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Essentials for Nursing Practice 8th Edition by Patricia A. Potter – Test Bank 

 

 

Chapter 05: Legal Principles in Nursing

Potter: Essentials for Nursing Practice, 8th Edition

 

MULTIPLE CHOICE

 

  1. Which information indicates the nurse has an accurate understanding of the State Nurse Practice Act?
a. It is a federal senate bill.
b. It is a law enacted by the federal government.
c. It is a statute enacted by state legislature.
d. It is a judicial decision.

 

 

ANS:   C

Nurse Practice Acts are examples of statutes enacted by state legislatures to regulate the practice of nursing. Common laws are based on judicial decisions or case law precedent. An example of a judicial decision that guides health care practice is Roe v. Wade, but not the nurse practice act. An example of a federal statute that affects health care practice is the Americans with Disabilities Act, but not the nurse practice act. The nurse practice act is a state law, not a federal senate bill.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    63

OBJ:    Describe the legal obligations and role of nurses regarding federal and state laws that affect health care.            TOP:               Nursing Process: Evaluation

MSC:   NCLEX: Management of Care

 

  1. A student nurse must pass the NCLEX® before practicing as a registered nurse. NCLEX® stands for __________ Examination.
a. Nursing Council of Licensing
b. Nightingale Code of Licensure
c. Nursing Code of Licensure
d. National Council Licensure

 

 

ANS:   D

To be licensed in a state, a nurse must have a passing score on the National Council Licensure Examination (NCLEX) to obtain the initial license and meet the educational requirements set by the state. Nursing Council of Licensing, Nightingale Code, and Nursing Code examinations do not exist to practice as a nurse.

 

PTS:    1                      DIF:    Cognitive Level: Remembering (Knowledge)

REF:    63

OBJ:    Describe the legal obligations and role of nurses regarding federal and state laws that affect health care.            TOP:               Nursing Process: Assessment

MSC:   NCLEX: Management of Care

 

  1. A registered nurse was accused of patient abandonment when the nurse became angry, quit the job, and left the hospital before the end of the shift. This is an example of violating legal standards/guidelines set by which organization?
a. The State Department of Health
b. The Joint Commission
c. The State Board of Nursing
d. The National League for Nursing

 

 

ANS:   C

Nurse Practice Acts permit the State Board of Nursing to set rules, regulations, and guidelines that specifically define the standard of care in nursing practice. An example is the guidelines that define patient abandonment. The State Department of Health, the Joint Commission, and the National League for Nursing do not set the legal rules and regulations for patient abandonment.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    63

OBJ:    Explain the legal concepts of standard of care and informed consent.

TOP:    Nursing Process: Evaluation              MSC:   NCLEX: Management of Care

 

  1. An RN suffers from chronic back pain that was the result of an injury suffered when pulling a patient up in bed. The nurse is addicted to pain medication and has recently been accused of stealing narcotics. This is an example of which violation of the law?
a. Misdemeanor
b. Tort
c. Malpractice
d. Felony

 

 

ANS:   D

A felony is a serious offense that results in significant harm to another person or society in general. Felony crimes may carry penalties of monetary restitution, imprisonment for greater than 1 year, or death. Examples of Nurse Practice Act violations that may carry criminal penalties include practicing nursing without a license and misuse of controlled substances. A misdemeanor is a crime that, although injurious, does not inflict serious harm. Torts are civil wrongful acts or omissions against a person or a person’s property that are compensated by awarding monetary damages to the individual whose rights were violated. Malpractice is an example of negligence, sometimes referred to as professional negligence. The law defines nursing malpractice as the failure to use the degree of care that a reasonable nurse would use under the same or similar circumstances.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    63-64

OBJ:    Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer.            TOP:               Nursing Process: Evaluation

MSC:   NCLEX: Management of Care

 

  1. The nurse is caring for a patient who refuses to cooperate for a dressing change. The nurse tells the patient that he or she will tie the patient down if the patient does not hold still. Which action did the nurse commit?
a. Assault
b. Unintentional tort
c. Battery
d. Felony

 

 

ANS:   A

Assault is an intentional threat toward another person that gives that person a reasonable fear of harmful contact. No actual contact is required for an assault to occur. An example of an assault in nursing practice is to threaten to restrain a patient for an x-ray procedure when the patient has refused consent. Battery is intentional offensive touching without consent or lawful justification. Negligence is an unintentional tort. A felony is a serious offense that results in significant harm to another person or society in general, like misusing controlled substances.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    64

OBJ:    Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer.            TOP:               Nursing Process: Evaluation

MSC:   NCLEX: Management of Care

 

  1. Which chart entry by a nurse would require follow up?
a. 0815 Patient found on floor.
b. 0816 Patient assessed and helped back to bed.
c. 0818 Physician notified of incident.
d. 0820 Occurrence report completed.

 

 

ANS:   D

Do not document in the nurses’ notes that an occurrence report was completed. All the other entries are accurate. Objectively record the details of the event and any statements

the patient makes. At the time of the event, always assess the patient thoroughly, and then contact the health care provider to examine him or her.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    66                    OBJ:    Identify nursing interventions to improve patient safety.

TOP:    Nursing Process: Evaluation              MSC:   NCLEX: Management of Care

 

  1. To establish the elements of malpractice against a nurse, which must be proved by the patient?
a. The patient must have been harmed as a result of the injury.
b. The patient must have paid for the health care services.
c. The patient must show evidence of malicious intent.
d. The patient must demonstrate personal accountability.

 

 

ANS:   A

To establish the elements of malpractice, the patient or plaintiff must prove the following: (1) the nurse defendant owed a duty to the patient, (2) the nurse breached that duty, (3) the patient was injured because of the nurse’s breach of duty, and (4) the patient has accrued damages as a result of the injury. The patient paying, showing evidence of malicious intent, and demonstrating personal accountability are not elements of malpractice.

 

PTS:    1                      DIF:    Cognitive Level: Remembering (Knowledge)

REF:    64

OBJ:    Explain the concept of negligence and identify the elements of professional negligence.    TOP:    Nursing Process: Assessment

MSC:   NCLEX: Management of Care

 

  1. Which behavior is the best way for a nurse to avoid being liable for malpractice?
a. Purchasing quality malpractice insurance coverage on a yearly basis
b. Practicing nursing that meets the generally accepted standard of care
c. Not sharing his or her last name with patients and families
d. Not delegating any tasks to unlicensed assistive personnel

 

 

ANS:   B

The best way to avoid being liable for malpractice is to give nursing care that meets the generally accepted standard of care. In a malpractice lawsuit the law uses nursing standards of care to measure nursing conduct and determine whether the nurse acted as any reasonably prudent nurse would act under the same or similar circumstances. Purchasing insurance, not sharing last name, and not delegating tasks are not appropriate behaviors to avoid malpractice.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    64

OBJ:    Explain the concept of negligence and identify the elements of professional negligence.    TOP:    Nursing Process: Assessment

MSC:   NCLEX: Management of Care

 

  1. A nurse wants to follow nursing standards of care. Which document should the nurse follow?
a. World Health Organization guidelines
b. National League for Nursing brochure
c. Health care facility’s written procedure manual
d. Department of Health and Human Services guidelines

 

 

ANS:   C

The health care facility’s written procedure manual is defined as a standard of care. Standards of care are defined by the following: (1) State Nurse Practice Acts, (2) state and federal hospital licensing laws and accreditation rules, (3) professional and specialty organizations, and (4) written policies and procedures of the nurse’s health care facility. Brochures are not standards of care. World Health Organization and Department of Health and Human Services are not state or federal hospitals or professional and specialty organizations for nurses.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    64                    OBJ:    List sources for standards of care for nurses.

TOP:    Nursing Process: Evaluation              MSC:   NCLEX: Management of Care

 

  1. What is the nurse’s best proof against malpractice?
a. The nurse supervisor’s memory of the event
b. Recorded documentation written carelessly
c. The nurse’s memory of the event
d. Recorded documentation of nursing care

 

 

ANS:   D

Documentation of nursing care is the only record of what actually was done for a patient and will serve as proof that a nurse acted reasonably and safely. Nursing notes written at the time of the event, are seen as better evidence of the facts of the event than any one person’s memory. Nurses’ notes written carelessly and without regard to detail or hospital standards of documentation do not reflect well on the health care provider’s credibility or appearance of accountability to a judge or jury.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    66

OBJ:    Explain the concept of negligence and identify the elements of professional negligence.    TOP:    Nursing Process: Evaluation

MSC:   NCLEX: Management of Care

 

  1. A registered nurse is caring for a patient 2 days after a colon resection. The patient called for assistance to go to the bathroom. Instead of waiting for help, the patient decided to get up without help. The patient fell but was not injured. After contacting the patient’s primary health care provider, which action should the nurse take next?
a. Nothing; the patient was not injured.
b. Call the ethics committee.
c. Submit an incident report.
d. Insist that the patient have a radiograph done.

 

 

ANS:   C

When there is a deviation from the standard of care, such as a patient or visitor falls or an error is made, a nurse makes specific documentation of the event or incident in the form of an occurrence/incident report. The nurse should complete an occurrence report when anything unusual happens that could potentially cause harm to a patient, visitor, or employee. Just because the patient was not injured does not mean the report can be neglected. The health care provider orders follow-up care or treatment when necessary, not the nurse. The ethics committee is involved in ethical dilemmas, not occurrence/incident reports.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    66                    OBJ:    Identify nursing interventions to improve patient safety.

TOP:    Nursing Process: Implementation      MSC:   NCLEX: Management of Care

 

  1. A nurse completes an occurrence report. Which is the best way for the nurse to document this occurrence?
a. “Patient found lying on right side on floor. No noted injuries, patient stated, ‘I slipped on a wet spot on the floor. I don’t think I am injured.’”
b. “Patient slipped on a wet spot on the floor. No noted injuries, physician notified.”
c. “Patient in too much of a hurry and was walking too fast and fell. Was not injured. Patient instructed to slow down and not be in such a hurry. Health care provider notified.”
d. “Patient fell while going outside to smoke. Patient denied any injuries. Health care provider notified. Patient counseled.”

 

 

ANS:   A

Objectively record the details of the event and any statements the patient makes. An example is as follows: “Patient found lying on floor on right side. Abrasion on right forehead. Patient stated, ‘I fell and hit my head.’” Patient slipped on wet spot and patient fell while going outside should not be charted unless the nurse actually observed the event; otherwise, chart what found: Patient lying on floor. Patient in too much of a hurry includes subjective assumptions and statements; assigning blame or fault is inappropriate when completing the report.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    66                    OBJ:    Identify nursing interventions to improve patient safety.

TOP:    Nursing Process: Implementation      MSC:   NCLEX: Safety and Infection Control

 

  1. A clinic nurse stopped at an automobile accident to assist. There was one victim who was not breathing. The nurse provided CPR at the scene, but the victim died. The victim’s family sued the nurse. Which will provide the best protection to the nurse in this case?
a. Clinic’s malpractice insurance policy
b. Good Samaritan Law
c. State Board of Nursing
d. Institute of Medicine

 

 

ANS:   B

The Good Samaritan Law protects the nurse because CPR is within a nurse’s scope of practice. Although Good Samaritan Laws provide immunity to the nurse who does what is reasonable to save a person’s life, if the nurse performs a procedure for which he or she has no training, the nurse will be liable for any injury resulting from that act. Therefore, provide only care that is consistent with your level of expertise. The insurance policy, state boards of nursing, and Institute of Medicine do not provide protection to the nurse under the Good Samaritan Law.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    66

OBJ:    Describe the legal obligations and role of nurses regarding federal and state laws that affect health care.            TOP:               Nursing Process: Evaluation

MSC:   NCLEX: Management of Care

 

  1. Which patient would the nurse consider to be competent to give informed consent?
a. A 27-year-old unconscious patient
b. A 16-year-old emancipated minor
c. A 43-year-old patient who is drunk
d. A 33-year-old patient who has been declared legally incompetent

 

 

ANS:   B

Even though an emancipated minor has not achieved the legal age of consent, he or she may give consent for procedures and treatment. If a patient is unconscious, you need to obtain consent from a person legally authorized to give consent on his or her behalf. A patient who is legally incompetent needs to have the consent of a legal guardian, which is determined through a legal proceeding. A person who is drunk cannot fully understand the procedure and cannot sign the consent form.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    67-68

OBJ:    Explain the legal concepts of standard of care and informed consent.

TOP:    Nursing Process: Assessment             MSC:   NCLEX: Management of Care

 

  1. A patient is confused and is attempting to get out of the hospital bed. The nurse is tired after working for more than 10 hours and is concerned for the patient’s safety. What is the best action that the nurse should take to prevent the patient from harm?
a. Restrain the patient with wrist restraints.
b. Place the patient with a belt restraint in a chair.
c. Sedate the patient with medication.
d. Ask a family member to sit with the patient.

 

 

ANS:   D

Asking a family member to sit with the patient is the best answer because it does not restrain the patient physically or chemically. The Joint Commission has set guidelines for the use of restraints in hospitals. These regulations set the standard that all patients have the right to be free from seclusion and physical or chemical restraints except to ensure the patient’s safety in emergency situations. The standards specifically prohibit restraining patients for staff convenience, punishment, or retaliation.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    68                    OBJ:    List sources for standards of care for nurses.

TOP:    Nursing Process: Implementation      MSC:   NCLEX: Safety and Infection Control

 

  1. As part of the admission process the nurse asks if the patient has an advance directive. The patient doesn’t know for sure. What is the nurse’s best response?
a. It is autopsy permission.
b. It is a living will.
c. It is informed consent.
d. It is an organ donation card.

 

 

ANS:   B

Many times the decision regarding lifesaving treatment is in writing in the patient’s living will or advance directive. Living wills are documents instructing the health care provider to withhold or withdraw life-sustaining procedures in a patient who is terminally ill. Advanced directives are not an organ donation card, nor informed consent, nor autopsy permission.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    69

OBJ:    Describe the legal obligations and role of nurses regarding federal and state laws that affect health care.            TOP:               Nursing Process: Implementation

MSC:   NCLEX: Management of Care

 

  1. Which example demonstrates a breach of confidentiality and a violation of the Health Insurance Portability and Accountability Act (HIPAA) of 1996?
a. Giving a report to the oncoming nurse in a conference room
b. Discussing a patient’s diagnosis with the patient’s health care provider
c. Providing patient information to the nursing assistant caring for the patient
d. Sharing with other nurses in the cafeteria that a patient is HIV positive

 

 

ANS:   D

Although HIPAA does not require such things as soundproof rooms in hospitals, it does mandate that nurses and health care providers avoid discussing patients in public hallways and provide reasonable levels of privacy in communicating with and about patients in any matter. Issues of disclosure, privacy, and confidentiality are important concerns when working with patients or peers infected with blood-borne illnesses such as human immunodeficiency virus (HIV) or acquired immunodeficiency virus (AIDS), hepatitis, and sexually transmitted illnesses. Providing continuity of care, giving reports, talking to the health care provider, and providing information to the nursing assistant do not violate HIPAA.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    70

OBJ:    Describe the legal obligations and role of nurses regarding federal and state laws that affect health care.            TOP:               Nursing Process: Assessment

MSC:   NCLEX: Management of Care

 

  1. An RN has been caring for a patient. The nurse received an erroneous order for a medication. The primary health care provider has a reputation for impatience and irritability. Knowing this health care provider’s nature, which action by the nurse would be most appropriate?
a. Clarify the order with the pharmacy.
b. Ask the patient to remember.
c. Clarify the order with the primary health care provider.
d. Ask another nurse to look at the order to try to clarify it.

 

 

ANS:   C

A nurse will assess all physician or health care provider orders, and if the nurse determines they are erroneous or harmful, obtain clarification from that physician or health care provider. Calling pharmacy, asking the patient, and asking another nurse are not the best ways to handle erroneous orders.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    70

OBJ:    Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer.            TOP:               Nursing Process: Implementation

MSC:   NCLEX: Management of Care

 

  1. Which task can a nurse safely delegate to a student nurse who is working as a nursing assistant?
a. Distributing medications to patients
b. Administering insulin injections
c. Collecting intake and output data
d. Assessing patients

 

 

ANS:   C

During the time when a student nurse works as an employee of a health care facility, perform only tasks that appear in a job description for a nurse’s aide or nursing assistant. For example, even if a student nurse has learned how to administer intramuscular medications, do not perform this task as a nurse’s aide.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    71

OBJ:    Describe the legal obligations and role of nurses regarding federal and state laws that affect health care.            TOP:               Nursing Process: Assessment

MSC:   NCLEX: Management of Care

 

  1. Only one nurse was scheduled to care for 12 postsurgical patients with a nursing assistant. The nurse is concerned for the safety of the patients and the nursing license. What is the most appropriate first step in this situation?
a. Contacting the nursing supervisor and documenting the action
b. Refusing to care for the patients without appropriate help and leaving
c. Contacting the State Board of Nursing and documenting the action
d. Contacting the hospital administrator on call to complain and documenting the action

 

 

ANS:   A

If a nurse is assigned to care for more patients than is reasonable for safe care, he or she should notify the nursing supervisor. If the nurse is required to accept the assignment, he or she must document this information in writing and provide the document to nursing administrators. Although documentation does not relieve a nurse of responsibility if patients suffer harm because of inattention, it shows that the nurse attempted to act appropriately. Refusing to care for the patients without appropriate help and leaving could be regarded as abandonment. Complaining to the administrator is not the first step, nor is calling the Board of Nursing.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    71

OBJ:    Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer.            TOP:               Nursing Process: Implementation

MSC:   NCLEX: Management of Care

 

  1. A patient died from suspicious circumstances. What should the nurse do next?
a. Notify the coroner.
b. Notify the newspaper.
c. Chart what the nurse thinks happened.
d. Chart opinions from the health care staff.

 

 

ANS:   A

State statutes specify that, when there are reasonable grounds to believe that a patient died as a result of violence, homicide, suicide, accident, or death occurring in any unusual or suspicious manner, you need to notify the coroner. Notifying the newspaper would break confidentiality. Charting must be objective and factual, not what the nurse thinks happened or opinions.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    69

OBJ:    Describe the legal obligations and role of nurses regarding federal and state laws that affect health care.            TOP:               Nursing Process: Implementation

MSC:   NCLEX: Management of Care

 

  1. A patient falls out of bed because the nurse did not raise the side rails. Which action did the nurse commit?
a. Felony
b. Assault
c. Battery
d. Negligence

 

 

ANS:   D

Negligence is conduct that falls below the generally accepted standard of care of a reasonably prudent person. A felony is a serious offense that has a penalty of imprisonment for greater than a year or possibly even death such as practicing nursing without a license. Assault is any intentional threat to bring about harmful or offensive contact with another individual. Battery is any intentional touching without consent.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    64

OBJ:    Explain the concept of negligence and identify the elements of professional negligence.    TOP:    Nursing Process: Assessment

MSC:   NCLEX: Safety and Infection Control

 

  1. Which situation will enable a nurse to use restraints?
a. To punish a patient
b. To ensure the patient’s safety
c. To retaliate against poor behavior
d. To ensure staff convenience

 

 

ANS:   B

Regulations set the standard that all patients have the right to be free from seclusion and physical or chemical restraints except to ensure the patient’s safety in emergency situations. The standards specifically prohibit restraining patients for staff convenience, punishment, or retaliation.

 

PTS:    1                      DIF:    Cognitive Level: Remembering (Knowledge)

REF:    68

OBJ:    Explain the legal concepts of standard of care and informed consent.

TOP:    Nursing Process: Assessment             MSC:   NCLEX: Safety and Infection Control

 

  1. Which information indicates the nurse has an accurate understanding of when the institution’s malpractice insurance covers the nurse?
a. While driving to work
b. While driving home from work
c. While tending to people in the neighborhood
d. While working within the scope of employment

 

 

ANS:   D

If a nurse works for a health care institution, generally the institution’s insurance will cover the nurse during employment. Malpractice insurance usually provides nurses with an attorney, payment of those fees, and payment of any judgment or settlement if a patient sues a nurse for medical malpractice. If a nurse provides care on a voluntary basis outside the health care facility, hospital-provided malpractice insurance would not cover the nurse. The nurse will need to carry additional insurance. Driving to and from work is not malpractice.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    65

OBJ:    Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer.            TOP:               Nursing Process: Evaluation

MSC:   NCLEX: Management of Care

 

  1. When a nurse suspects child abuse or neglect, which action must the nurse take?
a. Report it to the proper legal authority.
b. Inform the parents that their actions are illegal.
c. Call the security department to handle the problem.
d. Prevent the parents from seeing the child during hospitalization.

 

 

ANS:   A

Health care providers are required to report incidents such as child, spousal, or elder abuse; rape; gunshot wounds; attempted suicide; and certain communicable diseases. Health care providers are provided legal immunity if the report is made in good faith. Not reporting suspected child abuse or neglect can cause a nurse to be liable in civil or criminal legal actions. It is not the nurse’s responsibility to inform the parents of illegal activity or to prevent the parents from seeing the child. The nurse is responsible for reporting the suspected abuse, not call security to handle the problem.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    72

OBJ:    Describe the legal obligations and role of nurses regarding federal and state laws that affect health care.            TOP:               Nursing Process: Implementation

MSC:   NCLEX: Management of Care

 

  1. A nurse is maintaining precise records regarding the dispensing, wasting, and storage of a drug that is securely locked. Which drug is the nurse administering?
a. Routine medication
b. Controlled substance
c. Over-the-counter medication
d. Substance not requiring an order

 

 

ANS:   B

Controlled substances are securely locked away, and only authorized personnel have access to them. Maintain precise records regarding the dispensing, wasting, and storage of controlled substances. There are criminal penalties for the misuse of controlled substances. Routine and over-the-counter drugs are not controlled substances. Controlled substances required an order by a licensed physician or in some states advanced practice nurses.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    72

OBJ:    Describe the legal obligations and role of nurses regarding federal and state laws that affect health care.            TOP:               Nursing Process: Implementation

MSC:   NCLEX: Pharmacological and Parenteral Therapies

 

  1. Which action is the nurse required by law to perform when a patient is admitted?
a. Notify the family.
b. Notify the attorney.
c. Ask how payment will be made.
d. Ask about advance directives.

 

 

ANS:   D

The Patient Self-Determination Act (1991) requires health care institutions to inquire whether a patient has created an advance directive, give patients information on advance directives, and document whether a patient states that he or she has an advance directive. Notifying the family and attorney is breaking confidentiality. Asking how payment will be made is not required by law and is not the responsibility of the nurse.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    69

OBJ:    Describe the legal obligations and role of nurses regarding federal and state laws that affect health care.            TOP:               Nursing Process: Implementation

MSC:   NCLEX: Management of Care

 

  1. A nurse must ask a family member to consider an organ donation. In which order should the nurse contact the individuals?
  2. Spouse
  3. Parent
  4. Guardian
  5. Grandparent
  6. Adult son or daughter
  7. Adult brother or sister
a. a, c, e, f, b, d
b. a, e, f, b, d, c
c. a, e, b, f, d, c
d. a, b, e, f, d, c

 

 

ANS:   C

You approach individuals in the following order to consider organ or tissue donations: (1) spouse, (2) adult son or daughter, (3) parent, (4) adult brother or sister, (5) grandparent, and (6) guardian.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    69

OBJ:    Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer.            TOP:               Nursing Process: Implementation

MSC:   NCLEX: Management of Care

 

MULTIPLE RESPONSE

 

  1. A nurse is about to administer a medication and notices that the physician’s or primary health care provider’s order looks incorrect regarding the amount of the medication. What should the nurse do? (Select all that apply.)
a. Notify the physician or health care provider.
b. Do not carry out the order.
c. Document the suspicion that the dosage is incorrect.
d. Administer the medication.
e. Notify the supervisor or nurse manager.

 

 

ANS:   A, B, E

Nurses are responsible for carrying out medical treatment unless the physician’s or health care provider’s order is in error, violates hospital policy, or is harmful to the patient. Therefore it is imperative to assess all orders and, if they appear to be erroneous or harmful to the patient, to obtain further clarification from the physician or health care provider. Do not carry out the order if there is a risk that harm will come to your patient; therefore do not administer the medication. Inform the nurse manager or the nursing supervisor. The nurse does not document suspicions or opinions, just objective, factual information.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    70-71               OBJ:    List sources for standards of care for nurses.

TOP:    Nursing Process: Implementation

MSC:   NCLEX: Pharmacological and Parenteral Therapies

 

  1. A nurse wants to follow the American Nurses Association’s Social Media Policy (2011). Which actions should the nurse take? (Select all that apply.)
a. Never name or describe a patient.
b. Never have a blog.
c. Never post an image of the patient.
d. Never disparage a fellow employee.
e. Never report breaches of privacy.

 

 

ANS:   A, C, D

The American Nurses Association has developed a Social Media Policy (2011), which recommends that when using social media sites, a nurse should never name or describe a patient, never post an image of a patient, and never disparage a fellow employee or employer. In addition, the professional nurse has an obligation to report breaches of privacy and confidentiality. Never having a blog is not a recommendation.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    70

OBJ:    Explain the legal concepts of standard of care and informed consent.

TOP:    Nursing Process: Implementation      MSC:   NCLEX: Management of Care

Chapter 21: Spiritual Health

Potter: Essentials for Nursing Practice, 8th Edition

 

MULTIPLE CHOICE

 

  1. An elderly patient is dying, and begins talking to loved ones who have died before him. The nurse feels a sense of inner peace as his patient quietly dies. What is the best term for this feeling of peace?
a. Self-transcendence
b. Intrapersonal connectedness
c. Interpersonal connectedness
d. Transpersonal connectedness

 

 

ANS:   A

Self-transcendence refers to connecting to your inner self, which allows you to go beyond yourself to understand the meanings of experiences, whereas transcendence is the belief that there is a positive force outside of and greater than oneself that allows you to develop new perspectives that are beyond physical boundaries. Examples of transcendent moments include the feelings of awe when holding a new baby or watching the sun rise over the mountains. Spirituality offers a sense of connectedness intrapersonally (connected with oneself), interpersonally (connected with others and the environment), and transpersonally (connected with God, the unseen, or a higher power).

 

PTS:    1                      DIF:    Cognitive Level: Remembering (Knowledge)

REF:    548

OBJ:    Describe the relationship among faith, hope, and spiritual well-being.

TOP:    Nursing Process: Assessment             MSC:   NCLEX: Psychosocial Integrity

 

  1. The nurse is caring for a patient who states that he does not believe in the existence of God. The nurse realizes that this person:
a. is not a spiritual person.
b. is an agnostic.
c. believes that people bring meaning into the world.
d. finds meaning in life through work and relationships.

 

 

ANS:   D

Atheists search for meaning in life through their work and relationships with others. Spirituality exists in all people regardless of their religious beliefs and it gives people the energy needed to maintain health and cope with difficult situations. Spirituality is an important concept for individuals who either do not believe in the existence of God (atheist) or who believe that any ultimate reality is unknown or unknowable (agnostic). It is important for agnostics to discover meaning in what they do or how they live because they find no ultimate meaning for the way things are. They believe that we, as people, bring meaning to what we do.

 

PTS:    1                      DIF:    Cognitive Level: Understanding (Comprehension)

REF:    549

OBJ:    Describe the relationship among faith, hope, and spiritual well-being.

TOP:    Nursing Process: Diagnosis                MSC:   NCLEX: Psychosocial Integrity

 

  1. A nurse is caring for a patient with a debilitating chronic illness. The patient mentions several times that faith would guide her healing. The nurse knows that faith can best be defined as a:
a. system of organized beliefs and worship.
b. relationship with a higher power, authority, or spirit.
c. source of energy needed to cope with difficult situations.
d. multidimensional concept that gives comfort while a person endures hardship.

 

 

ANS:   B

Faith is a relationship with a divinity, higher power, authority, or spirit that incorporates a reasoning faith (belief) and a trusting faith (action). Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality. Spirituality exists in all people regardless of their religious beliefs and it gives people the energy needed to maintain health and cope with difficult situations. Hope is multidimensional and gives comfort while a person endures hardship and personal challenges.

 

PTS:    1                      DIF:    Cognitive Level: Remembering (Knowledge)

REF:    549

OBJ:    Describe the relationship among faith, hope, and spiritual well-being.

TOP:    Nursing Process: Assessment             MSC:   NCLEX: Psychosocial Integrity

 

  1. A patient has been diagnosed with a terminal disease. Hope may be used effectively with this type of patient. Nurses can support a patient’s use of hope because hope provides a:
a. system of organized beliefs and worship.
b. belief in a higher power, spirit guide, God, or Allah.
c. cultural connectedness, structure, and guidance in difficult times.
d. motivation to achieve and the resources to use toward that achievement.

 

 

ANS:   D

Hope is energizing, giving individuals a motivation to achieve and the resources to use toward that achievement. Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality. Faith involves a belief in a higher power, spirit guide, God, or Allah. Spirituality offers a sense of connectedness. Spirituality is unique for each person. It is a unifying theme in life and a state of being.

 

PTS:    1                      DIF:    Cognitive Level: Remembering (Knowledge)

REF:    550

OBJ:    Describe the relationship among faith, hope, and spiritual well-being.

TOP:    Nursing Process: Assessment             MSC:   NCLEX: Psychosocial Integrity

 

  1. When caring for patients, a nurse must understand the difference between religion and spirituality. Religious care helps patients maintain their faithfulness to:
a. their belief systems and worship practices.
b. a relationship to a higher being or life force.
c. a sense of connectedness.
d. the awareness of one’s inner self.

 

 

ANS:   A

Religious care helps patients follow their belief systems and worship practices. Spirituality is an awareness of one’s inner self and a sense of connection to a higher being, nature, or some purpose greater than oneself. Spirituality offers a sense of connectedness. Spirituality is unique for each person. It is a unifying theme in life and a state of being.

 

PTS:    1                      DIF:    Cognitive Level: Remembering (Knowledge)

REF:    550                  OBJ:    Compare and contrast the concepts of religion and spirituality.

TOP:    Nursing Process: Assessment             MSC:   NCLEX: Psychosocial Integrity

 

  1. A patient who has been diagnosed with terminal liver cancer states that he does not believe in God, but he has had a meaningful life by contributing to the lives of those around him. This person is most likely which of the following?
a. Buddhist
b. Christian
c. Agnostic
d. Atheist

 

 

ANS:   D

Atheists search for meaning in life through their work and relationships with others. It is important for agnostics to discover meaning in what they do or how they live because they find no ultimate meaning for the way things are. They believe that we, as people, bring meaning to what we do. A Buddhist turns inward, valuing self-control, whereas a Christian looks to the love of God to provide enlightenment and direction in life.

 

PTS:    1                      DIF:    Cognitive Level: Remembering (Knowledge)

REF:    549                  OBJ:    Compare and contrast the concepts of religion and spirituality.

TOP:    Nursing Process: Assessment             MSC:   NCLEX: Psychosocial Integrity

 

  1. A nurse is caring for a 64-year-old patient who has survived cardiopulmonary resuscitation after a triple coronary artery bypass graft surgery. To help this patient cope with this experience, what is the best thing for the nurse to do?
a. Recommend that the patient not discuss the experience with family.
b. Assume that the near death experience was a positive experience.
c. Explain that people who have not had that experience will not understand.
d. Explore what happened with the patient.

 

 

ANS:   D

After patients have survived a near death experience (NDE), promote spiritual well-being by remaining open, giving patients a chance to explore what happened, and supporting patients as they share the experience with significant others. Patients who have an NDE are often reluctant to discuss it, thinking family or caregivers will not understand. Isolation and depression often occur. Furthermore, not all NDEs are positive experiences. However, individuals experiencing an NDE who discuss it openly with family or caregivers find acceptance and meaning from this powerful experience.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    552

OBJ:    Discuss the relationship of spirituality to an individual’s total being.

TOP:    Nursing Process: Implementation      MSC:   NCLEX: Psychosocial Integrity

 

  1. A nurse who works in a neonatal intensive care unit is caring for a critically ill infant with a poor prognosis. She is Christian and feels responsible to care for both the physical and spiritual needs of the infant and his parents. What is the best statement for the nurse to make to the parents of the infant?
a. “You should have the child baptized so that its soul will be saved.”
b. “Would you like me to call the chaplain to christen your child at the bedside?”
c. “What can I do to support your spiritual needs?”
d. “I have asked my pastor to stop by and talk to you.”

 

 

ANS:   C

Differentiate your personal spirituality from that of the patient. Your role is not to solve the spiritual problems of patients, but to provide an environment for your patients to express their spirituality. Having the child baptized or asking your pastor to come talk to the patient is applying your spiritual values on the patient. Asking permission to call the chaplain is assuming that the patient has value regarding that religious denomination.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    552

OBJ:    Discuss the relationship of spirituality to an individual’s total being.

TOP:    Nursing Process: Implementation      MSC:   NCLEX: Psychosocial Integrity

 

  1. A patient refuses to remove a specific spiritual garment for daily bathing. The most appropriate action for the nurse would be to:
a. remove the article anyway because the garment hinders daily care delivery.
b. respect the patient’s wishes and work around it.
c. explain to the patient that the garment has no real spiritual value.
d. identify the refusal as a sign of spiritual distress.

 

 

ANS:   B

To care for and meet the spiritual needs of your patients, it is essential to respect each patient’s personal beliefs. People experience the world and find meaning in life in different ways and the spiritual garment has meaning for the patient. Caring for your patients’ spiritual needs requires you to be compassionate and remove any personal biases or misconceptions. You need to recognize that not all patients have spiritual problems. Patients bring certain spiritual resources that help them assume healthier lives, recover from illness, or face impending death.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    554

OBJ:    Discuss the relationship of spirituality to an individual’s total being.

TOP:    Nursing Process: Implementation      MSC:   NCLEX: Psychosocial Integrity

 

  1. To assess, evaluate, and support a patient’s spirituality the best action a nurse should take includes:
a. recognizing that spirituality does not enhance therapeutic relationships.
b. performing a definitive spiritual assessment once because spirituality does not vary.
c. focusing the assessment on religious doctrine and faith.
d. remembering that spirituality is very subjective.

 

 

ANS:   D

Remember that spirituality is very subjective and has different meanings for different people. You are able to gather an accurate assessment of your patients’ spirituality when you take time to build therapeutic relationships with them. Conduct an ongoing spiritual assessment the entire time you care for a patient. Focus your assessment on aspects of spirituality most likely to be influenced by life experiences, events, and questions in the case of illness and hospitalization.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    554                  OBJ:    Compare and contrast the concepts of religion and spirituality.

TOP:    Nursing Process: Implementation      MSC:   NCLEX: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. Interventions a nurse can use to establish presence with a patient include which of the following? (Select all that apply.)
a. Giving attention
b. Answering questions
c. Listening
d. Administering medication
e. Speaking with the family

 

 

ANS:   A, B, C

Behaviors that establish your presence include giving attention, answering questions, listening, and having a positive and encouraging (but realistic) attitude. Presence is part of the art of nursing that involves “being with” a patient versus “doing for” a patient, as in administering medication and speaking with the family. Presence is being able to offer closeness with the patient, which helps to prevent emotional and environmental isolation.

 

PTS:    1                      DIF:    Cognitive Level: Understanding (Comprehension)

REF:    561                  OBJ:    Establish presence with patients.

TOP:    Nursing Process: Diagnosis                MSC:   NCLEX: Psychosocial Integrity

Chapter 31: Sleep

Potter: Essentials for Nursing Practice, 8th Edition

 

MULTIPLE CHOICE

 

  1. A college student who is working in northern Alaska during the summer reports that he or she has an increase in difficulty sleeping since moving north. During a pre-employment physical, the patient asks the health care provider what could be causing this. The health care provider suspects the sleep disturbance is most likely because of which factor?
a. Stress of the new job
b. Increased daylight hours in Northern Alaska
c. Physical demands of the new job
d. Change in diet

 

 

ANS:   B

Northern Alaska has extended daylight hours. Light and temperature affect all circadian rhythms, including the sleep-wake cycle. The most familiar rhythm is the 24-hour, day-night cycle known as the diurnal or circadian rhythm. When the sleep-wake cycle becomes disrupted (e. g., by working rotating shifts), other physiological functions change as well. Stress of the new job, physical demands of the new job, and a change in diet are not the issues. The patient stated that the difficulty started when he or she moved north.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    847

OBJ:    Explain the effect the 24-hour sleep-wake cycle has on biological function.

TOP:    Nursing Process: Assessment             MSC:   Client Needs: Physiological Integrity

 

  1. The health care provider is seeing a 16-year-old boy at the local clinic. The guardian is concerned about the patient’s lack of sleep. The guardian states that the patient “goes to school, works at a part-time job until 10 PM, and then stays up doing homework until after midnight. I am worried that he is not getting enough sleep.” What is the best response for the health care provider to give the patient and his guardian?
a. “I don’t get enough sleep either; I spend most of my time studying.”
b. “You need to discuss this with the primary health care provider.”
c. “Sleep deprivation can cause a person to get sick or have excessive daytime sleepiness.”
d. “High school is a tough time in life, but I’m sure he will be fine.”

 

 

ANS:   C

Adolescents need between 8 and 9 hours of sleep each night; however, the typical teenager gets about 7 hours of sleep per night. At a time when sleep needs actually increase, the typical adolescent is subject to a number of changes that often reduce the time spent sleeping, such as the time when school starts, after-school social events, part-time jobs, and extracurricular activities. The shortened sleep time in adolescents often results in excessive daytime sleepiness (EDS), which can reduce performance in school, increase risk of accidents, increase the use of alcohol, and lead to behavior and mood problems. Sleep deprivation affects immune functioning, metabolism, nitrogen balance, protein catabolism, and quality of life. Saying, “I don’t get enough sleep either” or “You need to discuss this with the primary health care provider” is not focusing on the guardian’s question. Saying the boy “will be fine” is false reassurance.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    849

OBJ:    Compare and contrast the characteristics of sleep for different age groups.

TOP:    Nursing Process: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. During a sleep study test, the patient states, “I never dreams anymore.” The health care provider tells the patient that everyone dreams, but most people forget about them upon awakening. The health care provider tells the patient that the best way to remember dreams is to do which of the following?
a. Eat spicy food before going to sleep.
b. Avoid caffeine in the afternoon.
c. Consciously think about the dreams upon awakening.
d. Become more creative.

 

 

ANS:   C

To remember a dream, a person must consciously think about it on awakening. People who recall dreams vividly usually awaken just after a period of rapid eye movement (REM) sleep. Personality influences the quality of dreams; for example, a creative person may have very vivid, unusual dreams, whereas a depressed person may have dreams of helplessness. Eating a large, heavy, and/or spicy meal within 3 to 4 hours of bedtime sometimes results in indigestion that interferes with sleep. Alcohol consumed in the evening has insomnia-producing and diuretic effects. Coffee, tea, cola, and chocolate contain caffeine and xanthines that cause sleeplessness as a result of central nervous system stimulation. Avoiding caffeine and becoming more creative do not increase a person’s memory for dreams.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    849                  OBJ:    Describe the normal stages of sleep.

TOP:    Nursing Process: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. A new mother has brought in her week-old infant to the health care provider for a 1-week well-baby checkup. She is breastfeeding and has only been sleeping a couple of hours at a time during the night between feedings. She asks the nurse, “When can I expect the baby to sleep through the night?” What is the nurse’s best response?
a. “Are you feeling tired, maybe you are experiencing depression.”
b. “Most children begin to sleep through the night around 3 months.”
c. “Most children begin to sleep through the night around 6 months.”
d. “Are you feeling tired? Maybe you are anemic?”

 

 

ANS:   B

Infants usually develop a nighttime pattern of sleep by 3 months of age. The neonate and infant up to the age of 3 months average about 16 hours of sleep a day. A symptom of anemia or depression is fatigue, but this does not focus on the question the new mother asked about the baby sleeping.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    849

OBJ:    Compare and contrast the characteristics of sleep for different age groups.

TOP:    Nursing Process: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. A 6-year-old girl is being seen at the clinic for a well-child checkup. The guardian tells the nurse that the child is having difficulty getting to sleep at night and asks for suggestions. What is the nurse’s best response?
a. “You should play an active game with her like basketball to wear her out.”
b. “It would be a good idea to save homework until right before bedtime.”
c. “Quiet activities like reading sometimes help to settle down children her age.”
d. “Try to delay dinner time until later to help make her sleepy.”

 

 

ANS:   C

A 6-year-old child averages 11 to 12 hours of sleep nightly. Encouraging quiet activities usually persuades the 6- or 7-year-old child to go to bed. Playing an active game, doing homework right before bed, and delaying dinner are not quiet activities.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    849

OBJ:    Discuss differences in sleep interventions for patients of different age groups.

TOP:    Nursing Process: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. A 67-year-old farmer is at the clinic because he has been sleepy during the day. Which sleep change occurs with age?
a. Older adults spend more time in stage 3.
b. Older adults spend more time in REM sleep.
c. Older adults spend more time in falling asleep.
d. Older adults spend more time in deep sleep.

 

 

ANS:   C

Older adults awaken more often during the night, and it takes more time for them to fall asleep. To compensate they increase the number of naps taken during the day. Older adults spend more time in stage 1 and have less stages 3 and 4 NREM sleep; some older adults have almost no NREM stage 4 or deep sleep. Episodes of REM sleep tend to shorten, and there is less deep sleep and more lighter sleep.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    850

OBJ:    Compare and contrast the characteristics of sleep for different age groups.

TOP:    Nursing Process: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. A 73-year-old patient reports to the nurse about waking up early and not being able to return to sleep. The patient states, “I do not go to bed until after the evening news.” What is the best advice for the nurse to give this patient to encourage a good night’s sleep?
a. Take a nap in the afternoon.
b. Go to bed earlier.
c. Go to bed later.
d. Take a benzodiazepine.

 

 

ANS:   B

Older patients become sleepier in the early evening (going to bed when the body is naturally sleepy is beneficial) and wake earlier in the morning, but still require the necessary 7 to 8 hours of sleep a day. Going to bed later would not be beneficial. Research indicates that exercise is beneficial, particularly for older adults, to improve nighttime sleep. General recommendations include increasing daytime activity or exercise, not taking a nap. The use of benzodiazepines in the older adult population is potentially dangerous. Long-term use and high doses in this population have been associated with suicidal ideation.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    850 | 851 | 854

OBJ:    Discuss differences in sleep interventions for patients of different age groups.

TOP:    Nursing Process: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. The nurse manager for a busy medical unit in an acute care hospital noticed a trend of complaints regarding the restful environment of the unit in the patient satisfaction reports. At the staff meeting, this issue was discussed with the staff, and they decide that the best thing to do is which of the following?
a. Administer sleeping medications at 2200 hours.
b. Cluster nursing activities at night.
c. Turn off all alarms after 2200.
d. Keep lights on in the main hallway for safety reasons.

 

 

ANS:   B

A challenge in the hospital is controlling noise. Because many patients spend only a short time in hospitals, it is easy to forget the importance of establishing good sleep conditions.

In the hospital setting, plan nursing care activities to avoid awakening patients. Try to schedule assessments, treatments, procedures, and routines for times when patients are awake. Perform nursing activities before the patient receives sleeping medication or begins to fall asleep. For example, you have a patient who has had surgery. Before the patient gets ready for bed, change the surgical dressing, reposition the patient, administer pain medication, and check vital signs (clustering nursing activities). Turning alarms off is a violation of safety protocols in most hospitals because of patient safety concerns. Lights on in the hallway can cause distraction to sleep patterns. Regular use of any sleep medication leads to tolerance, and withdrawal causes rebound insomnia.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    852                  OBJ:    Identify factors that promote or disrupt sleep.

TOP:    Nursing Process: Planning

MSC:   Client Needs: Safe and Effective Care Environment

 

  1. A 57-year-old patient is concerned about the inability to fall/stay asleep at night. This started about 3 months ago. The nurse asks about recent changes in lifestyle and activities of daily living. Which of the following changes is probably most responsible for the change in sleeping pattern?
a. Changing to a later evening mealtime
b. Using blackout blinds
c. Exercising 3 hours before bed time
d. Buying a new support mattress

 

 

ANS:   A

Alterations in routine that disrupt sleep patterns include performing unaccustomed heavy work or exercise, engaging in late-night social activities, and changing evening mealtime. Eating a large, heavy, and/or spicy meal within 3 to 4 hours of bedtime sometimes results in indigestion that interferes with sleep. The physical environment in which a person sleeps has a significant influence on the ability to fall and remain asleep. Exercising 2 or more hours (patient exercised 3 hours) before bedtime allows time for the body to cool and maintain a state of fatigue that promotes relaxation. A new support mattress will promote relaxation and sleep. Proper ventilation, a comfortable temperature, and a darkened (blackout blinds) or softly lit room are essential for restful sleep.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    852                  OBJ:    Identify factors that promote or disrupt sleep.

TOP:    Nursing Process: Assessment             MSC:   Client Needs: Physiological Integrity

 

  1. When visiting the clinic, a nurse takes the patient’s sleep history and notes the appearance of a deviated septum. The nurse knows that this structural abnormality predisposes the patient to which condition?
a. Narcolepsy
b. Cataplexy
c. Obstructive sleep apnea
d. Insomnia

 

 

ANS:   C

Structural abnormalities such as a deviated septum, nasal polyps, narrow lower jaw, or enlarged tonsils sometimes predispose a patient to obstructive sleep apnea. Insomnia is a symptom rather than the name of a disease and is common among patients suffering from depression. It is experienced by patients who have chronic difficulty falling asleep, frequent awakenings from sleep, and/or a sleep or a nonrestorative sleep. Narcolepsy is a rare central nervous system dysfunction of mechanisms that regulate sleep and wake states; during the day a person suddenly feels an overwhelming wave of sleepiness and falls asleep. Cataplexy is a sudden muscle weakness during intense emotions such as anger or laughter that occurs at any time during the day.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    852-854           OBJ:    Discuss characteristics of common sleep disorders.

TOP:    Nursing Process: Assessment             MSC:   Client Needs: Physiological Integrity

 

  1. A primary health care provider has diagnosed the patient with having a parasomnia. The patient asks the nurse to explain what that means. What is the best explanation?
a. A person is unable to breathe and sleep at the same time.
b. It is a sleep disorder that produces abnormal sleep movements.
c. It is a rare dysfunction of the mechanism that regulates sleep and wake states.
d. It is a sudden muscle weakness occuring during intense emotions.

 

 

ANS:   B

The parasomnias are sleep disorders that can occur during arousal from REM or partial arousal from NREM sleep. They include sleep walking, night terrors, nightmares, teeth grinding, and bed-wetting. Narcolepsy is a rare central nervous system dysfunction of mechanisms that regulate sleep and wake states. Excessive daytime sleepiness is the most common complaint associated with narcolepsy. Cataplexy is a sudden muscle weakness during intense emotions such as anger or laughter that occurs at any time during the day. If the cataplectic attack is severe, the patient loses voluntary muscle control and falls to the floor. Sleep apnea is a disorder in which the individual is unable to breathe and sleep at the same time.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    854                  OBJ:    Discuss characteristics of common sleep disorders.

TOP:    Nursing Process: Implementation      MSC:   Client Needs: Physiological Integrity

 

  1. Which of the following data are most important to assess if a patient is receiving sufficient sleep?
a. Hours of sleep each night
b. Sleep-wake pattern
c. Whether the patient feels rested
d. Number of times the patient awakens during sleep

 

 

ANS:   C

Because sleep is a subjective experience, only the patient is able to report whether it is sufficient and restful. Patients are your best resource for describing a sleep problem and any change from their usual sleep and waking patterns. Number of hours of sleep, sleep-wake pattern, and number times awakes while sleeping are not the most important to assess to determine effectiveness of the patient’s sleep, the subjective experience of the patient is the most important.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    855                  OBJ:    Conduct a sleep history.

TOP:    Nursing Process: Assessment             MSC:   Client Needs: Physiological Integrity

 

  1. A primary health care provider prescribes eszopiclone (Lunesta) for a patient. Which classification of drug will the nurse be administering to the patient?
a. Benzodiazepine
b. Melatonin agonist
c. L-tryptophan antagonist
d. Nonbenzodiazepine, benzodiazepine receptor agonist

 

 

ANS:   D

The nonbenzodiazepine, benzodiazepine receptor agonists are newer medications that appear to have better safety profiles and fewer adverse effects than the benzodiazepines. They are also associated with a lower risk of abuse and dependence than the benzodiazepines, although abuse and dependence do occur. Examples of medications in this class include zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta). Benzodiazepines are a common classification of drug used to treat sleep problems when a change in sleep hygiene is not effective. Examples of benzodiazepines include temazepam (Restoril), flurazepam (Dalmane), estazolam (ProSom), and triazolam (Halcion). A new class of drugs called melatonin agonists promotes the onset of sleep by increasing levels of the natural hormone melatonin, which helps normalize circadian rhythm and sleep-wake cycles. Ramelteon (Rozerem) belongs to this drug class. There is no such classification as L-tryptophan antagonist. L-tryptophan is thought to promote sleep.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    863

OBJ:    Describe interventions appropriate to promoting sleep for patients with various sleep disorders.     TOP:            Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity

 

  1. A nurse is admitting a patient to the hospital. The patient admits to a history of sleep problem. Which of the following questions will help the nurse understand the severity of the patient’s sleep problem?
a. “How long does it take you to fall asleep?”
b. “Tell me why you think you have a sleep problem.”
c. “Have you been told that you snore loudly?”
d. “When did you notice the problem?”

 

 

ANS:   A

Severity questions include: How long does it take you to fall asleep? How often during the week do you have trouble falling asleep or staying asleep? Nature of the problem question includes: Tell me what type of problem you have with your sleep. Signs and symptoms question includes: Have you been told that you snore loudly? Onset and duration question includes: When did you notice the problem?

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    856                  OBJ:    Conduct a sleep history.

TOP:    Nursing Process: Assessment             MSC:   Client Needs: Physiological Integrity

 

  1. A patient recently came to the clinic with complaints of having difficulty sleeping. After the primary health care provider assesses the patient the nurse instructs the patient and partner on how to keep a sleep-wake diary. Entries in the diary often include _____ of sleep-wake activities.
a. 24 hours
b. 72 hours
c. 1 to 2 weeks
d. 7 to 9 hours

 

 

ANS:   A

Entries in the diary often include 24-hour information on waking and sleeping activities such as exercise, work activities, mealtimes, and alcohol and caffeine intake. They should also include time and length of daytime naps, evening and bed routines, the time the patient tries to fall asleep, time and number of awakenings, and the time of morning awakening. 72 and 1 to 2 weeks are too long, whereas 7 to 9 hours is not long enough.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    856                  OBJ:    Conduct a sleep history.

TOP:    Nursing Process: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. A 45-year-old obese patient has been scheduled for cardiac bypass surgery. The nurse who is preparing the patient for surgery asks, “Do you have a history of sleep apnea?” This is important to know before surgery because patients with sleep apnea:
a. are prone to snore after surgery and require a private room.
b. who receive general anesthesia have a greater risk for airway obstruction.
c. generally need additional pain medication.
d. usually require sleep aids to provide more restful sleep.

 

 

ANS:   B

If a patient is scheduled for surgery, be sure to ask about a history of sleep apnea. Patients with sleep apnea who receive general anesthesia and pain medications after surgery have increased risk for developing airway obstruction during recovery. A private room is not necessary. Sleep apnea does not require a patient to need additional pain medication or sleep aids after surgery.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    857                  OBJ:    Conduct a sleep history.

TOP:    Nursing Process: Assessment             MSC:   Client Needs: Physiological Integrity

 

  1. A nurse is caring for an elderly patient with a sleeping disorder. When formulating a care plan for this patient it was determined that the goal will be that “the patient establishes a healthy sleep pattern.” Which of the following is the best example of a measurable outcome to meet this goal?
a. The patient will fall asleep more easily.
b. The patient will sleep longer throughout the night.
c. The patient will have less than two awakenings throughout the night.
d. The patient will wake up more refreshed in the morning.

 

 

ANS:   C

Outcomes serve as measurable guidelines to determine goal achievement. “Less than two awakenings” is a measurable goal. The other responses are subjective (more easily, sleep longer, more refreshed) and do not have a measurable outcome.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    858                  OBJ:    Describe ways to evaluate the effectiveness of sleep therapies.

TOP:    Nursing Process: Evaluation              MSC:   Client Needs: Physiological Integrity

 

  1. The long-term care facility nurse is assessing the patient’s sleep environment for safety. Which finding will cause the nurse to intervene as it is an unsafe situation for the patient?
a. A small night light left on in the bedroom
b. All clutter removed between the bed and the bathroom
c. Bed in high position with side rails up
d. Call bell at the bedside for the patient to alert family members

 

 

ANS:   C

A bed in high position with side rails up is a safety hazard. Safety precautions are important for patients who awaken during the night to use the bathroom and for those with excessive daytime sleepiness. Set beds lower to the floor to lessen the chance of the patient falling when first standing. Remove clutter, and move equipment from the path a patient uses to walk from the bed to the bathroom. If patient needs assistance in ambulating from the bed to the bathroom, make sure the call light is within the patient’s reach. The call light helps alert the nursing staff, not the family. A small night light is beneficial to help with vision

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    861

OBJ:    Discuss differences in sleep interventions for patients of different age groups.

TOP:    Nursing Process: Evaluation

MSC:   Client Needs: Safe and Effective Care Environment

 

  1. A patient has been hospitalized with pneumonia. The patient has had some difficulty sleeping while in the hospital. The patient would like to avoid taking medication for sleep because there have been problems with sleeping pills in the past. Which action by the nursing assistant personnel will cause the nurse to intervene?
a. Encouraging the patient to void before bedtime
b. Offering to give the patient a backrub
c. Giving the patient an extra blanket when cold
d. Providing a warm cup of hot cocoa before bedtime

 

 

ANS:   D

Coffee, tea, cola, and chocolate cause a person to stay awake or awaken throughout the night. Promote comfort by encouraging the patient to wear loose-fitting nightwear, void before bedtime, give a relaxing back rub, and offer an extra blanket to prevent chilling when trying to fall asleep.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    861-863

OBJ:    Describe interventions appropriate to promoting sleep for patients with various sleep disorders.     TOP:            Nursing Process: Implementation

MSC:   Client Needs: Safe and Effective Care Environment

 

  1. While making night shift rounds, the nursing assistive personnel become concerned when a patient stops breathing from 1 to 2 minutes several times during the shift. The nurse informs the nursing assistive personnel that this condition is known as which of the following?
a. Cataplexy
b. Insomnia
c. Narcolepsy
d. Sleep apnea

 

 

ANS:   D

Sleep apnea is a disorder in which the individual is unable to breathe and sleep at the same time and has periods of apnea throughout the night. Cataplexy is a sudden muscle weakness during intense emotions such as anger or laughter that occurs at any time during the day. Insomnias are primary disorders related to difficulty falling asleep. Narcolepsy is a central nervous system dysfunction of mechanisms that regulate sleep and wake states.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    852-854           OBJ:    Discuss characteristics of common sleep disorders.

TOP:    Nursing Process: Implementation      MSC:   Client Needs: Physiological Integrity

 

  1. An older adult widow reports having problems sleeping at night and states, “I miss my spouse.” The nurse also recognizes that older patients:
a. are difficult to assess.
b. take less time to fall asleep.
c. may suffer from emotional stress or depressive mood problems.
d. require less sleep than middle-age adults.

 

 

ANS:   C

The elderly frequently experience losses, such as retirement and death of a loved one, which may lead to emotional stress or depressive mood problems that affect sleep efficacy. Older adults have a harder time falling asleep and more trouble staying asleep than do young adults. Sleep studies on older adults show a decline in REM sleep and an increase in nighttime awakenings. It is a common misconception that sleep needs decrease with aging. Older adults still need 7 to 8 hours of sleep a day, just like middle-aged adults. Older adults are not more difficult to assess.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    857

OBJ:    Compare and contrast the characteristics of sleep for different age groups.

TOP:    Nursing Process: Evaluation              MSC:   Client Needs: Physiological Integrity

 

  1. A 2-year-old child in the pediatric unit resists going to sleep. To promote sleep, which is the best action for the nurse to take?
a. Eliminate a daytime nap.
b. Offer the child warm chocolate milk.
c. Maintain the child’s home bedtime routine.
d. Allow the child to sleep longer in the morning.

 

 

ANS:   C

A bedtime routine (e.g., same hour for bedtime or quiet activity) used consistently helps toddlers and preschool children avoid delaying sleep. Parents need to reinforce patterns of preparing for bedtime. Reading stories, allowing children to sit in a parent’s lap while listening to music or praying, and coloring are routines associated with preparing for bed. Toddlers still need naps. Sleeping longer will continue to disrupt the normal routine. Chocolate can cause a person to stay awake or wake up throughout the night.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    861-862

OBJ:    Discuss differences in sleep interventions for patients of different age groups.

TOP:    Nursing Process: Implementation      MSC:   Client Needs: Physiological Integrity

 

  1. A patient’s vital signs are significantly lower than normal while sleeping. The nurse understands this to be a normal finding when the patient is in what stage of the sleep cycle?
a. 1
b. 2
c. 3
d. 4

 

 

ANS:   D

Vital signs are significantly lower in stage 4 sleep than during waking hours. During stage 1, a gradual fall in vital signs and metabolism begins; during stage 2, body functions continue to slow; during stage 3, vital signs decline but remain regular. During stage 4, vital signs significantly lower. A healthy adult’s normal heart rate throughout the day averages 70 to 80 beats per minute. However, during sleep the heart rate normally falls to 60 beats per minute or less, thus preserving cardiac function. Other biological functions decreased during sleep are respirations, blood pressure, and muscle tone.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    848                  OBJ:    Describe the normal stages of sleep.

TOP:    Nursing Process: Assessment             MSC:   Client Needs: Physiological Integrity

 

  1. The nurse encourages a postoperative patient to get adequate amounts of sleep after discharge from the health care facility. When the patient asks why, how should the nurse respond?
a. Sleep restores biological processes.
b. Sleep stimulates appetite on waking.
c. Sleep causes a mental and physiological calm.
d. Sleep produces dreams that decrease epinephrine.

 

 

ANS:   A

Because the patient is postoperative, the primary reason for sleep it to help the body to heal by restoring biological processes. Sleep allows the body to restore biological processes. During deep slow-wave (NREM stage 4) sleep, the body releases human growth hormone for the repair and renewal of epithelial and specialized cells such as brain cells. Protein synthesis and cell division for the renewal of tissues also occur during rest and sleep. The basal metabolic rate is lowered during sleep, which conserves the body’s energy supply. REM sleep is important for cognitive restoration. During REM sleep patients experience rapid eye movement, fluctuation in heart and respiratory rate, increased/fluctuating blood pressure, loss of skeletal muscle tone, and increase in gastric secretions. (This is not a mental and physical calm.) During REM sleep there is increased oxygen consumption and epinephrine is released, not decreased. Sleep does not cause an increase in appetite as the metabolic rate slows down.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    849                  OBJ:    Explain the functions of sleep.

TOP:    Nursing Process: Implementation      MSC:   Client Needs: Physiological Integrity

 

  1. A patient asks the nurse to explain how sleep occurs. The nurse explains to the patient that the physiology of sleep is a complex process. However, in simple terms, what is the nurse’s best response?
a. Circadian sleep rhythm controls sleep.
b. Sleep occurs when a person’s basal metabolic rate falls.
c. Sleep is a dreaming process.
d. Interrelated mechanisms of the brain control wake and sleep cycles.

 

 

ANS:   D

The major sleep center in the body is the hypothalamus. The suprachiasmatic nucleus (SCN) nerve cells in the hypothalamus control the rhythm of the sleep-wake cycle and coordinate this cycle with other circadian rhythms. Researchers believe that the ascending reticular activating system located in the upper brainstem contains special cells that maintain alertness and wakefulness. Circadian rhythms influence the 24-hour pattern of major biological and behavioral functions such as the predictable changing of body temperature, heart rate, blood pressure, hormone secretion, sensory acuity, and mood. Sleep causes the basal metabolic rate to fall; falling of the metabolic rate does not cause sleep. Normal sleep involves two phases: nonrapid eye movement (NREM) sleep and rapid eye movement (REM) sleep.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    847 | 848         OBJ:    Discuss mechanisms that regulate sleep.

TOP:    Nursing Process: Implementation      MSC:   Client Needs: Physiological Integrity

 

  1. Which of the following bedtime snack(s) helps to promote sleep in a patient?
a. Cereal and milk
b. A full meal
c. Chips and cola
d. Coffee and toast

 

 

ANS:   A

A bedtime snack containing protein and carbohydrates such as cereal and milk or cheese and crackers, which contain L-tryptophan, may help to promote sleep. A full meal before bedtime often causes gastrointestinal upset and interferes with the ability to fall asleep. Coffee, tea, cola, and chocolate cause a person to stay awake or wake up throughout the night.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    863                  OBJ:    Identify factors that promote or disrupt sleep.

TOP:    Nursing Process: Implementation      MSC:   Client Needs: Physiological Integrity

 

  1. A patient arrives at the ambulatory clinic for a routine physical. The nurse inquires about the patient’s sleep pattern. The patient has a history of sleep pattern disturbances. The nurse evaluates that the patient is sleeping better when he or she states which of the following?
a. “I don’t take melatonin as frequently.”
b. “I increased my alcohol consumption before bedtime.”
c. “I decreased my activity level.”
d. “I take more daytime power naps.”

 

 

ANS:   A

Melatonin is a neurohormone produced in the brain that helps control circadian rhythms. It is a popular nutritional supplement in the United States used to aid sleep. The recommended dose is 0.3 to 1 mg taken 2 hours before bedtime. Alcohol interrupts sleep cycles and reduces the amount of deep sleep. Early morning and late afternoon napping interferes with sleeping. Exercise is beneficial to improve nighttime sleep.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    863                  OBJ:    Describe ways to evaluate the effectiveness of sleep therapies.

TOP:    Nursing Process: Evaluation              MSC:   Client Needs: Physiological Integrity

 

  1. A patient has returned from back surgery. The family has brought in the patient’s continuous positive airway pressure (CPAP) machine. What is the best rationale for allowing the patient to use the CPAP machine at night?
a. It will keep the patient in deep levels of REM, which will decrease the need for pain medication.
b. It will help decrease hospital noise that will keep the patient awake.
c. The patient needs ventilator support owing to the increased chance of postoperative respiratory complications.
d. The patient needs to follow the same bedtime routine to promote a safe environment for sleep.

 

 

ANS:   C

These patients need ventilator support in the postoperative period because obstructive sleep apnea is linked to increased postoperative respiratory complications. After surgery the patient achieves very deep levels of REM sleep that lead to muscle relaxation and airway obstruction. In these patients the anesthesia in combination with pain medications used after surgery reduces the patient’s defenses against airway obstruction. Make sure that patients use their home CPAP equipment. Use pain medication carefully in these patients. Promoting the home bedtime routine is beneficial, but that is not the primary reason for using the CPAP; it is to prevent complications from surgery.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    864

OBJ:    Describe interventions appropriate to promoting sleep for patients with various sleep disorders.     TOP:            Nursing Process: Evaluation

MSC:   Client Needs: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. A nurse is caring for a patient who suffers from a sleep pattern disturbance. To promote adequate sleep, what are the most appropriate nursing interventions? (Select all that apply.)
a. Straighten and change any soiled bed linens.
b. Synchronize the medication, treatment, and vital signs schedule.
c. Provide personal hygiene before bedtime.
d. Discuss with the patient the benefits of beginning a long-term nighttime medication regimen.
e. Assist the patient to use the toilet before bed.

 

 

ANS:   A, B, C, E

You will make the patient more comfortable in an acute care setting by providing personal hygiene before bedtime. A warm bath or shower is very relaxing. Offer patients restricted to bed the opportunity to wash their face and hands. Tooth brushing and care of dentures also help to prepare the patient for sleep. Have patients void before going to bed so they are not kept awake by a full bladder. While a patient prepares for bed, help to position the patient off any potential pressure sites. Offering a back rub or massage helps relax the patient. Removal of irritating stimuli is another way to improve the patient’s comfort for a restful sleep. Diaphoretic patients will benefit from a cool bath and dry clothes or linens. Perform nursing activities before the patient receives sleeping medications or begins to fall asleep. Long-term nighttime medication regimen can lead to abuse and dependence and is to be avoided.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    864 | 865

OBJ:    Describe interventions appropriate to promoting sleep for patients with various sleep disorders.     TOP:            Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity

 

  1. A nurse has been temporarily assigned to the night shift. A change in this circadian rhythm may cause which of the following? (Select all that apply.)
a. Anxiety
b. Weight gain
c. Decreased appetite
d. Increased periods of sleep
e. Impaired judgment

 

 

ANS:   A, C, E

When the sleep-wake cycle becomes disrupted (e.g., by working rotating shifts), other physiological functions change as well. For example, a new nurse who starts working the night shift experiences a decreased appetite and loses weight, not weight gain. Anxiety, restlessness, irritability, and impaired judgment are other common symptoms of sleep cycle disturbances. Decreased, not increased, periods of sleep can occur. Failure to maintain an individual’s usual sleep-wake cycle negatively influences the person’s overall health.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    847

OBJ:    Explain the effect the 24-hour sleep-wake cycle has on biological function.

TOP:    Nursing Process: Assessment             MSC:   Client Needs: Physiological Integrity

 

  1. The nurse is triaging a patient for an annual check-up with the health care provider. When questioned about changes in sleep habits the patient replies, “Since my spouse passed away last month, I have not been sleeping well at all.” What are the most appropriate interventions for the nurse to make? (Select all that apply.)
a. Speaking to the health care provider for a benzodiazepine sleeping aid
b. Contacting a pastoral care professional
c. Consulting with a psychiatric clinical nurse specialist
d. Consulting with a clinical psychologist
e. Referring the patient for evaluation to the sleep clinic

 

 

ANS:   B, C, D

The nature of a sleep disturbance determines whether referrals to additional health care providers are necessary. For example, if a sleep problem is related to a situational crisis or emotional problem, refer the patient to a psychiatric clinical nurse specialist, pastoral care professional or clinical psychologist for counseling. When chronic insomnia is the problem, a medical referral or referral to a sleep center is beneficial. Benzodiazepine can lead to tolerance, abuse, and dependence.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    860

OBJ:    Describe interventions appropriate to promoting sleep for patients with various sleep disorders.     TOP:            Nursing Process: Implementation

MSC:   Client Needs: Psychosocial Integrity