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Fundamentals Nursing Care Skills 2nd Edition By Ludwig Burton – Test Bank 

 

Chapter 1. The Vista of Nursing

 

Multiple Choice

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

 

____    1.   The nurse is educating a nursing student about nursing history. The nurse teaches the nursing student that throughout ancient history, nursing care was provided by family members and

A. Nurses.
B. Physicians.
C. Male priests.
D. Female priests.

 

 

____    2.   The nurse teaches a student nurse about the history of nursing. The nurse informs the student nurse that in 1836, the first school of nursing was established in Kaiserworth, Germany by

A. Jean Watson.
B. Clara Barton.
C. Theodore Fliedner.
D. Florence Nightingale.

 

 

____    3.   The nurse educates the student nurse that in 1897, the Nurses Associated Alumnae of the United States was formed in an effort to

A. Set standards and rules in nursing education.
B. Keep nurses aware of the newest medical information.
C. Oversee training to protect patients from incompetent nurses.
D. Keep nurses updated on the newest information about nursing education.

 

 

____    4.   A nursing instructor is a member of the National League for Nursing. The purpose of this professional organization is to

A. Set standards and rules in nursing education.
B. Keep nurses aware of the newest medical information.
C. Oversee training to protect patients from incompetent nurses.
D. Keep nurses updated on the newest information about nursing education.

 

 

____    5.   The nursing instructor teaches a group of nursing students that all states required practical nurses to be licensed in the year

A. 1940.
B. 1945.
C. 1950.
D. 1955.

 

 

____    6.   The nursing instructor teaches a class of student nurses that the title Licensed Practical Nurse, or LPN, is used in all states except California and

A. Texas.
B. Maine.
C. Alaska.
D. Arizona.

 

 

____    7.   The student nurse recognizes that the National Council Licensure Examination for practical nursing is

A. Taken in order to practice as a nurse.
B. Given as an entrance exam for nursing school.
C. Individualized based on where an examinee resides.
D. Taken in order to practice as a certified nursing assistant (CNA).

 

 

____    8.   The nurse recruiter interviews new graduate nurses for a staff nurse position. The nurse recruiter is seeking a graduate nurse who has been educated more extensively on management and leadership. The graduate nurse who most likely fits this description is the

A. Diploma nurse.
B. Associate degree nurse.
C. Licensed vocational nurse.
D. Baccalaureate degree nurse.

 

 

____    9.   A nursing instructor is educating a group of student nurses about the Nurse Practice Act. The nursing instructor teaches that

A. The Nurse Practice Act clarifies who can supervise a physician.
B. The Nurse Practice Act is the law that governs the actions of nurses.
C. The Nurse Practice Act is determined by the National League of Nursing.
D. The Nurse Practice Act specifies the tasks of the unlicensed assistive personnel.

 

 

____  10.   The nurse educates a nursing student about the Nurse Practice Act. The nursing student demonstrates understanding when stating,

A. “The Nurse Practice Act is the same in every state.”
B. “The Nurse Practice Act does not specify who can supervise a nurse.”
C. “The Nurse Practice Act is determined by the American Nurses Association.”
D. “The Nurse Practice Act establishes the scope of practice for each level of nurse.”

 

 

____  11.   While caring for a patient, the nurse performs a nursing action that is not within her scope of practice. The nurse has violated the

A. Ethics Committee.
B. Nurse Practice Act.
C. State Department of Health.
D. National League for Nursing.

 

 

____  12.   A nurse administers the wrong medication to a patient. The nurse has violated the Nurse Practice Act which is enforced by the

A. State Board of Nursing.
B. County Health Department.
C. State Department of Health.
D. National League for Nursing.

 

 

____  13.   The nurse is caring for a resident in a long-term setting. The nurse best demonstrates a caring approach when

A. Performing all activities of daily living for the resident.
B. Asking the resident’s spouse to bring a family picture for the resident’s room.
C. Answering the resident’s questions quickly without allowing time for clarification.
D. Encouraging the resident’s spouse to decide which activities the resident should do.

 

 

____  14.   The nurse is caring for five patients on a psychiatric unit. The nurse best demonstrates a caring approach when

A. Providing identical care to each patient.
B. Individualizing care provided to each patient.
C. Viewing the patients in terms of a cellular disorder.
D. Viewing the patients as mentally ill and needing a cure.

 

 

____  15.   The nurse is educating a student nurse about the responsibilities of a student nurse. The nurse recognizes that additional teaching is needed when the student nurse states,

A. “I will check lab results on my patients often.”
B. “I am responsible for noting abnormal assessment findings.”
C. “I will frequently check the patient’s chart for diagnostic test results.”
D. “It is not within my scope of practice to notify someone of abnormal findings.”

 

 

____  16.   The nursing instructor teaches a student nurse about the importance of joining a professional organization. The nursing instructor recognizes that further instruction is necessary when the student nurse states,

A. “Professional organizations allow me to have a collective voice.”
B. “Professional organizations limit my ability to influence laws and policies.”
C. “Professional behavior is demonstrated by joining a professional organization.”
D. “By joining a professional organization, I will have opportunities for leadership.”

 

 

____  17.   The nursing instructor educates a class of nursing students about Florence Nightingale. The nursing instructor teaches that Florence Nightingale was

A. The founder of contemporary nurse’s notes.
B. A provider of nursing care during the Crimean War.
C. The first president of what is known today as the American Red Cross.
D. Known as the “Angel of the Battlefield” during the United States Civil War.

 

 

____  18.   A student nurse is learning about nursing history. The student nurse recognizes that Lillian Wald is best described as

A. Instrumental in providing nursing care during the Crimean War.
B. The first visiting nurse, who opened the Henry Street Settlement.
C. Instrumental in establishing a 3-year training program for nurses.
D. The first president of what is known today as the American Red Cross.

 

 

____  19.   A student nurse is learning about women who molded nursing history. The student nurse recognizes that Mary Mahoney is best described as

A. The first visiting nurse who opened the Henry Street Settlement.
B. The first president of the National Association for Colored Graduate Nurses.
C. An activist for nursing labor reform who advocated for meal breaks for nurses.
D. An activist for better mental health care and the establishment of psychiatric hospitals.

 

 

____  20.   The nurse works in a hospital that provides care based on the nursing theory of Martha Rogers. The nurse recognizes that this theory is based on the goal of

A. Assisting clients to attain total self-care.
B. Providing nursing care that is culturally diverse.
C. Maintaining an environment free of negative energy.
D. Recognizing one’s pattern of interacting with the environment.

 

 

____  21.   A nursing student is learning about the nursing theory of Margaret Newman. The nursing student recognizes that this theory is based on the goal of

A. Assisting clients to attain total self-care.
B. Providing nursing care that is culturally diverse.
C. Maintaining an environment free of negative energy.
D. Recognizing one’s pattern of interacting with the environment.

 

 

____  22.   A nurse works in a facility that promotes assisting clients to attain total self-care. The nurse recognizes this approach as adhering to the ideas of nursing theorist

A. Martha Rogers.
B. Dorothea Orem.
C. Virginia Henderson.
D. Hildegard E. Peplau.

 

 

____  23.   When caring for a patient, a nurse maintains an environment that is free of negative energy. The nurse is demonstrating care based on nursing theorist

A. Imogene King.
B. Betty Neuman.
C. Martha Rogers.
D. Sister Callista Roy.

 

 

____  24.   A student nurse is learning about nursing theorists. Based on this learning, the student nurse writes a care plan focused on providing culturally diverse care. The student nurse is adopting the approach of nursing theorist

A. Myra Levine.
B. Dorothea Orem.
C. Sister Callista Roy.
D. Madeleine M. Leininger.

 

 

Multiple Response

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

 

____    1.   A nursing instructor teaches about the importance of professional behavior. The instructor provides examples of unprofessional conduct that could lead to having a nursing license revoked or suspended. Examples of unprofessional conduct are (select all that apply):

A. Consistently showing up for work on time.
B. Failure to adhere to the Nurse Practice Act.
C. Documenting patient care in a timely manner.
D. Diversion of drugs from prescribed patient to personal use.
E. Use of drugs or alcohol in a way that could endanger patients.
F. Failure to supervise nursing assistants and unlicensed assistive personnel.

Chapter 2. Health Care Delivery and Economics

 

Multiple Choice

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

 

____    1.   The federal government’s health insurance program for people older than 65 years of age or those with certain disabilities or conditions is known as

A. Medicaid.
B. Medicare.
C. Social Security.
D. Private insurance.

 

 

____    2.   The nurse recognizes that a system of health care delivery aimed at managing the cost and quality of access to health care is known as

A. Medicaid.
B. Medicare.
C. Managed care.
D. Private insurance.

 

 

____    3.   The student nurse is caring for a patient who will be transferred to a skilled nursing facility (SNF). When educating the student nurse about an SNF, the nurse recognizes that further instruction is needed when the student nurse states,

A. “Medicare will most likely pay for my patient’s care at the SNF.”
B. “I hope that my patient gets to return home after going to the SNF.”
C. “My patient will never get to go home again if he’s transferred to an SNF.”
D. “My patient will receive skilled nursing care such as physical therapy as needed.”

 

 

____    4.   The student nurse is caring for a patient who will be transferred to a skilled nursing facility (SNF). When collaborating with the case manager about transferring the patient to an SNF, the case manager tells the student that the SNF will most likely be covered by Medicare if

A. The patient stays longer than 100 days per year.
B. The patient enters the SNF within 60 days of a hospitalization.
C. The patient has been hospitalized for at least 1 day prior to admission.
D. The patient makes regular progress as documented by the medical professionals.

 

 

____    5.   A student nurse is caring for a patient at a rehabilitation facility. The student nurse educates the patient about the rehabilitation facility. The nurse intervenes when the student states,

A. “You will receive intense therapy services while you’re here.”
B. “You must participate in at least 6 hours of therapy each day.”
C. “You will be seen by a physician who specializes in rehabilitation.”
D. “If you get sick while you’re here, we can transfer you to the hospital.”

 

 

____    6.   A patient is considering moving to an assisted-living facility. When providing education about an assisted-living facility, the nurse states,

A. “An assisted-living facility provides a home-like atmosphere.”
B. “An assisted-living facility provides a hospital-like atmosphere.”
C. “Your physician will make daily visits while you’re at an assisted-living facility.”
D. “You should move to an assisted-living facility when you’re no longer independent.”

 

 

____    7.   A nursing instructor is teaching a group of nursing students about which communicable diseases should be reported to the health department. The nursing instructor recognizes that further instruction is needed when a nursing student states,

A. “Syphilis should be reported to the health department.”
B. “Hepatitis should be reported to the health department.”
C. “Influenza should be reported to the health department.”
D. “Emphysema should be reported to the health department.”

 

 

____    8.   When working in a health clinic, the nurse recognizes that a communicable disease that should be reported to the health department is

A. Gonorrhea.
B. Grave’s disease.
C. Diabetes mellitus.
D. Cushing’s syndrome.

 

 

____    9.   The home health care nurse delegates to the home health care aide the responsibility of

A. Administering tap water enemas until clear.
B. Transporting the patient to the physician’s office.
C. Teaching the patient how to turn, cough, and deep breathe.
D. Administering nitroglycerin when the patient experiences angina.

 

 

____  10.   When supervising a home health care aide, the nurse intervenes when observing the home health care aide

A. Giving the patient a back massage.
B. Preparing the patient’s favorite meal.
C. Transporting the patient to the grocery store.
D. Teaching the patient how to check his or her apical pulse.

 

 

____  11.   When supervising a home health care aide, the nurse intervenes when observing the home health care aide

A. Braiding a patient’s hair.
B. Driving a patient to church.
C. Giving a patient a bed bath.
D. Teaching a patient about nutrition.

 

 

____  12.   A hospice nurse provides an in-service about the purpose of hospice to a group of nursing students. The hospice nurse tells the students that the National Hospice Organization defines hospice as a

A. Nurse-directed physician-coordinated program.
B. Medically directed nurse-coordinated program.
C. Nurse-directed psychiatrist-coordinated program.
D. Medically directed psychologist-coordinated program.

 

 

____  13.   A patient’s spouse asks the nurse about hospice. The nurse educates that hospice is

A. A service that provides care to the terminally ill patient only.
B. Warranted when the patient still seeks a cure for his or her terminal illness.
C. A program that focuses on palliative treatment and emotional support.
D. Appropriate when the patient is expected to live for fewer than 9 months.

 

 

____  14.   The nurse is supervising a certified nursing assistant (CNA). The nurse intervenes when the CNA asks a patient,

A. “What is your pain level?”
B. “Would you like a snack?”
C. “When would you like your bath?”
D. “Is it okay if I take your vital signs?”

 

 

____  15.   A nursing instructor educates a group of nursing students about client-centered care. The nursing instructor recognizes that further teaching is needed when a nursing student states,

A. “Client-centered care fosters a feeling of dependence.”
B. “Client-centered care is often seen in a rehabilitation setting.”
C. “Client-centered care empowers the patient to manage his or her care.”
D. “Client-centered care empowers the patient to take control of his or her care.”

 

 

____  16.   A nurse demonstrates understanding of client-centered care when

A. Managing every aspect of the patient’s care.
B. Performing as many tasks as possible for the patient.
C. Performing all activities of daily living for the patient.
D. Limiting the patient’s decision making to alleviate anxiety.

 

 

____  17.   A nurse is working in a critical care unit where the focus is on primary-care nursing. The nurse demonstrates understanding of primary-care nursing when

A. Asking the unlicensed assistant to give a bed bath.
B. Asking another nurse to call the physician for orders.
C. Providing all aspects of nursing care for assigned patients.
D. Instructing the nursing assistant to take the patient’s vital signs.

 

 

____  18.   A nursing instructor is educating a group of nursing students about primary-care nursing. The nursing instructor teaches that in primary-care nursing

A. A nursing assistant is assigned to give baths to each patient on the unit.
B. Each patient has a nursing assistant to assist with feeding and linen changes.
C. One nurse is responsible for all aspects of nursing care for an assigned patient.
D. Two nurses are responsible for all aspects of nursing care for an assigned patient.

 

 

____  19.   A nurse is educating a student nurse about primary-care nursing. The nurse recognizes that additional teaching is warranted when the student nurse states,

A. “In primary-care nursing, the nurse must be able to work quickly under stress.”
B. “In primary-care nursing, the nurse must be able to work efficiently in a crisis.”
C. “In primary-care nursing, the nurse must be able to assess the patient carefully.”
D. “In primary-care nursing, the nurse must supervise the nursing assistants closely.”

 

 

____  20.   The student nurse is caring for a patient who is covered by Medicaid. When speaking with the case manager about Medicaid, the case manager tells the student nurse that Medicaid

A. Offers the same benefits in every state.
B. Is funded by the city health department.
C. Is a county government matching funding program.
D. Offers assistance to pregnant impoverished women.

 

 

____  21.   A case manager is giving an in-service about public health insurance to a group of nursing students. The case manager recognizes that additional instruction is warranted when a nursing student states,

A. “Aetna is an example of public health insurance.”
B. “Medicaid is an example of public health insurance.”
C. “Medicare is an example of public health insurance.”
D. “Indian Health Service is an example of public health insurance.”

 

 

____  22.   When teaching a class of nursing students about advanced practice nursing, the nursing instructor states,

A. “A nurse practitioner cannot diagnose illnesses.”
B. “A nurse practitioner is not able to prescribe medications.”
C. “A nurse practitioner must be supervised by a registered nurse.”
D. “A nurse practitioner can diagnose illnesses within his or her scope of practice.”

 

 

____  23.   When teaching a student nurse about the scope of practice for the licensed practical/vocational nurse (LPN or LVN), the nursing instructor notes that additional teaching is needed when the student nurse states,

A. “The LPN or LVN can practice independently.”
B. “The LPN or LVN can practice under the supervision of a dentist.”
C. “The LPN or LVN can practice under the supervision of a physician.”
D. “The LPN or LVN can practice under the supervision of a registered nurse.”

 

 

____  24.   The nurse is caring for a patient with increasing dyspnea. The nurse recognizes that the most appropriate health care worker to collaborate with is the

A. Physical therapist.
B. Respiratory therapist.
C. Occupational therapist.
D. Speech and language therapist.

 

 

____  25.   The nurse is caring for a patient with a nursing diagnosis of impaired physical mobility. The nurse recognizes that the most appropriate health care worker to collaborate with is the

A. Physical therapist.
B. Respiratory therapist.
C. Occupational therapist.
D. Speech and language therapist.

Chapter 3. Nursing Ethics and Law

 

Multiple Choice

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

 

____    1.   After providing am care for his patient, the nurse forgot to put the bed in the lowest position and left one of the bed rails down. The patient got out of bed and fell. The nurse could be reported to the board of nursing for

A. Assault.
B. Battery.
C. Negligence.
D. Libel.

 

 

____    2.   A nurse has been reported to the board of nursing for performing skills that are outside the scope of practice. The nurse should expect

A. A lawsuit by the institution for malpractice.
B. A hearing by the board of nursing to determine if charges are true.
C. Immediate revocation of nursing license.
D. Requirement to complete a minimum of 10 CEUs.

 

 

____    3.   A nurse witnesses a coworker taking a medication ordered for a patient. The nurse’s first course of action is to

A. Ask the other nurses on the unit what they would do.
B. Tell the coworker that the incident will be reported the next time it happens.
C. Offer to care for the nurse’s patients until the medication is no longer effective.
D. Report the incident to the nurse supervisor.

 

 

____    4.   A 17-year-old patient, injured during a football game, is in the emergency room. Prior to treatment it is the responsibility of the nurse to

A. Have the stepparent sign the informed consent.
B. Have the patient sign the informed consent.
C. Obtain the custodial parent’s signature on the informed consent.
D. Solicit the signature of the noncustodial parent on the informed consent.

 

 

____    5.   A mentally competent patient with a terminal illness refuses to take his medications stating, “I don’t want to live like this.” The nurse will

A. Ask the physician to change the patient’s medications so they can be given intravenously.
B. Speak to the patient’s family about his refusal of medications so they can discuss it with him.
C. Report the patient’s decision to the physician and continue to provide appropriate compassionate care.
D. Explain to the patient the unwise nature of his decision and the effect that it will have on his family.

 

 

____    6.   The nurse feels that the patient needs to be placed in a protective-restraint device to protect him from injury. In order to place a patient in restraints

A. The patient must give his or her consent for restraints to be used.
B. A family member must give his or her consent to use restraints.
C. The nurse must have documentation that other methods have been used and failed to protect the patient.
D. The patient must be alert and oriented.

 

 

____    7.   The nurse explains to a patient that an instructional directive means

A. A family member has been appointed as having power of attorney.
B. A patient’s wishes must be followed in the event of a major illness.
C. There is a Do-Not-Resuscitate (DNR) order for emergency personnel.
D. There are written guidelines specifying care desired and under what circumstances.

 

 

____    8.   A patient requests that the nurse copy his chart for his daughter. The nurse replies,

A. “I’ll get a copy made right away. How many copies do you need?”
B. “Only your lawyer can request a copy so you need to contact her.”
C. “The chart belongs to the hospital, but if you give written permission, a copy can be made for you.”
D. “HIPAA prevents the hospital from copying your chart, but you could speak to your physician about it.”

 

 

____    9.   The nurse explains to coworkers that care provided for the patient is based on the Nurse Practice Act (NPA) which covers the

A. Patient’s Bill of Rights.
B. Rules and regulations which nurses must practice.
C. American Nurses Association’s (ANA) guidelines.
D. Reasons that nurses may have action taken against their licenses.

 

 

____  10.   The patient has refused to take the medications brought in by the nurse. The nurse will chart,

A. “Instructed patient that the medications will be taken now or later.”
B. “Explained to patient that unless medications are taken, the physician will likely issue a discharge.”
C. “Medications refused; physician notified.”
D. “Physician notified that patient is uncooperative.”

 

 

____  11.   Following a discussion with a patient about treatment options given by the primary care physician, the nurse assures the patient that the physician will support whatever decision is made. This nurse is acting as the patient’s

A. Ethics board.
B. Value system.
C. Advocate.
D. Conscience.

 

 

____  12.   Aware that continuing education is a must in providing a high standard of patient care, the nurse will enhance her practice by

A. Taking a cooking class.
B. Becoming computer literate.
C. Studying the history of nursing.
D. Utilizing research to improve practice.

 

 

Multiple Response

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

 

____    1.   The potential exists for a complaint of sexual harassment if the nurse states (select all that apply):

A. “Would you please help me with one of my female patients? She is uncomfortable asking me to assist her to the restroom.”
B. “If I take the patient in Room 203 her pain medication, what are you going to do for me?”
C. “When my patient’s physician arrives on the floor, let me know. I would like to make rounds with him.”
D. “Could you help me with my patient? She’s very large and difficult to get up.”
E. “Male nurses never carry their weight. I think they use that a female patient won’t let them catheterize them as an excuse so they don’t have to put in a Foley catheter.”

 

 

____    2.   In some situations, a nurse is required by law to report findings from nurse-patient interaction and/or the nurse’s assessment. The nurse will notify the proper authorities when (select all that apply):

A. A patient admits that her husband frequently hits her and has broken several bones.
B. An elderly patient tells the nurse that she is afraid of her grandson.
C. There are multiple bruises of varying colors on the back and abdomen of a 9 year old.
D. An adolescent has a black eye.
E. A patient refuses to answer the nurse’s question because his or her son will be mad.

 

 

Completion

Complete each statement.

 

            1.         The nurse manager discusses with staff that tort law may be applicable in certain patient situations. The five areas of tort law that apply to nurses are negligence, malpractice, assault and battery, false imprisonment, and _____________.

 

Chapter 4. The Nursing Process and Decision Making

 

Multiple Choice

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

 

____    1.   When educating a class of nursing students about the nursing process, the nursing instructor teaches that the nursing process is a

A. Decision-making framework used by nurses to determine the needs of patients.
B. Decision-making framework used by social workers when discharging patients.
C. Decision-making framework used by nursing assistants when caring for patients.
D. Decision-making framework used by physicians to determine the needs of patients.

 

 

____    2.   When reviewing the nursing diagnoses in a student nurse’s written care plan, the nursing instructor recognizes that additional teaching is warranted when the student nurse includes a nursing diagnosis of:

A. “Pain related to abdominal incision.”
B. “Altered sensory perception related to surgery.”
C. “Chronic fatigue syndrome related to poor diet.”
D. “Altered nutrition related to nausea and vomiting.”

 

 

____    3.   The nurse encourages the student nurse to practice using skillful reasoning and logical thought to determine the merits of a belief or action. This approach best describes

A. Critical thinking.
B. Sensory overload.
C. Concrete thinking.
D. Logical reasoning.

 

 

____    4.   The nurse receives an order from the physician for an anticoagulant to be administered to a patient who has a deep vein thrombosis. The nurse recognizes that the patient has a critical international normalized ratio (INR) level. The nurse should

A. Redraw the INR level.
B. Call the lab for clarification.
C. Inform the physician of the INR level.
D. Administer the anticoagulant in 1 hour.

 

 

____    5.   While caring for a newly admitted patient, the nurse interviews the patient to obtain a health history, performs a head-to-toe assessment, and reviews laboratory and diagnostic tests. This step in the nursing process is called

A. Planning.
B. Evaluation.
C. Assessment.
D. Implementation.

 

 

____    6.   When caring for a patient who complains of abdominal pain, the nurse determines that analgesics must be given to manage the patient’s pain. This step in the nursing process is called

A. Planning.
B. Diagnosis.
C. Assessment.
D. Implementation.

 

 

____    7.   The nurse is caring for a patient who has a hip spica cast. The nurse monitors the patient for pain, pallor, parasthesia, pulselessness, and paralysis. When the patient complains of pain, the nurse administers analgesics. When the nurse medicates the pain, he or she is performing the step in the nursing process that is called

A. Planning.
B. Evaluation.
C. Assessment.
D. Implementation.

 

 

____    8.   The nurse is caring for a patient with a diagnosis of asthma who is experiencing increased dyspnea. The nurse notifies the respiratory therapist who administers a nebulizer treatment. After the treatment, the patient continues to experience dyspnea. The nurse reflects on treatment to determine if the goal of relief from dyspnea has been accomplished. When the nurse determines if the goal has been met, he or she is performing the step in the nursing process that is called

A. Planning.
B. Diagnosis.
C. Evaluation.
D. Implementation.

 

 

____    9.   The nurse has just finished completing an admission assessment of a newly admitted patient. Next the nurse should

A. Implement the plan of care.
B. Plan the nursing interventions.
C. Formulate a nursing diagnosis.
D. Evaluate the effects of interventions.

 

 

____  10.   The nurse receives a patient who was a direct admission. The nurse initially completes an assessment on the patient and gathers a health history. The nurse determines the top-priority nursing diagnosis. Next the nurse should

A. Implement the plan of care.
B. Plan the nursing interventions.
C. Implement the nursing interventions.
D. Evaluate the effects of interventions.

 

 

____  11.   The nurse admits a patient and selects the priority nursing diagnosis of acute pain. The nurse plans to administer analgesics as needed. When the patient complains of pain, the nurse medicates the patient. Next the nurse should

A. Assess the patient’s lab values.
B. Create a new nursing diagnosis.
C. Administer an additional analgesic.
D. Evaluate the effects of the analgesic.

 

 

____  12.   A patient arrives to the nursing unit as a direct admit. First the nurse should

A. Assess the patient.
B. Ambulate the patient.
C. Create a nursing diagnosis.
D. Evaluate the patient’s nursing goals.

 

 

____  13.   When the nurse gathers information through signs and symptoms and obtains the patient history, he or she is performing the step in the nursing process that is called

A. Planning.
B. Diagnosis.
C. Assessment.
D. Implementation.

 

 

____  14.   When the nurse formulates nursing diagnoses through analysis of the assessment information, he or she is performing the step in the nursing process that is called

A. Planning.
B. Diagnosis.
C. Assessment.
D. Implementation.

 

 

____  15.   When the nurse determines priorities and what nursing actions should be performed to help resolve or manage each patient problem, he or she is performing the step in the nursing process that is called

A. Planning.
B. Diagnosis.
C. Assessment.
D. Implementation.

 

 

____  16.   When the nurse takes actions to resolve a patient’s problems, he or she is performing the step in the nursing process that is called

A. Planning.
B. Diagnosis.
C. Assessment.
D. Implementation.

 

 

____  17.   When the nurse reflects on the interventions that he or she has performed and decides if they have brought the patient closer to achieving the goals and outcomes set in the planning step, he or she is performing the step in the nursing process that is called

A. Planning.
B. Diagnosis.
C. Evaluation.
D. Implementation.

 

 

____  18.   The registered nurse (RN) supervises the licensed practical nurse (LPN/LVN). The RN recognizes that the most appropriate task to delegate to the LPN/LVN is

A. Formulating a nursing diagnosis.
B. Performing an initial admission assessment.
C. Obtaining a patient’s morning weight.
D. Administering an intramuscular analgesic.

 

 

____  19.   The registered nurse (RN) is supervising the licensed practical nurse (LPN). The RN would intervene if the LPN was

A. Formulating a nursing diagnosis.
B. Administering subcutaneous insulin.
C. Culturing a patient’s wound drainage.
D. Obtaining a patient’s morning weight.

 

 

____  20.   The registered nurse (RN) is supervising the licensed practical nurse (LPN). The RN would intervene if the LPN was

A. Writing medication orders.
B. Obtaining a urine culture.
C. Checking a patient’s blood sugar.
D. Administering a transdermal patch.

 

 

____  21.   The registered nurse (RN) recognizes that there are three components to the assessment of patients when he or she gathers information about their problems and needs. These three components are

A. Interviewing, problem solving, and prioritizing.
B. Interviewing, assessment, and creating a list of nursing diagnoses.
C. Interviewing, assessment, and reviewing laboratory and diagnostic tests.
D. Interviewing, setting goals for the patient, and implementing those goals.

 

 

____  22.   The nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies as objective data that

A. The patient reports feelings of depression.
B. The patient demonstrates facial grimacing.
C. The patient complains of feeling nauseated.
D. The patient complains of visual disturbances.

 

 

____  23.   The nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies as subjective data that

A. The patient is short of breath.
B. The patient has wound drainage.
C. The patient demonstrates guarding.
D. The patient reports feelings of fatigue.

 

 

____  24.   When performing an admission history on a confused patient, the registered nurse (RN) collects secondary data, an example of which is that

A. The patient reports history of chest pain.
B. The patient complains of chronic constipation.
C. The patient verbalizes anxiety about hospitalization.
D. The patient’s spouse reports experiencing marital issues.

 

 

____  25.   When performing an admission history on a patient, the nurse collects primary data. An example of primary data is that

A. The patient’s spouse reports patient has difficulty sleeping.
B. The patient’s caregiver complains of feeling overwhelmed.
C. The patient reports history of chronic obstructive pulmonary disease.
D. The patient’s daughter appears anxious about patient’s hospitalization.

 

 

____  26.   A nursing instructor is teaching a class of nursing students about performing a patient assessment and formulating nursing diagnoses. The nursing instructor states that the health care team member responsible for performing a patient assessment and formulating nursing diagnoses is

A. The medical doctor (MD).
B. The registered nurse (RN).
C. The licensed practical nurse (LPN).
D. The unlicensed assistive personnel (UAP).

 

 

____  27.   When performing an initial admission assessment, the nurse visually examines the patient’s body for rashes, breaks in the skin, and normal appearance of eyes, ears, nose, mouth, limbs, and genitals. This is an example of the assessment technique that is called

A. Palpation.
B. Inspection.
C. Percussion.
D. Auscultation.

 

 

____  28.   When performing an initial admission assessment, the nurse touches and feels the patient’s pulses bilaterally. This is an example of the assessment technique that is called

A. Palpation.
B. Inspection.
C. Percussion.
D. Auscultation.

 

 

____  29.   When performing an initial admission assessment, the nurse listens to the patient’s heart and lung sounds. This is an example of the assessment technique that is called

A. Palpation.
B. Inspection.
C. Percussion.
D. Auscultation.

 

 

____  30.   When performing an initial admission assessment, the nurse taps on the patient’s abdomen to detect abnormalities. This is an example of the assessment technique that is called

A. Palpation.
B. Inspection.
C. Percussion.
D. Auscultation.

 

 

____  31.   The nurse educates the student nurse that the formulation of nursing diagnoses is a function of the

A. Physician.
B. Registered nurse.
C. Nurse practitioner.
D. Physician’s assistant.

 

 

____  32.   The registered nurse (RN) formulates four nursing diagnoses for her patient. The nurse recognizes that the priority nursing diagnosis is

A. Altered nutrition.
B. Risk for infection.
C. Chronic low self-esteem.
D. Ineffective airway clearance.

 

 

____  33.   A patient is admitted to the hospital with pneumonia. The assessment reveals that he is short of breath at rest, has a weak cough, and is unable to bring up mucus that can be heard in his lungs and throat. He complains of chest discomfort and has a temperature of 101.6°F, pulse of 110, respirations 23, and blood pressure 126/82. When auscultating his lungs, the nurse hears crackles and wheezes. The patient is weak and becomes short of breath with exertion. His oxygen saturation is 96% at rest. The nurse selects as a priority nursing diagnosis

A. Risk for infection.
B. Activity intolerance.
C. Impaired gas exchange.
D. Ineffective airway clearance.

 

 

Multiple Response

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

 

____    1.   A nursing instructor is educating a student nurse about how to formulate an outcome statement on a care plan. The student nurse demonstrates understanding when stating (select all that apply):

A. “An outcome statement should be a realistic, specific action.”
B. “An outcome statement should be a specific action to be taken by the nurse.”
C. “An outcome statement is an action that is measurable and can be evaluated.”
D. “An outcome statement should be an action the patient is unable to perform.”
E. “An outcome statement should be a specific action to be taken by the patient.”
F. “An outcome statement has a definite time frame for completion of the action.”

 

 

____    2.   The nursing instructor is educating a student nurse about indirect patient care. The student nurse demonstrates understanding when identifying an example of indirect patient care as (select all that apply):

A. Bathing a patient.
B. Administering an analgesic.
C. Documenting the patient’s bath.
D. Listening to a patient’s complaints.
E. Informing the physician about patient’s pain.
F. Teaching a patient how to turn, cough, and deep breathe.

Chapter 5. Documentation

 

Multiple Choice

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

 

____    1.   The nurse is educating a student nurse about documentation. The nurse recognizes that additional teaching is required when the student nurse states,

A. “Documentation serves as a temporary part of the medical record.”
B. “Documentation is one of the most important tasks that I’ll perform in nursing.”
C. “Documentation is the act of charting pertinent information related to a patient.”
D. “Documentation is evidence of what transpired during an event requiring medical care.”

 

 

____    2.   When documenting in a patient’s chart, the nurse recognizes that

A. Documentation serves as a temporary part of the medical record.
B. Documentation is one of the least important tasks performed in nursing.
C. Documentation is the act of charting only abnormal information related to a patient.
D. Documentation is evidence of what transpired during an event requiring medical care.

 

 

____    3.   The nurse is educating a student nurse about the purpose of written documentation. The nurse recognizes that additional teaching is warranted when the student nurse states,

A. “The purpose of written documentation is to communicate pertinent data to the health care team.”
B. “The purpose of written documentation is to serve as a record of accountability for accreditation.”
C. “The purpose of written documentation is to serve as a legal record for the health care provider only.”
D. “The purpose of written documentation is to serve as a record of accountability for quality assurance.”

 

 

____    4.   The nurse educates a nursing student about effective patient care. The nurse recognizes that additional instruction is needed when the nursing student states,

A. “For patient care to be effective, it must be delivered periodically.”
B. “For patient care to be effective, it must be delivered continuously.”
C. “For patient care to be effective, it must be evaluated continuously.”
D. “For patient care to be effective, it must be delivered systematically.”

 

 

____    5.   A hospitalized patient tells the nurse that he wishes to take the original chart copy of his medical record home. The nurse’s best response is:

A. “You may not have it because it belongs to your physician.”
B. “It is your medical record and you are allowed to take it home.”
C. “It is against hospital policy for you to look at your medical record.”
D. “You are allowed to have a copy of your medical record to take home.”

 

 

____    6.   A nurse is caring for a patient who just fell from the bed onto the floor. The nurse should write a(n)

A. Emergency record.
B. Incident report.
C. Progress report.
D. Grievance report.

 

 

____    7.   The nurse is aware that the best method to ensure documentation accuracy is to consistently chart

A. At the completion of each shift.
B. Within 4 hours of providing care.
C. Immediately after care is provided.
D. Immediately prior to providing care.

 

 

____    8.   The nurse teaches a student nurse about what type of occurrence requires completion of an incident report. The nurse recognizes that additional instruction is warranted when the student nurse states,

A. “If my patient falls out of a chair, I will complete an incident report.”
B. “If I give the wrong medication to my patient, I will complete an incident report.”
C. “If a visitor is injured while seeing my patient, I will complete an incident report.”
D. “If my patient refuses to ambulate with physical therapy, I will complete an incident report.”

 

 

____    9.   A nurse discovers a patient lying on the floor. When completing an incident report, the nurse should write:

A. “Patient fell out of bed onto the floor.”
B. “Heard patient fall from the bed to the floor.”
C. “Patient accidentally fell out of bed onto the floor.”
D. “Found patient lying face down on the floor beside the bed.”

 

 

____  10.   A nursing instructor is educating a student nurse about military time. The time is 6:00 PM The student nurse demonstrates understanding by documenting the time as

A. 1500.
B. 1600.
C. 1700.
D. 1800.

 

 

____  11.   A student nurse is caring for a patient who is on a clear liquid diet. The best example of nursing documentation related to this patient is:

A. “Average intake of clear liquid diet noted.”
B. “Patient tolerates the clear liquid diet well.”
C. “Patient swallowing clear liquids normally.”
D. “No complaints of nausea while on clear liquid diet.”

 

 

____  12.   A nursing instructor is educating a class of student nurses about patient documentation. The best example of patient documentation is:

A. States “He vomited everything he ate and drank yesterday.”
B. States “He is in excruciating pain. The pain is unrelieved by analgesics.”
C. States “The pain is getting worse. I don’t know if I can stand it or not.”
D. States “His pain is getting worse and he doesn’t know if he can stand it or not.”

 

 

____  13.   When documenting in a patient’s chart, the nurse realizes that it is the wrong patient’s chart. The nurse should

A. Write over the incorrect letters.
B. Use correction fluid to blank-out the mistaken entry.
C. Use correction tape to blank-out the mistaken entry.
D. Write “mistaken entry” and his or her initials just above incorrect entry.

 

 

____  14.   The nursing instructor observes a student nurse documenting in the wrong patient’s chart. The nursing instructor would intervene when observing the student nurse

A. Writing initials just above the incorrect entry.
B. Using a marker to blacken the incorrect entry.
C. Writing “mistaken entry” just above incorrect entry.
D. Marking a single horizontal line through the incorrect entry

 

 

____  15.   The nursing instructor educates a class of nursing students about SOAPIER charting. The nursing instructor teaches that the acronym SOAPIER stands for

A. Symptoms, Objective, Assessment data, Plan, Intervention, Evaluation, Revision.
B. Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Results.
C. Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision.
D. Subjective data, Objective data, Assessment data, Problems, Intervention, Evaluation, Revision.

 

 

____  16.   The nursing instructor educates a class of nursing students about a common type of focus charting known as DAR. The nursing instructor teaches that the acronym DAR stands for

A. Data, Action, Response.
B. Data, Assessment, Revision.
C. Diagnosis, Action, Response.
D. Data, Assessment, Response.

 

 

____  17.   A patient complains of left-sided chest pain radiating to the left shoulder. Using the SOAPIER method, the nurse should chart this complaint under the initial

A. S.
B. O.
C. A.
D. P.

 

 

____  18.   A patient appears anxious. The patient speaks quickly and paces the hospital halls. Using the SOAPIER method, the nurse should chart this finding under the initial

A. S.
B. O.
C. A.
D. P.

 

 

____  19.   A patient complains of feeling short of breath. His oxygen saturation level is 86%. When auscultating his lung sounds, the nurse notes wheezes and crackles throughout. The patient has a productive cough of thick green mucus. The nurse should chart these actions under the section of DAR charting that is called

A. Data.
B. Action.
C. Response.
D. Assessment.

 

 

____  20.   When a patient complains of pain, the nurse assesses the pain level and administers an analgesic. The nurse should chart these actions under the section of DAR charting that is called

A. Data.
B. Action.
C. Response.
D. Assessment.

 

 

Multiple Response

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

 

____    1.   A nursing instructor teaches a class of nursing students about the purpose of written documentation, which includes (select all that apply):

A. To communicate pertinent data to the health care team.
B. To serve as a record of accountability for accreditation.
C. To serve as a legal record for the health care provider only.
D. To serve as a record of accountability for quality assurance.
E. To serve as a record of accountability for reimbursement purposes.
F. To provide a permanent record of medical diagnoses and nursing diagnoses.

 

 

____    2.   The staff members at a hospital are preparing for a visit from The Joint Commission. The nursing supervisor explains to the staff that The Joint Commission (select all that apply):

A. Provides a team of reviewers who ensure that standards are met.
B. Acts as an insurance company by offering reimbursement to hospitals.
C. Seeks to improve safety and quality of care that health care organizations provide to the public.
D. Offers accreditation when a facility practices in a manner that meets The Joint Commission’s standards.
E. Sends a team of reviewers who visit the facility to assess its policies, procedures, and actual performance.
F. Sets the standards by which the quality of health care is managed nationally and internationally.

 

 

____    3.   A nursing instructor is educating a group of student nurses about the Health Insurance Portability and Accountability Act (HIPAA). The nursing instructor teaches that HIPAA (select all that apply):

A. Guarantees the patient the right to view his or her medical record.
B. Guarantees the patient the right to take the original medical chart.
C. Asks the patient to specify who can obtain his or her personal health data.
D. Guarantees the patient the right to obtain a copy of his or her medical record.
E. Ensures the right of the patient to amend his or her own health information.
F. Requires hospitals to disclose the way in which the patient’s health data will be used.

 

 

____    4.   The hospital risk management team provides the nursing staff with an in-service about incident reports. The in-service should include that (select all that apply):

A. An incident report always involves the patient.
B. Incident reports are part of the patient’s medical record.
C. An incident report is also referred to as a variance report.
D. A medication error should be documented on an incident report.
E. A patient, visitor, or employee injury should be documented on an incident report.
F. An incident report is used to document out-of-the-ordinary things that happen in a facility.

 

 

____    5.   The nursing instructor teaches a class of nursing students that the problem-oriented medical record consists of the (select all that apply):

A. Database.
B. Problem list.
C. Plan of care.
D. Progress notes.
E. Incident reports.
F. Variance reports.

Chapter 6. Communication and Relationships

 

Multiple Choice

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

 

____    1.   The nurse recognizes that in order to effectively meet the goal of shared meaning in communication, verbal and nonverbal language should be

A. Absent.
B. Congruent.
C. Equally direct.
D. Noncongruent.

 

 

____    2.   While bathing a patient, the nurse recognizes that the personal space-distance zone that he or she is in when physically touching the patient is

A. Public.
B. Intimate.
C. Casual-personal.
D. Social-consultative.

 

 

____    3.   While obtaining a patient health history, the nurse recognizes that the personal space-distance zone that he or she is in when standing within 3 feet of the patient is

A. Public.
B. Intimate.
C. Casual-personal.
D. Social-consultative.

 

 

____    4.   When interacting with a physician, the nurse recognizes that the personal space-distance zone that he or she is in when standing within 5 feet of the physician is

A. Public.
B. Intimate.
C. Casual-personal.
D. Social-consultative.

 

 

____    5.   When teaching a class of nursing students, the nursing instructor stands 15 feet from her audience. The personal space-distance zone that the nursing instructor is in is

A. Public.
B. Intimate.
C. Casual-personal.
D. Social-consultative.

 

 

____    6.   When interacting with patients, the nurse demonstrates a willingness to communicate when

A. Standing over seated patients.
B. Slumping while talking to patients.
C. Folding arms while talking to patients.
D. Leaning slightly forward toward patients.

 

 

____    7.   A patient who appears to be in pain does not ask the nurse for pain medication because he feels it would upset the nurse. The style of communication that the patient is demonstrating is

A. Passive.
B. Assertive.
C. Aggressive.
D. Demeaning.

 

 

____    8.   A patient throws his urinal at the nurse and tells the nurse that he thinks she is a terrible nurse. The nurse informs the patient that his behavior is inappropriate. The style of communication that the nurse is demonstrating is

A. Passive.
B. Assertive.
C. Aggressive.
D. Demeaning.

 

 

____    9.   When the nurse educates a patient about his medications, the patient tells the nurse that she should go back to nursing school because she doesn’t know very much about medications. The style of communication that the patient is demonstrating is

A. Passive.
B. Avoidant.
C. Assertive.
D. Aggressive.

 

 

____  10.   A nursing instructor teaches a class of student nurses that the most effective communication style for nurses to practice is

A. Passive.
B. Avoidant.
C. Assertive.
D. Aggressive.

 

 

____  11.   A nurse is caring for a patient who has end-stage renal disease and will require dialysis three times per week. The patient states, “I’m upset that I didn’t visit all the places I’d like to see. Now that I’m on dialysis I won’t be able to.” The most therapeutic response by the nurse is:

A. “You are upset that it’s too late to visit places that you would like to see?”
B. “There are many people who feel exactly the same as you do.”
C. “Don’t worry. You can still visit all of the places that you would like to see.”
D. “I think you should visit the places you would like to see before it’s too late.”

 

 

____  12.   The nurse is caring for a patient who has just been diagnosed with a brain tumor. The patient asks the nurse if he should choose to have surgery. The nurse’s most therapeutic response is:

A. “Tell me what you know about surgery.”
B. “I would never decide against having surgery.”
C. “If I were you, I would definitely have the surgery.”
D. “Don’t worry. You will be fine if you don’t have surgery.”

 

 

____  13.   The nurse is caring for a patient who develops dyspnea that does not improve with oxygen therapy and nebulizer treatment. The nurse immediately calls the patient’s primary health care provider. This type of communication is called

A. Upward.
B. Bilateral.
C. Horizontal.
D. Downward.

 

 

____  14.   The nurse is caring for a patient who requires assistance with feeding. The nurse delegates this task to the certified nursing assistant (CNA). This type of communication is called

A. Upward.
B. Bilateral.
C. Horizontal.
D. Downward.

 

 

____  15.   The nurse observes a student nurse caring for a hearing-impaired patient. The nurse would intervene if the student nurse

A. Speaks clearly without shouting.
B. Speaks directly to the patient’s interpreter.
C. Positions himself or herself in front of the patient when speaking.
D. Turns down the radio volume when speaking to the patient.

 

 

____  16.   The nurse is caring for a patient who was admitted to the hospital for a cerebrovascular accident (CVA) resulting in difficulty understanding speech. The nurse recognizes that the patient is experiencing

A. Receptive aphasia.
B. Expressive aphasia.
C. Receptive dysphagia.
D. Expressive dysphagia.

 

 

Multiple Response

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

 

____    1.   A nursing instructor is educating a class of nursing students about effective communication. The nursing instructor teaches that effective communication (select all that apply):

A. Is essential in proper documentation practices.
B. Is the foundation of nurse-patient relationships.
C. Helps establish proper transfer of health care information.
D. Is a vital component in building professional relationships.
E. Is something that nurses often feel prepared to do in clinical situations.
F. Is a key element when reporting information to other health care members.

 

 

____    2.   The nurse understands that when communicating with a patient face-to-face, communication is (select all that apply):

A. An active process.
B. As simple as telling.
C. As simple as informing.
D. A passive, one-sided event.
E. Completed when the receiver offers feedback.
F. Involves both parties sending and receiving messages simultaneously.

 

 

____    3.   When performing an admission assessment, the nurse assesses the patient’s verbal communication. The nurse recognizes that verbal communication includes (select all that apply):

A. The patient’s tense posture.
B. The patient’s written words.
C. The patient’s facial grimacing.
D. The patient’s verbal complaints.
E. The patient’s vocalization of pain.
F. The patient’s disheveled appearance.

 

 

____    4.   When performing an admission assessment, the nurse assesses the patient’s nonverbal communication. The nurse recognizes that nonverbal communication includes (select all that apply):

A. The patient’s rigid posture.
B. The patient’s written words.
C. The patient’s brow tightening.
D. The patient’s verbal complaints.
E. The patient’s manicured appearance.
F. The patient’s vocalization of anxiety.

 

 

____    5.   The nurse demonstrates active listening when (select all that apply):

A. Ignoring nonverbal cues.
B. Tuning out intrusions and distractions.
C. Using all of the senses to interpret verbal messages.
D. Paying attention to what the speaker is saying.
E. Using all of the senses to interpret nonverbal messages.
F. Paying attention to what the speaker is not saying.

 

 

____    6.   To complete the process of active listening, the nurse should (select all that apply):

A. Share perceptions.
B. Avoid confrontation.
C. Exhibit a superior attitude.
D. Refrain from sharing feelings.
E. Respond to the content heard in the message.
F. Provide feedback about understanding what was said.

 

 

____    7.   When communicating with a patient, the nurse recognizes that patient-centered communication is defined as communication that (select all that apply):

A. Is focused primarily on the nurse.
B. Empowers patients to participate in their care.
C. Encourages patients to participate in their care.
D. Discourages patients to participate in their care.
E. Discourages patients from participating in decisions.
F. Is essential to establishing a positive nurse-patient relationship.

 

 

____    8.   The nurse is caring for a patient with Wernicke’s aphasia. When communicating with the patient, the nurse should (select all that apply):

A. Speak slowly.
B. Speak rapidly.
C. Use long sentences.
D. Ask yes or no questions.
E. Avoid interrupting the patient.
F. Speak in a normal tone of voice.

 

 

Completion

Complete each statement.

 

1.         The distance or personal space that people place between themselves and others is called _________.

Chapter 7. Promoting Health and Wellness

 

Multiple Choice

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

 

____    1.   The nurse explains to the patient that health is measured on a continuum scale and that

A. It proves that health is constant and rarely fluctuates.
B. The higher the measurement is, the better one’s health is.
C. It measures only the physical aspects of health.
D. It would be more accurate if mental and emotional aspects could be measured.

 

 

____    2.   A male patient with severe chronic obstructive pulmonary disease (COPD) was brought to the hospital by emergency personnel. He lives alone, has no relatives or friends living nearby, and lives on a fixed income, which prevents him from purchasing all of the medications that he needs. Based on Dunn’s wellness grid, the nurse determines that the quadrant that the patient is in is

A. High-level wellness in a favorable environment.
B. Emergent high-level wellness in an unfavorable environment.
C. Protected poor health in a favorable environment.
D. Poor health in an unfavorable environment

 

 

____    3.   The nurse educator explains to student nurses Fitzpatrick’s rhythm model theory. According to this theory, the patient’s health

A. Is only a state of mind over matter and is controlled by the patient.
B. Is always changing and fluctuates throughout four wellness quadrants.
C. Defines how well the individual promotes his or her physical well-being.
D. Is the result of the interaction between an individual and the environment.

 

 

____    4.   The nurse discusses with the patient ways to improve health and prevent disease. The nurse suggests that the patient

A. Use emergency and urgent care facilities for routine care.
B. Worry less about food groups and more about calories.
C. Eliminate certain food groups from the diet.
D. Participate in stress-management techniques.

 

 

____    5.   The nurse educates the patient in ways to prevent long-term illnesses or diseases. The nurse states,

A. “It is important that you receive the flu vaccination every year.”
B. “Your diet should be moderate in calories and include a variety of foods.”
C. “Running at least 4 to 5 miles per day will ensure that you do not develop cancers or heart diseases.”
D. “Smoking cigarettes that are low in tar and nicotine will greatly decrease your risk of developing respiratory problems.”

 

 

____    6.   A patient being seen in the clinic tells the nurse, “The pain is in my right side.” The patient’s phase of illness is

A. Prodromal.
B. Symptomatic.
C. Seeking help.
D. Dependency.

 

 

____    7.   The nurse instructs the patient, “You can decrease your risks for developing many diseases and illnesses by developing healthy habits and participating in health screenings.” The patient validates understanding when he or she states,

A. “As long as I begin to limit the amount of bad carbohydrates in my diet and begin exercising by the age of 50, I probably will not develop type 2 diabetes.”
B. “Performing monthly breast self-exams if I have a family history of breast cancer will decrease my chances of developing it.”
C. “I can take responsibility for reducing risks by eating a well-balanced diet and seeing my primary care physician for routine health screenings.”
D. “Since I am at risk for developing high cholesterol, it will be important for me to ask my primary care physician for medications to prevent it.”

 

 

____    8.   The patient told the nurse, “I can’t remember anything right before or after my wreck, but the officer told me that I left lots of black marks trying to stop.” The nurse explains to the patient,

A. “When scared, the parasympathetic system stimulates the fight-or-flight response.”
B. “Your fight-or-flight response pumps adrenaline into your system, which enhances your ability to react quickly.”
C. “Cortisol, a natural hormone, ceases production and, as a result, we are able to respond quickly in an emergency.”
D. “The sympathetic nervous system blocks your endocrine glands, resulting in additional hormones enabling a quick response.”

 

 

____    9.   A patient who is admitted for observation following an episode of chest pain relieved by rest and two nitroglycerin tabs, tells the nurse that his job as CEO of a large firm is becoming too much to handle. According to Selye, the nurse suspects that the patient most likely is experiencing

A. An interaction between the individual and the environment.
B. Protected poor health in a favorable environment.
C. The seeking help phase of illness.
D. The exhaustion phase of stress.

 

 

____  10.   A 42-year-old female patient who was just admitted states, “I must be under too much stress. I just do not feel well.” The nurse understands that her complaint could be a symptom of stress and is not surprised to find that

A. Her blood pressure is 178/96.
B. She sets aside some time each day to relax.
C. Her pupils are constricted and reactive to light.
D. She is limiting fats and sugar in her diet.

 

 

____  11.   The elderly patient with a history of congestive heart failure was just admitted for chest pain. The patient asks the nurse, “Why did my chest pain begin after I thought someone was trying to break into my house?” The best response by the nurse is:

A. “Response to fear increases the body’s demand for oxygen, which can place additional stress on your damaged heart and cause chest pain.”
B. “The parasympathetic system used all of your available adrenaline, leaving you so tired that you developed chest pain.”
C. “Because the release of cortisol blocks the body’s response to fear, you weren’t allowed sufficient time rest, which can cause chest pain.”
D. “The decrease in oxygen utilization during the fight-or-flight response is most likely the reason that you developed chest pain.”

 

 

____  12.   The nurse educator explains to student nurses that according to Selye, the general adaptation syndrome, or GAS, is

A. An explanation of how the body’s response to stress prevents death.
B. Validated by how many people are struggling with terminal illnesses, such as cancer.
C. A theory explaining the body’s attempt to adjust to stress.
D. What prevents the threat to health when there is long-term stress.

 

 

Multiple Response

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

 

____    1.   A nurse encourages a patient to be proactive in promoting and maintaining health by (select all that apply):

A. Introducing the patient to the benefits of a regular exercise program.
B. Discussing the obvious and hidden dangers of drug and alcohol abuse.
C. Referring an uninsured patient to a facility that allows payment plans.
D. Suggesting that medical care is accessed in acute emergencies and that alternative forms of treatment are used when it is not.
E. Explaining the importance of obtaining required immunizations for children.

 

 

____    2.   The nurse explains to the patient that Healthy People 2010 was established by the Office of Disease Prevention and Health Promotions to (select all that apply):

A. Fund exercise programs in businesses.
B. Increase quality of life and longevity.
C. Force tobacco companies to close.
D. Eliminate disparities in health issues.
E. Legally require obese individuals to lose weight.

 

 

____    3.   During a discussion with a patient participating in a health screening, the nurse suggests positive ways to cope with stress, such as (select all that apply):

A. Relaxing with family and friends.
B. Accepting all challenges.
C. Saying no when one has other obligations.
D. Eating a diet high in fat and carbohydrates.
E. Getting rid of excessive possessions.

 

 

____    4.   A patient, recently terminated at his place of employment, has been admitted to the hospital via the emergency room. He smokes approximately two packs of cigarettes and drinks approximately a six-pack of beer daily, and he states that he exercises three times a week for 30 minutes. According to Healthy People 2010, the nurse identifies the indicators that place the patient at risk for illness as (select all that apply):

A. Tobacco use.
B. Substance abuse.
C. Environmental quality.
D. Access to health care.
E. Physical activity.

 

Chapter 8. Ethnic, Cultural, and Spiritual Aspects of Care

 

Multiple Choice

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

 

____    1.   The nurse carefully plans care that will be provided to the patients assigned to her. In order to provide culturally competent nursing care, the nurse will

A. Deliver appropriate care that is not discriminating to any race, gender, or ethnic group.
B. Become familiar with any facet of the patient’s culture that may have an impact on his or her care.
C. Show respect for each individual for whom she provides care.
D. Openly discuss her thoughts and beliefs about the patient’s culture.

 

 

____    2.   In preparation for contributing to the patient’s plan of care, the nurse will assess a patient’s rituals, values, customs, and beliefs. The nurse is assessing the patient’s

A. Culture.
B. Race.
C. Ethnicity.
D. Heritage.

 

 

____    3.   The nurse provides care that is unique to the patient’s race. The nurse is taking into account the patient’s

A. Acculturation.
B. Ethnocentrism.
C. Diversity.
D. Ethnicity.

 

 

____    4.   The nurse provides care based upon the patient’s expectations, behavior, and decision-making processes. The nurse is providing care that is

A. Culturally competent.
B. Culturally insensitive.
C. Culturally incompetent.
D. Culturally assimilated.

 

 

____    5.   The nurse plans care that includes a patient’s health care beliefs because

A. The patient otherwise could accuse the nurse of stereotyping.
B. Not doing so could result in a patient’s discrimination claim.
C. It could determine whether or not a patient rejects treatment.
D. It results in more expedient and cost-effective care.

 

 

____    6.   The nurse suspects that a female patient may have difficulty in increasing the protein in her diet. The patient most likely is

A. Hindu.
B. Jewish.
C. Asian.
D. Mexican.

 

 

____    7.   It is important for the nurse to understand that the American family of a dying Hindu patient

may

A. Expect the nurse to prepare the body for burial.
B. Use amulets to ward off evil spirits lingering after death.
C. Get comfort from visiting with a psychiatrist or psychologist.
D. Exhibit grieving by thinking only happy thoughts about their loved one.

 

 

____    8.   The nurse of a Jewish patient who has just died is aware that a very important aspect of the Jewish religion is that

A. No one, with the exception of close family members, is permitted to touch the body.
B. Only a Jewish priest may touch or prepare the body for burial.
C. The eyes must not be closed, nor may anyone remain with the body after preparation for burial.
D. The patient’s feet must be positioned away from the exit.

 

 

____    9.   A female Muslim patient is hospitalized and is scheduled for surgery later today. In preparing the patient for surgery, the nurse will

A. Need to get the patient’s husband to also sign the consent form.
B. Make arrangements for family members to bring kosher food from home since a normal diet is allowed.
C. Perform “laying on of the hands,” or allow a trained individual to do so.
D. Allow a shaman to perform a healing ritual in an attempt to thwart surgical intervention

 

 

____  10.   An Asian patient has been placed on a restricted-sodium diet by his primary care physician. The nurse will ask a dietician to speak with the patient about the diet, but is aware that

A. Cheese, high in sodium, is a staple of the Asian American diet and the patient is not likely to avoid it.
B. Yogurts and sweets must be eaten at every meal so it will be difficult to avoid sodium.
C. The patient may feel it is sinful to refuse to eat food offered by others.
D. Vegetables high in sodium are the mainstay of the Asian American’s diet.

 

 

____  11.   A nurse may fail to provide spiritual care for a patient if

A. The nurse does not understand the relationship between mind, body, and spirit.
B. The nurse’s religious background differs greatly from that of his or her patient.
C. The nurse believes that a patient’s illness is caused by his or her lack of religious practice.
D. The nurse notifies a clergyman, with the patient’s consent, to provide spiritual care.

 

 

____  12.   A Native American patient tells the nurse that she does not desire medical treatment for her terminal illness. Respecting the patient’s decision, the nurse explains to staff nurses that

A. The Native American culture dictates that terminal illnesses are only to be treated by folk healers.
B. Terminal illness is believed to be a condition created by an imbalance in yin and yang.
C. Some Native Americans feel that rituals performed by a shaman are effective against illness.
D. Illness is a result of sinful behavior so medical treatment will not be effective.

 

 

____  13.   A nurse, in addressing spirituality concerns of a patient, will first assess

A. Whether the patient practices a religion.
B. A patient’s understanding of religion.
C. The patient’s definition of morality.
D. If the patient has a lower frequency of health complaints.

 

 

____  14.   Nurses who are comfortable in their religious beliefs are more likely to understand the importance of good spiritual health in patients because

A. It determines patients’ concepts of good health practices.
B. Patients who practice religion do not suffer spiritual distress.
C. Patients with strong belief systems do not suffer long-term illnesses.
D. It gives individuals hope and motivates them toward a better outcome.

 

 

____  15.   A patient admitted for depression tells the nurse that he feels so hopeless that he doesn’t care if he lives or dies. The patient tells the nurse that he no longer attends church with his family. The nurse identifies that possibly the patient

A. Does not value faith the way he previously had.
B. Wishes to be left alone to reflect on his lost faith.
C. Could be experiencing spiritual distress.
D. Wants the nurse to discuss his feelings with his family.

 

 

____  16.   While the nurse is trying to complete the morning care for a male patient, he tells the nurse that he does not want him or her in the room while his spiritual advisor is visiting. The nurse will

A. Assure the patient that once his bath is done, he may see his spiritual advisor.
B. Suggest that he ask his spiritual advisor to visit later since there are several more patients that need to be cared for as well.
C. Tell the patient that the nurse will leave the room if his spiritual advisor visits.
D. Ask the patient when the spiritual advisor plans to visit and schedule his care around it.

 

 

____  17.   The nurse is caring for a Mormon patient who had complications following the birth of her sixth child. Although the physician has told the patient that another pregnancy could result in her death, the patient tells the nurse that she refuses permanent sterilization. The nurse is aware that

A. The Mormon faith does not permit sterilization.
B. The patient is afraid of having more children.
C. If the patient becomes pregnant again, she will most likely seek an abortion.
D. The patient believes her complications were caused by her sins.

 

 

____  18.   A patient in spiritual distress asks the nurse what she thinks about religion. The nurse replies,

A. “Religion is not for everyone. Whether you go to church or not does not affect your health, so don’t worry so much about it.”
B. “We all worry from time to time about whether our beliefs are based upon truth or not, so it’s normal to worry some.”
C. “An individual’s feelings about religion are personal. I cannot divulge personal information about myself.”
D. “I find comfort in my religious beliefs. Is there a member of the clergy with whom you would like to visit?”

 

 

____  19.   A male patient in dire need of medical assistance has refused treatment, stating it is against his religion. The nurse correctly identifies and documents the patient’s refusals of treatment because he is a

A. Latter Day Saint.
B. Seventh Day Adventist.
C. Scientologist.
D. Buddhist.

 

 

____  20.   A female patient who was admitted for severe low back pain has asked the nurse if she can have more pain medication yet. The nurse tells coworkers that patients admitted with back pain are drug-seeking. The nurse is likely demonstrating

A. Misunderstanding.
B. Prejudice.
C. Discrimination.
D. Empathy.

 

 

____  21.   The charge nurse will take into consideration when making nursing assignments that a 62-year-old Muslim female will

A. Need to be assigned a female nurse.
B. Require more care than other patients.
C. Require yogurt and sweets be provided at every meal.
D. Need a nurse who has an understanding of astrology.

 

 

____  22.   After a Seventh Day Adventist clergyman performed anointing of oil, the nurse bathed the patient. Upon entering the room the family immediately became upset. Upon questioning by the nurse the family states,

A. “Bathing is painful and we don’t wish anyone to cause him further discomfort.”
B. “He should not have been bathed for several hours following anointment with oils.”
C. “The Church forbids anyone but family to bathe loved ones.”
D. “His bath should be done by a nurse of the same gender.”

 

 

____  23.   An elderly female Caucasian patient tells a male nurse that she does not want him to be her nurse. The initial response by the nurse will be:

A. “You are not comfortable with a male nurse?”
B. “You need to calm down.”
C. “Discriminating against me may affect the care you receive.”
D. “I’ll stay with you until you feel more comfortable with me.”

 

 

Multiple Response

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

 

____    1.   The family of a recently expired patient has told the nurse that they will refuse an autopsy because not all of the family members agree that it is necessary. The nurse is aware that the consent of all of the family members is required before allowing an autopsy if the faith of the patient is a (select all that apply):

A. Catholic.
B. Protestant.
C. Mormon.
D. Scientologist.
E. Jehovah’s Witness.

 

 

____    2.   The nurse has been asked by family members if their loved one can receive anointment with oils. The nurse provides privacy for the anointing because he or she knows that the patient is likely a (select all that apply):

A. Catholic.
B. Seventh Day Adventist.
C. Latter Day Saint.
D. Scientologist.
E. Member of the Amish faith.

 

 

____    3.   The nurse is aware that a patient who is experiencing spiritual distress may (select all that apply):

A. Exhibit feelings of hopelessness.
B. Show signs of depression.
C. Read the Bible.
D. Request a visit from a member of the clergy.
E. Exhibit anger at God.

 

 

____    4.   A nursing diagnosis for a patient suffering a terminal illness is “Spiritual distress.” Based on the diagnosis, an appropriate nursing intervention is (select all that apply):

A. Allowing the patient to express concerns about dying.
B. Soliciting an appropriate member of the clergy with the patient’s consent.
C. Suggesting that family members limit their visits during the patient’s distress.
D. Providing comfort by sitting quietly at the patient’s bedside.
E. Encouraging the patient to leave the TV on and to keep room blinds open.

 

 

Completion

Complete each statement.

 

  1. A nurse tells the charge nurse that her patient will not accept his lunch tray. When questioned, the nurse states, “Well, I think it’s because Asians are mostly Buddhists and they are vegetarians.” This is an example of _______________.

 

  1. A nurse who provides holistic nursing care is said to be ____________  ______________.

 

Short Answer

 

  1. The nurse manager discusses the differences between religion and spirituality with a staff nurse. Compare and contrast the differences between religion and spirituality.

Chapter 9. Growth and Development Throughout the Lifespan

 

Multiple Choice

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

 

____    1.   The nurse recognizes that the term for the physical changes that occur in the size of human beings is

A. Growth.
B. Spirituality.
C. Regression.
D. Development.

 

 

____    2.   The nurse recognizes that the increase in complexity of skills performed by a person is called

A. Growth.
B. Regression.
C. Ambivalence.
D. Development.

 

 

____    3.   The nurse recognizes that the physical size and functioning of a person is called

A. Moral development.
B. Physical development.
C. Cognitive development.
D. Psychosocial development.

 

 

____    4.   The nurse recognizes that the ability to think at higher levels and develop a value system that differentiates right from wrong is called

A. Moral development.
B. Physical development.
C. Cognitive development.
D. Psychosocial development.

 

 

____    5.   The nurse recognizes that how an individual learns is called

A. Moral development.
B. Physical development.
C. Cognitive development.
D. Psychosocial development.

 

 

____    6.   The nurse recognizes that the type of development that occurs throughout one’s life in distinct stages, each stage requiring that specific tasks must be mastered, is called

A. Moral development.
B. Physical development.
C. Cognitive development.
D. Psychosocial development.

 

 

____    7.   A psychologist who theorized that cognitive development occurs from birth to adolescence in an orderly sequence of four stages is

A. Jean Piaget.
B. Erik Erikson.
C. James Fowler.
D. Lawrence Kohlberg.

 

 

____    8.   A psychoanalyst who theorized that psychosocial development occurs throughout one’s life in distinct stages is

A. Jean Piaget.
B. Erik Erikson.
C. James Fowler.
D. Lawrence Kohlberg.

 

 

____    9.   A developmental psychologist who defined faith as a universal concern that is a process of developing trust and who developed six stages of spiritual development is

A. Jean Piaget.
B. Erik Erikson.
C. James Fowler.
D. Lawrence Kohlberg.

 

 

____  10.   An American psychologist who acknowledged that not all people reach all stages of moral development, and who based his theory on preconventional morality, conventional morality, and postconventional morality is

A. Jean Piaget.
B. Erik Erikson.
C. James Fowler.
D. Lawrence Kohlberg.

 

 

____  11.   The nurse is caring for a toddler who obeys authority in order to avoid punishment. The nurse recognizes that the toddler is in the stage of Lawrence Kohlberg’s moral development theory that is called

A. Conventional morality.
B. Preoperational morality.
C. Preconventional morality.
D. Postconventional morality.

 

 

____  12.   The nurse is caring for a child who wants his parents to buy him a cat when he gets better. The parents refuse because they are both allergic to cat hair. The child states, “That’s not fair. I want a cat.” The nurse recognizes that the child is in the stage of Lawrence Kohlberg’s moral development theory that is called

A. Conventional morality.
B. Preoperational morality.
C. Preconventional morality.
D. Postconventional morality.

 

 

____  13.   An adolescent volunteers to read to hospitalized children without being paid. The nurse recognizes that the adolescent is in the stage of Lawrence Kohlberg’s moral development theory that is called

A. Conventional morality.
B. Preoperational morality.
C. Preconventional morality.
D. Postconventional morality.

 

 

____  14.   An adolescent actively participates in scouting activities. The nurse recognizes that the adolescent is in the stage of Lawrence Kohlberg’s moral development theory that is called

A. Conventional morality.
B. Preoperational morality.
C. Preconventional morality.
D. Postconventional morality.

 

 

____  15.   The nurse is caring for a patient who was hit by a drunk driver while stopped in his vehicle at a red light. The patient states, “I always stop at a red light even when no one is watching and there is no other traffic.” The nurse recognizes that the patient is in the stage of Lawrence Kohlberg’s moral development theory that is called

A. Conventional morality.
B. Preoperational morality.
C. Preconventional morality.
D. Postconventional morality.

 

 

____  16.   The nurse is caring for a patient who has been attending a local university to earn a law degree. The patient states, “I want to earn my degree so that I can fight for justice and human rights for people throughout the world.” The nurse recognizes that the patient is in the stage of Lawrence Kohlberg’s moral development theory that is called

A. Conventional morality.
B. Preoperational morality.
C. Preconventional morality.
D. Postconventional morality.

 

 

____  17.   The mother of a 1-year-old child asks the nurse how much her child should weigh. The nurse asks the mother what the child weighed at birth. The mother responds that the child weighed 7 pounds and 8 ounces at birth. The nurse tells the mother that the child’s weight at 1 year of age should be

A. 21.5 pounds.
B. 22.5 pounds.
C. 23.5 pounds.
D. 24.5 pounds.

 

 

____  18.   The nurse instructs a postpartum patient who wishes to breastfeed to gently touch the infant’s cheek that is closest to her breast in order to cause the infant to turn toward the breast and open his or her mouth to find milk. The nurse explains to the patient this will elicit the

A. Moro reflex.
B. Rooting reflex.
C. Sucking reflex.
D. Babinski reflex.

 

 

____  19.   When teaching a student nurse about performing an assessment on a neonate, the nurse strokes the sole of the infant’s foot, which causes fanning of the toes while the great toe pulls upward. The nurse teaches the student nurse that this assessment finding is

A. Indicative of cerebral edema.
B. A normal assessment finding.
C. Indicative of a genetic anomaly.
D. An abnormal assessment finding.

 

 

____  20.   When performing a physical assessment on a neonate, the nurse notes a triangular-shaped soft area that is not yet fused together toward the back of the top of the head. The nurse should

A. Notify the health care provider.
B. Assess the neonate’s vital signs.
C. Document this as a normal assessment finding.
D. Document this as an abnormal assessment finding.

 

 

____  21.   The nurse intervenes when he or she observes a student nurse, who is caring for a toddler

A. Encourage the toddler to feed himself.
B. Guide the toddler gently if he makes a mistake.
C. Offer the toddler unlimited choices on what time to go to bed.
D. Ask the toddler if he would like to wear the red shirt or the blue shirt.

 

 

____  22.   The nursing instructor supervises a student nurse who is administering an intramuscular analgesic medication to a school-aged child. The nursing instructor intervenes when the student nurse tells the child:

A. “My injections don’t hurt.”
B. “This will only hurt for a little while.”
C. “This will feel like a prick and will hurt a little.”
D. “This medication will help take your pain away.”

 

 

____  23.   When supervising a certified nursing assistant (CNA) caring for a toddler, the nurse intervenes when

A. The CNA leaves the toddler alone in the bathtub.
B. The CNA feeds the toddler pieces of cheese for a snack.
C. The CNA removes small objects from the toddler’s crib.
D. The CNA puts the crib side rails up when the toddler is resting.

 

 

Multiple Response

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

 

____    1.   When educating a class of nursing students, the nursing instructor teaches that growth (select all that apply):

A. Occurs in an orderly pattern.
B. Occurs in a predictable pattern.
C. Occurs in a disorganized pattern.
D. Occurs in a proximodistal pattern.
E. Occurs in a cephalocaudal pattern.
F. Occurs in an unpredictable pattern.

 

 

____    2.   When caring for a hospitalized adolescent, the nurse should (select all that apply):

A. Talk down to the adolescent.
B. Treat the adolescent with respect.
C. Encourage peers to visit.
D. Insist that the parent be present during exams.
E. Assume that the adolescent has no knowledge of his or her illness.
F. Tell the adolescent that he or she must allow a parent to accompany him or her to procedures.

Chapter 10. Loss, Grief, and Dying

 

Multiple Choice

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

 

____    1.   The nurse understands that when the terminal patient states, “No, I don’t need anything. What would you get me anyway?” he or she is most likely in the stage of grief called

A. Denial.
B. Acceptance.
C. Anger.
D. Bargaining.

 

 

____    2.   A nurse has just witnessed a terminally ill patient telling the physician that he does not wish to have his life prolonged as stated in his living will. The nurse expects that the physician will

A. Explain to the patient why he should be more hopeful.
B. Write a Do-Not-Resuscitate (DNR) order.
C. Speak to the patient’s family before writing a DNR order.
D. Ignore the patient’s request.

 

 

____    3.   A patient dying from colon cancer tells the nurse that he is sure that he can beat the cancer if he changes his eating habits. The nurse understands that the patient is likely in the stage defined by Kübler-Ross that is called

A. Acceptance.
B. Anger.
C. Denial.
D. Bargaining.

 

 

____    4.   When questioned by a patient about the difference between palliative care and the services provided by hospice, the nurse explains that palliative treatment

A. Is aggressive, but administered to cure the disease.
B. Is geared toward the patient, family, and their wishes.
C. May be aggressive and is directed at eliminating discomfort.
D. Indicates the patient has fewer than 6 months to live.

 

 

____    5.   The nurse realizes that a terminally ill patient is ready to talk about dying when he or she states,

A. “I’m feeling a little stronger each day.”
B. “Do you think you could just sit with me for a while?”
C. “I’ve decided to begin taking chemotherapy again.”
D. “What do you think death feels like?”

 

 

____    6.   The wife of a patient who is nearing the end of his life tells the nurse that she is worried because her husband is not getting enough fluids. The nurse responds by saying,

A. “He will drink when he gets thirsty. Don’t worry about him.”
B. “It is natural to become dehydrated before death and it will actually make him more comfortable.”
C. “I will let his physician know about it. He may want to start an IV to keep him hydrated.”
D. “Your husband has signed a living will indicating he doesn’t want to be given food and water.”

 

 

____    7.   Immediately following a patient’s death, the nurse performs postmortem care. Correct care would include

A. Insisting that the family bathe the patient so they can begin the grieving process.
B. Documenting the time when the patient stopped breathing and the heart ceased.
C. Notifying the physician so that the patient will be legally pronounced dead.
D. Bathing the body and removing all tubes, unless an autopsy might be ordered.

 

 

____    8.   A wife is extremely upset about her husband’s respirations. The nurse explains that this type of breathing is a symptom of end-stage disease; the breathing is called Cheyne-Stokes and is characterized by

A. Slow, shallow respirations.
B. Slow, deep respirations.
C. A cycle of shallow and deep respirations.
D. Cyanosis of the hands and feet.

 

 

____    9.   The family of a terminally ill patient asks the nurse what they should expect when he dies. The nurse tells the family:

A. “His heart will stop and then a few minutes later he will stop breathing.”
B. “Respirations and heart rate first become very irregular and then stop altogether.”.
C. “Everybody is different so it will be difficult to say.”
D. “His breathing will stop and then within a few minutes his heart will cease beating.”

 

 

____  10.   The nurse understands that perhaps the most important care that can be provided for the terminally ill patient is

A. Caring and touching.
B. Encourage reminiscing.
C. Giving pain medication.
D. Encouraging visits from a member of the clergy.

 

 

____  11.   The nurse understands that a physical change associated with the dying process that typically creates the most anxiety for the family is

A. Restlessness and difficulty in sleeping.
B. Pallor and circumoral cyanosis.
C. Accumulation of secretions in the trachea.
D. Conjunctival dryness that causes tearing of the eyes.

 

 

____  12.   A patient has a written document containing medical decisions should the patient be unable to make them as the illness progresses. The nurse understands that the patient has a

A. Durable Power of Attorney.
B. Do-Not-Resuscitate (DNR) order.
C. Living will.
D. Terminal illness.

 

 

____  13.   The nurse explains to the family that research supports that the last sense to leave a dying patient is

A. Sight.
B. Hearing.
C. Taste.
D. Vision.

 

 

____  14.   While caring for a patient who has just been informed he has a terminal illness, the nurse expects him to exhibit the traditional first stage of grief, which is called

A. Bargaining.
B. Anger.
C. Denial.
D. Depression.

 

 

____  15.   A patient with a terminal illness does not have a Do-Not-Resuscitate (DNR) order, and upon entering his room, the nurse finds that he is not breathing. The first action that the nurse will take is to

A. Ask another nurse to write the order for a DNR.
B. Call the physician to get an order for a DNR.
C. Begin cardiopulmonary resuscitation (CPR) since an order for a DNR is not written.
D. Notify the selected funeral home that the patient has expired

 

 

Multiple Response

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

 

____    1.   The nurse explains to the family members that they can anticipate that death is very near for their loved one when they see (select all that apply):

A. Mottling of feet and legs.
B. Edema of lower extremity.
C. Pulse is slow and thready.
D. Agitation and withdrawal.
E. Nonresponsiveness

 

 

____    2.   When asked by family members of a terminally ill patient what benefit their loved one would experience as a result of dehydration, the nurse explains that (select all that apply):

A. Mucous secretions increase and provide comfort to the mouth and throat.
B. Dehydration will contribute to less edema and discomfort from ascites.
C. Gastric fluid excretions increase so as to lessen nausea.
D. Urinary output decreases, which results in less discomfort from toileting.
E. Dehydration results in an interruption in perception of pain.

 

 

Completion

Complete each statement.

 

  1. When asked by the family of an 86-year-old terminally ill patient about treatment options, the nurse states, “Treatment options are more difficult with the elderly as the choices are dependent upon the patient’s dependence upon others, the terminal illness itself, and _________________.”

 

Short Answer

 

1.         A nurse explains to a terminally ill patient’s family members that they should expect their loved one to experience the five stages of grief. What is the typical order in which grief is experienced?

 

Chapter 11. Complementary and Alternative Therapies

 

Multiple Choice

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

 

____    1.   The nurse recognizes that the relationship among all living things is

A. Holism.
B. Acupressure.
C. Acupuncture.
D. Allopathic medicine.

 

 

____    2.   The nurse recognizes that a therapy used instead of conventional treatment is

A. Physical therapy.
B. Alternative therapy.
C. Conventional therapy.
D. Complementary therapy.

 

 

____    3.   The nurse recognizes that a therapy used along with conventional treatment is

A. Physical therapy.
B. Alternative therapy.
C. Conventional therapy.
D. Complementary therapy.

 

 

____    4.   A patient complains of pain and joint stiffness. The nurse recommends that the patient seek a calming massage that features long flowing strokes, kneading, vibration, and compression. This type of massage is called

A. Shiatsu.
B. Swedish.
C. Reflexology.
D. Deep tissue.

 

 

____    5.   A patient is treated with a Japanese-style massage that uses thumb pressure to work along energy meridians and is similar to acupressure. This type of massage is called

A. Shiatsu.
B. Swedish.
C. Reflexology.
D. Deep tissue.

 

 

____    6.   A complementary and alternative medicine (CAM) practitioner offers a type of massage in which the belief is that internal organs are associated with the nerve endings on the sole of the foot and is based on the idea of energy pathways that are present in the body. This type of massage is called

A. Shiatsu.
B. Swedish.
C. Reflexology.
D. Deep tissue.

 

 

____    7.   A patient seeks a vigorous, strenuous massage with focused pressure applied to tightened muscle areas and trigger points. This type of massage is called

A. Shiatsu.
B. Swedish.
C. Reflexology.
D. Deep tissue.

 

 

____    8.   The nurse recognizes that the ancient practice of inserting fine needles into carefully selected points located along meridians, or energy pathways, in the body is called

A. Holism.
B. Acupressure.
C. Acupuncture.
D. Allopathic medicine.

 

 

____    9.   A hospital dietitian conducts an in-service about the Ornish diet. The dietitian teaches that patients who adhere to this diet will most likely limit

A. Steak and potatoes.
B. Tossed green salad.
C. Oatmeal with banana slices.
D. Peanut butter on whole wheat bread.

 

 

____  10.   A nurse is performing an initial admission assessment on a patient. The patient states that he takes an herb named chamomile. The nurse recognizes that chamomile is used to treat

A. Insomnia.
B. Migraine headaches.
C. Hypercholesterolemia.
D. Irritable bowel syndrome.

 

 

____  11.   A nurse is performing an initial admission assessment on a patient. The patient states that he takes an herb named feverfew. The nurse recognizes that feverfew is used to treat

A. Insomnia.
B. Migraine headaches.
C. Hypercholesterolemia.
D. Irritable bowel syndrome.

 

 

____  12.   A new mother complains that her infant is experiencing acute diarrhea. The mother asks the nurse what type of herb she could use to treat the diarrhea. The nurse responds that an herb that helps improve acute diarrhea in infants is

A. Soy.
B. Valerian.
C. Capsaicin.
D. Saw Palmetto.

 

 

____  13.   The nurse is performing an admission assessment on a patient who states that he adheres to a discipline in which the mind is focused on an object of thought or awareness, and usually involves turning attention to a single point of reference. The nurse recognizes that the patient participates in a form of complementary and alternative medicine (CAM) known as

A. Meditation.
B. Biofeedback.
C. Aromatherapy.
D. Phytonutrients.

 

 

Multiple Response

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

 

____    1.   When caring for a patient, the nurse focuses on providing holistic health care by using complementary and alternative medicine (CAM). The nurse recognizes that holistic health care emphasizes (select all that apply):

A. Uniqueness of each individual.
B. Multiple factors as causes of illness.
C. Multiple factors as causes of disease.
D. Interaction between mind, body, and spirit.
E. A single factor as a cause for illness and disease.
F. The patient’s participation in treatment and healing.

 

 

____    2.   In Eastern medicine, illness and disease are viewed as (select all that apply):

A. Balance of energy in the body.
B. A defect of energy in the body.
C. Harmony of energy in the body.
D. Functional changes in the body.
E. An energy imbalance in the body.
F. Disharmony of energy in the body.

 

 

____    3.   Complementary and alternative medicine (CAM) practitioners focus on (select all that apply):

A. Symptom relief.
B. Symptom removal.
C. The need for crisis care.
D. A medical model of healing.
E. The need for preventative care.
F. The need to treat the cause of illness.

 

 

____    4.   A nursing instructor teaches a class of nursing students about the benefits of massage therapy. The nursing instructor states that massage therapy (select all that apply):

A. Relieves stress.
B. Assists with pain relief.
C. Relieves muscle tension.
D. Provides a sense of well-being.
E. Stimulates the circulatory system.
F. Stimulates the production of endorphins.

 

 

____    5.   The National Institutes of Health (NIH) issued a statement for the use of acupuncture that states that there is clear evidence that supports the effectiveness of acupuncture for the treatment of (select all that apply):

A. Postoperative nausea.
B. Postoperative vomiting.
C. Chemo-induced nausea.
D. Nausea with pregnancy.
E. Postoperative dental pain.
F. Chemo-induced vomiting.

 

 

____    6.   A nursing instructor teaches a class of nursing students about yoga. The nursing instructor states that yoga (select all that apply):

A. Includes meditation.
B. Includes physical postures.
C. Is a mind-body intervention.
D. Includes breathing exercises.
E. Includes pharmacological interventions.
F. Invokes ideas of harmony, health, and balance.

 

 

Completion

Complete each statement.

 

1.         The nurse recognizes that _______________ _______________ is the name used to describe traditional medicine, conventional medicine, or Western medicine.