Test Bank For Concepts for Nursing Practice 3rd Edition By Giddens Chapter 1-26 | Complete Guide Newest Version

Test Bank For Concepts for Nursing Practice 3rd Edition By Giddens Chapter 1-26 | Complete Guide Newest Version . The school nurse talking with a high school class about the difference between growth and development would best describe growth as a. processes by which early cells specialize. b. psychosocial and cognitive changes. c. qualitative changes associated with aging. d. quantitative changes in size or weight. ANS: D Growth is a quantitative change in which an increase in cell number and size results in an increase in overall size or weight of the body or any of its parts. The processes by which early cells specialize are referred to as differentiation. Psychosocial and cognitive changes are referred to as development. Qualitative changes associated with aging are referred to as maturation. S - The Marketplace to Buy and Sell your Study Material REF: 2 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 4. The most appropriate response of the nurse when a mother asks what the Denver II does is that it a. can diagnose developmental disabilities. b. identifies a need for physical therapy. c. is a developmental screening tool. d. provides a framework for health teaching. ANS: C The Denver II is the most commonly used measure of developmental status used by health care professionals; it is a screening tool. Screening tools do not provide a diagnosis. Diagnosis requires a thorough neurodevelopment history and physical examination. Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. The need for any therapy would be identified with a comprehensive evaluation, not a screening tool. Some providers use the Denver II as a framework for teaching about expected development, but this is not the primary purpose of the tool. REF: 4 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 5. To plan early intervention and care for an infant with Down syndrome, the nurse considers knowledge of other physical development exemplars such as a. cerebral palsy. b. failure to thrive. c. fetal alcohol syndrome. d. hydrocephaly. ANS: D Hydrocephaly is also a physical development exemplar. Cerebral palsy is an exemplar of adaptive developmental delay. Failure to thrive is an exemplar of social/emotional developmental delay. Fetal alcohol syndrome is an exemplar of cognitive developmental delay. REF: 9 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 6. To plan early intervention and care for a child with a developmental delay, the nurse would consider knowledge of the concepts most significantly impacted by development, including a. culture. b. environment. c. functional status. d. nutrition. ANS: C S - The Marketplace to Buy and Sell your Study Material Function is one of the concepts most significantly impacted by development. Others include sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept that is considered to significantly affect development; the difference is the concepts that affect development are those that represent major influencing factors (causes), hence determination of development and would be the focus of preventive interventions. Environment is considered to significantly affect development. Nutrition is considered to significantly affect development. REF: 1 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 7. A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks to her toys and makes up stories. The mother wants her child to have a psychologic evaluation. The nurse’s best initial response is to a. refer the child to a psychologist. b. explain that playing make believe with dolls and people is normal at this age. c. complete a developmental screening. d. separate the child from the mother to get more information. ANS: B By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal at this age. A referral to a psychologist would be premature based only on the complaint of the mother. Completing a developmental screening would be very appropriate but not the initial response. The nurse would certainly want to get more information, but separating the child from the mother is not necessary at this time. REF: 5 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 8. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is so needy and acting like a child. The best response of the nurse is that in the hospital, adolescents a. have separation anxiety. b. rebel against rules. c. regress because of stress. d. want to know everything. ANS: C Regression to an earlier stage of development is a common response to stress. Separation anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually not an issue if the adolescent understands the rules and would not create childlike behaviors. An adolescent may want to “know everything” with their logical thinking and deductive reasoning, but that would not explain why they would act like a child. REF: 4 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance Concept 2: Functional Ability Test Bank MULTIPLE CHOICE 1. The nurse is assessing a patient's functional ability. Which activities most closely match the definition of functional ability? a. Healthy individual, works outside the home, uses a cane, well groomed b. Healthy individual, college educated, travels frequently, can balance a checkbook c. Healthy individual, works out, reads well, cooks and cleans house d. Healthy individual, volunteers at church, works part time, takes care of family and house ANS: D Functional ability refers to the individual's ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being. The other options are good; however, each option has advanced or independent activities in the context of the option. REF: 11 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort 2. The nurse is assessing a patient's functional performance. What assessment parameters will be most important in this assessment? a. Continence assessment, gait assessment, feeding assessment, dressing assessment, transfer assessment b. Height, weight, body mass index (BMI), vital signs assessment c. Sleep assessment, energy assessment, memory assessment, concentration assessment d. Healthy individual, volunteers at church, works part time, takes care of family and house ANS: A Functional impairment, disability, or handicap refers to varying degrees of an individual's inability to perform the tasks required to complete normal life activities without assistance. Height, weight, BMI, and vital signs are physical assessment. Sleep, energy, memory, and concentration are part of a depression screening. Healthy, volunteering, working, and caring for family and house are functional abilities, not performance. REF: 11 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the patient's functional ability. What question would be the most appropriate? a. "Are you able to shop for yourself?" b. "Do you use a cane, walker, or wheelchair to ambulate?" c. "Do you know what today's date is?" d. "Were you sad or depressed more than once in the last 3 days?" ANS: B S - The Marketplace to Buy and Sell your Study Material "Do you use a cane, walker, or wheelchair to ambulate?" will assist the nurse in determining the patient's ability to perform self-care activities. A nutritional health risk assessment is not the functional assessment. Knowing the date is part of a mental status exam. Assessing sadness is a question to ask in the depression screening. REF: 11-12 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation 4. The nurse is developing an interdisciplinary plan of care using the Roper-Logan-Tierney Model of Nursing for a patient who is currently unconscious. Which interventions would be most critical to developing a plan of care for this patient? a. Eating and drinking, personal cleansing and dressing, working and playing b. Toileting, transferring, dressing, and bathing activities c. Sleeping, expressing sexuality, socializing with peers d. Maintaining a safe environment, breathing, maintaining temperature ANS: D The most critical aspects of care for an unconscious patient are safe environment, breathing, and temperature. Eating and drinking are contraindicated in unconscious patients. Toileting, transferring, dressing, and bathing activities are BADLs. Sleeping, expressing sexuality, and socializing with peers are a part of the Roper-Logan-Tierney Model of Nursing; however, these are not the most critical for developing the plan of care in an unconscious patient. REF: 13 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The home care nurse is trying to determine the necessary services for a 65-year-old patient who was admitted to the home care service status after left knee replacement. Which tool(s) will assist with this determination? a. Minimum Data Set (MDS) b. Functional Status Scale (FSS) c. 24-Hour Functional Ability Questionnaire (24hFAQ) d. The Edmonton Functional Assessment Tool ANS: C The 24hFAQ assesses the postoperative patient in the home setting. The MDS is for nursing home patients. The FSS is for children. The Edmonton is for cancer patients. REF: 13 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 6. The nurse is assessing a patient's functional abilities and asks the patient, "How would you rate your ability to prepare a balanced meal?" "How would you rate your ability to balance a checkbook?" "How would you rate your ability to keep track of your appointments?" Which tool would be indicated for the best results of this patient's perception of their abilities? a. Functional Activities Questionnaire (FAQ)™ b. Mini Mental Status Exam (MMSE) c. 24hFAQ d. Performance-based functional measurement ANS: A S - The Marketplace to Buy and Sell your Study Material Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material The FAQ is an example of a self-report tool which provides information about the patient's perception of functional ability. The MMSE assesses cognitive impairment. The 24hFAQ is used to assess functional ability in postoperative patients. Performance-based tools involve actual observation of a standardized task, completion of which is judged by objective criteria. REF: 12 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance MULTIPLE RESPONSE 1. A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse is assessing the patient's risk for falls so that falls prevention can be implemented if necessary. Select all the risk factors that apply from this patient's history and physical. (Select all that apply.) a. Being a woman b. Taking more than six medications c. Having hypertension d. Having cataracts e. Muscle strength 3/5 bilaterally f. Incontinence ANS: B, D, E, F Adverse effects of medications can contribute to falls. Cataracts impair vision, which is a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine or stool increases risk for falls. Men have a higher risk for falls. Hypertension itself does not contribute to falls. Dizziness does contribute to falls. REF: 14 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential OTHER 1. Match the activities listed with the appropriate functional level of ability: Use A for instrumental activities of daily living (IADLs) and use B for basic activities of daily living (BADLs). (Your answer should appear as letters separated by commas and spaces [e.g., A, A, A, A, A, A].) A. Uses a cane B. Bathes daily C. Takes medications as prescribed D. Dresses self E. Balances the checkbook F. Cleans the house ANS: B, B, A, B, A, A Functional impairment, disability, or handicap refers to varying degrees of an individual's inability to perform the tasks required to complete normal life activities without assistance. IADLs are more complex skills that are essential to living in the community. REF: 14 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential Powered by TCPDF () S - The Marketplace to Buy and Sell your Study Material Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material Concept 3: Family Dynamics Test Bank MULTIPLE CHOICE 1. The most appropriate initial nursing intervention when the nurse notes dysfunctional interactions and lack of family support for a patient would be to a. enforce hospital visiting policies. b. monitor the dysfunctional interactions. c. notify the primary care provider. d. role model appropriate support. ANS: D Nurses can, at times, role model more appropriate interactions or provide suggestions for improving communication and interactions among family members. If the nurse determines that the number of visitors has a negative impact on the patient, hospital policy may be to limit visitors, but that would not be the initial action. Monitoring the dysfunctional interactions would not be an adequate response. The primary care provider should certainly be notified, but that would not be the initial response. REF: 22 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 2. The nurse caring for a patient would identify a need for additional interventions related to family dynamics when a. extended family offers to help. b. family members express concern. c. the ill member demands attention. d. memories are shared. ANS: C It is not uncommon for the ill family member to become demanding and indicate that they deserve special treatment and care, and the supportive family may need assistance in understanding the dynamics of the illness in order to continue to be supportive. Offers from extended family to help can be indicative of positive dynamics. Concern expressed by family members can be indicative of positive dynamics. Sharing of family memories can be indicative of positive dynamics. REF: 24-25 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 3. Jane and Janet have an established long-term relationship and are attending parenting classes in anticipation of finalizing adoption of baby Joan. Jane and Janet would be considered which type of family? a. Cohabiting b. Nuclear c. Same-sex d. Single parent ANS: C This study source was downloaded by from CourseH on :48:28 GMT -05:00 S - The Marketplace to Buy and Sell your Study Material Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material Jane and Janet would be considered a same-sex family. Cohabiting refers to a couple who live together with no legal bond. Nuclear refers to the traditional male and female core family with one or more children. Single parent refers to a family with one adult and one or more children. REF: 20 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 4. Critical Thinking: The nurse identifies the family with a child graduating from college as being in the family life cycle of a. single young adult leaving home. b. new couple joins their families through marriage or living together. c. families with young children. d. launching children and moving on. ANS: D The launching children and moving cycle occurs when the children become independent and establish their own home, as when they graduate and begin to establish their own lives, separate from the family of origin. The single young adult leaving home cycle occurs when the "child" establishes their own home away from the family they grew up with. The new couple joins their families through marriage or living together cycle begins when a couple establishes a household separate from the family of origin. The families with young children cycle begins with the addition of a child to the family. REF: 23|27 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 5. When reviewing the purposes of a family assessment, the nurse educator would identify a need for further teaching if the student responded that family assessment is used to gain an understanding of the family a. development. b. function. c. political views. d. structure. ANS: C An understanding of the political views of family members is not a primary purpose of a family assessment. A family assessment provides the nurse with information and an understanding of family dynamics. This is important to nurses for the provision of quality health care. A family assessment provides an understanding of family development, function, and structure. REF: 23-24 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 6. The nurse planning to assess the structure of a family would which question? a. "Who lives with you?" b. "Who does the grocery shopping?" c. "Who provides support in your family?" d. "How old are the members of your family?" ANS: A This study source was downloaded by from CourseH on :48:28 GMT -05:00 S - The Marketplace to Buy and Sell your Study Material Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material The structure of the family includes who is in the family and what their relationship is. "Who does the shopping?" would provide information about family functioning. "Who provides support?" would provide information about family functioning. "How old are the members?" would provide information about family development. REF: 23-24 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 7. Factors which would alert the nurse to negative/dysfunctional family dynamics include a. aging of family members. b. chronic illness of a family member. c. disability of a family member. d. intimate partner violence. ANS: D Intimate partner violence is an exemplar of negative/dysfunctional family dynamics. Aging of family members is an exemplar of changes to family dynamics. Chronic illness of a family member is an exemplar of changes to family dynamics. Disability of a family member is an exemplar of changes to family dynamics. REF: 24-25 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity This study source was downloaded by from CourseH on :48:28 GMT -05:00 Powered by TCPDF () S - The Marketplace to Buy and Sell your Study Material Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material Concept 4: Culture Test Bank MULTIPLE CHOICE 1. The nurse is triaging a hysterical patient in the ER. The patient is crying, with uncontrollable spasms, trembling, and shouting. It is important to identify manifestation of illness in order to effectively treat a patient. The nurse identifies this as a culture-bound syndrome called a. shenjing sharo. b. loco de la cabeza. c. ataque de nervios. d. neuroasthenia. ANS: C Ataque de nervios is a Latin-Caribbean culture-bound syndrome that usually occurs in response to a specific stressor and is characterized by dissociation or trance-like states, crying, uncontrollable spasms, trembling, or shouting. Shenjeng sharo refers to “weakness of nerves” in Chinese culture; it is caused by a decrease in vital energy that reduces the function of the internal organ systems and lowers resistance to disease. Loco de la cabeza is a Spanish phrase meaning crazy in the mind and not necessarily manifested by physical symptoms. Neuroasthenia is an Asian term characterized by extreme fatigue after mental effort and bodily weakness of persistent duration. REF: 30 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity and Physiological Integrity: Basic Care and Comfort 2. Understanding cultural differences in health care is important because it will help the nurse to understand the manner in which people decide on obtaining treatments and medical care. In independent cultures an individual will a. put himself first. b. consult family members for advice. c. ask for a second opinion. d. travel great distances to receive the best care. ANS: A In independent cultures, an individual will put himself first in the case of a life-threatening illness, whereas even in dire circumstances, members of collectivist cultures may still consult other family members for the best course of action. In independent cultures, an individual will not consult with other family members, ask for a second opinion, or travel great distances to receive the best care. REF: 31 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 3. When teaching an Asian patient with newly diagnosed diabetes, the nurse notes the patient nodding yes to everything that is being said. With a better understanding of cultural interdependence in self-concept, a nurse should immediately a. write everything down for the patient to refer to later. b. prompt further to elicit additional questions or concerns. c. call the recognized elder for this patient. This study source was downloaded by from CourseH on :49:30 GMT -05:00 S - The Marketplace to Buy and Sell your Study Material Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material d. call the oldest male relative for help with decision making. ANS: B When a nurse provides nutritional education to a patient who is from a culture that values greater power distance, it might appear that the patient is willing to accept all that the nurse suggests, when further prompting would elicit additional questions or concerns. The patient from a collectivist culture will usually consult family members for a best course of action. It is not acceptable for nurses to take it upon themselves to call the recognized elder or oldest male relative for help with decision making. While writing everything down may be OK for some cultures, with Asian patients it may be best to prompt further to elicit additional questions or concerns. REF: 31 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 4. Women who are given the job of caretaker for aging relatives are subject to caregiver strain due to a. feminine attributes. b. unequal gender. c. fixed gender roles. d. female inequality. ANS: C In cultures with more fixed gender roles, women are usually given the role of caretaker for aging relatives and may suffer the stresses of caregiver strain. Feminine attributes refers to harmonious relationships, modesty, and taking care of others. Unequal gender refers to roles of males and females being unevenly distributed. Female inequality refers to female gender and roles being less than or unequal to male roles. REF: 31 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 5. Mr. Giuseppe is a 60-year-old Italian immigrant who presents for an annual physical. He is counseled about diagnostic testing including laboratory testing, colonoscopy, influenza vaccination, and pneumococcal vaccination. His reply is “If it ain’t broke, don’t try to fix it.” Understanding that respect for traditions and fulfilling obligations is important in developing a nursing plan of care. Mr. Giuseppe’s cultural orientation is towards a. short term. b. long term. c. leisurely term. d. noncommittal. ANS: A Short-term cultural orientation is towards the present or past and emphasizes quick results. Long-term cultural orientation is towards the future and long-term rewards. Long-termoriented cultures favor thrift, perseverance, and adopting to changing circumstances. Leisurely term and noncommittal are undefined in cultural orientation. REF: 31-32 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 6. The emphasis on understanding cultural influence on health care is important because of a. disability entitlements. b. HIPAA requirements. This study source was downloaded by from CourseH on :49:30 GMT -05:00 S - The Marketplace to Buy and Sell your Study Material Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material c. increasing global diversity. d. litigious society. ANS: C Culture is an essential aspect of health care because of increasing diversity. Disability entitlements refer to defined benefits for eligible mental or physically disabled beneficiaries in relation to housing, employment, and health care. HIPAA requirements refers to the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety. Litigious society refers to excessively ready to go to law or initiate a lawsuit. REF: 29 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 7. What interrelated constructs facilitate a nurse to become culturally competent? a. Cultural diversity, self-awareness, cultural skill, and cultural knowledge b. Cultural desire, self-awareness, cultural knowledge, and cultural identity c. Cultural desire, self-awareness, cultural knowledge, and cultural diversity d. Cultural desire, self-awareness, cultural knowledge, and cultural skill ANS: D The process of cultural competence consists of four interrelated constructs: cultural desire, self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of health care refers to achieving the highest level of health care for all people by addressing societal inequalities and historical and contemporary injustices. Cultural identity is the norms, values, beliefs, and behaviors of a culture learned through families and group members. REF: 34 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity This study source was downloaded by from CourseH on :49:30 GMT -05:00 Powered by TCPDF () S - The Marketplace to Buy and Sell your Study Material Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material Concept 6: Adherence Test Bank MULTIPLE CHOICE 1. A patient has been newly diagnosed with hypertension. The nurse assesses the need to develop a collaborative plan of care that includes a goal of adhering to the prescribed regimen. When the nurse is planning teaching for the patient, which is the most important initial learning goal? a. The patient will select the type of learning materials they prefer. b. The patient will verbalize an understanding of the importance of following the regimen. c. The patient will demonstrate coping skills needed to manage hypertension. d. The patient will verbalize the side effects of treatment. ANS: A Adults learn best when given information they can understand that is tailored to their learning styles and needs. Verbalizing an understanding is important; however, the nurse will first need to teach the patient. REF: 50 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 2. After the nurse implements a teaching plan for a newly diagnosed patient with hypertension, the patient can explain the information but fails to take the medications as prescribed. The nurse's next action would be to a. reeducate the patient, because learning did not occur because the patient's behavior did not change. b. assess the patient's perception and attitude towards the risks associated with not taking their anti-hypertensives. c. take full responsibility for helping the patient make dietary changes. d. ask the provider to prescribe a different medication, because the patient does not want to take this medication. ANS: B Although the patient behavior has not changed, the patient's ability to explain the information indicates that learning has occurred. The nurse would need to ask what the patient’s perceptions are of taking the medications to determine if the patient understands the ramifications of not taking the medication. The patient may be in the contemplation or preparation state (see Health Belief Model). The nurse should reinforce the need for change and continue to provide information and assistance with planning for change. REF: 52 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 3. A diabetic patient presents to the diabetes clinic with A1c levels of 7.5%. The nurse has met this patient for the first time. When applying principles of Theory of Planned Behavior (TPB), which teaching strategy by the nurse is most likely to be effective? a. Provide information on the importance of blood glucose control in maintenance of long-term health and evaluate how the patient has been following the prescribed regime. b. Establish a rapport with the patient by complimenting them on what they did This study source was downloaded by from CourseH on :53:01 GMT -05:00 S - The Marketplace to Buy and Sell your Study Material Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material correctly, and ask what strategies they have tried thus far. c. Refer the patient to a certified diabetic educator, because the educator is an expert on management of diabetes complications. d. Have the patient explain what medications they are on and what diet they should be following. ANS: B Principles of a TPB indicate that the patient will need to establish a good rapport with the nurse in order to talk about nonadherence. If the patient finds it difficult to discuss their diabetes self-management and adherence with the nurse, the patient may not open up to the nurse. Although a referral to an educator is a good idea, it would be better to use this resource as a follow-up for this visit. Having the patient verbalize medications and diet is not part of the TPB method. REF: 52 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 4. The nurse is assessing a newly diagnosed diabetic, and the patient's readiness to learn about glucose monitoring. Before planning teaching activities, which approach would be most effective? a. Assist the patient with long-term goals and plan teaching according to these goals. b. Provide the patient with all the latest research from the Internet on glucose monitoring. c. Refer the patient to the diabetic specialist who can assist the patient with the glucometer. d. Assist the patient in developing realistic short-term goals. ANS: D Concordance reflects development of an alliance with patients based on realistic expectations. Providing the patient with the research will not help with the practical skill of using the glucometer. Long-term goals are useful; however, the goals need to be immediate with a newly diagnosed patient learning a new skill. Referring the patient would be useful if the patient has not been able to grasp the concept after several attempts. REF: 55 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 5. The nurse is developing a care plan for a patient who has low motivation and nonadherence with blood glucose monitoring. Which statement by the patient would indicate to the nurse that the patient is not motivated and will most likely not comply? a. "I do not like to test my sugar, but I do it because my wife nags me." b. "I forget to check my sugar once in a while." c. "I don't see or feel any different when I do keep my blood sugars under control." d. "I have no idea what the signs of low blood sugar are." ANS: C If patients do not perceive any benefit from changing their behavior, sustaining the change becomes very difficult. Having someone remind the patient is more likely to reinforce compliance. Forgetting to check glucose occasionally may indicate the patient needs memory cues or joggers. The patient who doesn't know the signs of low glucose will need further teaching. REF: 52 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance This study source was downloaded by from CourseH on :53:01 GMT -05:00 S - The Marketplace to Buy and Sell your Study Material Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 6. The nurse is doing discharge teaching on a patient who has peripheral vascular disease and has poor circulation to the feet. Which learning goal should the nurse include in the teaching plan? a. The nurse will demonstrate the proper technique for trimming toenails. b. The patient will understand the rationale for proper foot care after instruction. c. The nurse will instruct the patient on appropriate foot care before discharge. d. The patient will post reminder stickers on their calendar to check feet every day and record scheduled appointments with podiatrist. ANS: D To improve the patient adherence to treatment, it will be important to help them develop reminder strategies that fit into their lifestyle. Options A and C describe actions that the nurse will take, rather than behaviors that indicate that patient learning has occurred. Option B is too vague and nonspecific to measure whether learning has occurred. REF: 55 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 7. A patient with hypertension is prescribed a low-sodium diet. The patient's teaching plan includes this goal: "The patient will select a 2-gram sodium diet from the hospital menu for the next 3 days." Which intervention would be most effective at increasing the patient's compliance with the diet? a. Check the sodium content of the patient's menu choices over the next 3 days. b. Ask the patient to identify which foods on the hospital menus are high in sodium. c. Have the patient list favorite foods that are high in sodium and foods that could be substituted for these favorites. d. Compare the patient's sodium intake over the next 3 days with the sodium intake before the teaching was implemented. ANS: C Including a patient's favorite foods will most likely increase compliance because the patient is not being deprived. Checking the sodium will be useful for teaching strategies but will not be the most effective means of increasing adherence. REF: 55 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 8. The nurse is evaluating the need to refer a patient with osteoarthritis for a home care visit to be sure the patient can function in accomplishing daily activities independently. What is the nurse's first priority? a. Determine if the patient has had home visits before and if the experience was positive. b. Check the patient's ability to bathe without any assistance the next day. c. Have the patient demonstrate the learned skills at the end of the teaching session. d. Arrange a physical therapy visit before the patient is discharged from the hospital. ANS: A To begin the assessment of adherence, it is first important to clarify with the patient (a) their beliefs and perceptions about their health risk status, (b) their existing knowledge about cardiovascular disease risk reduction, (c) any prior experience with health care professionals, and (d) their degree of confidence with controlling the disease. The other actions allow evaluation of the patient's short-term response to teaching