TEST BANK For Critical Care Nursing 8th Edition by Urden

Chapter 03: Legal Issues Urden: Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. What is the legal standard of care for a nurse's actions? a. Minimal competency under the state Nurse Practice Act b. The ability to distinguish what is right or wrong for the patient c. The demonstration of satisfactory knowledge of policies and procedures d. The care that an ordinary prudent nurse would perform under the same circumstances ANS: D The legal standard of care for nurses is established by expert testimony and is generally “the care that an ordinarily prudent nurse would perform under the same circumstances.” PTS: 1 DIF: Cognitive Level: Understanding REF: p. 27 OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 2. A patient is admitted with chest pain, and his electrocardiogram shows elevated ST segments. The nurse bases her plan of care on the nursing diagnosis of pneumonia. What type of negligence may be present? a. Assessment failure b. Planning failure c. Implementation failure d. Evaluation failure ANS: B Basing nursing care on an erroneous diagnosis is a failure in planning. Standards of care include assessment, the collection of relevant data pertinent to the patient’s health or situation; diagnosis, analysis of the assessment data in determining diagnosis and care issues; implementation, coordinating care delivery and plan and using strategies to promote health and a safe environment; and evaluation, evaluation of the progress of the patient toward attaining outcomes. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 27|p. 30|Box 3-3 OBJ: Nursing Process Step: Assessment TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 3. What is an injury resulting from the failure to meet an ordinary duty called? a. Negligence b. Malpractice c. Assault d. Battery ANS: A Injury resulting from the failure to meet an ordinary duty or standard of care is negligence. Malpractice is a specialized form of negligence. Assault and battery are examples of intentional acts. PTS: 1 DIF: Cognitive Level: Understanding REF: pp. 27-28 OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 4. A night nurse is notified by the laboratory that the patient has a critical magnesium level of 1.1 mEq/L. The patient has a do-not-resuscitate order. The nurse does not notify the practitioner because of the patient’s code status. In doing so, the nurse is negligent for what? a. Failure to analyze the level of care needed by the patient b. Failure to respect the patient’s wishes c. Wrongful death d. Failure to take appropriate action ANS: D Nurses caring for acutely and critically ill patients must appropriately notify physicians of situations warranting treatment actions. Furthermore, the full no-code, do-not-resuscitate order does not exclude this patient from receiving treatment to correct the critical laboratory value. Failure to take appropriate action in cases involving acutely and critically ill patients has included not only physician-notification issues but also failure to follow physician orders, failure to properly treat, and failure to appropriately administer medication. PTS: 1 DIF: Cognitive Level: Applying REF: pp. 28-29 OBJ: Nursing Process Step: Assessment | Nursing Process Step: Implementation TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 5. Two nurses are talking about a patient’s condition in the cafeteria. In doing so, these nurses could be accused of what? a. Failure to take appropriate action b. Failure to timely communicate patient findings c. Failure to preserve patient privacy d. Failure to document patient information ANS: C Nurses have a duty to preserve patient privacy, and failure to do so is a breach of patient confidentiality and failure to preserve patient privacy. Nurses should also refrain from having discussions about specific patients with anyone except other health care professionals involved in the care of the patient. When discussing specific patients with other health care professionals, it is imperative that patient-specific discussions occur in non-public settings. Discussions about specific patients are never appropriate in public areas such as elevators, cafeterias, gift shops, and parking lots. PTS: 1 DIF: Cognitive Level: Applying REF: p. 31 OBJ: Nursing Process Step: Assessment TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 6. What is negligence called when it applies to an individual who is a professional? a. Breach b. Malpractice c. Duty d. Harm ANS: B Whereas negligence claims may apply to anyone, malpractice requires the alleged wrongdoer to have special standing as a professional. If a nurse caring for acutely and critically ill patients is accused of failing to act in a manner consistent with the standard of care, that nurse is subject to liability for professional malpractice (negligence applied to a professional). PTS: 1 DIF: Cognitive Level: Understanding REF: p. 28 OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 7. A nurse fails to recognize an intubated patient’s need for suctioning. The endotracheal tube becomes clogged, and the patient has a respiratory arrest. What type of negligence may be present? a. Assessment failure b. Planning failure c. Implementation failure d. Evaluation failure ANS: A Nurses have a duty to assess and analyze the care required by each patient they care for. Failure to do so puts the nurse at risk for negligence related to failure to assess the patient’s needs. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 30 OBJ: Nursing Process Step: Assessment TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 8. What element of malpractice is based on the existence of a nurse–patient relationship? a. Duty b. Breach c. Damages d. Harm caused by the breach ANS: A Duty to the injured party is the first element of a malpractice case and is premised on the existence of a nurse–patient relationship. Breach is failure to act consistently within applicable standards of care. Harm caused by the breach occurs when the patient sustained injuries because of the breach of duty. Damages are derived from the harm or injury sustained by the acutely or critically ill patient and are calculated as a dollar amount. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 28 OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 9. A patient is getting heparin by intravenous infusion. The nurse received an order to increase the heparin infusion rate and obtain a partial thromboplastin time (PTT) in 1 hour. The PTT was drawn correctly and revealed a critically elevated level. The nurse was busy with another patient and failed to report the critical result to the physician within 30 minutes according to the facility’s policy. Subsequently, the patient sustained a massive intracerebral bleed. What type of negligence may be present? a. Assessment failure b. Planning failure c. Implementation failure d. Evaluation failure ANS: C Failure to communicate and document patient findings in a timely manner is a form of failure to implement appropriate action. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 30 OBJ: Nursing Process Step: Assessment TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 10. On the way to surgery, a patient expresses doubt about proceeding with the planned procedure. The patient states that the doctor did not explain it very well and she would like to talk to her again before starting the procedure. The nurse knows the surgery schedule is very tight, reassures the patient that everything will be all right, and administers the preoperative sedation. This scenario describes what possible type of negligence? a. Assessment failure b. Planning failure c. Implementation failure d. Evaluation failure ANS: D The nurse has a duty to act as a patient advocate, in this case by holding the preoperative sedation until the doctor and the patient can speak and the patient is satisfied that she has the necessary information to make this decision. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 31 OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 11. Which statement is accurate regarding a nurse’s job description? a. As long as the nurse follows the American Nurses Association Standards of Care, the job description is irrelevant in a negligence allegation. b. Job descriptions must be reflective of the accepted standard of care. c. Institution-specific job descriptions are not legally acceptable. d. Job descriptions should be vague in describing nursing functions to avoid claims of negligence. ANS: B Although job descriptions can be institution specific, they should be reflective of the national and community standards of care. Job descriptions are based on professional accountability as outlined by state boards of nursing and standards of practice. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 29 OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 12. The ability to practice as a licensed professional nurse is a privilege granted by what entity? a. Employee contract b. State legislature c. State boards of nursing d. Congress ANS: B The very ability to practice as a licensed professional nurse is a privilege granted by the state and is a function of each state’s authority to promote and protect the health and welfare of its citizens. State boards of nursing (BON) are administrative bodies created by—and that operate under—state statutes, or more generally written state laws created by state legislatures and signed by the governor. In turn, the BONs develop more specific rules (or regulations) for obtaining and maintaining licensure. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 24 OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 13. Why is restraining a competent patient against his or her wishes considered an intentional tort? a. The nurse did not document the patient’s need for restraints. b. The nurse failed to get a physician’s order for restraints. c. The nurse touched the patient in an unauthorized manner. d. The nurse do not inform the patient that the restraints were needed. ANS: C Assault and battery are examples of intentional torts that are frequently brought against health care providers. Battery occurs if the health care professional actually touches the patient in an unauthorized manner. The act of restraining a patient without consent is battery. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 32 OBJ: Nursing Process Step: Intervention TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 14. What is the best action a nurse could take to prevent allegations of malpractice? a. Carrying malpractice insurance b. Clarifying orders with the nursing supervisor c. Delegating care to nursing assistants d. Providing care according to standards of practice ANS: D Maintaining standards of practice is the best way to reduce risk. The hallmark of risk reduction is knowledge of the professional standards of care, delivery and documentation of that care, and consistent demonstration that the standards are met. Nurses caring for acutely and critically ill patients may be alleged to have acted in a manner that is inconsistent with standards of care or standards of professional practice and may find themselves involved in civil litigation that focuses in whole or in part on the alleged failure. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 24 OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 15. While participating in rounds, a nurse is interrupted by the wife of a ventilated patient, who informs the nurse that her husband is having difficulty breathing. The patient is found to be disconnected from the ventilator and unresponsive when the nurse enters the room after rounds. The alarm mode on the ventilator had been turned off. This situation an example of what legal situation? a. Assault b. Battery c. Injury d. Malpractice ANS: D All four elements of negligence are present: duty and standard of care, breach of duty, causation, and injury. If a nurse caring for acutely and critically ill patients is accused of failing to act in a manner consistent with the standard of care, that nurse is subject to liability for professional malpractice (negligence applied to a professional). Assault occurs if the patient fears harmful or offensive touching. Battery is any intentional act that brings about actual harmful or offensive contact with the plaintiff. PTS: 1 DIF: Cognitive Level: Evaluating REF: pp. 27-28 OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 16. After admission a patient shares with the nurse a concern that her adult children will not be able to reach agreement on what to do if she is no longer able to make decisions for herself. The nurse informs the patient that it is possible to grant authority to one person to make decision through which mechanism? a. Court-appointed guardian b. Do-not-resuscitate order c. Durable power of attorney for health care d. Living will ANS: C A durable power of attorney for health care includes legally binding documents that allow individuals to specify a variety of preferences, particular treatments he or she wants to avoid, and circumstances in which he or she wishes to avoid them. The durable power of attorney for health care is a directive through which a patient designates an “agent,” someone who will make decisions for the patient if the patient becomes unable to do so. A living will specifies that if certain circumstances occur, such as terminal illness, the patient will decline specific treatments, such as cardiopulmonary resuscitation and mechanical ventilation. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 36 OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 17. In which situation did the nurse disregard the patient’s right to privacy? a. Informing the physician that the patient was verbalizing suicidal thoughts b. Notifying the health department of a patient’s tuberculosis diagnosis c. Reporting possible dependent-adult abuse to the police d. Warning a visitor to wear gloves when giving a back rub because the patient is HIV positive ANS: D Telling a visitor of the patient’s HIV status violated the patient’s right to privacy. The nurse could have ensured the visitor’s safety by providing gloves and explaining universal precautions. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 31 OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 18. Which statement best describes the definition of assault? a. An intentional act that causes the patient to believe that harm may have been done b. A statement that causes injury to the patient’s standing in the community c. Negligence that results in harm to a spousal relationship d. An intentional act that brings about harm or offensive contact with the patient ANS: A Assault occurs if the patient fears harmful or offensive touching. Battery is defined as an intentional act that brings about harm or offensive contact with the patient. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 32 OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 19. During transport to the operating room for mitral valve replacement, a patient with a signed consent form says that she does not want to go through with the surgery and asks to be returned to her room. What is the best response from the nurse? a. “The operating room is prepared; let’s not keep the surgeon waiting.” b. “You have the right to cancel surgery, but it could be weeks before you are rescheduled.” c. “You sound frightened; tell me what you are thinking.” d. “Your preoperative medications will have you feeling more relaxed in a minute; it will be OK.” ANS: C The patient has the right to withdraw consent at any time. The nurse must listen and then clarify whether that is really what the patient desires. If it is, the surgeon should then be notified. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 34 OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 20. Which situation would be considered a failure of proper implementation? a. Not identifying and analyzing symptoms appropriately b. Not documenting the patient’s response to pain medication c. Not recognizing a malfunctioning chest tube d. Not asking the patient about code or no code wishes ANS: B Nurses caring for acutely and critically ill patients are required not only to take appropriate action but also to accurately document their findings, interventions performed, and patients’ response to those interventions. Failure to thoroughly and accurately document any aspect of care gives rise to negligence causes of action. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 30 OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 21. Which agency is responsible for maintaining the expectations and limits of nursing practice? a. State Hospital Association b. Court system c. State Board of Nursing d. State Department of Health ANS: C State Boards of Nursing (SBONs) maintain expectations for and limits of nursing practice in each state through the licensure of nurses and also through challenges to non-nurses engaged in professional activities that intrude upon the nursing scope of practice. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 24 OBJ: Nursing Process Step: N/A TOP: Nurse Practice Act MSC: NCLEX: Safe and Effective Care Environment 22. A nurse providing care for a patient with a recent tracheostomy notes the presence of an ulceration or wound at the tracheotomy site. The nature of the ulceration or wound clearly indicates it has been present for at least several days. The nurse finds no documentation regarding the ulceration or wound since the insertion of the tracheostomy tube 12 days earlier. This situation an example of what legal situations? a. Assessment and implementation failure b. Failure to appropriately diagnose c. Failure to follow practitioners orders d. Planning and evaluation failure ANS: A This situation is an example of the prior nurses’ failure to assess and implement appropriately. Assessment and implementation failures are related to a failure to assess and analyze a care need, communicate findings to a physician, take appropriate action, and document. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 30 OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 23. The patient received a blood transfusion based on test results of critically low hemoglobin. The nurse records vital signs (VS) per hospital protocol. One hour after the transfusion was started, the nurse records VS as temperature (T) 102F, pulse (P) 110, respirations (R) 24, blood pressure (BP) 136/88. The nurse continues to administer the blood. This situation an example of what legal situation? a. Malpractice b. Assault c. Battery d. Libel ANS: A To avoid liability associated with administration of blood and blood products, nurses must carefully follow organizational procedures and protocols that govern these interventions. Battery is any intentional act that brings about actual harmful or offensive contact with the plaintiff. Assault occurs if the patient fears harmful or offensive touching. Libel is defined as publishing false statements that are damaging to a person’s reputation. PTS: 1 DIF: Cognitive Level: Analyzing REF: pp. 33-34 OBJ: Nursing Process Step: N/A TOP: Legal Issues MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. What elements or criteria must be present for negligence cases to go forward? (Select all that apply.) a. Duty to another person b. Acknowledgement of wrong doing c. Harm that would not have occurred in the absence of the breach d. Breach of duty e. Damages that have a monetary value ANS: A, C, D, E There are four criteria or elements for all negligence cases: (1) duty to another person; (2) breach of that duty; (3) harm that would not have occurred in the absence of the breach (causation); and (4) damages that have a monetary value. All four elements must be satisfied for a case to go forward. Acknowledgement of wrong doing is not required. PTS: 1 DIF: Cognitive Level: Applying REF: pp. 27-28 OBJ: Nursing Process Step: N/A TOP: Legal Issues MSC: NCLEX: Safe and Effective Care Environment 2. Which actions by a nurse demonstrate the act of battery? (Select all that apply.) a. Performing cardiopulmonary resuscitation (CPR) on a patient with a do-not-resuscitate (DNR) order b. Threatening to punch someone c. Sexual misconduct with a patient d. Drawing blood without the patient’s consent e. Threatening to restrain a patient for not using his or her call light for mobility assistance ANS: A, C, D Battery is any intentional act that brings about actual harmful or offensive contact with the plaintiff. Battery occurs if the health care professional actually touches the patient in an unauthorized manner. Assault occurs if the patient fears harmful or offensive touching. Assault may be alleged if the patient was aware that he or she was going to be touched in a manner not authorized by informed consent. Threatening to punch someone and threatening to restrain a patient for not using his or her call light for mobility assistance are examples of assault. PTS: 1 DIF: Cognitive Level: Applying REF: p. 32 OBJ: Nursing Process Step: N/A TOP: Legal Issues MSC: NCLEX: Safe and Effective Care Environment Chapter 06: Psychosocial and Spiritual Alterations and Management Urden: Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. According to the transactional theories on stress, what does a person do first when confronted by stress? a. Determines coping mechanisms to deal with the stress b. Determines the perceived degree of threat imposed c. Determines what the response will be to the stress d. Denies the stress exists ANS: B An alarm reaction is initiated by the hypothalamus, which, upon receiving sensory and chemical information regarding the presence of a stressor, signals the release of corticotrophin-releasing factor (CRF). During the resistance stage, the person’s systems fight back, leading to adaptation and a return of normal functioning. If the stressors continue, exhaustion occurs, a stage in which reserves have been depleted. Reversal of stress exhaustion can be accomplished by restoration of one’s reserves through the use of medications, nutrition, and other stress reduction measures. PTS: 1 DIF: Cognitive Level: Remembering REF: pp. 79-80 OBJ: Nursing Process Step: Assessment TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 2. A patient has recently been weaned off mechanical ventilation after 3 weeks of treatment. The patient is now refusing to have the ventilator removed from the room. What type of alteration is the patient experiencing? a. Disturbed self-esteem b. Regression c. Hopelessness d. Disturbed body image ANS: D Body image disturbances arise when disruption exists in the way individuals perceive their bodies. Patients temporarily requiring mechanical ventilation must extend their body images to include the ventilator. When the ventilator is no longer needed, the patient should no longer perceive the ventilator as part of the self. Illness robs a person of perspective, often leading to low self-esteem and feelings of powerlessness, helplessness, and depression. Low self-esteem impairs one’s ability to adapt. PTS: 1 DIF: Cognitive Level: Applying REF: p. 78 OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 3. A patient with low self-esteem may manifest which behaviors? a. Refusal to participate in care b. Feelings that his or her body has betrayed him or her c. Acceptance and ownership of problems d. Disruption in the perception of the body ANS: A Patients with low self-esteem may refuse to participate in self-care, exhibit self-destructive behavior, or be too compliant. Feelings that his or her body has betrayed him or her is an example of disruption in the perception of the body. PTS: 1 DIF: Cognitive Level: Applying REF: p. 78 OBJ: Nursing Process Step: Assessment TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 4. Which statement regarding patients with an external locus of control is true? a. They believe that they can influence the outcome of their illness. b. They should be forced to take control of their discharge planning. c. They usually start out with an internal locus of control until a major illness occurs. d. They believe that events are related to chance or fate. ANS: D People with an external locus of control tend to believe that events are related to chance or fate. Individuals who have an internal locus of control perceive themselves to be responsible for the outcome of events. People vary in the amount of control they prefer. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 79 OBJ: Nursing Process Step: Assessment TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 5. Which intervention should be included in the patient management plan for a patient with powerlessness? a. Maintain control of the environment b. Set limits on the behavior c. Maintain a routine schedule so that the patient can anticipate activities d. Prepare the patient for transfer to the medical floor ANS: B Interventions for patients with powerlessness include setting limits on behavior, encouraging independence and participation in self-care, counseling, and involving family members in establishing realistic goals. Powerlessness can be manifested by a refusal to participate in decision making, disengagement from plan of care, expressions of self-doubt, or a seeming lack of interest in recovery. PTS: 1 DIF: Cognitive Level: Applying REF: p. 79|Appendix A|Nursing Management Plan: Powerlessness OBJ: Nursing Process Step: Intervention TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 6. Which statement regarding regression as a coping mechanism for critical care patients is accurate? a. It is necessary to some degree to allow staff to administer care. b. It indicates deterioration of the physical state. c. It is adaptive when the patient calls every 15 minutes, even for trivial matters. d. It is best avoided to ensure successful recovery. ANS: A Regression allows patients to give up their usual roles, autonomy, and privacy to become passive recipients of medical and nursing care. Behaviors such as whining, clinging to staff, needing the nurse constantly at the bedside, and giving evidence of an inability to self-modulate feelings of anxiety or fear can interfere with patient recovery and negatively impact nurse–patient relationships. PTS: 1 DIF: Cognitive Level: Applying REF: p. 80 OBJ: Nursing Process Step: Assessment TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 7. Which concept supports patients and helps them endure the physical and psychologic insults of their critical illness? a. Regression b. Denial c. Hope d. Trust ANS: C Hope is a subjective, dynamic internal process essential to life. Considered to be a spiritual process, hope is an energy that arises out of a sense of being meaningfully connected to one’s self, others, and powers greater than the self. With hope, a person is able to transition from a state of vulnerability to a point of being able to live as fully as possible. Regression is an unconscious defense mechanism characterized by a retreat, in the face of stress, to behaviors characteristic of an earlier developmental level. Denial is defined as the “conscious and unconscious attempts to disavow knowledge or the meaning of an event to reduce anxiety and fear.” Trust manifests itself in critical care patients’ belief that the people they depend on will get them through the illness and will be able to manage any untoward event that might occur. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 79 OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity 8. Which therapeutic technique may be used to enhance coping in the critical care environment? a. Encourage the patient to let the staff have total control of the patient’s care b. Encourage the patient to deny the presence of the illness c. Inform the patient that everything will be all right d. Foster trust in the interprofessional health care team ANS: D Trust manifests itself in critical care patients’ belief that the people they depend on will get them through the illness and will be able to manage any untoward event that might occur. A patient needs to trust the nurse’s competence in the physical and technical aspects of care and rely on what the nurse says. PTS: 1 DIF: Cognitive Level: Applying REF: p. 79 OBJ: Nursing Process Step: Intervention TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 9. Which nursing intervention can help family members who are extremely upset? a. Encouraging the family to visit as much as possible b. Conveying what the patient is experiencing to the family c. Supporting the family members away from the bedside d. Assuring the family that the staff will take care of the technical aspects of the patient’s care ANS: C If family members are so upset that they completely lose composure, a brief attempt at supporting them away from the bedside may be adequate. In doing so, nurses may determine that family members need a consistent outside source of support and may make a referral according to department guidelines. PTS: 1 DIF: Cognitive Level: Applying REF: p. 83 OBJ: Nursing Process Step: Intervention TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 10. A patient has been admitted with a severed spinal cord injury at the T2 level. The patient has been in halo traction with immobilization for the past week. The practitioner explains to the patient that the spinal cord has been severed and that the patient will not be able to walk again. The patient becomes overtly hostile to everyone. What psychosocial concept is the patient demonstrating? a. Regression b. Loss of autonomy c. Ineffective coping d. Hope ANS: C Ineffective coping is defined as an impairment of a person’s adaptive behaviors and problem-solving abilities when meeting life’s demands and necessary roles. Manifestations of ineffective coping in critical illness include verbalization of an inability to cope, anxiety, and being unable to meet basic needs. Regression is an unconscious defense mechanism characterized by a retreat, in the face of stress, to behaviors characteristic of an earlier developmental level. Hope is a subjective, dynamic internal process essential to life. Considered to be a spiritual process, hope is an energy that arises out of a sense of being meaningfully connected to one’s self, others, and powers greater than the self. PTS: 1 DIF: Cognitive Level: Applying REF: p. 80 OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 11. A patient has been admitted with a severed spinal cord injury at the T2 level. The patient has been in halo traction with immobilization for the past week. The practitioner has explained to the patient that the spinal cord has been severed and that the patient will not be able to walk again. The patient states, “I can’t wait until I can get on my feet and walk again.” Which defense mechanism is the patient exhibiting in this statement? a. Denial b. Posttraumatic stress disorder (PTSD) c. Regression d. Trust ANS: A Denial is an unconscious defense mechanism that reduces anxiety by eliminating or reducing the seriousness of the perceived threat. As with stress overload, posttraumatic stress disorder (PTSD) is not a disordered response to stress resulting from a failure of a person’s will, strength, endurance, or courage. Regression is an unconscious defense mechanism characterized by a retreat, in the face of stress, to behaviors characteristic of an earlier developmental level. Trust manifests itself in critical care patients’ belief that the people they depend on will get them through the illness and will be able to manage any untoward event that might occur. PTS: 1 DIF: Cognitive Level: Applying REF: p. 80 OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 12. A patient has been admitted with a severed spinal cord injury at the T2 level. The patient has been in halo traction with immobilization for the past week. The patient continually tries to get out of bed and states, “My legs are only sleeping.” Which nursing diagnoses would be appropriate for the patient? a. Disturbed body image b. Powerlessness c. Situational low self-esteem d. Ineffective role performance ANS: A Body image disturbances arise when disruption exists in the way individuals perceive their bodies. Self-esteem refers to how well one’s behavior correlates with a sense of the ideal self and is most closely linked to one’s sense of self-worth. Patients who have a pervasive sense that they can do nothing to change or control their circumstances are at risk for feeling powerless. PTS: 1 DIF: Cognitive Level: Applying REF: p. 78 OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 13. A patient is in the critical care unit having undergone surgery a week ago for multiple fractures to the legs secondary to a fall from a rooftop. The patient refuses to participate in morning care activities such as brushing his own teeth or washing his face and hands. The patient yells at the nurse, “You do it! Can’t you see that my legs are broken?” What psychosocial disturbance is the patient exhibiting? a. Self-concept b. Self-esteem c. Body image d. Personal identity ANS: B Illness and trauma can rob the person of perspective and shrinks both the familiar world and the one of possibility, often leading to low self-esteem and feelings of powerlessness, helplessness, and depression. A low self-regard impairs one’s ability to adapt. The person may refuse to participate in self-care, exhibit self-destructive behavior, or be too compliant. PTS: 1 DIF: Cognitive Level: Applying REF: p. 78 OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 14. An adult patient sustains third- and fourth-degree burns to more than 70% of her body related to a house fire. The patient begins a pattern of behavior similar to that of a young child, in which she repeatedly whines and throws “temper tantrums” in an attempt to keep her nurse at the bedside. What coping mechanism is the patient exhibiting? a. Regression b. Identity disturbance c. Denial d. Trust ANS: A Regression is a normal reaction to severe burns. The person may become childlike in interactions with staff. Behaviors such as whining, clinging to staff, and attempting to keep the nurse at the bedside constantly are not uncommon. A personal identity disturbance, as a type of altered self-concept, is defined as an inability of a person to differentiate the self as a unique and separate human being from others within a social environment. PTS: 1 DIF: Cognitive Level: Applying REF: p. 80 OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 15. A patient is admitted with the diagnosis of gunshot wound to the head due to a suicide attempt. While the patient is in the critical care unit, the plan of care should include which intervention? a. Limiting interaction with the patient due to antisocial behaviors exhibited by the suicidal attempt b. Overlooking the patient’s need to talk about the incident c. Validating the patient’s worth and self-esteem d. Discontinuing any psychotropic medications ANS: C While the patient is in the unit, primary nursing interventions include validating the patient’s worth and self-esteem and helping him or her regulate emotional states and behaviors. Patients who have attempted suicide are often stigmatized, and caregivers can resent caring for a person whose critical condition is self-inflicted. A suicide attempt indicates, however, that the patient was experiencing personal and spiritual distress to the point of wanting to end his or her life. The critical care team should make every effort to continue medications for mental health conditions during the critical care stay unless medically contraindicated. If the patient is unable to take oral medications, the team should attempt to find an alternative route if possible. PTS: 1 DIF: Cognitive Level: Applying REF: p. 84 OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 16. What happens when the critical illness is so severe that the patient or family becomes overwhelmed? a. Anxiety b. Spiritual distress c. Stress overload d. Hopelessness ANS: C Stress overload does not occur because the patient or family members have coping deficits or psychologic disorders. Rather, the stressors of critical illness are so numerous and severe that people become overwhelmed. Anxiety, hopelessness, and spiritual distress are examples of stress-related nursing diagnoses that occur because of an inability of coping mechanisms or strategies. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 75 OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 17. Which medications are commonly used for alcohol withdrawal symptoms? a. Chlordiazepoxide and folic acid b. Chlordiazepoxide and lorazepam c. Lorazepam and promethazine d. Promethazine and thiamine ANS: B Commonly used medications include chlordiazepoxide and lorazepam for withdrawal symptoms and ondansetron and promethazine for nausea. Thiamine, folic acid, and multivitamins should be added to intravenous fluids. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 84 OBJ: Nursing Process Step: Intervention TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 18. Prolonged periods of anxious waiting, disrupted sleep patterns, witnessing emergency interventions, and financial concerns could put family members at risk for developing what problem? a. Powerlessness b. Hopelessness c. Anxiety d. Posttraumatic stress disorder ANS: D Family members are at risk for developing posttraumatic stress reactions related to prolonged periods of uncertainty, anxious waiting, disrupted sleep patterns, financial concerns, witnessing emergency interventions, and confronting fears of loss and death. Anxiety is a normal and common subjective human response to a perceived or actual threat, which can range from a vague, generalized feeling of discomfort to a state of panic and loss of control. Conditions that increase a person’s risk for feeling hopeless include a loss of dignity, long-term stress, loss of self-esteem, spiritual distress, and isolation, all of which can be present in a critical care experience. Patients who have a pervasive sense that they can do nothing to change or control their circumstances are at risk for feeling powerless. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 76 OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 19. Anxiety can cause emotional changes in which part of the brain? a. Hypothalamus b. Limbic system c. Cerebral cortex d. Pituitary gland ANS: B The neurotransmitters’ complex and elusive integration of these responses within the central nervous system relies on communication among the cerebral cortex, limbic system, thalamus, hypothalamus, pituitary gland, and the reticular activating system. Whereas the cortex is involved with cognition, attention, and alertness, emotional responses to stress are located in the limbic system. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 77 OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 20. A patient is admitted complaining of pain from a femur fracture and is anxious and agitated. The patient is receiving steroids and theophylline for exacerbation of asthma. What disorder should the nurse suspect the patient may be experiencing? a. Anxiety b. Low self-esteem c. Regression d. Suicidal ideations ANS: A Pain triggers anxiety, and increased anxiety intensifies pain experiences. This reciprocal relationship varies, depending on whether pain is produced by disease processes or invasive procedures, is acute or chronic in nature, or if the pain is anticipated. Medications such as theophylline, anticholinergics, dopamine, levodopa, salicylates, and steroids can also contribute to feelings of anxiety. Self-esteem refers to how well one’s behavior correlates with a sense of the ideal self and is most closely linked to one’s sense of self-worth. Regression is an unconscious defense mechanism characterized by a retreat, in the face of stress, to behaviors characteristic of an earlier developmental level. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 77 OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 21. A patient tells his family, “I don’t know why I was placed on this earth just to suffer from cancer all my life. I just want to die.” What psychosocial issue is the patient experiencing? a. Lost control b. Spiritual distress c. Anxiety d. Powerlessness ANS: B Some individuals with spiritual distress may question their existence, verbalize their wish to die, or display anger toward religious traditions. Patients who have a pervasive sense that they can do nothing to change or control their circumstances are at risk for feeling powerless. Anxiety is a normal and common subjective human response to a perceived or actual threat, which can range from a vague, generalized feeling of discomfort to a state of panic and loss of control. PTS: 1 DIF: Cognitive Level: Applying REF: p. 79 OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 22. Through what mechanism can a nurse demonstrate caring and support to a patient? a. Demonstrating superior clinical skills b. Ensuring continuity of care c. Providing empathy and physical contact d. Organizing and prioritizing care ANS: C Many patients interpret a nurse’s expressions of empathy and physical contact as evidence of caring and support. Caring, compassionate verbal and nonverbal communication patterns give substance to nursing activities that promote expert psychosocial and spiritual care interventions. None of the top challenges have to do with technical issues of medical management. Instead, the top challenges include inadequate patterns of communication between the critical care team and family members, insufficient staff knowledge of effective communication, unrealistic family and provider expectations, family disagreements, lack of advance directives, voiceless patients, and suboptimal space for having meaningful conversations. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 81 OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 23. What serious concern regarding the critical care environment affects the patient’s ability to cope and heal? a. Lack of consistent visiting policies b. Misuse of complementary therapies c. Deprivation of sleep d. Mishandling of integrative therapies ANS: C Alterations in the physical environment of critical care units can provide a sense of calm, enhance patient coping, and facilitate healing. Sleep deprivation is a serious concern in critical care environments. To prevent light exposures that awaken patients, nurses should group care activities to limit nighttime interruptions and collaborate with lab personnel to decrease sleep interruptions. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 83 OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. What outcomes do psychosocial and spiritual interventions have the power to employ in a patient? (Select all that apply.) a. Hope b. Fear c. Will to survive d. Energy e. Ability to meet life’s challenges. ANS: A, C, D, E Psychologic and spiritual interventions have the power to engage a patient’s hope, energy, will to survive, and ability to meet life’s challenges. Fear is a coping deficit. PTS: 1 DIF: Cognitive Level: Applying REF: p. 75 OBJ: Nursing Process Step: Assessment TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity 2. What actions can a critical care nurse take to decrease stressors at work? (Select all that apply.) a. Request temporary assignments in a less stressful setting b. Use self-reflection when feeling overwhelmed c. Maintain good physical health d. Ignore feelings of frustration and anger e. Use stress management techniques ANS: A, B, C, E Stress management techniques help to restore energy and enjoyment in caring for patients. In some instances, nurses choose to work temporarily in less emotionally stressful settings. Nurses can maintain their physical health by eating well, exercising, engaging in relaxing activities, laughing, and getting enough sleep. Nurses should first use self-reflection when they feel overwhelmed, considering the possible reasons for their feelings. PTS: 1 DIF: Cognitive Level: Applying REF: pp. 84-85 OBJ: Nursing Process Step: Intervention TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity