Test bank for Medical Surgical Nursing 7th Edition Ignatavicius and M.Linda Workman

Test bank for Medical Surgical Nursing 7th Edition Ignatavicius and M.Linda Workman. The nurse is caring for a client with left-sided weakness. Which gait-training techniques will the physical therapist and the nurse use when assisting the client to walk with a cane? (Select all that apply.) a. Place the cane in the client’s left hand. b. Hold the cane with the client’s stronger hand. Test bank for Medical Surgical Nursing 7th edition by Donna D.Ignatavicius and M.Linda Workman c. Move the cane forward, followed by legs stepping forward. d. Take one step forward, followed by the cane moving forward. e. Step forward with the stronger leg, then the weaker leg. f. Move the weaker leg one step forward, followed by the stronger leg. ANS: B, C, F Placing the cane in the client’s weaker hand does not provide sufficient stability. After the cane in the stronger hand is moved ahead, the cane and the stronger leg provide a stable base for movement of the weaker leg. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Implementation) 6. The nurse is implementing nutritional changes to reduce the risk for skin breakdown in a client with impaired physical mobility. Which dietary modifications will the nurse reinforce? (Select all that apply.) a. High-protein b. Low-protein c. High-carbohydrate d. Low-carbohydrate e. High-fat Test bank for Medical Surgical Nursing 7th edition by Donna D.Ignatavicius and M.Linda Workman f. Low-fat ANS: A, C, F The goal of nutrition therapy is to provide sufficient nutrients to promote wound healing, prevent skin breakdown, and avoid gaining excessive weight. The two most important nutrients to stimulate cell division and prevent loss of muscle mass are carbohydrates and proteins. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration) MSC: Integrated Process: Nursing Process (Implementation) Test bank for Medical Surgical Nursing 7th edition by Donna D.Ignatavicius and M.Linda Workman Chapter 9: End-of-Life Care Chapter 9: End-of-Life Care Test Bank MULTIPLE CHOICE 1. The client tells the nurse that even though it has been 4 months since her sister’s death, she frequently finds herself crying uncontrollably. The client is afraid that she is “losing her mind.” What is the nurse’s best response? a. “Most people move on within a few months. You should see a grief counselor.” b. “Whenever you start to cry, distract yourself from thoughts of your sister.” c. “You should try not to cry. I’m sure your sister is in a better place now.” d. “Your feelings are completely normal and may continue for a long time.” ANS: D Frequent crying is not an abnormal response. The nurse should let the client know that this is normal and okay. Although the client may benefit from talking with a grief counselor, it is not unusual for her to still be grieving after a few months. The other responses are not as therapeutic because they justify or minimize the client’s response. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication) MSC: Integrated Process: Caring Test bank for Medical Surgical Nursing 7th edition by Donna D.Ignatavicius and M.Linda Workman 2. The nurse is discussing advance directives with a client. Which statement by the client indicates good understanding of the purpose of an advance directive? a. “An advance directive will keep my children from selling my home when I’m old.” b. “An advance directive will be completed as soon as I’m incapacitated and can’t think for myself.” c. “An advance directive will specify what I want done when I can no longer make decisions about health care.” d. “An advance directive will allow me to keep my money out of the reach of my family.” ANS: C An advance directive is a written document prepared by a competent individual that specifies what, if any, extraordinary actions a person would want taken when he or she can no longer make decisions about personal health care. It does not address issues such as the client’s residence in his or her own home. DIF: Cognitive Level: Comprehension/Understanding REF: p. 108 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Advance Directives) MSC: Integrated Process: Nursing Process (Assessment) 3. The nurse is caring for a client who is considering being admitted to hospice. What is the nurse’s best response? a. “Hospice admission has specific criteria. You may not be a viable candidate, so we will look at alternative plans for your discharge.” b. “Hospice care focuses on a holistic approach to health care. It is designed not to hasten death, but rather to relieve symptoms.” Test bank for Medical Surgical Nursing 7th edition by Donna D.Ignatavicius and M.Linda Workman c. “Hospice care will not help with your symptoms of depression. I will refer you to the facility’s counseling services instead.” d. “You seem to be experiencing some difficulty with this stage of the grieving process. Let’s talk about your feelings.” ANS: B As both a philosophy and a system of care, hospice care uses an interdisciplinary approach to assess and address the holistic needs of clients and families to facilitate quality of life and a peaceful death. This holistic approach neither hastens nor postpones death but provides relief of symptoms experienced by the dying client. DIF: Cognitive Level: Comprehension/Understanding REF: p. 108 TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care) MSC: Integrated Process: Caring 4. A hospitalized American Indian client is approaching death. Family members who are standing vigil in the client’s room begin to divide up his possessions among themselves as his symptoms progress. What is the nurse’s most important intervention? a. Ask the family members to step outside the room so the client cannot hear them. b. Tell the family that they are being insensitive and their behavior is inappropriate. c. Recognize that this is a culturally appropriate activity and document it in the chart. d. Report these activities to the client’s physician and the nursing supervisor. ANS: C Test bank for Medical Surgical Nursing 7th edition by Donna D.Ignatavicius and M.Linda Workman American Indians often disperse material possessions before or after death to friends and family members. Recognizing this culturally appropriate activity would not be consistent with removing the family, stopping the activity, or reporting the client’s family’s behaviors. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Cultural Diversity) MSC: Integrated Process: Caring 5. The spouse of a dying client states that she is concerned that her husband is choking to death. What is the nurse’s best response? a. “Do not worry. The choking sound is normal during the dying process.” b. “I will administer more morphine to keep your husband comfortable.” c. “I can ask the respiratory therapist to suction secretions out through his nose.” d. “I will have another nurse assist me to turn your husband on his side.” ANS: D The choking sound or “death rattle” is common in dying clients. The nurse should acknowledge the spouse’s concerns and provide interventions that will reduce the choking sounds. Repositioning the client onto one side with a towel under the mouth to collect secretions is the best intervention. Morphine will assist with comfort but will not decrease the choking sounds. Nasal tracheal suctioning is not appropriate in a dying client. The nurse should not minimize the spouse’s concerns. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care) MSC: Integrated Process: Caring 6. The terminally ill client is prescribed morphine to help cope with increasing discomfort. A family member expresses concern that the client is on “too much morphine.” What is the nurse’s best response? Test bank for Medical Surgical Nursing 7th edition by Donna D.Ignatavicius and M.Linda Workman a. “What has the physician told you about your family member’s illness?” b. “Don’t worry about that. We’re following the physician’s plan of care.” c. “Tell me more about what you mean by too much morphine.” d. “You should talk with your physician about this when he makes rounds.” ANS: C Asking family members to explain what they mean by “too much morphine” serves to gain more information for the nurse. The other questions will not help the nurse obtain more information about the client’s care or the family’s concerns. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication) MSC: Integrated Process: Caring and Communication 7. The nurse is teaching a family member about various types of complementary therapies that might be effective for relieving the dying client’s anxiety and restlessness. Which statement by the family member indicates understanding of the nurse’s teaching? a. “Maybe we should just hire a round-the-clock sitter to stay with Grandmother.” b. “I have some of her favorite hymns on a CD that I could bring for music therapy.” c. “I don’t think that she’ll need pain medication along with her herbal treatments.” Test bank for Medical Surgical Nursing 7th edition by Donna D.Ignatavicius and M.Linda Workman d. “I will burn therapeutic incense in the room so we can stop the anxiety pills.” ANS: B Music therapy is a complementary therapy that may produce relaxation by quieting the mind and removing a client’s inner restlessness. Complementary therapies are used in conjunction with traditional therapy. The complementary therapy would not replace pain or anxiety medication but may help decrease the need for these medications. Hiring an around-the-clock sitter does not demonstrate that the client’s family understands complementary therapies. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort Interventions) MSC: Integrated Process: Caring 8. A terminally ill client has just died in a hospital setting with family members at the bedside. The health care provider is also present. What should be the nurse’s priority intervention as postmortem care begins? a. Call for emergency assistance so that resuscitation procedures can begin. b. Ask the family members if they would like to spend time alone with the client. c. Ensure that a death certificate has been completed by the physician. d. Request family members to prepare the client’s body for the funeral home. ANS: B Before moving the client’s body to the funeral home, the nurse should ask family members if they would like to be alone with the client. Emergency assistance will not be necessary. Although it is important to ensure that a death certificate has been completed before the client is moved to the mortuary, the nurse first should ask family members if they would like to be alone with the client. The client’s family should not be expected to prepare the body for the funeral home. Test bank for Medical Surgical Nursing 7th edition by Donna D.Ignatavicius and M.Linda Workman DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care) MSC: Integrated Process: Caring 9. The nurse is providing care for a hospice client who is in the last stages of the dying process. The client develops a pressure ulcer on her sacrum, and family members tell the nurse that they would like a specialist consulted to treat the ulcer. When the nurse discusses this with the client, the client states that the ulcer does not bother her, that it is not causing her pain, and that she’d rather not have additional caregivers at this time. What should the hospice nurse do next? a. Tell the family the wound care specialist will be consulted and treatment will begin. b. Ask the social worker and the chaplain to talk with family members about the dying process. c. Explain the client’s desires to the family, emphasizing that the client will be made as comfortable as possible. d. Ask the agency mental health nurse to speak with the client about refusing treatment. ANS: C When palliative care is provided to the dying client, symptoms will be actively treated only if they are causing the client distress. In this case, the client has stated that the pressure ulcer is not causing her distress, and she does not want further intervention. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care) MSC: Integrated Process: Caring 10. The nurse is being trained in hospice care. Which intervention by the nurse is most compatible with the goals of end-of-life care for the client? Test bank for Medical Surgical Nursing 7th edition by Donna D.Ignatavicius and M.Linda Workman a. Administer influenza and pneumococcal vaccinations. b. Prevent the client with chronic obstructive pulmonary disease from smoking. c. Perform passive range-of-motion exercises to prevent contractures. d. Permit the client with diabetes mellitus to have a serving of ice cream. ANS: D When a client is near the end of life, nursing interventions should be focused toward facilitating peaceful death by granting the client’s wishes and identifying his or her needs. Allowing a client who wishes to have something that is not permitted in the diet can be comforting if he or she has a craving or a desire for that food. There is no reason to withhold it at this time.