Test Bank - MedicalSurgical Nursing: Assessmentand Management of Clinical Problems 10e

Table of Contents Table of Contents Chapter 01: Professional Nursing Practice Chapter 02: Health Disparities and Culturally Competent Care Chapter 03: Health History and Physical Examination Chapter 04: Patient and Caregiver Teaching Chapter 05: Chronic Illness and Older Adults Chapter 06: Stress and Stress Management Chapter 07: Sleep and Sleep Disorders Chapter 08: Pain Chapter 09: Palliative Care at End of Life Chapter 10: Substance Use Disorders Chapter 11: Inflammation and Wound Healing Chapter 12: Genetics and Genomics Chapter 13: Altered Immune Responses and Transplantation Chapter 14: Infection and Human Immunodeficiency Virus Infection Chapter 15: Cancer Chapter 16: Fluid, Electrolyte, and Acid-Base Imbalances Chapter 17: Preoperative Care Chapter 18: Intraoperative Care Chapter 19: Postoperative Care Chapter 20: Assessment of Visual and Auditory Systems Chapter 21: Visual and Auditory Problems Chapter 22: Assessment of Integumentary System Chapter 23: Integumentary Problems Chapter 24: Burns Chapter 25: Assessment of Respiratory System Chapter 26: Upper Respiratory Problems Chapter 27: Lower Respiratory Problems Chapter 28: Obstructive Pulmonary Diseases Chapter 29: Assessment of Hematologic System Chapter 30: Hematologic Problems Chapter 31: Assessment of Cardiovascular System Chapter 32: Hypertension Chapter 33: Coronary Artery Disease and Acute Coronary Syndrome Chapter 34: Heart Failure Chapter 35: Dysrhythmias Chapter 36: Inflammatory and Structural Heart Disorders Chapter 37: Vascular Disorders Chapter 38: Assessment of Gastrointestinal System Chapter 39: Nutritional Problems Chapter 40: Obesity Chapter 41: Upper Gastrointestinal Problems Chapter 42: Lower Gastrointestinal Problems Chapter 43: Liver, Pancreas, and Biliary Tract Problems Chapter 44: Urinary System Chapter 45: Renal and Urologic Problems Chapter 46: Acute Kidney Injury and Chronic Kidney Disease Chapter 47: Assessment of Endocrine System Chapter 48: Diabetes Mellitus Chapter 49: Endocrine Problems Chapter 50: Assessment of Reproductive System Test Bank - Medical-Surgical Nursing: Assessment and Management of1 Clinical Problems 10e 657 669 678 700 716 725 743 757 773 783 798 805 826 837 858 877 890 903 Chapter 51: Breast Disorders Chapter 52: Sexually Transmitted Infections Chapter 53: Female Reproductive and Genital Problems Chapter 54: Male Reproductive and Genital Problems Chapter 55: Assessment of Nervous System Chapter 56: Acute Intracranial Problems Chapter 57: Stroke Chapter 58: Chronic Neurologic Problems Chapter 59: Dementia and Delirium Chapter 60: Spinal Cord and Peripheral Nerve Problems Chapter 61: Assessment of Musculoskeletal System Chapter 62: Musculoskeletal Trauma and Orthopedic Surgery Chapter 63: Musculoskeletal Problems Chapter 64: Arthritis and Connective TissueDiseases Chapter 65: Critical Care Chapter 66: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome Chapter 67: Acute Respiratory Failure and Acute Respiratory Distress Syndrome Chapter 68: Emergency and Disaster Nursing Test Bank - Medical-Surgical Nursing: Assessment and Management of2 Clinical Problems 10e Chapter 01: Professional Nursing Practice Test Bank MULTIPLE CHOICE 1. The nurse teaches a student nurse about how to apply the nursing process when providing patient care. Which statement, if made by the student nurse, indicates that teaching was successful? a. The nursing process is a scientific-based method of diagnosing the patients health care problems. b. The nursing process is a problem-solvingtool used to identify and treat patients health care needs. c. The nursing process is based on nursing theory that incorporates the biopsychosocial nature of humans. d. The nursing process is used primarily to explain nursing interventions to other health care professionals. ANS: B The nursing process is a problem-solvingapproach to the identification and treatment of patients problems. Diagnosis is only one phase of the nursing process.The primary use of the nursing process is in patient care, not to establish nursing theory or explain nursing interventions to other health care professionals. DIF: Cognitive Level: Understand (comprehension) REF: 7 TOP: NursingProcess: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. The nurse describes to a student nurse how to use evidence-based practice guidelines when caring for patients. Which statement, if made by the nurse, would be the most accurate? a. Inferences from clinical research studies are used as a guide. b. Patient care is based on clinical judgment, experience, and traditions. c. Data are evaluated to show that the patient outcomes are consistently met. d. Recommendations are based on research, clinical expertise, and patient preferences. ANS: D Evidence-based practice (EBP) is the use of the best research-based evidence combined with clinician expertise. Clinical judgment based on the nurses clinical experience is part of EBP, but clinical decision making should also incorporate current research and research-based guidelines. Evaluation of patient outcomes is important, but interventions should be based on research from randomized control studies with a large number of subjects. DIF: Cognitive Level: Remember (knowledge) REF: 11 TOP: NursingProcess: Planning MSC: NCLEX: Safe and Effective Care Environment Test Bank - Medical-Surgical Nursing: Assessment and Management of3 Clinical Problems 10e 3. The nurse completes an admission database and explains that the plan of care and discharge goals will be developed with the patients input. The patient states, How is this different from what the doctor does? Which response would be most appropriate for the nurse to make? a. The role of the nurse is to administer medications and other treatments prescribed by your doctor. b. The nurses job is to help the doctor by collecting information and communicating any problems that occur. c. Nurses performmany of the same procedures as the doctor, but nurses are with the patients for a longer time than the doctor. d. In additionto caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health. ANS: D This response is consistent with the American Nurses Association (ANA) definition of nursing,which describes the role of nurses in promoting health. The other responses describe some of the dependent and collaborative functions of the nursing role but do not accurately describe the nurses role in the health care system. DIF: Cognitive Level: Understand (comprehension) REF: 3 TOP: NursingProcess: Implementation MSC: NCLEX: Safe and Effective Care Environment 4. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the left hip. Which nursing diagnosis is most appropriate? a. Impaired physical mobility related to left-sided paralysis b. Risk for impaired tissue integrity related to left-sided weakness c. Impaired skin integrity related to altered circulation and pressure d. Ineffective tissue perfusion related to inability to move independently ANS: C The patients major problem is the impaired skin integrity as demonstrated by the presence of a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by frequently repositioning the patient. Although left-sided weakness is a problem for the patient, the nurse cannot treat the weakness. The risk for diagnosis is not appropriate for this patient, who already has impaired tissue integrity. The patient does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health problem is. DIF: Cognitive Level: Apply (application) REF: 7 TOP: NursingProcess: Diagnosis MSC: NCLEX: Physiological Integrity 5. A patient has been admitted to the hospital for surgery and tells the nurse, I do not feel comfortable leaving my childrenwith my parents. Which action should the nurse take next? Test Bank - Medical-Surgical Nursing: Assessment and Management of4 Clinical Problems 10e a. Reassure the patient that these feelings are common for parents. b. Have the patient call the childrento ensure that they are doing well. c. Gather more data about the patients feelings about the child-care arrangements. d. Call the patients parents to determine whether adequate child care is being provided. ANS: C Since a complete assessment is necessary in order to identify a problem and choose an appropriate intervention, the nurses first action should be to obtain more information. The other actions may be appropriate, but more assessment is needed before the best intervention can be chosen. DIF: Cognitive Level: Apply (application) REF: 6 OBJ: Special Questions: Prioritization TOP: NursingProcess: Assessment MSC: NCLEX: Psychosocial Integrity 6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis. Which outcome would the nurse recognize as most appropriate for this patient? a. Patient has a balanced intake and output. b. Patients beddingis changed when it becomes damp. c. Patient understands the need for increased fluid intake. d. Patientsskin remains cool and dry throughout hospitalization. ANS: A This statement gives measurable data showing resolution of the problem of deficient fluid volume that was identified in the nursing diagnosis statement. The other statements would not indicate that the problem of deficient fluid volume was resolved. DIF: Cognitive Level: Apply (application) REF: 7 TOP: NursingProcess: Planning MSC: NCLEX: Physiological Integrity 7. A nurse asks the patient if pain was relievedafter receiving medication. What is the purpose of the evaluation phase of the nursing process? a. To determine if interventions have been effective in meetingpatient outcomes b. To document the nursing care plan in the progress notes of the medical record c. To decide whetherthe patients health problems have been completely resolved Test Bank - Medical-Surgical Nursing: Assessment and Management of5 Clinical Problems 10e d. To establish if the patient agrees that the nursing care provided was satisfactory ANS: A Evaluation consists of determining whetherthe desired patient outcomes have been met and whetherthe nursing interventions were appropriate. The other responses do not describe the evaluation phase. DIF: Cognitive Level: Understand (comprehension) REF: 7 TOP: NursingProcess: Evaluation MSC: NCLEX: Safe and Effective Care Environment 8. The nurse interviews a patient while completing the health history and physical examination. What is the purpose of the assessment phase of the nursing process? a. To teach interventions that relieve health problems b. To use patient data to evaluate patient care outcomes c. To obtain data with which to diagnose patient problems d. To help the patient identify realistic outcomes for health problems ANS: C During the assessment phase, the nurse gathers information about the patient to diagnose patient problems. The other responses are examples of the planning, intervention, and evaluation phases of the nursing process. DIF: Cognitive Level: Understand (comprehension) REF: 7 TOP: NursingProcess: Assessment MSC: NCLEX: Safe and Effective Care Environment 9. Which nursing diagnosis statement is written correctly? a. Altered tissue perfusion related to heart failure b. Risk for impaired tissue integrity related to sacral redness c. Ineffective coping related to response to biopsy test results d. Altered urinary elimination related to urinary tract infection ANS: C This diagnosis statement includes a NANDA nursing diagnosis and an etiologythat describes a patients response to a health problem that can be treated by nursing.The use of a medical diagnosis as an etiology(as in the responses beginning Altered tissue perfusion and Altered urinary elimination) is not appropriate. The response beginning Risk for impaired tissue integrity uses the defining characteristic as the etiology. DIF: Cognitive Level: Understand (comprehension) REF: 7 TOP: NursingProcess: Diagnosis MSC: NCLEX: Safe and Effective Care Environment Test Bank - Medical-Surgical Nursing: Assessment and Management of6 Clinical Problems 10e 10. The nurse admits a patient to the hospital and develops a plan of care. What components should the nurse include in the nursing diagnosis statement? a. The problem and the suggested patient goals or outcomes b. The problem with possiblecauses and the planned interventions c. The problem, its cause, and objective data that support the problem d. The problem with an etiologyand the signs and symptoms of the problem ANS: D When writing nursing diagnoses, this format should be used: problem, etiology, and signs and symptoms. The subjective, as well as objective, data should be included in the defining characteristics. Interventions and outcomes are not included in the nursing diagnosis statement. DIF: Cognitive Level: Remember (knowledge) REF: 8 TOP: NursingProcess: Diagnosis MSC: NCLEX: Safe and Effective Care Environment 11. A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse to delegate to experienced unlicensed assistive personnel (UAP)? a. Monitorfor shortness of breath or fatigue after ambulation. b. Instruct the patient about the need to alternate activity and rest. c. Obtain the patients blood pressure and pulse rate after ambulation. d. Determine whetherthe patient is ready to increasethe activity level. ANS: C UAP education includes accurate vital sign measurement. Assessment and patient teaching require registered nurse education and scope of practice and cannot be delegated. DIF: Cognitive Level: Apply (application) REF: 15 OBJ: Special Questions: Delegation TOP: NursingProcess: Planning MSC: NCLEX: Safe and Effective Care Environment 12. A nurse is caring for a group of patients on the medical-surgical unit with the help of one float registered nurse (RN), one unlicensed assistive personnel (UAP), and one licensedpractical/vocational nurse (LPN/LVN). Which assignment, if delegated by the nurse, would be inappropriate? a. Measurement of a patients urine output by UAP b. Administration of oral medications by LPN/LVN Test Bank - Medical-Surgical Nursing: Assessment and Management of7 Clinical Problems 10e c. Check for the presence of bowel sounds and flatulence by UAP d. Care of a patient with diabetesby RN who usually works on the pediatric unit ANS: C Assessment requiresRN education and scope of practice and cannot be delegated to an LPN/LVN or UAP. The other assignments made by the RN are appropriate. DIF: Cognitive Level: Apply (application) REF: 15 OBJ: Special Questions: Delegation TOP: NursingProcess: Planning MSC: NCLEX: Safe and Effective Care Environment 13. Which task is appropriate for the nurse to delegate to a licensedpractical/vocational nurse (LPN/LVN)? a. Complete the initial admission assessment and plan of care. b. Document teaching completed before a diagnostic procedure. c. Instruct a patient about low-fat, reduced sodium dietary restrictions. d. Obtain bedside blood glucose on a patient before insulin administration. ANS: D The education and scope of practice of the LPN/LVN include activities such as obtaining glucose testing using a finger stick. Patient teaching and the initial assessment and development of the plan of care are nursing actions that require registered nurse education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 15 OBJ: Special Questions: Delegation TOP: NursingProcess: Planning MSC: NCLEX: Safe and Effective Care Environment 14. A nurse is assigned as a case manager for a hospitalized patient with a spinal cord injury. The patient can expect the nurse functioning in this role to performwhich activity? a. Care for the patient during hospitalization for the injuries. b. Assist the patient with home care activities during recovery. c. Determine what medical care the patient needs for optimal rehabilitation. d. Coordinate the servicesthat the patient receivesin the hospital and at home. ANS: D The role of the case manager is to coordinate the patients care through multiple settings and levels of care to Test Bank - Medical-Surgical Nursing: Assessment and Management of8 Clinical Problems 10e allow the maximal patient benefit at the least cost. The case manager does not provide direct care in either the acute or home setting. The case manager coordinates and advocates for care but does not determine what medical care is needed; that would be completed by the health care provider or other provider. DIF: Cognitive Level: Apply (application) REF: 15 TOP: NursingProcess: Implementation MSC: NCLEX: Safe and Effective Care Environment 15. The nurse is caring for an older adult patient who had surgery to repair a fractured hip. The patient needs continued nursing care and physical therapy to improve mobility before returning home. The nurse will help to arrange for transfer of this patient to which facility? a. A skilled care facility b. A residential care facility c. A transitional care facility d. An intermediate care facility ANS: C Transitional care settings are appropriate for patients who need continued rehabilitation before discharge to home or to long-term care settings.The patient is no longer in need of the more continuous assessment and care given in acute care settings.There is no indication that the patient will need the permanent and ongoing medical and nursing services available in intermediate or skilled care. The patient is not yet independent enough to transfer to a residential care facility. DIF: Cognitive Level: Apply (application) REF: eTable 1-1 | eTable 1-2 | eTable 1-3 TOP: NursingProcess: Planning MSC: NCLEX: Safe and Effective Care Environment 16. A home care nurse is planning care for a patient who has just been diagnosed with type 2 diabetesmellitus. Which task is appropriate for the nurse to delegate to the home health aide? a. Assist the patient to choose appropriate foods. b. Help the patient with a daily bath and oral care. c. Check the patients feet for signs of breakdown. d. Teach the patient how to monitor blood glucose. ANS: B Assisting with patient hygiene is included in home health-aide education and scope of practice. Assessment of the patient and instructing the patient in new skills, such as diet and blood glucose monitoring, are complex skills that are included in registered nurse education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 14 Test Bank - Medical-Surgical Nursing: Assessment and Management of9 Clinical Problems 10e OBJ: Special Questions: Delegation TOP: NursingProcess: Implementation MSC: NCLEX: Safe and Effective Care Environment 17. The nurse is providing education to nursing staff on quality care initiatives. Which statement would be the most accurate description of the impact of health care financing on quality care? a. Hospitals are reimbursed for all costs incurred if care is documented electronically. b. Payment for patient care is primarily based on clinical outcomes and patient satisfaction. c. If a patient develops a catheter-related infection, the hospital receivesadditional funding. d. Because hospitals are accountable for overall care, it is not nursings responsibility to monitor care delivered by others.