Lewis s medical sugrical nursing 11th edition testbank pdf

Lewis’s Medical-Surgical Nursing: Assessment
and Management of Clinical Problems 11th Edition
TESTBANK
Table of Contents
Chapter 1. Professional Nursing
MULTIPLE CHOICE
1. The nurse completes an admission database and explains that the plan of care and
discharge goals will be developed with the patients input. The patient states, How is
this different from what the doctor does? Which response would be most appropriate
for the nurse to make?
a. The role of the nurse is to administer medications and other treatments
prescribed by your doctor.
b. The nurses job is to help the doctor by collecting information and
communicating any problems that occur.
c. Nurses perform many of the same procedures as the doctor, but nurses
are with the patients for a longer time than the doctor.
d. In addition to caring for you while you are sick, the nurses will assist
you to develop an individualized plan to maintain your health.
ANS: D
This response is consistent with the American Nurses Association (ANA) definition
of nursing, which describes the role of nurses in promoting health. The other
responses describe some of the dependent and collaborative functions of the nursing
role but do not accurately describe the nurses role in the health care system.
DIF: Cognitive Level: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
2. The nurse describes to a student nurse how to use evidence-based practice
guidelines when caring for patients. Which statement, if made by the nurse, would be
the most accurate?
a. Inferences from clinical research studies are used as a guide.
b. Patient care is based on clinical judgment, experience, and traditions.
c. Data are evaluated to show that the patient outcomes are consistently
met.
d. Recommendations are based on research, clinical expertise, and patient
preferences.
ANS: D
Evidence-based practice (EBP) is the use of the best research-based evidence
combined with clinician expertise. Clinical judgment based on the nurses clinical
experience is part of EBP, but clinical decision making should also incorporate
current research and research-based guidelines. Evaluation of patient outcomes is
important, but interventions should be based on research from randomized control
studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) REF: 11
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
3. The nurse teaches a student nurse about how to apply the nursing process when
providing patient care. Which statement, if made by the student nurse, indicates that
teaching was successful?
a. The nursing process is a scientific-based method of diagnosing the
patients health care problems.
b. The nursing process is a problem-solving tool used to identify and treat
patients health care needs.
c. The nursing process is based on nursing theory that incorporates the
biopsychosocial nature of humans.
d. The nursing process is used primarily to explain nursing interventions to
other health care professionals.
ANS: B
The nursing process is a problem-solving approach to the identification and treatment
of patients problems. Diagnosis is only one phase of the nursing process. The primary
use of the nursing process is in patient care, not to establish nursing theory or explain
nursing interventions to other health care professionals.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. A patient has been admitted to the hospital for surgery and tells the nurse, I do not
feel comfortable leaving my children with my parents. Which action should the nurse
take next?
a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Gather more data about the patients feelings about the child-care
arrangements.
d. Call the patients parents to determine whether adequate child care is
being provided.
ANS: C
Since a complete assessment is necessary in order to identify a problem and choose an
appropriate intervention, the nurses first action should be to obtain more information.
The other actions may be appropriate, but more assessment is needed before the best
intervention can be chosen.
DIF: Cognitive Level: Apply (application) REF: 6-7
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Psychosocial Integrity
5. A patient who is paralyzed on the left side of the body after a stroke develops a
pressure ulcer on the left hip. Which nursing diagnosis is most appropriate?
a. Impaired physical mobility related to left-sided paralysis
b. Risk for impaired tissue integrity related to left-sided weakness
c. Impaired skin integrity related to altered circulation and pressure
d. Ineffective tissue perfusion related to inability to move independently
ANS: C
The patients major problem is the impaired skin integrity as demonstrated by the
presence of a pressure ulcer. The nurse is able to treat the cause of altered circulation
and pressure by frequently repositioning the patient. Although left-sided weakness is a
problem for the patient, the nurse cannot treat the weakness. The risk for diagnosis is
not appropriate for this patient, who already has impaired tissue integrity. The patient
does have ineffective tissue perfusion, but the impaired skin integrity diagnosis
indicates more clearly what the health problem is.
DIF: Cognitive Level: Apply (application) REF: 7-9
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume
related to excessive diaphoresis. Which outcome would the nurse recognize as most
appropriate for this patient?
a. Patient has a balanced intake and output.
b. Patients bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patients skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficient
fluid volume that was identified in the nursing diagnosis statement. The other
statements would not indicate that the problem of deficient fluid volume was resolved.
DIF: Cognitive Level: Apply (application) REF: 7-9
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. A nurse asks the patient if pain was relieved after receiving medication. What is the
purpose of the evaluation phase of the nursing process?
a. To determine if interventions have been effective in meeting patient
outcomes
b. To document the nursing care plan in the progress notes of the medical
record
c. To decide whether the patients health problems have been completely
resolved
d. To establish if the patient agrees that the nursing care provided was
satisfactory
ANS: A
Evaluation consists of determining whether the desired patient outcomes have been
met and whether the nursing interventions were appropriate. The other responses do
not describe the evaluation phase.
DIF: Cognitive Level: Understand (comprehension) REF: 7-9
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
8. The nurse interviews a patient while completing the health history and physical
examination. What is the purpose of the assessment phase of the nursing process?
a. To teach interventions that relieve health problems
b. To use patient data to evaluate patient care outcomes
c. To obtain data with which to diagnose patient problems
d. To help the patient identify realistic outcomes for health problems
ANS: C
During the assessment phase, the nurse gathers information about the patient to
diagnose patient problems. The other responses are examples of the planning,
intervention, and evaluation phases of the nursing process.
DIF: Cognitive Level: Understand (comprehension) REF: 7-9
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
9. Which nursing diagnosis statement is written correctly?
a. Altered tissue perfusion related to heart failure
b. Risk for impaired tissue integrity related to sacral redness
c. Ineffective coping related to response to biopsy test results
d. Altered urinary elimination related to urinary tract infection
ANS: C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that
describes a patients response to a health problem that can be treated by nursing. The
use of a medical diagnosis as an etiology (as in the responses beginning Altered tissue
perfusion and Altered urinary elimination) is not appropriate. The response beginning
Risk for impaired tissue integrity uses the defining characteristic as the etiology.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
10. The nurse admits a patient to the hospital and develops a plan of care. What
components should the nurse include in the nursing diagnosis statement?
a. The problem and the suggested patient goals or outcomes
b. The problem with possible causes and the planned interventions
c. The problem, its cause, and objective data that support the problem
d. The problem with an etiology and the signs and symptoms of the
problem
ANS: D
When writing nursing diagnoses, this format should be used: problem, etiology, and
signs and symptoms. The subjective, as well as objective, data should be included in
the defining characteristics. Interventions and outcomes are not included in the
nursing diagnosis statement.
DIF: Cognitive Level: Remember (knowledge) REF: 8-9
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
11. A nurse is caring for a patient with heart failure. Which task is appropriate for the
nurse to delegate to experienced unlicensed assistive personnel (UAP)?
a. Monitor for shortness of breath or fatigue after ambulation.
b. Instruct the patient about the need to alternate activity and rest.
c. Obtain the patients blood pressure and pulse rate after ambulation.
d. Determine whether the patient is ready to increase the activity level.
ANS: C
UAP education includes accurate vital sign measurement. Assessment and patient
teaching require registered nurse education and scope of practice and cannot be
delegated.
DIF: Cognitive Level: Apply (application) REF: 15
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
12. A nurse is caring for a group of patients on the medical-surgical unit with the help
of one float registered nurse (RN), one unlicensed assistive personnel (UAP), and one
licensed practical/vocational nurse (LPN/LVN). Which assignment, if delegated by
the nurse, would be inappropriate?
a. Measurement of a patients urine output by UAP
b. Administration of oral medications by LPN/LVN
c. Check for the presence of bowel sounds and flatulence by UAP
d. Care of a patient with diabetes by RN who usually works on the
pediatric unit
ANS: C
Assessment requires RN education and scope of practice and cannot be delegated to
an LPN/LVN or UAP. The other assignments made by the RN are appropriate.
DIF: Cognitive Level: Apply (application) REF: 15-16
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
13. Which task is appropriate for the nurse to delegate to a licensed
practical/vocational nurse (LPN/LVN)?
a. Complete the initial admission assessment and plan of care.
b. Document teaching completed before a diagnostic procedure.
c. Instruct a patient about low-fat, reduced sodium dietary restrictions.
d. Obtain bedside blood glucose on a patient before insulin administration.
ANS: D
The education and scope of practice of the LPN/LVN include activities such as
obtaining glucose testing using a finger stick. Patient teaching and the initial
assessment and development of the plan of care are nursing actions that require
registered nurse education and scope of practice.
DIF: Cognitive Level: Apply (application) REF: 15-16
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
14. A nurse is assigned as a case manager for a hospitalized patient with a spinal cord
injury. The patient can expect the nurse functioning in this role to perform which
activity?
a. Care for the patient during hospitalization for the injuries.
b. Assist the patient with home care activities during recovery.
c. Determine what medical care the patient needs for optimal
rehabilitation.
d. Coordinate the services that the patient receives in the hospital and at
home.
ANS: D
The role of the case manager is to coordinate the patients care through multiple
settings and levels of care to allow the maximal patient benefit at the least cost. The
case manager does not provide direct care in either the acute or home setting. The case
manager coordinates and advocates for care but does not determine what medical care
is needed; that would be completed by the health care provider or other provider.
DIF: Cognitive Level: Apply (application) REF: 15
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
15. The nurse is caring for an older adult patient who had surgery to repair a fractured
hip. The patient needs continued nursing care and physical therapy to improve
mobility before returning home. The nurse will help to arrange for transfer of this
patient to which facility?
a. A skilled care facility
b. A residential care facility
c. A transitional care facility
d. An intermediate care facility
ANS: C
Transitional care settings are appropriate for patients who need continued
rehabilitation before discharge to home or to long-term care settings. The patient is no
longer in need of the more continuous assessment and care given in acute care
settings. There is no indication that the patient will need the permanent and ongoing
medical and nursing services available in intermediate or skilled care. The patient is
not yet independent enough to transfer to a residential care facility.
DIF: Cognitive Level: Apply (application)
REF: eTable 1-1 | eTable 1-2 | eTable 1-3 TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
16. A home care nurse is planning care for a patient who has just been diagnosed with
type 2 diabetes mellitus. Which task is appropriate for the nurse to delegate to the
home health aide?
a. Assist the patient to choose appropriate foods.
b. Help the patient with a daily bath and oral care.
c. Check the patients feet for signs of breakdown.
d. Teach the patient how to monitor blood glucose.
ANS: B
Assisting with patient hygiene is included in home health-aide education and scope of
practice. Assessment of the patient and instructing the patient in new skills, such as
diet and blood glucose monitoring, are complex skills that are included in registered
nurse education and scope of practice.
DIF: Cognitive Level: Apply (application) REF: 14
OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
17. The nurse is providing education to nursing staff on quality care initiatives. Which
statement would be the most accurate description of the impact of health care
financing on quality care?
a. Hospitals are reimbursed for all costs incurred if care is documented
electronically.
b. Payment for patient care is primarily based on clinical outcomes and
patient satisfaction.
c. If a patient develops a catheter-related infection, the hospital receives
additional funding.
d. Because hospitals are accountable for overall care, it is not nursings
responsibility to monitor care delivered by others.
ANS: B
Payment for health care services programs reimburses hospitals for their performance
on overall quality-of-care measures. These measures include clinical outcomes and
patient satisfaction. Nurses are responsible for coordinating complex aspects of
patient care, including the care delivered by others, and identifying issues that are
associated with poor quality care. Payment for care can be withheld if something
happens to the patient that is considered preventable (e.g., acquiring a catheter-related
urinary tract infection).
DIF: Cognitive Level: Apply (application) REF: 4-5
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
18. The nurse documenting the patients progress in the care plan in the electronic
health record before an interdisciplinary discharge conference is demonstrating
competency in which QSEN category?
a. Patient-centered care
b. Quality improvement
c. Evidence-based practice
d. Informatics and technology
ANS: D
The nurse is displaying competency in the QSEN area of informatics and technology.
Using a computerized information system to document patient needs and progress and
communicate vital information regarding the patient with health care team members
provides evidence that nursing practice standards related to the nursing process have
been maintained during the care of the patient.
DIF: Cognitive Level: Apply (application) REF: 5 | 10-11
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. Which information will the nurse consider when deciding what nursing actions to
delegate to a licensed practical/vocational nurse (LPN/LVN) who is working on a
medical-surgical unit (select all that apply)?
a. Institutional policies
b. Stability of the patient
c. State nurse practice act
d. LPN/LVN teaching abilities
e. Experience of the LPN/LVN
ANS: A, B, C, E
The nurse should assess the experience of LPN/LVNs when delegating. In addition,
state nurse practice acts and institutional policies must be considered. In general,
LPN/LVN scope of practice includes caring for patients who are stable, while
registered nurses should provide most of the care for unstable patients. Since
LPN/LVN scope of practice does not include patient education, this will not be part of
the delegation process.
DIF: Cognitive Level: Apply (application) REF: 14
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
2. The nurse is administering medications to a patient. Which actions by the nurse
during this process are consistent with promoting safe delivery of care (select all that
apply)?
a. Throws away a medication that is not labeled
b. Uses a hand sanitizer before preparing a medication
c. Identifies the patient by the room number on the door
d. Checks lab test results before administering a diuretic
e. Gives the patient a list of current medications upon discharge
ANS: A, B, D, E
National Patient Safety Goals have been established to promote safe delivery of care.
The nurse should use at least two reliable ways to identify the patient such as asking
the patients full name and date of birth before medication administration. Other
actions that improve patient safety include performing hand hygiene, disposing of
unlabeled medications, completing appropriate assessments before administering
medications, and giving a list of the current medicines to the patient and caregiver
before discharge.
DIF: Cognitive Level: Apply (application) REF: 15-16
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
OTHER
1. The nurse uses the Situation-Background-Assessment-Recommendation (SBAR)
format to communicate a change in patient status to a health care provider. In which
order should the nurse make the following statements? (Put a comma and a space
between each answer choice [A, B, C, D].)
a. The patient needs to be evaluated immediately and may need intubation and
mechanical ventilation.
b. The patient was admitted yesterday with heart failure and has been receiving
furosemide (Lasix) for diuresis, but urine output has been low.
c. The patient has crackles audible throughout the posterior chest and the most recent
oxygen saturation is 89%. Her condition is very unstable.
d. This is the nurse on the surgical unit. After assessing the patient, I am very
concerned about increased shortness of breath over the past hour.
ANS:
D, B, C, A
The order of the nurses statements follows the SBAR format.
Chapter 2. Health Equity and Culturally Competent Care
MULTIPLE CHOICE
1. The nurse is obtaining a health history from a new patient. Which data will be the
focus of patient teaching?
a. Age and gender
b. Saturated fat intake
c. Hispanic/Latino ethnicity
d. Family history of diabetes
ANS: B
Behaviors are strongly linked to many health care problems. The patients saturated fat
intake is a behavior that the patient can change. The other information will be useful
as the nurse develops an individualized plan for improving the patients health, but will
not be the focus of patient teaching.
DIF: Cognitive Level: Apply (application) REF: 31
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
2. The nurse works in a clinic located in a community with many Hispanics. Which
strategy, if implemented by the nurse, would decrease health care disparities for the
Hispanic patients?
a. Improve public transportation to the clinic.
b. Update equipment and supplies at the clinic.
c. Obtain low-cost medications for clinic patients.
d. Teach clinic staff about Hispanic health beliefs.
ANS: D
Health care disparities are due to stereotyping, biases, and prejudice of health care
providers. The nurse can decrease these through staff education. The other strategies
also may be addressed by the nurse but will not directly impact health disparities.
DIF: Cognitive Level: Apply (application) REF: 24-25
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
3. What information should the nurse collect when assessing the health status of a
community?
a. Air pollution levels
b. Number of health food stores
c. Most common causes of death
d. Education level of the individuals
ANS: C
Health status measures of a community include birth and death rates, life expectancy,
access to care, and morbidity and mortality rates related to disease and injury.
Although air pollution, access to health food stores, and education level are factors
that affect a communitys health status, they are not health measures.
DIF: Cognitive Level: Understand (comprehension) REF: 19
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
4. The nurse is caring for a Native American patient who has traditional beliefs about
health and illness. Which action by nurse is most appropriate?
a. Avoid asking questions unless the patient initiates the conversation.
b. Ask the patient whether it is important that cultural healers are
contacted.
c. Explain the usual hospital routines for meal times, care, and family
visits.
d. Obtain further information about the patients cultural beliefs from a
family member.
ANS: B
Because the patient has traditional health care beliefs, it is appropriate for the nurse to
ask whether the patient would like a visit by a shaman or other cultural healer. There
is no cultural reason for the nurse to avoid asking the patient questions because they
are necessary to obtain health information. The patient (rather than the family) should
be consulted about personal cultural beliefs. The hospital routines for meals, care, and
visits should be adapted to the patients preferences rather than expecting the patient to
adapt to the hospital schedule.
DIF: Cognitive Level: Apply (application) REF: 26
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
5. The nurse is caring for an Asian patient who is being admitted to the hospital.
Which action would be most appropriate for the nurse to take when interviewing this
patient?
a. Avoid eye contact with the patient.
b. Observe the patients use of eye contact.
c. Look directly at the patient when interacting.
d. Ask a family member about the patients cultural beliefs.
ANS: B
Observation of the patients use of eye contact will be most useful in determining the
best way to communicate effectively with the patient. Looking directly at the patient
or avoiding eye contact may be appropriate, depending on the patients individual
cultural beliefs. The nurse should assess the patient, rather than asking family
members about the patients beliefs.
DIF: Cognitive Level: Apply (application) REF: 28 | 31
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
6. A female staff nurse is assessing a male patient of Arab descent who is admitted
with complaints of severe headaches. It is most important for the charge nurse to
intervene if the nurse takes which action?
a. The nurse explains the 0 to 10 intensity pain scale.
b. The nurse asks the patient when the headaches started.
c. The nurse sits down at the bedside and closes the privacy curtain.
d. The nurse calls for a male nurse to bring a hospital gown to the room.
ANS: C
Many males of Arab ethnicity do not believe it is appropriate to be alone with any
female except for their spouse. The other actions are appropriate.
DIF: Cognitive Level: Apply (application) REF: 28
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
7. The nurse cares for a patient who speaks a different language. If an interpreter is not
available, which action by the nurse is most appropriate?
a. Talk slowly so that each word is clearly heard.
b. Speak loudly in close proximity to the patients ears.
c. Repeat important words so that the patient recognizes their significance.
d. Use simple gestures to demonstrate meaning while talking to the patient.
ANS: D
The use of gestures will enable some information to be communicated to the patient.
The other actions will not improve communication with the patient.
DIF: Cognitive Level: Understand (comprehension) REF: 32
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
8. The nurse plans care for a hospitalized patient who uses culturally based treatments.
Which action by the nurse is best?
a. Encourage the use of diagnostic procedures.
b. Coordinate the use of folk treatments with ordered medical therapies.
c. Ask the patient to discontinue the cultural treatments during
hospitalization.
d. Teach the patient that folk remedies will interfere with orders by the
health care provider.
ANS: B
Many culturally based therapies can be accommodated along with the use of Western
treatments and medications. The nurse should attempt to use both traditional folk
treatments and the ordered Western therapies as much as possible. Some culturally
based treatments can be effective in treating Western diseases. Not all folk remedies
interfere with Western therapies. It may be appropriate for the patient to continue
some culturally based treatments while he or she is hospitalized.
DIF: Cognitive Level: Apply (application) REF: 26
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
9. The nurse is caring for a newly admitted patient. Which intervention is the best
example of a culturally appropriate nursing intervention?
a. Insist family members provide most of the patients personal care.
b. Maintain a personal space of at least 2 feet when assessing the patient.
c. Ask permission before touching a patient during the physical
assessment.
d. Consider the patients ethnicity as the most important factor in planning
care.
ANS: C
Many cultures consider it disrespectful to touch a patient without asking permission,
so asking a patient for permission is always culturally appropriate. The other actions
may be appropriate for some patients but are not appropriate across all cultural groups
or for all individual patients. Ethnicity may not be the most important factor in
planning care, especially if the patient has urgent physiologic problems.
DIF: Cognitive Level: Understand (comprehension) REF: 28
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
10. A staff nurse expresses frustration that a Native American patient always has
several family members at the bedside. Which action by the charge nurse is most
appropriate?
a. Remind the nurse that family support is important to this family and
patient.
b. Have the nurse explain to the family that too many visitors will tire the
patient.
c. Suggest that the nurse ask family members to leave the room during
patient care.
d. Ask about the nurses personal beliefs about family support during
hospitalization.
ANS: D
The first step in providing culturally competent care is to understand ones own beliefs
and values related to health and health care. Asking the nurse about personal beliefs
will help achieve this step. Reminding the nurse that this cultural practice is important
to the family and patient will not decrease the nurses frustration. The remaining
responses (suggest that the nurse ask family members to leave the room, and have the
nurse explain to family that too many visitors will tire the patient) are not culturally
appropriate for this patient.
DIF: Cognitive Level: Apply (application) REF: 30-31
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
11. An older Asian American patient tells the nurse that she has lived in the United
States for 50 years. The patient speaks English and lives in a predominantly Asian
neighborhood. Which action by the nurse is most appropriate?
a. Include a shaman when planning the patients care.
b. Avoid direct eye contact with the patient during care.
c. Ask the patient about any special cultural beliefs or practices.
d. Involve the patients oldest son to assist with health care decisions.
ANS: C
Further assessment of the patients health care preferences is needed before making
further plans for culturally appropriate care. The other responses indicate stereotyping
of the patient based on ethnicity and would not be appropriate initial actions.
DIF: Cognitive Level: Apply (application) REF: 31
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
12. The nurse plans health care for a community with a large number of recent
immigrants from Vietnam. Which intervention is the most important for the nurse to
implement?
a. Hepatitis testing
b. Tuberculosis screening
c. Contraceptive teaching
d. Colonoscopy information
ANS: B
Tuberculosis (TB) is endemic in many parts of Asia, and the incidence of TB is much
higher in immigrants from Vietnam than in the general U.S. population. Teaching
about contraceptive use, colonoscopy, and testing for hepatitis may also be
appropriate for some patients but is not generally indicated for all members of this
community.
DIF: Cognitive Level: Apply (application) REF: 29
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
13. When doing an admission assessment for a patient, the nurse notices that the
patient pauses before answering questions about the health history. Which action by
the nurse is most appropriate?
a. Interview a family member instead.
b. Wait for the patient to answer the questions.
c. Remind the patient that you have other patients who need care.
d. Give the patient an assessment form listing the questions and a pen.
ANS: B
Patients from some cultures take time to consider a question carefully before
answering. The nurse will show respect for the patient and help develop a trusting
relationship by allowing the patient time to give a thoughtful answer. Asking the
patient why the answers are taking so much time, stopping the assessment, and
handing the patient a form indicate that the nurse does not have time for the patient.
DIF: Cognitive Level: Apply (application) REF: 28
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
14. Which strategy should be a priority when the nurse is planning care for a diabetic
patient who is uninsured?
a. Obtain less expensive medications.
b. Follow evidence-based practice guidelines.
c. Assist with dietary changes as the first action.
d. Teach about the impact of exercise on diabetes.
ANS: B
The use of standardized evidence-based guidelines will reduce the incidence of health
care disparities among various socioeconomic groups. The other strategies may also
be appropriate, but the priority concern should be that the patient receives care that
meets the accepted standard.
DIF: Cognitive Level: Apply (application) REF: 23 | 31
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
15. A Hispanic patient complains of abdominal cramping caused by empacho. Which
action should the nurse take first?
a. Ask the patient what treatments are likely to help.
b. Massage the patients abdomen until the pain is gone.
c. Administer prescribed medications to decrease the cramping.
d. Offer to contact a curandero(a) to make a visit to the patient.
ANS: A
Further assessment of the patients cultural beliefs is appropriate before implementing
any interventions for a culture-bound syndrome such as empacho. Although
medication, a visit by a curandero(a), or massage may be helpful, more information
about the patients beliefs is needed to determine which intervention(s) will be most
helpful.
DIF: Cognitive Level: Apply (application) REF: 26 | 30
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Psychosocial Integrity
16. The nurse performs a cultural assessment with a patient from a different culture.
Which action by the nurse should be taken first?
a. Request an interpreter before interviewing the patient.
b. Wait until a family member is available to help with the assessment.
c. Ask the patient about any affiliation with a particular cultural group.
d. Tell the patient what the nurse already knows about the patients culture.
ANS: C
An early step in performing a cultural assessment is to determine whether the patient
feels an affiliation with any cultural group. The other actions may be appropriate if the
patient does identify with a particular culture.
DIF: Cognitive Level: Apply (application) REF: 30-31
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Psychosocial Integrity
17. The nurse working in a clinic in a primarily African American community notes a
higher incidence of uncontrolled hypertension in the patients. To correct this health
disparity, which action should the nurse take first?
a. Initiate a regular home-visit program by nurses working at the clinic.
b. Schedule teaching sessions about low-salt diets at community events.
c. Assess the perceptions of community members about the care at the
clinic.
d. Obtain low-cost antihypertensive drugs using funding from government
grants.
ANS: C
Before other actions are taken, additional assessment data are needed to determine the
reason for the disparity. The other actions also may be appropriate, but additional
assessment is needed before the next action is selected.
DIF: Cognitive Level: Apply (application) REF: 30-31
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The nurse is performing an admission assessment for a non-English speaking
patient who is from China. Which actions could the nurse take to enhance
communication (select all that apply)?
a. Use an electronic translation application.
b. Use a telephone-based medical interpreter.
c. Wait until an agency interpreter is available.
d. Ask the patients teenage daughter to interpret.
e. Use exaggerated gestures to convey information.
ANS: A, B, C
Electronic translation applications, telephone-based interpreters, and agency
interpreters are all appropriate to use to communicate with nonEnglish-speaking
patients. When no interpreter is available, family members may be considered, but
some information that will be needed in an admission assessment may be
misunderstood or not shared if a child is used as the interpreter. Gestures are
appropriate to use, but exaggeration of the gestures is not needed.
Chapter 3. Health History and Physical Examination
MULTIPLE CHOICE
1. A patient who is actively bleeding is admitted to the emergency department. Which
approach is best for the nurse to use to obtain a health history?
a. Briefly interview the patient while obtaining vital signs.
b. Obtain subjective data about the patient from family members.
c. Omit subjective data collection and obtain the physical examination.
d. Use the health care providers medical history to obtain subjective data.
ANS: A
In an emergency situation the nurse may need to ask only the most pertinent questions
for a specific problem and obtain more information later. A complete health history
will include subjective information that is not available in the health care providers
medical history. Family members may be able to provide some subjective data, but
only the patient will be able to give subjective information about the bleeding.
Because the subjective data about the cause of the patients bleeding will be essential,
obtaining the physical examination alone will not provide sufficient information.
DIF: Cognitive Level: Apply (application) REF: 45
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
2. Immediate surgery is planned for a patient with acute abdominal pain. Which
question by the nurse will elicit the most complete information about the patients
coping-stress tolerance pattern?
a. Can you rate your pain on a 0 to 10 scale?
b. What do you think caused this abdominal pain?
c. How do you feel about yourself and your hospitalization?
d. Are there other major problems that are a concern right now?
ANS: D
The coping-stress tolerance pattern includes information about other major stressors
confronting the patient. The health perceptionhealth management pattern includes
information about the patients ideas about risk factors. Feelings about self and the
hospitalization are assessed in the self-perceptionself-concept pattern. Intensity of
pain is part of the cognitive-perceptual pattern.
DIF: Cognitive Level: Apply (application) REF: 41
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
3. During the health history interview, a patient tells the nurse about periodic fainting
spells. Which question by the nurse will best elicit any associated clinical
manifestations?
a. How frequently do you have the fainting spells?
b. Where are you when you have the fainting spells?
c. Do the spells tend to occur at any special time of day?
d. Do you have any other symptoms along with the spells?
ANS: D
Asking about other associated symptoms will provide the nurse more information
about all the clinical manifestations related to the fainting spells. Information about
the setting is obtained by asking where the patient was and what the patient was doing
when the symptom occurred. The other questions from the nurse are appropriate for
obtaining information about chronology and frequency.
DIF: Cognitive Level: Apply (application) REF: 42
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
4. The nurse records the following general survey of a patient: The patient is a 50-
year-old Asian female attended by her husband and two daughters. Alert and oriented.
Does not make eye contact with the nurse and responds slowly, but appropriately, to
questions. No apparent disabilities or distinguishing features. What additional
information should the nurse add to this general survey?
a. Nutritional status
b. Intake and output
c. Reasons for contact with the health care system
d. Comments of family members about his condition
ANS: A
The general survey also describes the patients general nutritional status. The other
information will be obtained when doing the complete nursing history and
examination but is not obtained through the initial scanning of a patient.
DIF: Cognitive Level: Understand (comprehension) REF: 39-41
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
5. A nurse performs a health history and physical examination with a patient who has
a right leg fracture. Which assessment would be a pertinent negative finding?
a. Patient has several bruised and swollen areas on the right leg.
b. Patient states that there have been no other recent health problems.
c. Patient refuses to bend the right knee because of the associated pain.
d. Patient denies having pain when the area over the fracture is palpated.
ANS: D
The nurse expects that a patient with a leg fracture will have pain over the fractured
area. The bruising and swelling and pain with bending are positive findings. No other
recent health problems is neither a positive nor a negative finding with regard to a leg
fracture.
DIF: Cognitive Level: Apply (application) REF: 41
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
6. The nurse who is assessing an older adult with rectal bleeding asks, Have you ever
had a colonoscopy? The nurse is performing what type of assessment?
a. Focused assessment
b. Emergency assessment
c. Detailed health assessment
d. Comprehensive assessment
ANS: A
A focused assessment is an abbreviated assessment used to evaluate the status of
previously identified problems and monitor for signs of new problems. It can be done
when a specific problem is identified. An emergency assessment is done when the
nurse needs to obtain information about life-threatening problems quickly while
simultaneously taking action to maintain vital function. A comprehensive assessment
includes a detailed health history and physical examination of one body system or
many body systems. It is typically done on admission to the hospital or onset of care
in a primary care setting.
DIF: Cognitive Level: Understand (comprehension) REF: 42
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
7. The nurse is preparing to perform a focused assessment for a patient complaining of
shortness of breath. Which equipment will be needed?
a. Flashlight
b. Stethoscope
c. Tongue blades
d. Percussion hammer
ANS: B
A stethoscope is used to auscultate breath sounds. The other equipment may be used
for a comprehensive assessment but will not be needed for a focused respiratory
assessment.
DIF: Cognitive Level: Understand (comprehension) REF: 42
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
8. The nurse plans to complete a physical examination of an alert, older patient. Which
adaptations to the examination technique should the nurse include?
a. Avoid the use of touch as much as possible.
b. Use slightly more pressure for palpation of the liver.
c. Speak softly and slowly when talking with the patient.
d. Organize the sequence to minimize the position changes.
ANS: D
Older patients may have age-related changes in mobility that make it more difficult to
change position. There is no need to avoid the use of touch when examining older
patients. Less pressure should be used over the liver. Because the patient is alert, there
is no indication that there is any age-related difficulty in understanding directions
from the nurse.
DIF: Cognitive Level: Apply (application) REF: 42
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
9. While the nurse is taking the health history, a patient states, My mother and sister
both had double mastectomies and were unable to be very active for weeks. Which
functional health pattern is represented by this patients statement?
a. Activity-exercise
b. Cognitive-perceptual
c. Coping-stress tolerance
d. Health perceptionhealth management
ANS: D
The information in the patient statement relates to risk factors and important
information about the family history. Identification of risk factors falls into the health
perceptionhealth maintenance pattern.
DIF: Cognitive Level: Understand (comprehension) REF: 39-40
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
10. A patient is seen in the emergency department with severe abdominal pain and
hypotension. Which type of assessment should the nurse do at this time?
a. Focused assessment
b. Subjective assessment
c. Emergency assessment
d. Comprehensive assessment
ANS: C
Because the patient is hemodynamically unstable, an emergency assessment is
needed. Comprehensive and focused assessments may be needed after the patient is
stabilized. Subjective information is needed, but objective data such as vital signs are
essential for the unstable patient.
DIF: Cognitive Level: Understand (comprehension) REF: 42 | 45
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
11. The registered nurse (RN) cares for a patient who was admitted a few hours
previously with back pain after falling. Which action can the RN delegate to
unlicensed assistive personnel (UAP)?
a. Finish documenting the admission assessment.
b. Determine the patients priority nursing diagnoses.
c. Obtain the health history from the patients caregiver.
d. Take the patients temperature, pulse, and blood pressure.
ANS: D
The RN may delegate vital signs to the UAP. Obtaining the health history,
documentation of the admission assessment, and determining nursing diagnoses
require the education and scope of practice of the RN.
DIF: Cognitive Level: Apply (application) REF: 38
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
12. When assessing for formation of a possible blood clot in the lower leg of a patient,
which action should the nurse take first?
a. Visually inspect the leg.
b. Feel for the temperature of the leg.
c. Check the patients pedal pulses using the fingertips.
d. Compress the nail beds to determine capillary refill time.
ANS: A
Inspection is the first of the major techniques used in the physical examination.
Palpation and auscultation are then used later in the examination.
DIF: Cognitive Level: Apply (application) REF: 41
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
13. When assessing a patients abdomen during the admission assessment, which action
should the nurse take first?
a. Feel for any masses.
b. Palpate the abdomen.
c. Listen for bowel sounds.
d. Percuss the liver borders.
ANS: C
When assessing the abdomen, auscultation is done before palpation or percussion
because palpation and percussion can cause changes in bowel sounds and alter the
findings. All of the techniques are appropriate, but auscultation should be done first.
DIF: Cognitive Level: Understand (comprehension) REF: 41
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
14. When admitting a patient who has just arrived on the unit with a severe headache,
what should the nurse do first?
a. Complete only basic demographic data before addressing the patients
pain.
b. Medicate the patient for the headache before doing the health history
and examination.
c. Take the initial vital signs and then address the headache before
completing the health history.
d. Inform the patient that the headache will be treated as soon as the health
history is completed.
ANS: C
The patient priority in this situation will be to decrease the pain level because the
patient will be unlikely to cooperate in providing demographic data or the health
history until the nurse addresses the pain. However, obtaining information about vital
signs is essential before using either pharmacologic or nonpharmacologic therapies for
pain control. The vital signs may indicate hemodynamic instability that would need to
be addressed immediately.
DIF: Cognitive Level: Apply (application) REF: 37
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
OTHER
1. In what order will the nurse perform these actions when doing a physical
assessment for a patient admitted with abdominal pain? (Put a comma and a space
between each answer choice [A, B, C, D].)
a. Percuss the abdomen to locate any areas of dullness.
b. Palpate the abdomen to check for tenderness or masses.
c. Inspect the abdomen for distention or other abnormalities.
d. Auscultate the abdomen for the presence of bowel sounds.
ANS:
C, D, A, B
When assessing the abdomen, the initial action is to inspect the abdomen.
Auscultation is done next because percussion and palpation can alter bowel sounds
and produce misleading findings.
Chapter 4. Patient and Caregiver Teaching
MULTIPLE CHOICE
1. A patient with newly diagnosed colon cancer has a nursing diagnosis of deficient
knowledge about colon cancer. The nurse should initially focus on which learning
goal for this patient?
a. The patient will select the most appropriate colon cancer therapy.
b. The patient will state ways of preventing the recurrence of the cancer.
c. The patient will demonstrate coping skills needed to manage the disease.
d. The patient will choose methods to minimize adverse effects of
treatment.
ANS: A
Adults learn best when given information that can be used immediately. The first
action the patient will need to take after a cancer diagnosis is to choose a treatment
option. The other goals may be appropriate as treatment progresses.
DIF: Cognitive Level: Apply (application) REF: 48
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
2. After the nurse provides dietary instructions for a patient with diabetes, the patient
can explain the information but fails to make the recommended dietary changes. How
would the nurse evaluate the patients situation?
a. Learning did not occur because the patients behavior did not change.
b. Choosing not to follow the diet is the behavior that resulted from
learning.
c. The nursing responsibility for helping the patient make dietary changes
has been fulfilled.
d. The teaching methods were ineffective in helping the patient learn the
dietary instructions.
ANS: B
Although the patient behavior has not changed, the patients ability to explain the
information indicates that learning has occurred and the patient is choosing at this
time not to change the diet. The patient may be in the contemplation or preparation
stage in the Transtheoretical Model. The nurse should reinforce the need for change
and continue to provide information and assistance with planning for change.
DIF: Cognitive Level: Apply (application) REF: 49
TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance
3. A patient is diagnosed with heart failure after being admitted to the hospital for
shortness of breath and fatigue. Which teaching strategy, if implemented by the nurse,
is most likely to be effective?
a. Assure the patient that the nurse is an expert on management of heart
failure.
b. Teach the patient at each meal about the amounts of sodium in various
foods.
c. Discuss the importance of medication control in maintenance of long-
term health.
d. Refer the patient to a home health nurse for instructions on diet and fluid
restrictions.
ANS: B
Principles of adult education indicate that readiness and motivation to learn are high
when facing new tasks (such as learning about the sodium amounts in various food
items) and when demonstration and practice of skills are available. Although a home
health referral may be needed for this patient, teaching should not be postponed until
discharge. Adult learners are independent. The nurse should act as a facilitator for
learning, rather than as the expert. Adults learn best when the topic is of immediate
usefulness. Long-term goals may not be very motivating.
DIF: Cognitive Level: Apply (application) REF: 48
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
4. A patient who was admitted to the hospital with hyperglycemia and newly
diagnosed diabetes mellitus is scheduled for discharge the second day after admission.
When implementing patient teaching, what is the priority action for the nurse?
a. Instruct about the increased risk for cardiovascular disease.
b. Provide detailed information about dietary control of glucose.
c. Teach glucose self-monitoring and medication administration.
d. Give information about the effects of exercise on glucose control.
ANS: C
When time is limited, the nurse should focus on the priorities of teaching. In this
situation, the patient should know how to test blood glucose and administer
medications to control glucose levels. The patient will need further teaching about the
role of diet, exercise, various medications, and the many potential complications of
diabetes, but these topics can be addressed through planning for appropriate referrals.
DIF: Cognitive Level: Apply (application) REF: 50
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
5. A patient states, I told my husband I wouldnt buy as much prepared food snacks, so
I will go the grocery store to buy fresh fruit, vegetables, and whole grains. When
using the Transtheoretical Model of Health Behavior Change, the nurse identifies that
this patient is in which stage of change?
a. Preparation
b. Termination
c. Maintenance
d. Contemplation
ANS: A
The patients statement indicating that the plan for change is being shared with
someone else indicates that the preparation stage has been achieved. Contemplation of
a change would be indicated by a statement like I know I should exercise.
Maintenance of a change occurs when the patient practices the behavior regularly.
Termination would be indicated when the change is a permanent part of the lifestyle.
DIF: Cognitive Level: Understand (comprehension) REF: 49
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
6. While admitting a patient to the medical unit, the nurse determines that the patient
is hard of hearing. How should the nurse use this information to plan teaching and
learning strategies?
a. Motivation and readiness to learn will be affected.
b. The family must be included in the teaching process.
c. The patient will have problems understanding information.
d. Written materials should be provided with verbal instructions.
ANS: D
The information that the patient is hard of hearing indicates that the nurse should use
written and verbal materials in teaching along with other strategies. The patient does
not indicate a lack of motivation or an inability to understand new information. The
patients decreased hearing does not necessarily imply that the family must be included
in the teaching process.
DIF: Cognitive Level: Understand (comprehension) REF: 52
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
7. A patient who is morbidly obese states, Ive recently made some changes in my life.
Ive decreased my fat intake and Ive stopped smoking. Which statement, if made by
the nurse, is the best initial response?
a. Although those are important, it is essential that you make other
changes, too.
b. Are you having any difficulty in maintaining the changes you have
already made?
c. Which additional changes in your lifestyle would you like to implement
at this time?
d. You have already accomplished changes that are important for the health
of your heart.
ANS: D
Positive reinforcement of the learners achievements is critical in making lifestyle
changes. This patient is in the action stage of the Transtheoretical Model, when
reinforcement of the changes being made is an important nursing intervention. The
other responses are also appropriate, but are not the best initial response.
DIF: Cognitive Level: Apply (application) REF: 49
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
8. The nurse is planning a teaching session with a patient newly diagnosed with
migraine headaches. To assess a patients readiness to learn, which question should the
nurse ask?
a. What kind of work and leisure activities do you do?
b. What information do you think you need right now?
c. Can you describe the types of activities that help you learn new
information?
d. Do you have any religious beliefs that are inconsistent with the planned
treatment?
ANS: B
Motivation and readiness to learn depend on what the patient values and perceives as
important. The other questions are also important in developing the teaching plan, but
do not address what information most interests the patient at present.
DIF: Cognitive Level: Apply (application) REF: 48
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
9. The nurse considers a nursing diagnosis of ineffective health maintenance related to
low motivation for a patient with diabetes. Which finding would the nurse most likely
use to support this nursing diagnosis?
a. The patient does not perform capillary blood glucose tests as directed.
b. The patient occasionally forgets to take the daily prescribed medication.
c. The patient states that dietary changes have not made any difference at
all.
d. The patient cannot identify signs or symptoms of high and low blood
glucose.
ANS: C
The patients motivation to follow a diabetic diet will be decreased if the patient feels
that dietary changes do not affect symptoms. The other responses do not indicate that
the ineffective health maintenance is caused by lack of motivation.
DIF: Cognitive Level: Apply (application) REF: 48-49
TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance
10. A patient with diabetic neuropathy requires teaching about foot care. Which
learning goal should the nurse include in the teaching plan?
a. The nurse will demonstrate the proper technique for trimming toenails.
b. The patient will list three ways to protect the feet from injury by
discharge.
c. The nurse will instruct the patient on appropriate foot care before
discharge.
d. The patient will understand the rationale for proper foot care after
instruction.
ANS: B
Learning goals should state clear, measurable outcomes of the learning process.
Demonstrating technique for trimming toenails and providing instructions on foot care
are actions that the nurse will take rather than behaviors that indicate that patient
learning has occurred. A learning goal that states that the patient will understand the
rationale for proper foot care is too vague and nonspecific to measure whether
learning has occurred.
DIF: Cognitive Level: Apply (application) REF: 55
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
11. The nurse educator teaches students how to be more assertive. Which teaching
strategy, if implemented by the nurse educator, would be most effective?
a. Role playing
b. Peer teaching
c. Printed materials
d. Lecture-discussion
ANS: A
Role playing allows the students to practice assertive behavior and receive feedback
about how the behavior is perceived. Lecture-discussion, peer-teaching, and printed
materials are more useful for other learning needs.
DIF: Cognitive Level: Understand (comprehension) REF: 56
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
12. The nurse and the patient who is diagnosed with hypertension develop this goal:
The patient will select a 2-gram sodium diet from the hospital menu for the next 3
days. Which evaluation method will be best for the nurse to use when determining
whether teaching was effective?
a. Have the patient list substitutes for favorite foods that are high in
sodium.
b. Check the sodium content of the patients menu choices over the next 3
days.
c. Ask the patient to identify which foods on the hospital menus are high in
sodium.
d. Compare the patients sodium intake before and after the teaching was
implemented.
ANS: B
All of the answers address the patients sodium intake, but the desired patient
behaviors in the learning objective are most clearly addressed by evaluating the
sodium content of the patients menu choices.
DIF: Cognitive Level: Apply (application) REF: 57-58
TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance
13. The nurse prepares written handouts to be used as part of the standardized teaching
plan for patients who have been recently diagnosed with diabetes. What statement
would be appropriate to include in the handouts?
a. Eating the right foods can help in keeping blood glucose at a near-
normal level.
b. Polyphagia, polydipsia, and polyuria are common symptoms of diabetes
mellitus.
c. Some diabetics control blood glucose with oral medications, injections,
or nutritional interventions.
d. Diabetes mellitus is characterized by chronic hyperglycemia and the
associated symptoms than can lead to long-term complications.
ANS: A
The reading level for patient teaching materials should be at the 5th grade level. The
other responses have words with three or more syllables, use many medical terms,
and/or are too long.
DIF: Cognitive Level: Apply (application) REF: 53
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
14. The hospital nurse implements a teaching plan to assist an older patient who lives
alone to independently accomplish daily activities. How would the nurse best evaluate
the patients long-term response to the teaching?
a. Make a referral to the home health nursing department for home visits.
b. Have the patient demonstrate the learned skills at the end of the teaching
session.
c. Arrange a physical therapy visit before the patient is discharged from the
hospital.
d. Check the patients ability to bathe and get dressed without any
assistance the next day.
ANS: A
A home health referral would allow for the assessment of the patients long-term
response after discharge. The other actions allow evaluation of the patients short-term
response to teaching.
DIF: Cognitive Level: Apply (application) REF: 58
TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance
15. A patient who smokes a pack of cigarettes per day tells the nurse, I enjoy smoking
and have no plans to quit. Which nursing diagnosis is most appropriate?
a. Health seeking behaviors related to cigarette use
b. Ineffective health maintenance related to tobacco use
c. Readiness for enhanced self-health management related to smoking
d. Deficient knowledge related to long-term effects of cigarette smoking
ANS: B
The patients statement indicates that he or she is not considering smoking cessation.
Ineffective health maintenance is defined as the inability to identify, manage, and/or
seek out help to maintain health.
DIF: Cognitive Level: Apply (application) REF: 49
TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance
16. An older Asian patient, who is seen at the health clinic, is diagnosed with protein
malnutrition. What priority action should the nurse include in the teaching plan?
a. Suggest the use of liquid supplements as a way to increase protein
intake.
b. Encourage the patient to increase the dietary intake of meat, cheese, and
milk.
c. Ask the patient to record the intake of all foods and beverages for a 3-
day period.
d. Focus on the use of combinations of beans and rice to improve daily
protein intake.
ANS: C
Assessment is the first step in assisting a patient with health changes. The other
answers may be appropriate for the patient, but the nurse will not be able to determine
this until the assessment of the patient is complete.
DIF: Cognitive Level: Apply (application) REF: 52-54
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
17. A middle-aged patient who has diabetes tells the nurse, I want to know how to give
my own insulin so I dont have to bother my wife all the time. What is the priority
action of the nurse?
a. Demonstrate how to draw up and administer insulin.
b. Discuss the use of exercise to decrease insulin needs.
c. Teach about differences between the various types of insulin.
d. Provide handouts about therapeutic and adverse effects of insulin.
ANS: A
Adult education is most effective when focused on information that the patient thinks
is needed right now. All of the indicated information will need to be included when
planning teaching for this patient, but the teaching will be most effective if the nurse
starts with the patients stated priority topic.
DIF: Cognitive Level: Apply (application) REF: 48
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
18. The nurse plans to teach a patient and the caregiver how to manage high blood
pressure (BP). Which action should the nurse take first?
a. Give written information about hypertension to the patient and
caregiver.
b. Have the dietitian meet with the patient and caregiver to discuss a low
sodium diet.
c. Teach the caregiver how to take the patients BP using a manual blood
pressure cuff.
d. Ask the patient and caregiver to select information from a list of high BP
teaching topics.
ANS: D
Because adults learn best when given information that they view as being needed
immediately, asking the caregiver and patient to prioritize learning needs is likely to
be the most successful approach to home management of health problems. The other
actions may also be appropriate, depending on what learning needs the caregiver and
patient have, but the initial action should be to assess what the learners feel is
important.
DIF: Cognitive Level: Apply (application) REF: 54
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
19. A postoperative patient and caregiver need discharge teaching. Which actions
included in the teaching plan can the nurse delegate to unlicensed assistive personnel
(UAP)?
a. Evaluate whether the patient and caregiver understand the teaching.
b. Show the caregiver how to accurately check the patients temperature.
c. Schedule the discharge teaching session with the patient and caregiver.
d. Give the patient a pamphlet reinforcing teaching already done by the
nurse.
ANS: D
Providing a pamphlet to a patient to reinforce previously taught material does not
require nursing judgment and can safely be delegated to UAP. Demonstration of how
to take a temperature accurately, determining the best time for teaching, and
evaluation of the success of patient teaching all require judgment and critical thinking
and should be done by the registered nurse.
DIF: Cognitive Level: Apply (application) REF: 47-48
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
20. A family caregiver tells the home health nurse, I feel like I can never get away to
do anything for myself. Which action is best for the nurse to take?
a. Assist the caregiver in finding respite services.
b. Assure the caregiver that the work is appreciated.
c. Encourage the caregiver to discuss feelings openly with the nurse as
needed.
d. Teach the caregiver that family members can also provide excellent
patient care.
ANS: A
Respite services allow family caregivers to have time away from their caregiving
responsibilities. The other actions may also be helpful, but the caregivers statement
clearly indicates the need for some time away.
DIF: Cognitive Level: Apply (application) REF: 51
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
MULTIPLE RESPONSE
1. The nurse plans to provide instructions about diabetes to a patient who has a low
literacy level. Which teaching strategies should the nurse use (select all that apply)?
a. Discourage use of the Internet as a source of health information.
b. Avoid asking the patient about reading abilities and level of education.
c. Provide illustrations and photographs showing various types of insulin.
d. Schedule one-to-one teaching sessions to practice insulin administration.
e. Obtain CDs and DVDs that illustrate how to perform blood glucose
testing.
ANS: C, D, E
For patients with low literacy, visual and hands-on learning techniques are most
appropriate. The nurse will need to obtain as much information as possible about the
patients reading level in order to provide appropriate learning materials. The nurse
should guide the patient to Internet sites established by reputable heath care
organizations such as the American Diabetes Association.
Chapter 5. Chronic Illness and Older Adults
MULTIPLE CHOICE
1. When caring for an older patient with hypertension who has been hospitalized after
a transient ischemic (TIA), which topic is the most important for the nurse to include
in the discharge teaching?
a. Effect of atherosclerosis on blood vessels
b. Mechanism of action of anticoagulant drug therapy
c. Symptoms indicating that the patient should contact the health care
provider
d. Impact of the patients family history on likelihood of developing a
serious stroke
ANS: C
One of the tasks for patients with chronic illnesses is to prevent and manage a crisis.
The patient needs instruction on recognition of symptoms of hypertension and TIA
and appropriate actions to take if these symptoms occur. The other information also
may be included in patient teaching but is not as essential in the patients selfmanagement of the illness.
DIF: Cognitive Level: Apply (application) REF: 63
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
2. The nurse performs a comprehensive geriatric assessment of a patient who is being
assessed for admission to an assisted living facility. Which question is the most
important for the nurse to ask?
a. Have you had any recent infections?
b. How frequently do you see a doctor?
c. Do you have a history of heart disease?
d. Are you able to prepare your own meals?
ANS: D
The patients functional abilities, rather than the presence of an acute or chronic
illness, are more useful in determining how well the patient might adapt to an assisted
living situation. The other questions will also provide helpful information but are not
as useful in providing a basis for determining patient needs or for developing
interventions for the older patient.
DIF: Cognitive Level: Apply (application) REF: 71
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
3. An older patient who takes multiple medications for chronic cardiac and pulmonary
diseases is alert and lives with a daughter who works during the day. During a clinic
visit, the patient verbalizes to the nurse that she has a strained relationship with her
daughter and does not enjoy being alone all day. Which nursing diagnosis should the
nurse assign as the priority for this patient?
a. Risk for injury related to drug interactions
b. Social isolation related to weakness and fatigue
c. Compromised family coping related to the patients many care needs
d. Caregiver role strain related to need to adjust family employment
schedule
ANS: A
The patients age and multiple medications indicate a risk for injury caused by
interactions between the multiple drugs being taken and a decreased drug metabolism
rate. Problems with social isolation, caregiver role strain, or compromised family
coping are not physiologic priorities. Drug-drug interactions could cause the most
harm to the patient and is therefore the priority.
DIF: Cognitive Level: Apply (application) REF: 73-74
TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance
4. The nurse plans to complete a thorough assessment of an older patient. Which
method should the nurse use to gather the most complete information?
a. Use a geriatric assessment instrument to evaluate the patient.
b. Ask the patient to write down medical problems and medications.
c. Interview both the patient and the primary caregiver for the patient.
d. Review the patients medical record for a history of medical problems.
ANS: A
The most complete information about the patient will be obtained through the use of
an assessment instrument specific to the geriatric population, which includes
information about both medical diagnoses and treatments and about functional health
patterns and abilities. A review of the medical record, interviews with the patient and
caregiver, and written information by the patient are all included in a comprehensive
geriatric assessment.
DIF: Cognitive Level: Apply (application) REF: 71
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
5. An older patient is hospitalized with pneumonia. Which intervention should the
nurse implement to provide optimal care for this patient?
a. Use a standardized geriatric nursing care plan.
b. Minimize activity level during hospitalization.
c. Plan for transfer to a long-term care facility upon discharge.
d. Consider the preadmission functional abilities when setting patient
goals.
ANS: D
The plan of care for older adults should be individualized and based on the patients
current functional abilities. A standardized geriatric nursing care plan will not address
individual patient needs and strengths. A patients need for discharge to a long-term
care facility is variable. Activity level should be designed to allow the patient to retain
functional abilities while hospitalized and also to allow any additional rest needed for
recovery from the acute process.
DIF: Cognitive Level: Apply (application) REF: 71
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
6. The nurse cares for an older adult patient who lives in a rural area. Which
intervention should the nurse plan to implement to best meet this patients needs?
a. Suggest that the patient move to an urban area.
b. Assess the patient for chronic diseases that are unique to rural areas.
c. Ensure transportation to appointments with the health care provider.
d. Obtain adequate medications for the patient to last for 4 to 6 months.
ANS: C
Transportation can be a barrier to accessing health services in rural areas. The patient
living in a rural area may lose the benefits of a familiar situation and social support by
moving to an urban area. There are no chronic diseases unique to rural areas. Because
medications may change, the nurse should help the patient plan for obtaining
medications through alternate means such as the mail or delivery services, not by
purchasing large quantities of the medications.
DIF: Cognitive Level: Apply (application) REF: 66-67
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
7. Which nursing action will be most helpful in decreasing the risk for drug-drug
interactions in an older adult?
a. Teach the patient to have all prescriptions filled at the same pharmacy.
b. Instruct the patient to avoid taking over-the-counter (OTC) medications.
c. Make a schedule for the patient as a reminder of when to take each
medication.
d. Have the patient bring all medications, supplements, and herbs to each
appointment.
ANS: D
The most information about drug use and possible interactions is obtained when the
patient brings all prescribed medications, OTC medications, and supplements to every
health care appointment. The patient should discuss the use of any OTC medications
with the health care provider and obtain all prescribed medications from the same
pharmacy, but use of supplements and herbal medications also need to be considered
in order to prevent drug-drug interactions. Use of a medication schedule will help the
patient take medications as scheduled but will not prevent drug-drug interactions.
DIF: Cognitive Level: Understand (comprehension) REF: 74
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
8. A patient who has just moved to a long-term care facility has a nursing diagnosis of
relocation stress syndrome. Which action should the nurse include in the plan of care?
a. Remind the patient that making changes is usually stressful.
b. Discuss the reason for the move to the facility with the patient.
c. Restrict family visits until the patient is accustomed to the facility.
d. Have staff members write notes welcoming the patient to the facility.
ANS: D
Having staff members write notes will make the patient feel more welcome and
comfortable at the long-term care facility. Discussing the reason for the move and
reminding the patient that change is usually stressful will not decrease the patients
stress about the move. Family member visits will decrease the patients sense of stress
about the relocation.
DIF: Cognitive Level: Apply (application) REF: 70
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
9. An older patient complains of having no energy and feeling increasingly weak. The
patient has had a 12-pound weight loss over the last year. Which action should the
nurse take initially?
a. Ask the patient about daily dietary intake.
b. Schedule regular range-of-motion exercise.
c. Discuss long-term care placement with the patient.
d. Describe normal changes associated with aging to the patient.
ANS: A
In a frail older patient, nutrition is frequently compromised, and the nurses initial
action should be to assess the patients nutritional status. Active range of motion may
be helpful in improving the patients strength and endurance, but nutritional
assessment is the priority because the patient has had a significant weight loss. The
patient may be a candidate for long-term care placement, but more assessment is
needed before this can be determined. The patients assessment data are not consistent
with normal changes associated with aging.
DIF: Cognitive Level: Apply (application) REF: 67
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
10. The nurse admits an acutely ill, older patient to the hospital. Which action should
the nurse take first?
a. Speak slowly and loudly while facing the patient.
b. Obtain a detailed medical history from the patient.
c. Perform the physical assessment before interviewing the patient.
d. Ask a family member to go home and retrieve the patients cane.
ANS: C
When a patient is acutely ill, the physical assessment should be accomplished first to
detect any physiologic changes that require immediate action. Not all older patients
have hearing deficits, and it is insensitive of the nurse to speak loudly and slowly to
all older patients. To avoid tiring the patient, much of the medical history can be
obtained from medical records. After the initial physical assessment to determine the
patients current condition, then the nurse could ask someone to obtain any assistive
devices for the patient if applicable.
DIF: Cognitive Level: Apply (application) REF: 71
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
11. The nurse cares for an alert, homeless older adult patient who was admitted to the
hospital with a chronic foot infection. Which intervention is the most appropriate for
the nurse to include in the discharge plan for this patient?
a. Refer the patient to social services for further assessment.
b. Teach the patient how to assess and care for the foot infection.
c. Schedule the patient to return to outpatient services for foot care.
d. Give the patient written information about shelters and meal sites.
ANS: A
An interdisciplinary approach, including social services, is needed when caring for
homeless older adults. Even with appropriate teaching, a homeless individual may not
be able to maintain adequate foot care because of a lack of supplies or a suitable place
to accomplish care. Older homeless individuals are less likely to use shelters or meal
sites. A homeless person may fail to keep appointments for outpatient services
because of factors such as fear of institutionalization or lack of transportation.
DIF: Cognitive Level: Apply (application) REF: 67
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
12. The home health nurse cares for an older adult patient who lives alone and takes
several different prescribed medications for chronic health problems. Which
intervention, if implemented by the nurse, would best encourage medication
compliance?
a. Use a marked pillbox to set up the patients medications.
b. Discuss the option of moving to an assisted living facility.
c. Remind the patient about the importance of taking medications.
d. Visit the patient daily to administer the prescribed medications.
ANS: A
Because forgetting to take medications is a common cause of medication errors in
older adults, the use of medication reminder devices is helpful when older adults have
multiple medications to take. There is no indication that the patient needs to move to
assisted living or that the patient does not understand the importance of medication
compliance. Home health care is not designed for the patient who needs ongoing
assistance with activities of daily living (ADLs) or instrumental ADLs (IADLs).
DIF: Cognitive Level: Apply (application) REF: 65
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
13. The home health nurse visits an older patient with mild forgetfulness. The nurse is
most concerned if which information is obtained?
a. The patient tells the nurse that a close friend recently died.
b. The patient has lost 10 pounds (4.5 kg) during the last month.
c. The patient is cared for by a daughter during the day and stays with a
son at night.
d. The patients son uses a marked pillbox to set up the patients medications
weekly.
ANS: B
A 10-pound weight loss may be an indication of elder neglect or depression and
requires further assessment by the nurse. The use of a marked pillbox and planning by
the family for 24-hour care are appropriate for this patient. It is not unusual that an 86year-old would have friends who have died.
DIF: Cognitive Level: Apply (application) REF: 67
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
14. Which statement, if made by an older adult patient, would be of most concern to
the nurse?
a. I prefer to manage my life without much help from other people.
b. I take three different medications for my heart and joint problems.
c. I dont go on daily walks anymore since I had pneumonia 3 months ago.
d. I set up my medications in a marked pillbox so I dont forget to take
them.
ANS: C
Inactivity and immobility lead rapidly to loss of function in older adults. The nurse
should develop a plan to prevent further deconditioning and restore function for the
patient. Self-management is appropriate for independently living older adults. On
average, an older adult takes seven different medications so the use of three
medications is not unusual for this patient. The use of memory devices to assist with
safe medication administration is recommended for older adults.
DIF: Cognitive Level: Apply (application) REF: 73
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
15. The nurse assesses an older patient who takes diuretics and has a possible urinary
tract infection (UTI). Which action should the nurse take first?
a. Palpate over the suprapubic area.
b. Inspect for abdominal distention.
c. Question the patient about hematuria.
d. Invite the patient to use the bathroom.
ANS: D
Before beginning the assessment of an older patient with a UTI and on diuretics, the
nurse should have the patient empty the bladder because bladder fullness or
discomfort will distract from the patients ability to provide accurate information. The
patient may seem disoriented if distracted by pain or urgency. The physical
assessment data are obtained after the patient is as comfortable as possible.
DIF: Cognitive Level: Apply (application) REF: 71
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
16. Which patient is most likely to need long-term nursing care management?
a. 72-year-old who had a hip replacement after a fall at home
b. 64-year-old who developed sepsis after a ruptured peptic ulcer
c. 76-year-old who had a cholecystectomy and bile duct drainage
d. 63-year-old with bilateral knee osteoarthritis who weighs 350 lb (159
kg)
ANS: D
Osteoarthritis and obesity are chronic problems that will require planning for longterm interventions such as physical therapy and nutrition counseling. The other
patients have acute problems that are not likely to require long-term management.
DIF: Cognitive Level: Apply (application) REF: 70
OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
17. When completing an admission assessment on an older adult, the nurse gives the
patient a high fall risk score. Which action should the nurse take first?
a. Use a bed alarm system on the patients bed.
b. Administer the prescribed PRN sedative medication.
c. Ask the health care provider to order a vest restraint.
d. Place the patient in a geri-chair near the nurses station.
ANS: A
The use of the least restrictive restraint alternative is required. Physical or chemical
restraints may be necessary, but the nurses first action should be an alternative such as
a bed alarm.
DIF: Cognitive Level: Apply (application) REF: 75
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
18. An older adult patient presents with a broken arm and visible scattered bruises
healing at different stages. Which action should the nurse take first?
a. Notify an elder protective services agency about the possible abuse.
b. Make a referral for a home assessment visit by the home health nurse.
c. Have the family member stay in the waiting area while the patient is
assessed.
d. Ask the patient how the injury occurred and observe the family members
reaction.
ANS: C
The initial action should be assessment and interviewing of the patient. The patient
should be interviewed alone because the patient will be unlikely to give accurate
information if the abuser is present. If abuse is occurring, the patient should not be
discharged home for a later assessment by a home health nurse. The nurse needs to
collect and document data before notifying the elder protective services agency.
DIF: Cognitive Level: Apply (application) REF: 68-69
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
19. The family of an older patient with chronic health problems and increasing
weakness is considering placement in a long-term care (LTC) facility. Which action
by the nurse will be most helpful in assisting the patient to make this transition?
a. Have the family select a LTC facility that is relatively new.
b. Obtain the patients input about the choice of a LTC facility.
c. Ask that the patient be placed in a private room at the facility.
d. Explain the reasons for the need to live in LTC to the patient.
ANS: B
The stress of relocation is likely to be less when the patient has input into the choice
of the facility. The age of the long-term care facility does not indicate a better fit for
the patient or better quality of care. Although some patients may prefer a private
room, others may adjust better when given a well-suited roommate. The patient
should understand the reasons for the move but will make the best adjustment when
involved with the choice to move and the choice of the facility.
DIF: Cognitive Level: Apply (application) REF: 70
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
20. The nurse manages the care of older adults in an adult health day care center.
Which
action can the nurse delegate to unlicensed assistive personnel (UAP)?
a. Obtain information about food and medication allergies from patients.
b. Take blood pressures daily and document in individual patient records.
c. Choose social activities based on the individual patient needs and
desires.
d. Teach family members how to cope with patients who are cognitively
impaired.
ANS: B
Measurement and documentation of vital signs are included in UAP education and
scope of practice. Obtaining patient health history, planning activities based on the
patient assessment, and patient education are all actions that require critical thinking
and will be done by the registered nurse.
DIF: Cognitive Level: Apply (application) REF: 72
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. Which nursing actions will the nurse take to assess for possible malnutrition in an
older adult patient (select all that apply)?
a. Observe for depression.
b. Review laboratory results.
c. Assess teeth and oral mucosa.
d. Ask about transportation needs.
e. Determine food likes and dislikes.
ANS: A, B, C, D
The laboratory results, especially albumin and cholesterol levels, may indicate chronic
poor protein intake or high-fat/cholesterol intake. Transportation impacts patients
ability to shop for groceries. Depression may lead to decreased appetite. Oral sores or
teeth in poor condition may decrease the ability to chew and swallow. Food likes and
dislikes are not necessarily associated with malnutrition.
Chapter 6. Stress Management
MULTIPLE CHOICE
1. An adult patient arrived in the emergency department (ED) with minor facial
lacerations after a motor vehicle accident and has an initial blood pressure (BP) of
182/94. Which action by the nurse is most appropriate?
a. Start an IV line to administer antihypertensive medications.
b. Discuss the need for hospital admission to control blood pressure.
c. Treat the abrasions and discuss the risks associated with hypertension.
d. Recheck the blood pressure after the patient is stabilized and has
received treatment.
ANS: D
When a patient experiences an acute stressor, the blood pressure increases. The nurse
should plan to recheck the BP after the patient has stabilized and received treatment.
This will provide a more accurate indication of the patients usual blood pressure.
Elevated blood pressure that occurs in response to acute stress does not increase the
risk for health problems such as stroke, indicate a need for hospitalization, or indicate
a need for IV antihypertensive medications.
2. A female patient who initially came to the clinic with incontinence was recently
diagnosed with endometrial cancer. She is usually well organized and calm but the
nurse who is giving her preoperative instructions observes that she is irritable, has
difficulty concentrating, and yells at her husband. Which action should the nurse take?
a. Ask the health care provider for a psychiatric referral.
b. Focus teaching on preventing postoperative complications.
c. Try to calm patient and reinforce and repeat teaching about the surgery.
d. Encourage the patient to have bladder repair at the same time as the
hysterectomy.
ANS: C
Since behavioral responses to stress include temporary changes such as irritability,
changes in memory, and poor concentration, patient teaching will need to be repeated.
It is also important to try to calm the patient by listening to her concerns and fears.
Psychiatric referral will not necessarily be needed for her, but that can better be
evaluated after surgery. Focusing on postoperative care does not address the need for
preoperative instruction such as the procedure, NPO instructions before surgery, date
and time of surgery, medications to be taken and/or discontinued before surgery, etc.
The issue of incontinence is not immediately relevant in the discussion of preoperative
teaching for her hysterectomy.
3. An adult patient who is hospitalized following a motorcycle accident when a car ran
a red light tells the nurse, I didnt sleep last night because I worried about missing
work at my new job and losing my insurance coverage. Which nursing diagnosis is
appropriate to include in the plan of care?
a. Anxiety
b. Defensive coping
c. Ineffective denial
d. Risk prone health behavior
ANS: A
The information about the patient indicates that anxiety is an appropriate nursing
diagnosis. The patient data do not support defensive coping, ineffective denial, or risk
prone health behavior as problems for this patient.
4. A patient is extremely anxious about having a biopsy on a femoral lymph node in
the groin area. Which relaxation technique would be best for the nurse to use at this
time?
a. Meditation
b. Yoga stretching
c. Guided imagery
d. Relaxation breathing
ANS: D
Relaxation breathing is an easy relaxation technique to teach and use. The patient
should remain still during the biopsy and not move or stretch any of his extremities.
Meditation and guided imagery require more time to practice and learn.
5. A patient who suffers from frequent migraines tells the nurse, My life feels chaotic
and out of my control. I will not be able to manage if anything else happens. Which
response should the nurse make initially?
a. Regular exercise may get your mind off the pain.
b. Guided imagery can be helpful in regaining control.
c. Tell me more about how your life has been recently.
d. Your previous coping strategies can be very helpful to you now.
ANS: C
The nurses initial strategy should be further assessment of the stressors in the patients
life. Exercise, guided imagery, or understanding how to use coping strategies that
worked in the past may be of assistance to the patient, but more assessment is needed
before the nurse can determine this.
6. A nurse prepares an adult patient with a severe burn injury for a dressing change.
The nurse knows that this is a painful procedure and wants to provide music to help
the patient relax. Which action is best for the nurse to take?
a. Use music composed by Mozart.
b. Ask the patient about music preferences.
c. Select music that has 60 to 80 beats/minute.
d. Encourage the patient to use music without words.
ANS: B
Although music with 60 to 80 beats/minute, music without words, and music
composed by Mozart are frequently recommended to reduce stress, each patient
responds individually to music and personal preferences are important.
7. The nurse teaches a patient who is experiencing stress at work how to use imagery
as a relaxation technique. Which statement by the nurse would be most appropriate?
a. Think of a place where you feel peaceful and comfortable.
b. Place the stress in your life in an image that you can destroy.
c. Bring what you hear and sense in your present work environment into
your image.
d. If your work environment is stressful, continue visualizing to overcome
the distress.
ANS: A
Imagery is the use of ones mind to generate images that have a calming effect on the
body.
When using imagery for relaxation, the patient should visualize a comfortable and
peaceful place. The goal is to offer a relaxing retreat from the actual work
environment. Imagery can also be used to specifically target a disease, problem, or
stressor.
8. An overweight female patient who had enjoyed active outdoor activities is stressed
because she is limited in what she can do because she has osteoarthritis in her hips.
Which action by the nurse will best assist the patient to cope with this situation?
a. Ask the patient what activities she misses the most.
b. Have the patient practice frequent relaxation breathing.
c. Teach the patient to use imagery to decrease pain and decrease stress.
d. Encourage the patient to think about how weight loss might improve
symptoms.
ANS: D
For problems that can be changed or controlled, problem-focused coping strategies,
such as encouraging the patient to lose weight, are most helpful. The other strategies
also may assist the patient in coping with her problem, but they will not be as helpful
as a problem-focused strategy.
9. A hospitalized patient with diabetes tells the nurse, I dont understand why I can
keep my blood sugar under control at home with diet alone, but when I get sick, my
blood sugar goes up. This is so frustrating. Which response by the nurse is most
appropriate?
a. It is probably just coincidental that your blood glucose is higher when
you are ill.
b. Stressors such as illness cause the release of hormones that increase
blood glucose.
c. Increased blood glucose occurs because the liver is not able to
metabolize glucose as well during stressful times.
d. Your diet is different here in the hospital than at home and that is the
most likely cause of the increased glucose level.
ANS: B
The release of cortisol, epinephrine, and norepinephrine increase blood glucose levels.
The increase in blood glucose is not coincidental. The liver does not control blood
glucose. A diabetic patient who is hospitalized will be on an appropriate diet to help
control blood glucose.
10. A middle-aged male patient with usually well-controlled hypertension and diabetes
visits the clinic. Today he has a blood pressure of 174/94 and a blood glucose level of
190 mg/dL. What additional patient information may indicate that an intervention by
the nurse is needed?
a. The patient indicates that he usually does blood glucose monitoring
several times each day.
b. The patient states that he usually takes his prescribed antihypertensive
medications on a daily basis.
c. The patient reports that he and his wife are getting divorced and are in a
custody battle over their 12-year-old son.
d. The patient states that the results are related to his family history
because both of his parents have high blood pressure and diabetes.
ANS: C
The increase in blood pressure and glucose levels possibly suggests that stress caused
by his divorce and custody battle may be adversely affecting his health. The nurse
should assess this further and develop an appropriate plan to assist the patient in
decreasing his stress. Although he has been very compliant with his treatment plan in
the past, the nurse should assess whether the stress in his life is interfering with his
management of his health problems. The family history will not necessarily explain
why he has had changes in his blood pressure and glucose levels.
11. A patient who is taking antiretroviral medication to control human
immunodeficiency virus (HIV) infection tells the nurse about feeling mild depression
and anxiety. Which additional information about the patient is mostimportant to
communicate to the health care provider?
a. The patients blood pressure is 152/88 mm Hg.
b. The patient uses over-the-counter St. Johns wort.
c. The patient recently experienced the death of a close friend.
d. The patient expresses anxiety about whether the drugs are effective.
ANS: B
St. Johns wort interferes with metabolism of medications that use the cytochrome
P450 enzyme system, including many HIV medications. The health care provider will
need to check for toxicity caused by the drug interactions. Teaching is needed about
drug interactions. The other information will also be reported but does not have
immediate serious implications for the patients health.
MULTIPLE RESPONSE
1. A patient who is hospitalized with a pelvic fracture after a motor vehicle accident
just received news that the driver of the car died from multiple injuries. What actions
should the nurse take based on knowledge of the physiologic stress reactions that may
occur in this patient (select all that apply)?
a. Assess for bradycardia.
b. Ask about epigastric pain.
c. Observe for decreased appetite.
d. Check for elevated blood glucose levels.
e. Monitor for a decrease in respiratory rate.
ANS: B, C, D
The physiologic changes associated with the acute stress response can cause changes
in appetite, increased gastric acid secretion, and increase blood glucose levels. In
addition, stress causes an increase in respiratory and heart rates.
Chapter 7. S…