4. An ethnic older adult may feel a loss of self-worth when the nurse
a.informs the patient about ethnic support services.
b.allows a patient to rely on ethnic health beliefs and practices.
c.has to use an interpreter to provide explanations and teaching.
d.emphasizes that a therapeutic diet does not allow ethnic foods.
Give this one a try later!
Correct answer: d
Rationale: An older adult with strong ethnic and cultural beliefs may
experience loss of self if nurses deny or ignore ethnic and cultural
practices and behaviors.
4 A nurse is caring for a patient with end-stage lung disease. The patient wants to go
home on oxygen and be comfortable. The family wants the patient to have a new
surgical procedure. The nurse explains the risk and benefits of the surgery to the
family and discusses the patient's wishes with the family. The nurse is acting as the
,patient's:
1Educator
2Advocate
3Caregiver
4Case manager
Give this one a try later!
Answer: 2.
An advocate protects the patient's human and legal right to make choices
about his or her care. An advocate may also provide additional information
to help a patient decide whether or not to accept a treatment or find an
interpreter to help family members communicate their concerns.
9 When communicating with a patient who has expressive aphasia, the highest priority
for the nurse is:
1To ask open-ended questions.
2To understand that the patient will be uncooperative.
3To coach the patient to respond.
4To offer pictures or a communication board so the patient can point.
Give this one a try later!
Answer: 4.
Patients who have expressive aphasia understand questions but have
difficulty expressing an answer. To promote interaction with the patient,
offer pictures or a communication board so the patient can point to key
words or images. Listen to the patient and wait for him or her to
communicate. Use simple, short questions and facial gestures to give
additional cues.
7 A patient had a left-sided cerebrovascular accident 3 days ago and is receiving
5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The
patient is receiving enteral feedings through a small-bore nasogastric (NG) tube
,because of dysphagia. Which of the following symptoms requires the nurse to call the
health care provider immediately?
1Pale yellow urine
2Unilateral neglect
3Slight movement noted on the R side
4Coffee ground-like aspirate from the feeding tube
Give this one a try later!
Answer: 4.
When patients are receiving medications such as heparin or enoxaparin
(Lovenox), you must assess for signs of bleeding. These include overt signs
such as bleeding from their gums or covert signs, which can be detected
by testing their stool or observing their aspirate from NG tubes for coffee
ground-like matter. These are signs of bleeding in the gastrointestinal tract.
13 You are caring for an 80-year-old man who recently lost his wife. He shares with
you that he has been drinking more than he ever did in the past and feels hopeless
without his wife. He reports that he rarely sees his children and feels isolated and
alone. This patient is at risk for:
1Dementia.
2Liver failure.
3Dehydration.
4Suicide.
Give this one a try later!
Answer: 4.
The patient is sharing that he is depressed. Key concepts include recent
loss of his wife, excessive drinking, hopelessness, and isolation, making him
at risk for suicide.
, A patient needs to learn to use a walker. Which domain is required for learning this
skill?
1Affective domain
2Cognitive domain
3Attentional domain
4Psychomotor domain
Give this one a try later!
Answer: 4.
Using a walker requires the integration of mental and muscular activity.
12 Immobilized patients are at risk for impaired skin integrity. Which of the following
interventions would reduce this risk? (Select all that apply.)
1Repositioning patient every 1 to 2 hours while awake
2Using an objective, valid scale to assess patient's risk for pressure ulcer development
3Using a device to relieve pressure when patient is seated in chair
4Teaching patient how to shift weight at regular intervals while sitting in a chair
5A good rule is: the higher the risk for skin breakdown, the shorter the interval
between position changes
Give this one a try later!
12. Answer: 2, 3, 4, 5.
Patients must be repositioned around the clock, not just when they are
awake; therefore answer 1 is incorrect. An objective assessment scale allows
the nurse to assess for pressure ulcer risk over time. Once the risk is
identified, the assessment tool guides the nurse in selecting appropriate
pressure-relief devices. Showing the patient how to reduce his or her risk
by shifting pressure is also important. Frequent and meaningful position
changes that are in concert with the patient's condition and risk factors are
necessary to reduce pressure ulcer developments.
a.informs the patient about ethnic support services.
b.allows a patient to rely on ethnic health beliefs and practices.
c.has to use an interpreter to provide explanations and teaching.
d.emphasizes that a therapeutic diet does not allow ethnic foods.
Give this one a try later!
Correct answer: d
Rationale: An older adult with strong ethnic and cultural beliefs may
experience loss of self if nurses deny or ignore ethnic and cultural
practices and behaviors.
4 A nurse is caring for a patient with end-stage lung disease. The patient wants to go
home on oxygen and be comfortable. The family wants the patient to have a new
surgical procedure. The nurse explains the risk and benefits of the surgery to the
family and discusses the patient's wishes with the family. The nurse is acting as the
,patient's:
1Educator
2Advocate
3Caregiver
4Case manager
Give this one a try later!
Answer: 2.
An advocate protects the patient's human and legal right to make choices
about his or her care. An advocate may also provide additional information
to help a patient decide whether or not to accept a treatment or find an
interpreter to help family members communicate their concerns.
9 When communicating with a patient who has expressive aphasia, the highest priority
for the nurse is:
1To ask open-ended questions.
2To understand that the patient will be uncooperative.
3To coach the patient to respond.
4To offer pictures or a communication board so the patient can point.
Give this one a try later!
Answer: 4.
Patients who have expressive aphasia understand questions but have
difficulty expressing an answer. To promote interaction with the patient,
offer pictures or a communication board so the patient can point to key
words or images. Listen to the patient and wait for him or her to
communicate. Use simple, short questions and facial gestures to give
additional cues.
7 A patient had a left-sided cerebrovascular accident 3 days ago and is receiving
5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The
patient is receiving enteral feedings through a small-bore nasogastric (NG) tube
,because of dysphagia. Which of the following symptoms requires the nurse to call the
health care provider immediately?
1Pale yellow urine
2Unilateral neglect
3Slight movement noted on the R side
4Coffee ground-like aspirate from the feeding tube
Give this one a try later!
Answer: 4.
When patients are receiving medications such as heparin or enoxaparin
(Lovenox), you must assess for signs of bleeding. These include overt signs
such as bleeding from their gums or covert signs, which can be detected
by testing their stool or observing their aspirate from NG tubes for coffee
ground-like matter. These are signs of bleeding in the gastrointestinal tract.
13 You are caring for an 80-year-old man who recently lost his wife. He shares with
you that he has been drinking more than he ever did in the past and feels hopeless
without his wife. He reports that he rarely sees his children and feels isolated and
alone. This patient is at risk for:
1Dementia.
2Liver failure.
3Dehydration.
4Suicide.
Give this one a try later!
Answer: 4.
The patient is sharing that he is depressed. Key concepts include recent
loss of his wife, excessive drinking, hopelessness, and isolation, making him
at risk for suicide.
, A patient needs to learn to use a walker. Which domain is required for learning this
skill?
1Affective domain
2Cognitive domain
3Attentional domain
4Psychomotor domain
Give this one a try later!
Answer: 4.
Using a walker requires the integration of mental and muscular activity.
12 Immobilized patients are at risk for impaired skin integrity. Which of the following
interventions would reduce this risk? (Select all that apply.)
1Repositioning patient every 1 to 2 hours while awake
2Using an objective, valid scale to assess patient's risk for pressure ulcer development
3Using a device to relieve pressure when patient is seated in chair
4Teaching patient how to shift weight at regular intervals while sitting in a chair
5A good rule is: the higher the risk for skin breakdown, the shorter the interval
between position changes
Give this one a try later!
12. Answer: 2, 3, 4, 5.
Patients must be repositioned around the clock, not just when they are
awake; therefore answer 1 is incorrect. An objective assessment scale allows
the nurse to assess for pressure ulcer risk over time. Once the risk is
identified, the assessment tool guides the nurse in selecting appropriate
pressure-relief devices. Showing the patient how to reduce his or her risk
by shifting pressure is also important. Frequent and meaningful position
changes that are in concert with the patient's condition and risk factors are
necessary to reduce pressure ulcer developments.
