an p expected p outcome p should p be: p (Select p all p that p apply.)
• realistic.

• approved p by p the p physician.

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• attainable.

• within p a p defined p time.

• included p after p patient p

collaboration. p ANSWER: p A, p C, p D, p E

An p expected p outcome p should p be p realistic p and p attainable p and p should p have p a p defined p time p line p after

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collaboration p with p the p patient.DIF: p Cognitive p Level: p Knowledge p REF: p d p 63 p OBJ: p Theory p #6 p TOP: p Nursing p Process p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Physiological p

Integrity: p basic p care p and p comfort

• A p nurse p is p caring p for p a p patient p with p a p nursing p diagnosis p of p impaired p physical p

mobility p related p to p neurologic p impairment p and p muscular p weakness. p Appropriate p interventions p for p this p patient p would p include p which p of p the p following? p (Select p all p that p apply.)

• Assist p with p range-of-motion p exercises p every p 4 p hours p and p as p needed.

• Instruct p patient p to p call p for p assistance p when p needing p to p get p out p of p bed.

• Apply p wrist p and p ankle p restraints p to p promote p safety p and p prevent p falls.

• Teach p about p exercises p that p will p strengthen p muscles p while p lying p in p bed.

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• Ambulate p with p physical p therapy p assistance p at p least p three p

times p a p day. p ANSWER: p A, p B, p D, p E

The p nurse p selects p appropriate p nursing p interventions p to p alleviate p the p problems p and p assist p the p patient p in p achieving p the p expected p outcomes. p Consider p all p possible p interventions p for p relief p of p the p problems p and p then p select p those p most p likely p to p be p effective.DIF: p Cognitive p Level: p Application p REF: p d p 65 p OBJ: p Clinical p Practice p #5 p TOP: p Assessment p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• Appropriate p nursing p roles p in p the p initial p assessment p would p include: p (Select p all p that p apply.)
• LPN p obtains p the p vital p signs p of p a p new p patient.

• RN p performs p a p complete p physical p assessment.

• LPN p organizes p data p into p a p database.

• RN p reviews p the p patients p chart p for p past p medical/surgical p history.

• LVN p contributes p ongoing p

assessments. p ANSWER: p A, p B, p D, p E

The p LPN/LVN, p under p the p NFLPN p standard, p contributes p assessments; p the p RN p performs p the p physical p assessment p and p medical p records p review p and p organizes p the p database.DIF: p Cognitive p Level: p Comprehension p REF: p d p 61 p OBJ: p Theory p #2 TOP: p Planning p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p N/A

• Aside p from p the p information p obtained p from p the p patient p (primary p source) p in p the

p admission p interview, p the p nurse p will p also p access: p (Select p all p that p apply.)

• the p patients p family.

• a p reliable p and p up-to-date p reference p book.

• the p admission p note.

• the p physicians p history p and p physical.

• an p observation p of p the p patient p for p non-verbal p

clues. p ANSWER: p A, p C, p D, p E

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The p nurse p conducting p the p interview p uses p information p from p the p patients p family, p from p the p physicians p admission p note p and p history p and p physical, p and p from p personal p observation p of p the p patient. p DIF: p Cognitive p Level: p Comprehension p REF: p d p 55 p OBJ: p Theory p #2

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TOP: p Assessment p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

26. A p nursing p diagnosis p identifies: p (Select p all p that p apply.)

• patients p response p to p illness.

• related p signs p and p symptoms.

• underlying p medical p diagnosis.

• causative p factors.

• potential p risk p for p health p

problems. p ANSWER: p A, p B, p D, p E

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Defining p characteristics p of p nursing p diagnosis p include p the p patients p response p to p illness p and p the p causative p factors. p Signs p and p symptoms p must p also p be p identified p for p a p nurse p to p select p an p appropriate p nursing p diagnosis. p Medical p diagnoses p label p an p illness; p nursing p diagnoses p are p independent p of p medical p diagnoses.DIF: p Cognitive p Level: p Comprehension p REF: p d p 61 p OBJ: p Theory p #5 p TOP: p Defining p Characteristics p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p statements p that p are p correctly p stated p as p expected p outcomes p are: p (Select p all p that p apply.)
• Patient p will p be p able p to p void p in p the p bathroom p independently.

• Patient p will p be p able p to p ambulate p using p a p walker p independently p within p 3 p days.

• The p nurse p will p assist p the p patient p to p the p bathroom p three p times p a p day.

• Patient p will p perform p active p range p of p motion p (ROM) p of p her p upper p extremities p

independently p every p 4

• The p family p will p bring p food p from p home p to p improve p patient

p appetite. p ANSWER: p B, p D

Expected p outcomes p need p to p have p a p time p frame p and p be p measurable. p Ambulating p with p a p walker p within p three p days p and p performing p ROM p independently p for p four p hours p are p both p measurable p outcomes p with p clear p time p frames. p The p outcome p of p voiding p independently p does p not p have p a p time p frame. p Assisting p the p patient p to p the p bathroom p is p a p nursing p intervention.DIF: p Cognitive p Level: p Comprehension p REF: p d p 63 p OBJ: p Theory p #6 p TOP: p Expected p Outcomes p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p nurse p should p make p a p point p when p closing p the p initial p interview p to: p (Select p all p that p apply.)
• develop p rapport.

• summarize p the p problems p discussed.

• thank p the p patient p for p his p or p her p time.

• discuss p the p nursing p goals p associated p with p nursing p diagnoses.

• give p a p copy p of p the p nursing p care p plan p to p

the p patient. p ANSWER: p B, p C

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The p nurse p should p summarize p the p problems p discussed, p thank p the p patient p for p his p or p her p time, p and p explain p what p happens p next p and p when p the p nurse p will p return.

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DIF: p Cognitive p Level: p Comprehension p REF: p d p 58 p OBJ: p Theory p #1 p TOP: p Nursing p Process p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p seven p domains p of p the p Nursing p Interventions p Classification p (NIC) p taxonomy

p include: p (Select p all p that p apply.)

• community.

• health p system.

• socioeconomic p level.

• safety.

• behavioral.

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ANSWER: p A, p B, p D, p E

The p seven p domains p of p the p NIC p taxonomy p are: p physiological: p basic; p physiological: p complex; p behavioral; p safety; p family; p health p system; p and p community.DIF: p Cognitive p Level: p Knowledge p REF: p d p 65 p OBJ: p Theory p #5 p TOP: p NIC p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p purpose p of p the p Nursing p Outcomes p Classification p (NOC) p is p to: p (Select p all p that p apply.)
• validate p classification p by p field p test.

• identify p labels.

• provide p language p labels p for p desired p outcomes.

• generate p a p ready-made p nursing p care p plan p for p a p patient.

• identify p patient p outcomes p and p

indicators. p ANSWER: p A, p B, p C, p E

The p purpose p of p NOC p is p to p provide p language p labels p to p help p identify p and p classify p patient p outcomes p and p validate p classifications p by p field p testing.

Chapter p 13 p Special p Examinations p and p Tests MULTIPLE p CHOICE

• A p patient p who p is p on p an p anticoagulant p (Coumadin) p asks, p What p did p the p physician p

mean p when p he p said p I p was p to p have p my p blood p tested p every p 2 p weeks? p The p nurse p explains, p It p is p important p to p monitor p the p effects p of p the p drug p to p see p how p long p it p takes p your p blood p to p clot. p The p blood p test p the p physician p was p talking p about p is p the:

• complete p blood p count p (CBC).

• activated p partial p thromboplastin p time p (APTT).

• international p normalized p ratio p (INR).

• erythrocyte p sedimentation p rate p

(ESR). p ANSWER: p C

The p INR p is p a p method p for p reporting p the p prothrombin p time, p which p is p prolonged p with p warfarin p (Coumadin) p therapy.DIF: p Cognitive p Level: p Knowledge p REF: p d p 403 p OBJ: p Theory p #2

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TOP: p Blood p Tests p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p patient p is p scheduled p to p have p a p blood p chemistry p profile p drawn p at p 8 p AM p

tomorrow. p The p note p should p be p added p on p the p care p plan p and p report p provided p to p the p

oncoming p shift p to p withhold p food p and p drink p after:

• 6 p AM.

• 12 p midnight p tonight.

• 4 p AM p today.

• noon p

today.

ANSWER: p B

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Food p and p drink p are p usually p withheld p for p 8 p to p 12 p hours p before p blood p chemistry p tests p are p performed.DIF: p Cognitive p Level: p Application p REF: p d p 403 p OBJ: p Theory p #3 p TOP: p Blood p Tests p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Safe p Effective p Care p

Environment: p coordinated p care

• A p patient p wants p to p know p what p was p meant p when p the p doctor p said p that p his p

white p blood p cell p (WBC) p count p had p a p shift p to p the p left. p The p nurse p explains p that

p a p shift p to p the p left p indicates:

• an p improvement p in p an p infectious p process.

• the p relative p effectiveness p of p the p antibiotic p therapy.

• an p increase p in p the p number p of p immature p WBCs.

• that p the p infection p is p viral p in p

nature. p ANSWER: p C

In p reporting p a p differential p WBC, p the p less p mature p WBCs p are p reported p on p the p left p side p of p the p page. p An p increase p in p immature p WBCs p causes p the p left p side p of p the p report p to p show p large p numbers p and p indicates p an p infection.DIF: p Cognitive p Level: p Comprehension p REF: p d p 403, p Clinical p cues p OBJ: p Clinical p Practice p #1 p TOP: p Differential KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p instructing p in p the p collection p of p a p midstream p urine p catch p would p tell p the p

patient p to p first p cleanse p the p external p genitalia p and p then p to:

• begin p voiding p into p the p specimen p cup.

• let p a p few p drops p of p urine p dribble p into p the p specimen p cup.

• void p until p the p bladder p is p almost p empty p and p then p collect p the p end p portion p of p the p voiding

p in p the p cup.

• pass p a p small p amount p of p urine p into p the p toilet p and p then p collect p

the p specimen. p ANSWER: p D

To p collect p a p midstream p specimen, p the p external p genitalia p are p cleansed, p a p small p amount p of p urine p is p passed, p and p then p a p midportion p of p the p voiding p is p collected p in p a p

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sterile p container p and p used p for p a p culture.DIF: p Cognitive p Level: p Application p REF: p d p 409 p OBJ: p Clinical p Practice p #1

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TOP: p Urinalysis p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p instructs p an p outpatient p female p patient p preparing p for p an p abdominal p

ultrasonography p that p prior p to p the p procedure, p she p should:

• eat p or p drink p nothing p after p midnight.

• drink p a p liter p of p water.

• empty p the p bladder p fully.

• use p enemas p at p home p to p clear p the p

bowel p fully. p ANSWER: p B

For p abdominal p ultrasonography, p the p patient p is p asked p to p drink p a p liter p of p water p before p the p procedure. p This p helps p change p the p echo-reflection p pattern p from p the p bladder, p helping p to p better p distinguish p the p bladder p from p the p female p reproductive p organs p that p lie p nearby.

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DIF: p Cognitive p Level: p Application p REF: p d p 413 p OBJ: p Clinical p Practice p #1 TOP: p Abdominal p Ultrasonography p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p preparing p a p patient p for p a p magnetic p resonance p imaging p (MRI) p should p

determine p if p the p patient p has:

• respiratory p allergies.

• claustrophobia.

• fear p of p the p dark.

• dizziness.

p ANSWER: p B

The p patient p with p claustrophobia p can p be p reassured p that p there p are p methods p to p contact p persons p outside p the p cylinder.DIF: p Cognitive p Level: p Application p REF: p d p 415 p OBJ: p Theory p #1 p TOP: p Fluoroscopy p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p

Integrity: p coping p and p adaptation

• Prior p to p the p nurse p transporting p the p patient p to p have p a p magnetic p resonance p

imaging p (MRI), p it p is p essential p that p the p nurse p confirm p that p the p patient:

• has p eaten p a p meal.

• has p drunk p a p liter p of p fluid.

• is p not p wearing p anything p with p metal.

• has p a p Foley p catheter p in p

place. p ANSWER: p C

Nursing p care p before p an p MRI p involves p obtaining p consent p and p ensuring p that p all p metal p is p removed p from p the p patients p body, p because p the p machine p emits p a p strong p magnetic p field.DIF: p Cognitive p Level: p Application p REF: p d p 415 p OBJ: p Clinical p Practice p #4 p TOP: p MRI p KEY: p Nursing p Process p Step: p Implementation

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MSC: p NCLEX: p Safe p Effective p Care p Environment: p safety p and p infection p control

• A p patient p who p is p scheduled p for p a p cardiac p catheterization p asks p what p the p

catheterization p will p reveal p that p an p electrocardiogram p would p not. p The p nurse p explains p

that p the p catheterization p shows:

• the p entire p heart p to p find p evidence p of p cancer.

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• heart p rhythm.

• electrical p activity p of p the p heart p action.

• oxygen p concentration p at p various p

sites. p ANSWER: p D

Cardiac p catheterization p is p a p procedure p that p determines p the p function p of p the p heart, p valves, p and p coronary p circulation p with p its p attendant p oxygen p concentration.DIF: p Cognitive p Level: p Comprehension p REF: p d p 416, p Box p 24-3 p OBJ: p Clinical p Practice p #1 p TOP: p Catheterization KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p patient p who p is p to p have p a p treadmill p stress p test p at p 11:00 p AM p today p should p not p consume:

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• toast p and p jam.

• coffee p and p cream.

• oatmeal p and p sugar.

• pancakes p and p

syrup. p ANSWER: p B

The p patient p should p avoid p caffeine p and p smoking p for p 6 p hours p before p the p test, p but p may p have p a p light p meal p 2 p or p more p hours p beforehand.DIF: p Cognitive p Level: p Comprehension p REF: p d p 418 p OBJ: p Clinical p Practice p #1 p TOP: p Treadmill p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p patient p who p has p undergone p endoscopy p is p fully p awake p and p asks p the p nurse p for

p something p to p drink. p After p confirming p that p liquids p are p allowed p on p the p physician p

order p sheet, p the p nurse p should:

• assist p the p patient p to p the p bathroom p to p void.

• listen p to p lung p sounds.

• take p a p blood p pressure p and p pulse.

• check p for p the p return p of p gag p and p swallow p

reflexes. p ANSWER: p D

The p patient p should p take p nothing p by p mouth p until p the p effects p of p local p anesthesia p have p worn p off p and p airway p protective p reflexes p (such p as p gag p and p swallow p reflexes) p have p returned.DIF: p Cognitive p Level: p Analysis p REF: p d p 419 p OBJ: p Clinical p Practice p #1 TOP: p Endoscopic p Examinations p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Safe p Effective p Care p Environment: p safety p and p infection p control

• The p patient p in p the p skilled p nursing p facility p who p is p to p have p a p colonoscopy p

tomorrow p complains p about p his p limited p diet p prior p to p the p examination. p The p nurse p may p

offer p the p patient:

• lime p Jell-O.

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• strawberry p soda.

• oatmeal p thinned p with p milk.

• vanilla p ice p

cream. p ANSWER: p A

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The p patient p is p placed p on p a p clear-liquid p diet p for p 24 p hours p before p colonoscopy p and p should p avoid p liquids p that p contain p red p or p purple p dye. p Jell-O p is p part p of p a p clear p liquid p diet.DIF: p Cognitive p Level: p Application p REF: p d p 410 p OBJ: p Clinical p Practice p #1 p TOP: p Endoscopic p Examinations p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p patient p has p undergone p cystoscopy p and p has p a p Foley p catheter p in p place p on p return p

to p the p nursing p unit. p Immediately p after p the p procedure, p the p nurse p expects p the p urine p

color p to p be:

• clear p as p water.

• bright p red p with p clots.

• pink p tinged.

• cherry p colored.

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ANSWER: p C

It p is p common p for p the p urine p to p be p pink p tinged p after p cystoscopy, p but p red p bleeding p and p clots p should p be p reported p to p the p physician.DIF: p Cognitive p Level: p Comprehension p REF: p d p 420 p OBJ: p Clinical p Practice p #1 p TOP: p Cystoscopy p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p patient p will p undergo p endoscopic p retrograde p cholangiopancreatography p (ERCP) p to

p determine p the p cause p of p jaundice. p Before p the p test, p the p nurse p would p assess p this p patient

p for p an p allergy p to:

• eggs.

• pork.

• aspirin.

• shellfish.

ANSWER: p D

Allergy p to p shellfish p is p assessed, p because p an p iodine-based p contrast p medium p is p used p during p the p test. p Shellfish p hold p and p store p iodine.DIF: p Cognitive p Level: p Application p REF: p d p 421, p Safety p Alert p OBJ: p Clinical p Practice p #1 p TOP: p

Endoscopic p Examinations p KEY: p Nursing p Process p

Step: p Assessment

MSC: p NCLEX: p Physiological p Integrity: p pharmacological p and p parenteral p therapies

• For p the p patient p who p just p had p a p liver p biopsy p performed, p the p nurse p should p position p him:
• prone p for p 1 p hour.

• on p his p right p side-lying p for p 2 p hours.

• supine p for p 3 p hours.

• on p his p left p side-lying p for p 4 p

hours. p ANSWER: p B

The p patient p should p be p turned p onto p the p right p side p for p 2 p hours p after p the p procedure p to p minimize p bleeding p from p the p site.

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DIF: p Cognitive p Level: p Comprehension p REF: p d p 422, p Table p 24-5 p OBJ: p Clinical p Practice p #5 p TOP: p Liver p Biopsy

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KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• Following p a p colonoscopy p with p polyp p removal, p the p wife p of p the p patient p is p distressed

p that p there p is p slight p bleeding p from p her p husbands p rectum. p The p nurses p most p helpful p

response p would p be:

• This p small p amount p of p bleeding p is p expected p after p the p removal p of p polyps.

• I p will p notify p the p physician p about p this p hemorrhage.

• I p will p watch p your p husband p very p carefully p to p assess p any p further p hemorrhage.

• Dont p worry. p This p small p amount p of p blood p happens p with p these p

procedures. p ANSWER: p A

A p small p amount p of p bleeding p following p a p colonoscopy p with p polyp p removal p is p to p be p expected. p The p family p should p be p prepared p for p the p slight p bleeding.DIF: p Cognitive p Level: p Application p REF: p d p 419 p OBJ: p Clinical p Practice p #1

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TOP: p Colonoscopy p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• To p improve p the p comfort p of p an p elderly p patient p who p is p to p be p in p the p radiology p

department p for p several p hours, p the p nurse p should p send p a(n):

• family p member p with p the p patient.

• extra p pillow.

• blanket.

• newspaper p to p

read. p ANSWER: p C

Elderly p people p may p become p chilled p by p the p cooler p temperatures p commonly p experienced p in p ancillary p departments p such p as p radiology.DIF: p Cognitive p Level: p Application p REF: p d p 423, p Elder p Care OBJ: p Theory p #4 p TOP: p Elder p Care p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• An p elderly p patient p has p had p a p series p of p enemas p in p preparation p for p a p

gastrointestinal p diagnostic p procedure. p Which p electrolytes p should p be p monitored p following p the p enemas?

• Calcium p and p chloride

• Sodium p and p potassium

• Magnesium p and p phosphorus

• Selenium p and p

zinc p ANSWER: p B

A p series p of p enemas p can p upset p electrolyte p balance, p especially p potassium p and p sodium. p DIF: p Cognitive p Level: p Application p REF: p d p 419 p OBJ: p Theory p #4 TOP: p Loss p of p Electrolytes p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p explains p to p the p patient p that p the p significance p of p the p hematocrit p is p that p it:

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• indicates p the p number p of p circulating p white p blood p cells.

• indicates p the p value p of p the p hemoglobin.

• refers p to p the p separation p of p blood p cells p from p plasma.

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• will p decrease p when p the p patient p is p in p

shock. p ANSWER: p C

The p hematocrit p refers p to p the p relationship p of p blood p cells p to p plasma p in p the p circulating p volume. p DIF: p Cognitive p Level: p Knowledge p REF: p d p 402 p OBJ: p Theory p #2 TOP: p Hematocrit p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• When p obtaining p a p capillary p blood p sample p for p blood p glucose, p the p nurse p will p select p the p puncture

site p to p cause p the p least p amount p of p discomfort, p which p is:

• the p end p of p the p index p finger.

• the p ball p of p the p third p finger.

• at p right p angles p to p the p fingerprint p lines.

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• the p ball p of p the p

thumb. p ANSWER: p C

Using p the p right p angle p to p the p fingerprint p lines p places p the p puncture p on p the p side p of p the p finger p rather p than p on p more p sensitive p areas.DIF: p Cognitive p Level: p Application p REF: p d p 407, p Skill p 24-9 p OBJ: p Theory p #3 p TOP: p Capillary p Blood p Test KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• A p patient p asks p why p the p blood p glucose p meter p directions p state p to p wipe p away p the

p first p drop p of p blood. p The p most p informative p response p by p the p nurse p would p be:

• This p eliminates p microorganisms p from p the p sample.

• The p first p drop p is p usually p too p small.

• The p first p drop p is p usually p contaminated.

• The p first p drop p has p serous p fluid p that p can p dilute p the p

specimen. p ANSWER: p D

Some p machines p state p to p wipe p away p the p first p drop p of p blood, p which p often p contains p a p large p portion p of p serous p fluid p that p can p dilute p the p specimen, p causing p a p false p result.DIF: p Cognitive p Level: p Comprehension p REF: p d p 407, p Skill p 24-9 p OBJ: p Theory p #3 p TOP: p Blood p Glucose p Testing KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• A p patient p in p the p outpatient p clinic p has p provided p a p urine p sample. p To p perform p a p

urine p dipstick p test p accurately, p the p nurse p wets p the p dipstick p and p starts p timing:

• immediately.

• after p 5 p seconds.

• after p 10 p seconds.

• after p 30 p

seconds. p ANSWER: p A

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The p stick p is p inserted p into p the p urine p specimen p and p removed p quickly, p and p timing p is p started p immediately. p It p is p tapped p gently p on p the p side p of p the p container p to p remove p excess p urine.

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DIF: p Cognitive p Level: p Knowledge p REF: p d p 409, p Skill p 24-3 p OBJ: p Theory p #3 p TOP: p Urine p Dipstick p Test KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

22. The p nurse p obtaining p a p wound p culture p would:

• use p clean p gloves.

• rotate p the p swab p vigorously p in p the p wound p bed.

• rinse p the p exudate p on p the p swab p with p normal p saline.

• place p the p swab p in p the p culture p tube p without p touching p

the p sides. p ANSWER: p D

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The p nurse p should p use p sterile p gloves, p rotate p the p swab p gently p in p the p wound p bed, p and p place p it p directly p into p the p culture p tube p without p touching p the p sides p of p the p tube.DIF: p Cognitive p Level: p Knowledge p REF: p d p 425, p Skill p 24-5 p OBJ: p Theory p #3 p TOP: p Wound p Culture KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Safe p Effective p Care p Environment: p safety p and p infection p control

• The p patient p who p has p just p returned p to p the p unit p after p an p angiography p test p

should p be p assessed p immediately p for:

• swelling p of p tongue.

• pulmonary p congestion.

• bleeding p at p insertion p site.

• hypotension.

p ANSWER: p C

The p insertion p site p is p monitored p for p bleeding p or p formation p of p a p hematoma. p DIF: p Cognitive p Level: p Application p REF: p d p 418 p OBJ: p Clinical p Practice p #1 p TOP: p Angiography p KEY: p Nursing p Process p

Step: p Implementation

MSC: p NCLEX: p Safe p Effective p Care p Environment: p safety p and p infection p control

• The p nurse p instructing p a p patient p who p is p to p have p a p Papanicolaou p smear p (Pap p

smear) p in p 2 p days p would p tell p the p patient p to p avoid:

• sexual p intercourse.

• douching.

• eating p shellfish.

• taking p a p bubble p

bath. p ANSWER: p B

The p patient p who p is p to p have p a p Pap p smear p should p avoid p douching p or p using p any p vaginal p medication p that p might p interfere p with p the p collection p of p the p cells p of p the p cervix.DIF: p Cognitive p Level: p Application p REF: p d p 426, p Skill p 24-6 p OBJ: p Clinical p Practice p #7 p TOP: p Pelvic p Examination

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KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Safe p Effective p Care p Environment

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• The p statement p made p by p a p patient p that p would p delay p a p scheduled p CT p scan p would p be:
• I p have p terrible p claustrophobia.

• I p have p just p been p started p on p metformin.

• I p am p allergic p to p penicillin.

• I p have p an p implanted p

pacemaker. p ANSWER: p B

Metformin p should p be p discontinued p before p the p test p with p an p iodine-based p contrast p medium p because p metformin p significantly p alters p renal p function.DIF: p Cognitive p Level: p Analysis p REF: p d p 414, p Clinical p Cues OBJ: p Theory p #1 p TOP: p Metformin p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p pharmacological p and p parenteral p therapies

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• The p nurse p evaluates p a p prothrombin p time p (PT/INR) p for p a p patient p who p is p taking p

heparin. p The p nurses p initial p action p should p be p to:

• document p the p findings p in p the p chart.

• notify p the p lab p that p they p have p made p an p error.

• check p the p physicians p order.

• notify p the p physician p of p the p lab p

finding. p ANSWER: p C

Check p the p physicians p orders p to p determine p what p test p was p ordered. p If p the p PT/INR p was p ordered, p confer p with p the p charge p nurse p or p physician p as p to p the p intent. p The p PT/INR p measures p the p effectiveness p of p the p drug p warfarin p (Coumadin), p not p heparin. p A p partial p thromboplastin p is p the p test p used p to p evaluate p the p effectiveness p of p heparin.DIF: p Cognitive p Level: p Analysis p REF: p d p 403 p OBJ: p Theory p #2 TOP: p Partial p Thromboplastin p KEY: p Nursing p Process p Step: p Evaluation p MSC: p NCLEX: p Safe p Effective p Care p Environment: p management p of p care

• A p major p concern p for p an p 86-year-old p patient p who p has p been p NPO p for p 8 p

hours p prior p to p a p diagnostic p test p would p be:

• fatigue.

• circulatory p status.

• hydration p status.

• nutritional p

status. p ANSWER: p C

The p elderly p who p are p kept p on p an p NPO p status p for p prolonged p periods p of p time p are p susceptible p to p dehydration p and p electrolyte p imbalances.DIF: p Cognitive p Level: p Comprehension p REF: p d p 419, p Elder p Care p OBJ: p Theory p #4 p TOP: p Dehydration p in p the p Elderly KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

COMPLETION

• The p nurse p is p aware p that p a p patient p who p is p to p have p a p colonoscopy p is p requested

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p to p stop p taking p drugs p that p contain p iron p for prior p to p the p test.

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ANSWER:

• p days p

three p days Drugs p containing p iron p are p held p 3 p days p before p a p colonoscopy p because p iron p salts p can p obscure p the p film. p Iron p can p also p cause p constipation, p which p makes p the p cleansing p of p the p bowel p more p difficult. p DIF: p Cognitive p Level: p Knowledge p REF: p d p 417 p OBJ: p Theory p #1 TOP: p Colonoscopy p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Physiological p Integrity: p pharmacological p and p parenteral p therapies p MULTIPLE p RESPONSE

• The p nurse p is p aware p that p the p chart p of p a p patient p going p for p a p cardiac p catheterization p should

have:(Select p all p that p apply.)

• a p signed p consent p form.

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• a p complete p history p and p physical p examination.

• evidence p of p the p initiation p of p NPO p status p at p least p 2 p hours p prior.

• evidence p of p patient p teaching p done p before p the p consent p form p is p signed.

• report p of p kidney p function p tests.

• administration p of p ordered p preoperative p

medications. p ANSWER: p A, p B, p D, p F

Patient p teaching p must p be p done p before p a p signed p consent p form p is p initiated. p A p complete p history p and p physical p examination p is p done p and p NPO p status p is p initiated p at p least p 6 p hours p prior p to p the p procedure. p The p patient p is p also p given p ordered p preoperative p medications.DIF: p Cognitive p Level: p Application p REF: p d p 410, p Patient p Teachng p OBJ: p Clinical p Practice p #1 p TOP: p Informed p Consent KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p physician p has p ordered p the p collection p of p a p 24-hour p urine p specimen. p The p nurses

p instructions p to p the p patient p for p proper p collection p of p the p urine p specimen p include: p (Select p all p that p apply.)

• keep p the p container p refrigerated p as p needed.

• empty p the p bladder p into p the p toilet p and p begin p timing p the p collection.

• void p a p small p amount p of p urine p after p external p genitalia p are p cleansed.

• keep p the p container p on p ice p if p instructed p to p do p so.

• save p only p the p first p voiding p in p the p

morning. p ANSWER: p A, p B, p D

When p a p 24-hour p urine p specimen p is p collected, p the p patient p should p be p instructed p to p empty p the p bladder p into p the p toilet p and p begin p timing p the p collection p of p the p specimen; p to p add p all p urine p to p the p collection p container p for p the p next p 24 p hours; p to p keep p the p container p on p ice p or p refrigerated; p and p when p the p 24 p hours p are p up, p to p empty p the p bladder p and p add p the p urine p to p the p collection p container p and p then p seal p it p and p send p it p to p the p laboratory.

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DIF: p Cognitive p Level: p Application p REF: p d p 415 p OBJ: p Clinical p Practice p #1 p TOP: p Health p Teaching p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p is p aware p that p patients p who p are p not p candidates p for p magnetic p resonance p imaging

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(MRI) p include p patients p with: p (Select p all p that p apply.)

• a p hip p prostheses.

• bleeding p tendencies.

• allergy p to p iodine.

• cardiac p pacemakers.

• previous p radiological p

treatment. p ANSWER: p A, p D

Patients p with p prosthetic p hips p and p knees, p implanted p pacemakers, p or p metal p clips p or p staples p are p not p candidates p for p an p MRI p because p of p the p magnetic p field p the p test p creates.DIF: p Cognitive p Level: p Comprehension p REF: p d p 421, p Safety p Alert

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OBJ: p Clinical p Practice p #4 p TOP: p Topic: p MRI p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Safe p Effective p Care p Environment: p safety p and p infection p control

• The p nurse p informs p the p patient p who p is p to p have p an p electroencephalogram p (EEG)

p that p the p technician p will p try p to p stimulate p seizure p activity p by p asking p the p patient p to: p (Select p all p that p apply.)

• close p his p eyes.

• hyperventilate.

• breathe p in p a p rapid p shallow p fashion.

• hold p a p flashing p light p over p his p face.

• submerge p his p hands p in p cold p

water. p ANSWER: p B, p C, p D

During p an p EEG, p abnormal p brain p activity p can p be p stimulated p by p the p patient p being p requested p to p hyperventilate, p breathe p rapidly p with p shallow p breaths, p and p respond p to p a p flashing p light p over p his p face.DIF: p Cognitive p Level: p Comprehension p REF: p d p 401, p Skill p 24-1 OBJ: p Theory p #1 p TOP: p EEG p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort OTHER

• The p nurse p is p to p collect p a p sample p of p blood p for p a p lab p test. p Arrange p the p

sequence p of p a p phlebotomy. p (Separate p letters p with p a p comma p and p space p as p

follows: p A, p B, p C, p D, p E, p F, p G, p H.)

• Place p vacutainer p tube p inside p holder.
• Press p tube p stopper p onto p needle.
• Puncture p site.
• Apply p tourniquet p and p cleanse p site.
• Label p tube.
• Fill p tube p completely.
• Loosen p tourniquet p and p apply p pressure p to p site.

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• Perform p hand p hygiene p and p apply p

gloves. p ANSWER:

E, p H, p A, p D, p C, p B, p F, p G The p nurse p should p label p the p tube p with p patient p identification, p perform p hand p hygiene p and p apply

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gloves, p place p the p vacutainer p tube p inside p the p holder, p apply p the p tourniquet p and p cleanse p the p site, p puncture p the p site, p press p the p tube p stopper p onto p the p needle, p fill p the p tube p completely, p and p then p loosen p the p tourniquet p and p apply p pressure p to p the p site.

Chapter p 14 p Nutrition est p Bank MULTIPLE p CHOICE

• The p nurse p reminds p the p patient p that p the p salivary p glands p excrete p saliva, p which p initiates p the

digestion p of:

• proteins.

• starches.

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• fats.

• fiber.

ANSWER: p B

Saliva p initiates p the p digestion p of p starches.DIF: p Cognitive p Level: p Knowledge p REF: p d p 453 p OBJ: p

Theory p #1 p TOP: p Functions p of p the p Gastrointestinal p

System KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

2. The p nurse p is p aware p that p vitamin p B12 p is p absorbed p in p the:

• stomach.

• large p intestine.

• liver.

• gallbladder.

p ANSWER: p A

Vitamin p B12, p an p aid p in p hemoglobin p syntheses, p is p absorbed p in p the p stomach p through p the p action p of p the p intrinsic p factor, p which p is p secreted p from p the p stomach p wall.DIF: p Cognitive p Level: p Knowledge p REF: p d p 453 p OBJ: p Theory p #1 p TOP: p Absorption p of p Vitamins p KEY: p Nursing p Process p Step: p Planning p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p emphasizes p the p dietary p recommendations p made p by p the p American p Heart p

Association p is p to p limit p cholesterol p intake p to mg/day.

The p American p Heart p Association p recommends p an p intake p of p cholesterol p to p 300 p mg/day p or p less. p DIF: p Cognitive p Level: p Knowledge p REF: p d p 455, p Box p 26-1

a.

300

• 400
• 425

d.

ANS: A

500

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OBJ: p Theory p #4 p TOP: p Dietary p

Recommendations p KEY: p Nursing p Process p

Step: p Planning

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MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• A p patient p refuses p to p eat p all p types p of p meat, p which p has p led p to p a p protein p

deficiency. p The p nurse p recognizes p that p the p only p plant p source p that p contains p all p nine

p essential p amino p acids p is:

• bean p sprouts.

• lima p beans.

• kidney p beans.

• soybeans.

p ANSWER: p D

Soybeans p are p the p only p plant p source p that p provides p all p nine p essential p amino p acids. p DIF: p Cognitive p Level: p Knowledge p REF: p d p 455 p OBJ: p Clinical p Practice p #1 TOP: p Sources p of p Protein p KEY: p Nursing p Process p Step: p Planning

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MSC: p NCLEX: p Health p Promotion p and p Maintenance: p detection p and p early p prevention p of p disease

• A p patient p weighing p 132 p pounds p has p been p recommended p to p increase p daily p protein p

intake. p The p nurse p assists p the p patient p to p make p dietary p selections p of p protein p after p calculating p that p the p daily protein p requ irement p for p this p patient p is g.

• 24
• 36
• 48

d.

ANSWE

R: p C

60 The p protein p requirement p for p the p day p is p equal p to p the p number p of p kilograms p of p weight p (convert p lb p to p kg) p multiplied p by p 0.8 p (i.e., p 132/2.2 p = p 48).DIF: p Cognitive p Level: p Analysis p REF: p d p 456 p OBJ: p Clinical p Practice p #3 TOP: p Dietary p Protein p Recommendation p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• The p nurse p consults p with p a p patient p who p is p a p vegan p and p stresses p that p this p diet p

puts p the p patient p at p risk p for:

• diabetes.

• iron p deficiency.

• osteoporosis

• scurvy.

p ANSWER: p B

In p the p vegan p diet, p all p animal p food p sources p are p excluded, p placing p a p patient p who p eats p this p diet p most p at p risk p for p deficient p intake p of p protein p leading p to p an p iron p deficiency.DIF: p Cognitive p Level: p Comprehension p REF: p d p 456 p OBJ: p Clinical p Practice p #1 p TOP: p Vegan p Diets p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• The p nurse p in p a p long-term p care p facility p understands p that p the p 86-year-old p

residents p frequent p complaints p about p heartburn p are p most p likely p due p to p the p age-

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related p decreased:

• peristalsis.

• gag p reflex.

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• appetite.

• sphincter p

tone. p ANSWER: p D

The p age-related p loss p of p muscle p tone p in p the p sphincters p increases p the p incidence p of p heartburn p and p esophageal p reflux.DIF: p Cognitive p Level: p Comprehension p REF: p d p 454 p OBJ: p Theory p #63 p TOP: p Planning p KEY: p Nursing p Process p Step: p Evaluation MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• The p patient p states p that p he p uses p a p large p amount p of p table p sugar p (sucrose) p in p his p foods p because p it

gives p him p quick p energy. p The p nurse p explains p that p sucrose p will:

• quickly p raise p the p blood p sugar, p and p the p level p drops p slowly.

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• not p raise p the p blood p sugar p as p quickly p as p a p protein p source p will.

• cause p a p hunger p and p energy p lag p because p of p the p rapid p fall p of p the p blood p sugar.

• also p act p as p a p good p support p to p the p digestion p

of p fiber. p ANSWER: p C

Table p sugar p is p high p in p sucrose, p which p is p quickly p absorbed p into p the p bloodstream p and p can p cause p rapid p rises p and p falls p in p blood p glucose, p which p leads p to p hunger p and p an p energy p lag.DIF: p Cognitive p Level: p Comprehension p REF: p d p 457 p OBJ: p Theory p #2 p TOP: p Simple p Carbohydrates p KEY: p Nursing p Process p

Step: p Implementation

MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• The p nurse p evaluates p the p patients p understanding p of p the p fiber p content p of p grains p and p

cereals p when p the p patient p selects:

• white p bread p toast p with p an p orange.

• wheat p bread p toast p with p a p peeled p apple.

• shredded p wheat p and p a p banana.

• a p biscuit p and p a p

grapefruit. p ANSWER: p C

Shredded p wheat p and p a p banana p contain p a p total p of p 6 p g p of p fiber p per p serving, p whereas p wheat p toast p with p an p apple p contain p a p total p of p 4 p g, p white p bread p with p a p banana p contain p a p total p of p 3 p g, p and p a p biscuit p with p a p grapefruit p contain p a p total p of p 4 p g.DIF: p Cognitive p Level: p Comprehension p REF: p d p 458, p Table p 26-1 p OBJ: p Theory p #3 p TOP: p Fiber p KEY: p Nursing p Process p

Step: p Evaluation

MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• A p patient p has p been p placed p on p a p reduced-cholesterol p diet p to p help p control p heart p

disease. p The p serving p that p would p be p most p appropriate p for p the p patient p to p select p for p

supper p is:

• 3 p ounces p of p tuna p canned p in p water.

• 1 p frankfurter.

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• 1 p 3-ounce p pork p chop.

• chicken p breast p with p

skin. p ANSWER: p A

The p tuna p canned p in p water p contains p only p 2 p g p of p fat, p whereas p the p highest p fat p grams p are p found p in p the

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pork p chop p (19 p g) p followed p by p the p chicken p breast p with p skin p (18 p g). p DIF: p Cognitive p Level: p Application p REF: p d p 459, p Table p 26-2 OBJ: p Theory p #9 p TOP: p Cholesterol p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• The p nurse p points p out p to p the p newly p diagnosed p type p 2 p diabetic p patient p

that p complex p carbohydrates:

• do p not p affect p the p blood p sugar p level.

• keep p the p blood p sugar p at p an p unsatisfactory p high p level.

• lack p adequate p nutritional p potential.

• maintain p a p more p consistent p blood p sugar p level.

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ANSWER: p D

Complex p carbohydrates p (pasta, p cereal, p rice) p provide p a p more p consistent p blood p sugar p level p that p simple p sugars.DIF: p Cognitive p Level: p Application p REF: p d p 457 p OBJ: p Clinical p Practice p #4 p TOP: p Vitamins p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• When p a p patient p asks p how p is p a p good p way p to p increase p fiber p in p the p diet, p the p

nurses p best p response p would p be:

• eating p unpeeled p apples.

• increase p intake p of p dark p leafy p greens.

• eating p broiled p salmon.

• taking p daily p concentrated p fiber p

supplements. p ANSWER: p A

Eating p the p skins p of p fruits p is p a p good p source p of p fiber. p Fiber p concentrates p do p not p contain p needed p vitamins p and p minerals.DIF: p Cognitive p Level: p Application p REF: p d p 457 p OBJ: p Clinical p Practice p #4 p TOP: p Fiber p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• The p LPN/LVN p filling p out p the p Jewish p patients p dietary p menu p for p lunch p would p avoid p ordering:
• meat p and p fish.

• milk p and p vegetables.

• meat p and p milk.

• vegetables p and p

fruit. p ANSWER: p C

Common p food p practices p in p Judaism p include p not p eating p meat p and p milk p at p the p same p meal. p DIF: p Cognitive p Level: p Application p REF: p d p 469, p Table p 26-7 OBJ: p Theory p #7 p TOP: p Nutrition p and p Culture/Religion p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

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• A p nurse p takes p into p consideration p that p the p usual p diet p of p Asian p Americans p has p a p potential p for

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altering p health p because p the p diet p is p high p in:

• protein.

• starch.

• sodium.

• vitamin p

C.

ANSWER: p C

The p Asian p diet p is p high p in p sodium p and p fat.DIF: p Cognitive p Level: p Comprehension p REF: p d p 466 p OBJ: p Theory p #7 TOP: p Nutrition p and p Culture/Religion p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• The p mother p of p a p 4-month-old p infant p asks p what p type p of p cereal p is p most p

appropriate p to p feed p the p infant p as p a p first p solid p food. p The p best p response p from p the p

nurse p is p to p suggest:

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• wheat.

• barley.

• corn.

• rice.

ANSWER: p D

A p cereal p such p as p rice p is p the p best p initial p choice, p because p it p is p easily p tolerated, p provides p additional p calories p and p iron, p and p is p least p likely p to p be p allergenic.DIF: p Cognitive p Level: p Comprehension p REF: p d p 466 p OBJ: p

Theory p #8 p TOP: p Nutritional p Needs p Across p the p Life p Span

KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Health p Promotion p and p Maintenance: p growth p and p development

• A p mother p is p concerned p that p her p toddler p is p not p eating p enough p at p

mealtimes. p The p most p informative p suggestion p by p the p nurse p would p be p to:

• provide p large p servings p to p stimulate p appetite.

• provide p single-item p foods p that p do p not p touch p each p other p on p the p plate.

• increase p the p amount p of p milk p at p each p meal.

• use p plain p white p dishes p to p keep p attention p focused p

on p food. p ANSWER: p B

Toddlers p prefer p single-item p foods p in p small p quantities p that p do p not p touch p each p other p on p a p colorful p plate. p Milk p intake p should p decrease p during p the p toddler p years p as p solid p food p takes p the p place p of p milk. p DIF: p Cognitive p Level: p Application p REF: p d p 467 p OBJ: p Theory p #8

TOP: p Nutritional p Needs p Across p the p Life p

Span p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Health p Promotion p and p Maintenance: p growth p and p development

• On p assessment, p the p nurse p finds p that p the p female p patient p has p a p BMI p of p 26, p a p

waist p of p 37 p inches, p pale p conjunctiva, p and p a p large p muscle p mass. p The p indicator p of p this

p patient p being p overweight p is:

• BMI p level.

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• waist p measurement.

• conjunctiva.

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• large p muscle p

mass. p ANSWER: p B

A p waist p measurement p in p women p of p over p 35 p is p an p indicator p of p greater p risk p for p overweight p and p disease.DIF: p Cognitive p Level: p Analysis p REF: p d p 470 p OBJ: p Clinical p Practice p #2 p TOP: p Physical p Signs p of p Obesity p KEY: p Nursing p

Process p Step: p Assessment

MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• The p nursing p action p that p is p most p beneficial p toward p creating p an p atmosphere p conducive p to p eating

for p a p hospitalized p patient p immobilized p in p bed p is:

• lower p the p head p of p bed p as p tolerated.

• remove p the p urinal p from p the p over-the-bed p table.

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• invite p the p patient p to p wash p hands p and p face p before p eating.

• use p a p deodorizer p to p remove p any p unpleasant p odor p in p

the p room. p ANSWER: p B

Remove p distracting p articles p such p as p the p urinal p and p emesis p basin. p DIF: p Cognitive p Level: p Application p REF: p d p

472 p OBJ: p Theory p #6

TOP: p Promoting p Appetite p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p is p delivering p a p meal p tray p to p a p patient p in p a p skilled p nursing p facility p

who p is p a p Muslim. p The p nurse p should p confirm p the p meal p is p free p of:

• raw p fruits.

• eggplant.

• pork.

• lamb.

ANSWER: p C

People p of p the p Muslim p faith p are p prohibited p from p eating p pork. p DIF: p Cognitive p Level: p Application p REF: p d p 467, p Table p 26-7 p OBJ: p Theory p #7 p TOP: p Culture p and p Nutrition KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Psychosocial p Integrity: p coping p and p adaptation

• The p nurse p would p be p sure p the p diet p of p a p patient p in p an p extended p care p facility p

who p has p a p large p pressure p ulcer p on p his p sacrum p would p include p foods p rich p in p

vitamin:

• A.

• B1 p (thiamine).

• C.

• E.

ANSWER: p C

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Vitamin p C p helps p protect p the p body p against p infections p and p promotes p wound p healing. p DIF: p Cognitive p Level: p Application p REF: p d p 462, p Table p 26-4 OBJ: p Theory p #2 p TOP: p Vitamins p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

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• The p nurse p is p visiting p an p elderly p patient p who p lives p alone. p The p suggestion p made p

by p the p nurse p that p would p be p most p helpful p in p improving p the p patients p nutrition p would

p be:

• keep p the p environment p noise p free p to p concentrate p on p eating.

• decrease p intake p of p fluids p to p improve p appetite.

• use p salt p as p needed p to p spice p up p the p flavor p of p foods.

• cook p favorite p foods p in p bulk p and p freeze p in p individual p serving p

containers. p ANSWER: p D

Cooking p and p freezing p favorite p foods p for p easy p preparation p later p is p helpful p in p improving p the p overall p nutrition p of p an p elderly p patient.DIF: p Cognitive p Level: p Application p REF: p d p 469, p Patient p Teaching OBJ: p Clinical p Practice p #1 p TOP: p Nutritional p Needs p Across p the p Life p Span

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KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• When p assisting p with p the p nutritional p assessment p of p a p newly p admitted, p confused,

p emaciated p cancer p patient, p the p nurses p most p beneficial p intervention p to p support p the p

nutritional p status p of p this p patient p would p be p to:

• obtain p the p information p from p the p family.

• ask p simple p questions p of p the p patient.

• ask p for p a p dietitian p consult.

• request p an p order p for p a p full p

liquid p diet. p ANSWER: p C

A p dietitian p should p be p consulted p if p the p patient p has p high p nutritional p needs. p DIF: p Cognitive p Level: p Application p REF: p d p

462 p OBJ: p Theory p #9

TOP: p Nutritional p Assessment p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p caring p for p a p patient p with p human p immunodeficiency p syndrome p

HIV p would p encourage p the p intake p of p greater p amounts p of:

• vitamin p D.

• protein.

• vitamin p C.

• raw p fruits p and p

vegetables. p ANSWER: p B

Patients p with p HIV p lose p muscle p mass p and p need p to p increase p their p nutritional p intake p in p the p form p of p extra p calories p and p protein.DIF: p Cognitive p Level: p Comprehension p REF: p d p 464 p OBJ: p Clinical p Practice p #4 p TOP: p Nutrition p for p HIV p patient p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p home p health p nurse p is p visiting p an p elderly p patient p with p a p history p of p

malnutrition p and p memory p loss. p The p nurse p addresses p the p nutritional p needs p of p the

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p patient p by:

• writing p down p all p the p information p for p the p patient.

• giving p the p patient p MyPlate p for p reference.

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• involving p the p family.

• making p out p a p grocery p list p for p the p

patient. p ANSWER: p C

The p patient p may p not p be p able p to p remember p what p needs p to p be p done, p and p involving p the p family p will p help p in p meeting p the p patients p needs.DIF: p Cognitive p Level: p Application p REF: p d p 469 p OBJ: p Clinical p Practice p #1 p TOP: p Malnutrition p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p reduction p of p risk

• A p patient p of p Mexican-American p descent p has p a p blood p pressure p of p 160/90 p mm p Hg p and p is

moderately p obese. p The p nurse p can p help p the p patient p modify p his p diet p by p suggesting:

• decreasing p spices p when p cooking.

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• avoiding p fried p foods p altogether.

• limiting p corn p tortillas p to p two p per p day.

• substituting p the p use p of p lard p with p

canola p oil. p ANSWER: p D

Canola p oil p is p an p unsaturated p fat, p whereas p lard p is p saturated, p and p saturated p fats p should p be p limited p to p 10% p of p total p fat p intake.DIF: p Cognitive p Level: p Application p REF: p d p 459 p OBJ: p Clinical p Practice p #4 p TOP: p Patient p Education p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

COMPLETION

• The p nurse p takes p into p consideration p that p the p patient p with p pernicious p anemia p

who p lacks p the p intrinsic p factor p cannot p absorb .

ANSWER:

vitamin p B12 The p intrinsic p factor p excreted p by p the p wall p of p the p stomach p allows p the p absorption p of p vitamin p B12 p DIF: p Cognitive p Level: p Knowledge p REF: p d p 462, p Table p 26-4 OBJ: p Theory p #5 p TOP: p Pernicious p Anemia p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p uses p a p chart p to p show p an p obese p patient p who p is p trying p to p lose p

weight p by p counting p calories p that p each p gram p of p carbohydrate p supplies calories.

ANSWER:

4 four One p gram p of p carbohydrate p supplies p 4 p calories.DIF: p Cognitive p Level: p Knowledge p REF: p d p 457 p OBJ: p Clinical p Practice p #4 p TOP: p Calories p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p portion p of p carbohydrates p that p cannot p be p broken p down p by p intestinal p enzymes p and p juices p is

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p .p

ANSWER

:

fiber

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Fiber p is p the p portion p of p carbohydrates p that p cannot p be p broken p down p by p intestinal p flora.

Chapter p 15 p Fluid p and p Chemical p Balance Test p Bank p MULTIPLE p

CHOICE

• A p 10-month-old p infant p has p had p watery p green p stool p for p 2 p days p and p refuses p the p

bottle. p The p nurse p is p aware p that p the p primary p concern p for p this p baby p is:

• metabolic p acidosis.

• metabolic p alkalosis.

• weight p loss.

• diaper p rash.

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ANSWER: p A

Loss p of p bowel p contents p leads p to p metabolic p acidosis. p The p child p will p lose p weight p and p will p probably p have p diaper p rash, p but p the p primary p concern p is p the p electrolyte p imbalance.DIF: p Cognitive p Level: p Analysis p REF: p pp. p 436-437 p OBJ: p Clinical p Practice p #1 p TOP: p Dehydration p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p patient p who p was p admitted p after p vomiting p for p 3 p days p would p show p an p

abnormally p low p blood p pressure p because p of p a p fluid p shift p from:

• intracellular p to p the p extracellular.

• interstitial p to p intravascular.

• intravascular p to p the p interstitial.

• interstitial p to p the p

intracellular. p ANSWER: p C

If p intravascular p fluid, p a p type p of p extracellular p fluid p within p the p blood p vessels, p shifts p from p the p plasma p in p the p vascular p space p out p to p the p interstitial p space, p a p drop p in p blood p volume p occurs.DIF: p Cognitive p Level: p Comprehension p REF: p d p 432 p OBJ: p Theory p #3 TOP: p Distribution p of p Body p Fluids p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• An p isotonic p state p exists p within p a p patients p body p fluids p when p the p solute p concentration p of:
• interstitial p fluid p is p less p than p the p transcellular.

• intracellular p and p extracellular p fluid p is p equal.

• intracellular p fluid p is p greater p than p extracellular p fluid.

• extracellular p fluid p is p lesser p than p intracellular p

fluid. p ANSWER: p B

When p the p intracellular p and p extracellular p fluid p has p the p same p concentration p of p particles, p the p solution p is p called p isotonic p (equal p solute p concentration).DIF: p Cognitive p Level: p Comprehension p REF: p d p 433 p OBJ: p Theory p #3 p TOP: p Movement p of p Fluid p KEY: p Nursing p Process

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p Step: p N/A

MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p is p aware p that p an p infant p is p more p at p risk p for p dehydration p because p the p infant:

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• has p kidneys p that p reabsorb p water p from p the p intravascular p space.

• has p a p larger p body p surface p compared p with p body p weight.

• urinates p more p frequently.

• has p fat p that p absorbs p

water. p ANSWER: p B

Infants p are p more p at p risk p for p dehydration p because p they p have p a p larger p body p surface p compared p with p body p weight. p Their p immature p kidneys p cannot p reabsorb p water p as p well p as p an p adult, p and p fat p does p not p absorb p water.DIF: p Cognitive p Level: p Comprehension p REF: p d p 431 p OBJ: p Clinical p Practice p #1 p TOP: p Dehydration p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

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• The p nurse p points p out p that p non-electrolyte p products p of p metabolism p are p as p important p

to p health p as p electrolytes. p Non-electrolytes p include:

• magnesium.

• amino p acids.

• calcium.

• phosphates.

p ANSWER: p B

The p non-electrolytes p that p are p products p of p metabolism p and p serve p to p promote p health p in p the p body p are p amino p acids, p glucose, p and p fatty p acids.DIF: p Cognitive p Level: p Knowledge p REF: p d p 432 p OBJ: p Theory p #2 p TOP: p Non-electrolytes p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p assesses p that p the p patient p has p developed p abdominal p pain, p urinary p

retention, p and p confusion. p The p nurse p concludes p these p signs p are p the p result p of p an p

inadequate p supply p of:

• calcium p (Ca2+).

• sodium p (NA+).

• phosphates p (PO43).

• potassium p

(K+). p ANSWER: p D

The p symptoms p of p a p potassium p level p below p 3.5 p mEq/L p are p abdominal p pain, p urinary p retention, p confusion, p decreased p reflexes, p and p ECG p changes.DIF: p Cognitive p Level: p Analysis p REF: p d p 438, p Table p 25-4 p OBJ: p Theory p #4 p TOP: p Hypokalemia KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p nurse p gets p a p positive p Chvosteks p sign p on p a p young p woman p with p bulimia p who p

has p been p giving p herself p frequent p enemas p containing p phosphate. p The p nurse p anticipates p a p laboratory p finding p of

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p mEq/L.

• sodium p 140

• potassium p 4.5

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• magnesium p 1.6

• calcium p

6.5 p ANSWER: p D

The p low p level p of p calcium p is p responsible p for p the p sign. p The p positive p Chvosteks p sign p is p an p indicator p of p a p reduced p calcium p level.DIF: p Cognitive p Level: p Analysis p REF: p d p 438, p Table p 25-4 p OBJ: p Clinical p Practice p #2 p TOP: p Hypocalcemia KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• A p patient p has p been p identified p as p having p a p dietary p deficiency p of p vitamin p
• p The p nurse p understands p that p this p patient p is p also p at p risk p for p having p a p

deficiency p of:

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• calcium.

• magnesium.

• sodium.

• potassium.

p ANSWER: p A

Nutritional p deficiency p of p vitamin p D p can p result p in p hypocalcemia p because p of p the p patients p inability p to p absorb p calcium.DIF: p Cognitive p Level: p Comprehension p REF: p d p 440 p OBJ: p Clinical p Practice p #1 p TOP: p Hypocalcemia p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p explains p that p the p dehydrated p patients p urine p is p concentrated p because:
• renal p tubules p reabsorb p more p water p and p reduce p urine p output.

• kidneys p cease p to p function.

• blood p pressure p drops.

• the p colon p retains p more p fluid p from p the p fecal

p waste. p ANSWER: p A

When p dehydration p occurs, p the p renal p tubules p of p the p kidney p reabsorb p more p water p to p be p returned p to p the p circulating p volume, p making p the p urine p concentrated.DIF: p Cognitive p Level: p Comprehension p REF: p d p 433 p OBJ: p Theory p #3 p TOP: p Dehydration p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p is p aware p that p small p ions p such p as p glucose, p oxygen, p and p carbon p

dioxide p redistribute p themselves p through p semi-permeable p membranes p by p a p process p

called:

• diffusion.

• osmosis.

• blood p pressure.

• rehydration.

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p ANSWER: p A

Glucose, p oxygen, p carbon p dioxide, p and p other p small p ions p diffuse p through p membranes p until p they p are

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evenly p distributed.DIF: p Cognitive p Level: p Knowledge p REF: p d p 433 p OBJ: p Clinical p Practice p #5 p TOP: p Diffusion p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• A p patient p with p healthy p kidneys p experiences p metabolic p alkalosis p resulting p from p

episodes p of p vomiting. p The p nurse p takes p into p consideration p that p the p kidneys p can p clear p the p alkaline p substances p and p fully p stabilize p the p patients p pH p in p approximately:

• 3 p to p 5 p minutes.

• 12 p to p 24 p hours.

• 3 p days.

• 1 p week.

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ANSWER: p C

The p compensatory p ability p of p the p kidneys p takes p more p time p to p work p than p does p the p compensatory p action p of p the p lungs; p 3 p days p are p needed p for p the p kidneys p to p stabilize p pH p within p normal p range.DIF: p Cognitive p Level: p Knowledge p REF: p d p 441, p Clinical p Cues p OBJ: p Clinical p Practice p #5 p TOP: p AcidBase p Balance KEY: p Nursing p Process p Step: p N/A MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• A p patient p with p a p history p of p severe p chronic p obstructive p pulmonary p disease p

(COPD) p is p most p likely p to p have:

• respiratory p alkalosis.

• respiratory p acidosis.

• metabolic p alkalosis.

• metabolic p

acidosis. p ANSWER: p B

People p with p COPD p are p prone p to p chronic p respiratory p acidosis p because p of p the p retained p CO2. p DIF: p Cognitive p Level: p Comprehension p REF: p d p 441 p OBJ: p Clinical p Practice p #5 TOP: p AcidBase p Balance p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• A p patient p who p is p experiencing p severe p diarrhea p is p losing p excessive p bicarbonate p

ions. p This p patient p is p at p risk p for p developing:

• respiratory p alkalosis.

• respiratory p acidosis.

• metabolic p alkalosis.

• metabolic p

acidosis. p ANSWER: p D

Metabolic p acidosis p can p be p caused p by p either p an p excessive p loss p of p bicarbonate p ions p or p an p excessive p retention p of p hydrogen p ions.

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DIF: p Cognitive p Level: p Comprehension p REF: p d p 442, p Table p 25-5 p OBJ: p Theory p #5 p TOP: p AcidBase p Balance KEY: p Nursing p Process p Step: p Assessment

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MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• An p anxious p adult p patient p is p experiencing p a p respiratory p rate p of p 40 p

breaths/min. p The p most p appropriate p intervention p that p the p nurse p could p do p is p to p

instruct p the p patient p to:

• sit p up.

• lie p down.

• breathe p through p a p re-breather p mask.

• pant p with p mouth p

open. p ANSWER: p C

Anxiety p can p lead p to p hyperventilation, p causing p respiratory p alkalosis; p the p treatment p is p to p have p the p patient p breathe p through p a p re-breather p mask. p In p the p home p setting, p the p patient p can p be p asked p to p breathe p into p a p paper p bag.DIF: p Cognitive p Level: p Application p REF: p d p 442 p OBJ: p Theory p #5

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TOP: p AcidBase p Balance p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p is p aware p that p a p more p dynamic p process p that p moves p molecules p into p cells

p regardless p of p their p electrical p charge p or p concentration p in p the p cell p is:

• filtration.

• osmosis.

• active p transport.

• hydrostatic p

pressures. p ANSWER: p C

Active p transport p can p move p molecules p into p cells p regardless p of p their p electrical p charge p or p concentration p already p in p the p cell.DIF: p Cognitive p Level: p Knowledge p REF: p d p 434 p OBJ: p Theory p #3 p TOP: p Active p Transport p KEY: p Nursing p Process

p Step: p Planning

MSC: p NCLEX: p Physiological p Integrity: p pharmacological p and p parenteral p therapies

• For p the p accurate p measurement p to p detect p fluid p retention, p the p nurse p instructs p

the p nursing p assistants p to p measure p the p weight p with p the p same p scale:

• each p morning p before p breakfast p after p the p patient p has p voided.

• each p day p at p noon p before p lunch, p dressed p in p light p clothing

• in p between p meals, p dressed p in p light p clothing p after p voiding.

• just p before p bedtime, p while p the p patient p is p in p a p hospital p gown p

or p pajamas. p ANSWER: p A

Weight p is p measured p at p the p same p time p every p morning p on p the p same p scale, p after p the p patient p has p voided p and p before p eating.DIF: p Cognitive p Level: p Application p REF: p d p 444, p Assignment OBJ: p Clinical p Practice p #1 p TOP: p Assessment: p Fluid p and p Electrolytes p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• A p patient p with p congestive p heart p failure p has p gained p 1.1 p pounds p over p the p last p

24 p hours. p The p nurse p is p aware p that p this p weight p gain p represents p a p fluid p retention p

a.

0.25

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of L.

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• 0.5
• 1.0

d.

ANSWE

R: p B

2.0 Each p 2.2 p pounds p of p weight p equals p 1 p kg, p which p in p turn p equals p 1.0 p L p of p fluid.p Therefore, p 1.1 p pounds p equals p 0.5 p kg p and p is p equal p to p 0.5 p L p of p fluid.DIF: p Cognitive p Level: p Analysis p REF: p d p 444, p Clinical p Cues OBJ: p Theory p #4 p TOP: p Calculation p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p is p comparing p sitting p and p standing p vital p signs p for p a p patient p who p has p

been p diagnosed p with p dehydration. p The p pulse p rate p has p increased p by p 10 p beats/min p at p 1 p minute. p The p nurse p then p anticipates p the p blood p pressure p to p show p a(n) mm p Hg.

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• increase p of p 5

• drop p of p 40

• drop p of p 20

• increase p of p

10 p ANSWER: p C

A p drop p in p systolic p blood p pressure p by p at p least p 20 p mm p Hg p accompanied p by p a p pulse p rate p increase p of p at p least p 10 p beats/min p at p 1 p minute p following p position p change p is p suggestive p of p fluid-volume p deficit. p DIF: p Cognitive p Level: p Analysis p REF: p d p 444, p Clinical p cues OBJ: p Clinical p Practice p #1 p TOP: p Assessment: p Fluid p and p Electrolytes p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• A p patient p drank p a p cup p of p coffee, p a p half p glass p of p orange p juice, p and p half p a p

carton p of p milk p with p breakfast. p Using p common p equivalents p of p food p containers p as p a p guide, p the p nurse p notes p on p the p intake column p of the p intake p and p output p sheet p that p the p patient p consumed mL.

• 360
• 400
• 420

d.

ANSWER

: p C

600 A p coffee p cup p is p generally p equivalent p to p 240 p mL, p a p half p glass p of p juice p is p 60 p mL, p and p half p a p carton p of p milk p is p 120 p mL.DIF: p Cognitive p Level: p Analysis p REF: p d p 446, p Table p 25-8 p OBJ: p Clinical p Practice p #1 p TOP: p Intake p and p Output p KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• At p the p beginning p of p the p shift, p a p patients p IV p bag p has p 960 p mL p remaining. p The p

IV p fluid p is p running p at p 75 p mL/hr. p In p 8 p hours, p there p should p be p how p many p milliliters

a.

150

• 360
• 450

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p remaining p in p the p IV p bag?

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d.

ANSWER

: p B

600 75 p mL/hr p 8 p hours p = p 600; p 960 p 600 p = p 360.DIF: p Cognitive p Level: p Analysis p REF: p d p 446 p OBJ: p Clinical p Practice p #1 p TOP: p Intake p and p Output p KEY: p Nursing p Process p

Step: p Assessment

MSC: p NCLEX: p Physiological p Integrity: p pharmacological p and p parenteral p therapies

• The p physician p orders p fluid p restriction p for p a p patient p with p severe p fluid-volume p excess. p When p a

patient p is p placed p on p a p fluid p restriction, p the p allowance p of p fluids p should p be:

• greatest p during p the p day p shift.

• greatest p during p the p evening p shift.

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• greatest p during p the p night p shift.

• spaced p in p equal p increments p for p all p

shifts. p ANSWER: p A

The p greatest p amount p of p fluid p is p given p during p the p day p shift, p followed p by p the p evening p shift. p The p least p amount p of p fluid p is p given p at p night, p when p the p patient p should p be p sleeping.DIF: p Cognitive p Level: p Comprehension p REF: p d p 447 p OBJ: p Clinical p Practice p #1 p TOP: p Intake p and p Output p KEY: p Nursing p Process p Step: p Planning MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p is p aware p that p the p patient p who p suffered p a p brain p injury p with p cerebral p

edema p will p most p likely p receive p a p fluid p that p is:

• isotonic.

• hypertonic.

• hypotonic.

• enhanced p with p vitamin p

B. p ANSWER: p B

Hypertonic p fluids p draw p fluid p from p the p intracellular p space p and p reduce p edema. p DIF: p Cognitive p Level: p Comprehension p REF: p d p 446, p Table p 25-6 OBJ: p Clinical p Practice p #4 p TOP: p Hypertonic p Solutions p KEY: p Nursing p Process p Step: p N/A MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p patient p who p is p prescribed p a p diuretic p for p fluid-volume p excess p is p discharged

p home. p The p patient p verbalizes p understanding p of p his p disease p process p when p he p says:

• I p can p put p catsup p on p my p scrambled p eggs.

• I p can p snack p on p salted p popcorn.

• I p will p snack p on p raisins.

• I p will p avoid p

apricots. p ANSWER: p C

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The p patient p will p lose p electrolytes, p especially p potassium, p because p he p is p on p a p diuretic; p snacks p such p as p raisins p and p apricots p are p rich p in p potassium.DIF: p Cognitive p Level: p Analysis p REF: p d p 437, p Patient p Teaching

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OBJ: p Clinical p Practice p #3 p TOP: p Teaching p Plan p for p Sodium p Restriction p KEY: p Nursing p Process p Step: p Evaluation MSC: p NCLEX: p Health p Promotion p and p Maintenance: p prevention p and p early p detection p of p disease

• The p nurse p is p caring p for p a p patient p for p whom p a p dose p of p IV p potassium p has p been p

ordered. p Prior p to p hanging p the p potassium, p the p nurse p should:

• check p urine p output p to p be p above p 60 p mL/hr.

• check p the p dose p with p another p licensed p person.

• confirm p the p IV p fluid p running p is p compatible p with p potassium.

• start p potassium p with p another p

venipuncture. p ANSWER: p C

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The p nurse p must p confirm p that p the p IV p fluid p that p is p running p is p compatible p with p potassium. p A p urine p output p of p at p least p 30 p ml/hr p is p essential p prior p to p giving p IV p potassium.DIF: p Cognitive p Level: p Application p REF: p d p 449, p Safety p Alert p OBJ: p Clinical p Practice p #4 p TOP: p Intake p and p Output KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p caring p for p a p frail p 92-year-old p dehydrated p patient p should p add p to p the p

plan p of p care p the p potential p for

• over-hydration p related p to p excessive p thirst.

• diarrhea p related p to p dehydration.

• pulmonary p congestion p related p to p excessive p fluid p intake.

• fall p related p to p

confusion. p ANSWER: p D

The p dehydrated p patient p may p become p confused p because p of p fluid p and p electrolyte p losses. p DIF: p Cognitive p Level: p Analysis p REF: p d p 435, p Elder p Care OBJ: p Clinical p Practice p #4 p TOP: p Elder p Care p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p reduction p of p risk p potential

COMPLETION

• A p patient p with p a p serum p potassium p value p of p less p than p 3.5 p mEq/L p is

. p ANSWER:

hypokalemic The p normal p range p for p potassium p is p 3.5 p to p 5.0 p mEq/L. p DIF: p Cognitive p Level: p Analysis p REF: p d p 432, p Table p 25-2 OBJ: p Theory p #2 p TOP: p Electrolytes p KEY: p Nursing p Process p Step: p N/A p MSC: p NCLEX: p N/A

• The p nurse p clarifies p that p when p electrolytes p are p in p solution, p they p break p up p and p

become .

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p ANSWER:

ions Ions p are p charged p particles p of p electrolytes p in p solutions. p They p become p either p a p cation p with p a p positive p charge p or p an p anion p with p a p negative p charge.

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DIF: p Cognitive p Level: p Knowledge p REF: p d p 432 p OBJ: p Theory p #3 p TOP: p Ions p KEY: p Nursing p Process p Step: p Implementation MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation MULTIPLE p RESPONSE

• The p nurse p clarifies p that p the p electrolytes p include: p (Select p all p that p apply.)
• sodium.

• fatty p acids.

• potassium.

• magnesium.

• amino p acids.

• glucose.

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ANSWER: p A, p C, p D

The p intermediate p products p of p metabolismamino p acids p (proteins), p glucose, p and p fatty p acidsare p non- p electrolytes. p Sodium, p potassium, p and p magnesium p are p all p electrolytes.DIF: p Cognitive p Level: p Comprehension p REF: p d p 432, p Table p 25-2 OBJ: p Theory p #2 p TOP: p Electrolytes p KEY: p Nursing p Process p Step: p Implementation p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• Based p on p the p information p provided, p which p of p these p measurements p should p be p

recorded p on p the p output p sheet? p (Select p all p that p apply.)

• 250 p mL p nasogastric p secretions

• 200 p mL p diarrhea p stool

• 900 p mL p IV p therapy

• 650 p mL p urine p from p Foley p catheter

• 50 p mL p chest p tube p drainage

• 240 p mL p

milk p ANSWER: p A, p B, p

D, p E The p nurse p should p calculate p fluid p intake, p both p orally p and p intravenously, p and p mark p and p record p the p amount p of p gastric p suction p contents, p chest p tube p drainage, p Foley p catheter p drainage, p and p feces.DIF: p Cognitive p Level: p Application p REF: p d p 448, p Skill p 25-1 p OBJ: p Clinical p Practice p #1 p TOP: p Intake p and p Output KEY: p Nursing p Process p Step: p Assessment MSC: p NCLEX: p Physiological p Integrity: p basic p care p and p comfort

• The p nurse p assessing p a p newly p admitted p patient p with p marked p edema p from p severe

p congestive p failure p would p anticipate p that p the p patient p would p exhibit: p (Select p all p that p apply.)

• a p thready p pulse.

• concentrated p urine.

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• hypertension.

• weight p gain.

• crackles p heard p on p

auscultation. p ANSWER: p C, p D, p E

Persons p with p excess p fluid p volume p as p with p a p patient p in p congestive p failure p would p exhibit p a

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bounding p hypertension p and p weight p gain. p These p persons p would p also p have p a p bounding p pulse p and p copious p diluted p urine p as p the p kidneys p try p to p excrete p the p excess p fluid. p Because p of p fluid p accumulation p in p the p pleural p space, p crackles p can p be p heard p on p auscultation p when p assessing p a p person p with p congestive p failure.DIF: p Cognitive p Level: p Comprehension p REF: p d p 436 p OBJ: p Theory p #4 p TOP: p Overhydration p KEY: p Nursing p Process p Step: p Assessment p MSC: p NCLEX: p Physiological p Integrity: p physiological p adaptation

• The p nurse p explains p that p water p as p a p constituent p of p the p body p has p the p functions p of: p (Select p all p

that apply.)

• transportation p of p nutrients.

• blood p pressure p regulation.