Treas Funds TB05-1 Test Bank, Chapter 05
Chapter 5. Nursing Process: Planning Outcomes Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. For which patient would it be most important to perform a comprehensive discharge plan?
1)
A teen who is a first-time mother, single, and lives with her parents
2)
An older adult who has had a stroke affecting the left side of his body and lives alone
3)
A middle-aged man who has had outpatient surgery on his knee and requires crutches
4)
A young woman who was admitted to the hospital for observation following an accident
ANS: 2
A comprehensive discharge plan should be developed for older adults and anyone who has complex needs, including self-care deficits. The other patients do not have the complex needs of the older adult patient who has had a stroke that affects body function.
PTS: 1 DIF: Moderate REF: p. 83
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis
____ 2. The nurse is beginning discharge planning for an older adult with left-side weakness. All of the following are important, but which action is most important in ensuring that the discharge plan is successful?
1)
Start planning at admission. 2)
Involve the family members. 3)
Get patient input when making the plan. 4)
Involve the multidisciplinary team.
ANS: 3
The discharge plan may be developed in a timely manner and involve the family and a multidisciplinary team, but if the patient does not agree with the plan, it will not be successful.
PTS: 1 DIF: Moderate REF: pp. 83| p. 87
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
Treas Funds TB05-2 Test Bank, Chapter 05
____ 3. What do initial, ongoing, and discharge planning have in common? 1)
They are based on assessment and diagnosis.
2)
They focus on the patient’s perception of his needs. 3)
They require input from a multidisciplinary team. 4)
They have specific timelines in which to be completed.
ANS: 1
All planning is based on nursing assessment data and identified nursing diagnoses. The patient should have input, but the planning is based on the nursing assessment. The different types of planning are intertwined and may or may not be done at distinct, separate times. Discharge planning often requires a multidisciplinary team, but initial and ongoing planning may not. Initial planning is usually begun after the first patient contact, but there is no specified time for completion; ongoing planning is more or less continuous and is done as the need arises; discharge planning must be done before discharge.
PTS: 1 DIF: Moderate REF: p. 81-82
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 4. Which client has the greatest need for comprehensive discharge planning? 1)
A woman who has just given birth to her second child and lives with her husband and 18- month-old daughter
2)
A man who has been readmitted for exacerbation of his chronic obstructive pulmonary disease
3)
A 12-year-old boy who had outpatient surgery on his knee and lives with his mother 4)
A woman who was just diagnosed with renal failure and has started peritoneal dialysis
ANS: 4
Comprehensive discharge planning should be done for patients who have a newly diagnosed chronic disease or have complex needs. The other patients may require discharge planning but not as comprehensive as someone with a new diagnosis with complex treatment.
PTS: 1 DIF: Difficult REF: p. 83
Treas Funds TB05-3 Test Bank, Chapter 05
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 5. Which of the following is a benefit of standardized care plans, as defined in your text? Standardized care plans
1)
Apply to every patient on a particular unit
2)
Include both medical and nursing orders
3)
Specify patient outcomes for each day
4)
Help ensure that important interventions are not overlooked
ANS: 4
Standardized care plans help promote consistency of care and ensure that important interventions are not forgotten. They are not likely to apply to every patient on a unit because they are usually single-problem plans or are used with a particular medical diagnosis. Unlike protocols, they do not include medical orders. Unlike critical pathways, they do not specify predicted patient outcomes for each day.
PTS: 1 DIF: Moderate REF: p. 86
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Recall
____ 6. How are standardized (model) care plans similar to unit standards of care? Standardized (model) care plans
1)
Describe the care needed by patients in defined situations
2)
Include specific goals and nursing orders
3)
Become a part of the patient’s comprehensive care plan 4)
Usually describe ideal nursing care
ANS: 1
All of the statements are true for standardized care plans, but only 1 is true of both standardized care plans and unit standards of care. Both describe care needed by patients in defined situations, although unit standards usually describe care for groups of patients (e.g., all women admitted to a labor unit), and standardized care plans are often organized around a particular or all nursing diagnoses commonly occurring with a particular medical diagnosis. Unit standards are more general and do not have goals for each
Treas Funds TB05-4 Test Bank, Chapter 05
patient. Unit standards are kept on file in a central place on the unit and do not become a part of the care plan. Unit standards describe minimal, not ideal, care.
PTS: 1 DIF: Difficult REF: p. 87; requires analysis of text discussion. KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 7. The nurse is planning care for a patient. She is using a standardized care plan for Impaired Walking related to left-side weakness. Which of the following activities will the nurse perform when individualizing the plan for the patient?
1)
Validate conflicting data with the patient.
2)
Transcribe medical orders.
3)
State the frequency for ambulation.
4)
Perform a comprehensive assessment.
ANS: 3
Individualizing the care plan means identifying specific problems, outcomes, and interventions and the frequency of those interventions to meet the patient’s needs. Validating data ensures your assessment is accurate. Transcribing orders is a part of developing and implementing the care plan but not of individualizing the plan. Performing an assessment is the beginning step to developing a care plan. Assessment helps you to know the ways in which a standardized plan needs to be individualized.
PTS: 1 DIF: Moderate REF: p. 90
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
____ 8. Which of the following is the best example of an outcome statement? The patient will
1)
Use the incentive spirometer when awake
2)
Walk two times during day and evening shifts
3)
Maintain oxygen saturation above 92% while performing ADLs each morning 4)
Tolerate 10 sets of range-of-motion exercises with physical therapy
ANS: 3
Treas Funds TB05-5 Test Bank, Chapter 05
Outcome statements should have specific performance criteria and a target time; “maintain oxygen saturation” is the only one that meets those criteria. The incentive spirometer goal should say how many times the incentive spirometer should be used each hour as well as the volume. The walking goal should state how far the patient should walk. In the range-of-motion goal, tolerate is a vague word and is difficult to measure, and the outcome needs to specify how often.
PTS: 1 DIF: Moderate REF: p. 91-92
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 9. How are critical pathways and standardized nursing care plans similar? Both
1)
Specify daily, or even hourly, outcomes and interventions
2)
Prescribe minimal care needed to meet recommended lengths of stay
3)
Describe care common to all patients with a certain condition or situation 4)
Emphasize medical problems and interventions
ANS: 3
Both critical pathways and standardized care plans are preplanned documents; they describe care common to all patients who have a certain condition (e.g., all patients who have a heart attack need some of the same interventions). The other statements are true of critical pathways but not of standardized nursing care plans.
PTS: 1 DIF: Difficult REF: pp. 86–87; high-level question, answer not
given KEY:
verbatim
Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 10. How is NOC different from the Omaha System? 1)
NOC 2) NOC 3) NOC 4) NOC
ANS:
can be used to write health restoration outcomes. can be used in all specialty and practice areas. can be used for individuals, families, or groups. formulates goals based on nursing diagnoses.
2
Treas Funds TB05-6 Test Bank, Chapter 05
NOC was developed for all specialty and practice areas. The Omaha System was developed for community health nursing. Both address health restoration and can be used for individuals, family, or groups (community). Both base goals on nursing diagnoses, although Omaha does not use the NANDA-I taxonomy.
PTS: 1 DIF: Moderate REF: p. 95; answer based on analysis of text discussion | V1, p. 98; answer based on analysis of text discussion
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 11. How are short-term goals different from long-term goals? Short-term goals 1)
Can be met within a few hours or a few days
2)
Are developed from the problem side of the nursing diagnosis 3)
Must have target times/dates
4)
Specify desired client responses to interventions
ANS: 1
Short-term goals may be accomplished in hours or days; long-term goals usually are achieved over weeks, months, or even years. The other statements are true for both short- term and long-term goals.
PTS: 1 DIF: Moderate REF: p. 91
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 12. What do standardized nursing care plans and individualized care plans have in common? They both
1)
Reflect critical thinking for a specific patient
2)
Are preprinted to apply to needs common to a group of patients 3)
Address a patient’s individual needs
4)
Provide detailed nursing interventions
ANS: 4
They both provide detailed nursing interventions, although the individualized care plan is more specific to the patient’s needs and reflects critical thinking, whereas standardized
Treas Funds TB05-7 Test Bank, Chapter 05
plans do not. It is not true of individual nursing care plans that they are preprinted and apply to a group.
PTS: 1 DIF: Moderate REF: pp. 87
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 13. The nurse is individualizing Mr. Wu’s plan of care by writing a plan for his nursing diagnosis of Anxiety. Why does the nurse need to write goals/outcomes on the plan of care? Because outcomes describe
1)
Desired changes in the patient’s health status
2)
Specific patient responses to medical interventions
3)
Specific nursing behaviors to improve a patient’s health
4)
Criteria to evaluate the appropriateness of a nursing diagnosis
ANS: 1
Outcomes describe changes in the patient’s health status in response to nursing, rather than medical, interventions. Outcomes relate to patient behavior, not nursing behaviors. Outcomes are a measure of the effectiveness of nursing care for a specific nursing diagnosis, not whether the nursing diagnosis is appropriate.
PTS: 1 DIF: Moderate REF: p. 91
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension
____ 14. Which of the following outcome statements contains the best example of performance criteria? The patient will
1)
Turn herself in bed frequently while awake
2)
Understand how to use crutches by day 2
3)
State that pain is decreased after being medicated 4)
Eat 75% of each meal without complaint of nausea
ANS: 4
Performance criteria should be specific and measurable. “75% of each meal” is specific and measurable. “Frequently” is vague. You cannot observe whether someone “understands.” “Decreased” is vague; a numerical pain rating would be better.
Treas Funds TB05-8 Test Bank, Chapter 05
PTS: 1 DIF: Moderate REF: p. 92
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
____ 15. Which of the following is true for goals/outcomes for collaborative problems?
1)
They are monitored only by other disciplines.
2)
They are usually sensitive to nursing interventions. 3)
They state that a complication will not occur.
4)
They state only broad performance criteria.
ANS: 3
The goal for a collaborative problem is always that the complication will not occur. Other disciplines may be involved in helping to prevent the problem, but nurses still monitor for the complication. The outcomes to collaborative problems are not affected by nursing interventions alone. Goals for collaborative problems are specific to the medical condition/treatment.
PTS: 1 DIF: Moderate REF: pp. 93
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 16. How are NANDA-I problem labels and NOC outcome labels alike? Both describe
1)
Health status in terms of human responses
2)
Patient response before interventions are done 3)
Patient response in positive terms
4)
A pattern of related cues
ANS: 1
Both NANDA-I and NOC labels are stated as human responses. A NOC label can be used to describe patient responses both before and after intervention—NANDA-I before. NOC statements are neutral to allow for positive, negative, or no change in health status; NANDA-I diagnoses describe both problem responses and positive responses (wellness
Treas Funds TB05-9 Test Bank, Chapter 05
labels). NANDA-I labels are based on patterns of related cues; NOC labels are based on (linked to) NANDA-I labels.
PTS: 1 DIF: Difficult REF: pp. 94; also information about NANDA-I diagnoses from Chapter 4
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 17. The nursing diagnosis is Impaired Memory related to fluid and electrolyte imbalances A.M.B. inability to recall recent events. Which of the following goals/outcomes must be included on the care plan?
1)
Checks current medications for mind-altering side effects 2)
Demonstrates use of techniques to help with memory loss 3)
Drinks at least 1500 cc of fluid per day 4)
Takes electrolyte supplements with meals
ANS: 2
The essential goal/outcome is aimed at the problem response Impaired Memory. The other goals in this question address the etiology.
PTS: 1 DIF: Moderate REF: p. 93-94
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
____ 18. A client arrives in the emergency department, pale and breathing rapidly. He immediately becomes unconscious and collapses to the floor. The nurse rapidly assesses the patient and decides the first series of actions that are needed. This scenario demonstrates
1)
Formal planning 2)
Informal planning 3)
Ongoing planning 4)
Initial planning
ANS: 2
Informal planning is performed while doing other nursing process steps and is not written; this nurse is forming a plan in her mind. The end product of formal planning is a
Treas Funds TB05-10 Test Bank, Chapter 05
holistic plan of care that addresses the patient’s unique problems and strengths; this nurse has no time to create a holistic plan of care. Ongoing planning refers to changes made in the plan as you evaluate the patient’s responses to care; no care has been given at this point. Initial planning does indeed begin with the first patient contact. However, it refers to the development of the initial comprehensive plan or care; this nurse does not have enough data for a comprehensive plan, nor does she have time to make such a plan at the moment.
PTS: 1 DIF: Easy REF: p. 81
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 1. A nurse is caring for an 80-year-old patient of Chinese heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association standards for outcomes identification? Choose all that apply.
1)
Developing culturally appropriate outcomes
2)
Using the outcomes preprinted on the clinical pathway
3)
Choosing the best outcome for the patient, regardless of the costs involved in bringing it about
4)
Involving the patient and family in formulating the outcomes
ANS: 1, 4
ANA standard 3 includes “derives culturally appropriate expected outcomes from the diagnosis” and “involves the patient, family . . . in formulating expected outcomes. . . .” It is acceptable for the nurse to use outcomes on a clinical pathway, but these are not individualized; ANA standard 3 says that the nurse “identifies . . . outcomes for a plan individualized to the patient. . . .” The standard also says that the nurse should consider “associated risks, benefits, and costs. . . .”
PTS: 1 DIF: Moderate REF: p. 82
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension
Treas Fundmentals TB08-1 Test Bank, Chapter 08
Chapter 8. Nursing Theory & Research Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. Which commonly accepted practice came out of the Framingham study? Use of
1)
Mammography in breast cancer screening
2)
Colonoscopy in colon cancer screening
3)
Pap testing in cervical cancer screening
4)
Digital rectal examination in prostate cancer screening
ANS: 1
One commonly accepted practice that came out of the Framingham study is the link between mammography and breast cancer. Before the Framingham study, mammography was considered an unreliable tool in breast cancer screening.
PTS: 1 DIF: Easy REF: p. 137
KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Recall
____ 2. Which theorist developed the nursing theory known as the science of human caring?
1)
Florence Nightingale
2)
Patricia Benner 3)
Jean Watson
4)
Nola Pender
ANS: 3
Dr. Jean Watson developed the nursing theory known as the science of human caring. Her theory describes caring from a nursing perspective. Florence Nightingale developed the theory that stated that “a clean environment would improve the health of patients.” By changing the care environment, she dramatically reduced the death rate of soldiers. Dr. Patricia Benner’s theory described the progression of a beginning nurse who learns to be
Treas Fundmentals TB08-2 Test Bank, Chapter 08
an expert nurse. Nola Pender’s theory on health promotion became the basis for most health-promotion teaching done by nurses.
PTS: 1 DIF: Easy REF: p. 137
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
____ 3. A patient complains of pain after undergoing surgery. The nurse forms a mental image of pain based on her own experiences with pain. This mental image is known as a(n)
1)
Phenomenon 2)
Concept
3) Assumption 4)
Definition
ANS: 2
A concept is a mental image of a phenomenon, an aspect of reality that you can observe and experience. In the scenario above, the nurse forms a mental image of pain because of her past experiences with pain. Phenomena are the subject matter of a discipline. They mark the boundaries of a discipline. An assumption is an idea that is taken for granted. In a theory, the assumption is the idea that the researcher presumes to be true and does not intend to test with research. A definition is a statement of meaning of a term or concept that sets forth the concept’s characteristics or indicators.
PTS: 1 DIF: Moderate REF: p. 138
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application
____ 4. Hildegard Peplau was a nursing theorist whose major contribution to nursing was
1)
Transcultural nursing
2)
Health promotion
3)
Nurse-patient relationship 4)
Holistic comfort
ANS: 3
Treas Fundmentals TB08-3 Test Bank, Chapter 08
Hildegard Peplau was a psychiatric nurse who showed that developing a relationship with psychiatric patients made their treatment more effective. From her work, she developed the theory of interpersonal relations, which focuses on the nurse-patient relationship. This theory is in use every day in nursing.
PTS: 1 DIF: Easy REF: p. 142
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall
____ 5. The nurse and other hospital personnel strive to keep the patient care area clean. This most directly illustrates the ideas of which nursing theorist?
1)
Virginia Henderson
2)
Imogene Rigdon
3)
Katherine Kolcaba 4)
Florence Nightingale
ANS: 4
Florence Nightingale was instrumental in identifying the importance of a clean patient care environment. During the Crimean War, Nightingale dramatically reduced the death rate of soldiers by changing the healthcare environment. Virginia Henderson identified 14 basic needs that are addressed by nursing care. Imogene Rigdon developed a theory about bereavement of older women after noticing that older women handle grief differently than do men and younger women. Katherine Kolcaba developed a theory of holistic comfort in nursing.
PTS: 1 DIF: Moderate REF: p. 141
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
____ 6. A patient who emigrated from India is admitted to the medical step-down unit with a bowel obstruction. A nasogastric (NG) tube is inserted to decompress her stomach. She asks the nurse if her daughter can bring in garlic to administer through her NG tube. The nurse tells the patient that she will ask the physician when she makes rounds. This nurse is utilizing the theory developed by which nurse theorist?
1)
Betty Neuman 2)
Dorothea Orem 3)
Callista Roy
Treas Fundmentals TB08-4 Test Bank, Chapter 08
4)
Madeline Leininger
ANS: 4
The nurse is utilizing the theory developed by Madeline Leininger. Leininger’s theory focuses on the values of cultural diversity. According to her theory, the nurse must make cultural accommodations for the health benefit of the patient.
PTS: 1 DIF: Moderate REF: p. 142-143
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
____ 7. According to Maslow’s hierarchy of needs, which patient need should the nurse address first?
1)
Protecting the patient against falls
2)
Protecting the patient from an abusive spouse
3)
Promoting rest in the critically ill patient
4)
Promoting self-esteem after a body image change
ANS: 3
According to Maslow’s hierarchy of needs, basic physiological needs should be met first. They include the need for rest, food, air, water, temperature regulation, elimination, sex, and physical activity. Therefore, the nurse should address the critically ill patient’s need for rest first.
PTS: 1 DIF: Moderate REF: p. 144
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
____ 8. A nurse researcher is designing a research project. After identifying and stating the problem, the nurse researcher clarifies the purpose of the study. Which step in the research process should she complete next?
1)
Perform a literature review.
2)
Develop a conceptual framework. 3)
Formulate the hypothesis. 4)
Define the study variables.
Treas Fundmentals TB08-5 Test Bank, Chapter 08
ANS: 1
After identifying and stating the problem, the nurse researcher should clarify the purpose of the study. Next, the researcher should perform a literature search to find out what is already known about the problem. After the literature search, the researcher should choose a conceptual framework to guide the research, formulate the hypothesis or research question, and define the study variables.
PTS: 1 DIF: Moderate REF: p. 151-152
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Comprehension
____ 9. The mother of a child participating in a research study that uses high-dose steroids wishes to withdraw her child from the study. Despite reassurance that adverse reactions to steroids in children are uncommon, the mother still wishes to withdraw. By withdrawing from the study, the mother is exercising which right? The right
1)
Not to be harmed
2)
To self-determination 3)
To full disclosure
4)
Of confidentiality
ANS: 2
The mother is exercising the right to self-determination. This refers to the right of the participant (or parent in the case of a minor) to withdraw from a research study at any time and for any reason. The right to not be harmed outlines the safety protocols of the study. All research participants also have the right to full disclosure. This guarantees the participants answers to questions, such as the purpose of the research study, the risks and benefits, and what happens if the patient feels worse as a result of the study. Moreover, participants also have the right to confidentiality. Typically that right is preserved by giving participants an identification code rather than associating them by name.
PTS: 1 DIF: Moderate REF: p. 151
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
____ 10. After suffering an acute myocardial infarction, a patient attends cardiac rehabilitation. This will help to gradually build his exercise tolerance. According to Maslow’s hierarchy of needs, cardiac rehabilitation most directly addresses which need? 1)
Safety and security
Treas Fundmentals Test Bank, Chapter 08
2)
Physiological
3) Self-actualization 4)
Self-esteem
TB08-6
ANS: 2
Cardiac rehabilitation most directly addresses the patient’s physiological need for physical activity as well as for health and healing. Indirectly, of course, better physical condition might enable the patient to perform activities that would lead to higher self- esteem and even self-actualization.
PTS: 1 DIF: Moderate REF: p. 144
KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Application
____ 11. In his later work, Maslow identified growth needs that must be met before reaching self-actualization. These needs include
1)
Cognitive and aesthetic needs
2)
Love and belonging needs
3)
Safety and security needs
4)
Physiological and self-esteem needs
ANS: 1
In his later work, Maslow identified two growth needs that must be met before reaching self-actualization. They include cognitive (to know, understand, and explore) and aesthetic (for symmetry, order, and beauty) needs. The needs Maslow identified in his earlier work were physiological, safety and security, love and belonging, esteem, and self-actualization.
PTS: 1 DIF: Easy REF: p. 144-145
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall
____ 12. The PICO question reads, “Is TENS effective in the management of chronic low-back pain in adults?” Which part of this question comes from the “I” in PICO?
1)
Adults
Treas Fundmentals Test Bank, Chapter 08
2) Management 3)
Pain
4)
TENS
TB08-7
ANS: 4
TENS is the intervention (I) in the PICO system. “Adults” comes from patient (P). “Management” comes from the outcome (O). There is no comparison intervention (C) in this PICO question.
PTS: 1 DIF: Difficult REF: p. 152
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application
____ 13. While reading a journal article, the nurse asks herself these questions: “What is this about overall? Is it true in whole or in part? Does it matter to my practice?” What is this nurse doing?
1)
Reading the article analytically
2)
Performing a literature review
3)
Formulating a searchable question
4)
Determining the soundness of the article
ANS: 1
Analytical reading involves questioning the article to be sure you understand it and to determine whether it is applicable to your practice. Such reading asks these questions: “What is this about as a whole? Is it true in whole or in part? Does it matter to my practice?” A literature review is performed by searching indexes and databases and reading more than one article. Formulating a searchable question involves creating a PICO-type statement to guide a search of the literature. The nurse would determine whether the article is a research report by looking for the individual parts of the article to see if they were present in the form of research (e.g., title, problem, hypothesis, purpose, methods, data, data analysis, conclusions).
PTS: 1 DIF: Moderate REF: p. 153
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application
Completion
Complete each statement.
Treas Fundmentals TB08-8 Test Bank, Chapter 08
1. Nursing research is based on the ____________________ method.
ANS: scientific
Nursing research is based on the scientific method. It is the process in which the researcher, through use of senses, systematically collects observable, verifiable data to describe, explain, or predict events.
PTS: 1 DIF: Easy REF: p. 149
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
2. The unit council in the intensive care unit is designing a research study to see if they are meeting the spiritual needs of their patients. The study will involve patient interviews after discharge. After the interview process, the staff will examine patient statements for recurring themes. The unit council is conducting ____________________ research.
ANS: qualitative
The unit council is conducting qualitative research, which focuses on the lived experiences of people.
PTS: 1 DIF: Moderate REF: p. 149
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
3. A 56-year-old patient diagnosed with an acute myocardial infarction (heart attack) makes inappropriate sexual comments to the licensed practical nurse (LPN). The LPN is visibly upset. The registered nurse (RN) assigned to the patient informs the patient that his behavior is unacceptable and will not be tolerated. Is the RN demonstrating holistic or mechanistic nursing?
ANS: mechanistic
The nurse is demonstrating the mechanistic nursing approach, which focuses on getting the task done.
PTS: 1 DIF: Moderate REF: p. 136
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
4. A 23-year-old athlete decides to donate bone marrow for a child who requires a bone marrow transplant to fight leukemia. According to Maslow’s later work, this athlete is fulfilling his need for ____________________.
True/False
Treas Fundmentals TB08-9 Test Bank, Chapter 08
ANS: self-transcendence
Self-transcendence is the drive to connect to something beyond oneself and to help others recognize their potential. Donating bone marrow to someone to improve his or her life fulfills the need for self-transcendence.
PTS: 1 DIF: Difficult REF: p. 145
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Application
Indicate whether the statement is true or false.
____ 1. Institutional review boards were created to protect the rights of research participants.
ANS: T
Every healthcare facility and university that receives federal funding must have an institutional review board to protect the rights of research participants.
PTS: 1 DIF: Easy REF: p. 151
KEY:
____ 2. A novice nurse is not qualified to identify clinical problems for research. ANS: F
KEY:
Nursing process: N/A | Client need: SECE | Cognitive level: Recall
Even a
PTS: 1 DIF: Easy REF: p. 151
novice nurse can identify clinical problems for research.
Nursing process: N/A | Client need: N/A | Cognitive level: Recall
Treas Fundamentals TB12-1 Test Bank, Chapter 12
Chapter 12. Stress & Adaptation Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. When released in response to alarm, which of the following substances promotes a sense of well-being?
1)
Aldosterone
2)
Thyroid-stimulating hormone 3)
Endorphins
4)
Adrenocorticotropic hormone
ANS: 3
Endorphins act like opiates to produce a sense of well-being; they are released by the hypothalamus and posterior pituitary gland in response to alarm. Aldosterone promotes fluid retention by increasing the reabsorption of water by renal tubules. Thyroid-stimulating hormone increases the efficiency of cellular metabolism and fat conversion to energy for cell and muscle needs. Adrenocorticotropic hormone stimulates the adrenal cortex to produce and secrete glucocorticoids and mineralocorticoids.
PTS: 1 DIF: Moderate REF: p. 253
KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Recall
____ 2. After sustaining injuries in a motor vehicle accident, a patient experiences a decrease in blood pressure and an increase in heart rate and respiratory rate despite surgical intervention and fluid resuscitation. Which stage of the general adaptation syndrome is the patient most likely experiencing?
1)
Alarm
2) Resistance 3) Exhaustion 4) Recovery
ANS: 3
Treas Fundamentals TB12-2 Test Bank, Chapter 12
Physiological responses in the exhaustion stage include low blood pressure and high respiratory and heart rates. During the alarm stage, heart rate and blood pressure both increase. In the resistance stage, the body tries to maintain homeostasis; blood pressure and heart rate normalize. If adaptation is successful, recovery takes place.
PTS: 1 DIF: Difficult REF: p. 254
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
____ 3. You are caring for a patient who suddenly experiences a cardiac arrest. As you respond to this emergency, which substance will your body secrete in large amounts to help prepare you to react in this situation?
1)
Epinephrine
2)
Corticotrophin-releasing hormone 3)
Aldosterone
4)
Antidiuretic hormone
ANS: 1
During the shock phase of the general adaptation syndrome, large amounts of epinephrine prepare the body to react in an emergency situation. In response to the epinephrine release, the endocrine system releases corticotrophin-releasing hormone, aldosterone, and antidiuretic hormone.
PTS: 1 DIF: Moderate REF: p. 252
KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Application
____ 4. What is the function of antidiuretic hormone when released in the alarm stage of the general adaptation syndrome?
1)
Promotes fluid retention by increasing the reabsorption of water by kidney tubules
2)
Increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle 3)
Increases the use of fats and proteins for energy and conserves glucose for use by the brain 4)
Promotes fluid excretion by causing the kidneys to reabsorb more sodium
ANS: 1
Treas Fundamentals TB12-3 Test Bank, Chapter 12
Antidiuretic hormone promotes fluid retention by increasing the reabsorption of water by kidney tubules. Thyroid-stimulating hormone increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle. Cortisol increases the use of fats and proteins for energy and conserves glucose for use by the brain. Aldosterone promotes fluid retention by causing the kidneys to reabsorb more sodium.
PTS: 1 DIF: Moderate REF: p. 252
KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Recall
____ 5. A patient sustains a laceration of the thigh in an industrial accident. Which step in the inflammatory process will the patient experience first?
1)
Cellular inflammation
2)
Exudate formation 3)
Tissue regeneration 4)
Vascular response
ANS: 4
Immediately after the injury, the vascular response occurs. Blood vessels at the site constrict to control bleeding. After the injured cells release histamine, the vessels dilate, causing increased blood flow to the area. During the next phase, known as the cellular response phase, white blood cells migrate to the site of injury. In the exudate-formation phase, the fluid and white blood cells move from circulation to the site of injury, forming an exudate. Tissue regeneration occurs in the healing phase.
PTS: 1 DIF: Moderate REF: p. 254
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
____ 6. A patient complains of a vague, uneasy feeling of dread, and his heart rate is elevated. Which of the following nursing diagnoses is most appropriate for this patient?
1)
Anger
2)
Fear
3)
Anxiety
4) Hopelessness
Treas Fundamentals TB12-4 Test Bank, Chapter 12
ANS: 3
NANDA-International defines Anxiety as a vague, uneasy feeling of discomfort or dread accompanied by an autonomic response. This patient is most likely feeling anxious. Anger is not a nursing diagnosis. Fear, which is also a nursing diagnosis, is an emotion or feeling of apprehension from an identified danger, threat, or pain. Hopelessness is a nursing diagnosis defined as a state in which the patient sees few or no available alternatives and cannot mobilize energy on his own behalf.
PTS: 1 DIF: Moderate REF: p. 256
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application
____ 7. A patient who has been hospitalized for weeks becomes angry and tells the nurse who is caring for him, “I hate this place; nobody knows how to take care of me or I’d be home by now.” Which response by the nurse is best in this situation?
1)
“You seem angry; what’s going on that makes you hate this place?”
2)
“I’m sorry that we aren’t caring for you according to your expectations.” 3)
“You were very sick; don’t be angry; you’re lucky to be alive.”
4)
“You shouldn’t be angry with us; we’re trying to help you.”
ANS: 1
“You seem angry; what’s going on . . .” encourages the patient to express his feelings and may provide you with more information. The nurse should not take responsibility for the patient’s anger by apologizing (“I’m sorry . . .”). Advising the patient “don’t be angry” or “you shouldn’t be angry” diminishes the patient’s right to be angry.
PTS: 1 DIF: Moderate REF: p. 266
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis
____ 8. You are caring for a patient with numerous physiological complaints. A family member tells you that the patient is pretending to have the symptoms of a stomach ulcer to avoid going to work. Which somatoform disorder is this patient most likely experiencing?
1)
Hypochondriasis 2)
Somatization
3)
Somatoform pain disorder 4)
Treas Fundamentals TB12-5 Test Bank, Chapter 12
Malingering
ANS: 4
Malingering is a conscious effort to escape unpleasant situations by pretending to have symptoms of a disorder. With hypochondriasis, the patient is preoccupied with the idea that he is or will become seriously ill. In somatization, anxiety and emotional turmoil are expressed in physical symptoms. With somatoform pain disorder, emotional pain manifests physically.
PTS: 1 DIF: Moderate REF: p. 259
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application
____ 9. After a patient has an argument with her husband, she becomes verbally abusive to the nurse who is caring for her. Which coping mechanism is this patient exhibiting?
1)
Reaction formation
2) Displacement 3)
Denial
4) Conversion
ANS: 2
This patient is using displacement. She is transferring the emotions she feels toward her husband to the nurse. When a patient uses the coping mechanism of reaction formation, the patient is aware of her feelings but acts in an opposite manner to what she is really feeling. With the coping mechanism of denial, the patient transforms reality by refusing to acknowledge thoughts, feeling, desires, or impulses. With conversion, emotional conflict is changed into physical symptoms that have no physical basis.
PTS: 1 DIF: Moderate REF: p. 257
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
____ 10. A patient who has been diagnosed with breast cancer decides on a treatment plan and feels positive about her prognosis. Assuming the cancer diagnosis represents a crisis, this patient is most likely experiencing which phase of crisis?
1)
Precrisis 2) Impact 3)
Crisis
Treas Fundamentals TB12-6 Test Bank, Chapter 12
4) Adaptive
ANS: 4
When a patient begins to think rationally and problem-solve, she is most likely experiencing the adaptive phase of crisis. During the precrisis phase, the patient finds success using her previous coping strategies. Anxiety and confusion increase during the impact phase if usual coping strategies are ineffective. The patient may use new coping strategies, such as withdrawal, during the crisis phase.
PTS: 1 DIF: Moderate REF: pp. 259-260
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application
____ 11. A nurse identifies the nursing diagnosis Diarrhea related to stress for a patient. Which nursing intervention should be included in the nursing care plan to help the patient relieve the cause of the diarrhea?
1)
Monitor and record the frequency of stools on the graphic record.
2)
Administer prescribed antidiarrheal medications as needed.
3)
Encourage the patient to verbalize about stressors and anxiety.
4)
Provide oral fluids on a regular schedule.
ANS: 3
The nurse should encourage the patient to verbalize about stressors and anxiety to help relieve stress, which is the cause of the patient’s diarrhea. Monitoring stool frequency is an assessment, not a nursing intervention. The other interventions may be necessary to treat diarrhea, but they do not alleviate the cause of the diarrhea.
PTS: 1 DIF: Moderate REF: p. 259
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis
____ 12. When counseling a patient about behaviors to reduce stress, which of the following goals should the nurse put on the care plan?
1)
“The patient will limit his intake of fat to no more than 15% of the daily calories consumed.”
2)
“The patient will eat three meals per day at approximately the same time each day.” 3)
“The patient will limit his intake of sugar and salt, as well as sweet and salty foods.”
Treas Fundamentals TB12-7 Test Bank, Chapter 12
4)
“The patient will consume no more than three alcoholic beverages a day.”
ANS: 3
The nurse should advise the client to limit the intake of sugar and salt; limit the intake of fat to no more than 30% (not 15%) of daily calories; eat smaller, more frequent meals (not three meals a day); and consume no more than two alcoholic beverages per day but not necessarily every day.
PTS: 1 DIF: Moderate REF: p. 265
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
____ 13. At the end of a guided imagery session, which physical assessment finding would suggest that the relaxation technique was successful?
1)
Decreased blood pressure
2)
Decreased peripheral skin temperature 3)
Increased heart rate
4)
Increased respiratory rate
ANS: 1
Reassessment findings that suggest relaxation has been effective include decreased blood pressures, increased peripheral skin temperature, decreased heart rate, and decreased respiratory rate.
PTS: 1 DIF: Moderate REF: pp. 266-267
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Comprehension
____ 14. The nurse is caring for a patient with unresolved anger. For which associated complication should the nurse assess?
1)
Depression
2) Hypochondriasis 3)
Somatization
4)
Malingering
ANS: 1
Treas Fundamentals TB12-8 Test Bank, Chapter 12
Depression is sometimes associated with unresolved anger and may result from stress. A person with hypochondriasis is preoccupied with feelings that he will become seriously ill. In somatization, anxiety and emotional turmoil are expressed in physical symptoms, loss of physical function, pain that changes location often, and depression. Malingering is a conscious effort to avoid unpleasant situations. Hypochondriasis, somatization, and malingering are not associated with unresolved anger.
PTS: 1 DIF: Easy REF: p. 256
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension
____ 15. Before entering the room of a patient who is angry and yelling, the nurse removes her stethoscope from around her neck. The best rationale for doing so is that the stethoscope
1)
Could be used by the patient to hurt her
2)
Might cause the patient not to trust her
3)
Would distract her from focusing on the patient 4)
Will function as another stressor for the patient
ANS: 1
When dealing with an angry patient, the nurse must be alert to her own safety needs. A stethoscope, dangling jewelry, or anything else the patient might use as to harm the nurse should be removed before entering the patient’s room. It is unlikely that a stethoscope would cause the patient not to trust the nurse, nor function as a stressor because stethoscopes are common in the healthcare setting; nearly every caregiver carries a stethoscope. For the same reason, it would not likely distract the nurse. Nurses carry stethoscopes so routinely that they likely don’t even notice their presence.
PTS: 1 DIF: Moderate REF: p. 266
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis
____ 16. A patient is in crisis. After assessing the situation, what should the nurse do first? 1)
Determine the imminent cause of the crisis.
2)
Intervene to relieve the patient’s anxiety.
3)
Decide on the type of help the patient needs. 4)
Ensure the safety of both the nurse and patient. ANS: 4
Treas Fundamentals TB12-9 Test Bank, Chapter 12
The first goal of crisis intervention is to assess the situation. Then ensure safety of self and patient, defuse the situation, decrease the person’s anxiety, determine the problem (cause of the crisis), and decide on the type of help needed. Safety is always foremost.
PTS: 1 DIF: Moderate REF: p. 269
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 1. During the alarm stage of the general adaptation syndrome, which metabolic change(s) occur(s)? Choose all that apply.
1)
Rate of metabolism decreases.
2)
Liver converts more glycogen to glucose.
3)
Use of amino acids decreases.
4)
Amino acids and fats are more available for energy.
ANS: 2, 4
The metabolic changes that occur during the alarm stage of the general adaptation syndrome include the following: The rate of metabolism increases, the liver converts more glycogen to glucose, and there is increased use of amino acids and mobilization of fats for energy.
PTS: 1 DIF: Moderate REF: pp. 252-253
KEY: Nursing process: N/A | Client need: Physiological integrity | Cognitive level: Comprehension
____ 2. Two days after a patient undergoes abdominal surgery, his surgical incision is red and slightly edematous; it is oozing a small amount of serosanguineous (pink-tinged serous) fluid. On the basis of these data, what can you conclude? Choose all that apply.
1)
The wound is most likely infected.
2)
This is a vascular response to inflammation. 3)
Damaged cells are being regenerated.
4)
Exudate formation is occurring.
Treas Fundamentals TB12-10 Test Bank, Chapter 12
ANS: 2, 4
During the vascular response phase of the inflammatory process, blood vessels constrict to control bleeding. Fluid from the capillaries moves into tissues, causing edema. The fluid and white blood cells that move to the site of injury are called exudates; this includes the serosanguineous exudate that commonly appears at surgical incisions. When a wound becomes infected, yellow, foul- smelling drainage may form at the site; there is no mention of pus in the scenario. Regeneration occurs when identical or similar cells replace damaged cells; although this may be occurring, you cannot prove it with the data given here.
PTS: 1 DIF: Moderate REF: pp. 254-255
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
____ 3. A 75-year-old patient is tearful, shaky, and withdrawn. She tells you that she is “worrying herself to death” about losing her aging husband and being “all alone.” You recognize this reaction as Anxiety rather than Fear because (choose all that apply)
1)
It concerns future or anticipated events
2)
It concerns anticipation of danger rather than a present danger 3)
There is no shakiness or tearfulness present
4)
There is a psychological rather than a physical threat
ANS: 1, 2, 4
Anxiety is an emotional response related to future or anticipated events. Fear is a cognitive response to a present, usually identifiable, source. Anxiety results from psychological conflict, whereas fear can result from either a psychological or physical threat. Shakiness and tearfulness may occur in both anxiety and fear, which share several defining characteristics.
PTS: 1 DIF: Moderate REF: p. 256
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
