Test Bank for Fundamentals of Nursing 3rd Edition by Yoost All Chapters

Test Bank for Fundamentals of Nursing 3rd Edition by Yoost All Chapters Professional role boundaries define the limits and responsibilities of nurses within a specific setting. It is unprofessional and unethical to share personal phone numbers or meet with patients outside of the health care setting. Therapeutic touch, such as holding the patient’s hand or touching the patient’s shoulder, can provide comfort and may alleviate pain. This is especially true when a patient is undergoing a painful or stressful procedure. Conversing 6 feet away is appropriate because it falls in the realm of social space; intimate space is 0 to 1.5 feet, personal space is 1.5 to 4 feet, and public space is 12 feet or more. One method of interpersonal communication that has been adopted to increase interprofessional and hand-off communication is the SBAR model (situation, background, action/assessment/awareness, and recommendation). DIF: Applying OBJ: 3.3 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Ethics 14. During a shift report, the nurse briefly describes the history of a patient admitted with chronic gastrointestinal bleeding. In which SBAR topical area would this information be presented? a. Situation b. Background c. Assessment d. Recommendation ANS: B The “B” in SBAR stands for “Background,” or what led up to the current situation. The “S” stands for Situation or what is happening right now. The “A” stands for “Assessment,” or what is the identified problem, concern, or need. The “R” stands for “Recommendation,” or what actions or interventions sho N uld R be i I niti G at B ed . to C U S N T O alleviate the problem. M DIF: Remembering OBJ: 3.3 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Communication 15. The nurse is performing an abdominal assessment on a postoperative surgical patient. The nurse notes that the dressing needs to be changed twice a day and discusses when the patient would like to have it done. The nurse then plans to change the dressing at that time. In which phase of the nurse–patient helping relationship would this process occur? a. Introductory phase b. Orientation phase c. Working phase d. Termination phase ANS: C In the working phase, there is the development of a contract or plan of care to achieve identified patient goals; implementation of the care plan or contract; collaborative work among the nurse, patient, and other health care providers, as needed; enhancement of trust and rapport between the nurse and the patient; reflection by the patient on emotional aspects of illness; and use of therapeutic communication by the nurse to keep interactions focused on the patient. In the orientation phase or introductory phase, introductions are made, establishing professional role boundaries (formally or informally) and expectations, and clarifying the role of the nurse. Identifying the needs and resources of the patient through observing, interviewing, and assessing the patient, followed by validation of perceptions also occur in this phase. Termination involves alerting the patient to impending closure of the relationship, evaluating the outcomes achieved during the interaction, and concluding the relationship and transitioning patient care to another caregiver, as needed. DIF: Understanding OBJ: 3.5 TOP: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort NOT: Concepts: Communication 16. The nurse is collaborating with a patient to determine interventions to ensure compliance with medication administration after the pending discharge. The nurse understands that the goals and nursing interventions would be agreed upon in which phase of the nurse–patient relationship? a. Preinteraction phase b. Orientation phase c. Working phase d. Termination phase ANS: D Termination phase involves a N le U rt R in S g I th N e G pa T ti B . en C t M to O im pending closure of the relationship, evaluating the outcomes achieved during the interaction, and concluding the relationship and transitioning patient care to another caregiver, as needed. In this case, the “new” caregiver is the patient. The working phase involves the development of a contract or plan of care to achieve identified patient goals; implementation of the care plan or contract; collaborative work among the nurse, patient, and other health care providers, as needed; enhancement of trust and rapport between the nurse and the patient; reflection by the patient on emotional aspects of illness; and use of therapeutic communication by the nurse to keep interactions focused on the patient. In the orientation phase or introductory phase, introductions are made, establishing professional role boundaries (formally or informally) and expectations, and clarifying the role of the nurse. Identifying the needs and resources of the patient through observing, interviewing, and assessing the patient, followed by validation of perceptions also occur in this phase. DIF: Understanding OBJ: 3.5 TOP: Evaluation MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Caregiving 17. A patient complains that several staff members entered the room during the morning bath without knocking. Which component of professional nursing communication has been violated in this scenario? a. Collaboration b. Advocacy c. Assertiveness d. Respect ANS: D Respect for the patient includes providing privacy during procedures such as a bath. It is considered respectful to knock on a patient’s door prior to entering the room. Assertive communication allows for the expressions of feelings and ideas without hurting or judging. Collaboration refers to the interactions with patients and health care workers to accomplish mutually acceptable goals. Advocacy involves defending the rights of others, especially those who are vulnerable or unable to make decisions independently. DIF: Understanding OBJ: 3.6 TOP: Evaluation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Caregiving 18. The nurse is caring for a patient who is unable to take oral medications because of persistent nausea and vomiting. When the nurse decides to call the primary care physician and ask for a different medication administration route, this is a demonstration of what act? a. Collaboration b. Delegation c. Assertiveness d. Advocacy ANS: D The nurse acts as a patient advocate by promoting what is best for the patient and ensuring that the patient’s needs are met. Since the patient is unable to take medications by mouth, it is the nurse’s responsibility to inform the physician and obtain alternative medication routes, as appropriate. Assertive communication allows for the expressions of feelings and ideas without hurting or judging. Collabora N ti on R r U ef I er S s G to N th B e . in C te ra M ctions with patients and health care workers to accomplish mutually acceptable goals. Delegation is the art of transferring responsibility of an assigned task to another while at the same time retaining accountability for the outcome. T O DIF: Understanding OBJ: 3.6 TOP: Evaluation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Caregiving 19. The nurse is assisting a co-worker who is preparing to change a deep wound dressing on a patient’s abdomen. Several of the patient’s out-of-town friends are at the bedside watching a football game. Which action is most appropriate for the nurse to consider prior to the dressing change? a. Ask the friends to leave the room. b. Pull the curtain around the bed. c. Allow visitors to stay in the room during the procedure. d. Ask the patient to turn up the volume on the television. ANS: A It is appropriate for the nurse to ask visitors to leave a patient’s room for a few minutes. Several factors affect the location appropriate for communication with patients. Privacy and confidentiality are critical during the interviewing and assessment process. Simply pulling a cubicle curtain around a patient’s bed does not prevent the transmission of sound beyond the curtain. Make every effort to talk with patients in an environment with as few interruptions and distractions as possible. Ask the patient to turn off competing technology and to focus on the nurse–patient interaction as needed. DIF: Applying OBJ: 3.4 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Caregiving 20. The nurse is conducting a presurgical screening interview with a patient at a local surgical center. When performing a health assessment, the nurse identifies which source should be the primary source of information? a. Spouse b. Medical record c. Close relative d. Patient ANS: D The primary source from which data are collected is the patient. A secondary source would include a significant other, family members, caregivers, other members of the health team, and medical records. DIF: Remembering OBJ: 3.4 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Caregiving 21. A mother of a young child kicks a trashcan in anger and says to the nurse, “You just don’t understand! Why can’t the doctor find out what is wrong with my child?” The nurse understands that this behavior is most likely an example of which defense mechanism? a. Suppression b. Sublimation c. Displacement d. Rationalization ANS: C Displacement is an unconscious defense mechanism used to avoid conflict and anxiety by transferring emotions from one object to another object that is less anxiety-producing. The mother is upset that the health care team is not able to determine the cause of her child’s illness and expresses her anger by kicking the trashcan. Suppression is the conscious decision to conceal unacceptable or painful thoughts. Sublimation is the rechanneling of unacceptable impulses into socially acceptable activities. Rationalization is the act of suggesting a different explanation for one that is painful, negative, or unacceptable. DIF: Understanding OBJ: 3.8 TOP: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Coping 22. The nurse is caring for a patient scheduled for a partial mastectomy resulting from advanced cancer. The patient tells the nurse, “I’m sure when the surgeon operates on me, he will not find any cancer in my breast. It looks just fine.” The nurse recognizes that the patient is using which defense mechanism to cope with the medical diagnosis? a. Suppression b. Sublimation c. Displacement d. Denial ANS: D The patient is refusing to admit that the breast has to be removed because of cancer. This inability to accept the truth is termed denial. Displacement is an unconscious defense mechanism used to avoid conflict and anxiety by transferring emotions from one object to another object that is less anxiety producing. Suppression is the conscious decision to conceal unacceptable or painful thoughts. Sublimation is the rechanneling of unacceptable impulses into socially acceptable activities. DIF: Understanding OBJ: 3.8 TOP: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Coping MULTIPLE RESPONSE 1. The nurse understands that the nurse–patient relationship focuses on which areas? (Select all that apply.) a. Building trust b. Demonstrating sympathy c. Tearing down boundaries d. Developing a plan of care e. Applying cultural generalities ANS: A, C, D A helping relationship develops through ongoing, purposeful interaction between a nurse and a patient. The focal point of the nurse–patient helping relationship is the patient and the patient’s needs and concerns. Nurse–patient relationships focus on five areas: (1) building trust, (2) demonstrating empathy, (3) establishing boundaries, (4) recognizing and respecting cultural influences, and (5) developing a comprehensive plan of care. DIF: Understanding OBJ: 3.4 TOP: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Communication 2. When administering a bath to a hearing-impaired patient, what actions should the nurse carry out? (Select all that apply.) a. Speak very loudly into the patient’s right ear. b. Control background noise as much as possible. c. Turn away when responding to a question. d. Adjust the lighting in the room. e. Be wary of consistent affirmative answers. ANS: B, D, E When communicating with a hearing-impaired patient, the nurse should make sure that the area is well lit with as little background noise as possible. Hearing aids amplify all sounds, making noisy environments confusing and frustrating. Raising the voice level slightly, speaking clearly, and making sure that the patient can see the nurse’s face helps to facilitate communication. Adequate lighting enhances the patient’s ability to see the speaker’s mouth and face and interpret nonverbal communication. Consistent affirmative answers to the nurse’s questions may be an indication that the patient is not hearing the information being shared. Care should be taken to verify that patients truly understand the content of verbal interaction. Extra patience may be required by the nurse to demonstrate caring while communicating with hearing-impaired patients. DIF: Applying OBJ: 3.9 TOP: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Communication 3. The nursing student is writing a report on the use of nonverbal techniques to encourage therapeutic communication. Which examples would be included in the report? (Select all that apply.) a. Providing a backrub b. Remaining silent c. Refraining from distracting body movements d. Facing the patient e. Avoiding eye contact ANS: A, B, C, D Providing a backrub is considered therapeutic touch; additional examples include holding a patient’s hand and gently touching a patient’s arm. Silence refers to being present with a patient without verbal communication. Facing the patient and refraining from unusual body movements are active listening N R I G B.C M U tec S N hniq ues T . Avoid O ing eye contact does not facilitate communication. DIF: Remembering OBJ: 3.2 TOP: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Communication Chapter 04: Critical Thinking in Nursing Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative Practice, MULTIPLE CHOICE 1. The patient is complaining of severe incisional pain 2 days after surgery. The patient has Morphine ordered intravenously or by mouth. When the nurse chooses to give the medication orally, this is an example of which thought process? a. Decision making b. Reasoning c. Problem solving d. Judgment ANS: A Decision making requires choosing a solution to a problem. Reasoning is the process by which a nurse is able to focus and filter information and determine what is most important to consider. A systematic, analytic approach in finding solutions is termed problem solving, and judgment is the process of forming an opinion by comparing solutions through reasoning. DIF: Remembering OBJ: 4.1 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control NOT: Concepts: Clinical Judgment 2. The nurse is reviewing the last 3 days of a patient’s pain history and notes that the pain level has remained constant. The nurse validates the pain level with the patient and decides to contact the provider for further a. Decision making b. Reasoning c. Problem solving d. Judgment ANS: D N R I G B.C M U ord S ers. N In T this scen O ario, which process is the nurse is using? Processes dependent on critical thinking include problem solving, decision making, reasoning, and judgment. Judgment is the process of forming an opinion by comparing solutions through reasoning. The nurse observes that the patient’s pain level is not decreasing and further assesses the pain level through discussions with the patient. The nurse concludes that the patient’s pain should be further addressed and contacts the provider. Decision making requires choosing a solution to a problem. The student is making a decision by reviewing two pertinent resources related to the removal of staples. Reasoning is the process by which a nurse links thoughts, ideas and facts together in a logical way. A systematic approach in finding solutions is termed problem solving. DIF: Remembering OBJ: 4.1 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control NOT: Concepts: Clinical Judgment 3. The nurse has been hired for a first job and is nervous about making errors in clinical judgment. It is important for the nurse to realize that clinical reasoning and the ability to make decisions in a clinical setting occurs at which time? a. When it has been instilled in the content covered in nursing school. b. When it is solely based in clinical experience. c. When it develops over time with increased knowledge and expertise. d. When it is an expectation of all nurses regardless of experience. ANS: C Clinical reasoning uses critical thinking, knowledge, and experience to develop solutions to problems and make decisions in a clinical setting. A nurse’s clinical-reasoning skills develop over time with increased knowledge and expertise. DIF: Understanding OBJ: 4.1 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control NOT: Concepts: Clinical Judgment 4. The nurse is taking an advanced cardiac life support (ACLS) recertification class. As part of that class, the nurse and other nurses in the group rotate responsibilities during multiple mock code exercises simulating cardiac arrest scenarios. The nurse recognizes what process is assigning the nurses to these different responsibilities? a. Concept mapping b. Simulation c. Role playing d. Literature review ANS: C A role-play strategy involves assigning learners to different roles based on expected outcomes in a particular setting. Other learners and facilitators observe the role playing, and then all are involved in the debriefing or discussion of the scenario. As with simulation, this approach allows learners to interact in N a sa R fe U , c I o S nt G ro N ll B ed . e C nv ir M onment. The concept map is a way to organize and visualize data to identify relationships and solve problems. Simulated experiences enable the student to apply previously learned content in a safe and realistic environment that allows time for questioning, clarifying, and feedback. Students develop confidence in providing direct nursing care. Because critical thinking cannot occur about subjects that are unknown, a review of literature may foster this type of thinking by addressing knowledge deficits. T O DIF: Understanding OBJ: 4.7 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 5. The nurse is preparing to administer an anticoagulant when the patient says, “Why do I have these bruises on my arms?” The nurse reviews the patient’s blood tests and notes an abnormal bleeding time. When the nurse then decides to hold the medication and notify the health care provider, the nurse recognizes this to be an example of which action? a. Thinking aloud b. Reviewing the literature c. Applying knowledge d. Role playing ANS: C Nursing practice is based on the application of knowledge to address patient problems. In this case, the nurse is able to connect the medication, physical signs and laboratory data to determine a course of action. Nurses may “think aloud” as an inner dialogue to examine their thinking. The literature review is used to address knowledge gaps through the review of scholarly journals. A role-play strategy involves assigning learners to different roles based on expected outcomes in a particular setting. Other learners and facilitators observe the role playing, and then all are involved in the debriefing or discussion of the scenario. DIF: Understanding OBJ: 4.5 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 6. The nurse is preparing to restart a patient’s intravenous line and discovers that the patient has no usable veins in either arm. When working to solve this problem, the nurse should carry out which action? a. Discuss the problem with the nurse in charge. b. Not start the intravenous line. c. Conduct an Internet search for infusion journal articles. d. Contact the provider and report the concern. ANS: A Whether in an academic setting or in the clinical area, discussion of a problem, issue, or situation with colleagues may improve critical thinking. Through dialogue with others who have expertise or experience with the issue being faced, knowledge gaps can be filled, erroneous assumptions exposed, and unconscious biases addressed. Not starting the intravenous line is not an option at this point. A literature review to gain published information about intravenous complications may be appropriate after the patient’s concern has been addressed. Initially co U nta S ctin N g th T e provid O er without fully exploring the options for alternate insertion sites is neither wise nor recommended. N R I G B.C M DIF: Applying OBJ: 4.7 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 7. The nurse has finished a shift and is on the way home. During the shift, one of the patients attempted to climb out of bed and fell. When the nurse is returning home and is thinking about what could have been done differently to be prevent the fall, this would be an example of what concept? a. Evidence b. Standards c. Attributes or traits d. Reflection ANS: D Reflection is an effective tool that enables students and nurses to think about how best to improve their future caregiving in similar situations. The results of deliberate thinking are used to guide further thinking. Identification and use of evidence is necessary to guide analysis of situations and decision making. Nursing practice must be based on evidence gained through research and review of findings. Some personal characteristics are associated with critical thinking. Critical thinking needs to be assessed and evaluated according to standards to ensure the quality of thinking. Nursing practice is based on standards established by the American Nurses Association in areas such as the nursing process, ethics, education, research, communication, leadership, and collaboration. DIF: Applying OBJ: 4.2 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 8. When working on the ability to critically think, the nurse needs to develop a critical-thinking character that includes which quality? a. Developing honesty and confidence b. Learning from experiences c. Enhancing self-reliance d. Growing a “thick skin” to withstand criticism ANS: A To develop critical thinking, the nurse needs to develop a critical-thinking character, which includes maintaining high standards and developing critical-thinking qualities such as honesty, fair-mindedness, creativity, patience, persistence, and confidence. The next step in the development of critical thinking includes taking responsibility for personal learning and seeking needed experiences that can provide the necessary knowledge on which to base the N R I G B.C M thinking. Fostering interperson U al s S kills N , su T ch as te O amwork, conflict management, and advocacy, is important in the development of critical thinking. Self-evaluation and having thinking evaluated by others require the ability to accept and use constructive criticism. DIF: Applying OBJ: 4.2 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 9. The nurse is caring for a patient scheduled for a heart catheterization. During shift report, the nurse describes an overheard telephone conversation regarding the patient’s HIV-positive son-in-law. The nurse recognizes that this information should be evaluated for which characteristic? a. Accuracy b. Depth c. Breadth d. Relevance ANS: D Relevance is focusing on facts and ideas directly related and pertinent to a topic—how is this related to the question? The son-in-law’s HIV status has no bearing on the patient’s care. Accuracy involves representing something in a true and correct way. Depth is getting beneath the surface of the topic or problem to identify and manage related complexities, whereas breadth involves considering a topic, problem, or issue from every relevant viewpoint. DIF: Applying OBJ: 4.3 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 10. A patient arrives at the urgent care clinic and complains of vague pains in the legs and the nurse asks the patient to describe this pain in greater depth. The nurse knows this is a critical-thinking skill and can be developed in which context? a. Critical thinking is used to avoid repetition in providing care. b. Critical thinking can be enhanced through practice. c. Critical thinking should be based in thought and not spontaneity. d. Critical-thinking skills become dull when used routinely. ANS: B The ultimate goal is for these questions to become so spontaneous in thinking that they form a natural part of our inner voice, guiding us to better reasoning. As with any skill, critical thinking can be enhanced through practice. The routine use of these questions should promote critical thought. DIF: Understanding OBJ: 4.3 TOP: Evaluation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 11. The nurse is planning care for a group of patients and recognizes which activity may be delegated to unlicensed assistive personnel? a. Analysis of the patient’s physical condition b. Morning vital signs, height, and weight c. Evaluation of whether colostomy drainage is normal d. Determining patient read ANS: B N in es U R s fo S I r p o N G st -s T B . ur C gi ca l O M learning The nurse often works with unlicensed assistive personnel (UAP) to collect relevant data on height and weight, intake and output, and vital signs. The registered nurse uses critical thinking to guide decisions related to delegation of assignments and tasks. Before delegation of a task, the nurse must be knowledgeable about the role, scope of practice, and competency of the recipient of the delegated task. Analysis and evaluation of patient conditions and readiness for teaching require critical thinking and are nursing functions. DIF: Understanding OBJ: 4.5 TOP: Evaluation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 12. The nurse is caring for a patient who is suspected of having early stages of dementia and observes mild confusion, short-term memory loss, and restlessness. When the nurse conducts a mini-mental status exam, the nurse is using which component of critical thinking? a. Validation b. Interpretation c. Intuition d. Reasoning ANS: A