Test Bank For Focus on Adult Health: Medical-Surgical Nursing 2nd Edition By Linda Honan |All Chapters |100% A+ & LATEST

Test Bank For Focus on Adult Health: Medical-Surgical Nursing 2nd Edition By Linda Honan |All Chapters |100% A+ & LATEST TEST BANK Chapter 1 The nurse’s Role in Adult Health Nursing MULTIPLE CHOICE 1.The nurse ensures that a client’s beds pace is neat and clean with the call light within easy reach. The nurse is focusing on which nursing theorist who realized the importance of the environment for care? 1. Florence Nightingale 2. Sister Callista Roy 3. Dorothea Orem 4. Martha Rogers ANS: 1 Florence Nightingales theory focused on the environment for care. Sister Callista Roys model is based in systems theory and an individual’s ability to adapt. Dorothea Orems model is the selfcare deficit theory. Martha Rogers model is the science of unitary human beings. PTS:1DIF: Apply REF: Emergence of Contemporary Nursing in the United States 2.The nurse is instructing a client on self-administration of insulin so that the client will not need a health care provider to do this activity. The nurse is implementing which of the following aspects of Virginia Hendersons theory of nursing? 1. A caring relationship 2. Helping the client achieve independence from the nurses’ assistance as quickly as possible 3. Integration of objective and subjective data 4. Application of critical thinkingANS: 2 3. Virginia Hendersons theory of nursing is to help people achieve health or a peaceful death so that they can beindependent from the nurses’ assistance as quickly as possible. A caring relationship, integration of objectiveand subjective data, and application of critical thinking areincluded in the American Nurses Associations essential features of professional nursing. PTS:1DIF: Analyze REF: Emergence of Contemporary Nursing in the United States A. client tells the nurse that he has an HMO for his health insurance. The nurse understands that the purpose of this type of health plan is to: 1. ensure payment is made to Medicare for services rendered. 2. maximize the utilization of health care resources. 3. efficiently manage costs while providing quality care. 4. focus on the illness when providing care. ANS: 3 Health maintenance organizations (HMOs) were created to efficiently manage health care costs while providing quality care. An HMO is a type of managed care plan with the goal of providing wellness care and not focusing on the illness during the provision of care. HMOs do not ensure payment is made to Medicare for services rendered. HMOs also do not maximize the utilization of health care resources but rather uses financial incentives to decrease care costs. PTS: 1 DIF: Understand REF: Cost of Care 4.A client tells the nurse that he does not have a primary care physician but rather makesan appointment with a doctor who specializes in the area in which he is experiencing a problem. The nurse realizes this client is at risk for which of the following? 1. Fragmented care 2. Overpayment of services 3. Inability to sustain health 4. Finding an appropriate general practitioner ANS: 1 In the 1980s, the close and trusting relationship between an individual and the individual’s physician waned and was replaced by acquaintances with specialists based upon particular healthcare problems. These episodes of care cause fragmentation of care. The client who utilizes specialists is not at risk for overpayment of services, the inability to sustain health, orfinding an appropriate general practitioner. PTS:1DIF: Analyze REF Providers of Care 5.The nurse is attending a master’s degree program in efforts to be educationally prepared toserve as a hospital leader. The nurse realizes that this educational preparationwill: 1. hinder the nurses’ ability to work with physicians. 2. be viewed as not supporting the profession of nursing by other nurses. 3. ensure the nurse is biased towards clinician’s interests. prepare the nurse to serve as strong clinical support with the ability to integrate business and 4. caring. ANS: 4 The nurse is attending an educational program to serve as a hospital leader. This education will prepare the nurse to serve as strong clinical support with the ability to integrate business and caring. This education will not hinder the nurse’s ability to work with physicians. This education will not be viewed as unsupportive to the profession of nursing. The education will ensure that the nurse is not biased towards clinician’s interests. PTS: 1 DIF: Analyze REF: Clinical Systems Leadership 6.A client tells the nurse that all hospitals care about is doing the minimum for a client regardless of the outcome. Which of the following should the nurse respond to this client? 1. It does feel like that sometimes. 2. Health insurance companies have caused this problem. 3. The doctors will get paid regardless of the clients’ outcomes. There are quality programs in place to make sure clients receive the best quality of care regardless 4. of the cost. ANS: 4 In response to concerns about safety and quality of care voiced by clients and providers, total quality management and continuous quality improvement programs were initiated. These programs ensure society that cost management is not compromising safety or quality. This is what the nurse should respond to the client. The other choices do not address the clients concerns nor do they explain quality management programs. PTS: 1 DIF: Apply REF: Quality Measure Shift 7. The nurse is providing care at a time that is the most beneficial to the client. The nurse is implementing which of the following Joint Commission Dimensions of Quality Performance? 1. Safety 2. Timeliness 3. Efficiency 4. Availability ANS: 2 The dimension of timeliness means the degree in which interventions are provided at the most beneficial time to the client. Safety means the degree in which the risk of an intervention and risk to the environment are reduced for both client and health care provider. Efficiency means the degree in which care has the desired effect with a minimum of effort, waste, or expense. Availability means the degree in which appropriate interventions are available to meet theclients’ needs. PTS:1DIF: Analyze REF: Box 1-1 Joint Commission Dimensions of Quality Performance 8. The nurse is providing care while adhering to safety as a Joint Commission Dimension of Quality Performance. Which of the following did the nurse provide to the client? 1. Using a needleless device when providing intravenous medications 2. Keeping the side rails of the bed in the down position after providing a pain medication to a client 3. Having the client sit in a wheelchair with the wheels in the unlocked position 4. Placing cloth towels over a spill in the room of an ambulatory client ANS: 1 The dimension of safety means the degree in which the risk of an intervention and risk to the environment are reduced for both client and health care provider. The nurse who uses a needleless device when providing intravenous medications is adhering to this dimension. Keeping the side rails in the down position is not a safe practice. Having a client sit in a wheelchair with the wheels unlocked is not a safe practice. Placing cloth towels over a spill inthe room of an ambulatory client is not a safe practice. PTS:1DIF: Analyze REF: Box 1-1 Joint Commission Dimensions of Quality Performance 9. The nurse is planning and providing care while adhering to the American Nurses Association definition of professional nursing. Which of the following does the nurse include when implementing client care? 1. Follows the NANDA nursing diagnoses process 2. Integrates objective and subjective data 3. Respects cultural diversity of peers 4. Acknowledges the experience and training of physicians ANS: 2 The American Nurses Association acknowledges six essential features of professional nursing. These include: 1) a caring relationship, 2) attention to the full range of human health and illness experiences, 3) integrates objective and subjective data, 4) applies scientific knowledge and critical thinking, 5) advances nursing knowledge through scholarly inquiry, and 6) promotes social justice. The nurse integrating objective and subjective data is implementing one of the six essential features of professional nursing. The other choices are not essential features of professional nursing. PTS:1DIF: Analyze REF:Emergence of Contemporary Nursing in the United States 10. The nurse has shifted her practice from an illness focus to a health focus. Which of thefollowing has this nurse implemented? 1. Standardized care plans 2. Critical pathways 3. Instructing a client on relaxation techniques to aid with sleep 4. Holding around-the-clock medication when a client is asleep ANS: 3 The use of client education as a strategy to attain and maintain the potential for health is an example of the shift of care from an illness focus to a health focus. The nurse instructing a client on relaxation techniques to aid with sleep is implementing a health focus of care. The other choices do not support the shift from an illness focus to a health focus. PTS: 1 DIF: Analyze REF: Leadership 11. A client is admitted with a highly communicable disease. The nurses do not want to participate in the care of this client. Which of the following should be done to ensure the clientreceives the highest quality of care? 1. Adhere to strict standard precautions. 2. Plan to have the client transferred to another health care organization. 3. Ask the physician if the client can be cared for in the home. 4. Suspend the nurses without pay who refuse to care for the client. ANS: 1 When providing care in a highly global environment, the risks of communicable diseases increases. In the event that a client is admitted with a highly communicable disease and the nurses are fearing for their own health and safety, the only safe approach is to ensure all staff adhere to strict standard precautions. The other choices do not ensure that the client will receive the highest quality of care. The nurses must learn emotional intelligence and resolve issues underfire. PTS:1DIF:AnalyzeREF:Globalization 12. The nurse has been an employee of an organization for 2 years and is considering a jobchange. Which of the following does this nurses plan suggest to any future employers? 1. The nurse moves to other jobs too frequently. 2. The nurse is inflexible. 3. The nurse is searching for a more challenging environment with career opportunities. 4. The nurse is willing to sacrifice home and personal life for a job. ANS: 3 At one point in time, job changes every 2 or 3 years was considered a red flag for employers. This does not hold true today. The nurse who changes jobs every 2 or 3 years is interested in career advancement and success. Creativity is valued and opportunities are desired. Moving toanother job in 2 to 3 years does not mean the nurse is inflexible. The new generation of nursesdoes not want to sacrifice home and personal life for a job. PTS: 1 DIF: Analyze REF: Care Delivery Models 13. The nurse is experiencing pain and fatigue in both arms when using the computer to document client care. Which of the following can the nurse do to reduce these symptoms? 1. Refuse to use the computer and document using a pen and paper. 2. Stand up when using the computer. 3. Adjust the keyboard and chair to reduce the pressure on the wrists and arms. 4. Ask another nurse to input the information for client care activities. ANS: 3 Ergonomic hazards are increasing with health care providers and nurses in particular. Many of these hazards are because of the implementation of computers for documentation. The nurse should adjust the keyboard and chair to reduce the pressure on the wrists and arms when documenting with the computer. The nurse cannot refuse to use the computer. Standing up maynot reduce the nurse’s symptoms. The nurse cannot legally ask another nurse to document clientcare. PTS:1DIF:ApplyREF:Ergonomic Hazards MULTIPLE RESPONSE 1.The nurse is planning care for a client and reviewing appropriate educational materials to use for discharge instructions. Which domains of nursing is this nurse implementing? (Select all thatapply.) 1. Nursing process 2. Clinical practice 3. Education 4. Literature 5. Administration 6. Research ANS: 2, 3 The four domains of nursing are: 1) clinical practice, 2) education, 3) administration, and 4) research. When the nurse plans care for a client, the domain being implemented is clinical practice. When reviewing appropriate educational materials to use for discharge instructions, thedomain being implemented is education. The nurse is not utilizing the domains of research or administration. Nursing process and literature are not domains of nursing. PTS:1DIF: Apply REF:Emergence of Contemporary Nursing in the United States 2.The nurse suspects that another health care colleague may be chemically dependent whenwhich of the following is assessed? (Select all that apply.) 1. Prolonged work breaks 2. Clinical care omissions 3. Mood stability 4. Extraordinary accomplishments 5. Heavy use of fragrances 6. Inability to recall recent events ANS: 1, 2, 4, 5, 6 Clues of possible chemical dependency include tardiness, late sick calls, frequent or prolonged work breaks, inability to recall recent events, heavy use of fragrances, clinical care omissions or errors, patient complaints or requests for a change in care provider, mood instability, and extraordinary accomplishments. Mood stability is not a characteristic of a colleague who is experiencing chemical dependency. PTS:1DIF: Apply REF:Box 1-6 Clues to the Possibility of Chemical Dependence 3.The nurse is a member of a health care team that includes a physician and other health care providers. These providers work together to ensure the client is relieved of suffering, has diseases cured, and experiences enhanced health and performance. Which of the following arethe levels of care represented by this team of health care providers? (Select all that apply.) 1. Sustain life 2. Maintain health 3. Regain health 4. Minimize injury 5. Maximize cost 6. Attain enhanced health ANS: 1, 2, 3, 6 The medical teams mission is to relieve suffering and cure disease. This involved the three levelsof care: 1) sustain life, 2) regain health, and 3) maintain health. Once the shift toward health careoccurred, the fourth level of attaining enhanced health was added. Minimize injury and maximize cost is not a level of care. PTS:1DIF:AnalyzeREFroviders of Care 4.A client tells the nurse that she is disappointed that her employer is offering a health maintenance organization for a health care benefit. Which of the following can the nurse use asresponses to the client as advantages of this type of health plan? (Select all that apply.) 1. Since there is a nursing shortage, clients need to stay out of the hospital. 2. This type of plan provides wellness care at a minimal cost to keep people healthy. 3. This type of plan helps clients avoid illnesses with high costs. 4. An HMO standardizes diagnostic and treatment decisions across the nation. 5. This type of plan ensures coordinated services from wellness to death. This type of plan costs as much as the traditional plans, but the insurance companies get the extra 6. money from premiums. ANS: 2, 3, 4, 5 There are several missions and visions of managed care. The first is to provide wellness care at aminimal cost to keep people healthy and avoid providing illness care at a higher cost. Another mission is to standardize diagnostic and treatment decisions across the nation. Managed care emphasizes the delivery of coordinated services across the care spectrum from wellness to deathand uses financial incentives to decrease length of stay and achieve cost efficiency. Managed care was not implemented to address the nursing shortage. This type of plan does not cost as much as a traditional health plan nor do the insurance companies receive the extra money from premiums. PTS: 1 DIF: Apply REF: Cost of Care 5. The nurse has incorporated several criteria that are essential for being a memberof aprofession. Which of the following has this nurse done? (Select all that apply.) 1. Has passed the licensure examination 2. Works regularly scheduled shifts 3. Completed a bachelors degree in nursing 4. Limits absences from work 5. Joined the American Nurses Association 6. Reads evidenced-based information to incorporate into planning client care ANS: 1, 3, 5, 6 There are seven essential criteria for a profession. The nurse has incorporated four of these criteria by passing the licensure examination, the nurse has implemented a code of ethics; by completing a bachelors degree in nursing, the nurse has been educated in an institution of highereducation; by joining the American Nurses Association and reading evidenced-based information, the nurse is affiliated with a professional association that promotes and ensures quality practice. Working regularly scheduled shifts and limiting absences from work are not essential criteria for a profession. Chapter 2 Health Education and Health Promotion MULTIPLE CHOICE 1.A client is reviewing a videotape without the assistance of the nurse for instruction. The type ofteaching strategy this client is using is considered: 1. demonstration. 2. slides. 3. programmed instruction. 4. discussion. ANS: 3 Programmed instruction is often referred to as canned presentation and is intended for usewithout the nurse. Demonstration, slides, and discussion require a nurse to be present. PTS: 1 DIF: Analyze REF: Teaching Strategies: Programmed Instruction 2. The nurse is instructing a client regarding food safety, injury prevention, and occupationalhealth. Which of the following Healthy People 2010 objectives is the nurse instructing the client? 1. Promote healthy behaviors 2. Promote healthy and safe communities 3. Improve systems for personal health and public health 4. Prevent and reduce diseases and disorders ANS: 2 This objective addresses instruction that focuses on the health and safety of communities such asfood safety, prevention of injury, and occupational health. Promoting healthy behaviors would include weight reduction and smoking cessation. Improve systems for personal health and publichealth would include immunization programs. Prevent and reduce diseases and disorders would include instruction on screening programs, physician visits, and routine health maintenance care. PTS: 1 DIF: Analyze REF: Health Promotion on a Global Level 3.A client has inadequate resources and impairment of personal support systems. Which nursingdiagnosis would apply to this patient? 1. Noncompliance 2. Deficient knowledge 3. Ineffective health maintenance 4. Health-seeking behavior ANS: 3 Defining characteristics for ineffective health maintenance includes impairment of personal support systems, observed inability to take responsibility for meeting basic health practices, demonstrated lack of knowledge, failure to recognize important symptoms reflective to alteredhealth status, lack of health-seeking behaviors, and inadequate resources. Inadequate resourcesand impairment of personal support systems would not support the nursing diagnoses of Noncompliance, Deficient Knowledge, or Health-Seeking Behavior. PTS:1DIF:Apply REF: Box 3-3 Defining Characteristics for Ineffective Health Maintenance 4. While planning care for a client, the nurse identifies content that would address the clients diagnosis of Deficient Knowledge. The nurse will ensure time is allocated for client instruction because: 1. the client cannot be discharged without it. 2. it is a legal component of the nursing process. 3. it is a nice thing to do for a client. 4. the physician has written an order for instruction. ANS: 2 Patient education is a legal component of the nursing process that was identified in the PatientsBill of Rights. Patient education is a necessary function of nursing care. The client could be discharged without receiving instructions. Education is not done because it is a nice thing to dofor a client. Client education does not necessitate a physicians order. PTS:1DIF:ApplyREFatient Education 5.The nurse is engaged in an information teaching session with a client. Which of the followingwould be appropriate to instruct during an informal teaching session? 1. Expected effects of a new medication 2. Instruction on leg exercises to be used after surgery 3. How to use an incentive spirometer 4. Diet and medications to manage a new diagnosis of diabetes mellitus ANS: 1 Instruction can be either informal or formal. Informal instruction occurs intermittently and frequently during the course of client care. These instructions are simple, relate to the disease process, and answer client questions. Providing the expected effects of a new medication is a type of information instruction. Formal instructions are deliberate with specific goals and an evaluation process. Instructing on postoperative leg exercises, the use of an incentive spirometer, and diet and medications to manage a new health diagnosis are all examples of formal instruction. PTS: 1 DIF: Apply REF: Formal and Informal Patient Education 6.The nurse is planning a presentation to a group of senior citizens as part of a wellness program.Which of the following topics would be appropriate for the nurse to instruct this client population? 1. Importance of taking medications as prescribed 2. Ways to follow a physicians treatment plan 3. Ease of changing an abdominal dressing 4. Strategies to reduce salt in the diet and increase activity ANS: 4 Some educational topics can be instructed in a group setting. Strategies to reduce salt intake andincrease activity are two topics that would be appropriate for a group instruction. The other choices are appropriate for individual instruction. PTS: 1 DIF: Apply REF: Individual and Group Patient Education 7.A client is considering several changes in personal habits to improve his health. Which of thefollowing critical thinking strategies can the nurse use to help this client? 1. Ask the client to identify his goals to improve his health. 2. Remind the client that the physician has to approve all changes in his health improvement plan. 3. Suggest the client wait until he is discharged before planning to make personal habit changes. 4. Recommend that immediate changes are made to confuse the bodys responses. ANS: 1 Critical thinking is a self-directed, deliberate, self-corrected, results-oriented reasoning process that strives to problem-solve client care issues by combining logic, intuition, and creativity. The goal of critical thinking is to assist clients to use what they already know and work with the client to make changes that they identify through self-discovery. Asking the client to identify S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? goals to improve health is one strategy that the nurse can use when implementing critical thinking with client education. The other choices do not support critical thinking with clienteducation. PTS: 1 DIF: Apply REF: Critical Thinking and Patient Education 8.A client has several identified learning needs. Which of the following should the nurse assessprior to planning instruction for this client? 4. Programmed instruction ANS: 3 Demonstration is a practical strategy used when teaching a new skill such as self-injection of insulin. Discussion is an exchange of information and does not provide an opportunity for the client to learn a new skill. Role playing allows the client to apply knowledge in a simulated 1. Home address 2. Clients learning style 3. Living arrangements 4. Financial resources ANS: 2 Areas to include in the assessment of a clients learning needs include the clients ability to learn,style of learning, information about a health condition, cultural background, and other information as required. The clients home address, living arrangements, and financial resourcesare not a part of a clients assessment of learning needs. PTS: 1 DIF: Apply REF: Patient Education and the Nursing Process 9.Which of the following teaching strategy would best support a client who needs to learn how toself-administer insulin injections? 1. Discussion 2. Role-playing 3. Demonstration S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? environment. This strategy does not support learning a new skill. Programmed instruction is intended for use without the nurse. This strategy does not support learning a new skill.PTS:1DIF:ApplyREF:Teaching Strategies 10.A client tells the nurse that she uses audio CDs in her vehicle when driving to and from workto keep current with educational requirements for her job. The nurse would assess thisclient as preferring which type of learning style? 3. Self-image 4. Maintenance ANS: 2 1. Auditory 2. Visual 3. Kinesthetic 4. Anesthetic ANS: 1 The client who learns by hearing prefers an auditory learning style. The client who learns by reading uses a visual learning style. The client who learns by doing or touching is using a kinesthetic learning style. Anesthetic is not a type of learning style but rather a medication used for surgery. PTS:1DIF:AnalyzeREF:Teaching Strategies 11. The nurse is attempting to instruct a client on ways to eliminate smoking. The client tells the nurse that he has no health problems because of smoking and does not understand why he needs to quit. Which of the following is interfering with the nurses ability to instruct the client in healthpromotion behaviors? 1. Motivation 2. Perception S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? Perception is a clients sense and understanding of his current health status. If the client does notperceive a problem with current health maintenance activities, the nurse should not intervene at this time. Motivation is the internal drive or external stimulus to perform an action or thought. Maintenance is practicing a new behavior for an extended period of time. The clients self-imageis not interfering with the nurses ability to instruct the client in health promotion behaviors. PTS: 1 DIF: Analyze REF: Characteristics of Health Maintenance 12.The nurse is planning instruction to support health promotion behaviors. Which of thefollowing clients would benefit the most from these instructions? 1. 60-year-old client diagnosed with type 2 diabetes mellitus 2. 83-year-old client with hypertension 3. 75-year-old client recovering from a total hip replacement 4. 35-year-old client desiring to begin an exercise program ANS: 4 Health promotion interventions are for healthy individuals and are intended to maximize their health status. The 35-year-old client who wants to begin an exercise program would benefit fromhealth promotion instruction. The other clients are considered to be ill and would not benefit from instruction in health promotion behaviors. PTS:1DIF:AnalyzeREF:Health Promotion 13.The nurse and client have determined that goals established for health maintenance behaviors have not been achieved. In which step of the nursing process are the nurse and client working atthis time? 1. Evaluation 2. Assessment 3. Planning 4. Implementation ANS: 1 S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? The nurse and client together measure how well the client has achieved the goals for health maintenance in the plan of care. Goals that have not been achieved are evaluated and adjusted. This is an activity done during the evaluation step of the nursing process. Evaluationof goals isnot done during the assessment, planning, or implementation steps of the nursing process. PTS: 1 DIF: Analyze REF: Evaluation of Outcomes MULTIPLE RESPONSE 1.A client is demonstrating behaviors consistent with normal health maintenance. Which of thefollowing has this client demonstrated? (Select all that apply.) 1. Motivation 2. Health encouragement 3. Readiness 4. Maintenance 5. Health activities 6. Perception ANS: 1, 4, 6 The three characteristics of health maintenance are: 1) perception, 2) motivation, and 3) maintenance. Health encouragement, readiness, and health activities are not behaviors consistentwith normal health maintenance. PTS: 1 DIF: Analyze REF: Characteristics of Health Maintenance 2. The nurse is planning an instructional session with a client. When planning this session, thenurse should incorporate which teaching/learning principles? (Select all that apply.) 1. Assessment of how the client organizes knowledge 2. Motivation and self-efficacy 3. Setting goals S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? 4. Developmental level of the client 5. Time management 6. Self-engagement Characteristics of critical thinking with client education include organized and clearly explained with the use of examples, aimed at positive health outcomes, is knowledge-oriented, and is focused on making moral and ethical decisions. Critical thinking is not vague nor task-oriented. PTS: 1 DIF: Analyze REF: Table 3-1 What is Critical Thinking? ANS: 1, 2, 3, 4, 6 Principles of the teaching/learning process include how knowledge is organized by the learner, self-motivation and self-efficacy, setting measurable goals, developmental level of the learner,and self-engagement. Time management is not a teaching/learning principle. PTS:1DIF:Apply REF: Patient Education and Teaching/Learning Principles 3. The nurse is planning client instruction interventions to support critical thinking. Which of thefollowing are characteristics of critical thinking in the client education process? (Select all that apply.) 1. Organized 2. Clearly explained with examples 3. Vague 4. Task-oriented 5. Knowledge-oriented 6. Moral and ethically focused ANS: 1, 2, 5, 6 S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? 4.The nurse is utilizing the technique of motivational interviewing to instruct a client on ways tolimit alcohol intake. Which of the following are techniques used when implementing motivational interviewing? (Select all that apply.) 1. Express empathy 2. Develop discrepancy 4. Skin examination 5. Application of hydrocortisone cream for a skin disorder 6. Elevating edematous lower extremities 3. Avoid arguing 4. Roll with resistance 5. Support self-efficacy 6. Contract for goal achievement ANS: 1, 2, 3, 4, 5 Motivational interviewing has five specific techniques: 1) expressing empathy, 2) developing discrepancy, 3) avoiding argument, 4) rolling with resistance, and 5) supporting self-efficacy. Contracting for goal achievement is not a technique of motivational interviewing. PTS: 1 DIF: Apply REF: Motivational Interviewing 5.Which of the following self-examination techniques is a health maintenance behavior for thenurse to instruct a client? (Select all that apply.) 1. Breast self-examination 2. Capillary blood glucose testing 3. Testicular self-examination S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? ANS: 1, 3, 4 Physical self-examination is a health maintenance behavior that does not require any special equipment but requires proper instruction on the correct procedure. Examples of selfexaminations that a nurse can instruct a client include breast self-examination, testicular selfexamination, and skin examination. Capillary blood glucose testing needs the use of a glucometer. Application of hydrocortisone cream is a medication used for a diagnosed skin disorder. Elevating edematous lower extremities is an intervention for a peripheral vascular or cardiac disorder. Chapter 3 Chronic Illness and End-of-Life Care MULTIPLE CHOICE 1.The nurse believes that a client is eligible as a participant for The National Hospice Reimbursement Act of 1986. This act mandated that: 1. clients with terminal illnesses are reimbursed. 2. a physician must order hospice to be reimbursed. 3. to receive reimbursement that client must be eligible for Medicare. to receive benefits, the physician must certify that the client has a limited life expectancy of 6 4. months or less. ANS: 4 The Medicare hospice benefit is a reimbursement benefit for those with a prognosis of 6 monthsor less to live (certified by a physician). The act does not mandate reimbursement to clients withterminal illnesses, physicians do not have to order hospice for reimbursement, nor does a client have to be eligible for Medicare for hospice eligibility. PTS: 1 DIF: Analyze REF: History and Overview of Hospice Care 2. After a Native American client has died, the family begins the practice of purifying the body. The nurse realizes that the deceased client may stay with the family for what period of time? 1. 12 hours 2. 24 hours S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? 3. 36 hours 4. 48 hours ANS: 3 Native Americans believe that the soul departs from the body 36 hours after death. The family may want the body to remain at the place of death for this period. The other choices are incorrectlengths of time according to Native American culture. PTS:1DIF:Analyze REF: Table 7-1 Cultural Considerations Related to Dying 3.A client is receiving care for symptoms; however, the treatment will not alter the course of thedisease. This client is receiving which type of care? 1. Hospital-based 2. Managed 3. Palliative 4. Therapeutic ANS: 3 Palliative care, or comfort care, is directed at providing relief to a terminally ill client through symptom and pain relief. The goal is not curative. Care for symptoms that will not alter the course of the disease does not need to be provided in the hospital. Managed care is guided through the direction of a primary care physician. Therapeutic is a type of care that focuses on a specific treatment for a health problem. PTS: 1 DIF: Analyze REF: Overview of Palliative Care 4.A client diagnosed with a terminal illness is receiving an opioid/acetaminophen combinationfor pain control. The nurse realizes this client is being managed at which step of the World Health Organization approach to pain management? 1. Step 1 2. Step 2 S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? 3. Step 3 4. Step 4 ANS: 2 The World Health Organization approach to pain management involves three steps. Step 1:Clients are treated with around-the-clock doses of nonopioids. Step 2: The use of opioid/acetaminophen combinations are used to treat mild to moderate pain. Step 3: Strongopioids are used. There is no Step 4 in the World Health Organizations approach to pain management. PTS:1DIF:Analyze REF: Figure 7-2 Conceptual Model of Ladder Approach to Pain Management 5.A dying client is surrounded by family and friends at home. The hospice nurse talks with thespouse of the dying client to ensure that everything the family needs during this time is being done. The nurse is providing support to: 1. the client. 2. the bereaved. 3. ensure compliance with the hospice rules and regulations. 4. determine if the spouse understands that the client is dying. ANS: 2 Supporting the familys rituals and cultural practices gives structure to support the bereaved through this painful process when people are vulnerable and feel off balance. The nurse is not providing support to the client. The nurse is not providing support to ensure compliance with thehospice rules and regulations. The nurse is also not providing support to determine if the spouseunderstands that the client is dying. PTS: 1 DIF: Analyze REF: Role of the Hospice and Palliative Care Nurse 6.A client of the Hispanic culture is nearing death and the family requests that the client be prepared for discharge. The nurse realizes that the reason the family and client want to return home is because: S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? 1. individuals within this culture do not trust hospital caregivers. 2. the family wants to have a spiritual healer care for the client. 3. it is bad luck to die in the hospital. 4. the spirit may get lost if the client dies in the hospital, and it will not be able to find its way home. ANS: 4 Within the Hispanic culture, the client and family may not want to die in the hospital because thespirit may get lost and will not be able to find its way home. The reason the family and client want to return home is not because of a distrust of hospital caregivers. The family may want to have a spiritual healer conduct a ceremony for the client, but this does not need to be done in thehome. Members of the Hispanic culture do not believe that it is bad luck to die in the hospital. PTS:1DIF:Analyze REF: Table 7-1 Cultural Considerations Related to Dying 7. During the period of time when a client diagnosed with a terminal illness became comatose, a health care proxy made decisions about the clients care. When the client regained consciousness a few days later, the nurse consulted whom regarding the clients ongoing care decisions? 1. The client 2. The health care proxy 3. The clients family 4. The clients physicianANS: 1 A health care proxy is in effect whenever the client is unable to communicate and ceases to be ineffect as soon as the client regains decision-making capacity. The nurse should consult with the client regarding the clients ongoing care decisions. The nurse should not consult with the health care proxy, the family, or the physician. PTS:1DIF:Apply REF: Ethics in Practice: Legal and Ethical Considerations Related to Dying S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? 8.The nurse is concerned that the spouse of a terminally ill client is experiencing AnticipatoryGrieving when which of the following is assessed? 1. Confidence in the ability to care for the ill client at home 2. Expressing anger about the clients pending death and crying throughout the day 3. Large social support system 4. Knowledge of equipment function ANS: 2 Anticipatory grieving is the intellectual and emotional responses and behaviors by which individuals work through the process of modifying self-concept based on the perception of potential loss. Anger and crying about the clients pending death are signs of Anticipatory Grieving. The other assessment findings are evidence that the spouse is accepting the caregiver role. PTS:1DIF:AnalyzeREF:Nursing Diagnoses 9.The nurse administers additional intravenous medication to a hospice client with uncontrollablepain. After receiving the additional medication, the client demonstrates apneic periods and bradycardia. Which of the following does this nurses actions suggest? 1. Euthanasia 2. Assisted suicide 3. Double effect 4. Malpractice ANS: 3 The principle of double effect means that increasing the dose of medication to achieve pain control, even if death is hastened, is ethically justified. Euthanasia is the administration of medication to purposefully cause anothers death. Assisted suicide is the practice of providing medication to a client with the intent that the client use the medication to voluntarily commit suicide. Malpractice is conducting some aspect of care that causes a client harm. PTS:1DIF:AnalyzeREF:Managing Pain S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? 10.A client with a terminal illness was ingesting morphine sulfate 10 mg by mouth every 6 hoursfor pain. To ensure that the client receives the same degree of pain control when delivering the same medication through the intravenous route, which of the following should the nurse do? 1. Provide morphine sulfate 10 mg intravenous every 6 hours. 2. Provide morphine sulfate 20 mg intravenous every 4 hours. Provide a different medication since morphine sulfate cannot be given through the intravenous 3. route. Consult a dose equivalent table to determine the dose of morphine sulfate the client will need 4. through the intravenous route. ANS: 4 Dose equivalent tables should be used by the nurse when analgesics or the routes of administration are changed. The nurse should not provide the same dosage of the medication through the intravenous route since this may be too much. Morphine sulfate can be administeredthrough the intravenous route. PTS:1DIF:ApplyREF:Managing Pain 11.A terminally ill client is experiencing nausea. Which of the following interventions can be used to help the client at this time? 1. Administer diphenhydramine (Benadryl) as prescribed. 2. Provide three regular meals. 3. Limit mouth care. 4. Restrict iced fluids. ANS: 1 Diphenhydramine (Benadryl) acts on the vomiting center in the medulla. This is the intervention that would be the most helpful to the client at this time. The client should be provided with small,frequent meals. Mouth care should be provided when necessary. Iced fluids are helpful for dry mouth. PTS:1DIF:Apply S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? REF:Managing Loss of Appetite, Constipation, Nausea, and Vomiting 12. A terminally ill client is more alert and talkative, and she is requesting specific foods to eat.The nurse should caution the family regarding the clients behavior because this could indicate: 1. total remission of the disease process. 2. final surprising rally before retreating. 3. the client is cured of the terminal illness. 4. the client was misdiagnosed. ANS: 2 Nurses should prepare the family of a terminally ill client for an occasional final surprising rallyin which the client becomes temporarily more alert and responsive before retreating. The period of alertness does not indicate total remission of the disease process, the clients being cured of theterminal illness, or the clients being misdiagnosed. PTS: 1 DIF: Apply REF: Providing Care in the Active Phase of Dying 13. The nurse is concerned that a hospice client is approaching death when which of thefollowing is assessed? 1. Respiratory rate 16 and regular 2. Blood pressure 110/60 mmHg 3. Restlessness, irritability, and anxiety 4. Periods of wakefulness are greater than periods of sleep ANS: 3 Symptoms of hypoxia include restlessness, irritability, and anxiety. Respirations of 16 and regular is a normal respiratory rate. Blood pressure of 110/60 mmHg is within normal limits. Periods of wakefulness being greater than periods of sleep is also a normal physiological finding. PTS: 1 DIF: Analyze REF: Table 7-2 Physiology of Dying MULTIPLE RESPONSE S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? 1.The nurse is discussing end-of-life wishes with a client and his family. Since the client is notsure of what type of care he wants, the nurse provides the document Five Wishes because this document provides which of the following types of information? (Select all that apply.) 1. What the client wants his loved ones to know 2. The level of comfort that the client wants 3. Comments and ideas for health care providers 4. The person designated by the client to make health care decisions 5. The kinds of medical treatment that the client wants or does not want 6. The way in which the client wants to be treated ANS: 1, 2, 4, 5, 6 The Five Wishes document helps clients express themselves if they are seriously ill and unable to communicate their wishes for themselves. It looks at all of a clients needs: medical, personal,emotional, and spiritual. Comments and ideas for health care providers is not a part of the Five Wishes document. PTS: 1 DIF: Apply REF: Role of the Hospice and Palliative Care Nurse 2.The nurse is making a home visit to a client receiving hospice care. Which of the followingsymptoms will the nurse assess in the client during the visit? (Select all that apply.) 1. Aggression 2. Anxiety 3. Confusion 4. Depression 5. Increased appetite S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? 6. Urinary continence ANS: 2, 3, 4 Common symptoms of the client receiving hospice care include pain, dyspnea, nausea, vomiting,constipation, loss of appetite, urinary urgency and incontinence, insomnia, confusion, delirium, anxiety, and depression. Aggression, increased appetite, and urinary continence are not symptoms typically assessed in a client receiving hospice care. PTS:1DIF:Apply REF:Assessment of the Patient Receiving Hospice and Palliative Care 3.The nurse, assessing pain in a client receiving hospice care, uses the ABCDE model to guide pain management. Which of the following is a part of this pain management approach? (Selectall that apply.). 1. Ask about the pain regularly. 2. Believe the patient and family in their reports of pain. 3. Confront the patient if you believe pain control was not achieved. 4. Deliver interventions only when requested. 5. Enable the patient to control her course of pain management to the greatest extent possible. 6. Utilize complementary alternative medicine approaches first. ANS: 1, 2, 5 The ABCDE model is a guide to pain management. For A, the nurse should regularly ask about pain. For B, the nurse should believe the patient and family in their reports of pain and what relieves it. For C, the nurse should choose pain control options that are appropriate for the patient. The nurse should not confront the patient about pain control since this is not therapeutic.For D, interventions should be delivered in a timely, logical, and coordinated manner and not only when requested. For E, patients and families should be empowered. Complementary alternative medicine approaches should not be used first. PTS: 1 DIF: Apply REF: Box 7-2 ABCDE Guide to Pain Assessment S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? 4.The nurse is providing a terminally ill client with morphine for pain control. In addition to this medication, which of the following can be provided to enhance analgesic effect? (Select all that apply.) 1. Antihypertensive 2. Antidepressant 4. Fear of becoming addicted to pain medication 5. Fear of side effects 6. Concern about being labeled as a bad client 3. Antibiotic 4. Antiemetic 5. Anticonvulsant 6. Corticosteroid ANS: 2, 5, 6 Adjuvant medications can enhance analgesic effect and include antidepressants, anticonvulsants,and corticosteroids. Antihypertensives, antibiotics, and antiemetics are not considered adjuvant medications for pain control. PTS:1DIF:ApplyREF:Managing Pain 5.A client with a terminal illness refuses pain medication. The nurse realizes that the client maydecline pain medication for which of the following reasons? (Select all that apply.) 1. Fear that the pain means the disease is worse 2. Insufficient health plan benefits to pay for the medication 3. Cultural background prevents the use of pain medication S - The Marketplace to Buy and Sell your Study Material 3. intravascular. Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? ANS: 1, 4, 5, 6 Client barriers to sufficient pain management include fear that the disease is worse, fear of becoming addicted to pain medication, fear of side effects, and concern about being labeled as abad client. Insufficient health plan benefits to pay for the medication and cultural background preventing the use of pain medication are not identified client barriers to sufficient pain management. Chapter 4 Fluid and Electrolyte and Acid–Base Imbalances MULTIPLE CHOICE 1.The nurse is concerned that a client can become dehydrated when which of the following isassessed? 1. History of arthritis 2. Appendicitis diagnosis 3 years ago 3. Age 30 4. Obese female ANS: 4 An adult female has 50% of body weight that is fluid. Adipose cells contain less fluid than other cells. Females have more fat cells than males. Overweight people have less body fluid than thin people. A history of arthritis and appendicitis does not predispose the client to dehydration. PTS:1DIF:AnalyzeREF:Fluid Balance 2.A client has lost a significant amount of blood. The nurse realizes that the fluid compartmentmost effected with the blood loss will be: 1. intracellular. 2. interstitial. S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? PTS:1DIF:AnalyzeREF:Fluid Balance 3.A client is diagnosed with chronic renal failure. Which of the following electrolytes should thenurse monitor for this client? 1. Hydrogen 2. Phosphorus 3. Calcium 4. Vitamin D ANS: 1 The kidneys contribute to the regulation of electrolyte levels. Two electrolytes regulated by thekidneys are hydrogen and bicarbonate. The kidneys do not directly influence a clients phosphorus level. The kidneys affect calcium by activation of vitamin D; however, the kidneys do not regulate calcium levels. Vitamin D is not an electrolyte. PTS: 1 DIF: Analyze REF: Control of Fluid and Electrolyte Balance 4.A client had a 2 kg weight loss in one day. The nurse realizes this change in weight is due to: 1. fluid loss. 4. transcellular. ANS: 3 Intravascular fluid is the fluid in the bloodstream. Intracellular fluid is the fluid inside each cell. Interstitial fluid is the fluid between cells. Transcellular fluid is the fluid outside all of the other fluid compartments, and it includes cerebrospinal fluid, joint fluid, and fluid within the gastrointestinal tract. 2. poor appetite. 3. medications. 4. bed rest. S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? ANS: 1 A weight loss of more than 0.5 kg over 24 hours generally is the result of fluid loss and not of body mass. The client would not lose 2 kgs of body weight because of poor appetite,medications, or bed rest. PTS:1DIF:Analyze REF:Fluid Imbalances: Assessment with Clinical Manifestations 5.A client has a serum sodium level of 129 mEq/L. The nurse should prepare to administer whichof the following intravenous solutions? 1. Dextrose 5% and Lactated Ringer 2. Dextrose 5% and 0.45% Normal Saline 3. 0.9% Normal Saline 4. Dextrose 5% and 0.9% Normal SalineANS: 3 Normal saline (0.9%) is commonly provided to restore extracellular fluid volume and increase sodium levels. Dextrose 5% and Lactated Ringers, Dextrose 5% and 0.45% Normal Saline, and Dextrose 5% and 0.9% Normal Saline are hypertonic solutions, and they will move water fromthe cells into the bloodstream. PTS:1DIF:Apply REF: Table 12-3 Isotonic IV Solutions; Table 12-4 Hypertonic IV Solutions 6.A client is diagnosed with fluid volume excess. Which of the following will the nurse most likely assess in this client? 1. Poor skin turgor 2. Jugular vein distention 3. Dry mouth 4. Increased heart rate S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? ANS: 2 Excess fluid in the intravascular space causes an elevation in blood pressure, and increased jugular venous pressure may be visible in distended neck veins. Poor skin turgor, dry mouth, andincreased heart rate are findings consistent with fluid volume deficit. PTS:1DIF:Apply REF:Fluid Volume Excess: Assessment with Clinical Manifestations 7.A client is demonstrating dizziness and lightheadedness upon standing. The nurse is concernedthe client is experiencing postural hypotension when which of the following is assessed? 1. Lying BP 120/70 mmHg, P 70; standing BP 116/78 mmHg, P 78 2. Lying BP 116/64 mmHg, P 62; standing BP 94/58 mmHg, P 78 3. Lying BP 130/80 mmHg, P 84; standing BP 118/72 mmHg, P 90 4. Lying BP 126/74 mmHg, P 74; standing BP 108/62 mmHg, P 84ANS: 2 A decrease in systolic blood pressure of more than 20 mmHg when going from lying to standing,along with an increase in heart rate of 10 beats per minute or a decrease in diastolic blood pressure of more than 10 mmHg, along with a 10 beats per minute increase in heart rate,is considered postural hypotension. The other vital sign measurements do not support the criteria for postural hypotension. PTS:1DIF:Analyze REF:Fluid Imbalances: Assessment with Clinical Manifestations 8. The nurse assesses a client to have mild pitting edema of the lower extremities. The nursewould document this finding as being: 1. 0+. 2. 1+. 3. 2+. 4. 3+. S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? ANS: 2 Mild pitting edema is documented as being +1. No pitting edema would be documented as 0+. Moderate pitting edema would be documented as 2+. Moderately severe pitting edema would bedocumented as 3+. PTS: 1 DIF: Apply REF: Figure 12-4 Pitting Edema Grading Scale 9. An elderly client is demonstrating new signs of confusion. Which of the following should the nurse consider when caring for this client? 3. Bicarbonate 4. Magnesium ANS: 4 1. Assess forsigns of elevated sodium level. 2. Restrict fluids. 3. Administer prescribed diuretic medication. 4. Monitor daily weights. ANS: 1 Elderly clients who develop a new onset of confusion should have their serum sodium levels checked for an elevated serum sodium level. Restricting fluids, administering diuretics, and monitoring daily weights are all interventions appropriate for a client with a low-serum sodium level. PTS:1DIF:Apply REF:Excess Sodium Ion: Assessment with Clinical Manifestations 10.A client diagnosed with hypokalemia should have which of the following electrolytes alsoassessed? 1. 2. Sodium Calcium S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? Clients with hypokalemia often have concurrent hypomagnesemia. Hypokalemia is resistant to treatment unless the hypomagnesemia is corrected. Sodium, calcium, and bicarbonate changesare not associated with hypokalemia. PTS:1DIF:Apply REF: Deficient Potassium Ion: Planning and Implementation 11.A client is diagnosed with hypophosphatemia. The nurse realizes that this electrolyteimbalance is most likely associated with: 4. Hypermagnesemia ANS: 4 Signs and symptoms of hypermagnesemia are similar to those seen with hypercalcemia and include paresthesias, muscle weakness, anorexia, nausea, diminished bowel sounds, and 1. diabetes mellitus. 2. congestive heart failure. 3. arthritis. 4. chronic alcoholism. ANS: 4 A diet deficient in phosphorous may cause hypophosphatemia and reduced absorption of phosphorous occurs with chronic alcoholism. Hypophosphatemia is not associated with diabetesmellitus, congestive heart failure, or arthritis. PTS: 1 DIF: Analyze REF: Deficient Phosphorus Ion: Etiology 12.A client diagnosed with chronic renal failure is experiencing muscle weakness, paresthesias,and depression. Which of the following do these assessment findings suggest to the nurse? 1. Hyperkalemia 2. 3. Hyponatremia Hypocalcemia S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? constipation. Confusion, depression, lethargy, and coma can also occur. Muscle weakness, paresthesias, and depression are not seen in hyperkalemia, hyponatremia, or hypocalcemia. PTS:1DIF:Analyze REF:Excess Magnesium Ion: Assessment with Clinical Manifestations 13.A client begins rapid breathing and demonstrates anxiety after learning of a diagnosis of breast cancer. After a short while, the client complains of tingling lips and fingers. Which of thefollowing should the nurse do to assist this client? 1. Provide oxygen. 2. Coach the client in the use of an incentive spirometer. 3. Help the client slow the respiratory rate or breathe into a paper bag. 4. Administer intravenous fluids. ANS: 3 With the clients rapid respirations, too much carbon dioxide is being excreted. This leads to alkalosis. Symptoms of respiratory alkalosis include tingling of the lips and fingers. If the client is unable to control the respiratory rate, the nurse may have the client breathe into a paper bag, which forces the rebreathing of carbon dioxide. Providing oxygen, using an incentive spirometer,and intravenous fluids is not going to help correct the clients rapid respiratory rate and respiratory alkalosis. PTS:1DIF:ApplyREF:Respiratory Alkalosis MULTIPLE RESPONSE 1.A client is diagnosed with hyponatremia. Which of the following assessment findings wouldcause the nurse to become concerned? (Select all that apply.) 1. Confusion 2. Poor appetite 3. Restlessness 4. Lethargy S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? 5. Seizures 6. Coma ANS: 1, 3, 4, 5, 6 The change in osmolality that occurs with hyponatremia causes fluid to shift into the intracellularspace. Signs and symptoms associated with an expanded intracellular compartment include confusion, restlessness, lethargy, seizures, and coma. Poor appetite is not an assessment finding of hyponatremia. PTS:1DIF:Analyze REFeficient Sodium Ion: Assessment with Clinical Manifestations 2. After reviewing a clients most recent electrocardiogram, the nurse suspects the client is experiencing hyperkalemia. Which of the following did the nurse assess on the clients rhythmstrip? (Select all that apply.) 1. Tall peaked T-waves 2. Short QRS complex 3. Dysrhythmias 4. Wide QRS complex 5. Bradycardia 6. Tachycardia ANS: 1, 3 Tall peaked T-waves and dysrhythmias are seen on the electrocardiogram of a clientexperiencing hyperkalemia. The other choices are not seen with hyperkalemia. PTS: 1 DIF: Analyze REF: Excess Potassium Ion: Diagnostic Tests 3.A client has a serum potassium level of 2.9 mEq/L. Which of the following should be done to assist this client? (Select all that apply.) S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? 4. Monitor digoxin levels. 5. Monitor forseizure activity. ANS: 1, 3, 4 Interventionsfor a patient with hypokalemia are continuous cardiac monitoring; assessing for flattening T-waves; monitoring for digoxin toxicity, which may cause dysrhythmias; and assessing muscle strength, tone, and reflexes. Seizure activity is a sign of a sodium imbalance. PTS:1DIF:Apply REF: Deficient Potassium Ion: Assessment with Clinical Manifestations 4.Which of the following assessment techniques can the nurse use to determine if a client isexperiencing hypocalcemia? (Select all that apply.) 1. Allen test 2. Chvosteks sign 3. Percussion of the abdomen 4. Auscultation of the lungs 1. Implement continuous cardiac monitoring. 2. Check for an elevated ST segment. 3. Assess muscle strength, tone, and reflexes. 5. Trousseaus sign 6. Palpation of the neck ANS: 2, 5 Trousseaus sign is assessed by inflating a blood pressure cuff for up to 4 minutes and assessing for hand spasms as a sign of hypocalcemia. Chvosteks sign is done by tapping on the facial nerve S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? and assessing for a spasm of the facial muscle on the same side as evidence of hypocalcemia.The Allens test, percussion of the abdomen, auscultation of the lungs, and palpation of the neckare not performed specifically for hypocalcemia. PTS:1DIF:Apply REFeficient Calcium Ion: Assessment with Clinical Manifestations 5.A client is diagnosed with a serum calcium level of 11.2 mEq/L. Which of the followinginterventions would be appropriate for this client? (Select all that apply.) 1. Administer diuretics as prescribed. 2. Restrict fluids. 3. Administer intravenous fluids as prescribed. 4. Continuous cardiac monitoring. 5. Administer intravenous sodium as prescribed. 6. Change to a low fat diet. ANS: 1, 3, 4, 5 Management of hypercalcemia is focused on removing calcium, which is accomplished by administering diuretics, administering intravenous fluids, and administering intravenous sodium.Continuous cardiac monitoring is needed for clients at risk for developing dysrhythmias. Restricting fluids and changing to a low-fat diet are not used to treat hypercalcemia. PTS: 1 DIF: Apply REF: Excess Calcium Ion: Planning and Implementation 6. Which of the following components of the arterial blood gas will the nurse focus when ondetermining a clients acid-base status? (Select all that apply.) 1. pH 2. PO2 3. PCO2 S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? 4. HCO3 5. O2 Sat 6. Hgb ANS: 1, 3, 4 Interpretation of the clients acid-base status involves the evaluation of three components of the arterial blood gas: pH, PCO2 and HCO3-.. PO2 and O2 Sat are not used to evaluate the clients acid-base status. Hgb level is not a component of the arterial blood gas. Chapter 5 Perioperative Nursing MULTIPLE CHOICE 1.The nurse is identifying diagnoses appropriate for a client scheduled for a surgical procedure.Which of the following is a diagnosis commonly used for preoperative client? 1. Anxiety 2. Sleep deprivation 3. Excess fluid volume 4. Disturbed body image ANS: 1 The preoperative experience may be one of the most tension-producing periods of hospitalization. The nursing diagnosis anxiety is commonly used for preoperative clients. The other diagnoses are not commonly used as preoperative diagnoses. PTS:1DIF:Apply REF:Nursing Diagnoses Used During Preoperative Assessment 2.The preoperative nurse cares for the client until the client progresses into the intraoperativephase of care which begins when the client: S - The Marketplace to Buy and Sell your Study Material Med C Downloaded by: josephkmiringu95 | Distribution of this document is illegal Want to earn $1.236 extra per year? 1. signs the surgical consent form. 2. arrives at the surgical suite doors. 3. is transferred to the postanesthesia care unit. 4. accepts that surgery is pending. ANS: 2 The preoperative period ends and the intraoperative period begins when the patient and family are at the door to the surgical suites. Intraoperative care does not begin when the clientsigns thesurgical consent form, is transferred to the postanesthesia care unit, or accepts that surgery is pending. PTS: 1 DIF: Analyze REF: Introduction 3.The nurse is ensuring that a client is able to make knowledgeable decisions regarding an upcoming surgery and can provide informed consent. What is the responsibility of the nurseregarding informed consent? 1. Explain the surgical options 2. Explain the operative risks 3. Describe the oper