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DeWit’s Fundamental Concepts And Skills for Nursing, 5th Edition By Patricia A. Williams -Test Bank
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Chapter 01: Nursing and the Health Care System

Williams: deWit’s Fundamental Concepts and Skills for Nursing, 5th Edition

 

MULTIPLE CHOICE

 

  1. Florence Nightingale’s contributions to nursing practice and education:
a. are historically important but have no validity for nursing today.
b. were neither recognized nor appreciated in her own time.
c. were a major factor in reducing the death rate in the Crimean War.
d. were limited only to the care of severe traumatic wounds.

 

 

ANS:  C

By improving sanitation, nutrition ventilation, and handwashing techniques, Florence Nightingale’s nurses dramatically reduced the death rate from injuries in the Crimean War.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 2                OBJ:   Theory #1

TOP:   Nursing History                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Early nursing education and care in the United States:
a. were directed at community health.
b. provided independence for women through education and employment.
c. were an educational model based in institutions of higher learning.
d. have continued to be entirely focused on hospital nursing.

 

 

ANS:  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:   p. 2                OBJ:   Theory #4

TOP:   Nursing History                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. 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:
a. caregiver, educator, and collaborator.
b. nursing assistant, delegator, and environmental specialist.
c. medication dispenser, collaborator, and transporter.
d. dietitian, manager, and housekeeper.

 

 

ANS:  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:   p. 3                OBJ:   Theory #2

TOP:   Art and Science of Nursing            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Although nursing theories differ in their attempts to define nursing, all of them base their beliefs on common concepts concerning:
a. self-actualization, fundamental needs, and belonging.
b. stress reduction, self-care, and a systems model.
c. curative care, restorative care, and terminal care.
d. human relationships, the environment, and health.

 

 

ANS:  D

Although nursing theories differ, they all base their beliefs on human relationships, the environment, and health.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 4                OBJ:   Theory #2

TOP:   Nursing Theories                            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Standards of care for the nursing practice of the LPN are established by the:
a. Boards of Nursing Examiners in each state.
b. National Council of States Boards of Nursing (NCSBN).
c. American Nurses Association (ANA).
d. National Federation of Licensed Practical Nurses.

 

 

ANS:  D

The National Federation of Licensed Practical Nurses modified the standards published by the ANA in 2015 to better fit the role of the LPN. In 2015 the American Nurses Association (ANA) revised the Standards of Nursing Practice which contained 17 standards of national practice of nursing, describing all facets of nursing practice: who, what, when, where, how.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 6                OBJ:   Theory #2

TOP:   Standards of Care                           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The LPN demonstrates an evidence-based practice by:
a. using a drug manual to check compatibility of drugs.
b. using scientific information to guide decision making.
c. using medical history of a patient to direct nursing interventions.
d. basing nursing care on advice from an experienced nurse.

 

 

ANS:  B

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:   p. 7                OBJ:   Theory #3

TOP:   Evidence-Based Practice                KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Lillian Wald and Mary Brewster established the Henry Street Settlement Service in New York in 1893 in order to:
a. offer a shelter to injured war veterans.
b. found a nursing apprenticeship.
c. provide health care to poor persons living in tenements.
d. offer better housing to low-income families.

 

 

ANS:  C

Henry Street Settlement Service brought the provision of community health care to the poor people living in tenements.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 2                OBJ:   Theory #4

TOP:   Growth of Nursing                         KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. An educational pathway for an LPN/LVN refers to an LPN/LVN:
a. learning on the job and being promoted to a higher level of responsibility.
b. moving from a maternity unit to a more complicated surgical unit.
c. obtaining additional education to move from one level of nursing to another.
d. learning that advancement requires consistent work and commitment.

 

 

ANS:  C

By broadening the educational base, an LPN/LVN may advance and build a nursing career.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 7                OBJ:   Theory #7

TOP:   Nursing Education Pathways          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. When diagnosis-related groups (DRGs) were established by Medicare in 1983, the purpose was to:
a. put patients with the same diagnosis on the same unit.
b. attempt to contain the costs of health care.
c. increase the availability of medical care to older adults.
d. identify a patient’s condition more quickly.

 

 

ANS:  B

The purpose of instituting DRGs was to contain skyrocketing costs of health care.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 9                OBJ:   Theory #10

TOP:   Health Care Delivery                                KEY:              Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The advent of diagnosis-related groups (DRGs) required that nurses working in health care agencies:
a. record supportive documentation to confirm a patient’s need for care in order to qualify for reimbursement.
b. use the DRG rather than their own observations for patient assessment.
c. be aware of the specific drugs related to the diagnosis.
d. acquire cross-training to make staffing more flexible.

 

 

ANS:  A

DRGs required that nurses provide more supportive documentation of their assessments and identified patient’s needs to qualify the facility for Medicare reimbursement. Observant assessment might also indicate another DRG classification and consequently more reimbursement for the facility.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 10              OBJ:   Theory #10

TOP:   Managed Care                                           KEY:              Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. If a member of a health maintenance organization (HMO) is having respiratory problems such as fever, cough, and fatigue for several days and wants to see a specialist, the person is required to go:
a. directly to an emergency room for treatment.
b. to any general practitioner of choice.
c. directly to a respiratory specialist.
d. to a primary care provider for a referral.

 

 

ANS:  D

Participants in an HMO must see their primary provider to receive a referral for a specialist in order for the HMO to pay for the care.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 10              OBJ:   Theory #11

TOP:   Managed Care                                           KEY:              Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. An advantage of preferred provider organizations (PPOs) is that:
a. they make insurance coverage of employees less expensive to employers.
b. there are fewer physicians to choose from than in an HMO.
c. long-term relationships with physicians are more likely.
d. patients may go directly to a specialist for care.

 

 

ANS:  A

The use of PPOs allows insurance companies to keep their premiums low and in turn makes insurance coverage less expensive for the employers. There are usually more physicians from which to choose than from an HMO, but long-term relationships between physician and patient cannot be established easily. Patients still must see their primary physician before being referred to other specialties.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 11              OBJ:   Theory #11

TOP:   Preferred Provider Organizations    KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. After passing the National Council Licensure Examination for Practical Nurses (NCLEX PN), the nurse is qualified to take an additional certification in the field of:
a. pharmacology.
b. care of infants and children.
c. operating room technology.
d. community health.

 

 

ANS:  A

After becoming an LPN, the nurse may apply for additional certification in pharmacology or long-term care.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 7                OBJ:   Theory #6

TOP:   Educational Opportunities              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Nursing interventions are best defined as activities that:
a. are taken to improve the patient’s health.
b. involve researching methods to maintain asepsis.
c. include the family in nursing care.
d. review guidelines for handling infectious wastes.

 

 

ANS:  A

Interventions are actions taken to improve, maintain, or restore health.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 3                OBJ:   Theory #2

TOP:   Art and Science of Nursing            KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Detection of Disease

 

  1. Nurse Practice Acts define the legal scope of an LPN’s practice, which are written and enforced by:
a. American Nurses Association.
b. National Council Licensure Examiners.
c. each state.
d. each health care agency.

 

 

ANS:  C

Each state writes and enforces the Nurse Practice Act, which defines the legal scope of nursing practice.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 6                OBJ:   Theory #3

TOP:   Nurse Practice Act                          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Women volunteers were organized to give nursing care to the wounded soldiers during the Civil War by:
a. Florence Nightingale.
b. Dorothea Dix.
c. Clara Barton.
d. Lillian Wald.

 

 

ANS:  B

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

 

DIF:    Cognitive Level: Knowledge          REF:   p. 2                OBJ:   Theory #4

TOP:   Nursing History                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The nursing theory presented by Sister Calista Roy is based on:
a. reduction of stress.
b. achievement of maximum level of wellness.
c. relief of self-care deficit.
d. adaptation modes.

 

 

ANS:  D

Adaptation modes (physiological, psychological, sociological, and independence) are the basis of the nursing theory of Sister Calista Roy.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 5|Table 1-1

OBJ:   Theory #2      TOP:   Nursing Theory                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The founding of the Red Cross is attributed to:
a. Lillian Wald.
b. Dorothea Dix.
c. Florence Nightingale.
d. Clara Barton.

 

 

ANS:  D

Clara Barton founded the Red Cross.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 2                OBJ:   Theory #4

TOP:   Nursing History                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The nursing theorist whose practice framework is based on 14 fundamental needs is:
a. Dorothy Johnson.
b. Jean Watson.
c. Virginia Henderson.
d. Martha Rogers.

 

 

ANS:  C

Virginia Henderson’s nursing theory framework is based on 14 fundamental needs.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 5|Table 1-1

OBJ:   Theory #2      TOP:   Nursing Theorists                           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The nursing theory that uses seven behavioral subsystems in an adaptation model is:
a. Betty Neumann.
b. Sister Calista Roy.
c. Dorothy Johnson.
d. Patricia Benner.

 

 

ANS:  C

Dorothy Johnson’s practice framework is based on seven behavioral subsystems in an adaptation model.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 5|Table 1-1

OBJ:   Theory #2      TOP:   Nursing Theorists                           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The Standards of Nursing Practice are designed to direct LPNs to:
a. advance their nursing career.
b. seek a scientific basis for their interventions.
c. deliver safe, knowledgeable care.
d. a leadership role.

 

 

ANS:  C

The Standards of Nursing Practice are designed to guide the LPN to deliver safe, knowledgeable care.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 6                OBJ:   Theory #2

TOP:   Nursing Standards                          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A state’s Nurse Practice Act is designed to protect the:
a. physician.
b. nurse.
c. public.
d. hospital.

 

 

ANS:  C

Nurse Practice Acts are designed to protect the public.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 6                OBJ:   Theory #5

TOP:   Nurse Practice Act                          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. It is appropriate for practical nurses to provide direct patient care to persons in a hospital under the supervision of a:
a. medical assistant.
b. registered nurse on the unit.
c. supervising nurse who is responsible for care on several units.
d. more experienced LPN on the unit.

 

 

ANS:  B

Practical nurses provide direct patient care under the direct supervision of a registered nurse, physician, or dentist.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 7                OBJ:   Theory #9

TOP:   Scope of Practice                            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. An example of tertiary health care is:
a. hospice care.
b. restorative care.
c. emergency care.
d. home health care.

 

 

ANS:  A

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

 

DIF:    Cognitive Level: Comprehension   REF:   p. 11|Box 1-2

OBJ:   Theory #8      TOP:   Health Care Services                                 KEY:   Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which nursing care delivery systems have some nursing schools adopted as the foundation of their education programs?
a. Relationship-based care
b. Team nursing
c. Patient-centered care
d. Total patient care

 

 

ANS:  A

Relationship-based care appeared in the early 2000s (Koloroutis, 2004) and emphasizes three critical relationships: (a) the relationship between caregivers and the patients and families they serve; (b) the caregiver’s relationship with him- or herself; (c) the relationship among health team members (UCLA Department of Nursing, 2015). The motivation behind relationship-based care was to promote a cultural transformation by improving relationships to foster care for the patient. Some schools of nursing have adopted relationship-based care as the foundation of their nursing education curriculum.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 9                OBJ:   Theory #8

TOP:   Delivery of Nursing Care               KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which nursing care delivery system has been fully embraced by the nursing community and is identified as one of the seven QSEN competencies?
a. Relationship-based care
b. Team nursing
c. Patient-centered care
d. Total patient care

 

 

ANS:  C

Patient-centered care has been described since the 1950s, but came to the forefront in 2001 when the Institute of Medicine (IOM) targeted six areas for improvement in the US health care system, including safety, effective, patient-centered, timely, efficient, and equitable (Cliff, 2012). Patient-centered care has been fully embraced by the nursing community, and is identified as one of the seven QSEN competencies (QSEN.org, 2015).

 

DIF:    Cognitive Level: Knowledge          REF:   p. 18              OBJ:   Theory #8

TOP:   Delivery of Nursing Care               KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which of the following is considered a positive aspect of the Affordable Care Act?
a. A 38-year-old mother is penalized on her taxes for not purchasing health insurance.
b. A 42-year-old laborer who has chronic kidney disease is denied insurance coverage.
c. Jamie, age 24, cannot continue insurance coverage on his parent’s insurance since he has graduated from college.
d. Maria, age 60, is able to obtain health insurance at a rate that is manageable on her income.

 

 

ANS:  D

The Patient Protection and Affordable Care Act is being phased in over several years. There are positive and negative aspects to this act, and many people have strong opinions about it. Since 2013 there have been insurance exchanges, along with requirements for uninsured people to purchase health insurance. Starting in 2015 people who have failed to purchase health insurance are being penalized on their income taxes. Provisions in the bill now prevent denial of insurance to those with preexisting illnesses who formerly could not buy health insurance, and young adults have been allowed to remain on their parents’ insurance through age 26. Starting in 2013 affluent people began paying an extra 3.8% tax on unearned income; drug manufacturers and the insurance industry are paying large annual fees to help cover the overall costs. Costs of the Medicare program will be contained by reducing payments to hospitals and health care providers. As coverage under the Affordable Care Act has expanded, the national uninsured rate has fallen from 16% to 11% of people under age 65 (people over age 65 are generally have universal coverage by Medicare). People who have benefitted the most from this coverage include people ages 18-34, blacks, Hispanics, and those living in rural areas (Quealy and Sanger-Katz, 2014). It is expected that the emphasis on prevention and coordinated care will produce a shift in nursing from the hospital to the community. There are many controversial parts of the bill, and the country is divided about whether the bill should be repealed and other health care legislation written. What happens in the Congress in the coming years will determine if all parts of the legislation will remain.

 

DIF:    Cognitive Level: Analysis               REF:   p. 11              OBJ:   Theory #10

TOP:   The Patient Protection and Affordable Care Act             KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

MULTIPLE RESPONSE

 

  1. Characteristics of primary nursing include: (Select all that apply.)
a. elimination of fragmentation of care between shifts.
b. evolved in the mid-1950s.
c. planning and direction performed by one nurse.
d. ancillary workers used to increase productivity.
e. the care plan covering the entire day.
f. associate nurses taking over care and planning when the primary nurse is off duty.

 

 

ANS:  A, C, D, E, F

Primary care reduces fragmentation of care between shifts. Care is planned by one nurse to cover a 24-hour period using ancillary workers to increase the productivity. An associate nurse may take on direction of care in the absence of the primary nurse.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 8                OBJ:   Theory #8

TOP:   Nursing Care Delivery                    KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. In 1991, the American Nurses Association (ANA) published the Standards of Nursing Practice. These standards are designed to: (Select all that apply.)
a. set standards for safe nursing care delivery.
b. define the legal scope of practice.
c. state legal requirements for clinical practice.
d. protect the nurse, patient, and health care agency.
e. regulate the nursing profession.
f. define activities in which nurses may engage.

 

 

ANS:  A, D, F

The Standards of Nursing Practice generally define activities in which nurses may engage, set standards for nursing care and delivery, and thereby protect the nurse, patient, and health care agency.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 6|Box 1-1   OBJ:   Theory #2

TOP:   Nursing Practice                             KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. An example of the role of an LPN as a delegator is: (Select all that apply.)
a. changing a patient’s wound dressing.
b. assisting a patient to complete his or her bath.
c. assigning patient care tasks to certified nursing assistants.
d. requesting the housecleaning staff to mop the floor of a patient’s room.
e. instructing the unit secretary to page a physician to the floor.

 

 

ANS:  C, D, E

Delegation under the scope of the practice of an LPN is the assignment of a certified nursing assistant to certain nursing care or other nonmedical staff to aspects of patient care.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 3                OBJ:   Theory #5

TOP:   Art and Science of Nursing            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. During the Civil War, nursing schools offered education to women both in England and in the United States. The schools in the United States differed from those in Europe because in US schools: (Select all that apply.)
a. students worked without pay.
b. the core curriculum was the same.
c. instruction was presented by physicians at the bedside.
d. the educational focus was on nursing care.
e. classes were held separately from the clinical experience.

 

 

ANS:  A, C

In the United States, the students staffed the hospital and worked without pay. There were no formal classes; education was achieved through work. There was no set curriculum, and content varied depending on the type of cases present in the hospital. Instruction was done at the bedside by the physician and therefore came from a medical viewpoint.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 4                OBJ:   Theory #4

TOP:   Early Nursing Education                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

COMPLETION

 

  1. Preferred provider organizations (PPOs) use ____________ to finance their services and pay the physical cost of the service.

 

ANS:

capitated cost

 

The capitated cost is the set fee that is paid to the network for each patient enrolled to finance its services.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 11              OBJ:   Theory #8

TOP:   Capitated Cost                                           KEY:              Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. In the United States, the Young Women’s Christian Association (YMCA) in New York opened The ____________ School, the first practical nursing school.

 

ANS:

Ballard

 

In 1892, the YMCA opened The Ballard School, a 3-month course in practical nursing that was the first school of practical nursing.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 2                OBJ:   Theory #4

TOP:   Ballard School                                          KEY:              Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Such health services as surgical procedures, restorative care, and home health care would be classified as ________ care.

 

ANS:

secondary

 

Surgical procedures, restorative care, and home health are part of the many services classified as secondary care.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 11|Box 1-2

OBJ:   Theory #10    TOP:   Health Care Services                                 KEY:   Nursing Process Step: N/A

MSC:  NCLEX: N/A

Chapter 03: Legal and Ethical Aspects of Nursing

Williams: deWit’s Fundamental Concepts and Skills for Nursing, 5th Edition

 

MULTIPLE CHOICE

 

  1. A student nurse who is not yet licensed:
a. may not perform nursing actions until he or she has passed the licensing examination.
b. is not responsible for his or her actions as a student under the state licensing law.
c. are held to the same standards as a licensed nurse.
d. must apply for a temporary student nurse permit to practice as a student.

 

 

ANS:  C

Student nurses are held to the same standards as a licensed nurse. This means that although a student nurse may not perform a task as quickly or as smoothly as the licensed nurse would, the student is expected to perform it as effectively. In other words, she must achieve the same outcome without harm to the patient. The student is legally responsible for her own actions or inaction, and many schools require the student to carry malpractice insurance.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 32              OBJ:   Theory #1

TOP:   Practice Regulations for the Student Nurse                                KEY:   Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. During an employment interview, the interviewer asks the nurse applicant about HIV status. The nurse applicant can legally respond:
a. “No,” even though he or she has a positive HIV test.
b. “I don’t know, but I would be willing to be tested.”
c. “I don’t know, and I refuse to be tested.”
d. “You do not have a right to ask me that question.”

 

 

ANS:  D

In employment practice, it is illegal to discriminate against people with certain diseases or conditions. Asking a question about health status, especially HIV or AIDS infection, is illegal.

 

DIF:    Cognitive Level: Application          REF:   p. 34              OBJ:   Clinical Practice #1

TOP:   Discrimination                                KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. An example of a violation of criminal law by a nurse is:
a. taking a controlled substance from agency supply for personal use.
b. accidentally administering a drug to the wrong patient, who then has a serious reaction.
c. advising a patient to sue the doctor for a supposed mistake the doctor made.
d. writing a letter to the newspaper outlining questionable or unsafe hospital practices.

 

 

ANS:  A

Theft of a controlled substance is a federal crime and consequently a crime against society.

 

DIF:    Cognitive Level: Application          REF:   p. 32              OBJ:   Theory #2

TOP:   Criminal Law                                  KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The LPN (LVN) assigns part of the care for her patients to a nursing assistant. The LPN is legally required to perform which of the following for the residents assigned to the assistant?
a. Toilet the residents every 2 hours and as needed.
b. Feed breakfast to one of the residents who needs assistance.
c. Give medications to the residents at the prescribed times.
d. Transport the residents to the physical therapy department.

 

 

ANS:  C

Toileting, feeding, and transporting residents or patients are tasks that can be legally assigned to a nurse’s aide. Administering medications is a nursing act that can be performed only by a licensed nurse or by a student nurse under the supervision of a licensed nurse.

 

DIF:    Cognitive Level: Application          REF:   p. 33              OBJ:   Theory #3

TOP:   Delegation      KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. If a nurse is reported to a state board of nursing for repeatedly making medication errors, it is most likely that:
a. the nurse will immediately have his or her license revoked.
b. the nurse will have to take the licensing examination again.
c. a course in legal aspects of nursing care will be required.
d. there will be a hearing to determine whether the charges are true.

 

 

ANS:  D

The nurse may have his or her license revoked or be required to take a refresher course, but this would be based on the evidence presented at a hearing. The licensing examination is not usually required as a correction of the situation as described.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 33              OBJ:   Theory #3

TOP:   Professional Discipline                   KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A nurse co-worker arrives at work 30 minutes late, smelling strongly of alcohol. The fellow nurses’ legal course of action is to:
a. have the nurse lie down in the nurses’ lounge and sleep while others do the work.
b. state that, if this happens again, it will be reported.
c. report the condition of the nurse to the nursing supervisor.
d. offer a breath mint and instruct the nurse co-worker to work.

 

 

ANS:  C

Nurses must report the condition. It is a nurse’s legal and ethical duty to protect patients from impaired or incompetent workers. Allowing the impaired nurse to sleep enables the impaired nurse to avoid the consequences of his or her actions and to continue the risky behavior. Threatening to report “the next time” continues to place patients at risk, as does masking the signs of impairment with breath mints.

 

DIF:    Cognitive Level: Application          REF:   p. 33              OBJ:   Theory #3

TOP:   Professional Discipline                   KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. When a student nurse performs a nursing skill, it is expected that the student:
a. performs the skill as quickly as the licensed nurse.
b. achieves the same result as the licensed nurse.
c. not be held to the same standard as the licensed nurse.
d. always be directly supervised by an instructor.

 

 

ANS:  B

Students are not expected to perform skills as quickly or as smoothly as experienced nurses, but students must achieve the same result in a safe manner.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 33              OBJ:   Theory #1

TOP:   Practice Regulations for the Student Nurse                                KEY:   Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. If a nurse receives unwelcome sexual advances from a nursing supervisor, the first step the nurse should take is to:
a. send an anonymous letter to the nursing administration to alert them to the situation.
b. tell the nursing supervisor that she is uncomfortable with the sexual advances and ask the supervisor to refrain from this behavior.
c. report the nursing supervisor to the state board for nursing.
d. resign and seek employment in a more comfortable environment.

 

 

ANS:  B

The first step in dealing with sexual harassment in the workplace is to indicate to the person that the actions or conversations are offensive and ask the person to stop. If the actions continue, then reporting the occurrence to the supervisor or the offender’s supervisor is indicated.

 

DIF:    Cognitive Level: Application          REF:   p. 34              OBJ:   Clinical Practice #1

TOP:   Sexual Harassment                         KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A person who has been brought to the emergency room after being struck by a car insists on leaving, although the doctor has advised him to be hospitalized overnight. The nurse caring for this patient should:
a. have him sign a Leave Against Medical Advice (AMA) form.
b. tell him that he cannot leave until the doctor releases him.
c. immediately begin the process of involuntary committal.
d. contact the person’s health care proxy to assist in the decision-making process.

 

 

ANS:  A

A person has the right to refuse medical care, and agencies use the Leave AMA to document the medical advice given and the patient’s informed choice to leave against that advice.

 

DIF:    Cognitive Level: Application          REF:   p. 39              OBJ:   Clinical Practice #3

TOP:   Patient Rights                                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: N/A

 

  1. The information in a patient’s medical record may legally be:
a. copied by students for use in school reports or case studies.
b. provided to lawyers or insurers without the patient’s permission.
c. shared with other health care providers at the patient’s request.
d. withheld from the patient, because it is the property of the doctor or agency.

 

 

ANS:  C

A release or consent is required to provide information from a patient’s medical record to anyone not directly caring for that patient. The patient must provide consent to provide information to insurers, lawyers, or other health care agencies or providers. The patient has the right to access the information in his or her medical record (copies), but the agency or doctor retains ownership of the document.

 

DIF:    Cognitive Level: Application          REF:   p. 39              OBJ:   Theory #5

TOP:   Legal Documents                            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. If a patient indicates that he is unsure if he needs the surgery he is scheduled for later that morning, the nurse would best reply:
a. “Your doctor explained all of that yesterday when you signed the consent.”
b. “Your doctor is in the operating room; she can’t talk to you now.”
c. “You should have the surgery; your doctor recommended that you have it.”
d. “I will call the doctor to speak with you before you go to the operating room.”

 

 

ANS:  D

A consent can be withdrawn at any time before the treatment or procedure has been started. The primary care provider should be notified by the supervising nursing staff of the unit.

 

DIF:    Cognitive Level: Application          REF:   p. 38              OBJ:   Clinical Practice #4

TOP:   Informed Consent                          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A 16-year-old boy is admitted to the emergency room after fracturing his arm from falling off his bike while visiting with his stepfather who is not the custodial parent. The nurse is preparing him to go to the operating room but must obtain a valid informed consent by:
a. having the patient sign the consent for surgery.
b. obtaining the signature of his stepfather for the surgery.
c. declaring the patient to be an emancipated minor.
d. obtaining permission of the custodial parent for the surgery.

 

 

ANS:  D

The patient is a minor and cannot legally sign his own consent unless he is an emancipated minor; the guardian for this patient is the custodial parent. A step parent is not a legal guardian for a minor unless the child has been adopted by the step parent. The hospital does not have the authority to declare the patient an emancipated minor.

 

DIF:    Cognitive Level: Application          REF:   p. 38              OBJ:   Clinical Practice #3

TOP:   Consent          KEY:  Nursing Process Step: Intervention

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. A patient has advance directives spelled out in a durable power of attorney, with the appointment of his daughter as his health care agent. The daughter will be responsible for:
a. paying all the medical bills associated with the father’s illness.
b. making all informed consent decisions for her father.
c. making all choices about her father’s health care if the father is unable.
d. paying only for those health care decisions based on the advance directives.

 

 

ANS:  C

A health care agent makes decisions for the patient only when a patient is unable, according to the wishes made known by the patient in advance directives. A health care agent is not responsible for financial decisions or payments.

 

DIF:    Cognitive Level: Application          REF:   p. 39              OBJ:   Clinical Practice #5

TOP:   Advance Directives                        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A patient has signed a do-not-resuscitate (DNR) order. If a nurse performs cardiopulmonary resuscitation (CPR) when the patient stops breathing and then successfully revives the patient, the:
a. nurse could be found guilty of battery.
b. patient would have no grounds for legal action.
c. patient could charge the nurse with false imprisonment.
d. nurse could be found guilty of assault.

 

 

ANS:  A

A nurse who attempts CPR on a patient who had a doctor’s order for a DNR could be found guilty of battery.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 39              OBJ:   Clinical Practice #3

TOP:   DNR              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. A patient refuses to take his medications or to eat his breakfast. He is alert, mentally competent, and fairly comfortable. The nurse should:
a. give the medications by injection if the patient will not take them orally.
b. respect the patient’s right to refuse medications or food, because he is competent.
c. tell the patient that he must cooperate with his care.
d. contact the doctor to insert a feeding tube to supply both medicine and food.

 

 

ANS:  B

The competent patient has the right to refuse medicine, food, treatments, and procedures. Giving (or threatening to give) medications by injection over the patient’s objections is considered battery. Threatening the patient or overriding the patient’s wishes is a violation of the patient’s bill of rights and constitutes assault or battery.

 

DIF:    Cognitive Level: Application          REF:   p. 40              OBJ:   Clinical Practice #3

TOP:   Patient’s Rights                               KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A nurse remarks to several people that “Dr. X must be getting senile because she makes so many mistakes.” If that remark results in some of Dr. X’s patients changing to another doctor, Dr. X would have grounds to sue the nurse for:
a. slander.
b. libel.
c. invasion of privacy.
d. negligence.

 

 

ANS:  A

A person who makes untrue, malicious, or harmful remarks that damage a person’s reputation and cause injury (loss of business) is guilty of defamation and slander. Libel is defamation that is written.

 

DIF:    Cognitive Level: Application          REF:   p. 40              OBJ:   Clinical Practice #5

TOP:   Defamation/Slander                        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A licensed nurse is liable for charges of malpractice when she:
a. does not show up for work and fails to call to notify the agency.
b. clocks in for another nurse to prevent that nurse from having pay docked.
c. falsifies data, causing the patient to suffer problems resulting in death.
d. assists in performing CPR that is unsuccessful, and the patient dies.

 

 

ANS:  C

Malpractice is professional negligence or, in this case, doing (falsifying) something the reasonable and prudent nurse would not do. It is the proximate cause of the patient injury. This is a case of causation.

 

DIF:    Cognitive Level: Application          REF:   p. 40|Box 3-6

OBJ:   Theory #5      TOP:   Negligence and Malpractice            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A postoperative patient in the intensive care unit (ICU) is so confused and agitated that staff have not been able to safely care for him. He has pulled out his central line once, and he slides to the bottom of the bed, where he attempts to climb out, pulling and disrupting the various tubes and monitors. The nurse’s best course of action is to:
a. place him in a protective vest device.
b. use a sheet to tie him in a chair at the nurses’ station.
c. request that the doctor write an order for a protective device and/or medication.
d. call a family member to stay with the patient.

 

 

ANS:  C

A protective device may not be used (except in an emergency) without a doctor’s order, and it is used only when other less restrictive means do not provide safety for the patient.

 

DIF:    Cognitive Level: Application          REF:   p. 41              OBJ:   Clinical Practice #3

TOP:   False Imprisonment                        KEY:  Nursing Process Step: Implementation

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

 

  1. An elderly, slightly confused patient sustains an injury from a heating pad that was wrongly applied by the nurse. The nurse should:
a. pretend to be unaware of the injury to the patient.
b. report the incident to the risk management team via an incident report.
c. document in the patient’s medical record that an incident report was filled out.
d. not document anything about the injury in the patient’s medical record.

 

 

ANS:  B

When an incident occurs that has potential for a future lawsuit, the risk management team should be aware of it as soon as possible. An incident report should be filled out, and the patient medical record should be documented to describe the injury. No mention of the incident report is usually made in the patient medical record. Honesty and a forthright explanation to the patient reduce the risk of lawsuits.

 

DIF:    Cognitive Level: Application          REF:   p. 43              OBJ:   Theory #5

TOP:   Incident Reports                             KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Nursing liability insurance is a policy purchased and put into effect by the nurse for the purpose of:
a. providing protection against being sued.
b. reducing the chance of litigation.
c. paying attorney fees and any award won by the plaintiff.
d. providing the hospital with added protection.

 

 

ANS:  C

Nursing liability insurance pays attorney fees and any award won by the plaintiff.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 43              OBJ:   Theory #5

TOP:   Nursing Ethics                                           KEY:              Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Ethics and law are different from each other in that ethics:
a. bear a penalty if violated.
b. are voluntary.
c. rarely change.
d. can always direct all decisions.

 

 

ANS:  B

Ethics are voluntary and are based on values. Ethics may change as parameters of health care change. There is no penalty for violation.

 

DIF:    Cognitive Level: Analysis               REF:   p. 43              OBJ:   Theory #6

TOP:   Nursing Ethics                                           KEY:              Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. To best protect himself or herself from being sued, the nurse should:
a. continue to do procedures as taught in school.
b. purchase malpractice insurance.
c. maintain competency.
d. use evidence-based practice.

 

 

ANS:  C

Keeping up with continuing education, maintaining competency, and seeking to improve one’s own practice by self-evaluation will best protect the nurse.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 42|Box 3-7

OBJ:   Theory #5      TOP:   Avoiding Lawsuits                          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The Health Insurance Portability and Accountability Act’s (HIPAA) main focus is in keeping:
a. patients safe from harm.
b. patient information in a secure office area.
c. medications in a locked area.
d. hospital infections under control.

 

 

ANS:  B

HIPAA regulates the way patient information is conveyed and stored.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 37|Box 3-4

OBJ:   Clinical Practice #1                         TOP:   HIPAA           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which of the following could place the nurse in a serious legal situation?
a. A nurse posts a poem about the qualities of a compassionate nurse on his or her social media page.
b. A nurse’s mother shares a “selfie” of her daughter (a nurse) and a celebrity patient she is caring for on her social media page.
c. A nurse posts a request for prayer for strength after a difficult day at work.
d. A nurse posts a video of fellow nurse’s lip syncing and dancing to a popular song, “We are Strong.”

 

 

ANS:  B

Legal and Ethical Considerations

Social Media and HIPAA

Health care agencies and institutions have had to become more diligent in protecting personal health information (PHI) as a result. It is imperative that no PHI be disseminated, either intentionally or unintentionally, over social media. Posting of pictures, discussions (even those that do not use patient or hospital names), and images of x-rays all violate HIPAA and place the nurse in a serious legal situation. It is generally best to separate one’s personal and professional life when dealing with social media. The National Council of State Boards of Nursing (2011) provides guidelines and suggestions for nurses in dealing with social media and nursing practice.

 

DIF:    Cognitive Level: Analysis               REF:   p. 37              OBJ:   Clinical Practice #6

TOP:   Social Media and HIPAA               KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. When a patient asks a nurse to witness the signing of a will, the nurse should refer the request to the:
a. nurse supervisor.
b. hospital legal department.
c. notary public for the hospital.
d. nurse’s attorney.

 

 

ANS:  C

Although witnessing a legal document for a patient is not illegal, most agencies have a policy regarding the proper course of action by referring the patient to the notary public.

 

DIF:    Cognitive Level: Application          REF:   p. 39              OBJ:   Theory #1

TOP:   Witnessing Wills and Other Legal Documents

KEY:  Nursing Process Step: Implementation

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

 

  1. Criteria that justify becoming an emancipated minor and able to sign a medical consent include all of the following except:
a. independence established through a court order.
b. service in the armed forces.
c. a 14-year-old whose parents are dead.
d. a 17-year-old pregnant female.

 

 

ANS:  C

Criteria are that the minor be independent by court order, be a member of the military, be pregnant, or be married.

 

DIF:    Cognitive Level: Application          REF:   p. 38              OBJ:   Clinical Practice #3

TOP:   Emancipated Minor                        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A written statement expressing the wishes of a patient regarding future consent for or refusal of treatment in case the patient is incapable of participating in decision making is an example of:
a. a privileged relationship.
b. a health care agent.
c. an advance directive.
d. witnessed will.

 

 

ANS:  C

An advance directive makes the patient’s wishes known regarding medical decisions and consent in the event that he or she is unable to participate in decision making.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 39              OBJ:   Clinical Practice #5

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

 

  1. A nurse is caring for an unmarried 16-year-old patient who has just given birth to a baby boy. The nurse will get the consent to perform a circumcision on the patient’s son from the:
a. patient’s father.
b. patient’s primary care provider.
c. patient’s mother.
d. 16-year-old patient.

 

 

ANS:  D

Pregnancy qualifies as the basis for the 16-year-old to be treated as an emancipated minor.

 

DIF:    Cognitive Level: Application          REF:   p. 38              OBJ:   Clinical Practice #3

TOP:   Patient Rights                                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: N/A

 

  1. A 48-year-old man refuses to take a medication ordered for the control of his blood pressure. The nurse’s most effective response would be:
a. “Your doctor expects you to be compliant.”
b. “You have the right to refuse. This medication keeps your blood pressure under control.”
c. “Fine. I will document that you are refusing this drug.”
d. “Are you aware that you could have a stroke?”

 

 

ANS:  B

Patients have the right to refuse medication, but it is the nurse’s responsibility to explain the reason for the particular drug.

 

DIF:    Cognitive Level: Application          REF:   p. 38              OBJ:   Theory #1

TOP:   Legal Standards                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. The Occupational Safety and Health Act includes all of the following, except:
a. regulations for handling infectious materials.
b. radiation and electrical equipment safeguards.
c. staffing ratios and delegation criteria.
d. regulations for handling toxic materials.

 

 

ANS:  C

The Occupational Safety and Health Act was passed in 1970 to improve the work environment in areas that affect workers’ health or safety. It includes regulations for handling infectious or toxic materials, radiation safeguards, and the use of electrical equipment.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 34              OBJ:   N/A

TOP:   OSHA            KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. The most frequently cited cause of a sentinel event by the Joint Commission is a problem in:
a. applying physical restraints.
b. methods of patient transportation.
c. medication errors.
d. inadequate communication.

 

 

ANS:  D

The most frequently cited cause of a sentinel event by the Joint Commission is communication. During “handoff” communication, there is a risk that critical patient care information might be lost due to lack of communication.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 35              OBJ:   Clinical Practice #2

TOP:   Communication                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The acronym SBAR is a method to communicate with a primary care provider that clarifies a situation that may result in litigation. The acronym stands for:
a. situation, background, alterations, results.
b. subjective, believable, actual, recommendation.
c. situation, background, assessment, recommendation.
d. situation, basis, assessment, recommendation.

 

 

ANS:  C

SBAR is an acronym that stands for situation, background, assessment, and recommendation. This undetailed analysis clarifies the situation in a manner that is concise yet complete.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 35              OBJ:   Theory #5

TOP:   SBAR Reporting                             KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The patient who cannot legally sign his or her own surgical consent is:
a. a 17-year-old who is serving in the armed forces.
b. a 16-year-old who is legally married.
c. a 17-year-old emancipated minor.
d. an 18-year-old who received a narcotic 30 minutes ago.

 

 

ANS:  D

The person giving the consent must be able to take part in the decision making. A sedated person does not have this ability.

 

DIF:    Cognitive Level: Application          REF:   p. 38              OBJ:   Clinical Practice #3

TOP:   Patient Rights                                  KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The nurse who may be liable for invasion of privacy would be the nurse who is:
a. refusing to give patient information to a relative over the phone.
b. firmly closing the door prior to bathing the patient.
c. discussing her patients with a fellow nurse.
d. reporting the patient as a possible victim of elder abuse.

 

 

ANS:  C

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

 

DIF:    Cognitive Level: Application          REF:   p. 38              OBJ:   Clinical Practice #3

TOP:   Patient Rights                                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: N/A

 

  1. A characteristic of an advance directive is that:
a. advance directives do not expire.
b. only some states recognize advance directives.
c. advance directives can be nonverbal.
d. advance directives from one state are recognized by another.

 

 

ANS:  A

An advance directive is a written statement expressing the wishes of the patient regarding future consent for or refusal of treatment if the patient is incapable of participating in decision making, and they do not expire. All states recognize advance directives, but each state regulates advance directives differently, and an advance directive from one state may not be recognized in another.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 38              OBJ:   Clinical Practice #5

TOP:   Advance Directives                        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A patient who is refusing to take his medication is threatened that he will be held down and forced to take the dose. This is an example of:
a. battery.
b. defamation.
c. assault.
d. invasion of privacy.

 

 

ANS:  C

Assault is the threat to harm another or even to touch another without that person’s permission. The person being threatened must believe that the nurse has the ability to carry out the threat.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 40              OBJ:   Theory #3

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

 

  1. The nurse explains that a sentinel event is a situation in which a patient:
a. refuses care.
b. is accidentally exposed.
c. leaves the hospital against medical advice.
d. comes to harm.

 

 

ANS:  D

A sentinel event is an unexpected situation in which the patient comes to harm.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 35              OBJ:   Theory #5

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

 

MULTIPLE RESPONSE

 

  1. Professional accountability includes: (Select all that apply.)
a. understanding theory.
b. adhering to the dress code of the facility.
c. asking for assistance when unsure of a procedure or primary care provider order.
d. participating in continuing education classes.
e. meeting the health care needs of the patient.
f. reporting patient health status changes to all family members.

 

 

ANS:  A, C, D, E

Professional accountability is a nurse’s responsibility to meet the health care needs of the patient in a safe and caring application of nursing skills and understanding of human needs.

 

DIF:    Cognitive Level: Analysis               REF:   p. 33              OBJ:   Theory #3

TOP:   Professional Accountability            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A nurse arrives at the scene of a motor vehicle accident. A person in the vehicle mumbles incoherently when asked his name. Which actions are not covered by the Good Samaritan Law? (Select all that apply.)
a. Using two magazines and a bandana to splint a broken arm
b. Applying a tourniquet to a lacerated leg while awaiting emergency personnel
c. Pulling the individual from the surface of the highway
d. Initiating an emergency tracheotomy when the individual goes into respiratory arrest
e. Compressing a bleeding wound with a soiled shirt

 

 

ANS:  D

The Good Samaritan Law covers care given in an emergency, but only within the scope of one’s practice, and care that does not cause harm resulting from negligence.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 35              OBJ:   Theory #5

TOP:   Legal Scope of Practice                  KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The Ethics Committee of a facility has the responsibility to: (Select all that apply.)
a. develop policies.
b. address issues in their facility.
c. modify the established codes of ethics as suits the situation.
d. create a master plan for decision making to be followed in ethical dilemmas.
e. help to find a better understanding of ethical dilemmas from different standpoints.

 

 

ANS:  A, B, E

An Ethics Committee of an institution has representatives from various fields to formulate, address, and help clarify ethical problems that present themselves in their facility.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 45              OBJ:   Theory #6

TOP:   Ethics             KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. The commonalities of The Codes of Ethics of the National Association for Practical Education and Service (NAPNES) and The National Federation of Licensed Practical Nurses (NFLPN) include: (Select all that apply.)
a. commitment to continuing education.
b. respect for human dignity.
c. maintenance of competence.
d. requirement for membership in a national organization.
e. preserving the confidentiality of the nurse-patient relationship.

 

 

ANS:  A, B, C, E

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

 

DIF:    Cognitive Level: Application          REF:   p. 43              OBJ:   Theory #6

TOP:   Ethics             KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

COMPLETION

 

  1. In 2003, the Patients’ Bill of Rights was revised to become the _________: Understanding Expectations, Rights, and Responsibilities.

 

ANS:

Patient Care Partnership

 

The Patient Care Partnership addresses patient rights and the responsibility of health care facilities.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 33              OBJ:   Clinical Practice #3

TOP:   Patient Rights                                  KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. CAPTA, passed in 1973, is a law regarding the safety of minors. It is the ________ _________ and _______.

 

ANS:

Child Abuse Prevention; Treatment Act

 

This is a law that requires mandated reporting and defines who is a mandated reporter.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 34              OBJ:   Theory #1

TOP:   Professional Accountability            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

Chapter 11: Growth and Development: Infancy Through Adolescence

Williams: deWit’s Fundamental Concepts and Skills for Nursing, 5th Edition

 

MULTIPLE CHOICE

 

  1. A mother of an 11-month-old is concerned about her baby not walking and states that his older brother was walking at 10 months. The nurse’s response, based on knowledge of normal development, should be:
a. “Your son may be somewhat slow developmentally. You might have him evaluated by a neurologist.”
b. “The rate of development can be very different from one child to another, even among brothers and sisters.”
c. “Don’t worry. Children can be perfectly normal and not walk until they are 2 years of age.”
d. “It’s hard to predict when a child will walk. Some walk before they are able to crawl or sit alone.”

 

 

ANS:  B

Development follows a pattern (sit before creep, creep before walk) but varies in normal children. Eleven months is not developmentally slow, but children normally do walk before 2 years of age.

 

DIF:    Cognitive Level: Application          REF:   p. 148|Box 11-1

OBJ:   Theory #3      TOP:   Motor Development, Infants

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse is aware that according to Piaget’s theory, the child’s cognitive development is:
a. present at birth as a genetic imprint that will begin to unfold in the first year, independent of the child’s environment.
b. a series of psychosocial tasks to be accomplished at various stages throughout life, such as developing a sense of identity in adolescence.
c. the physical increase in size that occurs in the brain of the child, with most of the growth completed by the age of adolescence.
d. occurring in stages, which allows a child to organize knowledge and adapt to the environment in increasingly complex ways.

 

 

ANS:  D

Cognitive refers to intellectual aspects. It is strongly influenced by environment and is more than just physical development of the brain. Piaget theorized stages a child goes through in organizing knowledge and adapting to the environment.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 148            OBJ:   Theory #7

TOP:   Cognitive Development                  KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A new parent with her first child tells the nurse that her mother has advised her to feed the baby on a schedule and let the baby cry between feedings so that he does not get spoiled. Based on Erikson’s growth and development theory, the nurse’s most informative response would be:
a. a sense of trust is developed in infancy when a child’s needs are met by warm, loving people.
b. an infant who learns to adapt to uncomfortable situations and to comfort himself will develop autonomy and independence.
c. the infant learns cause and effect at this stage and will learn he can’t cry and get his own way.
d. in the first year, crying and learning to wait have positive outcomes for both the mother and the baby.

 

 

ANS:  A

Meeting the crying baby’s needs fosters trust; it does not “spoil” a child. Crying inconsolably is not a positive outcome for a baby when he fails to have his needs met.

 

DIF:    Cognitive Level: Application          REF:   p. 148            OBJ:   Theory #6

TOP:   Psychosocial Development, Infants

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A 4-year-old attends a preschool group three mornings a week. He has been treated kindly and lovingly at home. At school, according to Kohlberg’s theory of moral development, he is likely to:
a. treat his peers and siblings in a loving and kind manner, because he has internalized the value of treating others as he has been treated.
b. conform to social standards and rules to avoid feeling guilty or risking social disapproval.
c. follow the rules regarding peer interactions to avoid punishment.
d. be developmentally advanced and have a conscience that is based on an innate sense of justice and duty.

 

 

ANS:  C

According to Kohlberg, the child’s behavior at preschool will be preconventional reasoning, governed by fear of punishment. This stage lasts until about the age of 9 years.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 144            OBJ:   Theory #5

TOP:   Developmental Theories                 KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. During the first trimester of pregnancy, the most important teaching a nurse can provide the expectant mother is:
a. avoiding very strenuous exercises or activities.
b. eating large high caloric meals to provide for the growing fetus.
c. preparing self-physically and mentally for the work of labor.
d. acquiring adequate prenatal care.

 

 

ANS:  D

Early prenatal care is the most important factor in a healthy pregnancy outcome.

 

DIF:    Cognitive Level: Application          REF:   p. 146            OBJ:   Clinical Practice #1

TOP:   Prenatal Development                    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A nurse encourages the father of a newborn infant to hold the baby close, talk softly, stroke the baby’s fingers, and make eye contact in order to:
a. assist the father’s confidence in holding the baby.
b. promote bonding, which in turn promotes a sense of trust in infancy.
c. generate a sense of parenting.
d. accustom the baby to being handled by different caregivers.

 

 

ANS:  B

Bonding is an important feature of the parent-child relationship that must be supported and facilitated in the first weeks of life (a teachable moment).

 

DIF:    Cognitive Level: Comprehension   REF:   p. 148            OBJ:   Theory #6

TOP:   Psychosocial Development, Infant Bondings

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse confirms that in the embryonic stage of prenatal development (third to eighth week), the embryo’s:
a. growth slows.
b. organs begin to function.
c. limbs move.
d. heart begins to beat.

 

 

ANS:  D

The embryo’s heart begins to beat at 3.5 weeks.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 142            OBJ:   Clinical Practice #4

TOP:   Health Promotion, Infants              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A parent asks the nurse about how to discipline her 2-year-old who has become uncooperative and negative and is having temper tantrums. The most helpful suggestion made by the nurse would be for the parent to deal with this normal behavior by:
a. scolding the child sternly to discourage this behavior.
b. taking away a favorite toy until behavior improves.
c. using a “time-out” (a quiet time without toys).
d. asking the child to “help Mama” by not being naughty.

 

 

ANS:  C

This is a normal 2-year-old behavior; the mother needs to learn the use of “time-out” or nonpunitive, less authoritarian ways of dealing with the 2-year-old that are not so likely to provoke “no.”

 

DIF:    Cognitive Level: Application          REF:   p. 151            OBJ:   Clinical Practice #9

TOP:   Discipline, Young Child                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A woman in her first trimester of pregnancy asks the nurse how much weight she can expect to gain by the time of EDD (estimated delivery date). The nurse correctly responds approximately by informing her:
a. 5 to 10 pounds.
b. 15 to 20 pounds.
c. 25 to 30 pounds.
d. 35 to 40 pounds.

 

 

ANS:  D

A woman beginning pregnancy at a healthy weight should expect to gain approximately 30 pounds.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 146            OBJ:   Clinical Practice #1

TOP:   Nutrition        KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. The nurse reminds a parent that a major milestone for a 2- to 3-year-old child is to learn to:
a. play team games with others his age.
b. speak clearly and fluently.
c. use the toilet for bladder and bowel functions.
d. tie shoelaces.

 

 

ANS:  C

Toilet training is usually accomplished in the second or third year. Team games are a young school age phenomenon, as is tying shoelaces. Speaking clearly and fluently does not occur until after the toddler stage.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 150            OBJ:   Theory #8

TOP:   Motor Development, Young Child KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. When the clinic nurse speaks to the 3-year-old child and says, “You can get dressed now and put your shirt and pants back on,” she is promoting his sense of:
a. autonomy.
b. industry.
c. initiative.
d. trust.

 

 

ANS:  A

Autonomy is the sense of independence—“I can do it myself.” It is accomplished in the toddler stage as evidenced by toilet training, self-feeding, and self-dressing. Industry is a school age task, initiative is a 4- to 6-year-old task (preschool), and trust is a task of infancy.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 144|Tables 11-2 and 11-27

OBJ:   Theory #6      TOP:   Psychosocial Development, Young Child

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A 4-year-old child tells other children that last night he flew to the moon and walked around with his friend Sam. He says that he is the only one who can see Sam. The nurse should:
a. warn the child’s mother that he may be developing emotional problems.
b. interrupt the conversation with a comment that children can’t fly to the moon.
c. take the child aside and tell him gently that he should stop telling such stories or people will not trust him.
d. recognize that imaginary friends and fantasy are normal at this age.

 

 

ANS:  D

Fantasy and imaginary friends are normal in this age group.

 

DIF:    Cognitive Level: Analysis               REF:   p. 150            OBJ:   Theory #7

TOP:   Cognitive Development, Young Child

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The risk for poisoning is most likely in a situation in which:
a. a caretaker with an infant with a high fever has been instructed by the clinic nurse to give a liquid fever reducer (antipyretic).
b. a toddler is staying with his grandparents for a week while his mother is in the hospital.
c. a 7-year-old has asthma and uses daily medications for it.
d. a 12-year-old is home alone after school until his parents return from work.

 

 

ANS:  B

A toddler staying with grandparents for an extended emergency visit is at risk for poisoning related to the grandparents’ home not being “toddler proof.”

 

DIF:    Cognitive Level: Analysis               REF:   p. 150            OBJ:   Clinical Practice #7

TOP:   Cognitive Development, Young Child

KEY:  Nursing Process Step: Diagnosis

MSC:  NCLEX: Safe, Effective Care Environment: Growth and Development

 

  1. A 9-year-old has returned to the pediatric unit from the recovery room after having his appendix removed. He has an intravenous solution running into a vein and a dressing covering the operative site. His parents went home briefly. When he becomes upset and starts crying, the nurse should:
a. help the child recall the events of the previous day, explaining that his mother will be back later in the morning.
b. recognize his need for family by calling his mother on the telephone and telling her to come back and stay with her son.
c. appeal to his gender identity by telling him he is a big boy, and big boys don’t cry.
d. be aware that the child cannot reliably tell the nurse about pain at this age and call the care provider for an order for a pain medication or sedative.

 

 

ANS:  A

A 9-year-old can use cognitive abilities to understand the nurse’s explanation. He can also tell about pain.

 

DIF:    Cognitive Level: Application          REF:   p. 153|Table 11-3

OBJ:   Clinical Practice #7                         TOP:   Cognition, Middle and Older Child

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. In planning anticipatory guidance for the parents of an 18-month-old child at a well child clinic, the nurse should include information about the:
a. child’s need for and ability to participate in quiet activities such as reading stories and watching television and movies on a phone or computer for long periods of time.
b. advantages of having the child begin to attend day care to develop his social interactions and group play skills with other children.
c. need for close supervision and making the environment safe related to poisons, motor vehicles, stairs, and electrical hazards.
d. need for increased nutritional intake to maintain the continued rapid growth of infancy into this stage.

 

 

ANS:  C

Parents with a child at 18 months of age need to be guided in how to protect their child from his own curiosity and dangers. An 18-month-old is not capable of sitting still for stories for long periods, and at this age, children engage in parallel play rather than group play. His nutrition needs to be balanced but will probably decline in amount because growth is not as rapid as in infancy. The American Academy of Pediatrics guidelines recommend no television, smart phones, or computers for children under 2 years, and less than 2 hours of screen time per day for children and teens. These activities have been linked to an increase in attention problems, development of unhealthy eating habits, higher body mass index, and obesity.

 

DIF:    Cognitive Level: Application          REF:   p. 150            OBJ:   Clinical Practice #3

TOP:   Cognitive Development, Young Child

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment: Growth and Development

 

  1. A parent asks how long she should enforce a “time-out” for her 4-year-old, who frequently hits her younger brother and takes his toys. The nurse recommends:
a. 2 minutes.
b. 3 minutes.
c. 4 minutes.
d. 5 minutes.

 

 

ANS:  C

Time-outs are effective in this stage as a consequence for undesired behavior. A general guideline is that the length of time of the time-out should match the age (number of minutes = age).

 

DIF:    Cognitive Level: Application          REF:   p. 151            OBJ:   Theory #9

TOP:   Discipline, Young Child                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A dejected 8-year-old has brought home an art project that was finished at school that didn’t get put up on the bulletin board with some better projects. The best way to support the child’s sense of industry would be for the parents to:
a. remind the child that not all kids are artistic.
b. point out the areas in the project that could have been improved.
c. request that the teacher allows the project to be posted on the bulletin board.
d. post the project on the front of the refrigerator.

 

 

ANS:  D

Posting the project in a prominent place and remarking on the positive aspects of it like color selection or composition will boost the child’s sense of industry.

 

DIF:    Cognitive Level: Application          REF:   p. 153            OBJ:   Clinical Practice #6

TOP:   Psychosocial Development, Middle and Older Child

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The school nurse is teaching parents of fifth graders (10 year olds) about the physical changes of puberty that they can expect in their children, such as:
a. boys begin to change physically before girls.
b. there will be children in different stages of puberty throughout the next several years.
c. the physical changes of puberty occur gradually, and children adjust without difficulty.
d. most boys and girls will begin the physical changes of puberty by seventh grade (12 years old). If this has not happened, the child should be evaluated by a care provider.

 

 

ANS:  B

In general, girls begin to develop 2 to 3 years ahead of boys. A child may have great difficulty with body changes, especially if he is very much ahead of or behind his peers. Many boys do not begin to develop until the high school years and continue their growth into their 20s.

 

DIF:    Cognitive Level: Application          REF:   p. 154            OBJ:   Theory #11

TOP:   Physical Development, Middle and Older Child

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A 10-year-old girl has recently grown 3 inches and gained 20 pounds. She began having menstrual periods and is embarrassed about her breast development. The parents are concerned about her complaints of fatigue. The most helpful response from the nurse would be to suggest:
a. having her evaluated for a physical problem.
b. minimizing her feelings of embarrassment.
c. enrolling in a health club for exercise.
d. helping the child recognize bodily self-consciousness and fatigue as a normal part of maturation.

 

 

ANS:  D

Fatigue is a common teen complaint associated with rapid growth and change. Self-consciousness about body changes is also common.

 

DIF:    Cognitive Level: Application          REF:   p. 154            OBJ:   Clinical Practice #3

TOP:   Physical Development, Adolescent           KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The school nurse reminds the eighth grade boys’ physical education classes to make time for warm-up exercises and stretching before strenuous physical activity because:
a. warm-up exercises allow for a more proficient performance.
b. bones are growing faster than muscles and tendons and may result in injury.
c. the body’s circulating blood needs warm-up time to perfuse larger frames.
d. warm-ups give an opportunity for perspiration to cool overheated muscles.

 

 

ANS:  B

Bones are growing faster than muscles or tendons. Heavy physical activity without warm up exercises could cause injury.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 154|Safety Alert

OBJ:   Theory #3      TOP:   Psychosocial Development, Adolescent

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The school nurse recognizes that the adolescent most at risk for a problem relative to body image would be the 15-year-old:
a. girl with severe acne.
b. boy with a broken leg from a motorcycle accident.
c. boy with thinning hair.
d. girl who is 2 inches taller than classmates.

 

 

ANS:  A

Severe acne will have the most impact on body image because it alters the appearance of the face. Adolescents are very concerned about their appearance.

 

DIF:    Cognitive Level: Application          REF:   p. 157            OBJ:   Theory #11

TOP:   Adolescent Development, Concerns

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The home health nurse reminds parents that dental care for a child should begin:
a. when the child has all his permanent teeth.
b. when the child has all his deciduous teeth.
c. at approximately the age of 4 or 5 years, when the child can cooperate with a dentist.
d. with tooth brushing and flossing of the first teeth by a parent or caregiver.

 

 

ANS:  D

Dental care properly starts when the child first cuts teeth and the caregiver cleans them. Toddlers quickly learn to imitate adult behaviors and can brush their own teeth with supervision before all teeth have erupted.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 152            OBJ:   Theory #8

TOP:   Physical Development, Young Child

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. The well baby clinic nurse suggests that the most important aspect parents should consider when selecting a day care facility for their preschooler would be the:
a. cost and convenience of the facility.
b. educational qualifications of the teachers and the aides.
c. cleanliness and provision of healthy snacks.
d. facility’s approach to discipline and a nurturing atmosphere.

 

 

ANS:  D

Although all aspects listed may be important, the atmosphere of nurturing and the level of discipline should be the major consideration in selecting a day care facility.

 

DIF:    Cognitive Level: Application          REF:   p. 152            OBJ:   Theory #10

TOP:   Day Care        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The pediatric nurse identifies egocentrism in:
a. a 2-year-old who hits playmates and takes all the toys.
b. a 5-year-old who prefers to read or be read to instead of playing kickball.
c. a 12-year-old who is failing school and in frequent fights with his peers.
d. a 15-year-old who is a volunteer at the local hospital.

 

 

ANS:  A

Egocentric behavior is generally seen in the toddler and teenage groups. It is characterized by an intense focus on self, with little awareness of others or their needs.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 155            OBJ:   Theory #7

TOP:   Egocentrism   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse explains that the Denver Developmental Screening Test (DDST) evaluated gross motor skills by observing the child’s ability to:
a. stack a pile of blocks.
b. hop on one foot.
c. draw a detailed figure of a person.
d. use different colors when drawing a house.

 

 

ANS:  B

Gross motor skills evaluated by the DDST are walking, jumping, using a tricycle, throwing and catching a ball, and hopping or standing on one foot.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 150            OBJ:   Theory #8

TOP:   Denver Developmental Screening Test

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The anxious father to be asks the nurse when the sex of the fetus can be determined. The nurse’s answer is based on the knowledge that the external genitalia appear in the:
a. second month.
b. third month.
c. fourth month.
d. fifth month.

 

 

ANS:  B

External genitalia can be visualized on ultrasound in the third month.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 142            OBJ:   Theory #1

TOP:   Prenatal Development                    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A nurse assessing a 13-year-old girl observes that she has begun her menstruation cycle. The nurse is aware the hormone responsible for this change is:
a. parathyroid hormone (PTH).
b. thyroid-stimulating hormone (TSH).
c. adrenocorticotropic hormone (ACTH).
d. follicle-stimulating hormone (FSH).

 

 

ANS:  D

The pituitary hormone follicle-stimulating hormone (FSH) stimulates the ovaries to begin producing estrogen hormones that initiate menses.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 142            OBJ:   Theory #11

TOP:   Teaching        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A nurse instructing a group of adolescents about development includes in her remarks that the presence of follicle-stimulating hormone (FSH) will cause boys to:
a. have a significant growth spurt.
b. grow a beard.
c. maintain an erection.
d. produce sperm.

 

 

ANS:  D

Follicle-stimulating hormone (FSH) stimulates the testes to begin producing sperm.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 143            OBJ:   Theory #11

TOP:   Teaching        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A nurse assessing a 13-year-old female is aware that the presence of axillary and pubic hair indicates the presence of:
a. progesterone.
b. insulin.
c. estradiol.
d. cortisol.

 

 

ANS:  C

Estradiol is an estrogen secreted by the ovaries that is responsible for the appearance of secondary sex characteristics.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 142            OBJ:   Theory #11

TOP:   Teaching        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse encourages the parent to allow the toddler to dress himself and feed himself and make simple choices about clothing or food in order to follow the theory of:
a. Erik Erikson.
b. Jean Piaget.
c. Lawrence Kohlberg.
d. Sigmund Freud.

 

 

ANS:  A

Erik Erikson’s theory of psychosocial stages encourages the toddler toward autonomy by allowing the child to begin to become independent.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 144            OBJ:   Theory #6

TOP:   Theorists        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. When asked, the nurse explains that the superego described in Sigmund Freud’s theory influences human behavior by playing the part of the:
a. reality tester.
b. seeker of pleasure.
c. moral dictator.
d. primitive urges.

 

 

ANS:  C

Freud’s theory describes three parts of the personality: identity, ego, and superego. The superego represents the moral component of the personality.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 143            OBJ:   Theory #4

TOP:   Freud             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. When a 3-year-old toddler repeatedly tries to reach some cookies on top of a counter and then, after several failures to do so, drags a chair over to the counter and climbs on the chair to get the cookies, she is exhibiting:
a. adaptation as described by Piaget.
b. egocentricity as described by Freud.
c. sensorimotor motivation as described by Piaget.
d. preconventional reasoning as described by Kohlberg.

 

 

ANS:  A

Adaptation as described by Piaget outlines that a child can adjust thinking patterns as the child discovers new information.

 

DIF:    Cognitive Level: Analysis               REF:   p. 144            OBJ:   Theory #7

TOP:   Adaptation     KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. When a 4-year-old boy announces that he is going to marry his mother, the nurse recognizes that this statement is an indicator that he is in the Freudian stage of:
a. oral.
b. anal.
c. phallic.
d. latency.

 

 

ANS:  C

In the Freud’s phallic or Oedipal stage, children identify with the parent of the same sex. The little boy is imitating his father by declaring his desire to marry his mother.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 144|Table 11-1

OBJ:   Theory #4      TOP:   Theorists        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. An 11-year-old who obeys all the rules set down by the teacher to avoid guilt or disapproval is acting out Kohlberg’s theory of:
a. conventional reasoning.
b. preconventional reasoning.
c. postconventional reasoning.
d. concrete operations.

 

 

ANS:  A

During the conventional reasoning level of moral development, children obey rules to avoid guilt and disapproval. Moral values are not internalized. Most children are at this stage at about age 9 or 10 years of age.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 144            OBJ:   Theory #5

TOP:   Theorists        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse clarifies that growth differs from development in that growth:
a. is the same for all siblings in a family.
b. is solely dependent on heredity.
c. progresses in an orderly, predictable way.
d. continues throughout life.

 

 

ANS:  C

Growth progresses in an orderly and predictable way. Its patterns and stages can be anticipated. Growth potential is hereditary, but many things such as nutrition and illness can affect growth.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 145            OBJ:   Theory #3

TOP:   Growth           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A distressed mother confides in the school nurse that she witnessed her 15-year-old son and a 15-year-old friend masturbating in her son’s bedroom. The nurse’s best response would be:
a. “Perhaps you should ask your son if he has homosexual feelings toward his friend.”
b. “The fact that they were doing this secretly indicates that they feel guilty about the experience.”
c. “Many kids have a homosexual encounter, but it does not mean they are homosexual.”
d. “Mutual masturbation is frequently the initial experience of a person who is actively homosexual.”

 

 

ANS:  C

Approximately 8% of adolescents experience a homosexual encounter. This does not mean they are homosexual.

 

DIF:    Cognitive Level: Application          REF:   p. 156            OBJ:   Theory #13

TOP:   Adolescents Sexual                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The school nurse suspects a 14-year-old of having anorexia nervosa because the nurse has observed that the adolescent:
a. is binging on rich foods.
b. has early onset of sexual development.
c. uses frequent enemas and laxatives.
d. is doing excessive rigorous exercises.

 

 

ANS:  D

Anorexics control their weight be reducing nutritional intake and engaging in rigorous exercise. The body becomes emaciated and sexual development is delayed.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 157            OBJ:   Theory #13

TOP:   Anorexia Nervosa                          KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A 15-year-old girl reports to the school nurse that she feels she does not fit in and feels near tears all the time. She states her grades are declining. The nurse’s best approach to this situation would be:
a. “Everyone has ‘downtimes.’ Let’s get you signed up with a tutor.”
b. “I think I better refer you to the school psychologist to help you.”
c. “Don’t be silly…of course you fit in. You have many friends.”
d. “Come back again next week and we can talk some more about this problem.”

 

 

ANS:  B

The feelings of not fitting in and being close to tears all of the time in addition to declining grades are indicators of depression. Any adolescent who exhibits signs of depression should be evaluated by a mental health professional rather than being treated by the school nurse. The other options belittle the girl’s feelings.

 

DIF:    Cognitive Level: Application          REF:   p. 157            OBJ:   Theory #13

TOP:   Theorists        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The mother of a 13-year-old girl tells the school nurse that her daughter will appear one day neatly dressed and groomed and the next will have on tattered jeans and a T-shirt and untidy hair. The nurse realizes that these are “trials” to find:
a. initiative.
b. industry.
c. identity.
d. social approval.

 

 

ANS:  C

The major developmental task of Erik Erikson’s theory is that of discovery of one’s identity. The changing of clothing and behaviors indicate trying for a “fit.”

 

DIF:    Cognitive Level: Comprehension   REF:   p. 144|Table 11-2

OBJ:   Theory #4      TOP:   Erikson          KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A group of fifth grade boys play together at school and after school are seen in each other’s company. The school nurse is aware that this sort of group is representative of Freud’s:
a. anal stage.
b. oral stage.
c. latency stage.
d. phallic stage.

 

 

ANS:  C

The major developmental tasks of Sigmund Freud’s latency stage of psychosexual development include a focus on relationships with same sex peers.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 144|Table 11-1

OBJ:   Theory #4      TOP:   Theorists        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse recognizes that the parenting style in which a parent is firm, in control, and has a warm encouraging relationship with the child is:
a. authoritarian.
b. authoritative.
c. autocratic.
d. absolute.

 

 

ANS:  B

In the authoritative parenting style, a parent has a firm approach, is in control, and has a warm, loving, and encouraging relationship with their children.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 154|Table 11-4

OBJ:   Theory #4      TOP:   Parenting        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse tells a parent of adolescents that teenage pregnancies, although on the decline, often result in the baby having:
a. learning difficulties at a later age.
b. a low birth weight.
c. a congenital deformity.
d. retarded development.

 

 

ANS:  B

Because the teenage mother is still growing, the babies from a teen pregnancy are frequently of low birth weight. None of the other options are a direct result of teenage pregnancy.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 157            OBJ:   Theory #13

TOP:   Teen Pregnancy                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. An 8-year-old’s mother asked the child to set the table, but then remarked that it was not very neat and then reset the table herself. According to Erikson, this sort of behavior on the part of the mother will cause the child to feel:
a. mistrustful.
b. ashamed.
c. guilty
d. inferior.

 

 

ANS:  D

Erik Erikson’s psychosocial development theory includes the stage industry vs. inferiority, which is characterized by a child not being recognized for his or her industry.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 144|Table 11-2

OBJ:   Theory #6      TOP:   Erikson          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The school nurse is alert to the behavior of a child who has extremely permissive parents, because this sort of parenting style produces children who are:
a. mistrusting.
b. depressed.
c. anxious.
d. impulsive.

 

 

ANS:  D

Permissive parenting produces children who are impulsive, aggressive, and lacking in self-control.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 154|Table 11-4

OBJ:   Theory #9      TOP:   Permissive Parenting                                 KEY:   Nursing Process Step: N/A

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. Based on the theory of Erikson, the nurse advises that the best discipline for an adolescent would be to:
a. make him get a job.
b. increase his household chores.
c. implement a long period of “time-out.”
d. “ground” him and deprive him of contact with friends.

 

 

ANS:  D

Erik Erikson’s psychosocial development theory includes the stage of identity vs. identity confusion. This age values association with peers above everything else, so depriving the child from contacting his friends would have the most impact.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 144|Table 11-2

OBJ:   Theory #6      TOP:   Theorists        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A school nurse suspects that a 7-year-old child at the school is being physically abused. The nurse should:
a. interview the child about possible abuse.
b. notify the principal.
c. call the parent about her concern.
d. report the suspected abuse to the authorities.

 

 

ANS:  D

Most states require health workers to report child abuse to the authorities.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 154            OBJ:   Theory #9

TOP:   Child Abuse   KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse reminds parents that social competence can be recognized in their child if the child:
a. learns to cope with minor stressors.
b. develops a sense of humor.
c. finishes jobs and chores they start.
d. develops a talent.

 

 

ANS:  A

Persons with social competence can handle minor stressors and are aware of how their behavior influences others and how they may appear to others.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 153            OBJ:   Theory #8

TOP:   Social Competence                         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse instructs the parents that emotional intelligence can be supported in a child by the parents:
a. insisting on IQ testing.
b. talking to the child about his or her feelings.
c. allowing the child to bring friends into their home.
d. encouraging the child to read.

 

 

ANS:  B

Parents can assist their children in developing emotional intelligence by talking to their children about their feelings, taking their children’s feelings seriously, and helping them find ways to cope with their feelings.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 153            OBJ:   Theory #8

TOP:   Emotional Intelligence                    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A child who can draw pictures of objects not in evidence in the room is exhibiting Piaget’s:
a. preoperational stage.
b. sensorimotor stage.
c. concrete operations.
d. formal operations.

 

 

ANS:  A

Jean Piaget’s cognitive development theory includes the preoperational stage, which occurs from 2 to 7 years of age. During this stage, a child can draw and think about objects that are not in evidence in the immediate environment.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 144|Table 11-3

OBJ:   Theory #7      TOP:   Theorists        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A person who demonstrates the ability to logically manipulate abstract and unobservable concepts is in which stage of Jean Piaget’s cognitive development theory?
a. Preoperational stage
b. Sensorimotor stage
c. Concrete operations
d. Formal operations

 

 

ANS:  D

Jean Piaget’s cognitive development theory includes the formal operations stage, which occurs from 11 years of age to death. During this stage, a person demonstrates the ability to logically manipulate abstract and unobservable concepts.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 144|Table 11-3

OBJ:   Theory #6      TOP:   Theorists        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. An anxious father to be tells the nurse that his wife’s due date was 5 days ago and there are still no signs of labor. The nurse’s most helpful response would be:
a. “I think you should contact your wife’s doctor about this concern.”
b. “Just be patient…babies come when they are ready.”
c. “Any time 2 weeks on either side of the due date is considered normal.”
d. “Sometimes estimated due dates have been off by as much as 6 weeks.”

 

 

ANS:  C

Births occurring 2 weeks on either side of the estimated due date are considered normal.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 145            OBJ:   Clinical Practice #1

TOP:   Prenatal Care                                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A nurse teaches a woman who is considering pregnancy that her intake of folic acid to help prevent congenital abnormalities should be:
a. 100 mcg/day.
b. 200 mcg/day.
c. 300 mcg/day.
d. 400 mcg/day.

 

 

ANS:  D

If planning to become pregnant, a woman should be certain her intake of folic acid is at least 400 mcg/day to assist in preventing neural tubal defects.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 146            OBJ:   Clinical Practice #1

TOP:   Prenatal Care                                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A woman who has just given birth expresses concern about the cheesy, waxy substance that is covering her neonate. The nurse accurately responds:
a. “This material develops in the absence of adequate subcutaneous fat.”
b. “This material is often seen on infants who have experienced intrauterine stress.”
c. “This substance will be absorbed and used as a nutrient by your infant.”
d. “This is a normal finding and is called vernix caseosa.”

 

 

ANS:  D

At birth, the skin and scalp are often covered with vernix caseosa (a cheesy, waxy substance that protects the skin in fetal life). This wears off in a day or two.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 147            OBJ:   Theory #1

TOP:   Appearance of Newborn                KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. When the nurse makes a loud noise near the infant, the infant reacts by arching his back and assuming a typical posture with flexion and adduction of the extremities, and his fingers fan initially. This is called the:
a. stepping reflex.
b. grasping reflex.
c. Babinski reflex.
d. Moro reflex.

 

 

ANS:  D

The Moro reflex (startle response) can be elicited by making a loud noise near the baby, who will react by arching his back and assuming a typical posture with flexion and adduction of the extremities and fingers fanned initially.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 147            OBJ:   Theory #3

TOP:   Moro Reflex  KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse instructs the caregiver of a newborn that newborns should double their birth weight by:
a. 2 to 3 months.
b. 3 to 4 months.
c. 4 to 5 months.
d. 5 to 6 months.

 

 

ANS:  D

All babies should double their birth weight by 5 to 6 months, and triple it by 1 year.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 147            OBJ:   Theory #3

TOP:   Principles of Growth and Development

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse instructs the mother of an infant about infant safety factors. The nurse would assess the need for further instruction if the caregiver states:
a. “I will place my infant on her back for sleep.”
b. “I will place my infant in a car seat when driving.”
c. “I will not leave my infant alone in a house or a car.”
d. “I will place my infant on her stomach for sleep.”

 

 

ANS:  D

The infant should be restrained in a car seat in the back seat of the automobile whenever the vehicle is in motion. The infant should be placed on his back for sleep, with propping slightly on one side or the other for variation. No infant should be placed on the stomach to sleep. An infant should never be left alone in a house or car.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 148            OBJ:   Clinical Practice #8

TOP:   Infant Safety Factors                                 KEY:              Nursing Process Step: Implementation

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

 

  1. The nurse points out that an infant who pulls at a drawer handle to open a drawer that holds a toy that is out of view is exhibiting:
a. industry.
b. initiative.
c. concrete operations.
d. object permanence.

 

 

ANS:  D

By the time babies are about 8 months old, they realize that an object still exists even when they cannot see it. This is called object permanence. It is demonstrated when an infant is shown an object that is then hidden, and the baby looks for it.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 148            OBJ:   Theory #7

TOP:   Principles of Growth and Development

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse would anticipate that the child who prefers onlooker play would be:
a. 1 year old.
b. 3 years old.
c. 4 years old.
d. 5 years old.

 

 

ANS:  A

Onlooker play is a type of play in which a child watches others playing but does not interact. Children younger than the age of 2 engage normally in this type of play.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 152|Box 11-2

OBJ:   Theory #8      TOP:   Principles of Growth and Development

KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A nurse would expect a child of 2 years to communicate in:
a. squeals and pointing.
b. two word sentences.
c. three word sentences.
d. four word sentences.

 

 

ANS:  B

Children should be using two word sentences by the age of 2 years. Precocious children may be able to communicate with sentences of greater length.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 148            OBJ:   Theory #8

TOP:   Communication of Toddlers           KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse reminds parents that infants who have developed trust by the age of 6 months will be able to:
a. tolerate short separations from parents.
b. learn to speak at an earlier age.
c. attempt walking around 8 months of age.
d. seldom cry.

 

 

ANS:  A

Trustful infants can tolerate parental separations for short periods of time and will have confidence to explore new situations.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 149            OBJ:   Theory #8

TOP:   Principles of Growth and Development

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The well child clinic nurse reminds the parents of a 2-year-old that the primary environmental influence for physical development is:
a. play.
b. nurturing parents.
c. nutrition.
d. frequent checkups.

 

 

ANS:  C

Nutrition is the primary environmental influence on physical development.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 149            OBJ:   Theory #8

TOP:   Principles of Growth and Development

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A nurse arranges for cooperative play in a pediatric unit by:
a. coloring a picture in a coloring book with a 6-year-old patient.
b. arranging for two 3 year olds to play with their dolls at the same table.
c. showing an 11-year-old how to do a crossword puzzle.
d. organizing a checkers game between two 10 year olds.

 

 

ANS:  D

Cooperative play is a type of play in which children play together. Games have rules and goals that are accepted and followed.

 

DIF:    Cognitive Level: Application          REF:   p. 152|Box 11-2

OBJ:   Theory #8      TOP:   Principles of Growth and Development

KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse is assessing 6-month-old infant. The infant was born at 38 weeks gestation, weighed 4 pounds at birth, and was 18 inches long. Which of the following statements by the mother indicates that further parental education is needed?
a. My baby should weigh at least, 12 pounds today.
b. My baby is considered a preterm baby.
c. My baby is considered a small for date baby.
d. My baby should be at least 28 inches long.

 

 

ANS:  C

The average newborn weighs 7 to 7 1/2 lb and is 20 to 21 inches long. Less than 5.5 pounds is considered low birth weight and more than 8.8 pounds is considered high birth weight. There are two categories of low-birth-weight babies. The first is preterm babies, who are born before 37 weeks of gestation and weigh less than 5 pounds. The second category is small-for-dates babies. These infants are born at term but weigh less than 90% of what they should weigh. All babies should double their birth weight at 5 to 6 months and triple it by 1 year. They should also grow 1/2 to 1 inch per month the first 6 months and 3/8 inch per month from 6 to 12 months. At well baby visits the baby’s growth is measured and documented on standard growth charts.

 

DIF:    Cognitive Level: Analysis               REF:   p. 148            OBJ:   Theory #3

TOP:   Physical Development                    KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A school nurse is planning an education course for high school students on the effects of early sexual activity. Which of the following topical points, from the CDC would she include?
a. 35% of US high school students had experienced intercourse.
b. 89% of US high school students, who had experienced intercourse, used a condom.
c. Adolescent students may have difficulty with the emotional aspects of sexual activity.
d. Poor risk of sexually transmitted infections.

 

 

ANS:  C

Centers for Disease Control and Prevention (CDC) reported in 2013 that 47% of US high school students had experienced intercourse, and 41% had not used a condom the last time they had sex (CDC, 2015). Although the body is capable of intercourse in adolescence, many young people are not prepared for the emotional aspects of sexual activity. Early sexual activity is associated with high risk of sexually transmitted infections, pregnancy, and emotional pain (Wisnieski and Matzo, 2013).

 

DIF:    Cognitive Level: Comprehension   REF:   p. 156            OBJ:   Theory #13

TOP:   Sexuality        KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. As a nurse working in an adolescent mental health clinic, sees many young people struggle with sexual orientation issues. Which of the following is true according to the 2013 National Health Interview Survey?
a. 3.6% of the population is homosexual.
b. 0.7% of the population is bisexual.
c. 30% of the population is gay, lesbian, bisexual, or transgender.
d. 0.8% of the population identified themselves as gay, lesbian, bisexual, or transgender.

 

 

ANS:  B

According to the 2013 National Health Interview Survey, studies estimate that 1.6% of the population is homosexual and 0.7% is bisexual. However, according to 2015 Gallup polls, Americans who were surveyed estimated that 23% of the population is gay, lesbian, bisexual, or transgender, which is substantially higher than the 3.8% of the population who identified themselves in the early results of the survey.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 156            OBJ:   Theory #12

TOP:   Tasks of Adolescence                               KEY:              Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A middle school female student is evaluated for depression. During the assessment, it was evident that she was a victim of cyberbullying. According to The Cyberbullying Research Center, which of the following will promote a positive outcome for this patient?
a. She is not alone, 26% of middle school at high school students have been the victim of cyberbullying.
b. She is not alone, 16% of middle school at high school students have been involved in bullying.
c. She is at risk for substance abuse.
d. She has a group of loving, supportive adults in her family.

 

 

ANS:  D

According to The Cyberbullying Research Center, 26% of middle school and high school students have been victims of cyberbullying, and 16% have been involved in bullying. Studies demonstrate decreased substance use and mental health problems when youth view the family as a resource for support and advice (Ackley et al., 2014).

 

DIF:    Cognitive Level: Analysis               REF:   p. 157            OBJ:   Theory #13

TOP:   Concerns in Adolescent Development                            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

MULTIPLE RESPONSE

 

  1. The nurse emphasizes the influences that help maintain a healthy pregnancy, which are: (Select all that apply.)
a. early prenatal care.
b. health of the mother.
c. socioeconomic status.
d. mother’s age.
e. age when menses began.
f. emotional stress.

 

 

ANS:  A, B, D, F

Adequate prenatal care, health and age of the mother, good nutrition, and emotional status all influence the health of a pregnancy. Socioeconomics and the age of menarche are not direct influences.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 146            OBJ:   Clinical Practice #1

TOP:   Healthy Pregnancy                         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. Parents of a 5-month-old ask the nurse what they can feed their infant besides breast milk. The nurse would appropriately suggest: (Select all that apply.)
a. baby cereals.
b. strained fruits.
c. any food eaten by the parents.
d. small pieces of sausage.
e. grapes.
f. strained vegetables.

 

 

ANS:  A, B, F

Baby cereals and strained fruits and vegetables are appropriate foods to introduce at this age. Pieces of sausage, grapes, and some foods eaten by parents may be too small and may be aspirated.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 147            OBJ:   Clinical Practice #2

TOP:   Infant Nutrition                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

COMPLETION

 

  1. The sperm and ovum each contain __________ unpaired chromosomes.

 

ANS:

23

 

Each sperm and ovum contains 23 unpaired chromosomes, which become 46 chromosomes at fertilization.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 145            OBJ:   Theory #1

TOP:   Prenatal Development                    KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse advises the young mother that most pediatricians recommend feeding newborns using _____.

 

ANS:

breast milk

 

Breast milk is designed for the newborn’s digestive system and contains protective antibodies.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 147            OBJ:   Clinical Practice #2

TOP:   Infant Nutrition                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse explains that babies can lift their heads before they can lift their chests, control their shoulders before they control their arms and fingers, sit before they stand, and crawl before they walk. This is a result of ______________ development.

 

ANS:

cephalocaudal

 

Cephalocaudal development means development occurs from head to tail. Motor development follows from head to tail, which means that babies can use the upper body earlier than the lower body.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 148            OBJ:   Theory #8

TOP:   Principles of Growth and Development

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse uses a diagram to show that the fetal prenatal period begins after the ____________ week.

 

ANS:

eighth

 

The fetal period begins after the eighth week of intrauterine life and continues until birth.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 142            OBJ:   Theory #1

TOP:   Fetal Period    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

Chapter 21: Measuring Vital Signs

Williams: deWit’s Fundamental Concepts and Skills for Nursing, 5th Edition

 

MULTIPLE CHOICE

 

  1. The nurse would anticipate a patient diagnosed with damage to the hypothalamus after suffering a head injury from a fall to exhibit:
a. a blood pressure elevation.
b. a temperature abnormality.
c. a decrease in pulse rate.
d. depressed respirations.

 

 

ANS:   B

The hypothalamus, which is located between the cerebral hemispheres, controls body temperature. Any damage to the hypothalamus prevents the body from regulating its temperature.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 344              OBJ:    Theory #1

TOP:    Vital Signs: Temperature                    KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse documents vital signs on a newly admitted patient as: “blood pressure is 148/94 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min.” The nurse would record the pulse pressure as:
a. 14 mm Hg.
b. 54 mm Hg.
c. 64 mm Hg.
d. 80 mm Hg.

 

 

ANS:   B

In calculating pulse pressure, take the difference between the systolic and diastolic pressures (ie, 148 – 94 = 54).

 

DIF:    Cognitive Level: Analysis                  REF:    p. 364

OBJ:    Clinical Practice #4                            TOP:    Vital Signs: Blood Pressure

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A patient has been admitted with hypothermia after lying unconscious overnight in an unheated apartment. The most appropriate route to assess the patient’s core temperature would be:
a. rectal.
b. tympanic arterial thermometer.
c. axillary.
d. tympanic.

 

 

ANS:   D

The same blood vessels serve the hypothalamus and the tympanic membrane, so the tympanic temperature is an excellent indicator of core body temperature, although it can be affected by ear wax.

 

DIF:    Cognitive Level: Application             REF:    p. 348

OBJ:    Theory #3 | Clinical Practice #1         TOP:    Vital Signs: Temperature

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse would document a patient as being febrile if the patient’s temperature was over:
a. 99.5° F
b. 99.8° F
c. 100° F
d. 100.5° F

 

 

ANS:   D

A patient with a temperature above the normal range (100.2° F) is called febrile.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 349              OBJ:    Theory #3

TOP:    Vital Signs: Temperature                    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. To ensure an accurate reading when using a glass oral thermometer, it is necessary to:
a. rinse the thermometer with water.
b. wipe the thermometer with alcohol.
c. shake down the galinstan alloy to below normal.
d. dry the thermometer with a dry cotton ball.

 

 

ANS:   C

Oral thermometers remain at the last reading until they are shaken down; therefore, for accuracy, the thermometer must be below normal range before using.

 

DIF:    Cognitive Level: Application             REF:    p. 351

OBJ:    Clinical Practice #1                            TOP:    Vital Signs: Temperature

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse taking an apical pulse would place the stethoscope at:
a. the left of the sternum at the third intercostal space.
b. directly below the sternum.
c. slightly above the left nipple.
d. the left midclavicular line at the fifth intercostal space.

 

 

ANS:   D

The apical pulse is determined by placing a stethoscope on a point midway between the imaginary line running from the midclavicle through the left nipple in the fifth intercostal space.

 

DIF:    Cognitive Level: Application             REF:    p. 359| Skill 21-4

OBJ:    Theory #2 | Clinical Practice #2         TOP:    Vital Signs: Pulse

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse would record a pulse as bradycardic if the rate were:
a. 64 beats/min.
b. 62 beats/min.
c. 60 beats/min.
d. 59 beats/min.

 

 

ANS:   D

Bradycardia indicates a slow pulse that is less than 60 beats/min.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 373              OBJ:    Theory #3

TOP:    Vital Signs: Pulse                               KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse is aware that the use of an oral glass thermometer would be contraindicated in a:
a. 5-year-old with a facial laceration.
b. 12-year-old patient with a recent seizure.
c. 15-year-old with an abscessed tooth.
d. 20-year-old with severe dehydration.

 

 

ANS:   B

The rectal method is best for patients who have seizure activity so as not to put them at risk for biting and breaking the thermometer.

 

DIF:    Cognitive Level: Application             REF:    p. 349

OBJ:    Clinical Practice #1                            TOP:    Vital Signs: Temperature

KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse anticipates that if the stroke volume of a patient is reduced, the pulse will be:
a. stronger.
b. weaker.
c. bradycardic.
d. irregular.

 

 

ANS:   B

A weak pulse will result if the stroke volume is reduced, because this decreases circulating volume.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 345              OBJ:    Theory #2

TOP:    Vital Signs: Pulse                               KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. When caring for a victim with a gunshot wound to the abdomen who has lost a significant amount of blood, the nurse would anticipate the vital signs to reflect:
a. increase in temperature.
b. decrease in blood pressure.
c. decrease in pulse.
d. decrease in respirations.

 

 

ANS:   B

If blood volume decreases, as with bleeding, blood pressure decreases.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 347              OBJ:    Theory #2

TOP:    Vital Signs: Blood Pressure               KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. When a frail 83-year-old patient whose temperature was 96.8° F at 8:00 AM shows a temperature of 98.6° F at 4:00 PM, the nurse is:
a. pleased that the temperature has come up to normal.
b. satisfied that the patient is warm enough.
c. concerned about the evidence of fever.
d. relieved that the patient is improving.

 

 

ANS:   C

In older patients who have a frail frame, the normal temperature is often 97.2° F. An elevation of 2° F is indicative of fever.

 

DIF:    Cognitive Level: Application             REF:    p. 349              OBJ:    Theory #4

TOP:    Vital Signs in the Older Adult           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:
a. a breathing pattern of dyspnea followed by a short period of apnea.
b. rapid wheezing respirations for two or three breaths with short periods of apnea.
c. quick shallow respirations with long periods of apnea.
d. respirations gradually decreasing in rate and depth.

 

 

ANS:   A

Cheyne-Stokes respirations are faster and deeper rather than slower and are followed by a period of no breathing.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 363              OBJ:    Theory #5

TOP:    Vital Signs: Respirations                    KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse explains to a patient that the pulse oximeter can measure the arterial oxygen by:
a. assessing the amount of blood passing through the sensor.
b. assessing the relative warmth of the skin on the monitored part.
c. measuring the oxygenated hemoglobin through a capillary bed.
d. measuring the respirations to the blood pressure via infrared rays.

 

 

ANS:   C

The pulse oximeter measures oxygen saturation by means of a sensor/probe attached to peripheral digits, an earlobe, the nose, or the forehead as it passes through the capillary bed. Oxygenated blood absorbs more infrared than red light.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 364              OBJ:    Theory #5

TOP:    Vital Signs: Pulse                               KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. Because the older adult’s blood vessels are nonelastic, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to:
a. keep the patient in bed in a high Fowler’s position.
b. allow the patient to sit on the side of the bed for a minute before standing.
c. instruct the patient to use the wheelchair for all mobility activity.
d. help the patient to rise quickly and support the patient for a minute.

 

 

ANS:   B

The older adult often experiences orthostatic hypotension and are at risk for falls and should be encouraged to sit on the side of the bed a minute before standing. These patients also benefit from the use of elastic stockings.

 

DIF:    Cognitive Level: Application             REF:    p. 370              OBJ:    Theory #2

TOP:    Orthostatic Hypotension                    KEY:   Nursing Process Step: Planning

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

 

  1. An older adult patient has a tympanic temperature of 96.2° F (35.7° C). What nursing intervention would best meet this patient’s need?
a. Take the patient’s vital signs every 4 hours, including temperature.
b. Provide fluids to increase circulation.
c. Increase room temperature to 72° F (22.2° C) and add blankets to the bed.
d. Check the temperature orally to confirm the accuracy of the reading.

 

 

ANS:   C

Nursing interventions for treating hypothermia should focus on reducing heat loss and supplying additional warmth, such as increasing the room temperature and adding blankets to the bed.

 

DIF:    Cognitive Level: Application             REF:    p. 350              OBJ:    Theory #3

TOP:    Vital Signs: Temperature                    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse using either a regular or an electronic sphygmomanometer would ensure that the cuff is the correct size by:
a. using a narrow cuff for an obese patient.
b. making sure the width of the bladder is at least 3 inches.
c. confirming that the bladder goes around three fourths of the arm.
d. always using a wide cuff.

 

 

ANS:   C

For accuracy in a BP reading, the cuff of the sphygmomanometer should have a bladder that goes around three fourths of the arm.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 366

OBJ:    Clinical Practice #4                            TOP:    Vital Signs: Blood Pressure

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. For the nurse to assess the most accurate respiration count, the nurse should:
a. inform the patient about his respirations and ask him to breathe normally.
b. count each inhalation and expiration for 1 full minute.
c. watch the patient’s chest rise and fall from a distance.
d. continue to hold the patient’s radial pulse, and count the respirations for 30 seconds and multiply them by 2.

 

 

ANS:   D

The respirations should be counted for 30 seconds and multiplied by 2 if they are regular. If the patient knows the nurse is assessing the respiration, he or she may alter breathing.

 

DIF:    Cognitive Level: Application             REF:    p. 361|Skill 21-5

OBJ:    Clinical Practice #3                            TOP:    Vital Signs: Respirations

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. Older adult patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:
a. continue to listen until the cuff is deflated.
b. pump up the cuff until no sound is heard and then let the air out.
c. make sure the bell of the stethoscope is placed firmly over the artery.
d. stop midway and begin to inflate again.

 

 

ANS:   A

Many older adults with hypertension have an auscultatory gap in their Korotkoff sounds, making it important to listen until the cuff is deflated to avoid mistaking the auscultatory gap as the Korotkoff sound.

 

DIF:    Cognitive Level: Application             REF:    p. 368              OBJ:    Theory #6

TOP:    Vital Signs in the Older Adult           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. Regarding the blood pressure in children, the diastolic pressure is assessed by the auscultation of a:
a. clear tapping that gradually grows louder.
b. murmur or swishing sound that increases with depression of the cuff.
c. sudden change or muffling of the sound.
d. louder knocking sound that occurs with each heartbeat.

 

 

ANS:   C

A sudden change or muffling sound (Phase IV) indicates the diastolic pressure in children and in some adults.

 

DIF:    Cognitive Level: Application             REF:    p. 368

OBJ:    Clinical Practice #4                            TOP:    Vital Signs in Children

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse covers a newborn baby’s head with a cap, because the head:
a. is wet and needs to be dried.
b. has large fontanels.
c. allows loss of body heat.
d. can be reshaped more quickly.

 

 

ANS:   C

Infants lose considerable body heat through the scalp; therefore, a cap helps prevent heat loss.

 

DIF:    Cognitive Level: Application             REF:    p. 350              OBJ:    Theory #3

TOP:    Vital Signs: Infant Temperature         KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse is caring for a patient who had a cardiac catheterization 2 hours ago and has a pressure dressing to his left groin. In addition to taking routine vital signs, the nurse should also check the:
a. strength of the femoral pulse.
b. presence of the pedal pulse.
c. temperature of the right foot.
d. ability to move the left toes.

 

 

ANS:   B

Pedal pulses are checked to determine whether there is any blockage in the artery following a cardiac catheterization.

 

DIF:    Cognitive Level: Application             REF:    p. 360

OBJ:    Clinical Practice #7                            TOP:    Pedal Pulse

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The accuracy in measuring the apical pulse is enhanced when the nurse:
a. counts the radial pulse at the same time.
b. counts the beats for a minute.
c. keeps the patient warm.
d. uses the bell of the stethoscope.

 

 

ANS:   B

Using the diaphragm of the stethoscope, the nurse counts the beats for 1 full minute.

 

DIF:    Cognitive Level: Application             REF:    p. 359|Skill 21-4

OBJ:    Clinical Practice #2                            TOP:    Counting Apical Pulse

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:
a. notify the charge nurse of the hypotension.
b. notify the doctor of the bradycardia.
c. check medications that might be the cause of the irregularity.
d. check the patient’s record to determine his baseline blood pressure.

 

 

ANS:   D

Check to see what the patient’s baseline vital signs indicate regarding the cardiac arrhythmia.

 

DIF:    Cognitive Level: Application             REF:    p. 359

OBJ:    Clinical Practice #6                            TOP:    Vital Signs

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A nurse is caring for a patient with a cardiac disease history. When measuring vital signs, the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly:
a. listens to the apical pulse for 1 full minute.
b. takes the pulse for 30 seconds on the other wrist.
c. records the findings on the graphic sheet.
d. takes the pulse for 1 full minute on the other wrist.

 

 

ANS:   A

An apical pulse is measured whenever the radial pulse is irregular or when the patient has a cardiac disease history.

 

DIF:    Cognitive Level: Application             REF:    p. 359|Skill 21-6

OBJ:    Clinical Practice #2                            TOP:    Vital Signs: Pulse

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse caring for a 30-year-old postsurgical patient would assess that the patient is in pain as indicated by:
a. a temperature of 102° F.
b. respirations of 16 breaths/min.
c. a pulse rate of 120 beats/min.
d. blood pressure of 128/86 mm Hg.

 

 

ANS:   C

Pain increases the pulse rate.

 

DIF:    Cognitive Level: Application             REF:    p. 360|Table 21-2

OBJ:    Theory #2        TOP:    Vital Signs      KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse explains that one method of environmental heat loss is convection, which is exemplified by body heat being reduced by:
a. being transferred to ice packs.
b. production of sweat.
c. being removed by fast air currents from a fan.
d. exposure to a cool environment.

 

 

ANS:   C

Heat loss through convection can be accomplished by the use of a fan, which produces fast air currents.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 345              OBJ:    Theory #1

TOP:    Heat Loss by Convection                   KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction is warranted when the caregiver states, “I will:
a. offer warm fluids to the patient, if permitted.”
b. instruct the patient to remain on strict bed rest.”
c. provide the patient with additional blankets.”
d. encourage the patient to increase his muscle activity.”

 

 

ANS:   B

Nursing activities for treating the patient with a below normal body temperature should focus on reducing heat loss and supplying additional warmth. These activities may include (1) providing additional clothing or blankets for warmth (an electric blanket is most effective for raising temperature); (2) giving warm fluids, if permitted; (3) adjusting the temperature of the room to 72° F or higher; (4) eliminating drafts; and (5) increasing the patient’s muscle activity.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 350              OBJ:    Theory #3

TOP:    Vital Signs: Hypothermia                   KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A nurse educates patients with prehypertension to implement lifestyle changes that would decrease their systolic pressure from 140 to 120 mm Hg. Which of the following is his or her rationale for this?
a. Reduced deaths by 50% in people over age 40.
b. Reduced rates of strokes by 10%.
c. Reduced rates of COPD by 25%.
d. Reduced rates of heart attacks by 30%.

 

 

ANS:   D

A large study was recently stopped early because it demonstrated that lowering the systolic blood pressure to 120 instead of the recommended 140 reduced the rates of heart attacks and strokes by 30% and deaths by 25% in people over age 50 (AJN, 2015).

 

DIF:    Cognitive Level: Application             REF:    p. 370              OBJ:    Clinical #14

TOP:    Life Span Considerations                   KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

MULTIPLE RESPONSE

 

  1. Standards of the Joint Commission state that pain is the fifth vital sign and should be documented by assessments of: (Select all that apply.)
a. location.
b. duration.
c. usual methods of relief.
d. character.
e. intensity.

 

 

ANS:   A, B, D, E

Pain should be monitored when vital signs are monitored, to closely assess for any cardiac changes. Pain is documented by assessments relative to location, intensity, character, frequency, and duration.

 

DIF:    Cognitive Level: Application             REF:    p. 371              OBJ:    Theory #7

TOP:    Pain Assessment                                 KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a(n): (Select all that apply.)
a. previous mastectomy.
b. patent IV line.
c. injured hand.
d. 2-year-old hand amputation.
e. dialysis shunt.

 

 

ANS:   A, B, E

Arms affected by previous mastectomies, patent IVs, or dialysis shunts should not be used to assess the blood pressure using an inflatable cuff.

 

DIF:    Cognitive Level: Application             REF:    p. 366|Skill 21-6

OBJ:    Clinical Practice #4

TOP:    Contraindications for Blood Pressure Cuff Application

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)
a. dizziness upon rising to a standing position.
b. a drop of 15 to 20 mm Hg from baseline when changing position.
c. nausea.
d. syncope.
e. blurred vision.

 

 

ANS:   A, B, D, E

Assessment of dizziness, drop in up to 20 mm Hg from baseline BP, syncope, and blurred vision are all indicative of orthostatic hypotension.

 

DIF:    Cognitive Level: Application             REF:    p. 371|Box 21-5

OBJ:    Clinical Practice #6                            TOP:    Orthostatic Hypotension

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

COMPLETION

 

  1. The nurse clarifies the average cardiac output in the adult is about _____ L/min.

 

ANS:

5

 

The average cardiac output of the normal adult is about 5 L/min.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 345              OBJ:    Theory #2

TOP:    Cardiac Output                                  KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse converts the Fahrenheit temperature of 99.2 to a Celsius reading of _____________________.

 

ANS:

37.3

 

To convert Fahrenheit to Celsius: subtract 32 from the Fahrenheit reading and multiply by 5/9: 99.2 – 32 = 67.2 ´ 5 = 336/9 = 37.3.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 347|Tables 21-1 and 21-21

OBJ:    Clinical Practice #1                            TOP:    Conversion of Fahrenheit to Celsius

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort