Basic Nursing Concepts, Skills & Reasoning 1st Edition by Treas , Leslie S - Test Bank

Chapter 3. Nursing Process: Assessment Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. What is the role of the Joint Commission in regard to patient assessment? The Joint Commission 1) States what assessments are collected by individuals with different credentials 2) Regulates the time frames for when assessments should be completed 3) Identifies how data are to be collected and documented 4) Sets standards for what and when to assess the patient ANS: 4 The Joint Commission sets detailed standards regarding what and when to assess but does not address credentials. Nurse practice acts specify what data are collected and by whom. Agency policy may set time frames for when assessments should be done and how they should be documented. Nursing knowledge identifies “how” data are to be collected. PTS: 1 DIF: Moderate REF: p. 39 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall ____ 2. Which of the following is an example of data that should be validated? 1) The client’s weight measures 185 lb at the clinic. 2) The client’s liver function test results are elevated. 3) The client’s blood pressure is 160/94 mm Hg; he states that that is typical for him. 4) The client states she eats a low-sodium diet and reports eating processed food. ANS: 4 Validation should be done when the client’s statements are inconsistent (processed foods are generally high in sodium). Validation is not necessary for laboratory data when you suspect an error has been made in the results. Personal information that patients might be embarrassed about, such as weight, is best validated with a scale. PTS: 1 DIF: Moderate REF: p. 47 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application ____ 3. Which of the following examples includes both objective and subjective data? 1) The client’s blood pressure is 132/68 and her heart rate is 88. 2) The client’s cholesterol is elevated, and he states he likes fried food. 3) The client states she has trouble sleeping and that she drinks coffee in the evening. 4) The client states he gets frequent headaches and that he takes aspirin for the pain. ANS: 2 Elevated cholesterol is objective, and “states he likes fried food” is subjective. Objective data can be observed by someone other than the patient (e.g., from physical assessments or lab and diagnostic tests). Subjective data are information given by the client. Blood pressure and heart rate measurements are both objective. “States . . . trouble sleeping and . . . drinks coffee . . .” are both subjective. States “. . . frequent headaches and . . . takes aspirin . . .” are both subjective. PTS: 1 DIF: Moderate REF: pp. 40 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis ____ 4. The Joint Commission requires which type of assessment to be performed on all patients? 1) Functional ability 2) Pain 3) Cultural 4) Wellness ANS: 2 The Joint Commission requires that pain and nutrition assessment be performed on all patients. Other special needs assessments should be performed when cues indicate there are risk factors. PTS: 1 DIF: Moderate REF: p. 39 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis ____ 5. Which of the following is an example of an ongoing assessment? 1) Taking the patient’s temperature 1 hour after giving acetaminophen (Tylenol) 2) Examining the patient’s mouth at the time she complains of a sore throat 3) Requesting the patient to rate intensity on a pain scale with the first perception of pain 4) Asking the patient in detail how he will return to his normal exercise activities ANS: 1 An ongoing assessment occurs when a previously identified problem is being reassessed—for example, taking an hourly temperature when a patient has a fever. Examining the mouth is a focused assessment to explore the patient’s complaint of sore throat. Asking for a pain rating is a focused assessment at the first complaint of pain. A detailed interview about exercise is a special needs assessment; there is no way to know if it is initial or ongoing. PTS: 1 DIF: Moderate REF: p. 41 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application ____ 6. When should the nurse make systematic observations about a patient? 1) When the patient has specific complaints 2) With the first assessment of the shift 3) Each time the nurse gives medications to the patient 4) Each time the nurse interacts with the patient ANS: 4 The nurse should make observations about the patient each time she enters the room or interacts with the patient to gain ongoing data about the patient. PTS: 1 DIF: Easy REF: p. 41-42 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application ____ 7. Which of the following is an example of an open-ended question? 1) Have you had surgery before? 2) When was your last menstrual period? 3) What happens when you have a headache? 4) Do you have a family history of heart disease? ANS: 3 Open-ended questions such as “What happens when you have a headache?” are broad so as to encourage the patient to elaborate. The questions about surgery, menstrual period, and family history can all be answered with a “yes,” “no,” or short, specific answer (a date). PTS: 1 DIF: Moderate REF: pp. 45 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application ____ 8. Of the following recommended interviewing techniques, which one is the most basic? (That is, without that intervention, the others will all be less effective.) 1) Beginning with neutral topics 2) Individualizing your approach 3) Minimizing note taking 4) Using active listening ANS: 4 All are important techniques, but active listening focuses the attention on the patient and lets her know you are trying to understand her needs. The interviewer is more likely to get the patient to open up. Patients will forgive you for most errors in technique, but if they think you are not listening, that can negatively affect your relationship. PTS: 1 DIF: Difficult REF: 47 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application ____ 9. Which of the following is an example of the most basic motivation in Maslow’s hierarchy of needs? 1) Experiencing loving relationships 2) Having adequate housing 3) Receiving education 4) Living in a crime-free neighborhood ANS: 2 The most basic needs are centered on physiological survival—shelter (housing), food, and water. All other options are for higher needs. The order from most basic to highest level is physiologic, safety and security, love and belonging, esteem, and self-actualization. Loving relationships fall under the love and belonging category. Education is a form of self-actualization. Living in a crime-free neighborhood meets the need for safety and security. PTS: 1 DIF: Moderate REF: p. 48 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application ____ 10. What makes a nursing history different from a medical history? 1) A nursing history focuses on the patient’s responses to the health problem. 2) The same information is gathered; the difference is in who obtains the information. 3) A nursing history is gathered using a specific format. 4) A medical history collects more in-depth information. ANS: 1 A medical history focuses on the patient’s current and past medical/surgical problems. A nursing history focuses on the patient’s responses to and perception of the illness/injury or health problem, his coping ability, and resources and support. Nursing history formats vary depending on the patient, the agency, and the patient’s needs. Both nursing and medical histories typically use a specific format. A medical history does not necessarily contain more in-depth information. A nursing history can be in-depth, covering a wide range of topics, including biographical data, reason(s) patient is seeking healthcare, history of present illness, patient’s perception of health status and expectations for care, past medical history, use of complementary modalities, and review of functional ability associated with activities of daily living. Other topics might deal with nutrition, psychosocial needs, pain assessment, or other special needs topics. PTS: 1 DIF: Moderate REF: pp. 44-45 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension ____ 11. Why is it important to obtain information about nutritional and herbal supplements as well as about complementary and alternative therapies? 1) To determine what type of therapies are acceptable to the client 2) To identify whether the client has a nutrition deficiency 3) To help you to understand cultural and spiritual beliefs 4) To identify potential interaction with prescribed medication and therapies ANS: 4 Herbs and nutritional supplements can interact with prescription medications, and complementary and alternative treatments can interfere with conventional therapies. Physical assessment and laboratory tests are needed to assess a nutritional deficiency. To identify cultural and spiritual beliefs and well as what therapies are acceptable to the client, you need more than just information about nutritional and herbal supplements. PTS: 1 DIF: Difficult REF: p. 45 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application ____ 12. What do the nursing assessment models have in common? 1) They assess and cluster data into model categories. 2) They organize assessment data according to body systems. 3) They specify use of the nursing process to collect data. 4) They are based on the ANA Standards of Care. ANS: 1 All the models categorize or cluster data into functional health patterns, domains, or categories. None of the assessment models clusters data according to body system. Assessment is the first step of the nursing process; the nurse does not use the entire nursing process in data collection. The ANA Standards of Care describe a competent level of clinical nursing practice based on the nursing process; nursing models are not based on the ANA Standards of Care. PTS: 1 DIF: Difficult REF: pp. 48 KEY: Nursing process: Assessment | Client need: SACE | Cognitive level: Analysis ____ 13. Nondirective interviewing is a useful technique because it 1) Allows the nurse to have control of the interview 2) Is an efficient way to interview a patient 3) Facilitates open communication 4) Helps focus patients who are anxious ANS: 3 Nondirective interviewing helps build rapport and facilitates open communication. Because it puts the patient in control, it can be very time-consuming (inefficient) and produce information that is not relevant. Directive interviewing should be used to focus anxious patients. PTS: 1 DIF: Easy REF: p. 45 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Recall ____ 14. A nursing instructor is guiding nursing students on best practices for interviewing patients. Which of the following comments by a student would indicate the need for further instruction? 1) “My patient is a young adult, so I plan to talk to her without her parents in the room.” 2) “Because my patient is old enough to be my grandfather, I will call him ‘Mr.’” 3) “When reading my patient’s health record, I thought of a few questions to ask.” 4) “When I give my patient his pain medication, I will have time to ask questions.” ANS: 4 A patient should be comfortable when interviewing. The pain medication should have time to work before considering interviewing the patient, so asking questions when giving the medication is not a good idea. It is appropriate to interview patients without family/friends around. In nearly every culture, calling a patient Mr. or Mrs. shows respect and is therefore correct. Reading the patient’s health record is appropriate preparation for an interview. PTS: 1 DIF: Moderate REF: p. 46 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application ____ 15. A patient comes to the urgent care clinic because he stepped on a rusty nail. What type of assessment would the nurse perform? 1) Comprehensive 2) Ongoing 3) Initial focused 4) Special needs ANS: 3 An initial focused assessment is performed during a first exam for specific abnormal findings. A comprehensive assessment is holistic and is usually done upon admission to a healthcare facility. An ongoing assessment follows up after an initial database is completed or a problem is identified. A special needs assessment is performed when there are cues that more in-depth assessment is needed. PTS: 1 DIF: Moderate REF: pp. 42–43 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application ____ 16. A patient has left-sided weakness because of a recent stroke. Which type of special needs assessment would it be most important to perform? 1) Family 2) Functional 3) Community 4) Psychosocial ANS: 2 A functional assessment is most important because of discharge needs (e.g., self-care ability at home) and patient safety. A family and community assessment would be helpful to evaluate support systems, and a psychosocial assessment would be helpful to evaluate a patient’s understanding of and coping with his recent stroke. Remember that special needs assessments are lengthy and time-consuming, so they should be used only when in-depth information is needed about a topic. PTS: 1 DIF: Moderate REF: pp. 43 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Analysis ____ 17. The nurse is interviewing a patient who has a recent onset of migraine headaches. The patient is highly anxious and cannot seem to focus on what the nurse is saying. Which of the following questions would be best for the nurse to use to begin gathering data about the headaches? 1) “When did your migraines begin?” 2) “Tell me about your family history of migraines.” 3) “What are the types of things that trigger your headaches?” 4) “Describe what your headaches feel like.” ANS: 1 For someone who is anxious, it is best to use closed questions. (When did your migraines begin?) A closed question can be answered in one or very few words and has a very specific answer. The other questions are open-ended questions. PTS: 1 DIF: Moderate REF: p. 45 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application ____ 18. Which of the following is an example of an active listening behavior? 1) Taking frequent notes 2) Asking for more details 3) Leaning toward the patient 4) Sitting with legs crossed ANS: 3 Active listening behaviors include leaning toward the patient; facing the patient; open, relaxed posture without crossing arms or legs; and maintaining eye contact. Taking frequent notes makes it difficult to keep eye contact. Asking for more details may seem like idle curiosity. Sitting with legs crossed may indicate to the patient that you are not open to her. PTS: 1 DIF: Easy REF: p. 47 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension ____ 19. A nursing instructor asked his nursing students to discuss their experiences with charting assessment data. Which comment by the student indicates the need for further teaching? 1) “I find it difficult to avoid using phrases like, ‘The patient tolerated the procedure well.’” 2) “It’s confusing to have to remember which abbreviations this hospital allows.” 3) “I need to work on charting assessments and interventions right after they are done.” 4) “My patient was really quiet and didn’t say much, so I charted that he acted depressed.” ANS: 4 When charting data, chart only what was observed, not what it meant. Inferences should not be made about a patient’s behavior during data collection (“he acted depressed”); so that response reflects the student’s lack of knowledge and need for teaching. Chart specific data, not vague phrases; the student is acknowledging the importance of this. There are no universally accepted phrases, just agency-approved abbreviations; the student is acknowledging the need to use agency-approved abbreviations. The student is correct that charting should be completed as soon after data collection as possible. PTS: 1 DIF: Moderate REF: p. 50 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application ____ 20. For which of the following purposes is a graphic flow sheet superior to other methods of recording data? 1) Easy documentation of routine vital signs 2) Seeing the patterns of a patient’s fever 3) Describing the symptoms accompanying a rising temperature 4) Checking to make sure vital signs were taken ANS: 2 All are benefits of the graphic flow sheet, but to easily and graphically see trends over time, the graphic flow sheet is superior to other methods of documentation. For the other options, other kinds of flow sheets would be equally effective. PTS: 1 DIF: Moderate REF: p. 50 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis ____ 21. The most obvious reason for using a framework when assessing a patient is to 1) Prioritize assessment data 2) Organize and cluster data 3) Separate subjective and objective data 4) Identify primary from secondary data ANS: 2 A framework is used to organize and cluster data to find patterns. During the assessment phase, the nurse is collecting and recording data, not prioritizing the data. A framework includes subjective and objective data as well as primary and secondary data; it does not help you to separate them. PTS: 1 DIF: Easy REF: p. 48 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall ____ 22. Which situation is the most conducive to conducting a successful interview of an elderly woman whose husband and two children are in the hospital room visiting and watching television? The woman is alert and oriented. 1) Provide enough chairs so the family and you are able to sit facing the client. 2) Introduce yourself and ask, “Dear, what name do you prefer to go by?” before asking any questions. 3) After the family leaves, ask the client if she is comfortable and willing to answer a few questions. 4) Ask the client if you can talk with her while her family is watching the television. ANS: 3 The interview should be done when the client is comfortable and there are no distractions. Endearing terms are inappropriate unless the client prefers them. Family members may offer information that may or may not be pertinent and may distract from the interview. The presence of family members may also inhibit full disclosure of information by the client. PTS: 1 DIF: Difficult REF: p. 46-47 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. ____ 23. Which of the following questions would be effective for obtaining information from a patient? Choose all that apply. 1) “How did this happen to you?” 2) “What was your first symptom?” 3) “Why didn’t you seek healthcare earlier?” 4) “When did you start having symptoms?” ANS: 1, 2, 4 How, what, and when are acceptable lines of questioning. Asking “why” can put the patient on the defensive and may suggest disapproval, limiting the amount of information the patient is willing give. PTS: 1 DIF: Moderate REF: p. 45-46 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application ____ 24. A nurse with a large caseload of patients needs to delegate some assessment tasks to other members of the health team. The nurse is unsure which tasks can be delegated to nursing assistive personnel (NAP) and which are appropriate for a licensed practical nurse (LPN) or a registered nurse (RN). To which sources should the nurse turn for the answer to his question? Choose all that are appropriate. 1) The nurse practice act of his state 2) The American Medical Association guidelines 3) The Code of Ethics for Nurses 4) The American Nurses Association’s Scope and Standards of Practice ANS: 1, 4 State nurse practice acts specify which portions of the assessment can legally be completed by individuals with different credentials. The ANA Scope and Standards of Practice provide a guide for who is ultimately responsible and qualified to collect assessment data. The American Medical Association provides guidelines and standards for physicians, not nurses. The Code of Ethics for Nurses says merely that the nurse should delegate tasks appropriately; it does not speak to credentials of personnel. PTS: 1 DIF: Moderate REF: p. 40 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension ____ 25. Which of the following are cues rather than inferences? Choose all correct answers. 1) Ate 50% of his meal 2) Patient feels better today 3) States, “I slept well” 4) White blood cell count 15,000/mm3 ANS: 1, 3, 4 Cues are what the client says and what you observe. “Just the facts.” The only inference in the list is “slept well.” What did the nurse observe to tell her the client slept well? Those would be cues. If the client states, “I slept well” it is a cue, because it is a fact—that is what the client stated. PTS: 1 DIF: Easy REF: p. 50 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension Matching 26. Match the assessment technique to the data that should be collected. There may be more than one technique used to collect the data. 1) Auscultation 2) Inspection 3) Palpation 4) Percussion ____ 1. Skin pink, warm, and dry ____ 2. Lung sounds clear ____ 3. Abdomen is tympanic ____ 4. Abdomen soft and nontender 1. ANS: 2 PTS: 1 DIF: Moderate REF: p. 42 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 2. ANS: 1 PTS: 1 DIF: Moderate REF: p. 42 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 3. ANS: 4 PTS: 1 DIF: Moderate REF: p. 42 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 4. ANS: 3 PTS: 1 DIF: Moderate REF: p. 42 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 27. Match the type of special needs assessment with the correct example. 1) Do you perform monthly breast self-exams? 2) Do you live near any industrial manufacturing plants? 3) Who can you talk to when you feel sad? 4) Who do you live with? 5) What is your understanding of your diet? 6) Since you had your stroke, have you had any problems dressing yourself? 7) Do you have a religious preference? ____ 5. Community ____ 6. Family ____ 7. Functional ability ____ 8. Nutrition ____ 9. Psychosocial ____ 10. Wellness ____ 11. Spiritual 5. ANS: 2 PTS: 1 DIF: Easy REF: pp. 43–44 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 6. ANS: 4 PTS: 1 DIF: Easy REF: pp. 43–44 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 7. ANS: 6 PTS: 1 DIF: Easy REF: pp. 43–44 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 8. ANS: 5 PTS: 1 DIF: Easy REF: pp. 43–44 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 9. ANS: 3 PTS: 1 DIF: Easy REF: pp. 43–44 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 10. ANS: 1 PTS: 1 DIF: Easy REF: pp. 43–44 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 11. ANS: 7 PTS: 1 DIF: Moderate REF: pp. 43-44 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall 28. Match the assessment model with the intended use for that model. 1) Categorizes nursing diagnoses, client outcomes, and nursing interventions 2) Assesses the client’s ability to achieve balance (homeostasis) 3) Identifies deficits in activities of daily living that require nursing assistance 4) Formulates a model for nursing assessment and diagnosis but is not a theory 5) Categorizes nursing diagnoses ____ 12. Gordon’s Functional Health Patterns ____ 13. NANDA Nursing Diagnosis Taxonomy II ____ 14. Taxonomy of Nursing Practice ____ 15. Roy’s Adaptation model ____ 16. Orem’s Self-Care model 12. ANS: 4 PTS: 1 DIF: Moderate REF: p. 49 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall 13. ANS: 5 PTS: 1 DIF: Moderate REF: p. 49 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall 14. ANS: 1 PTS: 1 DIF: Moderate REF: p. 49 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall 15. ANS: 2 PTS: 1 DIF: Moderate REF: p. 49 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall 16. ANS: 3 PTS: 1 DIF: Moderate REF: p. 49 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall Chapter 7. Implementation & Evaluation Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. A physician prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, and she cannot find it in the hospital formulary or other references. How should she proceed? 1) Administer the medication as prescribed. 2) Hold the medication and notify the prescriber. 3) Consult with a pharmacist before administering it. 4) Ask the patient’s nurse for information about the medication. ANS: 3 The nurse must recognize when she does not have the knowledge or skill needed to implement an order. Because the nurse is unfamiliar with the medication, that does not mean she should hold it and delay patient treatment. It is wisest to first consult with the pharmacist for information before administering the medication to ensure safe practice. Administering the medication as prescribed, without knowing its expected actions and side effects, at the least prevents adequate reassessment; at the most, it is dangerous. Holding the medication and notifying the prescriber prevents the client from receiving timely treatment—many drugs are less effective if a consistent schedule is not maintained. Asking another nurse to administer the medication is also unsafe because it cannot be assumed that the other nurse has the correct knowledge. In addition, the nurse caring for the client must assess for adverse reactions to the medication. PTS: 1 DIF: Moderate REF: p. 118 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis ____ 2. Which task can be delegated to nursing assistive personnel (NAP)? 1) Turn and reposition the client every 2 hours. 2) Assess the client’s skin condition. 3) Change pressure ulcer dressings every shift. 4) Apply hydrocolloid dressing to the pressure ulcer. ANS: 1 The nurse can delegate turning the client every 2 hours to the NAP. Assessing the client’s skin condition, changing pressure ulcer dressings, and applying a hydrocolloid dressing to a pressure ulcer are all interventions that require nursing knowledge and judgment. PTS: 1 DIF: Moderate REF: pp. 122–124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application ____ 3. The nurse has just finished documenting that he removed a patient’s nasogastric tube. Which is the next logical step in the nursing process? 1) Assessment 2) Planning 3) Evaluation 4) Diagnosis ANS: 3 The implementation phase ends when you document nursing actions on the client’s chart. Implementation evolves into the evaluation step when you document the client’s response to your interventions. As a general rule, the steps in order are as follows: assessment diagnosis, planning outcomes, planning interventions, implementation, and evaluation. PTS: 1 DIF: Easy REF: p. 125 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Comprehension ____ 4. Which nursing intervention is best individualized to meet the needs of a specific client? 1) Suction the client every 2 hours per unit policy. 2) Use incentive spirometry every hour while awake per postoperative protocols. 3) Institute swallowing precautions. 4) Move client out of bed to the chair daily; client prefers to be out of bed for dinner. ANS: 4 Positioning the client in the chair for meals considers the client’s desire to be out of bed for dinner, so it is obviously individualized. An intervention performed according to unit policy or protocols is not necessarily individualized. “Institute swallowing precautions” does not provide instructions for the specific actions needed to do that for “this particular” client. PTS: 1 DIF: Moderate REF: p. 118; high-level question, answer not given verbatim KEY: Nursing process: Planning interventions | Client need: SECE | Cognitive level: Application ____ 5. The primary provider prescribes an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed? 1) Ask a colleague for help, because the nurse cannot safely perform the procedure alone. 2) Gather the equipment and prepare it before informing the client about the procedure. 3) Obtain an order to restrain the client before inserting the urinary catheter. 4) Inform the provider that the nurse cannot perform the procedure because the client is confused. ANS: 1 Before the nurse begins a procedure, she should review the care plan and look at the orders critically. Because this client is confused, she should ask a colleague to assist with the procedure to prevent undue stress for the client and nurse. The client should be informed about the procedure before the nurse gathers the equipment. Gathering the equipment and bringing it into the room before explaining the procedure might cause the client anxiety. Restraining the client should be done only as a last resort and to prevent client injury. Informing the primary provider that the procedure cannot be performed because the client is confused is inappropriate because the procedure can very likely be done with assistance. PTS: 1 DIF: Moderate REF: p. 118 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis ____ 6. A patient underwent surgery 3 days ago for colorectal cancer. The patient’s critical pathway states that he should participate in a teaching session with the wound ostomy nurse to learn colostomy self-care. The patient appears depressed and refuses to look at the colostomy or even make eye contact. How should the nurse proceed? 1) Postpone the teaching session until the patient is more receptive. 2) Follow the critical pathway for patient teaching about ostomy care. 3) Administer a prescribed antidepressant and notify the physician. 4) Explain to the patient the importance of skin care around the ostomy site. ANS: 1 A depressed affect and poor eye contact likely indicate that the client is having difficulty coping with the new colostomy. At this time, the client would not be physically and psychologically ready to obtain the most benefit from teaching pertaining to ostomy care. Therefore, the nurse should postpone the teaching session for this client until the client is receptive to receiving the information. The nurse should not perform the teaching session simply because the critical pathway indicates it is appropriate. Simply administering an antidepressant does not address the client’s readiness to participate in a teaching session and ultimately self-care of the ostomy. The nurse should encourage the client to verbalize his feelings. Client education is not effective unless the client is receptive to the information. Readiness to learn is important. Proceeding with teaching when the client is struggling with coping is not sensitive to the client’s individual needs. PTS: 1 DIF: Moderate REF: p. 120 KEY: Nursing process: Implementation | Client need: PHI | Cognitive level: Application ____ 7. Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill? 1) Psychomotor 2) Interpersonal 3) Cognitive 4) Critical thinking ANS: 2 Reassuring the client is an interpersonal skill. Inserting the nasogastric tube requires psychomotor skills. Checking catheter placement after insertion requires cognitive and psychomotor skills. Assessing whether there is an indication for the nasogastric tube requires critical thinking skills. PTS: 1 DIF: Moderate REF: p. 120 KEY: Nursing process: Implementation | Client need: PHI | Cognitive level: Comprehension ____ 8. Which intervention depends almost entirely on the client’s adhering to the therapy? 1) Inserting an IV catheter 2) Turning a client every 2 hours 3) Shortening a surgical drain 4) Following a low-fat, low-calorie diet ANS: 4 Instituting and adhering to a low-fat, low-calorie diet is an intervention that depends almost entirely on the client’s adhering to the therapy. Client cooperation is necessary for performing the other interventions, but the interventions do not depend on the client to the same extent. PTS: 1 DIF: Easy REF: p. 122 KEY: Nursing process: Planning interventions | Client need: SECE | Cognitive level: Analysis ____ 9. The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan? 1) Teaching the client that he must lose weight to control his blood sugar 2) Informing the client he must exercise at least three times per week 3) Explaining to the client that he must come to the diabetic clinic weekly 4) Determining the client’s main concerns about his diabetes ANS: 4 Determining the client’s main concerns promotes cooperation with the treatment regimen. For example, if the client is concerned about paying for diabetic monitoring equipment, he may disregard any teaching about the procedure. Although it is often important for a diabetic client to exercise and lose weight to control blood sugar levels, the client must want to do both. He will not exercise or lose weight simply because he is told to do so. The nurse must assess the client’s support systems and resources, not just tell him he must come to the diabetic clinic weekly. Some clients do not have access to transportation and, therefore, could not come to the clinic without social service intervention. Remember that knowledge does not necessarily change behavior. PTS: 1 DIF: Moderate REF: p. 122 KEY: Nursing process: Planning interventions | Client need: PHSI | Cognitive level: Analysis ____ 10. Which statement accurately describes delegation? 1) Transferring authority to another person to perform a task in a selected situation 2) Collaborating with other caregivers to make decisions and plan care 3) Scheduling treatments and activities with other departments 4) Performing a planned intervention from a critical pathway ANS: 1 Delegation is the transfer to another person of the authority to perform a task in a selected situation—the person delegating retains accountability for the outcome of the activity. Collaboration is described as working with other caregivers to plan, make decisions, and perform interventions. Coordination of care involves scheduling treatments and activities with other departments. Implementation is the process of performing planned interventions. PTS: 1 DIF: Easy REF: p. 122 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Knowledge ____ 11. Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP) about delegating a task? 1) “Record how much the patient drinks today, please.” 2) “Take the patient’s vital signs every 2 hours today.” 3) “Take the patient’s temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C).” 4) “Assist the patient with all of her meals.” ANS: 3 Clear communication about a task (such as “Take the patient’s temperature . . . ”) tells the NAP exactly what the task is, the specific time it needs to be done, and the method for reporting the results to the registered nurse. The other options are vague and leave room for misinterpretation. PTS: 1 DIF: Moderate REF: p. 124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis ____ 12. Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)? 1) Nurse who delegated the task 2) Licensed practical nurse working with the NAP 3) Unit nurse manager 4) Charge nurse for the shift ANS: 1 The nurse who delegates the task is responsible for supervising and evaluating the outcomes of tasks performed by the NAP. Another registered nurse, such as a staff nurse, nurse manager, or charge nurse, can answer questions and provide help, if necessary. PTS: 1 DIF: Easy REF: p. 124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Recall ____ 13. Which criterion might be used in structure evaluation? 1) Staff refrains from sharing computer password. 2) Healthcare provider washes hands with each client contact. 3) A defibrillator is accessible on each client care area. 4) Nurse verifies client identification before initiating care. ANS: 3 The criterion that states “a defibrillator is present on each client care area” is associated with structure evaluation. “Refrains from sharing computer password,” “washes hands before each client contact,” and “verifies client identification before initiating care” are criteria associated with process evaluation. PTS: 1 DIF: Moderate REF: p. 127 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis ____ 14. Which of the following is a client outcome criterion? 1) Central venous catheter site infection does not occur (90% of cases). 2) Client will sit out of bed in a chair for 20 minutes three times per day. 3) Postoperative phlebitis does not occur (95% of cases). 4) Falls will decrease by 2% between January 1 and March 30. ANS: 2 A client outcome criterion states the client health status or behaviors one wishes to effect. “Client will sit out of bed . . .” is a client outcome criterion. The other options are examples of organizational criteria used to evaluate the quality of care throughout the institution. PTS: 1 DIF: Moderate REF: pp. 127-128 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application ____ 15. When should the nurse collect evaluation data for this expected outcome: Patient will maintain urine output of at least 30 mL/hour? 1) At the end of the shift 2) Every 24 hours 3) Every 4 hours 4) Every hour ANS: 4 The nurse should collect evaluation data as defined in the expected outcome. For instance, in this case, the nurse would check the patient’s urine output every hour because the goal statement specifies an hourly rate (30 mL/hour). The unit of measurement in the goal guides how often the nurse would reassess the patient. PTS: 1 DIF: Easy REF: pp. 127-128 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application ____ 16. Which type of client-centered evaluation is performed at specific, scheduled times? 1) Intermittent 2) Ongoing 3) Terminal 4) Process ANS: 1 Intermittent evaluation is performed at specific times; it enables the nurse to judge the progress toward goal achievement and to modify the plan of care as needed. Ongoing evaluation is performed while implementing, immediately after an intervention, or with each client contact; these are not necessarily scheduled events. Terminal evaluation is performed at the time of discharge. It describes the client’s health status and progress toward goals at that time. Process evaluation focuses on the manner in which care is given. It may be performed at specific times, but it is not considered a client-centered evaluation. PTS: 1 DIF: Easy REF: p. 127 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Recall ____ 17. Which of the following is the most valid criterion for determining the status of a patient’s anxiety at discharge? The patient 1) Has a relaxed facial expression 2) States that he feels more relaxed today 3) Shows no physiological signs of anxiety (e.g., pallor) 4) Has no further questions about home care ANS: 2 A criterion is considered valid when it measures what it is intended to measure. Because anxiety is subjective (perceived by the patient), the best measure of anxiety is what the patient says about it. A relaxed facial expression and other physiological signs might or might not show the level of anxiety. Relaxation might occur, for example, because the patient is sleeping or falling asleep. The fact that a patient is not asking questions about his surgery could mean that he has adequate knowledge about the topic; it would not indicate the presence or absence of anxiety. All of the options except what the patient states could be measuring something other than anxiety. PTS: 1 DIF: Difficult REF: p. 127 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application ____ 18. The nurse works with the respiratory therapist to administer a patient’s breathing treatments. He reports the patient’s breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. This is an example of 1) Delegation 2) Collaboration 3) Coordination of care 4) Supervision of care ANS: 2 Collaboration means working with other caregivers to plan, make decisions, and perform interventions. Delegation is the transfer to another person of the authority to perform a task in a selected situation. Coordination of care involves scheduling treatments and activities with other departments, putting together all the patient data to obtain the “big picture.” Supervision is the process of directing, guiding, and influencing the outcome of an individual’s performance of an activity or task. PTS: 1 DIF: Moderate REF: pp. 122 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. ____ 1. The nurse and nursing assistive personnel (NAP) are caring for a group of patients on the medical-surgical floor. For which of the following patients can the nurse delegate to the NAP the task of bathing? Choose all that apply. 1) 75-year-old patient newly admitted to the hospital with dehydration 2) 65-year-old patient hospitalized for a stroke, whose blood pressure is 188/90 mm Hg 3) 92-year-old patient with stable vital signs who was admitted with a urinary tract infection 4) 56-year-old patient with chronic renal failure who has vital signs within his normal range ANS: 1, 3, 4 The nurse should not delegate bathing of a client newly diagnosed with a stroke whose blood pressure is unstable or otherwise abnormal. This client requires the keen assessment and critical thinking skills of a registered nurse. The nurse can safely delegate the care of stable clients, such as the client admitted with dehydration, the client admitted with a urinary tract infection, or the client with chronic renal failure. Any client who is very ill or who requires complex decision making should be cared for by a registered nurse. PTS: 1 DIF: Difficult REF: pp. 122–124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis 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 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 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 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) 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 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.” 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 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 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. 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 Chapter 21. Physical Assessment Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. A mother brings her 6-month-old infant to the clinic for a well-baby checkup. How should the nurse proceed when weighing the patient? 1) Have the mother remain outside the room. 2) Ask the mother to remove the infant’s clothing and diaper. 3) Weigh the infant wearing only the diaper. 4) Place the infant supine on the scale with his knees extended. ANS: 2 The nurse should ask the mother to remove the infant’s clothing and diaper before weighing and measuring the infant. An older child can be examined in his underwear; infants should be undressed. Infants are typically more comfortable with the parent close by, so the mother should remain in the room. The infant should be supine with knees extended on the examination table when being measured, not when being weighed. PTS: 1 DIF: Moderate REF: p. 517 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application ____ 2. Where should the nurse assess skin color changes in the dark-skinned patient? 1) Nailbeds 2) Any exposed area 3) Oral mucosa 4) Palms of the hands ANS: 3 In dark-skinned patients, look for color changes in the conjunctiva or oral mucosa. They should be pink and moist. In dark-skinned patients, skin color changes may not be apparent in nailbeds, palms of the hands, and other exposed areas. PTS: 1 DIF: Easy REF: pp. 497-498, 519 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall ____ 3. While the nurse assesses a newborn of African American descent, the mother points out a blue-black Mongolian spot on the newborn’s back and asks, “What’s that? Is something wrong with my baby?” Which response by the nurse is best? 1) “I’ll ask the physician to look at the spot.” 2) “Those spots are quite common and typically fade with time.” 3) “You may want a plastic surgeon to look at that.” 4) “That spot is benign so it’s nothing you need to worry about.” ANS: 2 The best response by the nurse is to explain that Mongolian spots are common in dark-skinned newborns and typically fade over time. The nurse should report the finding in the patient health record, but there is no need to notify the physician immediately. It is inappropriate for the nurse to recommend that the mother take her newborn to a plastic surgeon; Mongolian spots do not require treatment. Although it contains correct information, “nothing you need to worry about” is condescending. PTS: 1 DIF: Moderate REF: p. 497 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application ____ 4. An older adult comes to the clinic complaining of pain in the left foot. While assessing the patient, the nurse notes smooth, shiny skin that contains no hair on the client’s lower legs. Which condition does this finding suggest? 1) Venous insufficiency 2) Hyperthyroidism 3) Arterial insufficiency 4) Dehydration ANS: 3 Peripheral arterial insufficiency is associated with smooth, thin, shiny skin with little or no hair. Venous insufficiency leads to thick, rough skin that is commonly hyperpigmented. Hyperthyroidism is associated with abnormally warm skin. Decreased