GIDDENS CONCEPTS FOR NURSING PRACTICE, 3RD EDITION

a. Continence assessment, gait assessment, feeding assessment, dressing assessment, transfer assessment N b. Height, weight, body mass index (BMI), vital signs assessment c. Sleep assessment, energy assessment, memory assessment, concentration assessment d. Health and well-being, amount of community volunteer time, working outside the home, and ability to care for family and house ANS: A Functional impairment, disability, or handicap refers to varying degrees of an individual’s inability to perform the tasks required to complete normal life activities without assistance. Height, weight, BMI, and vital signs are part of a physical assessment. Sleep, energy, memory, and concentration are part of a depression screening. Healthy, volunteering, working, and caring for family and house are functional abilities, not performance. OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the patient’s functional ability. What question would be the most appropriate? a. “Are you able to shop for yourself?” b. “Do you use a cane, walker, or wheelchair to ambulate?” c. “Do you know what today’s date is?” d. “Were you sad or depressed more than once in the last 3 days?” ANS: B “Do you use a cane, walker, or wheelchair to ambulate?” will assist the nurse in determining the patient’s ability to perform self-care activities. A nutritional health risk assessment is not the functional assessment. Knowing the date is part of a mental status exam. Assessing sadness is a question to ask in the depression screening. OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 4. The nurse is developing an interdisciplinary plan of care using the Roper-Logan-Tierney Model of Nursing for a patient who is currently unconscious. Which interventions would be most critical to developing a plan of care for this patient? a. Eating and drinking, personal cleansing and dressing, working and playing b. Toileting, transferring, dressing, and bathing activities c. Sleeping, expressing sexuality, socializing with peers d. Maintaining a safe environment, breathing, maintaining temperature ANS: D The most critical aspects of care for an unconscious patient are safe environment, breathing, and temperature. Eating and drinking are contraindicated in unconscious patients. Toileting, transferring, dressing, and bathing activities are BADLs. Sleeping, expressing sexuality, and socializing with peers are a part of the Roper-Logan-Tierney Model of Nursing; however, these are not the most critical for developing the plan of care in an unconscious patient. OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The home care nurse is trying to determine the necessary services for a 65-year-old patient who was admitted to the home care service after left knee replacement. Which tool is the best for the nurse to utilize? N a. Minimum Data Set (MDS) b. Functional Status Scale (FSS) c. 24-Hour Functional Ability Questionnaire (24hFAQ) d. The Edmonton Functional Assessment Tool ANS: C The 24hFAQ assesses the postoperative patient in the home setting. The MDS is for nursing home patients. The FSS is for children. The Edmonton is for cancer patients. OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 6. The nurse is assessing a patient’s functional abilities and asks the patient, “How would you rate your ability to prepare a balanced meal?” “How would you rate your ability to balance a checkbook?” “How would you rate your ability to keep track of your appointments?” Which tool would be indicated for the best results of this patient’s perception of their abilities? a. Functional Activities Questionnaire (FAQ) b. Mini Mental Status Exam (MMSE) c. 24hFAQ d. Performance-based functional measurement ANS: A The FAQ is an example of a self-report tool which provides information about the patient’s perception of functional ability. The MMSE assesses cognitive impairment. The 24hFAQ is used to assess functional ability in postoperative patients. Performance-based tools involve actual observation of a standardized task, completion of which is judged by objective criteria. OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance MULTIPLE RESPONSE 1. A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse is assessing the patient’s risk for falls so that falls prevention can be implemented if necessary. Select all the risk factors that apply from this patient's history and physical. (Select all that apply.) a. Being a woman b. Taking more than six medications c. Having hypertension d. Having cataracts e. Muscle strength 3/5 bilaterally f. Incontinence ANS: B, D, E, F Adverse effects of medications can contribute to falls. Cataracts impair vision, which is a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine or stool increases risk for falls. Men have a higher risk for falls. Hypertension itself does not contribute to falls. Taking meNdications to treat hypertension that may lead to hypotension and dizziness is a fall risk. Dizziness does contribute to falls. OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential Concept 03: Family Dynamics Giddens: Concepts for Nursing Practice, 3rd Edition MULTIPLE CHOICE 1. The most appropriate initial nursing intervention when the nurse notes dysfunctional interactions and lack of family support for a patient would be to a. enforce hospital visiting policies. b. monitor the dysfunctional interactions. c. notify the primary care provider. d. role model appropriate support. ANS: D Nurses can, at times, role model more appropriate interactions or provide suggestions for improving communication and interactions among family members. If the nurse determines that the number of visitors has a negative impact on the patient, hospital policy may be to limit visitors, but that would not be the initial action. Monitoring the dysfunctional interactions would not be an adequate response. The primary care provider should certainly be notified, but that would not be the initial response. OBJ: NCLEX Client Needs Category: Psychosocial Integrity 2. The nurse caring for a patient would identify a need for additional interventions related to family dynamics when a. extended family offers to help. b. family members express cNoncern. c. the ill member demands attention. d. memories are shared. ANS: C It is not uncommon for the ill family member to become demanding and indicate that they deserve special treatment and care, and the supportive family may need assistance in understanding the dynamics of the illness in order to continue to be supportive. Offers from extended family to help can be indicative of positive dynamics. Concern expressed by family members can be indicative of positive dynamics. Sharing of family memories can be indicative of positive dynamics. OBJ: NCLEX Client Needs Category: Psychosocial Integrity 3. Two women have an established long-term relationship and are attending parenting classes in anticipation of finalizing adoption of a baby. The nurse identifies them as which type of family? a. Cohabiting b. Nuclear c. Same-sex d. Single parent ANS: C This family would be considered a same-sex family. Cohabiting refers to a couple who live together with no legal bond. Nuclear refers to the traditional male and female core family with one or more children. Single parent refers to a family with one adult and one or more children. OBJ: NCLEX Client Needs Category: Psychosocial Integrity 4. The nurse identifies the family with a child graduating from college as having which effect on the family life cycle? a. Minimal impact b. Considered to be a negative impact on the family unit c. Leads to role confusion d. Expectation of role change ANS: D The family life cycle developmental theory focuses on the growth and development of changes in role relationships during transitional periods. A child graduating from college is an example of a transition which requires a role change. As this is a transition, one would expect to see a change so minimal impact would not be expected. Graduation does not imply that it will be a negative change on the family life cycle or lead to role confusion. OBJ: NCLEX Client Needs Category: Psychosocial Integrity 5. When reviewing the purposes of a family assessment, the nurse educator would identify a need for further teaching if the student responded that family assessment is used to gain an understanding of which aspect of the family? a. Development N b. Function c. Political views d. Structure ANS: