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NURS 311 A&E I Comprehensive_Test_Bank | A&E I Comprehensive_Test_Bank_12 Weeks & 50 Chapters

A&E I Comprehensive Testbank Table of Contents Week 1 Care of Older Adults: Culture, Spirituality, Communication, Sexuality, Infection Control Chronic Illness and Older Adults__________________________________________________3 Cultural Awareness____________________________________________________________10 Older Adult__________________________________________________________________18 Communication_______________________________________________________________28 Patient Education_____________________________________________________________39 Infection Prevention and Control_________________________________________________51 Sexuality____________________________________________________________________69 Spiritual Health______________________________________________________________78 Week 2 Critical Thinking, The Nursing Process, Loss, Death, and Grief Critical Thinking in Nursing Practice_____________________________________________86 Nursing Assessment___________________________________________________________94 Nursing Diagnosis___________________________________________________________102 Planning Nursing Care________________________________________________________110 Implementing Nursing Care____________________________________________________119 Evaluation__________________________________________________________________128 The Experience of Loss, Death and Grief__________________________________________136 Week 3 Safety and Fall Prevention among Older Adults, Preventing Complications of Immobility Patient Safety and Quality_____________________________________________________146 Immobility__________________________________________________________________163 Activity and Exercise__________________________________________________________181 Week 4 Skin and Wound Care Hygiene, Introduction to Pharmacology and Medication Administration Medication Administration_____________________________________________________194 Hygiene____________________________________________________________________212 Skin Integrity and Wound Care__________________________________________________231 Week 5 Fluid & Electrolytes, Dehydration Fluid, Electrolyte and Acid-Base Balance_________________________________________251 Week 6 Pain and Sleep 1A&E I Comprehensive Testbank Pain Management____________________________________________________________268 Sleep______________________________________________________________________280 Week 7 Concepts related to Oxygenation, Circulation, and Tissue Perfusion, Chronic Obstructive Pulmonary Disease Oxygenation________________________________________________________________295 Obstructive Pulmonary Diseases________________________________________________314 Week 8 Diabetes Mellitus Diabetes Mellitus____________________________________________________________331 Week 9 Hypertension, Stroke Hypertension________________________________________________________________341 Stroke_____________________________________________________________________356 Week 10 Documentation and Informatics Documentation and Informatics______________________________________368 Week 11 Nutrition, Dysphagia_____________________________________382 Week 12 Care of the Surgical Patient________________________________398 Week 1 Care of Older Adults: Culture, Spirituality, Communication, Sexuality, Infection Control Chapter 05: Chronic Illness and Older Adults Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. When caring for an older patient with hypertension who has been hospitalized after a transient ischemic (TIA), which topic is the most important for the nurse to include in the discharge teaching? a) Effect of atherosclerosis on blood vessels b) Mechanism of action of anticoagulant drug therapy c) Symptoms indicating that the patient should contact the health care provider d) Impact of the patient’s family history on likelihood of developing a serious stroke ANS: C One of the tasks for patients with chronic illnesses is to prevent and manage a crisis. The patient 2A&E I Comprehensive Testbank needs instruction on recognition of symptoms of hypertension and TIA and appropriate actions to take if these symptoms occur. The other information may also be included in patient teaching but is not as essential in the patient’s self-management of the illness. 2. The nurse performs a comprehensive assessment of an older patient who is considering admission to an assisted living facility. Which question is the most important for the nurse to ask? a) “Have you had any recent infections?” b) “How frequently do you see a doctor?” c) “Do you have a history of heart disease?” d) “Are you able to prepare your own meals?” ANS: D The patient’s functional abilities, rather than the presence of an acute or chronic illness, are more useful in determining how well the patient might adapt to an assisted living situation. The other questions will also provide helpful information but are not as useful in providing a basis for determining patient needs or for developing interventions for the older patient. 3. An alert older patient who takes multiple medications for chronic cardiac and pulmonary diseases lives with a daughter who works during the day. During a clinic visit, the patient verbalizes to the nurse that she has a strained relationship with her daughter and does not enjoy being alone all day. Which nursing diagnosis should the nurse assign as the priority for this patient? a) Social isolation related to fatigue b) Risk for injury related to drug interactions c) Caregiver role strain related to family employment schedule d) Compromised family coping related to the patient’s care needs ANS: B The patient’s age and multiple medications indicate a risk for injury caused by interactions between the multiple drugs being taken and a decreased drug metabolism rate. Problems with social isolation, caregiver role strain, or compromised family coping are not physiologic priorities. Drug–drug interactions could cause the most harm to the patient and are therefore the priority. 4. Which method should the nurse use to gather the most complete assessment of an older patient? a) Review the patient’s health record for previous assessments. b) Use a geriatric assessment instrument to evaluate the patient. c) Ask the patient to write down medical problems and medications. d) Interview both the patient and the primary caregiver for the patient. 3A&E I Comprehensive Testbank ANS: B The most complete information about the patient will be obtained through the use of an assessment instrument specific to the geriatric population, which includes information about both medical diagnoses and treatments and about functional health patterns and abilities. A review of the medical record, interviews with the patient and caregiver, and written information by the patient are all included in a comprehensive geriatric assessment. 5. Which intervention should the nurse implement to provide optimal care for an older patient who is hospitalized with pneumonia? a) Plan for transfer to a long-term care facility. b) Minimize activity level during hospitalization. c) Consider the preadmission functional abilities. d) Use an approved standardized geriatric nursing care plan. ANS: C The plan of care for older adults should be individualized and based on the patient’s current functional abilities. A standardized geriatric nursing care plan will not address individual patient needs and strengths. A patient’s need for discharge to a long-term care facility is variable. Activity level should be designed to allow the patient to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process. 6. The nurse cares for an older adult patient who lives in a rural area. Which intervention should the nurse plan to implement to meet this patient’s needs? a) Suggest that the patient move closer to health care providers. b) Obtain extra medications for the patient to last for 4 to 6 months. c) Ensure transportation to appointments with the health care provider. d) Assess the patient for chronic diseases that are unique to rural areas. ANS: C Transportation can be a barrier to accessing health services in rural areas. The patient living in a rural area may lose the benefits of a familiar situation and social support by moving to an urban area. There are no chronic diseases unique to rural areas. Because medications may change, the nurse should help the patient plan for obtaining medications through alternate means such as the mail or delivery services, not by purchasing large quantities of the medications. 7. Which nursing action will be most helpful in decreasing the risk for drug-drug interactions in an older adult? a) Teach the patient to have all prescriptions filled at the same pharmacy. b) Make a schedule for the patient as a reminder of when to take each medication. c) Instruct the patient to avoid taking over-the-counter (OTC) medications or supplements. d) Ask the patient to bring all medications, supplements, and herbs to each appointment. 4A&E I Comprehensive Testbank ANS: D The most information about drug use and possible interactions is obtained when the patient brings all prescribed medications, OTC medications, and supplements to every health care appointment. The patient should discuss the use of any OTC medications with the health care provider and obtain all prescribed medications from the same pharmacy, but use of supplements and herbal medications also need to be considered in order to prevent drug–drug interactions. Use of a medication schedule will help the patient take medications as scheduled, but will not prevent drug–drug interactions. 8. A patient who has just moved to a long-term care facility has a nursing diagnosis of relocation stress syndrome. Which action should the nurse include in the plan of care? a) Remind the patient that making changes is usually stressful. b) Discuss the reason for the move to the facility with the patient. c) Restrict family visits until the patient is accustomed to the facility. d) Have staff members write notes welcoming the patient to the facility. ANS: D TestBankW Having staff members write notes will make the patient feel more welcome and comfortable at the long-term care facility. Discussing the reason for the move and reminding the patient that change is usually stressful will not decrease the patient’s stress about the move. Family member visits will decrease the patient’s sense of stress about the relocation. 9. An older patient complains of having “no energy” and feeling increasingly weak. The patient has had a 12-lb weight loss over the past year. Which action should the nurse take initially? a) Ask the patient about daily dietary intake. b) Schedule regular range-of-motion exercise. c) Discuss long-term care placement with the patient. d) Describe normal changes associated with aging to the patient. ANS: A In a frail older patient, nutrition is frequently compromised, and the nurse’s initial action should be to assess the patient’s nutritional status. Active range of motion may be helpful in improving the patient’s strength and endurance, but nutritional assessment is the priority because the patient has had a significant weight loss. The patient may be a candidate for long-term care placement, but more assessment is needed before this can be determined. The patient’s assessment data are not consistent with normal changes associated with aging. 10. The nurse is admitting an acutely ill, older patient to the hospital. Which action should the nurse take? a) Speak slowly and loudly while facing the patient. b) Obtain a detailed medical history from the patient. 5A&E I Comprehensive Testbank c) Perform the physical assessment before interviewing the patient. d) Ask a family member to go home and retrieve the patient’s cane. ANS: C When a patient is acutely ill, the physical assessment should be accomplished first to detect any physiologic changes that require immediate action. Not all older patients have hearing deficits, and it is insensitive of the nurse to speak loudly and slowly to all older patients. To avoid tiring the patient, much of the medical history can be obtained from medical records. After the initial physical assessment to determine the patient’s current condition, then the nurse could ask someone to obtain any assistive devices for the patient if applicable. 11. The nurse cares for an alert, homeless older adult patient who was admitted to the hospital with a chronic foot infection. Which intervention is the most appropriate for the nurse to include in the discharge plan for this patient? a) Teach the patient how to assess and care for the foot infection. b) Refer the patient to social services for assessment of resources. c) Schedule the patient to return to outpatient services for foot care. d) Give the patient written information about shelters and meal sites. ANS: B An interprofessional approach, including social services, is needed when caring for homeless older adults. Even with appropriate teaching, a homeless individual may not be able to maintain adequate foot care because of a lack of supplies or a suitable place to accomplish care. Older homeless individuals are less likely to use shelters or meal sites. A homeless person may fail to keep appointments for outpatient services because of factors such as fear of institutionalization or lack of transportation. 12. The home health nurse cares for an older adult patient who lives alone and takes several different prescribed medications for chronic health problems. Which intervention, if implemented by the nurse, would best encourage medication compliance? a) Use a marked pillbox to set up the patient’s medications. b) Discuss the option of moving to an assisted living facility. c) Remind the patient about the importance of taking medications. d) Visit the patient daily to administer the prescribed medications. ANS: A Because forgetting to take medications is a common cause of medication errors in older adults, the use of medication reminder devices is helpful when older adults have multiple medications to take. There is no indication that the patient needs to move to assisted living or that the patient does not understand the importance of medication compliance. Home health care is not designed for the patient who needs ongoing assistance with activities of daily living or instrumental ADLs. 6A&E I Comprehensive Testbank 13. The home health nurse visits an older patient with mild forgetfulness. Which new information is of most concern to the nurse? a) The patient tells the nurse that a close friend recently died. b) The patient has lost 10 lb (4.5 kg) during the past month. c) The patient is cared for by a daughter during the day and stays with a son at night. d) The patient’s son uses a marked pillbox to set up the patient’s medications weekly. ANS: B A 10-pound weight loss may be an indication of elder neglect or depression and requires further assessment by the nurse. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an 86-yr-old would have friends who have died. 14. Which statement, if made by an older adult patient, would be of most concern to the nurse? a. “I prefer to manage my life without much help from other people.” a) “I prefer to manage my life without much help from other people.” b) “I take three different medications for my heart and joint problems.” c) “I don’t go on daily walks anymore since I had pneumonia 3 months ago.” d) “I set up my medications in a marked pillbox so I don’t forget to take them.” ANS: C Inactivity and immobility lead rapidly to loss of function in older adults. The nurse should develop a plan to prevent further deconditioning and restore function for the patient. Selfmanagement is appropriate for independently living older adults. On average, an older adult takes seven different medications so the use of three medications is not unusual for this patient. The use of memory devices to assist with safe medication administration is recommended for older adults. 15. The nurse assesses an older patient who takes diuretics and has a possible urinary tract infection (UTI). Which action should the nurse take first? a) Palpate over the suprapubic area. b) Inspect for abdominal distention. c) Question the patient about hematuria. d) Request the patient empty the bladder. ANS: D Before beginning the assessment of an older patient with a UTI and on diuretics, the nurse should have the patient empty the bladder because bladder fullness or discomfort will distract from the patient’s ability to provide accurate information. The patient may seem disoriented if distracted by pain or urgency. The physical assessment data are obtained after the patient is as comfortable as possible. 7A&E I Comprehensive Testbank 16. Which patient is most likely to need long-term nursing care management? a) 72-yr-old who had a hip replacement after a fall at home b) 64-yr-old who developed sepsis after a ruptured peptic ulcer c) 76-yr-old who had a cholecystectomy and bile duct drainage d) 63-yr-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg) ANS: D Osteoarthritis and obesity are chronic problems that will require planning for long-term interventions such as physical therapy and nutrition counseling. The other patients have acute problems that are not likely to require long-term management. 17. An older adult being admitted is assessed at high risk for falls. Which action should the nurse take first? a) Use a bed alarm system on the patient’s bed. b) Administer the prescribed PRN sedative medication. c) Ask the health care provider to order a vest restraint. d) Place the patient in a “geri-chair” near the nurse’s station. ANS: A The use of the least restrictive restraint alternative is required. Physical or chemical restraints may be necessary, but the nurse’s first action should be an alternative such as a bed alarm. 18. An older adult patient presents with a broken arm and visible scattered bruises healing at different stages. Which action should the nurse take first? a) Notify an elder protective services agency about possible abuse. b) Make a referral for a home assessment visit by the home health nurse. c) Have the family member stay in the waiting area while the patient is assessed. d) Ask the patient how the injury occurred and observe the family member’s reaction. ANS: C The initial action should be assessment and interviewing of the patient. The patient should be interviewed alone because the patient will be unlikely to give accurate information if the abuser is present. If abuse is occurring, the patient should not be discharged home for a later assessment by a home health nurse. The nurse needs to collect and document data before notifying the elder protective services agency. 19. The family of an older patient with chronic health problems and increasing weakness is considering placement in a long-term care (LTC) facility. Which action by the nurse will be most helpful in assisting the patient to make this transition? a) Have the family select a LTC facility that is relatively new. b) Ask the patient’s preference for the choice of a LTC facility. 8A&E I Comprehensive Testbank c) Explain the reasons for the need to live in LTC to the patient. d) Request that the patient be placed in a private room at the facility. ANS: B The stress of relocation is likely to be less when the patient has input into the choice of the facility. The age of the long-term care facility does not indicate a better fit for the patient or better quality of care. Although some patients may prefer a private room, others may adjust better when given a well-suited roommate. The patient should understand the reasons for the move but will make the best adjustment when involved with the choice to move and the choice of the facility. 20. The nurse manages the care of older adults in an adult health day care center. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? TestBankW a) Obtain information about food and medication allergies from patients. b) Take blood pressures daily and document in individual patient records. c) Choose social activities based on the individual patient needs and desires. d) Teach family members how to cope with patients who are cognitively impaired. ANS: B Measurement and documentation of vital signs are included in UAP education and scope of practice. Obtaining patient health history, planning activities based on the patient assessment, and patient education are all actions that require critical thinking and will be done by the registered nurse. MULTIPLE RESPONSE 1. Which nursing actions will the nurse take to assess for possible malnutrition in an older adult patient (select all that apply)? a) Assess for depression. b) Review laboratory results. c) Determine food preferences. d) Inspect teeth and oral mucosa. e) Ask about transportation needs. ANS: A, B, D, E The laboratory results, especially albumin and cholesterol levels, may indicate chronic poor protein intake or high-fat or high-cholesterol intake. Transportation affects the patient’s ability to shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor condition may decrease the ability to chew and swallow. Food likes and dislikes are not necessarily associated with malnutrition. 9A&E I Comprehensive Testbank Chapter 09: Cultural Awareness Potter et al.: Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE 1. A nurse is working at a health fair screening people for liver cancer. Which population group should the nurse monitor most closely for liver cancer? ANS: B While Asian Americans generally have lower cancer rates than the non-Hispanic Caucasian population, they also have the highest incidence rates of liver cancer for both sexes compared with Hispanic, non-Hispanic Caucasians, or non-Hispanic African-Americans. 2. A nurse is caring for an immigrant with low income. Which information should the nurse consider when planning care for this patient? ANS: B Populations with health disparities (immigrant with low income) have a significantly increased incidence of disease or increased morbidity and mortality when compared with the general population. Although Americans’ health overall has improved during the past few decades, the health of members of marginalized groups has actually declined. 3. A nurse is assessing the health care disparities among population groups. Which area is the nurse monitoring? ANS: A While health disparities are the differences among populations in the incidence, prevalence, and outcomes of health conditions, diseases and related complications, health care disparities are differences among populations in the availability, accessibility, and quality of health care services (e.g. screening, diagnostic, treatment, management, and rehabilitation) aimed at prevention, treatment, and management of diseases and their complications. 4. A nurse is providing care to a patient from a different culture. Which action by the nurse indicates cultural competence? a. Hispanic b. Asian Americans c. Non-Hispanic Caucasians d. Non-Hispanic African-Americans a. There is a decreased frequency of morbidity. b. There is an increased incidence of disease. c. There is an increased level of health. d. There is a decreased mortality rate. a. Accessibility of health care services b. Outcomes of health conditions c. Prevalence of complications d. Incidence of diseases a. Communicates effectively in a multicultural context b. Functions effectively in a multicultural context c. Visits a foreign country d. Speaks a different language 10A&E I Comprehensive Testbank ANS: B Cultural competence refers to a developmental process that evolves over time that impacts ability to effectively function in the multicultural context. Communicates effectively and speaking a different language indicates linguistic competence. Visiting a foreign country does not indicate cultural competence. 5. The nurse learns about cultural issues involved in the patient’s health care belief system and enables patients and families to achieve meaningful and supportive care. Which concept is the nurse demonstrating? ANS: D The nurse is demonstrating culturally congruent care. Culturally congruent care, or care that fits a person’s life patterns, values, and system of meaning, provides meaningful and beneficial nursing care. Marginalized groups are populations left out or excluded. Health care disparities are differences among populations in the availability, accessibility, and quality of health care services (e.g. screening, diagnostic, treatment, management, and rehabilitation) aimed at prevention, treatment, and management of diseases and their complications. Transcultural nursing is a comparative study of cultures in order to understand their similarities (culture that is universal) and the differences among them (culture that is specific to particular groups). 6. A nurse is beginning to use patient-centered care and cultural competence to improve nursing care. Which step should the nurse take first? ANS: A Becoming more aware of your biases and attitudes about human behavior is the first step in providing patientcentered care, leading to culturally competent care. It is helpful to think about cultural competence as a lifelong process of learning about others and also about yourself. Learning about the world view, developing cultural skills, and understanding organizational forces are not the first steps. 7. A nurse is performing a cultural assessment using the ETHNIC mnemonic for communication. Which area will the nurse assess for the “H”? ANS: B The “H” in ETHNIC stands for healers: Has the patient sought advice from alternative health practitioners? While health, history, and homeland are important, they are not components of “H.” 8. The nurse is caring for a patient of Hispanic descent who speaks no English. The nurse is working with an interpreter. Which action should the nurse take? a. Marginalized groups b. Health care disparity c. Transcultural nursing d. Culturally congruent care a. Assessing own biases and attitude b. Learning about the world view of others c. Understanding organizational forces d. Developing cultural skills a. Health b. Healers c. History d. Homeland a. Use long sentences when talking. b. Look at the patient when talking. 11A&E I Comprehensive Testbank ANS: B Direct your questions to the patient. Look at the patient, instead of looking at the interpreter. Pace your speech by using short sentences, but do not break your sentences. Observe the patient’s nonverbal and verbal behaviors. 9. Which action indicates the nurse is meeting a primary goal of cultural competent care for patients? ANS: A Although cultural competence and patient-centered care both aim to improve health care quality, their focus is slightly different. The primary aim of cultural competence care is to reduce health disparities and increase health equity and fairness by concentrating on people of color and other marginalized groups, like transgender patients. Patient-centered care, rather than cultural competence care, provides individualized care and restores an emphasis on personal relationships; it aims to elevate quality for all patients. 10. The nurse is caring for a Chinese patient using the Teach-Back technique. Which action by the nurse indicates successful implementation of this technique? ANS: C The Teach-Back technique asks open-ended questions, like what will you tell your spouse about changing the dressing, to verify a patient’s understanding. When using the Teach-Back technique do not ask a patient, “Do you understand?” or “Do you have any questions?” Does this make sense and do you think you can do this at home are closed-ended questions. Would you tell me if you don’t understand something so we can go over it is not verifying a patient’s understanding about the teaching. 11. A nurse is using core measures to reduce health disparities. Which group should the nurse focus on to cause the most improvement in core measures? ANS: B To improve results, the nurse should focus on the highest disparity. Poor people received worse care than highincome people for about 60% of core measures. American Indians and Alaska Natives received worse care than Caucasians for about 30% of core measures. 12. A nurse is designing a form for lesbian, gay, bisexual, and transgender (LGBT) patients. Which design should the nurse use? c. Use breaks in sentences when talking. d. Look at only nonverbal behaviors when talking. a. Provides care to transgender patients b. Provides care to restore relationships c. Provides care to patients that is individualized d. Provides care to surgical patients a. Asks, “Does this make sense?” b. Asks, “Do you think you can do this at home?” c. Asks, “What will you tell your spouse about changing the dressing?” d. Asks, “Would you tell me if you don’t understand something so we can go over it?” a. Caucasians b. Poor people c. Alaska Natives d. American Indians a. Use partnered rather than married. 12A&E I Comprehensive Testbank ANS: A Include LGBT-inclusive language on forms and assessments to facilitate disclosure, knowing that disclosure is a choice impacted by many factors. For example, provide options such as “partnered” under relationship status. For parents, use parent/guardian, instead of mother/father. Use neutral and inclusive language when talking with patients (e.g., partner or significant other), listening and reflecting patient’s choice. Remember that some LGBT patients are also legally married. 13. A nurse is assessing population groups for the risk of suicide requiring medical attention. Which group should the nurse monitor mostclosely? ANS: A Gay, lesbian, and bisexual young people have a significantly increased risk for depression, anxiety, suicide attempts, and substance use disorders, being 4 times as likely as their straight peers to make suicide attempts that require medical attention. Caucasian youth, Asian Americans, and African-Americans are not as likely to attempt suicide resulting in medical attention. 14. A nurse is assessing a patient’s ethnohistory. Which question should the nurse ask? ANS: B An ethnohistory question is the following: How different is your life here from back home? Caring beliefs and practice questions include the following: Which caregivers do you seek when you are sick and How different is what we do from what your family does when you are sick? The language and communication is the following: What language do you speak at home? 15. A nurse is teaching patients about health care information. Which patient will the nurse assess closely for health literacy? ANS: B About 9 out of 10 people in the United States experience challenges in using health care information. Patients who are especially vulnerable are the elderly (age 65+), immigrants, persons with low incomes, persons who do not have a high-school diploma or GED, and persons with chronic mental and/or physical health conditions. A 35-year-old patient and patients with high-school and college education are not identified in the vulnerable populations. b. Use mother rather than father. c. Use parents rather than guardian. d. Use wife/husband rather than significant other. a. Young bisexuals b. Young caucasians c. Asian Americans d. African-Americans a. What language do you speak at home? b. How different is your life here from back home? c. Which caregivers do you seek when you are sick? d. How different is what we do from what your family does when you are sick? a. A patient 35 years old b. A patient 68 years old c. A patient with a college degree d. A patient with a high-school diploma 13A&E I Comprehensive Testbank 16. A nurse works at a hospital that uses equity-focused quality improvement. Which strategy is the hospital using? ANS: D Organizations can implement equity-focused quality improvement by recognizing disparities and committing to reducing them. Staff diversity is a priority for equity-focused quality improvement, not staff satisfaction. While the family is important, the focus is on the patients. Organizations should start by implementing a change on a small scale (pilot testing), learning from each test, and refining the intervention through performance improvement cycles (e.g., plan, do, study, and act). 17. A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful in the role of providing culturally congruent care? ANS: A The goal of transcultural nursing is to provide culturally congruent care, or care that fits the person’s life patterns, values, and system of meaning. Patterns and meanings are generated from people themselves, rather than from predetermined criteria. Discovering patients’ cultural values, beliefs, and practices as they relate to nursing and health care requires you to assume the role of learner (not become the leader) and to partner with your patients and their families to determine what is needed to provide meaningful and beneficial nursing care. Culturally congruent care is sometimes different from the values and meanings of the professional health care system. 18. A nurse is assessing the patient’s meaning of illness. Which area of focus by the nurse is priority? ANS: A To provide culturally congruent care, you need to understand the difference between disease and illness. Illness is the way that individuals and families react to disease, whereas disease is a malfunctioning of biological or psychological processes. The way a patient interacts to family/social interactions is communication processes and family dynamics. MULTIPLE RESPONSE 1. A nurse is using Campinha-Bacote’s model of cultural competency. Which areas will the nurse focus on to become competent? (Select all that apply.) a. Document staff satisfaction. b. Focus on the family. c. Implement change on a grand scale. d. Reduce disparities. a. Provides care that fits the patient’s valued life patterns and set of meanings b. Provides care that is based on meanings generated by predetermined criteria c. Provides care that makes the nurse the leader in determining what is needed d. Provides care that is the same as the values of the professional health care system a. On the way a patient reacts to disease b. On the malfunctioning of biological processes c. On the malfunctioning of psychological processes d. On the way a patient reacts to family/social interactions a. Cultural skills b. Cultural desire c. Cultural transition d. Cultural knowledge 14A&E I Comprehensive Testbank ANS: A, B, D, E Campinha-Bacote’s model of cultural competency has five interrelated components: cultural awareness; cultural knowledge; cultural skills; cultural encounters; and cultural desire. Cultural transition is not a component of this model. 2. A nurse is using the RESPECT mnemonic to establish rapport, the “R” in RESPECT. Which actions should the nurse take? (Select all that apply.) ANS: A, C The “R” in RESPECT stands for rapport and includes the following behaviors: connect on a social level; seek the patient’s point of view; and consciously attempt to suspend judgment. The “S” stands for support and includes the behavior of helping the patient overcome barriers. The “P” stands for partnership and includes the following behaviors: be flexible with regard to issues of control and stress that you will be working together to address medical problems. The “C” stands for cultural competence and includes the behavior of knowing your limitations in addressing medical issues across cultures. 3. A nurse is using the explanatory model to determine the etiology of an illness. Which questions should the nurse ask? (Select all that apply.) ANS: B, C, E The questions for etiology include “What do you call your problem?” and “What name does it have?” Recommended treatment is asked by the question “How should your sickness be treated?” Pathophysiology is asked by the question “How does this illness work inside your body?” The course of illness is asked by the question “What do you fear most about your sickness?” MATCHING A nurse is using Campinha-Bacote’s model of cultural competency to improve cultural care. Which actions describe the components the nurse is using? e. Cultural encounters a. Connect on a social level. b. Help the patient overcome barriers. c. Consciously attempt to suspend judgment. d. Stress that they will be working together to address problems. e. Know limitations in addressing medical issues across cultures. a. How should your sickness be treated? b. What do you call your problem? c. How does this illness work inside your body? d. What do you fear most about your sickness? e. What name does it have? a. In-depth self-examination of one’s own background b. Ability to assess factors that influence treatment and care c. Sufficient comparative understanding of diverse groups d. Motivation and commitment to continue learning about cultures e. Cross-cultural interaction that develops communication skills 15A&E I Comprehensive Testbank Chapter 14: Older Adult Potter et al.: Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE 1. A nurse is obtaining a history on an older adult. Which finding will the nurse most typically find? ANS: B In 2012, 57% of older adults in non-institutional settings lived with a spouse (45% of older women, 71% of older men); 28% lived alone (35% of older women, 19% of older men); and only 3.5% of all older adults resided in institutions such as nursing homes or centers. Most older adults have lost a spouse due to death rather than divorce. 2. A nurse is developing a plan of care for an older adult. Which information will the nurse consider? ANS: B Every older adult is unique, and the nurse needs to approach each one as a unique individual. The nursing care of older adults poses special challenges because of great variation in their physiological, cognitive, and psychosocial health. Aging does not automatically lead to disability and dependence. Chronological age often has little relation to the reality of aging for an older adult. 3. Which information from a co-worker on a gerontological unit will cause the nurse to intervene? ANS: A Most older people remain functionally independent despite the increasing prevalence of chronic disease; therefore, this misconception should be addressed. It is critical for you to respect older adults and actively involve them in care decisions and activities. You also need to identify an older adult’s strengths and abilities during the assessment and encourage independence as an integral part of your plan of care. 4. A nurse suspects an older-adult patient is experiencing caregiver neglect. Which assessment findings are consistent with the nurse’s suspicions? ANS: A a. Lives in a nursing home b. Lives with a spouse c. Lives divorced d. Lives alone a. Should be standardized because most geriatric patients have the same needs b. Needs to be individualized to the patient’s unique needs c. Focuses on the disabilities that all aging persons face d. Must be based on chronological age alone a. Most older people have dependent functioning. b. Most older people have strengths we should focus on. c. Most older people should be involved in care decision. d. Most older people should be encouraged to have independence. a. Flea bites and lice infestation b. Left at a grocery store c. Refuses to take a bath d. Cuts and bruises 16A&E I Comprehensive Testbank Caregiver neglect includes unsafe and unclean living conditions, soiled bedding, and animal or insect infestation. Abandonment includes desertion at a hospital, nursing facility, or public location such as a shopping center. Self-neglect includes refusal or failure to provide oneself with basic necessities such as food, water, clothing, shelter, personal hygiene, medication, and safety. Physical abuse includes hitting, beating, pushing, slapping, kicking, physical restraint, inappropriate use of drugs, fractures, lacerations, rope burns, and untreated injuries. 5. A nurse is teaching a group of older-adult patients. Which teaching strategy is best for the nurse to use? ANS: C Teaching strategies include the use of past experiences to connect new learning with previous knowledge, focusing on a single topic to help the patient concentrate, giving the patient enough time in which to respond because older adults’ reaction times are longer than those of younger persons, and keeping the tone of voice low; older adults are able to hear low sounds better than high-frequency sounds. 6. An older patient has fallen and suffered a hip fracture. As a consequence, the patient’s family is concerned about the patient’s ability to care for self, especially during this convalescence. What should the nurse do? ANS: D Nurses help older adults and their families by providing information and answering questions as they make choices among care options. Some older adults deny functional declines and refuse to ask for assistance with tasks that place their safety at great risk. The decision to enter a nursing center is never final, and a nursing center resident sometimes is discharged to home or to another less-acute residence. What defines quality of life varies and is unique for each person. 7. What is the best suggestion a nurse could make to a family requesting help in selecting a local nursing center? ANS: C a. Provide several topics of discussion at once to promote independence and making choices. b. Avoid uncomfortable silences after questions by helping patients complete their statements. c. Ask patients to recall past experiences that correspond with their interests. d. Speak in a high pitch to help patients hear better. a. Stress that older patients usually ask for help when needed. b. Inform the family that placement in a nursing center is a permanent solution. c. Tell the family to enroll the patient in a ceramics class to maintain quality of life. d. Provide information and answer questions as family members make choices among care options. a. Have the family members evaluate nursing home staff according to their ability to get tasks done efficiently and safely. b. Make sure that nursing home staff members get patients out of bed and dressed according to staff’s preferences. c. Explain that it is important for the family to visit the center and inspect it personally. d. Suggest a nursing center that has standards as close to hospital standards as possible. 17A&E I Comprehensive Testbank An important step in the process of selecting a nursing home is to visit the nursing home. The nursing home should not feel like a hospital. It is a home, a place where people live. Members of the nursing home staff should focus on the person, not the task. Residents should be out of bed and dressed according to their preferences, not staff preferences. 8. A 70-year-old patient who suffers from worsening dementia is no longer able to live alone. The nurse is discussing health care services and possible long-term living arrangements with the patient’s only son. What will the nurse suggest? ANS: C Some family caregivers consider nursing center placement when in-home care becomes increasingly difficult or when convalescence from hospitalization requires more assistance than the family is able to provide. An apartment setting and the use of home health visits are not appropriate because living at home is unsafe. Dementia is not a time of inactivity but an impairment of intellectual functioning. 9. A nurse is caring for an older adult. Which goal is priority? ANS: C Adjusting to retirement is one of the developmental tasks for an older person. A young or middle-aged adult has to adjust to career and/or divorce. A middle-aged adult has to adjust to grandchildren. 10. A nurse is observing for the universal loss in an older-adult patient. What is the nurse assessing? ANS: B The universal loss for older adults usually revolves around the loss of relationships through death. Life transitions, of which loss is a major component, include retirement and the associated financial changes, changes in roles and relationships, alterations in health and functional ability, changes in one’s social network, and relocation. However, these are not the universal loss. 11. A nurse is discussing sexuality with an older adult. Which action will the nurse take? a. An apartment setting with neighbors close by b. Having the patient utilize weekly home health visits c. A nursing center because home care is no longer safe d. That placement is irrelevant because the patient is retreating to a place of inactivity a. Adjusting to career b. Adjusting to divorce c. Adjusting to retirement d. Adjusting to grandchildren a. Loss of finances through changes in income b. Loss of relationships through death c. Loss of career through retirement d. Loss of home through relocation a. Ask closed-ended questions about specific symptoms the patient may experience. b. Provide information about the prevention of sexually transmitted infections. c. Discuss the issues of sexuality in a group in a private room. d. Explain that sexuality is not necessary as one ages. 18A&E I Comprehensive Testbank ANS: B Include information about the prevention of sexually transmitted infections when appropriate. Open-ended questions inviting an older adult to explain sexual activities or concerns elicit more information than a list of closed-ended questions about specific activities or symptoms. You need to provide privacy for any discussion of sexuality and maintain a nonjudgmental attitude. Sexuality and the need to express sexual feelings remain throughout the human life span. 12. A nurse is teaching a health promotion class for older adults. In which order will the nurse list the most common to least common conditions that can lead to death in older adults? 1. Chronic obstructive lung disease 2. Cerebrovascular accidents 3. Heart disease 4. Cancer ANS: B Heart disease is the leading cause of death in older adults followed by cancer, chronic lung disease, and stroke (cerebrovascular accidents). 13. A nurse is observing skin integrity of an older adult. Which finding will the nurse document as a normal finding? ANS: C Loss of skin elasticity is a common finding in the older adult. Other common findings include pigmentation changes, glandular atrophy (oil, moisture, and sweat glands), thinning hair (facial hair: decreased in men, increased in women), slower nail growth, and atrophy of epidermal arterioles. 14. An older-adult patient in no acute distress reports being less able to taste and smell. What is the nurse’s best response to this information? ANS: D Diminished taste and smell senses are common findings in older adults. Scheduling an appointment at a smell and taste disorders clinic, testing the vestibulocochlear nerve, or an attempt to rule out cranial nerve damage is unnecessary at this time as per the information provided. 15. A nurse is assessing an older adult for cognitive changes. Which symptom will the nurse report as normal? a. 4, 1, 2, 3 b. 3, 4, 1, 2 c. 2, 3, 4, 1 d. 1, 2, 3, 4 a. Oily skin b. Faster nail growth c. Decreased elasticity d. Increased facial hair in men a. Notify the health care provider immediately to rule out cranial nerve damage. b. Schedule the patient for an appointment at a smell and taste disorders clinic. c. Perform testing on the vestibulocochlear nerve and a hearing test. d. Explain to the patient that diminished senses are normal findings. 19A&E I Comprehensive Testbank ANS: C Slower reaction time is a common change in the older adult. Symptoms of cognitive impairment, such as disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are not normal aging changes and require further investigation of underlying causes. 16. An older patient with dementia and confusion is admitted to the nursing unit after hip replacement surgery. Which action will the nurse include in the plan of care? ANS: A Patients with dementia need a routine. Continuing to reorient a patient with dementia is nonproductive and not advised. Patients with dementia need limited choices. Social interaction based on the patient’s abilities is to be promoted. 17. A nurse is helping an older-adult patient with instrumental activities of daily living. The nurse will be assisting the patient with which activity? ANS: C Instrumental activities of daily living or IADLs (such as the ability to write a check, shop, prepare meals, or make phone calls) and activities of daily living or ADLs (such as bathing, dressing, and toileting) are essential to independent living. 18. A male older-adult patient expresses concern and anxiety about decreased penile firmness during an erection. What is the nurse’s best response? ANS: D Aging men typically experience an erection that is less firm and shorter acting and have a less forceful ejaculation. Testosterone lessens with age and sometimes (not always) leads to a loss of libido. However, for both men and women sexual desires, thoughts, and actions continue throughout all decades of life. Sexuality involves love, warmth, sharing, and touching, not just the act of intercourse. Touch complements traditional sexual methods or serves as an alternative sexual expression when physical intercourse is not desired or a. Disorientation b. Poor judgment c. Slower reaction time d. Loss of language skills a. Keep a routine. b. Continue to reorient. c. Allow several choices. d. Socially isolate patient. a. Taking a bath b. Getting dressed c. Making a phone call d. Going to the bathroom a. Tell the patient that libido will always decrease, as well as the sexual desires. b. Tell the patient that touching should be avoided unless intercourse is planned. c. Tell the patient that heterosexuality will help maintain stronger libido. d. Tell the patient that this change is expected in aging adults. 20A&E I Comprehensive Testbank possible. Clearly not all older adults are heterosexual, and there is emerging research on older adult, lesbian, gay, bisexual, and transgender individuals and their health care needs. 19. A patient asks the nurse what the term polypharmacy means. Which information should the nurse share with the patient? ANS: D Polypharmacy refers to the concurrent use of many medications. It does not have anything to do with side effects, adverse drug effects, or risks of medication use due to aging. 20. An outcome for an older-adult patient living alone is to be free from falls. Which statement indicates the patient correctly understands the teaching on safety concerns? ANS: A Postural hypotension is an intrinsic factor that can cause falls. Changing positions slowly indicates a correct understanding of this concept. Environmental hazards outside and within the home such as poor lighting, slippery or wet flooring, and items on floor that are easy to trip over such as throw rugs are other factors that can lead to falls. Impaired vision and poor lighting are other risk factors for falls and should be avoided (dim lighting). Inappropriate footwear such as smooth bottom socks also contributes to falls. 21. A nurse’s goal for an older adult is to reduce the risk of adverse medication effects. Which action will the nurse take? ANS: A Strategies for reducing the risk for adverse medication effects include reviewing the medications with older adults at each visit; examining for potential interactions with food or other medications; simplifying and individualizing medication regimens; taking every opportunity to inform older adults and their families about all aspects of medication use; and encouraging older adults to question their health care providers about all prescribed and over-the-counter medications. Although polypharmacy often reflects inappropriate prescribing, the concurrent use of multiple medications is often necessary when an older adult has multiple acute and chronic conditions. Older adults are at risk for adverse drug effects because of age-related changes in the absorption, distribution, metabolism, and excretion of drugs. Work collaboratively with the older adult to ensure safe and appropriate use of all medications—both prescribed medications and over-the-counter medications and herbal options. 22. An older-adult patient has developed acute confusion. The patient has been on tranquilizers for the past week. The patient’s vital signs are normal. What should the nurse do? a. This is multiple side effects experienced when taking medications. b. This is many adverse drug effects reported to the pharmacy. c. This is the multiple risks of medication effects due to aging. d. This is concurrent use of many medications. a. “I’ll take my time getting up from the bed or chair.” b. “I should dim the lighting outside to decrease the glare in my eyes.” c. “I’ll leave my throw rugs in place so that my feet won’t touch the cold tile.” d. “I should wear my favorite smooth bottom socks to protect my feet when walking around.” a. Review the patient’s list of medications at each visit. b. Teach that polypharmacy is to be avoided at all cost. c. Avoid information about adverse effects. d. Focus only on prescribed medications. 21A&E I Comprehensive Testbank ANS: A Some sedatives and tranquilizers prescribed for acutely confused older adults sometimes cause or exacerbate confusion. Carefully administer drugs used to manage confused behaviors, taking into account age-related changes in body systems that affect pharmacokinetic activity. When confusion has a physiological cause (such as an infection), specifically treat that cause, rather than the confused behavior. When confusion varies by time of day or is related to environmental factors, nonpharmacological measures such as making the environment more meaningful, providing adequate light, etc., should be used. Making phone calls to friends or family members allows older adults to hear reassuring voices, which may be beneficial. 23. Which assessment finding of an older adult, who has a urinary tract infection, requires an immediate nursing intervention? ANS: A Confusion is a common manifestation in older adults with urinary tract infection; however, the cause requires further assessment. There may be another reason for the confusion. Confusion is not a normal finding in the older adult, even though it is commonly seen with concurrent infections. Difficulty hearing, presbycusis, is an expected finding in an older adult. Older adults tend to have lower core temperatures. Coping with the death of a spouse is a psychosocial concern to be addressed after the acute physiological concern in this case. 24. Which patient statement is the most reliable indicator that an older adult has the correct understanding of health promotion activities? ANS: B General preventive measures for the nurse to recommend to older adults include keeping regular dental appointments to promote good oral hygiene, eating a low-fat, well-balanced diet, exercising regularly, and maintaining immunizations for seasonal influenza, tetanus, diphtheria and pertussis, shingles, and pneumococcal disease. 25. A 72-year-old woman was recently widowed. She worked as a teller at a bank for 40 years and has been retired for the past 5 years. She never learned how to drive. She lives in a rural area that does not have public transportation. Which psychosocial change does the nurse focus on as a priority? a. Take into account age-related changes in body systems that affect pharmacokinetic activity. b. Increase the dose of tranquilizer if the cause of the confusion is an infection. c. Note when the confusion occurs and medicate before that time. d. Restrict phone calls to prevent further confusion. a. Confusion b. Presbycusis c. Temperature of 97.9° F d. Death of a spouse 2 months ago a. “I need to increase my fat intake and limit protein.” b. “I still keep my dentist appointments even though I have partials now.” c. “I should discontinue my fitness club membership for safety reasons.” d. “I’m up-to-date on my immunizations, but at my age, I don’t need the influenza vaccine.” a. Sexuality b. Retirement 22A&E I Comprehensive Testbank ANS: D The highest priority at this time is the potential for social isolation. This woman does not know how to drive and lives in a rural community that does not have public transportation. All of these factors contribute to her social isolation. Other possible changes she may be going through right now include sexuality related to her advanced age and recent death of her spouse; however, this is not the priority at this time. She has been retired for 5 years, so this is also not an immediate need. She may eventually experience needs related to environment, but the data do not support this as an issue at this time. MULTIPLE RESPONSE 1. A recently widowed older-adult patient is dehydrated and is admitted to the hospital for intravenous fluid replacement. During the evening shift, the patient becomes acutely confused. Which possible reversible causes will the nurse consider when assessing this patient? (Select all that apply.) ANS: A, B, C, D Delirium, or acute confusional state, is a potentially reversible cognitive impairment that is often due to a physiological event. Physiological causes include electrolyte imbalances, untreated pain, infection, cerebral anoxia, hypoglycemia, medication effects, tumors, subdural hematomas, and cerebrovascular infarction or hemorrhage. Sometimes it is also caused by environmental factors such as sensory deprivation or overstimulation, unfamiliar surroundings, or sleep deprivation or psychosocial factors such as emotional distress. Dementia is a gradual, progressive, and irreversible cerebral dysfunction. MATCHING A nurse is using different strategies to meet older patients’ psychosocial needs. Match the strategy the nurse is using to its description. 1. Body image 2. Validation therapy 3. Therapeutic communication 4. Reality orientation 5. Reminiscence 1.ANS:E2.ANS:D3.ANS:A4.ANS:B5.ANS:C Chapter 24: Communication Potter et al.: Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE 1. Which types of nurses make the best communicators with patients? c. Environment d. Social isolation a. Electrolyte imbalance b. Sensory deprivation c. Hypoglycemia d. Drug effects e. Dementia a. Respecting the older adult’s uniqueness b. Improving level of awareness c. Listening to the patient’s past recollections d. Accepting describing of patient’s perspective e. Offering help with grooming and hygiene a. Those who learn effective psychomotor skills b. Those who develop critical thinking skills 23A&E I Comprehensive Testbank ANS: B Nurses who develop critical thinking skills make the best communicators. Just liking people does not make an effective communicator because it is important to apply critical thinking standards to ensure sound effective communication. Just learning psychomotor skills does not ensure that the nurse will use those techniques, and communication involves more than psychomotor skills.Critical thinking helps the nurse overcome perceptual biases or human tendencies that interfere with accurately perceiving and interpreting messages from others. Nurses who maintain perceptual biases do not make good communicators. 2. A nurse believes that the nurse-patient relationship is a partnership and that both are equal participants. Which term should the nurse use to describe this belief? ANS: C Effective interpersonal communication requires a sense of mutuality, a belief that the nurse-patient relationship is a partnership and that both are equal participants. Critical thinking in nursing, based on established standards of nursing care and ethical standards, promotes effective communication and uses standards such as humility, self-confidence, independent attitude, and fairness. To be authentic (one’s self) and to respond appropriately to the other person are important for interpersonal relationships but do not mean mutuality. Attending is giving all of your attention to the patient. 3. A nurse wants to present information about flu immunizations to the older adults in the community. Which type of communication should the nurse use? ANS: A Public communication is interaction with an audience. Nurses have opportunities to speak with groups of consumers about health-related topics, present scholarly work to colleagues at conferences, or lead classroom discussions with peers or students. When nurses work on committees or participate in patient care conferences, they use a small group communication process. Interpersonal communication is one-on-one interaction between a nurse and another person that often occurs face to face. Intrapersonal communication is a powerful form of communication that you use as a professional nurse. This level of communication is also called selftalk. 4. A nurse is using therapeutic communication with a patient. Which technique will the nurse use to ensure effective communication? ANS: C c. Those who like different kinds of people d. Those who maintain perceptual biases a. Critical thinking b. Authentic c. Mutuality d. Attend a. Public b. Small group c. Interpersonal d. Intrapersonal a. Interpersonal communication to change negative self-talk to positive self-talk b. Small group communication to present information to an audience c. Electronic communication to assess a patient in another city d. Intrapersonal communication to build strong teams 24A&E I Comprehensive Testbank Electronic communication is the use of technology to create ongoing relationships with patients and their health care team. Intrapersonal communication is self-talk. Interpersonal communication is one-on-one interaction between a nurse and another person that often occurs face to face. Public communication is used to present information to an audience. Small group communication is interaction that occurs when a small number of persons meet. When nurses work on committees or participate in patient care conferences, they use a small group communication process. 5. A nurse is standing beside the patient’s bed. Nurse: How are you doing? Patient: I don’t feel good. Which element will the nurse identify as feedback? ANS: D “I don’t feel good” is the feedback because the feedback is the message the receiver returns. The sender is the person who encodes and delivers the message, and the receiver is the person who receives and decodes the message. The nurse is the sender. The patient is the receiver. “How are you doing?” is the message. 6. A nurse is sitting at the patient’s bedside taking a nursing history. Which zone of personal space is the nurse using? ANS: B Personal space is 18 inches to 4 feet and involves things such as sitting at a patient’s bedside, taking a patient’s nursing history, or teaching an individual patient. Intimate space is 0 to 18 inches and involves things such as performing a physical assessment, bathing, grooming, dressing, feeding, and toileting a patient. The socioconsultative zone is 9 to 12 feet and involves things such as giving directions to visitors in the hallway and giving verbal report to a group of nurses. The public zone is 12 feet and greater and involves things such as speaking at a community forum, testifying at a legislative hearing, or lecturing. 7. A smiling patient angrily states, “I will not cough and deep breathe.” How will the nurse interpret this finding? ANS: C An inappropriate affect is a facial expression that does not match the content of a verbal message (e.g., smiling when describing a sad situation). The patient is smiling but is angry, which indicates an inappropriate affect. The patient’s personal space was not violated. The patient’s vocabulary is not poor. Individuals who use a common language share denotative meaning: baseball has the same meaning for everyone who speaks English, but code denotes cardiac arrest primarily to health care

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