Test Bank for Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition by Donna D. Ignatavicius

Medical Surgical Nursing 10th Edition Ignatavicius Workman Test Bank Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises the new nurse that which is the priority when working as a professional nurse? a. Attending to holistic client needs b. Ensuring client safety c. Not making medication errors d. Providing client-focused care ANS: B All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Health care errors have been widely reported for 25 years, many of which result in client injury, death, and increased health care costs. There are several national and international organizations that have either recommended or mandated safety initiatives. Every nurse has the responsibility to guard the client’s safety. The other actions are important for quality nursing, but they are not as vital as providing safety. Not making medication errors does provide safety, but is too narrow in scope to be the best answer. DIF: Understanding TOP: Integrated Process: Nursing Process: Intervention KEY: Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. A nurse is orienting a new client and family to the medical-surgical unit. What information does the nurse provide to best help the client promote his or her own safety? a. Encourage the client and family to be active partners. b. Have the client monitor hand hygiene in caregivers. c. Offer the family the opportunity to stay with the client. d. Tell the client to always wear his or her armband. ANS: A Each action could be important for the client or family to perform. However, encouraging the client to be active in his or her health care as a safety partner is the most critical. The other actions are very limited in scope and do not provide the broad protection that being active and involved does. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. A nurse is caring for a postoperative client on the surgical unit. The client’s blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the nurse take first? a. Call the Rapid Response Team. b. Document and continue to monitor. c. Notify the primary health care provider. d. Repeat the blood pressure in 15 minutes. ANS: A The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse would call the RRT. Changes in blood pressure, mental status, heart rate, temperature, oxygen saturation, and last 2 hours’ urine output are particularly significant and are part of the Modified Early Warning System guide. Documentation is vital, but the nurse must do more than document. The primary health care provider would be notified, but this is not more important than calling the RRT. The client’s blood pressure would be reassessed frequently, but the priority is getting the rapid care to the client. DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Rapid Response Team (RRT), Clinical judgment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best demonstrates this concept? a. Assesses for cultural influences affecting health care. b. Ensures that all the client’s basic needs are met. c. Tells the client and family about all upcoming tests. d. Thoroughly orients the client and family to the room. ANS: A Showing respect for the client and family’s preferences and needs is essential to ensure a holistic or “whole-person” approach to care. By assessing the effect of the client’s culture on health care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this competence. Simply telling the client about all upcoming tests is not providing empowering education. Orienting the client and family to the room is an important safety measure, but not directly related to demonstrating client-centered care. DIF: Understanding TOP: Integrated Process: Culture and Spirituality KEY: Client-centered care, Culture MSC: Client Needs Category: Psychosocial Integrity 5. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors? a. Bring a list of all medications and what they are for. b. Keep the provider’s phone number by the telephone. c. Make sure that all providers wash hands before entering the room. d. Write down the name of each caregiver who comes in the room. ANS: A Medication reconciliation is a formal process in which the client’s actual current medications are compared to the prescribed medications at the time of admission, transfer, or discharge. This National client Safety Goal is important to reduce medication errors. The client would not have to be responsible for providers washing their hands, and even if the client does so, this is too narrow to be the most important action to prevent errors. Keeping the provider’s phone number nearby and documenting everyone who enters the room also do not guarantee safety. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Client safety, Informatics MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 6. Which action by the nurse working with a client best demonstrates respect for autonomy? a. Asks if the client has questions before signing a consent. b. Gives the client accurate information when questioned. c. Keeps the promises made to the client and family. d. Treats the client fairly compared to other clients. ANS: A Autonomy is self-determination. The client would make decisions regarding care. When the nurse obtains a signature on the consent form, assessing if the client still has questions is vital, because without full information the client cannot practice autonomy. Giving accurate information is practicing with veracity. Keeping promises is upholding fidelity. Treating the client fairly is providing social justice. DIF: Applying TOP: Integrated Process: Caring KEY: Ethics, Autonomy MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse asks a more seasoned colleague to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) community. What answer by the faculty is most accurate? a. Avoid embarrassing the client by asking questions. b. Don’t make assumptions about his or her health needs. c. Most LGBTQ people do not want to share information. d. No differences exist in communicating with this population. ANS: B Many members of the LGBTQ community have faced discrimination from health care providers and may be reluctant to seek health care. The nurse would never make assumptions about the needs of members of this population. Rather, respectful questions are appropriate. If approached with sensitivity, the client with any health care need is more likely to answer honestly. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Health care disparities, LGBTQ MSC: Client Needs Category: Psychosocial Integrity 8. A nurse is calling the on-call health care provider about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed opioid pain medication. Which statement comprises the background portion of the SBAR format for communication? a. “I would like you to order a different pain medication.” b. “This client has allergies to morphine and codeine.” c. “Dr. Smith doesn’t like nonsteroidal anti-inflammatory meds.” d. “This client had a vaginal hysterectomy 2 days ago.” ANS: B SBAR is a recommended form of communication, and the acronym stands for Situation, Background, Assessment, and Recommendation. Appropriate background information includes allergies to medications the on-call health care provider might order. Situation describes what is happening right now that must be communicated; the client’s surgery 2 days ago would be considered background. Assessment would include an analysis of the client’s problem; none of the options has assessment information. Asking for a different pain medication is a recommendation. Recommendation is a statement of what is needed or what outcome is desired. DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Teamwork and collaboration, SBAR MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 9. A nurse working on a cardiac unit delegated taking vital signs to an experienced assistive personnel (AP). Four hours later, the nurse notes that the client’s blood pressure taken by the AP was much higher than previous readings, and the client’s mental status has changed. What action by the nurse would most likely have prevented this negative outcome? a. Determining if the AP knew how to take blood pressure b. Double-checking the AP by taking another blood pressure c. Providing more appropriate supervision of the AP d. Taking the blood pressure instead of delegating the task ANS: C Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on delegated tasks. The nurse would either have asked the AP about the vital signs or instructed the AP to report them right away. An experienced AP would know how to take vital signs and the nurse would not have to assess this at this point. Double-checking the work defeats the purpose of delegation. Vital signs are within the scope of practice for a AP and are permissible to delegate. The only appropriate answer is that the nurse did not provide adequate instruction to the AP. DIF: Analyzing TOP: Integrated Process: Communication and Documentation KEY: Teamwork and collaboration, Delegation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. A newly graduated nurse in the hospital states that because of being so new, participation in quality improvement (QI) projects is not wise. What response by the precepting nurse is best? a. “All staff nurses are required to participate in quality improvement here.” b. “Even being new, you can implement activities designed to improve care.” c. “It’s easy to identify what indicators would be used to measure quality.” d. “You should ask to be assigned to the research and quality committee.” ANS: B The preceptor would try to reassure the nurse that implementing QI measures is not out of line for a newly licensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how that is possible and is dismissive. Identifying indicators of quality is not an easy, quick process and would not be the best place to suggest a new nurse to start. Asking to be assigned to the QI committee does not give the nurse information about how to implement QI in daily practice. DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Systems thinking, Quality improvement MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 11. A nurse is talking with a co-worker who is moving to a new state and needs to find new employment there. What advice by the nurse is best? a. Ask the hospitals there about standard nurse–client ratios. b. Choose the hospital that has the newest technology. c. Find a hospital that has achieved Magnet status. d. Work in a facility affiliated with a medical or nursing school. ANS: C Client Magnet status is awarded by The Joint Commission (TJC) and certifies that nurses can demonstrate how best current evidence guides their practice. New technology doesn’t necessarily mean that the hospital is safe. Affiliation with a health profession school has several advantages, but safety is most important. DIF: Understanding TOP: Integrated Process: Communication and Documentation KEY: Evidence-based practice, Magnet status MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control MULTIPLE RESPONSE 1. A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas would the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (Select all that apply.) a. Collaborating with an interprofessional team b. Implementing evidence-based care c. Providing family-focused care d. Routinely using informatics in practice e. Using quality improvement in client care f. Formalizing systems thinking when implementing care ANS: A, B, D, E The IOM report lists five broad core competencies that all health care providers should practice. These include collaborating with the interprofessional team, implementing evidence-based practice, providing patient-focused care, using informatics in client care, and using quality improvement in client care. Systems thinking is required for quality improvement but is not a specified part of the IOM report. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Competencies, Institute of Medicine (IOM) MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. A nurse is interested in making interprofessional work a high priority. Which actions by the nurse best demonstrate this skill? (Select all that apply.) a. Consults with other disciplines on client care. b. Coordinates discharge planning for home safety. c. Participates in comprehensive client rounding. d. Routinely asks other disciplines about client progress. e. Shows the nursing care plans to other disciplines. f. Delegate tasks to unlicensed personnel appropriately. ANS: A, B, C, D, F Collaborating with the interprofessional team involves planning, implementing, and evaluating client care as a team with all other involved disciplines included. Simply showing other caregivers the nursing care plan is not actively involving them or collaborating with them. DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Teamwork and collaboration, Interprofessional team MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (Select all that apply.) a. Cost-saving measures b. Nurse’s expertise c. Client preferences d. Research findings e. Values of the client f. Plan-do-study-act model ANS: B, C, D, E EBP consists of utilizing current evidence, the client’s values and preferences, and the nurse’s expertise when planning care. It does not include cost-saving measures. The PDSA model is a systematic model for quality improvement, but is not a specific component of EBP. DIF: Remembering TOP: Integrated Process: Nursing Process: Planning KEY: Evidence-based practice (EBP) MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best help achieve this goal? (Select all that apply.) a. Attend hand-off rounds to coach and mentor. b. Create a template of suggested topics to include in report. c. Encourage staff to ask questions during hand-off. d. Give raises based on compliance with reporting. e. Provide education on the SBAR method of communication ANS: A, B, C, E The SBAR method of communication has been identified as an excellent method of communication between health care professionals. It is a formalized structure consisting of Situation, Background, Assessment, and Recommendation/Request. Using a formalized mechanism for communication helps ensure successful hand-off and fewer client errors. When establishing this new format for report, the most helpful actions by the manager would be to provide initial education on the process, develop a template with suggested topics under each heading, attend rounds to coach and mentor, and encourage staff to ask questions to clarify information. Basing raises on compliance would not be the most helpful method because raises are often determined only once a year and are based on multiple criteria. DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Teamwork and collaboration, Communication MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care Chapter 02: Clinical Judgment and Systems Thinking Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse asks the charge nurse to explain the difference between critical thinking and clinical judgment. What statement by the charge nurse is best? a. “Clinical judgment is often clouded by erroneous hypotheses.” b. “Clinical judgment is the observable outcome of critical thinking.” c. “Critical thinking requires synthesizing interactions within a situation.” d. “Critical thinking is the highest level of nursing judgment.” ANS: B Clinical judgment is the observable outcome of critical thinking and decision making. It can be, but most often is not, clouded by erroneous hypotheses. Recognizing, understanding, and synthesizing interactions and interdependencies in a set of components designed for a specific purpose is systems thinking. Critical thinking is not the highest level of nursing judgment. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Clinical judgment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The nurse understands which information regarding patient-centered care? a. A competency recognizing the client as the source of control of his or her care b. A project addressing challenges in implementing patient-centered care c. Purposeful, informed, and outcome-focused care of clients or families d. The ability to use best evidence and practice when making care-related decisions ANS: A Patient-centered care is a QSEN competency that recognizes the patient or caregiver as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient’s preferences, values, and needs. QSEN is a project addressing the challenge of preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care systems in which they work. Critical thinking is the application of purposeful, informed, and outcome-focused care. The ability to use best evidence and practice when making care-related decisions is evidence-based practice. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Patient-centered care MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A nurse wishes to participate in an activity that will influence health outcomes. What action by the nurse best meets this objective? a. Creating a transportation system for health care appointments b. Lobbying with a national organization for health care policy c. Organizing a food pantry in an impoverished community d. Running for election to the county public health board ANS: B All options are good choices for an altruistic nurse wishing to influence health outcomes; however, being involved in policy creation and health care reform is an activity specifically recognized to improve health outcomes. This action will also affect a wider population than the more local options. DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Health outcomes MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. What factor best predicts a nurse’s willingness to employ critical thinking? a. Caring b. Knowledge c. Presence d. Skills ANS: A All attributes are important in nursing, however; the nurse’s willingness to think critically is predicted by caring behaviors, self-reflection, and insight. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Critical thinking MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. To demonstrate clinical reasoning skills, what action does the nurse take? a. Collaborating with co-workers to buddy up for lunch breaks b. Delegating frequent vital signs on a new postoperative patient c. Documenting a complete history and physical on an admission d. Requesting the provider order medication for a client with high potassium ANS: D The components of clinical reasoning include assessing, analyzing, planning, implementing, and evaluating. This nurse shows the ability to analyze by interpreting the meaning of the lab value, to plan by anticipating the consequences of the lab value, and to implement by taking action. DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Clinical judgment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 6. The new nurse asks the preceptor how context affects clinical judgment. What response by the preceptor is best? a. “Context considers the whole of the patient’s story and circumstances.” b. “It shouldn’t, only nursing knowledge would affect clinical judgment.” c. “Outside influences such as environment in which you provide care, influence your decisions.” d. “The context of the situation provides an extra layer of complexity to consider.” ANS: C The context of a situation considers and supports clinical judgment. The factors within this layer—such as environment, time pressure, availability or content of electronic health records, resources, and individual nursing knowledge—have a direct impact on clinical judgment. The other two options are too vague to provide appropriate information. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Clinical judgment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. Once the nurse has considered all possible collaborative and client problems, what action does the nurse take next? a. Act on the observed cues. b. Determine desired outcomes. c. Generate solutions. d. Prioritize the hypotheses. ANS: D Analyzing cues lead to a list of potential hypotheses. The nurse prioritizes them, determines the desired outcomes, generates solutions, and acts. This is part of the six-step clinical judgment model. DIF: Understanding TOP: Integrated Process: Nursing Process: Diagnosis KEY: Clinical judgment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A nurse working in a medical home would do which of the following as part of the job? a. Advocate with insurance companies. b. Coordinate interprofessional care. c. Hold monthly team meetings. d. Provide out-of-network specialty referrals. ANS: B The medical home concept came into being to decrease the fragmentation of care. On a daily basis, this nurse would expect to coordinate with the interprofessional care team. Advocating with insurance companies would not be a daily function. Monthly team meetings may or may not be needed. Out of network referrals would not be needed as the interprofessional team strives to provide comprehensive care. DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Medical home MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 9. A nurse is confused on why systems thinking is important since working on the unit involves caring for a few specific clients. What explanation by the nurse manager is best? a. “It’s a good way to conduct root-cause analysis.” b. “It is important for quality improvement and safety.” c. “Systems thinking helps you see the bigger picture.” d. “You may enter management 1 day and need to know this.” ANS: B A systems thinking approach to care reinforces the nurse’s role in safety and quality improvement while expanding clinical judgment to include the patient’s place within the greater health care system in the context of care decisions. Root-cause analyses would be a small portion of systems thinking. It does give the nurse a big-picture view, but this answer is vague. The nurse may or may not ever join management. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Systems thinking MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. The expert nurse understands that critical thinking requires which elements to be present? (Select all that apply.) a. Based on logic, creativity, and intuition b. Driven by needs c. Focused on safety and quality d. Grounded in a specific theory e. Guided by standards f. Requires forming options about evidence ANS: A, B, C, E Critical thinking must be based on logic, creativity, and intuition; driven by patient, family, or community needs; focused on safety and quality; guided by standards, policies, ethics, and laws; based on principles of nursing process, problem-solving, and the scientific method (requires forming opinions and making decisions based on evidence); centered on identification of the key problems, issues, and risks; and grounded in strategies that make the most of human potential. It is not dependent on using a specific theory. DIF: Understanding TOP: Integrated Process: Nursing Process: Planning KEY: Critical thinking MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The nurse manager is conducting an annual evaluation of a staff nurse and is appraising the nurse’s clinical reasoning. What nurse actions does the manager observe to help form this judgment? (Select all that apply.) a. Anticipating consequences of actions b. Delegating appropriately c. Interpreting data d. Noticing cues e. Setting priorities ANS: A, C, D, E The phases of clinical reasoning include assessing (noticing cues), analyzing (interpreting data), planning (anticipating consequences and setting priorities), implementing, and evaluating. Delegating appropriately is not included in this model. DIF: Applying TOP: Integrated Process: Nursing Process: Evaluation KEY: Clinical reasoning MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. According to the WHO, what does primary care involve? (Select all that apply.) a. Empowered people and communities b. Essential public functions c. Multisectoral policy and action d. Primary care e. Priority consideration of chronic diseases f. Elimination of chronic diseases ANS: A, B, C, D According to the WHO, primary care involves three main areas: empowered people and communities, primary care and essential public functions, and multisectoral policy and action. Primary care focuses on both prevention and management of chronic disease. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Primary care, Systems thinking MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nurse wishes to work in a community-based practice setting. Which areas would this nurse explore for employment? (Select all that apply.) a. Hospice facility b. “Minute clinic” c. Mobile mammography unit d. Small community hospital e. Telehealth f. Home health care ANS: A, B, C, E, F The multiple avenues providing community-based care include hospice, “minute” or retail clinics, mobile screening and diagnostic services, telehealth, private medical practices, outpatient services, freestanding points of care, home health care, long-term ambulatory care, public health, and free clinics. Inpatient services in a hospital are not considered primary care sites. DIF: Remembering TOP: Integrated Process: NA KEY: Community-based care MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care Chapter 03: Overview of Health Concepts for Medical-Surgical Nursing Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse is caring for a client who is acidotic. The nurse asks the charge nurse why the client is breathing rapidly. What response by the charge nurse is best? a. Anxiety is causing the client to breathe rapidly. b. The client is trying to get rid of excess body acids. c. The rapid respirations cause buildup of bicarbonate. d. An increased respiratory rate is due to increased metabolism. ANS: B The client is acidotic, and the respiratory system is attempting to compensate by “blowing off” excess acid in the form of carbon dioxide. The increased respiratory rate is not due to anxiety or increased metabolism. An increased respiratory rate does not cause a buildup of bicarbonate. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Acid-base balance MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A client had a recent thromboembolism and must resume work which requires frequent car and plane travel. What self-care measure does the nurse teach to reduce the risk of impaired clotting in this client? a. Get up and walk around at least every 2 hours while traveling. b. Use a soft toothbrush and an electric razor for safety. c. Be sure to sit with the legs elevated as much as possible. d. Increase fiber in the diet so as not to strain to move the bowels. ANS: A Clients who are at risk of increased clotting (as evidenced by prior thromboembolic event) can take several measures to reduce their risk of further problems. One measure is to get up and walk frequently when sitting for a long period of time. Using a soft toothbrush and an electric razor and needing to prevent constipation would be important for a client at risk of bleeding. Elevating the legs is not as beneficial as ambulating. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Clotting, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse is caring for four clients. Which client does the nurse assess first for impaired cognition? a. A 28-year-old client 2 days post-open cholecystectomy b. An 88-year-old client 3 days post-hemorrhagic stroke c. A 32-year-old client with a 20–pack-year history of smoking d. A 42-year-old client with a serum sodium of 134 mEq/L (134 mmol/L) ANS: B There are many risk factors for impaired cognition including advanced age and diseases and disorders that affect the brain. The 88-year-old client who is recovering from a stroke has two such risk factors and is at highest risk for impaired cognition. The nurse assesses this client first. The other clients have a much lower risk of developing impaired cognition. DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Cognition, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. The assistive personnel (AP) reports to the registered nurse that a postoperative client has a pulse of 132 beats/min and a blood pressure of 168/90 mm Hg. What response by the nurse is most appropriate? a. Ask the AP to repeat the client’s vital signs in 15 minutes. b. Assess the client for pain. c. Ask the client if something is bothersome. d. Instruct the AP to reposition the client. ANS: B The “fight-or-flight” syndrome can occur from sympathetic nervous stimulation due to acute pain. Symptoms can include nausea, vomiting, diaphoresis, tachycardia, tachypnea, hypertension, and dilated pupils. Since this client is postoperative, it is reasonable to believe that he or she might be in pain. The nurse first assesses for pain or discomfort and treats it. If the client is not in pain, the nurse would conduct further assessments to determine the cause of the abnormal vital signs. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Pain, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A client has urinary incontinence. Which assessment finding indicates that outcomes for a priority nursing diagnosis have been met? a. Client reports satisfaction with undergarments for incontinence. b. Client reports drinking 8 to 9 glasses of water each day. c. Skin in perineal area is intact without redness on inspection. d. Family states that client is more active and socializes more. ANS: C Urinary incontinence can lead to skin breakdown and possibility of infection. Skin that is intact without redness shows that a major goal for this client has been met. Becoming more social is a positive finding as many adults with incontinence limit their social activities, but this psychosocial outcome is not the priority over a physical outcome. Being satisfied with undergarments is also not the priority. Drinking adequate water can sometimes help with incontinence and is important for general health, but is not directly related to an important goal for this client. DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Tissue integrity, Incontinence MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. The registered nurse asks the nursing assistant why a cardiac client’s morning weight has not yet been done. The nursing assistant says, “I’ll get to it, what’s the big deal?” When deciding how to respond, the nurse considers what information about weight? a. Decisions on treatment often depend on the daily weight. b. The nursing assistant needs to ensure that tasks are done on time. c. Weight is the most accurate noninvasive indicator of fluid status. d. A change in weight may indicate the need to change IV fluids. ANS: C Weight is the best (noninvasive) indicator of fluid status. Primary health care providers may base treatment decisions on weight, because the weight reflects fluid balance, but this answer does not explain why. IV fluid rates or solutions may change for the same reason. The nursing assistant would perform tasks on a timely basis, but this is not related to information about weight. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Fluid and electrolytes MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. The nurse in the emergency department (ED) is caring for four clients. Which client does the nurse assess for gas exchange abnormalities first? a. Involved in motor vehicle crash, has broken femur. b. Brought in unconscious by roommate after opioid overdose. c. Asthmatic client being discharged after bronchodilator therapy. d. History of COPD, presents to ED after being bitten by a dog. ANS: B Opioid medications can cause respiratory depression, so this client is most at risk for gas exchange problems. Diminished respirations will allow a buildup of carbon dioxide in the blood. The clients with asthma and COPD have the potential for gas exchange problems but this is not indicated in answer option as he or she is being discharged. The client with a broken femur does not have information suggesting gas exchange problems. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Gas exchange, Risk factors MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. The nurse caring for a client with malnutrition assesses which laboratory value as the priority? a. Albumin b. Prealbumin c. Prothrombin time d. Serum sodium ANS: B Both albumin and prealbumin are indicators for nutrition. However, prealbumin changes more rapidly with decreased nutrition, so it is the better test. Prothrombin time and serum sodium are not directly related to nutritional status. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Nutrition, Laboratory values 9. A nurse is planning primary prevention measures for community-dwelling adults to prevent visual impairment. What action by the nurse will best meet this objective? a. Provide glaucoma screening. b. Assess visual acuity. c. Teach clients about instilling eyedrops. d. Offer a healthy lifestyle class. ANS: D Primary prevention activities are those designed to actually prevent the onset of a disease or health problem. Secondary prevention focuses on screening and early diagnosis/detection. Tertiary measures are those that offer treatment and rehabilitation. Encouraging a healthy lifestyle through classes may help prevent diabetes, a common cause of visual impairment, and is a primary prevention measure. Assessing for glaucoma and visual acuity is a secondary prevention measure. Teaching clients how to instill eyedrops is tertiary. DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Sensory perception, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 10. The nurse tells the staff development nurse he/she is very uncomfortable discussing sexuality with clients, especially those who are older. What suggestion by the staff development nurse is most appropriate? a. “Find a trusted friend and role play.” b. “Don’t worry it will get easier.” c. “A sexual assessment is usually not needed.” d. “It’s hard for me to do, too.” ANS: A Discussing sexuality and sex is difficult for most people. Since it is important to be able to assess this aspect of people’s lives, the nurse needs to become comfortable. Role-playing with a trusted friend will build confidence and comfort. Saying that it will get easier and that it is hard for the staff development nurse too does not give the nurse any ideas for improvement. Sexuality is important to assess. DIF: Applying TOP: Integrated Process: Caring KEY: Sexuality, Nursing assessment MSC: Client Needs Category: Psychosocial Integrity MULTIPLE RESPONSE 1. A nurse is planning a community education event-related to impaired cellular regulation. What teaching topics would the nurse include in this event? (Select all that apply.) a. Ways to minimize exposure to sunlight b. Resources available for smoking cessation c. Strategies to remain hydrated during hot weather d. Use of indoor tanning beds instead of sunbathing e. Creative cooking techniques to increase dietary fiber f. How to determine sodium content in food? ANS: A, B, E Disrupted cellular regulation can lead to both benign and malignant tumors (cancer). Ways to minimize the risk of developing cancer include decreasing exposure to sunlight, smoking cessation, and increasing dietary fiber. Tanning beds do not reduce the risk of cancer as opposed to sunbathing. While staying hydrated is a good health measure, it is not related to cellular regulation. Maintaining a normal intake of sodium is also not related to cellular regulation. DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Cellular regulation, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 2. A nurse is caring for clients on an inclient surgical unit. Which clients does the nurse identify as having a risk for impaired immunity? (Select all that apply.) a. 86 years old b. Has type 2 diabetes c. Taking prednisone d. Has many allergies e. Drinks a beer a day f. Low socioeconomic status ANS: A, B, C, F Risk factors for impaired immunity include but are not limited to: older adults (diminished immunity due to normal aging changes), low socioeconomic groups (inability to obtain proper immunizations), nonimmunized adults, adults with chronic illnesses that weaken the immune system, adults taking chronic drug therapy such as corticosteroids and chemotherapeutic agents, adults experiencing substance use disorder, adults who do not practice a healthy lifestyle, and adults who have a genetic risk for decreased or excessive immunity. Allergies and one beer a day are not risk factors. DIF: Remembering TOP: Integrated Process: Nursing Process: Planning KEY: Immunity MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. The nurse is caring for a client with severely impaired mobility. What actions does the nurse place on the care plan to address potential complications? (Select all that apply.) a. Perform a depression screen once a day. b. Consult physical therapy for range of motion. c. Increase fiber in the client’s diet. d. Decrease fluid intake. e. Allow client to stay in a position of comfort. ANS: A, B, C There are many complications of immobility including depression, pressure injuries, constipation, urinary calculi, and muscle atrophy. The nurse would address these by assessing for depression, consulting physical therapy for activities such as range of motion the client can do, and increase fiber so the client does not become constipated. Decreasing fluid intake would increase the possibility of calculi and allowing the client to stay in one position would increase the risk of pressure injuries. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Mobility MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A client has impaired tissue integrity and a nonhealing wound. The nurse has taught the client about diet changes to improve wound healing. What diet selections does the nurse evaluate as good understanding by the client? (Select all that apply.) a. Chicken breast b. Orange juice c. Boost supplement d. Spinach salad e. Cantaloupe f. Whole wheat bread ANS: A, B, C, D Protein and vitamin C are important for wound healing. Foods high in protein include meat sources such as chicken and nutritional supplements. Foods high in vitamin C include orange juice and spinach. Cantaloupe is a good source of vitamin A. Whole wheat bread, while healthy, does not contribute directly to wound healing. DIF: Remembering TOP: Integrated Process: Nursing Process: Evaluation KEY: Nutrition MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation Chapter 04: Common Health Problems of Older Adults Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse learns that the fastest growing subset of the older population is which group? a. Elite old b. Middle old c. Old old d. Young old ANS: C The old old is the fastest growing subset of the older population. This is the group comprising those 85 to 99 years of age. The young old are between 65 and 74 years of age; the middle old are between 75 and 84 years of age; and the elite old are over 100 years of age. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Older adults MSC: Client Needs Category: Health Promotion and Maintenance 2. A nurse working with older adults in the community plans programming to improve morale and emotional health in this population. What activity would best meet this goal? a. Exercise program to improve physical function b. Financial planning seminar series for older adults c. Social events such as dances and group dinners d. Workshop on prevention from becoming an abuse victim ANS: A All activities would be beneficial for the older population in the community. However, failure in performing one’s own activities of daily living and participating in society has direct effects on morale and life satisfaction. Those who lose the ability to function independently often feel worthless and empty. An exercise program designed to maintain and/or improve physical functioning would best address this need. DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Older adult MSC: Client Needs Category: Psychosocial Integrity 3. A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment would the nurse perform first? a. Auscultate bowel sounds. b. Check skin turgor. c. Perform an oral assessment. d. Weigh the client. ANS: C Poorly fitting dentures and other dental problems are often manifested by a preference for soft foods and constipation from the lack of fiber. The nurse would perform an oral assessment to determine if these problems exist. The other assessments are important, but will not yield information specific to the client’s food preferences as they relate to constipation. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Older adult, Nutrition MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 4. A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the client demonstrates a need for further review? a. Barley soup b. Black beans c. White rice d. Whole-wheat bread ANS: C Older adults need 35 to 50 g of fiber a day. White rice is low in fiber. Foods high in fiber include barley, beans, and whole-wheat products. DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Older adult, Nutrition MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide to best address this issue? a. “Cut some sodium out of your diet.” b. “Dehydration can cause incontinence.” c. “Have something to drink every 1 to 2 hours.” d. “Take your diuretic in the morning.” ANS: C Older adults often lose their sense of thirst. Plus older adults have less body water than younger people. Since they should drink 1 to 2 L of water a day, the best remedy is to have the older adult drink something each hour or two, whether or not he or she is thirsty. Cutting “some” sodium from the diet will not address this issue and is vague. Although dehydration can cause incontinence from the irritation of concentrated urine, this information will not help prevent the problem of dehydration. Instructing the client to take a diuretic in the morning rather than in the evening also will not directly address this issue. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Older adult, Fluid and electrolyte balance MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A home health care nurse is planning an exercise program with an older adult who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this adult? a. Building strength and flexibility b. Improving exercise endurance c. Increasing aerobic capacity d. Providing personal training ANS: A This older adult is mostly homebound. Exercise regimens for homebound clients include things to increase functional fitness and ability for activities of daily living. Strength and flexibility will help the client to be able to maintain independence longer. The other plans are good but will not specifically maintain the client’s functional abilities. DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Older adult, Functional ability MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 7. An older adult recently retired and reports “being depressed and lonely.” What information would the nurse assess as a priority? a. History of previous depression b. Previous stressful events c. Role of work in the adult’s life d. Usual leisure time activities ANS: C Establishing and maintaining relationships with others throughout life are especially important to the older person’s happiness. When people retire, they may lose much of their social network, leading them to feeling depressed and lonely. This loss from a sudden change in lifestyle can easily lead to depression. The nurse would first assess the role that work played in the client’s life. The other factors can be assessed as well, but this circumstance is commonly seen in the older population. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Older adult, Depression MSC: Client Needs Category: Psychosocial Integrity 8. A nurse is assessing coping in older women in a support group for recent widows. Which statement by a participant best indicates potential for successful coping? a. “I have had the same best friend for decades.” b. “I think I am coping very well on my own.” c. “My kids come to see me every weekend.” d. “Oh, I have lots of friends at the senior center.” ANS: A Friendship and support enhance coping. The quality of the relationship is what is most important, however. People who have close, intimate, stable relationships with others in whom they confide are more likely to cope with crisis. The person who is “coping well on my own” may actually need resources to help with this transition. Having children visit is important but not as important as intimate, long-term friendships. “Friends at the senior center” may refer to good acquaintances and not real friends. DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Older adult, Coping MSC: Client Needs Category: Psychosocial Integrity 9. A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe on the steps? a. Have the client use a walker or cane on the steps. b. Teach the client to hold the handrail when using the steps c. Instruct the client to use the garage door instead. d. Tell the client to use a two-footed gait on the steps. ANS: B As a person ages, he or she may experience a decreased sense of touch. The older adult may not be aware of where his or her foot is on the step. Combined with diminished visual acuity, this can create a fall hazard. Holding the handrail would help keep the person safer. If the client does not need an assistive device, he or she would not use a cane or walker just on stairs. Using an alternative door may be necessary but does not address making the front steps safer. A two-footed gait may not help if the client is unaware of where the foot is on the step. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Older adult, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 10. An older adult is brought to the emergency department because of sudden onset of confusion. After the client is stabilized and comfortable, what assessment by the nurse is most important? a. Assess for orthostatic hypotension. b. Determine if there are new medications. c. Evaluate the client for gait abnormalities. d. Perform a delirium screening test. ANS: B Medication side effects and adverse effects are common in the older population. Something as simple as a new antibiotic can cause confusion and memory loss. The nurse would determine if the client is taking any new medications. Assessments for orthostatic hypotension, gait abnormalities, and delirium may be important once more is known about the client’s condition. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Older adult, Medication safety MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 11. An older adult client takes medication three times a day and becomes confused about which medication should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying “Those are for old people.” What action by the nurse would be most helpful? a. Arrange medications by time in a drawer. b. Encourage the client to use easy-open tops. c. Put color-coded stickers on the bottle caps. d. Write a list of when to take each medication. ANS: C Color-coded stickers are a fast, easy-to-remember system. One color is for morning meds, one for evening meds, and the third color is for nighttime meds. Arranging medications by time in a drawer might be helpful if the person doesn’t accidentally put them back in the wrong spot. Easy-open tops are not related. Writing a list might be helpful, but not if it gets misplaced. With stickers on the medication bottles themselves, the reminder is always with the medication. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Older adult, Medication safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 12. An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful in preventing falls in this client? a. Keep the light on in the bathroom at night. b. Order a bedside commode for the client. c. Put the client on a toileting schedule. d. Use side rails to keep the client in bed. ANS: A Although this older adult is independent and ambulatory, being hospitalized can create confusion. Getting up in a dark, unfamiliar environment can contribute to falls. Keeping the light on in the bathroom will help reduce the likelihood of falling. The client does not need a commode or a toileting schedule. Side rails used to keep the client in bed are considered restraints and would not be used in that fashion. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Older adult, Fall prevention MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 13. An older client had hip replacement surgery and the surgeon prescribed morphine sulfate for pain. The client is allergic to morphine and reports pain and muscle spasms. When the nurse calls the surgeon, which medication would he or she suggest in place of the morphine? a. Cyclobenzaprine b. Hydromorphone hydrochloride c. Ketorolac d. Meperidine ANS: B Cyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) are all on the Beers list of potentially inappropriate medications for use in older adults and would not be suggested. The nurse would suggest hydromorphone hydrochloride. DIF: Remembering TOP: Integrated Process: Communication and Documentation KEY: Older adult, Medication safety MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 14. A nurse admits an older adult from a home environment. The client lives with an adult son and daughter-in-law. The client has urine burns on the skin, no dentures, and several pressure injuries. What action by the nurse is most appropriate? a. Ask the family how these problems occurred. b. Call the police department and file a report. c. Notify Adult Protective Services. d. Report the findings as per agency policy. ANS: D These findings are suspicious for abuse. Health care providers are mandatory reporters for suspected abuse. The nurse would notify social work, case management, or whomever is designated in facility policies. That person can then assess the situation further. If the police need to be notified, that is the person who will notify them. Adult Protective Services is notified in the community setting. DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Older adult, Abuse MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 15. A nurse caring for an older client in the hospital is concerned the client is not competent to give consent for upcoming surgery. What action by the nurse is best? a. Call Adult Protective Services. b. Discuss concerns with the health care team. c. Do not allow the client to sign the consent. d. Have the client’s family sign the consent. ANS: B In this situation, each facility will have a policy designed for assessing competence. The nurse would bring these concerns to an interprofessional care team meeting. There may be physiologic reasons for the client to be temporarily too confused or incompetent to give consent. If an acute condition is ruled out, the staff would follow the legal procedure and policies in their facility and state for determining competence. The key is to bring the concerns forward. Calling Adult Protective Services is not appropriate at this time. Signing the consent would wait until competence is determined unless it is an emergency, in which case the next of kin can sign if there are grave doubts as to the client’s ability to provide consent. Simply not allowing the client to sign does not address the problem. DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Older adult, Autonomy MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A nurse working in an Acute Care of the Elderly unit learns that frailty in the older population includes which components? (Select all that apply.) a. Dementia b. Exhaustion c. Slowed physical activity d. Weakness e. Weight gain f. Frequent illness ANS: B, C, D Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and exhaustion, and weakness. Weight gain and dementia are not part of this syndrome. Frequent illness could occur due to frailty, but is also not part of the syndrome. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Older adult, Frailty MSC: Client Needs Category: Health Promotion and Maintenance 2. A home health care nurse assesses an older adult for the intake of nutrients needed in larger amounts than in younger adults. Which foods found in an older adult’s kitchen might indicate an adequate intake of these nutrients? (Select all that apply.) a. 1% milk b. Carrots c. Lean ground beef d. Oranges e. Vitamin D supplements f. Cheese sticks ANS: A, B, D, E Older adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk and cheese have calcium; carrots have vitamin A; vitamin D supplement has vitamin D; and oranges have vitamin C. Lean ground beef is healthier than more fatty cuts, but does not contain these needed nutrients. DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Older adults, Nutrition MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 3. A nurse working with older adults assesses them for common potential adverse medication effects. For what does the nurse assess? (Select all that apply.) a. Constipation b. Dehydration c. Mania d. Urinary incontinence e. Weakness f. Anorexia ANS: A, B, E, F Common adverse medication effects include constipation/impaction, dehydration, anorexia, and weakness. Mania and incontinence are not among the common adverse effects, although urinary retention is. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Older adult, Adverse medication effects MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A nurse manager institutes the Fulmer SPICES Framework as part of the routine assessment of older adults in the hospital. The nursing staff assesses for which factors? (Select all that apply.) a. Confusion b. Evidence of abuse c. Incontinence d. Problems with behavior e. Sleep disorders ANS: A, C, E SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion, and evidence of falls. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Older adult, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. A visiting nurse is in the home of an older adult and notes a 7-lb weight loss since last month’s visit. What actions would the nurse perform first? (Select all that apply.) a. Assess the client’s ability to drive or transportation alternatives. b. Determine if the client has dentures that fit appropriately. c. Encourage the client to continue the current exercise plan. d. Have the client complete a 3-day diet recall diary. e. Teach the client about proper nutrition in the older population. ANS: A, B, D Assessment is the first step of the nursing process and would be completed prior to intervening. Asking about transportation to get food, dentures, and normal food patterns would be part of an appropriate assessment for the client. There is no information in the question about the older adult needing to lose weight, so encouraging him or her to continue the current exercise regimen is premature and may not be appropriate. Teaching about proper nutrition is a good idea, but teaching needs to be tailored to the client’s needs, which the nurse does not yet know. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Older adult, Nutrition MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the registered nurse (RN) delegate to the assistive personnel (AP)? (Select all that apply.) a. Assess skin redness when turning. b. Document Braden Scale results. c. Keep the client’s skin dry. d. Obtain a pressure-relieving mattress. e. Turn the client every 2 hours. ANS: C, D, E The nurses’ aide or AP can assist in keeping the client’s skin dry, order a special mattress on direction of the RN, and turn the client on a schedule. Assessing the skin is a nursing responsibility, although the aide would be directed to report any redness noticed. Documenting the Braden Scale results is the RN’s responsibility as the RN is the one who performs that assessment. DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Older adult, Tissue integrity MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse admits an older adult to the hospital who lives at home with family. The nurse assesses that the client is malnourished. What actions by the nurse are best? (Select all that apply.) a. Contact Adult Protective Services or hospital social work. b. Request the primary health care provider prescribes tube feedings. c. Perform and document results of a Braden Scale assessment. d. Request a dietary consultation from the health care provider. e. Suggest a high-protein oral supplement between meals. f. Assess the client’s own teeth or the dentures for proper fit. ANS: C, D, E, F Malnutrition in the older population is multifactorial and has several potential adverse outcomes. Appropriate actions by the nurse include assessing the client’s risk for skin breakdown with the Braden Scale, requesting a consultation with a dietitian, suggesting a high-protein meal supplement, and assessing the client’s dentures or own teeth. There is no evidence that the client is being abused or needs a feeding tube at this time. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Older adult, Nutrition MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care Chapter 05: Assessment and Care of Patients With Pain Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A new nurse asks the precepting nurse “What is the best way to assess a client’s pain?” Which response by the nurse is best? a. Numeric pain scale b. Behavioral assessment c. Client’s self-report d. Objective observation ANS: C Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Pain, Nursing assessment MSC: Client Needs Category: Health Promotion and Maintenance 2. A new nurse reports to the nurse preceptor that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. Which response by the experienced nurse is best? a. “Being able to sleep doesn’t mean pain doesn’t exist.” b. “Have you ever experienced any type of pain?” c. “The client should be assessed for drug addiction.” d. “You’re right; I would put the medication back.” ANS: A A client’s description is the most accurate assessment of pain. The nurse would believe the client and provide pain relief. Physiologic changes due to pain vary from client to client, and assessments of them would not supersede th