A physician prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, and she cannot find it in the hospital formulary or other references. How should she proceed?
1)
Administer the medication as prescribed.
2)
Hold the medication and notify the prescriber.
3)
Consult with a pharmacist before administering it.
4)
Ask the patient’s nurse for information about the medication.
ANS: 3
The nurse must recognize when she does not have the knowledge or skill needed to implement an order. Because the nurse is unfamiliar with the medication, that does not mean she should hold it and delay patient treatment. It is wisest to first consult with the pharmacist for information before administering the medication to ensure safe practice. Administering the medication as prescribed, without knowing its expected actions and side effects, at the least prevents adequate reassessment; at the most, it is dangerous. Holding the medication and notifying the prescriber prevents the client from receiving timely treatment—many drugs are less effective if a consistent schedule is not maintained. Asking another nurse to administer the medication is also unsafe because it cannot be assumed that the other nurse has the correct knowledge. In addition, the nurse caring for the client must assess for adverse reactions to the medication.
PTS: 1 DIF: Moderate REF: p. 118
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis
____ 2. Which task can be delegated to nursing assistive personnel (NAP)?
1)
Turn and reposition the client every 2 hours.
2)
Assess the client’s skin condition.
3)
Change pressure ulcer dressings every shift.
4)
Apply hydrocolloid dressing to the pressure ulcer.
ANS: 1
The nurse can delegate turning the client every 2 hours to the NAP. Assessing the client’s skin condition, changing pressure ulcer dressings, and applying a hydrocolloid dressing to a pressure ulcer are all interventions that require nursing knowledge and judgment.
PTS: 1 DIF: Moderate REF: pp. 122–124
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application
____ 3. The nurse has just finished documenting that he removed a patient’s nasogastric tube. Which is the next logical step in the nursing process?
1)
Assessment
2)
Planning
3)
Evaluation
4)
Diagnosis
ANS: 3
The implementation phase ends when you document nursing actions on the client’s chart. Implementation evolves into the evaluation step when you document the client’s response to your interventions. As a general rule, the steps in order are as follows: assessment diagnosis, planning outcomes, planning interventions, implementation, and evaluation.
PTS: 1 DIF: Easy REF: p. 125
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Comprehension
____ 4. Which nursing intervention is best individualized to meet the needs of a specific client?
1)
Suction the client every 2 hours per unit policy.
2)
Use incentive spirometry every hour while awake per postoperative protocols.
3)
Institute swallowing precautions.
4)
Move client out of bed to the chair daily; client prefers to be out of bed for dinner.
ANS: 4
Positioning the client in the chair for meals considers the client’s desire to be out of bed for dinner, so it is obviously individualized. An intervention performed according to unit policy or protocols is not necessarily individualized. “Institute swallowing precautions” does not provide instructions for the specific actions needed to do that for “this particular” client.
PTS: 1 DIF: Moderate REF: p. 118; high-level question, answer not given verbatim
KEY: Nursing process: Planning interventions | Client need: SECE | Cognitive level: Application
____ 5. The primary provider prescribes an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed?
1)
Ask a colleague for help, because the nurse cannot safely perform the procedure alone.
2)
Gather the equipment and prepare it before informing the client about the procedure.
3)
Obtain an order to restrain the client before inserting the urinary catheter.
4)
Inform the provider that the nurse cannot perform the procedure because the client is confused.
ANS: 1
Before the nurse begins a procedure, she should review the care plan and look at the orders critically. Because this client is confused, she should ask a colleague to assist with the procedure to prevent undue stress for the client and nurse. The client should be informed about the procedure before the nurse gathers the equipment. Gathering the equipment and bringing it into the room before explaining the procedure might cause the client anxiety. Restraining the client should be done only as a last resort and to prevent client injury. Informing the primary provider that the procedure cannot be performed because the client is confused is inappropriate because the procedure can very likely be done with assistance.
PTS: 1 DIF: Moderate REF: p. 118
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis
____ 6. A patient underwent surgery 3 days ago for colorectal cancer. The patient’s critical pathway states that he should participate in a teaching session with the wound ostomy nurse to learn colostomy self-care. The patient appears depressed and refuses to look at the colostomy or even make eye contact. How should the nurse proceed?
1)
Postpone the teaching session until the patient is more receptive.
2)
Follow the critical pathway for patient teaching about ostomy care.
3)
Administer a prescribed antidepressant and notify the physician.
4)
Explain to the patient the importance of skin care around the ostomy site.
ANS: 1
A depressed affect and poor eye contact likely indicate that the client is having difficulty coping with the new colostomy. At this time, the client would not be physically and psychologically ready to obtain the most benefit from teaching pertaining to ostomy care. Therefore, the nurse should postpone the teaching session for this client until the client is receptive to receiving the information. The nurse should not perform the teaching session simply because the critical pathway indicates it is appropriate. Simply administering an antidepressant does not address the client’s readiness to participate in a teaching session and ultimately self-care of the ostomy. The nurse should encourage the client to verbalize his feelings. Client education is not effective unless the client is receptive to the information. Readiness to learn is important. Proceeding with teaching when the client is struggling with coping is not sensitive to the client’s individual needs.
PTS: 1 DIF: Moderate REF: p. 120
KEY: Nursing process: Implementation | Client need: PHI | Cognitive level: Application
____ 7. Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill?
1)
Psychomotor
2)
Interpersonal
3)
Cognitive
4)
Critical thinking
ANS: 2
Reassuring the client is an interpersonal skill. Inserting the nasogastric tube requires psychomotor skills. Checking catheter placement after insertion requires cognitive and psychomotor skills. Assessing whether there is an indication for the nasogastric tube requires critical thinking skills.
PTS: 1 DIF: Moderate REF: p. 120
KEY: Nursing process: Implementation | Client need: PHI | Cognitive level: Comprehension
____ 8. Which intervention depends almost entirely on the client’s adhering to the therapy?
1)
Inserting an IV catheter
2)
Turning a client every 2 hours
3)
Shortening a surgical drain
4)
Following a low-fat, low-calorie diet
ANS: 4
Instituting and adhering to a low-fat, low-calorie diet is an intervention that depends almost entirely on the client’s adhering to the therapy. Client cooperation is necessary for performing the other interventions, but the interventions do not depend on the client to the same extent.
PTS: 1 DIF: Easy REF: p. 122
KEY: Nursing process: Planning interventions | Client need: SECE | Cognitive level: Analysis
____ 9. The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan?
1)
Teaching the client that he must lose weight to control his blood sugar
2)
Informing the client he must exercise at least three times per week
3)
Explaining to the client that he must come to the diabetic clinic weekly
4)
Determining the client’s main concerns about his diabetes
ANS: 4
Determining the client’s main concerns promotes cooperation with the treatment regimen. For example, if the client is concerned about paying for diabetic monitoring equipment, he may disregard any teaching about the procedure. Although it is often important for a diabetic client to exercise and lose weight to control blood sugar levels, the client must want to do both. He will not exercise or lose weight simply because he is told to do so. The nurse must assess the client’s support systems and resources, not just tell him he must come to the diabetic clinic weekly. Some clients do not have access to transportation and, therefore, could not come to the clinic without social service intervention. Remember that knowledge does not necessarily change behavior.
PTS: 1 DIF: Moderate REF: p. 122
KEY: Nursing process: Planning interventions | Client need: PHSI | Cognitive level: Analysis
____ 10. Which statement accurately describes delegation?
1)
Transferring authority to another person to perform a task in a selected situation
2)
Collaborating with other caregivers to make decisions and plan care
3)
Scheduling treatments and activities with other departments
4)
Performing a planned intervention from a critical pathway
ANS: 1
Delegation is the transfer to another person of the authority to perform a task in a selected situation—the person delegating retains accountability for the outcome of the activity. Collaboration is described as working with other caregivers to plan, make decisions, and perform interventions. Coordination of care involves scheduling treatments and activities with other departments. Implementation is the process of performing planned interventions.
PTS: 1 DIF: Easy REF: p. 122
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Knowledge
____ 11. Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP) about delegating a task?
1)
“Record how much the patient drinks today, please.”
2)
“Take the patient’s vital signs every 2 hours today.”
3)
“Take the patient’s temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C).”
4)
“Assist the patient with all of her meals.”
ANS: 3
Clear communication about a task (such as “Take the patient’s temperature . . . ”) tells the NAP exactly what the task is, the specific time it needs to be done, and the method for reporting the results to the registered nurse. The other options are vague and leave room for misinterpretation.
PTS: 1 DIF: Moderate REF: p. 124
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis
____ 12. Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)?
1)
Nurse who delegated the task
2)
Licensed practical nurse working with the NAP
3)
Unit nurse manager
4)
Charge nurse for the shift
ANS: 1
The nurse who delegates the task is responsible for supervising and evaluating the outcomes of tasks performed by the NAP. Another registered nurse, such as a staff nurse, nurse manager, or charge nurse, can answer questions and provide help, if necessary.
PTS: 1 DIF: Easy REF: p. 124
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Recall
____ 13. Which criterion might be used in structure evaluation?
1)
Staff refrains from sharing computer password.
2)
Healthcare provider washes hands with each client contact.
3)
A defibrillator is accessible on each client care area.
4)
Nurse verifies client identification before initiating care.
ANS: 3
The criterion that states “a defibrillator is present on each client care area” is associated with structure evaluation. “Refrains from sharing computer password,” “washes hands before each client contact,” and “verifies client identification before initiating care” are criteria associated with process evaluation.
PTS: 1 DIF: Moderate REF: p. 127
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis
____ 14. Which of the following is a client outcome criterion?
1)
Central venous catheter site infection does not occur (90% of cases).
2)
Client will sit out of bed in a chair for 20 minutes three times per day.
3)
Postoperative phlebitis does not occur (95% of cases).
4)
Falls will decrease by 2% between January 1 and March 30.
ANS: 2
A client outcome criterion states the client health status or behaviors one wishes to effect. “Client will sit out of bed . . .” is a client outcome criterion. The other options are examples of organizational criteria used to evaluate the quality of care throughout the institution.
PTS: 1 DIF: Moderate REF: pp. 127-128
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application
____ 15. When should the nurse collect evaluation data for this expected outcome: Patient will maintain urine output of at least 30 mL/hour?
1)
At the end of the shift
2)
Every 24 hours
3)
Every 4 hours
4)
Every hour
ANS: 4
The nurse should collect evaluation data as defined in the expected outcome. For instance, in this case, the nurse would check the patient’s urine output every hour because the goal statement specifies an hourly rate (30 mL/hour). The unit of measurement in the goal guides how often the nurse would reassess the patient.
PTS: 1 DIF: Easy REF: pp. 127-128
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application
____ 16. Which type of client-centered evaluation is performed at specific, scheduled times?
1)
Intermittent
2)
Ongoing
3)
Terminal
4)
Process
ANS: 1
Intermittent evaluation is performed at specific times; it enables the nurse to judge the progress toward goal achievement and to modify the plan of care as needed. Ongoing evaluation is performed while implementing, immediately after an intervention, or with each client contact; these are not necessarily scheduled events. Terminal evaluation is performed at the time of discharge. It describes the client’s health status and progress toward goals at that time. Process evaluation focuses on the manner in which care is given. It may be performed at specific times, but it is not considered a client-centered evaluation.
PTS: 1 DIF: Easy REF: p. 127
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Recall
____ 17. Which of the following is the most valid criterion for determining the status of a patient’s anxiety at discharge? The patient
1)
Has a relaxed facial expression
2)
States that he feels more relaxed today
3)
Shows no physiological signs of anxiety (e.g., pallor)
4)
Has no further questions about home care
ANS: 2
A criterion is considered valid when it measures what it is intended to measure. Because anxiety is subjective (perceived by the patient), the best measure of anxiety is what the patient says about it. A relaxed facial expression and other physiological signs might or might not show the level of anxiety. Relaxation might occur, for example, because the patient is sleeping or falling asleep. The fact that a patient is not asking questions about his surgery could mean that he has adequate knowledge about the topic; it would not indicate the presence or absence of anxiety. All of the options except what the patient states could be measuring something other than anxiety.
PTS: 1 DIF: Difficult REF: p. 127
KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application
____ 18. The nurse works with the respiratory therapist to administer a patient’s breathing treatments. He reports the patient’s breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. This is an example of
1)
Delegation
2)
Collaboration
3)
Coordination of care
4)
Supervision of care
ANS: 2
Collaboration means working with other caregivers to plan, make decisions, and perform interventions. Delegation is the transfer to another person of the authority to perform a task in a selected situation. Coordination of care involves scheduling treatments and activities with other departments, putting together all the patient data to obtain the “big picture.” Supervision is the process of directing, guiding, and influencing the outcome of an individual’s performance of an activity or task.
PTS: 1 DIF: Moderate REF: pp. 122
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 1. The nurse and nursing assistive personnel (NAP) are caring for a group of patients on the medical-surgical floor. For which of the following patients can the nurse delegate to the NAP the task of bathing? Choose all that apply.
1)
75-year-old patient newly admitted to the hospital with dehydration
2)
65-year-old patient hospitalized for a stroke, whose blood pressure is 188/90 mm Hg
3)
92-year-old patient with stable vital signs who was admitted with a urinary tract infection
4)
56-year-old patient with chronic renal failure who has vital signs within his normal range
ANS: 1, 3, 4
The nurse should not delegate bathing of a client newly diagnosed with a stroke whose blood pressure is unstable or otherwise abnormal. This client requires the keen assessment and critical thinking skills of a registered nurse. The nurse can safely delegate the care of stable clients, such as the client admitted with dehydration, the client admitted with a urinary tract infection, or the client with chronic renal failure. Any client who is very ill or who requires complex decision making should be cared for by a registered nurse.
PTS: 1 DIF: Difficult REF: pp. 122–124
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis
Chapter 9. Development: Infancy Through Middle Age
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is providing prenatal counseling for a couple who is trying to become pregnant. The priority for the nurse is to include which of the following pieces of information?
1)
Stages of growth and development of the fetus
2)
Recommended schedule of visits to her healthcare provider
3)
Recommended average weight gain during pregnancy
4)
Healthy eating habits before and during pregnancy
ANS: 4
Maternal nutrition is vital to the healthy growth of the fetus. Poor maternal nutrition leads to an undergrown placenta. A small, poorly functioning placenta and smaller than normal umbilical cord are the causes for small-for-gestational age (otherwise known as small-for-dates) babies. The other options are all things the prospective mother needs to know, but they would not have an immediate impact on fetal health.
PTS: 1 DIF: Moderate REF: p. 166
KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Analysis
____ 2. Which of the following would indicate a 4-year-old child has successfully gone through Erikson’s Stage 3 (Initiative Versus Guilt)? The child
1)
Refrains from hitting a friend
2)
Plays cooperatively with friends
3)
Is able to develop friendships
4)
Is able to express his feelings
ANS: 1
Stage 3 is Initiative Versus Guilt, in which the child becomes responsible for his behavior, develops self-discipline, and is able to manage his impulses. Cooperation and expressing feelings are tasks for Stage 2. Children develop friendships during the preschool age.
PTS: 1 DIF: Moderate REF: pp. 163-164
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
____ 3. The nurse is preparing to assess a toddler. To make the assessment go smoothly, before examining the child the nurse should first
1)
Talk to the mother before talking to the child
2)
Ask the child about his favorite toy
3)
Get the child’s height and weight
4)
Ask the mother to undress the child
ANS: 2
Toddlers have a fear of strangers, so it would be important to establish rapport before examining the child. Although talking to the mother before the child prior to a physical assessment does not lead to distrust, the action simply does not contribute to building a rapport with the child. Undressing the child before a trusting relationship is established often creates anxiety in the child, leading to uncooperativeness, fear, or withdrawal. Obtaining the child’s height and weight would not help the child feel secure.
PTS: 1 DIF: Moderate REF: p. 175
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application
____ 4. According to Erikson, a behavior demonstrating an important psychosocial task for a toddler would be for the child to
1)
Act defiantly by refusing to hold her mother’s hand while crossing the street
2)
Recognize that it is wrong to take a toy away from someone else
3)
Be able to understand the concept of time in hours
4)
Express to his parents and playmates that he does not like something
ANS: 1
The primary task during Erikson’s stage 2, Autonomy Versus Shame and Doubt, is establishing an identity as separate from the parent/caregiver. A child between 18 months and 3 years typically tests the boundaries as part of exercising his will to control his environment. “No” is a declaration of independence and a bid for increased autonomy. Acts of independence and autonomy (e.g., refusing to hold her mother’s hand) are normal during this developmental stage. The toddler should be able to tolerate time away from her parents, delay gratification, and have elimination control. The other tasks are accomplished during the preschool stage.
PTS: 1 DIF: Moderate REF: p. 163
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
____ 5. A mother comes to the clinic with her infant for a newborn checkup at 1 week of age. The mother tells the nurse, “My baby looks yellow to me.” The nurse’s best response is which of the following?
1)
“What type of detergent are you using to wash the baby clothes?”
2)
“Is there a possibility you had hepatitis during your pregnancy?”
3)
“The color is from the breakdown of maternal red blood cells.”
4)
“There is a cream you can use to reduce the yellowing.”
ANS: 3
Jaundice results from the breakdown of the maternal red blood cells that are in the baby’s system after birth, which elevates the bilirubin in the serum. If detergent caused a reaction, the reaction would commonly present as a rash. Although hepatitis B virus may pass through the placenta to the fetus, the infant does not typically show signs at 1 week of life. If treatment becomes necessary, the infant would receive phototherapy; there is no cream to reduce the yellow appearance related to newborn jaundice.
PTS: 1 DIF: Moderate REF: p. 170
KEY: Nursing process: Implementation | Client need: PHSI | Cognitive level: Application
____ 6. A father brings his toddler to the clinic for well-child care. Which of the following would be most important for the nurse to assess?
1)
How successful the child is with potty training
2)
How the child acts when you enter the room
3)
Whether the child is using eating utensils
4)
Whether the home is child-proofed
ANS: 4
Although all of these areas address important developmental tasks during the toddler period, safety is the highest priority at this age because the child has increased dexterity, mobility, and determination and is becoming more independent. Potty training is typically accomplished between 18 months and 3 years of age but is not a safety concern. It would be normal for a child at this age to be afraid of strangers. The child should be using utensils for most foods, but again it is not a safety concern.
PTS: 1 DIF: Moderate REF: pp. 174-175
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Analysis
____ 7. Which comment made by a woman in her early 50s would be a cue indicating the need for further assessment for a problem?
1)
“My skin is so dry I need to use lotion every day after I bathe.”
2)
“I have episodes when I feel really hot even when others are not.”
3)
“It’s getting harder to lift those big bags of dog food.”
4)
“I have to write myself notes because I’m getting so forgetful.”
ANS: 4
Memory in middle adulthood should remain intact. There is a normal decrease in skin moisture and muscle tone in middle adulthood. The perimenopausal period occurs during this time, hallmarked by hot flashes and night sweats.
PTS: 1 DIF: Moderate REF: pp. 189-191
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
____ 8. The nurse has instructed a group of parents on common adolescent behavior. Which comment by the parent would indicate the most urgent need for further discussion?
1)
“I guess my daughter won’t be asking my opinion very much.”
2)
“I’m really going to watch my daughter’s eating habits.”
3)
“We are really going to have to think about rules we want to enforce after he gets his driver’s license.”
4)
“We don’t keep alcohol in the house, so that’s at least one thing we don’t need to worry about.”
ANS: 4
Concerns about alcohol intake during adolescence is highest priority, regardless of whether or not it is stored in the home. Alcohol-related injury and death are a risk that should be avoided in every circumstance. Not having alcohol in the house does not guarantee the teenager won’t consume it with his friends. During the teen years, the relationships among peers strengthen and strongly influence adolescent behavior. Although the parents typically still maintain influence on the core values in the home, teens seek peers’ opinions for matters about social life or concerns of everyday living. As teens are developmentally concerned with appearance and social relationships, there can be an overemphasis on body image, leading to obesityeating disorders. Motor vehicle accidents are the leading cause of death for teenagers, typically due to distractibility, inattention, impulsiveness, and inexperience in various driving situations.
PTS: 1 DIF: Moderate REF: p. 183
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis
____ 9. Which of the following would be the priority for most adolescents? Being
1)
A good student
2)
Sexually active
3)
Picked to be on the soccer team
4)
Able to function independently
ANS: 3
The developmental task during adolescence is to establish personal identity. Socially, preteens and teens are driven by a need to belong to a group. School-age children need to receive positive reinforcement for accomplishments and desired behavior, such as being good students. Although a small number of preadolescents are sexually active, it is not the major focus for this age. Functioning independently is a task for the young adult.
PTS: 1 DIF: Moderate REF: p. 182
KEY: Nursing process: Diagnosis | Client need: HPM | Cognitive level: Analysis
____ 10. During adolescence, it would be most important to encourage the teen to eat plenty of
1)
Grains
2)
Dairy products
3)
Vegetables
4)
Fruit
ANS: 2
Both males and females experience a growth spurt during adolescence. Although the child’s diet should include adequate amounts of all the food groups, peak bone mass is attained during this stage, so the child needs to consume adequate calcium, vitamin D, iron, and protein. These nutrients are found in dairy products.
PTS: 1 DIF: Easy REF: pp. 181-182
KEY: Nursing process: Implementation | Client need: HPM | Cognitive level: Application
____ 11. According to Erikson, which of the following must a middle-aged adult do to be prepared for the final stages of life?
1)
Accept the fact that she is getting older.
2)
Reconcile that death is a part of life.
3)
Feel she has made a contribution to society.
4)
Have had a meaningful and intimate relationship.
ANS: 3
Generativity Versus Stagnation is the stage Erikson describes for the middle adult. During this stage, a mature adult either continues to gain skills, be productive, and pass on his or her knowledge to the next generation or stagnates. During the middle years, many adults are realistic and insightful about age-related physical and emotional changes. Others experience difficulty coping with passing youth and advancing age. Accepting death as a part of the continuum of life is a task for the older adult. Developing meaningful relationships is a task most influential for the young adult.
PTS: 1 DIF: Moderate REF: p. 190
KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Recall
____ 12. The nurse teaches a mother of a preschool-age child about expected development. Which comment by the parent indicates that she understands the information?
1)
“She understands the monsters in books are not real.”
2)
“When I mention that her birthday is in a week, she understands.”
3)
“I am saving to buy her the roller skates she’s been asking for.”
4)
“I can’t expect her to understand when a friend doesn’t agree with her.”
ANS: 3
Preschoolers’ hand-eye coordination develops markedly during this period. They can hop on one foot, skip, and begin to learn to skate. The imagination of a preschool-age child is typically active, whereby they have fears of mythical figures, such as monsters. They have a limited ability to understand the concept of time or to tell time. A preschooler has the ability to consider simple viewpoints of other people.
PTS: 1 DIF: Moderate REF: p. 176
KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application
____ 13. A mother has brought her 8-month-old daughter to the healthcare clinic for a well-child appointment and any needed immunizations. To assess the child’s physical development with age-appropriate norms, which of the following questions should the nurse ask?
1)
“Is your child able to walk while holding onto furniture?”
2)
“Is your child able to crawl on her hands and knees?”
3)
“Is your child able to pick up food with her fingers?”
4)
“Is your child able to sit up without support?”
ANS: 4
At 7 months, most children can sit up by themselves. Cruising usually occurs around 8 to 12 months. At about 7 to 10 months, a child begins to crawl. Infants develop a pincer grasp around 10 months.
PTS: 1 DIF: Moderate REF: p. 171
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
____ 14. A mother comes to the healthcare clinic for a regular health examination for her 5-year-old son prior to kindergarten admission. Which comment by the mother would indicate the need for follow-up questions to the mother?
1)
“He’s not a good boy like my other son.”
2)
“I’ve had to treat him for lice a couple of times.”
3)
“He has an imaginary friend he calls Buddy.”
4)
“He’s so funny when he imitates his dad doing things.”
ANS: 1
Negative comments or comparisons with another child can be an indicator of or potential for child abuse. The nurse needs to determine whether this is an actual problem. Head lice are a common health problem for children of this age because of close physical contact with play. The mother seems to have a healthy attitude about the infestations and to be knowledgeable in the treatment. Imaginary play, magical thinking, and belief in mythical figures are normal at age 5. A child this age will normally imitate the same-sex parent.
PTS: 1 DIF: Difficult REF: p. 177
- 82
KEY: Nursing process: Diagnosis | Client need: HPM | Cognitive level: Analysis
____ 15. Which behavior by the mother is most likely to help the infant to develop trust?
1)
Talking to the infant
2)
Breastfeeding instead of bottle-feeding
3)
Promptly responding to the infant’s crying
4)
Having the infant sleep in the same room with the parent
ANS: 3
Because the infant is totally dependent on the parents, quickly responding to his cries promotes attachment and trust. Although all options may promote attachment, they are not absolutely necessary for bonding to occur. Mother-infant attachment is complex and involves all senses—not simply hearing the mother talk to him. There are physical and emotional benefits to breastfeeding, but it is not necessary for mother-infant attachment. Sleeping in the same room may help the parent respond more quickly to the infant’s needs but is not the basis for attachment.
PTS: 1 DIF: Moderate REF: p. 171
KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension
____ 16. The nurse is talking to a class of children, ages 9 to 11 years. For this age group, it would be most important for the nurse to discuss
1)
Safe sex practices
2)
Healthy food choices
3)
Use of seat belts and safety equipment
4)
The importance of getting enough sleep
ANS: 3
All are important topics to discuss with this age, but children of this age are very active, and injuries are common. Motor vehicle accidents are the most common cause of injury. They are just starting puberty, so sexual activity is still not usual. The discussion of appropriate food choices and getting enough sleep should be done throughout the child’s developmental stages; it is not peculiar to ages 10 to 12 years. The preteen years are particularly important for adequate sleep and rest primarily because of the physical changes, active social lives, and increasingly complex demands on their lives.
PTS: 1 DIF: Moderate REF: p. 181
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 17. A 38-year-old client comes into the clinic for a health examination. Knowing the psychosocial development tasks and common health problems for this age group, it would be most important for the nurse to ask
1)
If the client has episodes of feeling depressed
2)
Whether the client practices safe sex
3)
About the client’s exercise habits
4)
About the health history of the client’s parents
ANS: 1
Striving to be self-sufficient and successful and to establish a career and family are the tasks for this age. These tasks are demanding and can be emotionally difficult and potentially cause depression. Untreated depression is a leading cause of death among young adults. Sexually transmitted infections are a risk for this age group but are not as severe a threat as depression. Exercise is important to overall health but is not a source of stress. There are genetic health problems that can impact the client, but the question is asking about psychosocial development and common health problems.
PTS: 1 DIF: Difficult REF: p. 187-188
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
____ 18. A mother watches the nurse perform an assessment on her newborn and asks the nurse why she is doing things like “stroking the bottom of his feet.” The nurse should respond in which of the following ways?
1)
“I’m checking the blood flow to your baby’s feet to make sure it’s normal.”
2)
“I’m testing to see if your baby’s neuromuscular system is fully developed.”
3)
“I’m checking to see if your baby has the reflex responses we anticipate.”
4)
“I’m testing to see if your baby has normal sensation in his feet.”
ANS: 3
The Babinski reflex is elicited by stroking upward of the side of the sole of the foot. This is one of several reflexes that should be present at birth. Stoking the bottom of the foot is not an assessment of circulation to the feet. The neuromuscular system is not fully developed at birth, but reflexes are present. Because an infant is not able to report sensation, which is a subjective finding, this is not the purpose of the nurse’s action.
PTS: 1 DIF: Moderate REF: p. 168
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
____ 19. The nurse conducts a class on health promotion to a group of young adults. Which of the following comments would indicate the teaching was effective?
1)
“I need to get screened for colon cancer.”
2)
“I’ll start doing testicular self-exams.”
3)
“I have to have my prostate checked.”
4)
“I don’t need to do breast self-exams until I am 40.”
ANS: 2
Men may choose to perform monthly testicular exams until they are 40 years old. Colon cancer screening begins at age 50. Prostate exams are part of an annual health exam for middle adults. Even young adults should perform breast self-examination (although some practitioners question recommending it routinely). Whatever screening method is chosen, young adults do develop breast cancer; it is not a problem only for those past age 40.
PTS: 1 DIF: Easy REF: p. 186
KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application
____ 20. Which of the following is an example of a school-aged child’s meeting psychosocial development tasks? The child
1)
Wants to show off the latest trick he can do on his bike
2)
Becomes interested in friendships with the opposite sex
3)
Starts to see the value of making good decisions
4)
Wants to buy the same jacket his friend has
ANS: 4
Peers are increasingly more important to the school-age child. The child wants to have what his friends have. Pride in showing off new skills and possessions is normal for all stages of development, particularly during the preschool period. Friendships are typically between those the same sex at this age. A value system does not start to develop until adolescence.
PTS: 1 DIF: Moderate REF: p. 179
KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Analysis
____ 21. Which of the following would be the most important health assessment focus for middle adulthood?
1)
Cancer screening with the annual health examinations
2)
Seeking information about consistent use of seat belts
3)
Screening for eating disorders
4)
Mental status exam for cognitive changes
ANS: 1
Chronic diseases, including cancer, are major health problems for adults in the middle years. Habits for seat belt use should have already been established; although it may be important to reinforce seat belt use, the most important assessment is cancer screening. Eating disorders are more common in adolescence. In general, cognitive changes such as memory loss and dementia do not develop until older adulthood.
PTS: 1 DIF: Difficult REF: p. 190
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension
____ 22. A mother and father have brought their school-age child to the emergency department with injuries that cause the nurse to suspect child abuse. The nurse wishes to assess further for abuse and neglect. Which of the following should the nurse do?
1)
Interview the parents together and the child separately.
2)
Have one parent in the room to reassure the child during the interview.
3)
Interview the child and each parent separately.
4)
Request that a sexual assault nurse examiner (SANE) interview the family members.
ANS: 3
Interviewing each family member separately allows the suspected victim more freedom to express concerns. An abused person may be afraid to talk with the abuser present and may even support the abuser’s version of events. If two adults accompany a child, the situation still does not allow such freedom, because it may be that one of the adults is abusing both the partner and child. The nurse should separate the caregivers and child to be certain they all tell the same story. A SANE is needed to perform the physical examination only if sexual abuse is suspected from the interview.
PTS: 1 DIF: Difficult REF: p. 180
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension
Matching
Match the developmental milestones with the appropriate age group. There may be more than one answer for each age group.
1)
Infant
2)
Toddler
3)
Preschool
4)
School age
5)
Adolescent
- Bones have reached maximum strength
____ 2. Puts toys into toy box
____ 3. Ties her tennis shoes
____ 4. Matches colors and shapes
____ 5. Compares balls with blocks
- Writes sentences using appropriate grammar
____ 7. Understands that characters in cartoons are not real
____ 8. Finds toys that are hidden
____ 9. Applies reason to his thinking
____ 10. Puts a simple jigsaw puzzle together
____ 11. Tells someone his name, age, and address
____ 12. Understands how much a dollar is
____ 13. Understands what “no” means
- ANS: 5 PTS: 1 DIF: Moderate REF: pp. 171-187
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
- ANS: 1 PTS: 1 DIF: Moderate REF: pp. 171-187
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
- ANS: 4 PTS: 1 DIF: Moderate REF: pp. 171-187
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
- ANS: 2 PTS: 1 DIF: Moderate REF: pp. 171-187
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
- ANS: 3 PTS: 1 DIF: Moderate REF: pp. 171-187
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
- ANS: 4 PTS: 1 DIF: Moderate REF: pp. 171-187
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
- ANS: 3 PTS: 1 DIF: Moderate REF: pp. 171-187
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
- ANS: 2 PTS: 1 DIF: Moderate REF: pp. 171-187
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
- ANS: 5 PTS: 1 DIF: Moderate REF: pp. 171-187
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
- ANS: 1 PTS: 1 DIF: Moderate REF: pp. 171-187
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
- ANS: 3 PTS: 1 DIF: Moderate REF: pp. 171-187
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
- ANS: 4 PTS: 1 DIF: Moderate REF: pp. 171-187
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
- ANS: 1 PTS: 1 DIF: Moderate REF: pp. 171-187
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
Match the growth and development theory with the appropriate theorist.
1)
Human behavior and personality development are driven by instincts; there are four forces and five stages that influence a person’s personality.
2)
Cognitive development is progressive and sequential through four stages; the person must have the basic abilities of assimilation, accommodation, and adaptation.
3)
There are eight stages of personality development with tasks that must be accomplished at each stage; the greater the achievement of the tasks, the more adjusted the personality.
4)
Humans are born with instinctive needs; lower-level needs must be met before higher-level needs and the ability to achieve self-actualization is developed.
5)
People interact with their social environment in a process of lifelong learning; there are six stages, each with tasks that must be accomplished during that stage.
____ 14. Erikson
____ 15. Freud
____ 16. Havighurst
____ 17. Piaget
- ANS: 3 PTS: 1 DIF: Moderate REF: pp. 160-165
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
- ANS: 1 PTS: 1 DIF: Moderate REF: pp. 160-165
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
- ANS: 5 PTS: 1 DIF: Moderate REF: pp. 160-165
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
- ANS: 2 PTS: 1 DIF: Moderate REF: pp. 160-165
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
Chapter 17. Loss, Grief, & Dying
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A 73-year-old patient who suffered a stroke is being transferred from the acute care hospital to a nursing home for ongoing care because she is unable to care for herself at home. Which type of loss is this patient most likely experiencing?
1)
Environmental loss
2)
Internal loss
3)
Perceived loss
4)
Psychological loss
ANS: 1
This patient is most likely experiencing an environmental loss because she is unable to return to her familiar home setting. Instead, she is being transferred to the new environment of a nursing home. Internal, perceived, and psychological losses are internal and can only be identified by the person experiencing them.
PTS: 1 DIF: Easy REF: p. 358
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
____ 2. According to William Worden, which task in the grieving process takes longest to achieve?
1)
Accepting that the loved one is gone
2)
Experiencing the pain from the loss
3)
Adjusting to the environment without the deceased
4)
Investing emotional energy
ANS: 1
Worden described the tasks a grieving person must achieve. They progress from an initial numbness or denial through experiencing and working through pain and grief and eventually moving on with life. Shock with disbelief is not a Worden task.
PTS: 1 DIF: Easy REF: p. 359
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall
____ 3. What emotional response is typical during the Rando’s confrontation phase of the grieving process?
1)
Anger and bargaining
2)
Shock with disbelief
3)
Denial
4)
Emotional upset
ANS: 4
During the confrontation phase, the person faces the loss and experiences emotional upset. In the avoidance phase, the person experiences shock, disbelief, denial, anger, and bargaining. During the accommodation phase, the person begins to live with the loss, feel better, and resume routine activities.
PTS: 1 DIF: Moderate REF: p. 359
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Recall
____ 4. An elderly man lost his wife a year ago to cardiovascular disease. During a healthcare visit, he tells the nurse he has begun adjusting to life without his wife. According to John Bowlby, which stage of grief does this comment most likely indicate?
1)
Shock and numbness
2)
Yearning and searching
3)
Disorganization and despair
4)
Reorganization
ANS: 4
According to Bowlby, a person adjusts to life without the deceased during the reorganization phase. During the shock and numbness phase, the person experiences disorientation and a feeling of helplessness. The person wants to be reconnected with the deceased during the yearning and searching phase. The person feels pain and the emotions of grief during the disorganization and despair phase.
PTS: 1 DIF: Moderate REF: p. 359
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
____ 5. Which patient is at most risk for experiencing difficult grieving?
1)
The middle-aged woman whose grandmother died of advanced Parkinson’s disease
2)
The young adult with three small children whose wife died suddenly in an accident
3)
The middle-aged person whose spouse suffered a slow, painful death
4)
The older adult whose spouse died of complications of chronic renal disease
ANS: 2
Although it is impossible to predict with certainty and the grieving process is highly individual and personal, in general those who suffer a sudden loss typically have more difficult grieving than those who have had the time to prepare for the death. Family and friends of persons with chronic illnesses (e.g., cancer) have usually had time to emotionally prepare for the death, initiate the funeral and burial arrangements, and begin the grieving process before the death occurs.
PTS: 1 DIF: Moderate REF: p. 360
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
____ 6. During a health history, a patient whose wife died unexpectedly 6 months ago in a motor vehicle accident admits that he drinks at least six bourbon and waters every night before going to bed. Which type of grief does this best illustrate?
1)
Delayed
2)
Chronic
3)
Disenfranchised
4)
Masked
ANS: 4
Masked grief occurs when the person is grieving, but it may look as though something else is occurring; in this case, the person is abusing alcohol. Delayed grief occurs when grief is put off until a later time. Chronic grief begins as normal grief but continues long term with little resolution of feelings or ability to rejoin normal life. Disenfranchised grief is experienced when a loss is not socially supported.
PTS: 1 DIF: Moderate REF: p. 361
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
____ 7. According to the Uniform Determination of Death Act, which bodily function must be lost to declare death?
1)
Consciousness
2)
Brain stem function
3)
Cephalic reflexes
4)
Spontaneous respirations
ANS: 2
According to the Uniform Determination of Death Act, death can be declared when there is a loss of brain stem function. Higher-brain death occurs when there is a loss of consciousness, cephalic reflexes, and spontaneous respirations.
PTS: 1 DIF: Moderate REF: p. 362
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Recall
____ 8. A patient’s wife tells the nurse that she wants to be with her husband when he dies. The patient’s respirations are irregular, and he is congested. The wife tells the nurse that she would like to go home to shower but that she is afraid her husband might die before she returns. Which response by the nurse is best?
1)
“Certainly, go ahead; your husband will most likely hold on until you return.”
2)
“Your husband could live for days or a few hours; you should do whatever you are comfortable with.”
3)
“You need to take care of yourself; go home and shower, and I’ll stay at his bedside while you are gone.”
4)
“Don’t worry. Your husband is in good hands; I’ll look out for him.”
ANS: 2
The patient is exhibiting signs that typically occur days to a few hours before death. The nurse should provide information to the wife so she can make an informed decision about whether to leave her husband’s bedside. The nurse should not offer false reassurance by stating that the patient will most likely be fine until the wife’s return. The nurse should not offer her opinion by telling the wife that she needs to take care of herself. It is also unrealistic for the nurse to stay with the patient until his wife returns. The nurse would be minimizing the wife’s concern by telling her not to worry because her husband is in good hands. The issue for the family member is not trust in the competency of the healthcare provider but rather wanting to be present with her spouse at the time of death.
PTS: 1 DIF: Moderate REF: pp. 367-368
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
____ 9. Mr. Jackson is terminally ill with metastatic cancer of the colon. His family notices that he is suddenly more focused and coherent. They are questioning whether he is really going to die. The nurse recognizes that a sudden surge of activity may occur
1)
Moments before death
2)
Days to hours before death
3)
1 to 2 weeks before death
4)
1 to 3 months before death
ANS: 3
Days to hours before death, patients commonly experience a surge of energy that brings mental clarity and a desire to speak with family. One to 3 months before death, the dying person begins to withdraw from the world by sleeping more and eating less. One to 2 weeks before death, the body loses its ability to maintain itself, and body systems begin to deteriorate. Near the time of death, the dying person does not respond to touch or sound and cannot be awakened.
PTS: 1 DIF: Moderate REF: p. 367
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
____ 10. Which intervention takes priority for the patient receiving hospice care?
1)
Turning and repositioning the patient every 2 hours
2)
Assisting the patient out of bed into a chair twice a day
3)
Administering pain medication to keep the patient comfortable
4)
Providing the patient with small frequent, nutritious meals
ANS: 3
A priority intervention for the hospice team is administering pain medications to keep the patient comfortable. Turning the patient to prevent skin breakdown and promote comfort is also important, but it does not take priority over administering pain medications. The patient may not be able to eat meals or get out of bed into the chair and may tolerate only small amounts at a meal. During the dying process, bowel activity reduces and digestion is minimal, which often results in nausea or food intolerance. Additionally, the body’s need for nutrition and hydration is reduced as the body begins the desiccation process.
PTS: 1 DIF: Difficult REF: p. 363
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
____ 11. The nurse has been explaining advance directives to a patient. Which response by the patient would indicate that he has correctly understood the information? “An advance directive is a document
1)
Specifying your healthcare intentions should you become unable to make self-directed decisions”
2)
Identifying the activities considered to be evidence of quality care”
3)
Verifying your understanding of the risks and benefits associated with a procedure”
4)
Allowing you the autonomy to leave the hospital when you decide, even if it is against medical advice”
ANS: 1
An advance directive is a group of instructions stating the patient’s healthcare wishes should he become unable to make decisions. The Patient Care Partnership is a document that helps to ensure that patients receive quality care. An informed consent form verifies the patient’s understanding of risks and benefits associated with a procedure. An “against medical advice” form allows the patient to leave the hospital against medical advice and releases the hospital of responsibility for the patient.
PTS: 1 DIF: Moderate REF: p. 364
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive
level: Comprehension
____ 12. A patient with a history of chronic obstructive pulmonary disease has a living will that states he does not want endotracheal intubation and mechanical ventilation as a means of respiratory resuscitation. As the patient’s condition deteriorates, the patient asks whether he can change his decision. Which response by the nurse is best?
1)
“I’ll call your physician right away so he can discuss this with you.”
2)
“You have the right to change your decision about treatment at any time.”
3)
“Are you sure you want to change your decision?”
4)
“We must follow whatever is written in your living will.”
ANS: 2
The nurse should inform the patient that he has the right to change his decision about treatment at any time. Next, the nurse should notify the physician of the patient’s decision so that the physician can speak to the patient and revise the treatment plan as needed. Questioning the patient’s decision is judgmental. The patient has the right to change his living will at any time. The medical team should not follow the living will if the patient changes his decision about what is in it.
PTS: 1 DIF: Moderate REF: p. 364
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
____ 13. Which dysrhythmia confirms death?
1)
Asystole (absence of heart activity)
2)
Pulseless electrical activity
3)
Ventricular fibrillation
4)
Ventricular tachycardia
ANS: 1
Asystole is a dysrhythmia that commonly serves as a confirmation of death. Pulseless electrical activity, ventricular fibrillation, and ventricular tachycardia are potentially lethal dysrhythmias that may respond to treatment.
PTS: 1 DIF: Easy REF: p. 365
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
____ 14. A patient dying of heart failure has changed his choice about his end-of-life treatment measures several times. He says, “I just can’t make up my mind about it.” Which nursing diagnosis is most appropriate for this patient?
1)
Deficient Knowledge
2)
Spiritual Distress
3)
Decisional Conflict
4)
Death Anxiety
ANS: 3
This patient is experiencing Decisional Conflict related to his end-of-life treatment measures. Deficient Knowledge, Spiritual Distress, or Death Anxiety may be the etiology of his changing decisions, but his indecision about his treatment option clearly identifies his Decisional Conflict.
PTS: 1 DIF: Moderate REF: pp. 367-368; high-level question, not stated verbatim in text | V2, pp. 168–169; high-level question, not stated verbatim in text
KEY: Nursing process: Nursing diagnosis | Client need: PSI | Cognitive level: Analysis
____ 15. Which nursing intervention should be included in the plan of care for a patient dying of cancer?
1)
Encourage at least one family member to remain at the bedside at all times.
2)
Follow-up with other healthcare team members during weekly meetings.
3)
Avoid discussing the dying process with family (to reduce sadness).
4)
Encourage family members to participate in care of the patient when possible.
ANS: 4
The plan of care should include encouraging family members to help with the patient’s care when they are able. Family members should also be encouraged to take care of themselves. They often need to be encouraged to take breaks to eat and rest. Provide them with anticipatory guidance about the stages of death so they know what to expect. Follow up promptly (not weekly) with other healthcare team members to address family concerns.
PTS: 1 DIF: Moderate REF: pp. 369-371
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
____ 16. Which intervention by the nurse is most appropriate when she notices that her dying patient has developed a “death rattle”?
1)
Perform nasotracheal suctioning of secretions.
2)
Turn the patient on his side and raise the head of the bed.
3)
Insert a nasopharyngeal airway as needed.
4)
Administer morphine sulfate intravenously.
ANS: 2
If a “death rattle” occurs, turn the patient on his side, and elevate the head of the bed. Nasotracheal suctioning and inserting a nasopharyngeal airway are ineffective against a “death rattle” and may cause the patient unnecessary discomfort. The patient may require IV morphine sulfate to treat pain, but it does not help stop a “death rattle.” This narcotic analgesic can also reduce the respiratory drive, leading to hypoventilation and respiratory depression or arrest.
PTS: 1 DIF: Moderate REF: p. 376
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
____ 17. Which of the following patient goals is most appropriate when managing the patient dying of cancer? The patient will
1)
Request pain medication when needed
2)
Report or demonstrate satisfactory pain control
3)
Use only nonpharmacological measures to control pain
4)
Verbalize understanding that it may not be possible to control his pain
ANS: 2
The most important goal is that the patient will report or demonstrate satisfactory pain control. The nurse should administer pain medication on a regular schedule to ensure satisfactory pain control; pain may not be controlled if medication is administered on an “as needed” basis. Nonpharmacologic measures can be a helpful adjunct in controlling pain, but they are not likely to be adequate for pain associated with cancer. Effective pain-control medications are available and can be administered by several routes; it should be possible to control the pain.
PTS: 1 DIF: Moderate REF: p. 369
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
____ 18. When providing postmortem care, the nurse places dentures in the mouth and closes the eyes and mouth of the patient within 2 to 4 hours after death. Why is the timing of the action so important?
1)
To prevent blood from settling in the head, neck, and shoulders
2)
To perform these actions more easily before rigor mortis develops
3)
To set the mouth in a natural position for viewing by the family
4)
To prevent discoloration caused by blood settling in the facial area
ANS: 2
Rigor mortis develops 2 to 4 hours after death; therefore, the nurse should place dentures in the mouth and close the patient’s eyes and mouth before that time. The nurse should place a pillow under the head and shoulders to prevent blood from settling there and causing discoloration. Closing the patient’s mouth and tying a strip of soft gauze under the chin and around the head keeps the mouth set in a natural position for a viewing later. Closing the eyes after death creates a peaceful resting appearance when the body is later viewed but has nothing to do with setting the mouth. Placing dentures in the mouth and closing the eyes and mouth do not prevent discoloration in the facial area.
PTS: 1 DIF: Moderate REF: p. 378
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension
____ 19. How should the nurse respond to a family immediately after a patient dies?
1)
Ask the family to leave the patient’s room so postmortem care can be performed.
2)
Leave tubes and IV lines in place until the family has the opportunity to view the body.
3)
Express sympathy to the family (e.g., “I am sorry for your loss”).
4)
Tell the family that they will have limited time with their loved one.
ANS: 3
The nurse should express sympathy to the family immediately after the patient’s death. She should give the family as much time as they need with their loved one and take care to present the body in a restful pose. If family members are not present at the time of death, remove tubes and IV lines before they see the body, unless an autopsy is planned or the death is being investigated by the coroner. The body should not be removed from the patient care area until the family is ready.
PTS: 1 DIF: Moderate REF: p. 378
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
____ 20. The mother of a preschool child dies suddenly of a ruptured cerebral aneurysm. What recommendation should the nurse make to the family regarding how to most therapeutically care for the child?
1)
Take the child to the funeral even if he is frightened.
2)
Notify the physician immediately if the child shows signs of regression.
3)
Spend as much time as possible with the child.
4)
Provide distraction whenever the child begins to express feelings of sadness.
ANS: 3
The nurse should advise the family to spend as much time as possible with the child. If the child is frightened about attending the funeral, he should not be forced to attend. Signs of regression are a normal reaction to the loss of a loved one, especially a parent. The child should be encouraged to express his feelings and fears.
PTS: 1 DIF: Moderate REF: p. 380
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
____ 21. Which intervention should be included in the plan of care for a patient in the end-stage death process?
1)
Encourage the patient to accept as much help as possible.
2)
Avoid administering laxatives.
3)
Wet the lips and mouth frequently.
4)
Administer pain medication on an as-needed basis.
ANS: 3
If the patient is unable to take fluids, prevent dryness and cracking of lips and mucous membranes by wetting the lips and mouth frequently. Encourage the patient to be as independent as possible. Administer laxatives if constipation occurs. Administer pain medications on a regular schedule instead of waiting for the patient to request them.
PTS: 1 DIF: Moderate REF: p. 375
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
____ 22. Throughout the course of his illness, a patient has denied its seriousness, even though his health professionals have explained prognosis of death very clearly. Physiologic signs now indicate that he will probably die within a short period of time, but he is still firmly in a state of emotional denial. The patient says to the nurse, “Tell my wife to stop hovering and go home. I’m going to be fine.” How should the nurse respond?
1)
“Your physical signs indicate that you will likely not live more than a few more days.”
2)
“You seem very sure that you are not going to die. Please tell me more about what you are feeling.”
3)
“It seems to me you would be feeling some anger and wondering why all this is happening to you.”
4)
“It would be best for your family if you were able to work through this and come to accept the reality of your situation.”
ANS: 2
Not all patients go through all the traditional stages of grieving. It is not the nurse’s responsibility to move patients sequentially through each stage of the dying and grieving process with the goal that everyone ends life accepting death. It is a nursing responsibility to accept and support people “where they are” and help them to express their feelings. Nurses need to understand patients, not change them. In this situation, denial may be very important to this patient, as an emotional defense and coping strategy.
“You seem sure . . . tell me . . . what you are feeling” restates what the patient has said (indicating understanding) and encourages expression of feelings—both are supportive. Even though moving him through stages is not the goal in this situation, support does facilitate that.
Telling the patient that his physical signs indicate that death is imminent is presenting truth and reality; however, the exact time of death is not always predictable. Forecasting the hour of death can have negative impact on the family as they anticipate the event with emotion and exhaustion. Presenting reality is appropriate in certain circumstances earlier in the dying process, but not in this situation because it has already been tried with no change in the patient. Presenting reality does not support the patient’s needs at this time.
Saying “It seems to me you would be feeling some anger . . .” is directed toward moving the patient from denial and suggesting he should feel something he has not yet expressed. This is not therapeutic. Saying “It would be best for your family . . .” presumes that the nurse knows more about what is “best” for the patient’s family than the patient himself. This statement is also judgmental.
PTS: 1 DIF: Difficult REF: pp. 362-363
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
____ 23. A home health patient previously lived with her sister for more than 20 years. Although it has been over a year since her sister died, the patient tells the nurse, “It’s no worse now, but I never feel any relief from this overwhelming sadness. I still can’t sleep a full night. The house is a mess; I feel too tired, even to take a bath. But, sometimes at night, she comes to me and I can see her plain as can be.” The patient’s clothing is not clean and her hair is not combed. She is apparently not eating adequately. What can the nurse conclude? The patient is probably
1)
Grieving longer than usual because of the closeness of the relationship with her sister
2)
Experiencing a depressive disorder rather than simply grieving the loss of her sister
3)
Feeling guilt and worthlessness because her sister died and she is still alive
4)
Interpreting the holiday as a trigger event, which is causing her to hallucinate
ANS: 2
The patient is likely experiencing a depressive disorder. Her symptoms include unrelieved, overwhelming sadness; insomnia; difficulty carrying out ADLs; fatigue; and visual hallucinations. Note that her sadness is pervasive, not created by a trigger event (holiday). Of those symptoms, insomnia is common to both grief and depression, but the other symptoms are signs of depressive disorder. There is, of course, no “correct” timeline for what constitutes “longer than usual” grieving; however, the patient’s symptoms are typical of depression, not grief. She has not said she feels guilty or worthless, and there is nothing from which the nurse could infer that. She has specifically said that the holiday has not made her feel any worse—that is, it has not been a trigger event.
PTS: 1 DIF: Difficult REF: pp. 367-368
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 1. Which intervention is appropriate for a client receiving palliative care? Choose all that apply.
1)
Surgical insertion of a device to decrease the workload of the heart in a patient awaiting heart transplantation
2)
Administering IV dopamine to raise blood pressure of a patient with end-stage lung cancer
3)
Providing moisturizing eye drops to an unconscious patient whose eyes are dry
4)
Administering a medication to relieve the nausea of a patient with end-stage leukemia
ANS: 3, 4
Palliative care focuses on relieving symptoms for patients whose disease process no longer responds to treatment. Providing moisturizing eye drops and administering antinausea medication in a patient with end-stage leukemia are examples of palliative care. Surgical insertion of a device to decrease heart workload and administering dopamine are aggressive treatment measures.
PTS: 1 DIF: Moderate REF: p. 363
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
____ 2. To be eligible for insurance benefits covering hospice care, a physician must certify that which of the following apply to the patient? Choose all that apply.
1)
Life expectancy is not more than 6 months.
2)
Life expectancy is not more than 12 months.
3)
Condition is expected to improve slightly.
4)
Condition is not expected to improve.
ANS: 1, 4
For a patient to be eligible for hospice care insurance benefits, a physician must certify that the patient is not expected to improve or will most likely die within 6 months.
PTS: 1 DIF: Moderate REF: p. 363
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Recall
____ 3. Which of the following might be a warning sign that a child needs professional help after the death of a loved one? Choose all that apply.
1)
Interest in his usual activities
2)
Extended regression
3)
Withdrawal from friends
4)
Inability to sleep
5)
Intermittent sadness
ANS: 2, 3, 4
The warning signs that may indicate the need for professional help include inability to sleep, extended regression, loss of interest in daily activities, and withdrawal from friends. Interest in usual activities is a sign of coping; intermittent expressions of sadness and anger are to be expected, even over a long period of time, so they would not indicate a need for professional help.
PTS: 1 DIF: Easy REF: p. 380
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis
Chapter 21. Physical Assessment
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A mother brings her 6-month-old infant to the clinic for a well-baby checkup. How should the nurse proceed when weighing the patient?
1)
Have the mother remain outside the room.
2)
Ask the mother to remove the infant’s clothing and diaper.
3)
Weigh the infant wearing only the diaper.
4)
Place the infant supine on the scale with his knees extended.
ANS: 2
The nurse should ask the mother to remove the infant’s clothing and diaper before weighing and measuring the infant. An older child can be examined in his underwear; infants should be undressed. Infants are typically more comfortable with the parent close by, so the mother should remain in the room. The infant should be supine with knees extended on the examination table when being measured, not when being weighed.
PTS: 1 DIF: Moderate REF: p. 517
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
____ 2. Where should the nurse assess skin color changes in the dark-skinned patient?
1)
Nailbeds
2)
Any exposed area
3)
Oral mucosa
4)
Palms of the hands
ANS: 3
In dark-skinned patients, look for color changes in the conjunctiva or oral mucosa. They should be pink and moist. In dark-skinned patients, skin color changes may not be apparent in nailbeds, palms of the hands, and other exposed areas.
PTS: 1 DIF: Easy REF: pp. 497-498, 519
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall
____ 3. While the nurse assesses a newborn of African American descent, the mother points out a blue-black Mongolian spot on the newborn’s back and asks, “What’s that? Is something wrong with my baby?” Which response by the nurse is best?
1)
“I’ll ask the physician to look at the spot.”
2)
“Those spots are quite common and typically fade with time.”
3)
“You may want a plastic surgeon to look at that.”
4)
“That spot is benign so it’s nothing you need to worry about.”
ANS: 2
The best response by the nurse is to explain that Mongolian spots are common in dark-skinned newborns and typically fade over time. The nurse should report the finding in the patient health record, but there is no need to notify the physician immediately. It is inappropriate for the nurse to recommend that the mother take her newborn to a plastic surgeon; Mongolian spots do not require treatment. Although it contains correct information, “nothing you need to worry about” is condescending.
PTS: 1 DIF: Moderate REF: p. 497
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application
____ 4. An older adult comes to the clinic complaining of pain in the left foot. While assessing the patient, the nurse notes smooth, shiny skin that contains no hair on the client’s lower legs. Which condition does this finding suggest?
1)
Venous insufficiency
2)
Hyperthyroidism
3)
Arterial insufficiency
4)
Dehydration
ANS: 3
Peripheral arterial insufficiency is associated with smooth, thin, shiny skin with little or no hair. Venous insufficiency leads to thick, rough skin that is commonly hyperpigmented. Hyperthyroidism is associated with abnormally warm skin. Decreased turgor would be seen in dehydration.
PTS: 1 DIF: Moderate REF: p. 498
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application
____ 5. Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with traveler’s diarrhea?
1)
Edema
2)
Hyperhidrosis
3)
Pallor
4)
Tenting
ANS: 4
Tenting, skin that takes several seconds to return to normal after lifting up a fold, may be a sign of dehydration. Edema, an excessive amount of fluid in the tissues, may be a sign of heart failure, kidney disease, peripheral vascular disease, or low albumin levels. Hyperhidrosis is a term for excessive sweating, which may be a sign of thyrotoxicosis. Pallor, abnormal loss of skin color, may be a sign of anemia or blood loss.
PTS: 1 DIF: Moderate REF: p. 498
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
____ 6. A female patient has excessive facial hair. The nurse should document this finding as:
1)
Alopecia.
2)
Albinism.
3)
Hirsutism.
4)
Lanugo.
ANS: 3
The nurse should document this finding as hirsutism, excess facial or trunk hair. Hair loss should be documented as alopecia. Albinism is a condition caused by lack of pigment in which the patient has white hair and very pale skin. Lanugo is the fine, downy growth of hair that covers the body of a newborn.
PTS: 1 DIF: Moderate REF: p. 499
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
____ 7. The nurse should assess skin temperature by using the:
1)
Dorsum of the hand.
2)
Pad of the fingertip.
3)
Palm of the hand.
4)
Dorsum of the wrist.
ANS: 1
The dorsum of the hand should be used to assess skin temperature. The nurse should compare the temperature of the hands with that of the feet and compare the right side of the body with the left.
PTS: 1 DIF: Easy REF: p. 497
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall
____ 8. While assessing an older adult patient, the nurse notes clubbing of the fingers. This finding is a sign of:
1)
Fungal infection.
2)
Poor circulation.
3)
Iron deficiency.
4)
Long-term hypoxia.
ANS: 4
Clubbing (when the nail plate angle is 180° or more) is associated with long-term hypoxic states such as chronic lung disease. A thick nail with yellowing indicates a fungal infection. Spoon-shaped nails may result from iron-deficiency anemia. Brittle nails are commonly seen with malnutrition and hyperthyroidism.
PTS: 1 DIF: Moderate REF: p. 500
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
____ 9. A 6-week-old infant is brought to the pediatrician’s office for a well-baby checkup. The nurse notes a flattening of the skull. Flattening of the skull in the infant might suggest:
1)
The baby has been lying in the same position for several hours a day.
2)
A disorder associated with excessive growth hormone.
3)
An accumulation of excessive cerebrospinal fluid.
4)
Temporomandibular joint syndrome.
ANS: 1
Abnormal flattening of the skull in infants may result from placing the baby in the same position for several hours every day. A large head in an adolescent or adult may be associated with acromegaly, a disorder associated with excess growth hormone. In infants and children, a head that is growing disproportionately faster than the body may be a sign of hydrocephalus, which is fluid collection in the cavity within the brain. Irregular jaw movement and cracking of the jaw in adults may indicate temporomandibular joint (TMJ) syndrome.
PTS: 1 DIF: Moderate REF: p. 500
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
____ 10. The nurse notes ptosis in a patient who just arrived in the emergency department. The nurse quickly triages the patient because she knows that this finding, along with other symptoms, might suggest:
1)
Hyperthyroidism.
2)
Stroke.
3)
Glaucoma.
4)
Macular degeneration.
ANS: 2
Ptosis, or drooping of the eyelid, may be seen in a patient who experienced Bell’s palsy or a stroke. Exophthalmos is associated with hyperthyroidism. Mydriasis may be seen with glaucoma. Macular degeneration has no outward signs.
PTS: 1 DIF: Moderate REF: p. 500
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application
____ 11. Small hemorrhages are noted under the nailbed of a patient with a history of intravenous drug abuse. This finding is associated with:
1)
Low albumin levels.
2)
Zinc deficiency.
3)
Renal disease.
4)
Bacterial endocarditis.
ANS: 4
Small hemorrhages under the nailbed, known as splinter hemorrhages, are associated with bacterial endocarditis, a complication of IV drug abuse. A distal band of reddish-pink covering 20% to 60% of the nail (half and half nails) is seen in patients with low albumin levels and renal disease. White spots may indicate zinc deficiency.
PTS: 1 DIF: Difficult REF: p. 499
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
____ 12. A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease. Which finding might the nurse expect when assessing the patient’s nails?
1)
Soft, boggy nails
2)
Brittle nails
3)
Thickened nails
4)
Thick nails with yellowing
ANS: 1
Soft, boggy nails are seen with poor oxygenation. Brittle nails are seen with hypothyroidism, malnutrition, calcium, and iron deficiency. Thickened nails may result from poor circulation. A thick nail with yellowing is an indication of fungal infection known as onychomycosis.
PTS: 1 DIF: Moderate REF: p. 500
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
____ 13. A patient’s ankles appear swollen. When the nurse assesses the edema, the skin depresses 6 mm, and the depression lasts 2 minutes. The nurse should document this finding as:
1)
Trace edema.
2)
+1 edema.
3)
+2 edema.
4)
+3 edema.
ANS: 4
To assess edema, the nurse presses firmly with her fingertip for 5 seconds over a bony area. Trace appears as a minimal depression; +1 appears as a 2-mm depression with a rapid return of skin to position; +2 reveals a 4-mm depression, which disappears in 10 to 15 seconds; +3 displays a 6-mm depression that lasts 1 to 2 minutes; and +4 demonstrates an 8-mm depression that persists for 2 to 3 minutes. The area is grossly edematous.
PTS: 1 DIF: Moderate REF: p. 521
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
____ 14. Which abnormal laboratory value is associated with icteric sclerae?
1)
Bleeding time
2)
Bilirubin
3)
Hemoglobin
4)
Glucose
ANS: 2
Icteric sclerae are associated with elevated bilirubin levels. Low hemoglobin would indicate anemia. High hemoglobin is polycythemia, which is like thick blood. Low glucose is hypoglycemia, and high sugar is hyperglycemia.
PTS: 1 DIF: Easy REF: p. 500
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Recall
____ 15. The left pupil of a patient fails to accommodate. This finding may reflect an abnormality in which cranial nerve?
1)
CN III
2)
CN V
3)
CN VIII
4)
CN X
ANS: 1
CN III, the oculomotor nerve, is responsible for accommodation. Failure of a pupil to accommodate reflects an abnormality in this cranial nerve. CN V, the trigeminal nerve, controls the corneal reflex, chewing, and biting. CN VIII, the acoustic nerve, plays a role in hearing and the sense of balance. CN X, the vagus nerve, affects heart rate, peristalsis, swallowing, and the gag reflex.
PTS: 1 DIF: Moderate REF: p. 501
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
____ 16. When testing near vision, the nurse should position printed text how many inches away from the patient?
1)
20
2)
18
3)
16
4)
14
ANS: 4
Test near vision by having the client read text from a distance of 14 inches.
PTS: 1 DIF: Easy REF: p. 501
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall
____ 17. A 48-year-old patient comes to the physician’s office complaining of diminished near vision, which the nurse confirms with testing. She should document this finding as:
1)
Myopia.
2)
Diplopia.
3)
Presbyopia.
4)
Mydriasis.
ANS: 3
Diminished near vision in a patient over age 40 or so years is known as presbyopia. Diminished distant vision is known as myopia. Double vision is known as diplopia. Mydriasis or enlarged pupils may be seen with glaucoma.
PTS: 1 DIF: Moderate REF: p. 501
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
____ 18. Which portion of the ear is responsible for maintaining equilibrium?
1)
External ear
2)
Inner ear
3)
Middle ear
4)
Ossicles
ANS: 2
The inner ear is responsible for hearing and equilibrium. The middle ear, which contains the ossicles (auditory structures), conducts sound waves to the inner ear. The external ear collects and conveys sound waves to the middle ear.
PTS: 1 DIF: Easy REF: p. 502
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
____ 19. Which statement best describes the procedure used to assess capillary refill?
1)
Briefly press the tip of the nail with firm, steady pressure, then release and observe for changes in color.
2)
Press firmly with your fingertip for 5 seconds over a bony area, release pressure, and observe the skin for the reaction.
3)
Tap on the skin with short strokes from your fingers.
4)
Lift a fold of skin, and allow it to return to its normal position.
ANS: 1
To assess capillary refill, the nurse should briefly press the tip of the nail with firm, steady pressure, then release, and observe for changes in skin color. “Tap on the skin . . .” describes the procedure for performing percussion. “Lift a fold of skin . . .” demonstrates the procedure for assessing for tenting. The nurse should press firmly with her fingertip for 5 seconds over a bony area, then release her finger, and observe the skin for the reaction to grade edema.
PTS: 1 DIF: Moderate REF: p. 528
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall
____ 20. Which of the following is an abnormal capillary refill finding that the nurse should report?
1)
1 second
2)
2 seconds
3)
3 seconds
4)
4 seconds
ANS: 4
Normal capillary refill is less than 3 seconds; therefore, the nurse should report a capillary refill of 4 seconds.
PTS: 1 DIF: Easy REF: p. 528
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
____ 21. Which of the following is a correct developmental outcome for an infant? The infant’s anterior fontanel (soft spot) typically fuses:
1)
At about 8 weeks.
2)
At about 14 months.
3)
By 6 months of age.
4)
Before 1 year of age.
ANS: 2
The large soft spot on the top of the head, known as the anterior fontanel, typically fuses at about 12 to 18 months. The infant should be able to hold up his head by age 6 months. The posterior fontanel fuses at about 8 weeks of age.
PTS: 1 DIF: Moderate REF: p. 529
KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension
____ 22. The nurse assesses a 4-year-old child’s vision as 20/40. This finding is considered:
1)
Myopia.
2)
Hyperopia.
3)
Normal.
4)
Presbyopia.
ANS: 3
Children typically do not have 20/20 vision until the ages of 6 or 7 years. A finding of 20/60 in a 4-year-old child is considered normal, so of course 20/40 is normal as well. Myopia is diminished distant vision, which is associated with Snellen chart reading of 20/100. Hyperopia is diminished near vision and is represented by a large fraction, such as 20/15; when found in people over age 45 it is known as presbyopia.
PTS: 1 DIF: Moderate REF: p. 531
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Analysis
____ 23. Which test should the patient undergo when the Weber test is positive?
1)
Romberg test
2)
Rinne test
3)
Pure tone audiometry
4)
Tympanometry
ANS: 2
If the Weber test is positive, the patient should undergo the Rinne test to assess the type of hearing loss. The Romberg test is performed to test equilibrium. Pure tone audiometry uses a machine to hear sounds at different volumes while the patient wears a headset. Tympanometry assesses pressure in the ear; it does not assess hearing.
PTS: 1 DIF: Moderate REF: p. 502
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
____ 24. The nurse is performing an otoscopic examination on an adult patient. She has the patient tilt his head to the side not being examined and looks into the ear canal to make sure a foreign body is not present. Which step should she perform next?
1)
Straighten the ear canal by pulling the helix up and back.
2)
Insert the speculum into the ear canal slowly.
3)
Test the mobility of the tympanic membrane.
4)
Straighten the ear canal by pulling the helix down and back.
ANS: 1
Next, the nurse should straighten the ear canal by pulling the helix up and back. In a preschool child, the nurse should straighten the ear canal by pulling the helix down and back. After straightening the ear canal, the nurse should slowly insert the speculum and observe the ear canal.
PTS: 1 DIF: Moderate REF: p. 538
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
____ 25. An 85-year-old patient is brought to the emergency department with lethargy and hypotension. When the nurse assesses the patient’s tongue, she notes that it appears dry and furry. This finding suggests:
1)
Fungal infection.
2)
Dehydration.
3)
Allergy.
4)
Iron deficiency.
ANS: 2
A dry, furry tongue is associated with dehydration. A black, hairy tongue is characteristic of a fungal infection. Absence of papillae, reddened mucosa, and ulcerations may indicate allergy. Patients who have a deficiency of iron may have a smooth, red tongue.
PTS: 1 DIF: Moderate REF: p. 503
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
____ 26. Which assessment should the nurse perform if she notes a palpable thyroid gland?
1)
Illuminate the thyroid gland for the presence of fluid.
2)
Auscultate the thyroid gland for bruits.
3)
Percuss the thyroid gland for mass size.
4)
Measure the thyroid gland to assess change.
ANS: 2
Normally, the thyroid gland is smooth, firm, and nontender. It is often nonpalpable. If the thyroid gland is palpable, the nurse should auscultate it for bruits. It is not necessary to measure or illuminate the thyroid gland. The thyroid gland should not be percussed.
PTS: 1 DIF: Moderate REF: p. 548
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
____ 27. While palpating the anterior chest, the nurse notes crackling in the skin around the patient’s chest tube insertion site. The nurse recognizes this finding is:
1)
Tactile fremitus.
2)
Egophony.
3)
Bronchophony.
4)
Crepitus.
ANS: 4
The nurse should document this finding as crepitus, crackling skin caused by air leaking into the subcutaneous tissues. Tactile fremitus involves palpating for vibrations as the client says “99,” which indicates the presence of fluid in the chest. Bronchophony is present if the words “1, 2, 3” are clearly heard over the lungs as the nurse listens while the patient says those words. Egophony is present if the sound heard is “ay” when the nurse listens over the lung fields as the patient says “eee.”
PTS: 1 DIF: Easy REF: pp. 554-555
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
____ 28. Bronchovesicular breath sounds are best heard over which area?
1)
Midline over the trachea just below the larynx
2)
Fourth intercostal space, in the midclavicular line
3)
First and second intercostal spaces next to the sternum
4)
At the base of the lungs near the diaphragm
ANS: 3
Bronchovesicular breath sounds are best heard over the first and second intercostal spaces adjacent to the sternum on the anterior chest.
PTS: 1 DIF: Moderate REF: p. 557
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall
____ 29. High-pitched breath sounds produced by airway narrowing are known as:
1)
Rales.
2)
Crackles.
3)
Rhonchi.
4)
Wheezing.
ANS: 4
Wheezing is a high-pitched sound produced by narrowing of an airway. Rales and crackles are crackling sounds that indicate atelectasis, pulmonary edema, or pneumonia. Rhonchi are low-pitched snoring or rumbling sounds that result from mucous secretions in the large airways.
PTS: 1 DIF: Easy REF: ESG, Chapter 21, “Supplemental Materials,” “Abnormal Vocal Sounds,” and “Sound Files: Breath Sounds”on DavisPlus
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
____ 30. The nurse notes a small pulsation at the fifth intercostal space midclavicular line. This should be documented as a:
1)
Thrill.
2)
Murmur.
3)
Normal finding.
4)
Heave.
ANS: 3
A small pulsation at the fifth intercostal space midclavicular line is known as the point of maximal impulse (PMI) and is considered a normal finding. A thrill is a vibration or pulsation palpated in any area except the PMI. A murmur occurs when structural defects in the heart’s chambers or valves cause turbulent blood flow. A heave, which is a visible palpation, is associated with an enlarged ventricle.
PTS: 1 DIF: Moderate REF: p. 507
KEY: Nursing process: Implementation | Client need: PHSI | Cognitive level: Application
____ 31. The nurse notes an S3 heart sound while performing an assessment on a patient admitted with an acute myocardial infarction. The nurse notifies the physician of the finding, which most likely suggests:
1)
Heart failure.
2)
Coronary artery disease.
3)
Hypertension.
4)
Pulmonic stenosis.
ANS: 1
A third heart sound, commonly referred to as S3, is heard with heart failure or volume overload. S4 heart sound may be auscultated with coronary artery disease, hypertension, and pulmonic stenosis.
PTS: 1 DIF: Difficult REF: p. 507
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
____ 32. The admission assessment form indicates that the patient has pedal pulses that are rated 1 in amplitude. This documentation indicates that the patient’s pulses are:
1)
Bounding.
2)
Normal.
3)
Full.
4)
Diminished.
ANS: 4
Pulses documented as 1 are diminished and barely palpable; 2 are normal; 3 are full and increased; and 4 are bounding.
PTS: 1 DIF: Moderate REF: p. 563
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
____ 33. A patient’s jugular venous pressure measures 5 cm. This finding indicates:
1)
A normal finding.
2)
Hypovolemia.
3)
Heart failure.
4)
Dehydration.
ANS: 3
Normal jugular venous pressure is less than 3 cm. A jugular venous pressure of 5 cm is elevated and suggests heart failure.
PTS: 1 DIF: Moderate REF: p. 559
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Comprehension
____ 34. The nurse is caring for a patient who underwent abdominal surgery 24 hours ago and has a nasogastric tube to intermittent suction. How should the nurse proceed when performing an abdominal assessment on this patient?
1)
Avoid palpating the patient’s abdomen.
2)
Turn off the suction before auscultating bowel sounds.
3)
Listen for bowel sounds for 2 minutes in each quadrant.
4)
Percuss the abdomen before auscultating bowel sounds.
ANS: 2
The sound of suction attached to a nasogastric tube can be mistaken for bowel sounds; therefore, the nurse should discontinue the suction or clamp off the tube while auscultating bowel sounds. Light palpation can be performed in the postoperative patient. The nurse should listen for bowel sounds for at least 5 minutes before determining that they are absent. Auscultation should be performed before percussion in examining the abdomen.
PTS: 1 DIF: Moderate REF: p. 509
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
____ 35. Abdominal palpation should be avoided in a child who has which disorder?
1)
Appendicitis
2)
Wilms’ tumor
3)
Crohn’s disease
4)
Small bowel obstruction
ANS: 2
Abdominal palpation should be avoided in the child who has Wilms’ tumor, large diffuse pulsation, or a history of organ transplant. Abdominal palpation can be performed with appendicitis, Crohn’s disease, and small bowel obstruction.
PTS: 1 DIF: Moderate REF: p. 568
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall
____ 36. A father brings his 18-month-old child to the pediatric clinic for a well-baby checkup. The father tells the nurse that he is concerned because his child’s legs are bowed. Which response by the nurse is appropriate?
1)
“Your child will most likely require physical therapy.”
2)
“You should consider having your child seen by an orthopedic surgeon.”
3)
“This is a normal finding in children for 1 year after they begin walking.”
4)
“Your child is walking fine, so you don’t need to worry.”
ANS: 3
Genu varum, or bowlegs, is a normal finding in children for 1 year after they begin walking and the bones of the legs become more ossified with development and weight-bearing. However, assessment over time is important to be sure the gait and positioning develop normally. The nurse should allay the father’s concerns by providing him with this information. The child shows no signs, in the scenario above, that physical therapy is needed. It is not appropriate for the nurse to recommend an orthopedic surgeon; physician referrals are given by the physician or advanced practice nurse when appropriate. “Your child is walking fine . . .” is condescending and does not appropriately address the father’s concerns.
PTS: 1 DIF: Moderate REF: p. 571
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application
____ 37. The nurse asks the patient to spread his fingers and then bring them together again. Which of the following is the nurse testing when asking to bring his fingers together?
1)
Abduction
2)
Adduction
3)
Flexion
4)
Extension
ANS: 2
Asking the patient to spread his fingers tests abduction; asking him to bring them together assesses adduction. Asking the patient to make a fist tests flexion, whereas asking him to extend the hand tests extension.
PTS: 1 DIF: Moderate REF: p. 576
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall
____ 38. An adult admitted to the hospital after a stroke does not respond to verbal stimuli. What should the nurse do next to try to provoke a response?
1)
Apply pressure to the mandible at the jaw.
2)
Rub the patient’s sternum.
3)
Squeeze the trapezius muscle.
4)
Gently shake the patient’s shoulder.
ANS: 4
If the patient does not respond to verbal stimuli, the nurse should try tactile stimuli by gently shaking the patient’s shoulder. If the patient does not respond to tactile stimuli, the nurse should try painful stimuli by squeezing the trapezius muscle, rubbing the sternum, applying pressure on the mandible at the angle of the jaw, or applying pressure over the moon of the nail. But do not start out with painful stimulation before you are sure the patient is not going to react to a less invasive approach.
PTS: 1 DIF: Moderate REF: p. 579
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
____ 39. Which assessment question helps assess immediate memory?
1)
“How did you get to the hospital today?”
2)
“Can you repeat the numbers 2, 7, 9 for me?”
3)
“Do you recall the three items I mentioned earlier?”
4)
“What was your birth date including the year?”
ANS: 2
The nurse can assess immediate memory by asking the patient to repeat a series of three numbers and gradually increasing the length of the series until the patient cannot repeat the series correctly. The nurse can assess recent memory by asking the patient how he got to the hospital or by asking the patient to repeat three items that the nurse mentioned earlier in the examination. The nurse can assess remote memory by asking the patient his birth date or the date of a significant historical event.
PTS: 1 DIF: Moderate REF: p. 580
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
____ 40. Assuming that all are accurate, which documentation about a patient’s level of consciousness is best?
1)
Patient is lethargic and slept when undisturbed.
2)
Patient responds to tactile stimulation; falls back to sleep immediately after tactile and verbal stimulation are stopped.
3)
Patient slept throughout the day, missing his meals and bath.
4)
Patient appears to be tired as he slept throughout the day except when bathed.
ANS: 2
The option that includes the most detailed information provides the most accurate description of the patient’s level of consciousness. The other documentation provides little information about the level of consciousness. From those descriptions, the patient might have a decreased level of consciousness or could simply be exhausted.
PTS: 1 DIF: Moderate REF: p. 510; High-level question; answer not stated verbatim
KEY: Nursing process: Implementation | Client need: PHSI | Cognitive level: Analysis
____ 41. Based on developmental stage, how should the nurse modify the comprehensive physical examination of an older adult?
1)
Work rapidly to finish as quickly as possible.
2)
Sequence the exam to limit position changes.
3)
Demonstrate equipment before using it.
4)
Omit portions of the exam that may be tiring.
ANS: 2
Because older adults may tire easily and because they may have stiff muscles and arthritic joints, the nurse should arrange the sequence of the exam to limit position changes. The nurse should work efficiently; however, speed is not the goal, and the nurse should observe the patient’s energy level and stop for periods of rest as needed. It is appropriate to demonstrate equipment for school-age children but is not usually necessary for older adults, who have probably experienced other physical examinations. Because this is a comprehensive exam, it is not appropriate to omit portions of the exam because they may be tiring. As discussed, the patient should rest and then the nurse should return to the examination.
PTS: 1 DIF: Moderate REF: p. 515
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
____ 42. The nurse applies resistance to the top of the client’s foot and asks him to pull his toes toward his knee. The nurse observes active motion against some, but not against full, resistance. How should the nurse document this finding?
1)
5: Normal
2)
4: Slight weakness
3)
3: Weakness
4)
2: Poor ROM
ANS: 2
The nurse should document 4: Slight weakness. The following is the muscle strength rating scale:
Rating Criteria Classification
5
Active motion against full resistance
Normal
4
Active motion against some resistance
Slight weakness
3
Active motion against gravity
Weakness
2
Passive ROM
Poor ROM
1
Slight flicker of contraction
Severe weakness
0
No muscular contraction
Paralysis
PTS: 1 DIF: Difficult REF: pp. 577-578
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 1. The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday. Which finding(s) require(s) further assessment? Select all that apply.
1)
Blood pressure 110/64 mm Hg
2)
Pulse rate 118 beats/minute
3)
Respiratory rate 35 breaths/minute
4)
Oral temperature 98.6°F (37°C)
ANS: 2, 3
The pulse rate of 118 beats/minute and the respiratory rate of 35 breaths/minute are abnormally elevated and require further assessment. Blood pressure 110/64 mm Hg and oral temperature 98.6°F (37°C) are considered normal and do not require further assessment.
PTS: 1 DIF: Easy REF: p. 517
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
____ 2. Which disorder(s) might limit a patient’s visual field? Select all that apply.
1)
Diabetes
2)
Advanced glaucoma
3)
Peripheral vascular disease
4)
Cataracts
ANS: 1, 2, 4
Poorly controlled diabetes, cataracts, macular degeneration, and advanced glaucoma may limit the visual field. Peripheral vascular disease may be associated with diabetes, but it occurs in the extremities, not the eyes.
PTS: 1 DIF: Moderate REF: p. 501
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
