Chapter 01: Aspects of Medical-Surgical Nursing Linton: Medical-Surgical Nursing, 7th Edition

Chapter 01: Aspects of Medical-Surgical Nursing Linton: Medical-Surgical Nursing, 7th Edition. 1. What care skills are safe and appropriate for the licensed practical nurse (LPN) to teach family members in the home health care setting? (Select all that apply.) a. Insulin injection b. Sterile dressing changes c. Venipunctures d. Periodic Foley catheter insertions e. Instillation of eye drops f. Changing dressings on small wounds ANS: A, E, F Insulin injections, instillation of eye drops, and small wound dressing changes are safe to teach a nonprofessional caregiver. Sterile dressings, venipunctures, and inserting Foley catheters are considered skilled, and the costs for these are reimbursed by Medicare. DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: 3 TOP: Skills Taught by Home Health Nurse KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 2. The nursing care plan in a long-term care facility calls for the documentation of regressive behavior of a newly admitted 82-year-old resident who has had congestive heart failure and osteoarthritis. Of these behaviors observed by the nurse, which should be documented as regression? (Select all that apply.) a. Talks nonstop to staff and other residents. b. Wets and soils self several times a day. c. Wakes in the middle of the night and is unable to return to sleep. d. Wears the same clothes day after day. e. Cries frequently for no apparent reason. ANS: B, D, E Behaviors that are infantile or immature in the absence of dementia are considered regressive. Frequent episodes of crying and inattention to personal hygiene are regressive in nature. Excessive talking and wakefulness may be related to relocation anxiety, but they are not considered regressive. DIF: Cognitive Level: Analysis REF: pp. 20-21 OBJ: 10 TOP: Impact of Relocation KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 3. From what do most quality-of-care problems in home health care result? (Select all that apply.) a. Patient’s noncompliance b. Family’s reluctance to participate in the care c. Inadequate documentation d. Limited funding e. Defective communication among care team members ANS: C, E Inadequate communication and incomplete documentation create most of the quality-of-care problems. DIF: Cognitive Level: Comprehension REF: pp. 11-12 OBJ: 2 TOP: Communication in Home Health Setting KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 4. An 80-year-old man is newly admitted to a long-term care facility and suddenly becomes incontinent of urine at night. What nursing interventions should be used to help restore self-toileting? (Select all that apply.) a. Waking the resident every 2 hours and escorting him to the bathroom b. Leaving a night-light on c. Discouraging the use of long-legged pajama bottoms d. Placing a urinal at the bedside e. Keeping the room uncluttered ANS: B, C, D, E Providing light in an uncluttered room, encouraging clothing that does not impede self-toileting, and making the urinal available increase independence and alleviate situations that make self-toileting difficult. Waking a resident not only disturbs his or her rest, but doing so also increases dependency on the staff. DIF: Cognitive Level: Application REF: pp. 11-12 OBJ: 10 | 11 TOP: Independence in Long-Term Care Center KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation. 5.Based on guidelines from the Americans with Disability Act (ADA), which question is an appropriate choice for the director of nurses to ask a nurse with an artificial leg who is applying for a staff position in an extended care facility? a. “How long have you had your prosthesis?” b. “How many flights of stairs are you able to climb without assistance?” c. “Are you able to lift a load of 45 lb?” d. “Has your disability caused you to miss work?” ANS: C Queries to disabled job applicants can be made relative to specific job functions, but they cannot be asked relative to the severity of the disability or the degree of disability in general. DIF: Cognitive Level: Application REF: p. 16 OBJ: 7 | 8 TOP: ADA KEY: Nursing Process Step: N/A MSC: NCLEX: N/A. 6. A nurse reminds a resident in a long-term care facility that he has autonomy in many aspects of his institutionalization. What is an example of autonomy? a. Selection of medication times b. Availability of his own small electrical appliances c. Smoking in the privacy of his own room d. Application of advance directives ANS: D The application of advance directives is an autonomous decision. Agency protocols relative to medication times, access to private electrical devices, and smoking are rarely waived; these policies are not in the control of the resident. DIF: Cognitive Level: Comprehension REF: p. 22 OBJ: 10 TOP: Autonomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation.