FUNDAMENTAL CONCEPTS AND SKILLS FOR NURSING

MULTIPLE CHOICE 1. A patient who has questions about the availability of home health services after hospital discharge should be referred to the: a. primary care provider. b. registered nurse. c. occupational therapist. d. medical social worker (MSW). ANS: D An MSW can provide information about long-term planning, financial assistance, and community services available after discharge. DIF: Cognitive Level: Application REF: p. 404 OBJ: Clinical Practice #5 TOP: Discharge KEY...

MULTIPLE CHOICE 1. The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can open his eyes spontaneously, obeys all commands, and is oriented. The nurse documents a score of: a. 7. b. 10. c. 12. d. 15. ANS: D The Glasgow Coma Scale is used for the evaluation of neurologically impaired patients: spontaneous eye opening = 4, obeying commands = 6, orientation = 5. This is the highest possible score of 15. DIF: Cognitive Level: Analysis REF: p. 396|...

MULTIPLE CHOICE 1. An older adult patient has a tympanic temperature of 96.2° F (35.7° C). What nursing intervention would best meet this patient’s need? a. Take the patient’s vital signs every 4 hours, including temperature. b. Provide fluids to increase circulation. c. Increase room temperature to 72° F (22.2° C) and add blankets to the bed. d. Check the temperature orally to confirm the accuracy of the reading. ANS: C Nursing interventions for treating hypothermia should...

MULTIPLE CHOICE 1. An anxious adult patient is experiencing a respiratory rate of 40 breaths/min. The most appropriate intervention that the nurse could do is to instruct the patient to: a. sit up. b. lie down. c. breathe through a re-breather mask. d. pant with mouth open. ANS: C Anxiety can lead to hyperventilation, causing respiratory alkalosis; the treatment is to have the patient breathe through a re-breather mask. In the home setting, the patient can be asked to breathe into a...

MULTIPLE CHOICE 1. Following a colonoscopy with polyp removal, the wife of the patient is distressed that there is slight bleeding from her husband’s rectum. The nurse’s most helpful response would be: a. “This small amount of bleeding is expected after the removal of polyps.” b. “I will notify the primary care provider about this hemorrhage.” c. “I will watch your husband very carefully to assess any further hemorrhage.” d. “Don’t worry. This small amount of blood hap...

MULTIPLE CHOICE 1. A patient in the skilled nursing facility has left-sided paralysis from a stroke several years before, as well as generalized weakness. The nurse should ensure that which of the following devices is in place to prevent flexion contractures? a. A trochanter roll to keep her legs from turning outward b. A rolled washcloth in the palm of her left hand or a hand splint c. A protective vest to keep her sitting upright in the chair d. A trapeze to permit her to change her pos...

MULTIPLE CHOICE 1. An 84-year-old patient is hospitalized for an infected stasis ulcer on his ankle. The nurse is aware that this patient is at risk for a hospital-acquired infection (HAI) because the: a. patient already has a blood-borne infection. b. patient’s defenses are already engaged with the initial infection. c. ulcer will make this patient bedfast. d. stasis ulcers predispose the older adult to pneumonia and urinary infections. ANS: B Older adults have an impaired immun...

MULTIPLE CHOICE 1. The nurse instructing a patient in the home use of disinfectant would include the information that the disinfectant can be used to: a. decrease organisms on the patient’s body but take care not to use it around the patient’s eyes or in the mouth. b. sterilize instruments with a bacteriostatic disinfectant. c. thoroughly clean and rinse all soap off the equipment before disinfecting it. d. first remove all organic matter prior to disinfecting. ANS: C Disinfecta...

MULTIPLE CHOICE 1. When caring for a patient with acute radiation sickness (ARS) after an accident at an atomic power plant, the nurse should: a. wear a paper gown and boots, gloves, and a mask. b. stay in the room and talk to the patient to alleviate anxiety. c. decrease the amount of time spent in the room. d. wear a chemical mask with a filtered respirator. ANS: A For prolonged periods in caring for a patient with ARS, the nurse should use the barrier protection of gown, boots, ...

MULTIPLE CHOICE 1. Providing oral care to a patient who has dentures includes: a. asking the patient to place his teeth directly in a covered, labeled container for overnight storage. b. removing, cleaning, and storing the dentures in a labeled container at bedtime. c. cleaning the dentures in hot water after each meal to remove debris and bacteria. d. using a toothbrush and toothpaste to clean the dentures in the patient’s mouth. ANS: B Dentures should be removed and cleaned befo...

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CHAPTER 15: LOSS, GRIEF, AND END-OF-LIFE CARE Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th Edition MULTIPLE CHOICE 1. The nurse can assess Cheyne-Stokes respiration by its characteristics of respirations that are: a. harsh and rattling. b. wheezing and labored. c. shallow followed by periods of apnea. d. long periods of apnea followed by a hiccoughing breath. ANS: C Cheyne-Stokes respirations become more and more shallow followed by periods of apnea, and...

CHAPTER 14: CULTURAL AND SPIRITUAL ASPECTS OF PATIENT CARE Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th Edition MULTIPLE CHOICE 1. The nurse understands that when an Asian patient refers to yin, the patient is referring to a balancing force that is represented by: a. light. b. a masculine force. c. cold and feminine elements. d. harmony. ANS: C Yin is the balancing force to yang that is represented by elements that are dark, cold, and feminine. DIF: C...

CHAPTER 13: PROMOTING HEALTHY ADAPTATION TO AGING Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th Edition MULTIPLE CHOICE 1. An 84-year-old patient who is hospitalized for pneumonia says to the nurse, “I don’t know why I’ve lived so long. All my friends are gone, my children and grandchildren are all independent and successful—nobody needs me anymore.” An appropriate response by the nurse is: a. “You have a lot to live for. Your children and grandchildre...

CHAPTER 12: ADULTHOOD AND THE FAMILY Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th Edition MULTIPLE CHOICE 1. A 48-year-old woman asks the clinic nurse about symptoms she has experienced, such as trouble sleeping, because she wakes up feeling hot and sweaty. She has also felt tired and depressed about aging. The most helpful nursing response would be: a. “You may have an illness that the doctor should evaluate.” b. “It sounds to me as though you might have ...

CHAPTER 11: GROWTH AND DEVELOPMENT: INFANCY THROUGH ADOLESCENCE Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th Edition MULTIPLE CHOICE 1. The school nurse is alert to the behavior of a child who has extremely permissive parents, because this sort of parenting style produces children who are: a. mistrusting. b. depressed. c. anxious. d. impulsive. ANS: D Permissive parenting produces children who are impulsive, aggressive, and lacking in self-control. DI...

CHAPTER 10: DELEGATION, LEADERSHIP, AND MANAGEMENT Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th Edition MULTIPLE CHOICE 1. Nursing documentation that would best assist with reimbursement to a facility would be: a. Patient was up in chair for 2 hours after breakfast. b. Patient was ambulated in the hall three times this shift. c. Patient was assisted to a recliner chair to use the oxygen concentrator. d. Patient received bath in shower room. ANS: C Nurses...

CHAPTER 09: PATIENT TEACHING FOR HEALTH PROMOTION Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th Edition MULTIPLE CHOICE 1. Because a person may learn best in a particular manner, to improve patient teaching, the nurse should: a. ask the patient whether he learns best visually, aurally, or kinesthetically. b. use a hands-on approach, because it works best for most people. c. test the patient’s reading comprehension before using visual handouts. d. use a combin...

CHAPTER 08: COMMUNICATION AND THE NURSE-PATIENT RELATIONSHIP Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th Edition MULTIPLE CHOICE 1. The nurse is aware that the purpose of therapeutic communication is to: a. gather as much information as possible about the patient’s problem. b. direct the patient to communicate about his deepest concerns. c. focus on the patient and the patient needs to facilitate interaction. d. gain specific medical information and history...

CHAPTER 07: DOCUMENTATION OF NURSING CARE Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th Edition MULTIPLE CHOICE 1. A nurse begins the shift caring for a patient who has just returned from the recovery room after surgery. It is most important to document: a. at the end of the shift so that the nurse can give his full attention and time to the patient’s needs during the shift. b. a nursing care plan in the medical record before assessing the patient so that the n...