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Basic Nursing Concepts, Skills & Reasoning 1st Edition by Treas – Leslie S – Test Bank

 

 

Chapter 3. Nursing Process: Assessment

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.         What is the role of the Joint Commission in regard to patient assessment? The Joint Commission

1)

States what assessments are collected by individuals with different credentials

2)

Regulates the time frames for when assessments should be completed

3)

Identifies how data are to be collected and documented

4)

Sets standards for what and when to assess the patient

 

ANS:   4

The Joint Commission sets detailed standards regarding what and when to assess but does not address credentials. Nurse practice acts specify what data are collected and by whom. Agency policy may set time frames for when assessments should be done and how they should be documented. Nursing knowledge identifies “how” data are to be collected.

 

PTS:    1          DIF:    Moderate         REF:    p. 39

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Recall

 

 

 

____    2.         Which of the following is an example of data that should be validated?

1)

The client’s weight measures 185 lb at the clinic.

2)

The client’s liver function test results are elevated.

3)

The client’s blood pressure is 160/94 mm Hg; he states that that is typical for him.

4)

The client states she eats a low-sodium diet and reports eating processed food.

 

ANS:   4

Validation should be done when the client’s statements are inconsistent (processed foods are generally high in sodium). Validation is not necessary for laboratory data when you suspect an error has been made in the results. Personal information that patients might be embarrassed about, such as weight, is best validated with a scale.

 

PTS:    1          DIF:    Moderate         REF:    p. 47

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

 

 

 

____    3.         Which of the following examples includes both objective and subjective data?

1)

The client’s blood pressure is 132/68 and her heart rate is 88.

2)

The client’s cholesterol is elevated, and he states he likes fried food.

3)

The client states she has trouble sleeping and that she drinks coffee in the evening.

4)

The client states he gets frequent headaches and that he takes aspirin for the pain.

 

ANS:   2

Elevated cholesterol is objective, and “states he likes fried food” is subjective. Objective data can be observed by someone other than the patient (e.g., from physical assessments or lab and diagnostic tests). Subjective data are information given by the client. Blood pressure and heart rate measurements are both objective. “States . . . trouble sleeping and . . . drinks coffee . . .” are both subjective. States “. . . frequent headaches and . . . takes aspirin . . .” are both subjective.

 

PTS:    1          DIF:    Moderate         REF:    pp. 40

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

 

 

 

____    4.         The Joint Commission requires which type of assessment to be performed on all patients?

1)

Functional ability

2)

Pain

3)

Cultural

4)

Wellness

 

ANS:   2

The Joint Commission requires that pain and nutrition assessment be performed on all patients. Other special needs assessments should be performed when cues indicate there are risk factors.

 

PTS:    1          DIF:    Moderate         REF:    p. 39

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

 

 

 

____    5.         Which of the following is an example of an ongoing assessment?

1)

Taking the patient’s temperature 1 hour after giving acetaminophen (Tylenol)

2)

Examining the patient’s mouth at the time she complains of a sore throat

3)

Requesting the patient to rate intensity on a pain scale with the first perception of pain

4)

Asking the patient in detail how he will return to his normal exercise activities

 

ANS:   1

An ongoing assessment occurs when a previously identified problem is being reassessed—for example, taking an hourly temperature when a patient has a fever. Examining the mouth is a focused assessment to explore the patient’s complaint of sore throat. Asking for a pain rating is a focused assessment at the first complaint of pain. A detailed interview about exercise is a special needs assessment; there is no way to know if it is initial or ongoing.

 

PTS:    1          DIF:    Moderate         REF:    p. 41

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

 

 

 

____    6.         When should the nurse make systematic observations about a patient?

1)

When the patient has specific complaints

2)

With the first assessment of the shift

3)

Each time the nurse gives medications to the patient

4)

Each time the nurse interacts with the patient

 

ANS:   4

The nurse should make observations about the patient each time she enters the room or interacts with the patient to gain ongoing data about the patient.

 

PTS:    1          DIF:    Easy    REF:    p. 41-42

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Application

 

 

 

____    7.         Which of the following is an example of an open-ended question?

1)

Have you had surgery before?

2)

When was your last menstrual period?

3)

What happens when you have a headache?

4)

Do you have a family history of heart disease?

 

ANS:   3

Open-ended questions such as “What happens when you have a headache?” are broad so as to encourage the patient to elaborate. The questions about surgery, menstrual period, and family history can all be answered with a “yes,” “no,” or short, specific answer (a date).

 

PTS:    1          DIF:    Moderate         REF:    pp. 45

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Application

 

 

 

____    8.         Of the following recommended interviewing techniques, which one is the most basic? (That is, without that intervention, the others will all be less effective.)

1)

Beginning with neutral topics

2)

Individualizing your approach

3)

Minimizing note taking

4)

Using active listening

 

ANS:   4

All are important techniques, but active listening focuses the attention on the patient and lets her know you are trying to understand her needs. The interviewer is more likely to get the patient to open up. Patients will forgive you for most errors in technique, but if they think you are not listening, that can negatively affect your relationship.

 

PTS:    1          DIF:    Difficult          REF:    47

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

 

 

 

____    9.         Which of the following is an example of the most basic motivation in Maslow’s hierarchy of needs?

1)

Experiencing loving relationships

2)

Having adequate housing

3)

Receiving education

4)

Living in a crime-free neighborhood

 

ANS:   2

The most basic needs are centered on physiological survival—shelter (housing), food, and water. All other options are for higher needs. The order from most basic to highest level is physiologic, safety and security, love and belonging, esteem, and self-actualization. Loving relationships fall under the love and belonging category. Education is a form of self-actualization. Living in a crime-free neighborhood meets the need for safety and security.

 

PTS:    1          DIF:    Moderate         REF:    p. 48

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

 

 

 

____    10.       What makes a nursing history different from a medical history?

1)

A nursing history focuses on the patient’s responses to the health problem.

2)

The same information is gathered; the difference is in who obtains the information.

3)

A nursing history is gathered using a specific format.

4)

A medical history collects more in-depth information.

 

ANS:   1

A medical history focuses on the patient’s current and past medical/surgical problems. A nursing history focuses on the patient’s responses to and perception of the illness/injury or health problem, his coping ability, and resources and support. Nursing history formats vary depending on the patient, the agency, and the patient’s needs. Both nursing and medical histories typically use a specific format. A medical history does not necessarily contain more in-depth information. A nursing history can be in-depth, covering a wide range of topics, including biographical data, reason(s) patient is seeking healthcare, history of present illness, patient’s perception of health status and expectations for care, past medical history, use of complementary modalities, and review of functional ability associated with activities of daily living. Other topics might deal with nutrition, psychosocial needs, pain assessment, or other special needs topics.

 

PTS:    1          DIF:    Moderate         REF:    pp. 44-45

KEY:   Nursing process: Assessment  | Client need: SECE | Cognitive level: Comprehension

 

 

 

____    11.       Why is it important to obtain information about nutritional and herbal supplements as well as about complementary and alternative therapies?

1)

To determine what type of therapies are acceptable to the client

2)

To identify whether the client has a nutrition deficiency

3)

To help you to understand cultural and spiritual beliefs

4)

To identify potential interaction with prescribed medication and therapies

 

ANS:   4

Herbs and nutritional supplements can interact with prescription medications, and complementary and alternative treatments can interfere with conventional therapies. Physical assessment and laboratory tests are needed to assess a nutritional deficiency. To identify cultural and spiritual beliefs and well as what therapies are acceptable to the client, you need more than just information about nutritional and herbal supplements.

 

PTS:    1          DIF:    Difficult          REF:    p. 45

KEY:   Nursing process: Assessment | Client need: HPM | Cognitive level: Application

 

 

 

____    12.       What do the nursing assessment models have in common?

1)

They assess and cluster data into model categories.

2)

They organize assessment data according to body systems.

3)

They specify use of the nursing process to collect data.

4)

They are based on the ANA Standards of Care.

 

ANS:   1

All the models categorize or cluster data into functional health patterns, domains, or categories. None of the assessment models clusters data according to body system. Assessment is the first step of the nursing process; the nurse does not use the entire nursing process in data collection. The ANA Standards of Care describe a competent level of clinical nursing practice based on the nursing process; nursing models are not based on the ANA Standards of Care.

 

PTS:    1          DIF:    Difficult          REF:    pp. 48

KEY:   Nursing process: Assessment | Client need: SACE | Cognitive level: Analysis

 

 

 

____    13.       Nondirective interviewing is a useful technique because it

1)

Allows the nurse to have control of the interview

2)

Is an efficient way to interview a patient

3)

Facilitates open communication

4)

Helps focus patients who are anxious

 

ANS:   3

Nondirective interviewing helps build rapport and facilitates open communication. Because it puts the patient in control, it can be very time-consuming (inefficient) and produce information that is not relevant. Directive interviewing should be used to focus anxious patients.

 

PTS:    1          DIF:    Easy    REF:    p. 45

KEY:   Nursing process: Assessment | Client need: PSI | Cognitive level: Recall

 

 

 

____    14.       A nursing instructor is guiding nursing students on best practices for interviewing patients. Which of the following comments by a student would indicate the need for further instruction?

1)

“My patient is a young adult, so I plan to talk to her without her parents in the room.”

2)

“Because my patient is old enough to be my grandfather, I will call him ‘Mr.’”

3)

“When reading my patient’s health record, I thought of a few questions to ask.”

4)

“When I give my patient his pain medication, I will have time to ask questions.”

 

ANS:   4

A patient should be comfortable when interviewing. The pain medication should have time to work before considering interviewing the patient, so asking questions when giving the medication is not a good idea. It is appropriate to interview patients without family/friends around. In nearly every culture, calling a patient Mr. or Mrs. shows respect and is therefore correct. Reading the patient’s health record is appropriate preparation for an interview.

 

PTS:    1          DIF:    Moderate         REF:    p. 46

KEY:   Nursing process: Evaluation | Client need: SECE | Cognitive level: Application

 

 

 

____    15.       A patient comes to the urgent care clinic because he stepped on a rusty nail. What type of assessment would the nurse perform?

1)

Comprehensive

2)

Ongoing

3)

Initial focused

4)

Special needs

 

ANS:   3

An initial focused assessment is performed during a first exam for specific abnormal findings. A comprehensive assessment is holistic and is usually done upon admission to a healthcare facility. An ongoing assessment follows up after an initial database is completed or a problem is identified. A special needs assessment is performed when there are cues that more in-depth assessment is needed.

 

PTS:    1          DIF:    Moderate         REF:    pp. 42–43

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

 

 

 

____    16.       A patient has left-sided weakness because of a recent stroke. Which type of special needs assessment would it be most important to perform?

1)

Family

2)

Functional

3)

Community

4)

Psychosocial

 

ANS:   2

A functional assessment is most important because of discharge needs (e.g., self-care ability at home) and patient safety. A family and community assessment would be helpful to evaluate support systems, and a psychosocial assessment would be helpful to evaluate a patient’s understanding of and coping with his recent stroke. Remember that special needs assessments are lengthy and time-consuming, so they should be used only when in-depth information is needed about a topic.

 

PTS:    1          DIF:    Moderate         REF:    pp. 43

KEY:   Nursing process: Assessment  | Client need: SECE | Cognitive level: Analysis

 

 

 

____    17.       The nurse is interviewing a patient who has a recent onset of migraine headaches. The patient is highly anxious and cannot seem to focus on what the nurse is saying. Which of the following questions would be best for the nurse to use to begin gathering data about the headaches?

1)

“When did your migraines begin?”

2)

“Tell me about your family history of migraines.”

3)

“What are the types of things that trigger your headaches?”

4)

“Describe what your headaches feel like.”

 

ANS:   1

For someone who is anxious, it is best to use closed questions. (When did your migraines begin?) A closed question can be answered in one or very few words and has a very specific answer. The other questions are open-ended questions.

 

PTS:    1          DIF:    Moderate         REF:    p. 45

KEY:   Nursing process: Assessment | Client need: PSI | Cognitive level: Application

 

 

 

____    18.       Which of the following is an example of an active listening behavior?

1)

Taking frequent notes

2)

Asking for more details

3)

Leaning toward the patient

4)

Sitting with legs crossed

 

ANS:   3

Active listening behaviors include leaning toward the patient; facing the patient; open, relaxed posture without crossing arms or legs; and maintaining eye contact. Taking frequent notes makes it difficult to keep eye contact. Asking for more details may seem like idle curiosity. Sitting with legs crossed may indicate to the patient that you are not open to her.

 

PTS:    1          DIF:    Easy    REF:    p. 47

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension

 

 

 

____    19.       A nursing instructor asked his nursing students to discuss their experiences with charting assessment data. Which comment by the student indicates the need for further teaching?

1)

“I find it difficult to avoid using phrases like, ‘The patient tolerated the procedure well.’”

2)

“It’s confusing to have to remember which abbreviations this hospital allows.”

3)

“I need to work on charting assessments and interventions right after they are done.”

4)

“My patient was really quiet and didn’t say much, so I charted that he acted depressed.”

 

ANS:   4

When charting data, chart only what was observed, not what it meant. Inferences should not be made about a patient’s behavior during data collection (“he acted depressed”); so that response reflects the student’s lack of knowledge and need for teaching. Chart specific data, not vague phrases; the student is acknowledging the importance of this. There are no universally accepted phrases, just agency-approved abbreviations; the student is acknowledging the need to use agency-approved abbreviations. The student is correct that charting should be completed as soon after data collection as possible.

 

PTS:    1          DIF:    Moderate         REF:    p. 50

KEY:   Nursing process: Evaluation | Client need: SECE | Cognitive level: Application

 

 

 

____    20.       For which of the following purposes is a graphic flow sheet superior to other methods of recording data?

1)

Easy documentation of routine vital signs

2)

Seeing the patterns of a patient’s fever

3)

Describing the symptoms accompanying a rising temperature

4)

Checking to make sure vital signs were taken

 

ANS:   2

All are benefits of the graphic flow sheet, but to easily and graphically see trends over time, the graphic flow sheet is superior to other methods of documentation. For the other options, other kinds of flow sheets would be equally effective.

 

PTS:    1          DIF:    Moderate         REF:    p. 50

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Analysis

 

 

 

____    21.       The most obvious reason for using a framework when assessing a patient is to

1)

Prioritize assessment data

2)

Organize and cluster data

3)

Separate subjective and objective data

4)

Identify primary from secondary data

 

ANS:   2

A framework is used to organize and cluster data to find patterns. During the assessment phase, the nurse is collecting and recording data, not prioritizing the data. A framework includes subjective and objective data as well as primary and secondary data; it does not help you to separate them.

 

PTS:    1          DIF:    Easy    REF:    p. 48

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Recall

 

 

 

____    22.       Which situation is the most conducive to conducting a successful interview of an elderly woman whose husband and two children are in the hospital room visiting and watching television? The woman is alert and oriented.

1)

Provide enough chairs so the family and you are able to sit facing the client.

2)

Introduce yourself and ask, “Dear, what name do you prefer to go by?” before asking any questions.

3)

After the family leaves, ask the client if she is comfortable and willing to answer a few questions.

4)

Ask the client if you can talk with her while her family is watching the television.

 

ANS:   3

The interview should be done when the client is comfortable and there are no distractions. Endearing terms are inappropriate unless the client prefers them. Family members may offer information that may or may not be pertinent and may distract from the interview. The presence of family members may also inhibit full disclosure of information by the client.

 

PTS:    1          DIF:    Difficult          REF:    p. 46-47

KEY:   Nursing process: Assessment | Client need: PSI | Cognitive level: Application

 

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____    23.       Which of the following questions would be effective for obtaining information from a patient? Choose all that apply.

1)

“How did this happen to you?”

2)

“What was your first symptom?”

3)

“Why didn’t you seek healthcare earlier?”

4)

“When did you start having symptoms?”

 

ANS:   1, 2, 4

How, what, and when are acceptable lines of questioning. Asking “why” can put the patient on the defensive and may suggest disapproval, limiting the amount of information the patient is willing give.

 

PTS:    1          DIF:    Moderate         REF:    p. 45-46

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Application

 

 

 

____    24.       A nurse with a large caseload of patients needs to delegate some assessment tasks to other members of the health team. The nurse is unsure which tasks can be delegated to nursing assistive personnel (NAP) and which are appropriate for a licensed practical nurse (LPN) or a registered nurse (RN). To which sources should the nurse turn for the answer to his question? Choose all that are appropriate.

1)

The nurse practice act of his state

2)

The American Medical Association guidelines

3)

The Code of Ethics for Nurses

4)

The American Nurses Association’s Scope and Standards of Practice

 

ANS:   1, 4

State nurse practice acts specify which portions of the assessment can legally be completed by individuals with different credentials. The ANA Scope and Standards of Practice provide a guide for who is ultimately responsible and qualified to collect assessment data. The American Medical Association provides guidelines and standards for physicians, not nurses. The Code of Ethics for Nurses says merely that the nurse should delegate tasks appropriately; it does not speak to credentials of personnel.

 

PTS:    1          DIF:    Moderate         REF:    p. 40

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension

 

 

 

____    25.       Which of the following are cues rather than inferences? Choose all correct answers.

1)

Ate 50% of his meal

2)

Patient feels better today

3)

States, “I slept well”

4)

White blood cell count 15,000/mm3

 

ANS:   1, 3, 4

Cues are what the client says and what you observe. “Just the facts.” The only inference in the list is “slept well.” What did the nurse observe to tell her the client slept well? Those would be cues. If the client states, “I slept well” it is a cue, because it is a fact—that is what the client stated.

 

PTS:    1          DIF:    Easy    REF:    p. 50

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension

 

 

 

Matching

 

  1. Match the assessment technique to the data that should be collected. There may be more than one technique used to collect the data.

1)

Auscultation

2)

Inspection

3)

Palpation

4)

Percussion

 

____    1.         Skin pink, warm, and dry

 

____    2.         Lung sounds clear

 

____    3.         Abdomen is tympanic

 

____    4.         Abdomen soft and nontender

 

  1. ANS: 2          PTS:    1          DIF:    Moderate         REF:    p. 42

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

 

  1. ANS: 1          PTS:    1          DIF:    Moderate         REF:    p. 42

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

 

  1. ANS: 4          PTS:    1          DIF:    Moderate         REF:    p. 42

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

 

  1. ANS: 3          PTS:    1          DIF:    Moderate         REF:    p. 42

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

 

 

 

  1. Match the type of special needs assessment with the correct example.

1)

Do you perform monthly breast self-exams?

2)

Do you live near any industrial manufacturing plants?

3)

Who can you talk to when you feel sad?

4)

Who do you live with?

5)

What is your understanding of your diet?

6)

Since you had your stroke, have you had any problems dressing yourself?

7)

Do you have a religious preference?

 

 

 

____    5.         Community

 

____    6.         Family

 

____    7.         Functional ability

 

____    8.         Nutrition

 

____    9.         Psychosocial

 

____    10.       Wellness

 

____    11.       Spiritual

 

  1. ANS: 2          PTS:    1          DIF:    Easy    REF:    pp. 43–44

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Application

 

  1. ANS: 4          PTS:    1          DIF:    Easy    REF:    pp. 43–44

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Application

 

  1. ANS: 6          PTS:    1          DIF:    Easy    REF:    pp. 43–44

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Application

 

  1. ANS: 5          PTS:    1          DIF:    Easy    REF:    pp. 43–44

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Application

 

  1. ANS: 3          PTS:    1          DIF:    Easy    REF:    pp. 43–44

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Application

 

  1. ANS: 1          PTS:    1          DIF:    Easy    REF:    pp. 43–44

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Application

 

  1. ANS: 7          PTS:    1          DIF:    Moderate         REF:    pp. 43-44

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Recall

 

 

  1. Match the assessment model with the intended use for that model.

1)

Categorizes nursing diagnoses, client outcomes, and nursing interventions

2)

Assesses the client’s ability to achieve balance (homeostasis)

3)

Identifies deficits in activities of daily living that require nursing assistance

4)

Formulates a model for nursing assessment and diagnosis but is not a theory

5)

Categorizes nursing diagnoses

 

 

____    12.       Gordon’s Functional Health Patterns

 

____    13.       NANDA Nursing Diagnosis Taxonomy II

 

____    14.       Taxonomy of Nursing Practice

 

____    15.       Roy’s Adaptation model

 

____    16.       Orem’s Self-Care model

 

  1. ANS: 4          PTS:    1          DIF:    Moderate         REF:    p. 49

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Recall

 

  1. ANS: 5          PTS:    1          DIF:    Moderate         REF:    p. 49

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Recall

 

  1. ANS: 1          PTS:    1          DIF:    Moderate         REF:    p. 49

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Recall

 

  1. ANS: 2          PTS:    1          DIF:    Moderate         REF:    p. 49

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Recall

 

  1. ANS: 3          PTS:    1          DIF:    Moderate         REF:    p. 49

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Recall

 

 

Chapter 11. Experiencing Health & Illness

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.         In an effort to promote health, the home health nurse opens the client’s bedroom windows to let in fresh air and sunlight, washes her hands often, and teaches the patient and family about the importance of hygiene and cleanliness. This most closely illustrates the ideas of which of the following people?

1)

Jean Watson

2)

Jurgen Moltmann

3)

Florence Nightingale

4)

Robert Louis Stevenson

 

ANS:   3

Florence Nightingale believed that health was prevention of disease through the use of fresh air, pure water, efficient drainage, cleanliness, and light. Jean Watson believes that health has three elements: a high level of overall physical, mental, and social functioning; a general adaptive-maintenance level of daily functioning; and the absence of illness (or the presence of efforts that lead to its absence). Jurgen Moltmann believes that true health is the strength to live, the strength to suffer, and the strength to die. He also stated that health is not a condition of the body; it is the power of the soul to cope with the varying condition of that body. Robert Louis Stevenson wrote that health is not a matter of holding good cards; it is playing a poor hand well.

 

PTS:    1          DIF:    Easy    REF: p. 222

KEY:   Nursing process: N/A | Client need: HPM | Cognitive level: Recall

 

 

 

____    2.         Which of the following is known to be a healthy strategy for coping with stress?

1)

Performing meaningful work

2)

Consuming simple carbohydrates

3)

Drinking three glasses of red wine each day

4)

Weight training

 

ANS:   1

Many individuals find that meaningful work is a healthy way to cope with stressors. Consuming simple carbohydrates is not a healthy way to cope with stress. Drinking more than one glass of red wine each day is considered unhealthy. Weight training has been shown to increase bone density and reduce the risk of osteoporosis and heart disease but not necessarily to reduce stress.

 

PTS:    1          DIF:    Moderate         REF:    p. 225

KEY:   Nursing process: N/A | Client need: PSI | Cognitive level: Application

 

 

 

____    3.         Which family would most likely be helpful in encouraging the client to experience a high level of wellness? A family who

1)

Controls feelings to avoid conflict

2)

Teaches negotiation skills and independence

3)

Encourages risk taking and adventure

4)

Views themselves as helpless victims

 

ANS:   2

Families who promote independence and teach good negotiation skills enable family members to experience a high level of wellness by thinking for themselves. In contrast, families who tend to squelch personal feelings to avoid conflict may not allow a high level of wellness. Families who emphasize caution in new situations are more beneficial than those who encourage risk-taking. Families who view themselves as capable and successful are more advantageous than those who view themselves as helpless victims.

 

PTS:    1          DIF:    Easy    REF:    p. 225

KEY:   Nursing process: N/A | Client need: PSI | Cognitive level: Recall

 

 

 

____    4.         The client is a 76-year-old man who is experiencing chronic illness. He has a genetic-linked anemia. He says he does not eat a balanced diet, as he prefers sweets to meat and vegetables. Which of the following dimensions of health can the nurse most likely influence by teaching and counseling him?

1)

Age-related changes

2)

Genetic anemia

3)

Eating habits

4)

Gender-related issues

 

ANS:   3

The nurse is most likely to influence the patient’s eating habits because those are the dimension over which he has the most control and, therefore, has the most potential for changing. Although people consider biological factors when they describe themselves as well or ill, they are not entirely within our control. Biological factors include age and developmental stage, genetic makeup, and sex.

 

PTS:    1          DIF:    Easy    REF:    p. 224

KEY:   Nursing process: Planning | Client need: HPM | Cognitive level: Application

 

 

 

____    5.         What type of loss is most common among patients who are hospitalized for complex health conditions?

1)

Privacy

2)

Dignity

3)

Functional

4)

Identity

 

ANS:   2

Hospitalized patients commonly experience the loss of dignity. Wearing a hospital gown, having their body exposed, invasive procedures, loss of control over body functions—all of these contribute to loss of dignity, and all are very common among hospitalized patients. Healthcare providers have a duty to protect privacy and confidentiality of patients, even though it is certainly threatened by some situations during hospitalization. Some patients lose functioning and identity during hospitalization, but they are not common occurrences.

 

PTS:    1          DIF:    Moderate         REF:    p. 227

KEY:   Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension

 

 

 

____    6.         A 62-year-old patient is admitted to the hospital with hypertension. Which question by the nurse is most important when performing the initial assessment interview?

1)

“What medications do you take at home?”

2)

“Do you have any environmental, food, or drug allergies?”

3)

“Do you have an advance directive?”

4)

“What is the greatest concern you are dealing with today?”

 

ANS:   4

It is most important for the nurse to ask the patient about his greatest concern. His concern can then be incorporated into the plan of care, making sure that his needs are met. Asking about medications, allergies, and an advance directive is also important but does not take priority over asking about the patient’s greatest concern.

 

PTS:    1          DIF:    Moderate         REF:    p. 231

KEY:   Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis

 

 

 

____    7.         When developing goals, which guideline should the nurse keep in mind? Goals should be

1)

Realistic so that progress is recognized by the patient

2)

Developed solely by the healthcare team

3)

Developed without family input, to maintain confidentiality

4)

Valued by the multidisciplinary care providers

 

ANS:   1

Goals should be realistic so that progress is recognized by the patient. They should be valued by both the patient and family. The nurse should develop goals with input from the patient and his family.

 

PTS:    1          DIF:    Moderate         REF:    p. 231

KEY:   Nursing process: Planning  | Client need: SECE | Cognitive level: Comprehension

 

 

 

____    8.         Which one of the following important nursing actions is a hospitalized patient likely to experience on an emotional level and remember long after this hospitalization has ended?

1)

Administering her medications according to schedule

2)

Allowing flexible visitation by her family and friends

3)

Explaining treatment options in terms she can understand

4)

Providing a healing presence by listening and being attentive

 

ANS:   4

The nurse can contribute meaningfully to the patient’s hospitalization by providing a healing presence. The nurse can do this by listening to the patient and being attentive. Administering medications according to schedule, allowing flexible visitation, and explaining treatment options are important contributions that the nurse can make, but they will not be most meaningful to the patient. Patients may be impressed, even amazed, by the healthcare technology used to diagnose and treat their illnesses. However, often what they remember, perhaps through the rest of their lives, is the people who connected with them in a personal way.

 

PTS:    1          DIF:    Moderate         REF:    p. 232

KEY:   Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension

 

 

 

____    9.         Which statement best describes the health/illness continuum?

1)

Health is the absence of disease; illness is the presence of disease.

2)

Health and illness are along a continuum that cannot be divided.

3)

Health is remission of disease; illness is exacerbation of disease.

4)

Health is not having illness; illness is not having health.

 

ANS:   2

The health/illness continuum is best described as a graduated spectrum that cannot be divided.

 

PTS:    1          DIF:    Moderate         REF:    p. 223

KEY:   Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension

 

 

 

____    10.       Which of the following helps the body release growth hormone (growth hormone assists in tissue regeneration, synthesis of bone, and formation of red blood cells)?

1)

A healthy diet

2)

Physical activity

3)

Restful sleep

4)

Comfortable room temperature

 

ANS:   3

During sleep, our bodies release the majority of our growth hormone, which assists in tissue regeneration, synthesis of bone, and formation of red blood cells. Consuming healthy foods helps prevent disease. Physical activity reduces the risk of chronic disease and promotes longevity. Keeping the body at a comfortable temperature helps maintain health but not release of growth hormone.

 

PTS:    1          DIF:    Moderate         REF:    p. 224

KEY:   Nursing process: N/A | Client need: PHSI | Cognitive level: Recall

 

 

 

____    11.       A client has been hospitalized for 6 weeks. All of the following interventions are good ones, but which intervention is specifically focused on helping the patient cope with the emotional responses to prolonged hospitalization?

1)

Providing skin care every shift to prevent skin breakdown

2)

Encouraging the patient to get up in a chair to eat meals

3)

Assisting the patient to ambulate in the hallway for several minutes each day

4)

Designating a corner of the patient’s room to display personal mementos

 

ANS:   4

The patient’s environment can help nourish wellness. Helping the patient designate a corner of the room to display personal mementos can be healing and help the patient cope with the prolonged hospitalization. The other interventions might be helpful to the patient but are not as helpful in specifically dealing with “hospitalization” as is designating a portion of the room that is uniquely hers.

 

PTS:    1          DIF:    Moderate         REF:    p. 226

KEY:   Nursing process: Implementation | Client need: PSI | Cognitive level: Application

 

 

 

____    12.       Which of the following is particularly valuable in helping a patient with a terminal illness maintain a sense of self?

1)

Family relationships

2)

Spirituality

3)

Nutrition

4)

Sleep and rest

 

ANS:   2

When a patient is faced with a terminal illness, spirituality can help the patient maintain his sense of self. Family relationships can provide a loving, supportive source of comfort and reassurance but can sometimes cause the patient pain and a feeling of loneliness when faced with a terminal illness. Nutrition, sleep, and rest are healing but usually not as helpful to a patient with terminal illness as is spirituality.

 

PTS:    1          DIF:    Difficult          REF:    p. 226

KEY:   Nursing process: N/A | Client need: PSI | Cognitive level: Recall

 

 

 

____    13.       A client with a history of schizophrenia is diagnosed with a urinary tract infection. What is probably the most significant barrier this patient faces?

1)

Chronic urinary incontinence

2)

Stigma associated with mental illness

3)

Risk for recurring infections

4)

Auditory hallucinations (“hearing things”)

 

ANS:   2

Mental illness is associated with a stigma that is usually a barrier, and even considered a debilitating handicap. Chronic urinary incontinence is not commonly associated with urinary tract infection, and nothing in the scenario suggests that the patient is incontinent. The patient is at risk for recurring urinary tract infections, but this is not considered a debilitating handicap. Auditory hallucinations are associated with schizophrenia but have not been described as the most debilitating handicap.

 

PTS:    1          DIF:    Moderate         REF:    p. 226

KEY:   Nursing process: N/A | Client need: PSI | Cognitive level: Application

 

 

 

____    14.       A 76-year-old patient is admitted with an acute myocardial infarction (heart attack). The doctor tells the patient that an angioplasty is necessary. The patient agrees and signs the informed consent. This patient is experiencing which stage of illness behavior?

1)

Sick-role behavior

2)

Seeking professional care

3)

Experiencing symptoms

4)

Dependence on others

 

ANS:   4

This patient is experiencing the dependence-on-others stage of illness behavior; he has accepted the diagnosis and treatment of the healthcare provider. The patient entered the experiencing illness stage when he began having chest pain at home. He entered the sick-role behavior phase when he admitted to family that he was experiencing chest pain. When he decided to go to the emergency department for healthcare intervention, he entered the seeking-professional-care stage of illness.

 

PTS:    1          DIF:    Moderate         REF:    pp. 228-229

KEY:   Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis

 

 

 

____    15.       Many health providers define illness as pathology; however, people experience, rather than define, illness. Which of the following is how most people experience illness?

1)

“Feeling lousy,” a true sense of not being all right

2)

A change in the way they feel or a disruption in their typical life

3)

Something to be dreaded and avoided if at all possible

4)

An experience that offers the potential for learning and spiritual growth

 

ANS:   2

People typically describe their illness in terms of how it makes them feel or the effect it has on day-to-day life. “Feeling lousy” is inappropriate as many people do not feel “lousy” when they are ill. For example, hypertension is an illness that may have no symptoms. Similarly, patients may have chronic disease that is well managed and therefore does not make them feel ill. “Something to be dreaded and avoided . . .” is also not accurate. If a person has an external locus of control, he may view illness as a consequence of actions taken. From this viewpoint, he may have little control over whether he can avoid illness. Finally, although some people do grow and learn in the face of illness, most people do not hold such a positive view about illness—and the question asks how people experience illness.

 

PTS:    1          DIF:    Moderate         REF:    p. 222

KEY:   Nursing process: N/A | Client need: PSI | Cognitive level: Recall

 

 

 

____    16.       Dunn believes that an individual’s state of health should be evaluated in the context of the person’s environment. This approach illustrates that

1)

An unhealthy physical environment, characterized by poor living conditions, always has a negative effect on an individual’s health

2)

Adequate income, food, and shelter create a healthful environment and always improve physical health status

3)

Physical environment, family, and social support may help or hinder the health status of an individual

4)

The environment that should always be assessed is the client’s immediate surroundings; extended boundaries do not apply in an ill state

 

ANS:   3

The home environment, community, family, friends, and support system all influence health status. The balance among these variables has a net positive or negative effect on a client’s health status. The effect of poor living conditions may be offset by the presence of loving family and friends. Poverty does not always have a negative effect on health. Similarly, the presence of food, shelter, and clothing does not always convey protective health, as loneliness and hopelessness may counteract these positive influences. When examining the client’s environment, extended boundaries must be considered, especially when providing community-based care.

 

PTS:    1          DIF:    Difficult          REF:    p. 223

KEY:   Nursing process: Assessment | Client need: HPM | Cognitive level: Application

 

 

 

____    17.       Some people readily become ill when under stress. Others are able to deal with tremendous stress and remain physically and mentally healthy. This disparity is affected by a person’s level of hardiness. How can you apply this knowledge to your nursing care?

1)

You cannot use this information at all. People are innately hardy or not. This is something that you must merely recognize.

2)

You should encourage all people to develop some level of hardiness in order to get through difficult physical and emotional times.

3)

You should assess for your own level of hardiness: If you are hardy, you will be a better nurse; if you are not, you can learn more about hardiness.

4)

You can assess for hardiness in patients; you can encourage hardy patients to learn about their illness as a means for them to be more comfortable.

 

ANS:   4

Hardiness is a personality trait that helps many cope with stress and illness. As a personality trait, it is unlikely that you can teach or otherwise encourage this trait. Awareness of your own level of hardiness will help you understand your response to stress, but hardiness does not necessarily make you a better nurse.

 

PTS:    1          DIF:    Difficult          REF:    p. 229

KEY:   Nursing process: Interventions | Client need: PSI | Cognitive level: Application

 

 

 

____    18.       When preparing a room to receive a newly admitted patient, which of the following should the nursing assistive personnel (NAP) do?

1)

Mop the floor with an approved disinfecting solution.

2)

Fold the top bed linens back to “open” the bed.

3)

Hook up the suction machine and check to see that it is working.

4)

Position the bed in its lowest position.

 

ANS:   2

The NAP should create an “open” bed. The housekeeping department is almost always responsible for cleaning the room between patients. The nurse is responsible for hooking up and checking special equipment such as suction. The nurse would need to tell the NAP whether the patient is to be admitted ambulatory, by wheelchair, or by stretcher to know whether to position the bed high or low.

 

PTS:    1          DIF:    Moderate         REF:    p. 233

KEY:   Nursing process: Interventions | Client need: SECE | Cognitive level: Application

 

 

 

____    19.       When transferring a patient from a hospital to a long-term care facility, which of the following is most helpful in facilitating the patient’s planning and emotional adjustment?

1)

Notify the patient and family as much in advance of the transfer as possible.

2)

Send a complete copy of the patient’s medical records to the new facility.

3)

Carefully coordinate the transfer with the long-term facility to keep it smooth.

4)

Help arrange for transportation and accompany the patient to the transport vehicle.

 

ANS:   1

Notifying the patient and family well in advance of the transfer allows them time to adjust emotionally and to make any necessary plans. A copy of the records is usually sent, and the nurse does coordinate the transfer with the receiving facility; however, that does very little to assist with the patient’s emotional status or planning. Someone from the hospital may accompany the patient to the car; or if the transfer is by ambulance, perhaps not. Either way, that will not help the patient and family to do the necessary planning for the transfer.

 

PTS:    1          DIF:    Moderate         REF: p. 233

KEY:   Nursing process: Interventions | Client need: PSI | Cognitive level: Application

 

 

 

____    20.       A 36-year-old mother of three small children has had nausea, vomiting, and extreme fatigue for the past 2 days. She calls her mother and tells her she is ill and asks if her mother can care for the children. Which stage of illness behavior is she experiencing? Choose all that apply.

1)

Sick-role behavior

2)

Dependence on others

3)

Seeking professional care

4)

Experiencing symptoms

 

ANS:   1

The 36-year-old mother is assuming sick-role behavior because she is identifying herself as ill. She is also in the stage of experiencing symptoms; she is experiencing symptoms and realizes that illness is starting, even though she has not yet entered the stages of dependence and seeking professional care. By telling her mother of the illness, she is relieved of her normal duties—caring for her children. Dependence on others occurs when the client accepts a diagnosis and treatment from the healthcare provider. Seeking professional care occurs after the sick-role behavior stage. During this stage, the client makes the decision that she is ill and that professional healthcare is needed.

 

PTS:    1          DIF:    Moderate         REF:    p. 228

KEY:   Nursing process: N/A | Client need: PSI | Cognitive level: Application

Chapter 31. Sensory Perception

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____       1.   The nurse checks a patient’s pupils using a penlight. Which receptors is the nurse stimulating?

1)

Chemoreceptors

2)

Photoreceptors

3)

Proprioceptors

4)

Mechanoreceptors

 

ANS:       2

Photoreceptors located in the retina of the eyes detect visible light. Proprioceptors in the skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable an individual to sense the position of the body in space. Chemoreceptors are located in the taste buds and epithelium of the nasal cavity. They play a role in taste and smell. Thermoreceptors in the skin detect variations in temperature. Mechanoreceptors in the skin and hair follicles detect touch, pressure, and vibration.

 

PTS:    1                      DIF:    Easy                REF:    p. 1068

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

 

 

 

 

____       2.   Which structure within the brain is responsible for consciousness and alertness?

1)

Reticular activating system

2)

Cerebellum

3)

Thalamus

4)

Hypothalamus

 

 

ANS:       1

The reticular activating system, located in the brainstem, controls consciousness and alertness. The cerebellum maintains muscle tone, coordinates muscle movement, and controls balance. The thalamus is a relay system for sensory stimuli. The hypothalamus controls body temperature.

 

PTS:    1                      DIF:    Easy                REF:    p. 1068

KEY:   Nursing process: N/A | Client need: HPM | Cognitive level: Recall

 

 

 

____       3.   The nurse has been teaching a parent about stimuli to develop her infant’s auditory nervous system. Which behavior by a parent toward the child provides evidence that learning occurred?

1)

Cuddling

2)

Speaking

3)

Feeding

4)

Soothing

 

 

ANS:       2

Exposure to voices, music, and ambient sound helps develop the infant’s auditory nervous system. Cuddling, feeding, and soothing provide comfort and pleasure and teach the infant about his external environment.

 

PTS:    1                      DIF:    Easy                REF:    p. 1069

KEY:   Nursing process: Evaluation | Client need: HPM | Cognitive level: Recall

 

 

 

____       4.   A patient complains to the nurse that since taking a medication he has suffered from excessively dry mouth. What term should the nurse use to document this complaint?

1)

Exophthalmos

2)

Anosmia

3)

Insomnia

4)

Xerostomia

 

 

ANS:       4

The nurse should document excessively dry mouth as xerostomia. Exophthalmos is abnormal bulging of the eyeballs that commonly occurs with thyrotoxicosis. Anosmia is losing the sense of smell. Insomnia is inability to sleep.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1072

KEY:   Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

 

 

 

____       5.   Which nursing diagnosis has the highest priority for a patient with impaired tactile perception?

1)

Self-Care Deficit: Dressing and Grooming

2)

Impaired Adjustment

3)

Risk for Injury

4)

Activity Intolerance

 

 

ANS:       3

The patient with impaired tactile perception is unable to perceive touch, pressure, heat, cold, or pain, placing him at risk for injury. Self-Care Deficit, Impaired Adjustment, and Activity Intolerance are also likely to be appropriate for this patient but are not as high a priority as Risk for Injury. Risk for Injury is directly related to safety, which must always be a priority.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1072

KEY:   Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

 

 

 

____       6.   A patient with Parkinson’s disease is at risk for which complication?

1)

Impaired kinesthesia

2)

Macular degeneration

3)

Seizures

4)

Xerostomia

 

 

ANS:       1

Patients with Parkinson’s disease are at risk for impaired kinesthesia, placing them at risk for falling. Drooling, not excessive dry mouth (xerostomia), is common with Parkinson’s disease. Seizures and macular degeneration are not associated with Parkinson’s disease.

 

PTS:    1                      DIF:    Moderate        REF:    pp. 1074-1075

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

 

 

 

____       7.   The nurse is caring for a patient with dementia who becomes agitated every evening. Which intervention by the nurse is best for calming this patient?

1)

Encouraging family members to visit only during the day

2)

Applying wrist restraints during periods of agitation

3)

Playing soft, calming music during the evening

4)

Administering lorazepam (a tranquilizer)

 

 

ANS:       3

Soft, calming music is sometimes helpful for patients with dementia. Encouraging a family member to sit with the patient might have a calming effect, but the option does not provide for that during the evening when the patient is symptomatic. Applying bilateral wrist restraints might further agitate the patient. Lorazepam will provide sedation but might cause further confusion.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1081

KEY:   Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis

 

 

 

____       8.   Which intervention is appropriate for the patient with a nursing diagnosis of Disturbed Sensory Perception: Gustatory?

1)

Limit oral hygiene to one time a day.

2)

Teach the patient to combine foods in each bite.

3)

Assess for sores or open areas in the mouth.

4)

Instruct the patient to avoid salt substitutes.

 

 

ANS:       3

The nurse should assess for sores or open areas in the mouth and provide frequent oral hygiene. The nurse should also teach the patient to eat foods separately to allow the taste of food to be distinguishable. Seasonings, salt substitutes, spices, or lemon may improve the taste of foods, so the patient should not avoid them.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1083

KEY:   Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

 

 

 

____       9.   A patient diagnosed with macular degeneration asks the nurse to explain his condition. Which statement by the nurse best describes macular degeneration?

1)

“The portion of your eye called the macula, which is responsible for central vision, is damaged.”

2)

“Your lens became cloudy, causing your blurred vision. This cloudiness will increase over time.”

3)

“The pressure in the anterior cavity of your eye became elevated, shifting the position of your lens.”

4)

“There’s an irregular curvature of your cornea, causing your blurred vision.”

 

 

ANS:       1

Macular damage (degeneration) causes diminished central vision. Cataracts are caused by a cloudy lens and result in blurred vision. Glaucoma is pressure in the anterior cavity of the eye, which shifts the lens position. Astigmatism is irregular curvature of the cornea, resulting in blurred vision.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1072

KEY:   Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

 

 

 

____     10.   A patient who sustained a head injury in a motor vehicle accident has damage to the temporal lobe. This injury places the patient at risk for which type of hearing loss?

1)

Otosclerosis

2)

Conduction deafness

3)

Presbycusis

4)

Central deafness

 

 

ANS:       4

Central deafness results from damage to the auditory areas in the temporal lobes. Otosclerosis is hardening of the bones of the middle ear, especially the stapes. Conduction deafness results when one of the structures that transmits vibrations is affected. Presbycusis is a progressive sensorineural loss associated with aging.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1072

KEY:   Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application

 

 

 

____     11.   A patient comes to the clinic complaining of a taste disturbance. Which medication that the patient is currently prescribed is most likely responsible for this disturbance?

1)

Furosemide, a diuretic

2)

Phenytoin, an anticonvulsant

3)

Glyburide, an antidiabetic

4)

Heparin, an anticoagulant

 

 

ANS:       2

Phenytoin is a medication that has a high incidence of associated taste disturbance. Furosemide, glyburide, and heparin are not implicated in taste disturbances.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1073

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Application

 

 

 

____     12.   Which instruction should the nurse be certain to include when providing discharge teaching for a patient who has a serious visual deficit?

1)

Install blinking lights to alert an incoming phone call.

2)

Have gas appliances inspected regularly to detect gas leaks.

3)

Wear properly fitting shoes and socks.

4)

Avoid using throw rugs on the floors.

 

ANS:       4

The nurse should instruct the visually impaired patient to avoid using throw rugs on the floors at home. She should instruct the patient with a hearing deficit to install blinking lights to alert him to an incoming phone call. She should instruct the patient with an olfactory deficit to have gas appliances inspected regularly to detect leaks. The patient with a tactile deficit should be instructed to use properly fitting shoes and socks.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1084

KEY:   Nursing process: Planning | Client need: PHSI | Cognitive level: Application

 

 

 

____     13.   The nurse must irrigate the ear of a 4-year-old child. How should the nurse pull the pinna to straighten the child’s ear canal?

1)

Up and back

2)

Straight back

3)

Down and back

4)

Straight upward

 

 

ANS:       3

The nurse should straighten the ear canal of a small child by pulling the pinna down and back. To straighten the ear canal of an adult, the nurse should pull the pinna up and outward.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1086

KEY:   Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

 

 

 

____     14.   Which step should the nurse take first when performing otic irrigation in an adult?

1)

Warm the irrigation solution to room temperature.

2)

Position the patient so she is sitting with her head tilted away from the affected ear.

3)

Straighten the ear canal by pulling up and back on the pinna.

4)

Place the tip of the nozzle into the entrance of the ear canal.

 

 

ANS:       1

The nurse should warm the irrigation solution to room temperature first. Next, the nurse should assist the patient into a sitting position, with the head tilted away from the affected ear; straighten the ear canal by pulling up and back on the pinna; place the tip of the nozzle into the entrance of the ear canal; and direct the stream of irrigating solution gently along the top of the ear canal toward the back of the patient’s head. Then continue irrigating until the canal is clean.

 

PTS:    1                      DIF:    Easy                REF:    p. 1086

KEY:   Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis

 

 

 

____     15.   Which essential oil might the nurse trained in aromatherapy use to uplift and stimulate a patient?

1)

Lavender

2)

Roman chamomile

3)

Rosemary

4)

Ylang-ylang

 

 

ANS:       3

Rosemary is very stimulating and uplifting. Lavender, Roman chamomile, and Ylang-ylang are used to promote relaxation.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1073

KEY:   Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

 

 

 

____     16.   Which assessment finding is considered an age-related change?

1)

Presbycusis

2)

Hyperopia

3)

Increased sensitivity to touch

4)

Increased sensitivity to taste

 

 

ANS:       1

Presbycusis, the loss of high-frequency tones, is an age-related change. Hyperopia is the ability to see distant objects well; it is not an age-related change. The ability to perceive touch and taste diminishes with age; it does not increase.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1069, 1072

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

 

 

 

____     17.   After sustaining a stroke, the patient lacks attention to the right side of his body. Which nursing diagnosis best describes the patient’s problem?

1)

Disturbed Sensory Perception

2)

Unilateral Neglect

3)

Risk for Peripheral Vascular Dysfunction

4)

Acute Confusion

 

 

ANS:       2

This patient lacks attention to the right side of his body after sustaining a stroke; therefore, the most appropriate nursing diagnosis is Unilateral Neglect. The patient may also have Disturbed Sensory Perception, Risk for Peripheral Vascular Dysfunction, and Acute Confusion, but they are not the most appropriate for the defined problem.

 

PTS:    1                      DIF:    Difficult          REF:    p. 1079

KEY:   Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

 

 

 

____     18.   A patient is admitted with an exacerbation of asthma. Which factor places the patient at highest risk for sensory overload?

1)

Administering albuterol (a central nervous stimulant) as needed

2)

Administering a tranquilizer intravenously every 2 hours as prescribed

3)

Delivering oxygen at 6 L/min via nasal cannula

4)

Maintaining complete bedrest in a quiet, dimly lit room

 

 

ANS:       1

Medications that stimulate the central nervous system, such as albuterol, place the patient at risk for sensory overload. A tranquilizer and a quiet darkened room may help the patient to relax, thus preventing sensory overload. If the patient’s oxygen needs are met with oxygen at 6 L/min via nasal cannula, the patient should not experience sensory overload related to oxygen therapy alone.

 

PTS:    1                      DIF:    Difficult          REF:    p. 1071

KEY:   Nursing process: Interventions | Client need: SECE | Cognitive level: Application

 

 

 

____     19.   A patient complains of an impaired sense of smell. Which cranial nerve might have been affected?

1)

Trigeminal

2)

Glossopharyngeal

3)

Olfactory

4)

Vagus

 

 

ANS:       3

The olfactory nerve is responsible for the sense of smell. Damage to this nerve causes an impaired sense of smell. The trigeminal nerve transmits stimuli from the face and head. The glossopharyngeal nerve is responsible for taste. The vagus nerve is responsible for sensations of the throat, larynx, and thoracic and abdominal viscera.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1072

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

 

 

 

____     20.   Which intervention is helpful when caring for a patient with impaired vision?

1)

Suggest the patient use bright overhead lighting.

2)

Advise the patient to avoid wearing sunglasses when outdoors.

3)

Do not offer large-print books, as this may embarrass the patient.

4)

Place the patient’s eyeglasses within easy reach.

 

 

ANS:       4

The nurse should place the patient’s eyeglasses within easy reach and make sure that they are clean and in good repair. The patient should have sufficient light but avoid bright light, which might cause glare. The patient should be encouraged to wear sunglasses, visors, or hats with brims when outdoors. A magnifying lens or large-print books may be helpful.

 

PTS:    1          DIF:    Moderate         REF:    p. 1082

KEY:   Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

 

 

 

____     21.   A patient tells the nurse that since taking a medication he has suffered from excessively dry mouth. Which of the following assessments would be needed in order to plan interventions for that symptom?

1)

Asking the patient if foods taste different now

2)

Checking the patient’s sense of smell

3)

Having the patient stand to check for balance

4)

Assessing for a history of seizures

 

 

ANS:       1

Many medications cause xerostomia (dry mouth), and xerostomia is the most common cause of impaired taste. Impaired sense of smell also affects the sense of taste; however, there is no reason to assume impaired smell in this patient. Balance is related the inner ear and to kinesthetic sense, not to taste and xerostomia. Xerostomia would be related to seizures only if a patient experienced dry mouth as an aura; this would be unusual. Even if this were the case, the information would allow the nurse to plan care for seizures, but not for the symptom of dry mouth.

 

PTS:    1                      DIF:    Difficult          REF:    p. 1072

KEY:   Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

 

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____       1.   For a particular patient, it has become essential to minimize the risk of further damage to the auditory nerve. Which of the following medications may need to be discontinued if the patient is taking them? Choose all that are correct.

1)

Furosemide, a diuretic

2)

Digoxin, a cardiotonic

3)

Famotidine, an antacid

4)

Aspirin, an analgesic

 

 

ANS:   1, 4

Aspirin and furosemide may cause ototoxicity, leading to auditory nerve impairment. Digoxin and famotidine do not place the patient at risk for auditory nerve impairment.

 

PTS:    1                      DIF:    Difficult          REF:    p. 1070

KEY:   Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension

 

 

 

____       2.   Which factors in a health history place a patient at risk for hearing loss? Choose all that apply.

1)

Being an older adult

2)

Childhood chickenpox

3)

Frequent otitis media

4)

Diabetes mellitus

 

 

ANS:   1, 3

Having had frequent ear infections (otitis media) places a patient at risk for hearing loss because of scarring that may have occurred. Older adults experience a generalized decrease in the number of nerve conduction fibers and structural changes in the ear, which cause hearing loss. Chickenpox and diabetes mellitus do not place the patient at risk for hearing loss.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1072

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

 

 

 

____       3.   The nurse caring in the intensive care unit suspects that one of her patients is experiencing sensory overload. Which findings(s) has/have aroused her suspicion? Choose all that apply.

1)

Disorientation

2)

Restlessness

3)

Hallucinations

4)

Depression

 

 

ANS:   1, 2

The patient with sensory overload might exhibit disorientation, confusion, restlessness, decreased ability to perform tasks, anxiety, muscle tension, and muscle tension. Sensory deprivation causes irritability, confusion, depression, heart palpitations, hallucinations, and delusions.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1071

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

 

 

 

____       4.   Which action(s) can the nurse take to prevent sensory overload? Choose all that apply.

1)

Leave the television on to block out other noises.

2)

Minimize unnecessary light in the patient’s room.

3)

Plan care to provide uninterrupted periods of sleep.

4)

Speak calmly with a moderate voice volume.

 

 

ANS: 2, 3, 4

To prevent sensory overload, minimize unnecessary light, plan care to provide uninterrupted periods of sleep, and speak to the patient in a moderate tone of voice using a calm and confident manner. Television can be used to provide sensory stimuli, but not to prevent sensory overload. When used, it should not be left on indiscriminately.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1081

KEY:   Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

 

 

 

____       5.   For an unconscious patient, which of the following interventions are necessary to provide for patient safety? Choose all that apply.

1)

Talk to the patient as you provide care.

2)

Incorporate more touch in the plan of care.

3)

Give frequent eye care if blink reflex is absent.

4)

Keep the side rails up and bed in low position.

 

ANS:   3, 4

Safety measures are a priority for unconscious clients. Keep the bed in low position when you are not at the bedside, and keep the side rails up. If the patient’s blink reflex is absent or her eyes do not close totally, you may need to give frequent eye care to keep secretions from collecting along the lid margins. The eyes may be patched to prevent corneal drying, and lubricating eye drops may be ordered. It is important to talk to the patient because the sense of hearing may still be intact. This provides some stimulation and may help with reality orientation. Providing touch will also help prevent sensory deficit; however, it is not a safety measure.

 

PTS:    1                      DIF:    Difficult          REF:    p. 1085

KEY:   Nursing process: Interventions | Client need: PHSI | Cognitive level: Application