Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care, 2-Volume Set 9th Edition Test Bank

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Chapter 1: Foundations to Medical-Surgical Nursing PracticeIgnatavicius: Medical-Surgical Nursing, 9th EditionMULTIPLE CHOICE1. A new nurse is working with a preceptor on an inpatient medical-surgical unit. Thepreceptor advises the student that which is the priority when working as a professionalnurse?a. Attending to holistic client needsb. Ensuring client safetyc. Not making medication errorsd. Providing client-focused careANS: BAll actions are appropriate for the professional nurse. However, ensuring client safety is thepriority. Up to 98,000 deaths result each year from errors in hospital care, according to the2000 Institute of Medicine report. Many more clients have suffered injuries and less seriousoutcomes. Every nurse has the responsibility to guard the clients safety.DIF: Understanding/Comprehension REF: 2 KEY: Patient safetyMSC: Integrated Process: Nursing Process: InterventionNOT: Client Needs Category: Safe and Effective Care Environment: Safety and InfectionControl2. A nurse is orienting a new client and family to the inpatient unit. What information doesthe nurse provide to help the client promote his or her own safety?a. Encourage the client and family to be active partners.b. Have the client monitor hand hygiene in caregivers.c. Offer the family the opportunity to stay with the client.d. Tell the client to always wear his or her armband.ANS: AEach action could be important for the client or family to perform. However, encouraging theclient to be active in his or her health care as a partner is the most critical. The other actionsare very limited in scope and do not provide the broad protection that being active andinvolved does.

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DIF: Understanding/Comprehension REF: 3 KEY: Patient safetyMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Safe and Effective Care Environment: Safety and InfectionControl3. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressurewas 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse isbest?a. Call the Rapid Response Team.b. Document and continue to monitor.c. Notify the primary care provider.d. Repeat blood pressure measurement in 15 minutes.ANS: AThe purpose of the Rapid Response Team (RRT) is to intervene when clients aredeteriorating before they suffer either respiratory or cardiac arrest. Since the client hasmanifested a significant change, the nurse should call the RRT. Changes in blood pressure,mental status, heart rate, and pain are particularly significant. Documentation is vital, but thenurse must do more than document. The primary care provider should be notified, but this isnot the priority over calling the RRT. The clients blood pressure should be reassessedfrequently, but the priority is getting the rapid care to the client.DIF: Applying/Application REF: 3KEY: Rapid Response Team (RRT)| medical emergenciesMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Physiological Integrity: Physiological Adaptation4. A nurse wishes to provide client-centered care in all interactions. Which action by thenurse best demonstrates this concept?a. Assesses for cultural influences affecting health careb. Ensures that all the clients basic needs are metc. Tells the client and family about all upcoming testsd. Thoroughly orients the client and family to the roomANS: ACompetency in client-focused care is demonstrated when the nurse focuses oncommunication, culture, respect, compassion, client education, and empowerment. By

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assessing the effect of the clients culture on health care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this competence. Simplytelling the client about all upcoming tests is not providing empowering education. Orientingthe client and family to the room is an important safety measure, but not directly related todemonstrating client-centered care.DIF: Understanding/Comprehension REF: 3KEY: Patient-centered care| culture MSC: Integrated Process: CaringNOT: Client Needs Category: Psychosocial Integrity5. A client is going to be admitted for a scheduled surgical procedure. Which action doesthe nurse explain is the most important thing the client can do to protect against errors?a. Bring a list of all medications and what they are for.b. Keep the doctors phone number by the telephone.c. Make sure all providers wash hands before entering the room.d. Write down the name of each caregiver who comes in the room.ANS: AMedication errors are the most common type of health care mistake. The JointCommissions Speak Up campaign encourages clients to help ensure their safety. Onerecommendation is for clients to know all their medications and why they take them. Thiswill help prevent medication errors.DIF: Applying/Application REF: 4KEY: Speak Up campaign| patient safety MSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Safe and Effective Care Environment: Safety and InfectionControl6. Which action by the nurse working with a client best demonstrates respect for autonomy?a. Asks if the client has questions before signing a consentb. Gives the client accurate information when questionedc. Keeps the promises made to the client and familyd. Treats the client fairly compared to other clientsANS: AAutonomy is self-determination. The client should make decisions regarding care. When thenurse obtains a signature on the consent form, assessing if the client still has questions is

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vital, because without full information the client cannot practice autonomy. Giving accurateinformation is practicing with veracity. Keeping promises is upholding fidelity. Treating theclient fairly is providing social justice.DIF: Applying/Application REF: 4KEY: Autonomy| ethical principles MSC: Integrated Process: CaringNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care7. A student nurse asks the faculty to explain best practices when communicating with aperson from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ)community. What answer by the faculty is most accurate?a. Avoid embarrassing the client by asking questions.b. Dont make assumptions about their health needs.c. Most LGBTQ people do not want to share information.d. No differences exist in communicating with this population.ANS: BMany members of the LGBTQ community have faced discrimination from health careproviders and may be reluctant to seek health care. The nurse should never makeassumptions about the needs of members of this population. Rather, respectful questionsare appropriate. If approached with sensitivity, the client with any health care need is morelikely to answer honestly.DIF: Understanding/Comprehension REF: 4 KEY: LGBTQ| diversityMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Psychosocial Integrity8. A nurse is calling the on-call physician about a client who had a hysterectomy 2 days agoand has pain that is unrelieved by the prescribed narcotic pain medication. Which statementis part of the SBAR format for communication?a. A: I would like you to order a different pain medication.b. B: This client has allergies to morphine and codeine.c. R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds.d. S: This client had a vaginal hysterectomy 2 days ago.ANS: BSBAR is a recommended form of communication, and the acronym stands for Situation,

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Background, Assessment, and Recommendation. Appropriate background informationincludes allergies to medications the on-call physician might order. Situation describes whatis happening right now that must be communicated; the clients surgery 2 days ago would beconsidered background. Assessment would include an analysis of the clients problem;asking for a different pain medication is a recommendation. Recommendation is astatement of what is needed or what outcome is desired; this information about thesurgeons preference might be better placed in background.DIF: Applying/Application REF: 5KEY: SBAR| communicationMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care9. A nurse working on a cardiac unit delegated taking vital signs to an experiencedunlicensed assistive personnel (UAP). Four hours later, the nurse notes the clients bloodpressure is much higher than previous readings, and the clients mental status has changed.What action by the nurse would most likely have prevented this negative outcome?a. Determining if the UAP knew how to take blood pressureb. Double-checking the UAP by taking another blood pressurec. Providing more appropriate supervision of the UAPd. Taking the blood pressure instead of delegating the taskANS: CSupervision is one of the five rights of delegation and includes directing, evaluating, andfollowing up on delegated tasks. The nurse should either have asked the UAP about thevital signs or instructed the UAP to report them right away. An experienced UAP shouldknow how to take vital signs and the nurse should not have to assess this at this point.Double-checking the work defeats the purpose of delegation. Vital signs are within thescope of practice for a UAP and are permissible to delegate. The only appropriate answer isthat the nurse did not provide adequate instruction to the UAP.DIF: Applying/Application REF: 6KEY: Supervision| delegation| unlicensed assistive personnelMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

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10. A newly graduated nurse in the hospital states that, since she is so new, she cannotparticipate in quality improvement (QI) projects. What response by the precepting nurse isbest?a. All staff nurses are required to participate in quality improvement here.b. Even being new, you can implement activities designed to improve care.c. Its easy to identify what indicators should be used to measure quality.d. You should ask to be assigned to the research and quality committee.ANS: BThe preceptor should try to reassure the nurse that implementing QI measures is not out ofline for a newly licensed nurse. Simply stating that all nurses are required to participatedoes not help the nurse understand how that is possible and is dismissive. Identifyingindicators of quality is not an easy, quick process and would not be the best place tosuggest a new nurse to start. Asking to be assigned to the QI committee does not give thenurse information about how to implement QI in daily practice.DIF: Applying/Application REF: 6KEY: Quality improvementMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care11. A nurse is talking with a client who is moving to a new state and needs to find a newdoctor and hospital there. What advice by the nurse is best?a. Ask the hospitals there about standard nurse-client ratios.b. Choose the hospital that has the newest technology.c. Find a hospital that is accredited by The Joint Commission.d. Use a facility affiliated with a medical or nursing school.ANS: CAccreditation by The Joint Commission (TJC) or other accrediting body gives assurancethat the facility has a focus on safety. Nurse-client ratios differ by unit type and change overtime. New technology doesnt necessarily mean the hospital is safe. Affiliation with a healthprofessions school has several advantages, but safety is most important.DIF: Understanding/Comprehension REF: 2KEY: The Joint Commission (TJC)| accreditationMSC: Integrated Process: Communication and Documentation

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NOT: Client Needs Category: Safe and Effective Care Environment: Safety and InfectionControlMULTIPLE RESPONSE1. A nurse manager wishes to ensure that the nurses on the unit are practicing at theirhighest levels of competency. Which areas should the manager assess to determine if thenursing staff demonstrate competency according to the Institute of Medicine (IOM) reportHealth Professions Education: A Bridge to Quality? (Select all that apply.)a. Collaborating with an interdisciplinary teamb. Implementing evidence-based carec. Providing family-focused cared. Routinely using informatics in practicee. Using quality improvement in client careANS: A, B, D, EThe IOM report lists five broad core competencies that all health care providers shouldpractice. These include collaborating with the interdisciplinary team, implementingevidence-based practice, providing client-focused care, using informatics in client care, andusing quality improvement in client care.DIF: Remembering/Knowledge REF: 3KEY: Competencies| Institute of Medicine (IOM)MSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Safe and Effective Care Environment: Safety and InfectionControl2. A nurse is interested in making interdisciplinary work a high priority. Which actions by thenurse best demonstrate this skill? (Select all that apply.)a. Consults with other disciplines on client careb. Coordinates discharge planning for home safetyc. Participates in comprehensive client roundingd. Routinely asks other disciplines about client progresse. Shows the nursing care plans to other disciplinesANS: A, B, C, DCollaborating with the interdisciplinary team involves planning, implementing, and

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evaluating client care as a team with all other disciplines included. Simply showing othercaregivers the nursing care plan is not actively involving them or collaborating with them.DIF: Applying/Application REF: 4KEY: Collaboration| interdisciplinary teamMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care3. The nurse utilizing evidence-based practice (EBP) considers which factors when planningcare? (Select all that apply.)a. Cost-saving measuresb. Nurses expertisec. Client preferencesd. Research findingse. Values of the clientANS: B, C, D, EEBP consists of utilizing current evidence, the clients values and preferences, and thenurses expertise when planning care. It does not include cost-saving measures.DIF: Remembering/Knowledge REF: 6KEY: Evidence-based practice (EBP)MSC: Integrated Process: Nursing Process: PlanningNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care4. A nurse manager wants to improve hand-off communication among the staff. Whatactions by the manager would best help achieve this goal? (Select all that apply.)a. Attend hand-off rounds to coach and mentor.b. Conduct audits of staff using a new template.c. Create a template of topics to include in report.d. Encourage staff to ask questions during hand-off.e. Give raises based on compliance with reporting.ANS: A, B, C, DA good tool for standardizing hand-off reports and other critical communication is theSHARE model. SHARE stands for standardize critical information, hardwire within yoursystem, allow opportunities to ask questions, reinforce quality and measurement, and

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educate and coach. Attending hand-off report gives the manager opportunities to educateand coach. Conducting audits is part of reinforcing quality. Creating a template is hardwiringwithin the system. Encouraging staff to ask questions and think critically about theinformation is allowing opportunities to ask questions. The manager may need to tie raisesinto compliance if the staff is resistive and other measures have failed, but this is not part ofthe SHARE model.DIF: Applying/Application REF: 5KEY: SHARE| hand-off communicationMSC: Integrated Process: Nursing Process: InterventionNOT: Client Needs Category: Safe and Effective Care Environment: Management of CareChapter 2. Overview of Health Concepts for Medical-Surgical NursingMULTIPLE CHOICEMULTIPLE CHOICE1. A nurse identifies clinical practice problems on a cardiac unit. Which question is abackground question?a. How should a client experiencing chest pain be prioritized?b. What is the experience of a cardiac catheterization like for middle-aged men?c. How are a clients vital signs affected by anxiety?d. What is the best treatment for a myocardial infarction?ANS: CA background question asks for a fact. The response of anxiety on vital signs is abackground question. A foreground question asks a question of relationship and may becontroversial (best treatment). Questions related to a clients experience and best treatmentare foreground questions.DIF: Understanding/Comprehension REF: 65KEY: Foreground| backgroundMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care2. A nurse researcher is evaluating clinical questions. Which is a quantitative question?a. What are the effects of hourly rounding on client fall rates?b. How do middle-aged men respond to premature balding?c. What are the lived experiences of postoperative clients with pain?d. What is the experience of having breast cancer like for young women?

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ANS: AQuantitative questions ask about the relationship between or among defined, measurablephenomena and include statistical analysis of information that is collected to answer aquestion. Qualitative questions focus on the meanings and interpretations of humanphenomena or experiences of people, and usually analyze the content of what a personsays during an interview or what a researcher observes.DIF: Understanding/Comprehension REF: 65KEY: Foreground| backgroundMSC: Integrated Process: Nursing Process: EvaluationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care3. A nurse is looking for the best interventions for postoperative pain control. When are thefacilitys policies and procedures an appropriate source of evidence?a. When policies are based on high-quality clinical practice guidelinesb. When evidence is derived from a valid and reliable quantitative research studyc. When procedures originated from opinions of the facilitys chief surgeond. When evidence is founded on recommendations from experienced nursesANS: AFacility policies and procedures can be used as evidence of specific nursing practice in theclinical setting if the policies are based on high-quality evidence. Clinical practice guidelinesare based on systematic reviews, which provide the highest level of evidence. Policiesbased on quantitative research, opinions, and experience should not be used because theyare not founded on evidence of the highest quality.DIF: Understanding/Comprehension REF: 67KEY: Policies| clinical practice guidelinesMSC: Integrated Process: Nursing Process: PlanningNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care4. A medical-surgical nurse asks the nurse researcher, What is the difference betweenqualitative and quantitative questions? How should the nurse researcher respond?a. Quantitative questions analyze the content of what a person says or does.b. Qualitative questions utilize a strict statistical analysis of information.c. Quantitative questions identify relationships between measurable concepts.d. Qualitative questions ask about associations among defined phenomena.ANS: CQuantitative questions ask about the relationship between or among defined, measurablephenomena and include statistical analysis of information that is collected to answer aquestion. Qualitative questions focus on the meanings and interpretations of humanphenomena or experiences of people and usually analyze the content of what a personsays during an interview or what a researcher observes.DIF: Understanding/Comprehension REF: 65KEY: Qualitative research| quantitative researchMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care5. A nurse is searching for evidence related to a qualitative PICOT question. Which type ofevidence should the nurse search first?

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a. Meta-analyses with credible synthesized findingsb. Systematic reviewsc. Multi-site randomized clinical trialsd. Meta-synthesesANS: DIf searching for answers to qualitative questions, the nurse should first look for meta-syntheses. Top-level evidence for quantitative questions includes meta-analyses,systematic reviews, and multi-site randomized clinical trials.DIF: Remembering/Knowledge REF: 67 KEY: Level of evidenceMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care6. A nurse assesses this PICOT question: In the adult hospitalized client, does a COX-2inhibitor decrease the risk of gastrointestinal bleeding compared with other NSAIDs? Whatis the outcome component in this question?a. Adult hospitalized clientb. Cyclooxygenase-2 (COX-2) inhibitorc. Decreased risk of gastrointestinal bleedingd. Other nonsteroidal anti-inflammatory drugs (NSAIDs)ANS: CThe outcome component of the clinical question specifies the measureable and desiredoutcomes of the practice innovation. In this question, the decreased risk of gastrointestinalbleeding is the outcome. The population is adult hospitalized clients, the comparisoncomponent is NSAIDs, and innovative practice is COX-2 inhibitors.DIF: Remembering/Knowledge REF: 66 KEY: PICOT questionMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care7. A health care facility is implementing a new evidence-based nursing protocol. Whichaction is necessary to ensure successful implementation?a. Develop evaluation processes to validate the protocol.b. Ask for recommendations from senior nursing administration.c. Assess cost-effectiveness of the evidence-based protocol.d. Attain support from nurses who are implementing the protocol.ANS: DComplete buy-in from the people who will be involved in implementing the new protocol isessential to the success of implementation.DIF: Remembering/Knowledge REF: 68 KEY: PICOT questionMSC: Integrated Process: Nursing Process: PlanningNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care8. A research nurse meets with the nurse manager to discuss plans for the development ofevidence-based practice (EBP) guidelines using the Reavy and Tavernier model. Whichstatement should the nurse include in the discussion?a. Our efforts should focus on forming a team to develop an EBP initiative.b. I will assist staff nurses with literature reviews and the synthesis of evidence.c. You should identify barriers to evidence-based implementation.

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d. I will develop a PICOT question and share it with the staff nurses.ANS: BThe Reavy and Tavernier model views the staff nurse as the clinical expert and believesthat the expertise of a nurse researcher should facilitate the EBP process by supportingnursing staff in identifying areas for improvement, assisting staff with literature reviews andsynthesis of evidence, and helping with the implementation and evaluation of EBP projects.Team forming is a component of the Iowa model. Identification of strengths and barriers toEBP implementation is a component of the ARCC model. Staff nurses should identify theirown PICOT questions from burning clinical questions.DIF: Applying/Application REF: 69KEY: Reavy and Tavernier modelMSC: Integrated Process: Nursing Process: PlanningNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care9. A nurse who wants to incorporate evidence-based practices into client care on a medicalunit is meeting resistance. Which barrier does the nurse identify as preventing nurses fromengaging in evidence-based practices?a. Difficulty accessing research materialsb. Lack of value for client preferencesc. Trouble understanding client needsd. Inadequate nurse-client ratiosANS: AMajor barriers that prevent nurses from engaging in evidence-based practice include lack oftime, lack of value for research in practice, lack of understanding of organization or structureof electronic databases, difficulty accessing research materials, lack of computer skills, anddifficulty understanding research articles.DIF: Remembering/Knowledge REF: 66KEY: Barriers| nurse engagement MSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care10. A nurse wants to explore why clients who receive patient-controlled analgesia (PCA)after abdominal surgery ambulate sooner than clients who receive nurse-administered painmedications. Which action should the nurse take first?a. Contact the medical centers clinical pharmacist.b. Search the medical library for the best evidence.c. Recommend PCA for all clients.d. Appraise data obtained through client chart audits.ANS: BAfter asking the burning question, the nurse should find the very best evidence to try toanswer it. The clinical pharmacist may be knowledgeable, but this is not the best evidenceavailable. Information from client chart audits may demonstrate better outcomes with PCA,but this again is not the best evidence. The nurse should wait and recommend clinicalpractice changes until best evidence is found, appraised, and synthesized.DIF: Applying/Application REF: 67KEY: Steps of evidence-based practiceMSC: Integrated Process: Nursing Process: AnalysisNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

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11. A nurse manager educates staff nurses in the use of clinical practice guidelines. Whichstatement should the nurse include in this teaching?a. Clinical practice guidelines are implemented by The Joint Commission.b. Practice guidelines are based on hospital management staffs expertise.c. Clinical practice guidelines are official recommendations based on evidence.d. Practice guidelines allow for greater reimbursement from insurance companies.ANS: CClinical practice guidelines are based on evidence and provide an official recommendationfor the diagnosis and/or management of health problems. These are usually developed fromhigh-quality evidence. Although The Joint Commission publishes guidelines, clinical practiceguidelines are not implemented by The Joint Commission. The hospitals management staffmay be involved in the development and implementation of clinical practice guidelines, butthese guidelines should not be based solely on management expertise. Clinical guidelinesprovide for better client outcomes. These guidelines are not focused on reimbursement.DIF: Understanding/Comprehension REF: 67KEY: Steps of evidence-based practice; level of evidenceMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care12. A cardiac nurse wants to know about the best practices to prevent pneumonia afteropen-heart surgery. In what order do the steps of the evidence-based practice (EBP)process take place?1. Asking burning clinical questions2. Making recommendations for practice improvement3. Implementing accepted recommendations4. Finding the very best evidence to try to answer those questions5. Evaluating outcomes6. Critically appraising and synthesizing the relevant evidencea. 5, 1, 4, 6, 3, 2b. 1, 5, 4, 3, 2, 6c. 1, 4, 6, 2, 3, 5d. 5, 2, 1, 4, 6, 3ANS: CThe process of EBP is systematic and includes the following steps: (1) asking burningclinical questions; (2) finding the very best evidence to try to answer those questions; (3)critically appraising and synthesizing the relevant evidence; (4) making recommendationsfor practice improvement; (5) implementing accepted recommendations; and (6) evaluatingoutcomes.DIF: Remembering/Knowledge REF: 65KEY: Steps of evidence-based practiceMSC: Integrated Process: Nursing Process: PlanningNOT: Client Needs Category: Safe and Effective Care Environment: Management of CareMULTIPLE RESPONSE1. A nurse is developing a clinical question in a PICOT format. What components areincluded in the question? (Select all that apply.)a. Patient

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b. Comparisonc. Outcomed. Implementatione. TimeANS: B, C, EThe major components of a PICOT question are population, intervention, comparison, andoutcome, with an added time component when appropriate.DIF: Remembering/Knowledge REF: 65 KEY: PICOT questionMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care2. A nurse plans evidence-based care for a client on a medical-surgical unit. Whichelements should the nurse assess when developing this plan of care? (Select all that apply.)a. Client valuesb. Nurses experiencesc. Organizational budgetd. Staffing ratiose. Best available evidenceANS: A, B, EEvidence-based practice incorporates best current evidence with the expertise of theclinician and the clients values.DIF: Understanding/Comprehension REF: 64KEY: Steps of evidence-based practiceMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Safe and Effective Care Environment: Management of CareChapter 3: Common Health Problems of Older AdultsIgnatavicius: Medical-Surgical Nursing,MULTIPLE CHOICE1. A nursing faculty member working with students explains that the fastest growing subsetof the older population is which group?a. Elite oldb. Middle oldc. Old oldd. Young oldANS: CThe old old is the fastest growing subset of the older population. This is the groupcomprising those 85 to 99 years of age. The young old are between 65 and 74 years of age;the middle old are between 75 and 84 years of age; and the elite old are over 100 years ofage.

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DIF: Remembering/Knowledge REF: 9KEY: Adulthood| aging| old old MSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance2. A nurse working with older adults in the community plans programming to improvemorale and emotional health in this population. What activity would best meet this goal?a. Exercise program to improve physical functionb. Financial planning seminar series for older adultsc. Social events such as dances and group dinnersd. Workshop on prevention from becoming an abuse victimANS: AAll activities would be beneficial for the older population in the community. However, failurein performing ones own activities of daily living and participating in society has direct effectson morale and life satisfaction. Those who lose the ability to function independently oftenfeel worthless and empty. An exercise program designed to maintain and/or improvephysical functioning would best address this need.DIF: Applying/Application REF: 12KEY: Independence| autonomy| older adultMSC: Integrated Process: Nursing Process: PlanningNOT: Client Needs Category: Psychosocial Integrity3. A nurse caring for an older client on a medical-surgical unit notices the client reportsfrequent constipation and only wants to eat softer foods such as rice, bread, and puddings.What assessment should the nurse perform first?a. Auscultate bowel sounds.b. Check skin turgor.c. Perform an oral assessment.d. Weigh the client.ANS: CPoorly fitting dentures and other dental problems are often manifested by a preference forsoft foods and constipation from the lack of fiber. The nurse should perform an oralassessment to determine if these problems exist. The other assessments are important, butwill not yield information specific to the clients food preferences as they relate toconstipation.DIF: Applying/Application REF: 10KEY: Nutrition| dentures| older adultMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort4. A nurse caring for an older adult has provided education on high-fiber foods. Which menuselection by the client demonstrates a need for further review?a. Barley soupb. Black beansc. White riced. Whole wheat breadANS: COlder adults need 25 to 50 grams of fiber a day. White rice is low in fiber. Foods high infiber include barley, beans, and whole wheat products.

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DIF: Applying/Application REF: 11KEY: Nutrition| fiber| older adultMSC: Integrated Process: Nursing Process: EvaluationNOT: Client Needs Category: Physiological Integrity: Physiological Adaptation5. A nurse is working with an older client admitted with mild dehydration. What teachingdoes the nurse provide to best address this issue?a. Cut some sodium out of your diet.b. Dehydration can cause incontinence.c. Have something to drink every 1 to 2 hours.d. Take your diuretic in the morning.ANS: COlder adults often lose their sense of thirst. Since they should drink 1 to 2 liters of water aday, the best remedy is to have the older adult drink something each hour or two, whetheror not he or she is thirsty. Cutting some sodium from the diet will not address this issue.Although dehydration can cause incontinence from the irritation of concentrated urine, thisinformation will not help prevent the problem of dehydration. Instructing the client to take adiuretic in the morning rather than in the evening also will not directly address this issue.DIF: Applying/Application REF: 11KEY: Dehydration| older adult| hydration MSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Physiological Integrity: Physiological Adaptation6. A home health care nurse is planning an exercise program with an older client who livesat home independently but whose mobility issues prevent much activity outside the home.Which exercise regimen would be most beneficial to this adult?a. Building strength and flexibilityb. Improving exercise endurancec. Increasing aerobic capacityd. Providing personal trainingANS: AThis older adult is mostly homebound. Exercise regimens for homebound clients includethings to increase functional ability for activities of daily living. Strength and flexibility willhelp the client to be able to maintain independence longer. The other plans are good but willnot specifically maintain the clients functional abilities.DIF: Applying/Application REF: 12KEY: Exercise| functional ability| older adultMSC: Integrated Process: Nursing Process: PlanningNOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential7. An older adult recently retired and reports being depressed and lonely. What informationshould the nurse assess as a priority?a. History of previous depressionb. Previous stressful eventsc. Role of work in the adults lifed. Usual leisure time activitiesANS: COften older adults lose support systems when their roles change. For instance, whenpeople retire, they may lose their entire social network, leading them to feeling depressed

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and lonely. The nurse should first assess the role that work played in the clients life. Theother factors can be assessed as well, but this circumstance is commonly seen in the olderpopulation.DIF: Applying/Application REF: 12KEY: Depression| older adultMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Psychosocial Integrity8. A nurse is assessing coping in older women in a support group for recent widows. Whichstatement by a participant best indicates potential for successful coping?a. I have had the same best friend for decades.b. I think I am coping very well on my own.c. My kids come to see me every weekend.d. Oh, I have lots of friends at the senior center.ANS: AFriendship and support enhance coping. The quality of the relationship is what is mostimportant, however. People who have close, intimate, stable relationships with others inwhom they confide are more likely to cope with crisis.DIF: Remembering/Knowledge REF: 12KEY: Coping| relationships| older adultMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Psychosocial Integrity9. A home health care nurse has conducted a home safety assessment for an older adult.There are five concrete steps leading out from the front door. Which intervention would bemost helpful in keeping the older adult safe on the steps?a. Have the client use a walker or cane on the steps.b. Install contrasting color strips at the edge of each step.c. Instruct the client to use the garage door instead.d. Tell the client to use a two-footed gait on the steps.ANS: BAs a person ages, he or she may experience a decreased sense of touch. The older adultmay not be aware of where his or her foot is on the step. Installing contrasting color strips atthe end of each step will help increase awareness. If the client does not need an assistivedevice, he or she should not use one just on stairs. Using an alternative door may benecessary but does not address making the front steps safer. A two-footed gait may nothelp if the client is unaware of where the foot is on the step.DIF: Applying/Application REF: 13KEY: Safety| falls| older adultMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Safety and InfectionControl10. An older adult is brought to the emergency department because of sudden onset ofconfusion. After the client is stabilized and comfortable, what assessment by the nurse ismost important?a. Assess for orthostatic hypotension.

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b. Determine if there are new medications.c. Evaluate the client for gait abnormalities.d. Perform a delirium screening test.ANS: BMedication side effects and adverse effects are common in the older population. Somethingas simple as a new antibiotic can cause confusion and memory loss. The nurse shoulddetermine if the client is taking any new medications. Assessments for orthostatichypotension, gait abnormalities, and delirium may be important once more is known aboutthe clients condition.DIF: Applying/Application REF: 13KEY: Medications| medication safety| older adultMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Pharmacological and ParenteralTherapies11. An older adult client takes medication three times a day and becomes confused aboutwhich medication should be taken at which time. The client refuses to use a pill sorter withslots for different times, saying Those are for old people. What action by the nurse would bemost helpful?a. Arrange medications by time in a drawer.b. Encourage the client to use easy-open tops.c. Put color-coded stickers on the bottle caps.d. Write a list of when to take each medication.ANS: CColor-coded stickers are a fast, easy-to-remember system. One color is for morning meds,one for evening meds, and the third color is for nighttime meds. Arranging medications bytime in a drawer might be helpful if the person doesnt accidentally put them back in thewrong spot. Easy-open tops are not related. Writing a list might be helpful, but not if it getsmisplaced. With stickers on the medication bottles themselves, the reminder is always withthe medication.DIF: Applying/Application REF: 14KEY: Medications| medication safety| older adultMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Safety and InfectionControl12. An older adult client is in the hospital. The client is ambulatory and independent. Whatintervention by the nurse would be most helpful in preventing falls in this client?a. Keep the light on in the bathroom at night.b. Order a bedside commode for the client.c. Put the client on a toileting schedule.d. Use siderails to keep the client in bed.ANS: AAlthough this older adult is independent and ambulatory, being hospitalized can createconfusion. Getting up in a dark, unfamiliar environment can contribute to falls. Keeping thelight on in the bathroom will help reduce the likelihood of falling. The client does not need acommode or a toileting schedule. Siderails used to keep the client in bed are consideredrestraints and should not be used in that fashion.

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DIF: Applying/Application REF: 21KEY: Falls| safety| older adultMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Safety and InfectionControl13. An older client had hip replacement surgery and the surgeon prescribed morphinesulfate for pain. The client is allergic to morphine and reports pain and muscle spasms.When the nurse calls the surgeon, which medication should he or she suggest in place ofthe morphine?a. Cyclobenzaprine (Flexeril)b. Hydromorphone hydrochloride (Dilaudid)c. Ketorolac (Toradol)d. Meperidine (Demerol)ANS: BCyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain)are all on the Beers list of potentially inappropriate medications for use in older adults andshould not be suggested. The nurse should suggest hydromorphone hydrochloride.DIF: Remembering/Knowledge REF: 16KEY: Medications| Beers list| older adultMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Physiological Integrity: Pharmacological and ParenteralTherapies14. A nurse admits an older client from a home environment where she lives with her adultson and daughter-in-law. The client has urine burns on her skin, no dentures, and severalpressure ulcers. What action by the nurse is most appropriate?a. Ask the family how these problems occurred.b. Call the police department and file a report.c. Notify Adult Protective Services.d. Report the findings as per agency policy.ANS: DThese findings are suspicious for abuse. Health care providers are mandatory reporters forsuspected abuse. The nurse should notify social work, case management, or whomever isdesignated in policies. That person can then assess the situation further. If the police needto be notified, that is the person who will notify them. Adult Protective Services is notified inthe community setting.DIF: Applying/Application REF: 19 KEY: Abuse| older adultMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care15. A nurse caring for an older client in the hospital is concerned the client is not competentto give consent for upcoming surgery. What action by the nurse is best?a. Call Adult Protective Services.b. Discuss concerns with the health care team.c. Do not allow the client to sign the consent.d. Have the clients family sign the consent.ANS: B

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In this situation, each facility will have a policy designed for assessing competence. Thenurse should bring these concerns to an interdisciplinary care team meeting. There may bephysiologic reasons for the client to be temporarily too confused or incompetent to giveconsent. If an acute condition is ruled out, the staff should follow the legal procedure andpolicies in their facility and state for determining competence. The key is to bring theconcerns forward. Calling Adult Protective Services is not appropriate at this time. Signingthe consent should wait until competence is determined unless it is an emergency, in whichcase the next of kin can sign if there are grave doubts as to the clients ability to provideconsent.DIF: Applying/Application REF: 16KEY: Competence| autonomy| older adultMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of CareMULTIPLE RESPONSE1. A nursing student working in an Adult Care for Elders unit learns that frailty in the olderpopulation includes which components? (Select all that apply.)a. Dementiab. Exhaustionc. Slowed physical activityd. Weaknesse. Weight gainANS: B, C, DFrailty is a syndrome consisting of unintentional weight loss, slowed physical activity andexhaustion, and weakness. Weight gain and dementia are not part of this cluster ofmanifestations.DIF: Remembering/Knowledge REF: 9KEY: Frailty| frail elderly| older adultMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Health Promotion and Maintenance2. A home health care nurse assesses an older client for the intake of nutrients needed inlarger amounts than in younger adults. Which foods found in an older adults kitchen mightindicate an adequate intake of these nutrients? (Select all that apply.)a. 1% milkb. Carrotsc. Lean ground beefd. Orangese. Vitamin D supplementsANS: A, B, D, EOlder adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk hascalcium; carrots have vitamin A; the vitamin D supplement has vitamin D; and oranges havevitamin C. Lean ground beef is healthier than more fatty cuts, but does not contain theseneeded nutrients.DIF: Applying/Application REF: 10KEY: Nutrition| nutritional requirements| older adults

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MSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort3. A nurse working with older adults assesses them for common potential adversemedication effects. For what does the nurse assess? (Select all that apply.)a. Constipationb. Dehydrationc. Maniad. Urinary incontinencee. WeaknessANS: A, B, ECommon adverse medication effects include constipation/impaction, dehydration, andweakness. Mania and incontinence are not among the common adverse effects, althoughurinary retention is.DIF: Remembering/Knowledge REF: 14KEY: Medications| adverse effectsMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Pharmacological and ParenteralTherapies4. A nurse manager institutes the Fulmer Spices Framework as part of the routineassessment of older adults in the hospital. The nursing staff assesses for which factors?(Select all that apply.)a. Confusionb. Evidence of abusec. Incontinenced. Problems with behaviore. Sleep disordersANS: A, C, ESPICES stands for sleep disorders, problems with eating or feeding, incontinence,confusion, and evidence of falls.DIF: Remembering/Knowledge REF: 20KEY: SPICES| older adultMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential5. A visiting nurse is in the home of an older adult and notes a 7-pound weight loss sincelast months visit. What actions should the nurse perform first? (Select all that apply.)a. Assess the clients ability to drive or transportation alternatives.b. Determine if the client has dentures that fit appropriately.c. Encourage the client to continue the current exercise plan.d. Have the client complete a 3-day diet recall diary.e. Teach the client about proper nutrition in the older population.ANS: A, B, DAssessment is the first step of the nursing process and should be completed prior tointervening. Asking about transportation, dentures, and normal food patterns would be partof an appropriate assessment for the client. There is no information in the question aboutthe older adult needing to lose weight, so encouraging him or her to continue the current

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exercise regimen is premature and may not be appropriate. Teaching about proper nutritionis a good idea, but teaching needs to be tailored to the clients needs, which the nurse doesnot yet know.DIF: Applying/Application REF: 10KEY: Nutrition| older adultMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Physiological Adaptation6. A hospitalized older adult has been assessed at high risk for skin breakdown. Whichactions does the registered nurse (RN) delegate to the unlicensed assistive personnel(UAP)? (Select all that apply.)a. Assess skin redness when turning.b. Document Braden Scale results.c. Keep the clients skin dry.d. Obtain a pressure-relieving mattress.e. Turn the client every 2 hours.ANS: C, D, EThe nurses aide or UAP can assist in keeping the clients skin dry, order a special mattresson direction of the RN, and turn the client on a schedule. Assessing the skin is a nursingresponsibility, although the aide should be directed to report any redness noticed.Documenting the Braden Scale results is the RNs responsibility as the RN is the one whoperforms that assessment.DIF: Applying/Application REF: 22KEY: Skin breakdown| older adult| delegation| unlicensed assistive personnelMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care7. A nurse admits an older client to the hospital who lives at home with family. The nurseassesses that the client is malnourished. What actions by the nurse are best? (Select allthat apply.)a. Contact Adult Protective Services or hospital social work.b. Notify the provider that the client needs a tube feeding.c. Perform and document results of a Braden Scale assessment.d. Request a dietary consultation from the health care provider.e. Suggest a high-protein oral supplement between meals.ANS: C, D, EMalnutrition in the older population is multifactorial and has several potential adverseoutcomes. Appropriate actions by the nurse include assessing the clients risk for skinbreakdown with the Braden Scale, requesting a consultation with a dietitian, and suggestinga high-protein meal supplement. There is no evidence that the client is being abused orneeds a feeding tube at this time.DIF: Applying/Application REF: 20KEY: Nutrition| malnutrition| older adult| Braden ScaleMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

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Chapter 4: Assessment and Care of Patients with PainIgnatavicius: Medical-Surgical Nursing,MULTIPLE CHOICE1. A student asks the nurse what is the best way to assess a clients pain. Which responseby the nurse is best?a. Numeric pain scaleb. Behavioral assessmentc. Objective observationd. Clients self-reportANS: DMany ways to measure pain are in use, including numeric pain scales, behavioralassessments, and other objective observations. However, the most accurate way to assesspain is to get a self-report from the client.DIF: Remembering/Knowledge REF: 25KEY: Pain| pain assessmentMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Health Promotion and Maintenance2. A new nurse reports to the precepting nurse that a client requested pain medication, andwhen the nurse brought it, the client was sound asleep. The nurse states the client cannotpossibly sleep with the severe pain the client described. What response by the experiencednurse is best?a. Being able to sleep doesnt mean pain doesnt exist.b. Have you ever experienced any type of pain?c. The client should be assessed for drug addiction.d. Youre right; I would put the medication back.ANS: AA clients description is the most accurate assessment of pain. The nurse should believe theclient and provide pain relief. Physiologic changes due to pain vary from client to client, andassessments of them should not supersede the clients descriptions, especially if the pain ischronic in nature. Asking if the new nurse has had pain is judgmental and flippant, and doesnot provide useful information. This amount of information does not warrant an assessmentfor drug addiction. Putting the medication back and ignoring the clients report of pain servesno useful purpose.DIF: Understanding/Comprehension REF: 28KEY: Pain| pain assessmentMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Health Promotion and Maintenance3. The nurse in the surgery clinic is discussing an upcoming surgical procedure with a client.What information provided by the nurse is most appropriate for the clients long-termoutcome?a. At least you know that the pain after surgery will diminish quickly.b. Discuss acceptable pain control after your operation with the surgeon.c. Opioids often cause nausea but you wont have to take them for long.d. The nursing staff will give you pain medication when you ask them for it.

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ANS: BThe best outcome after a surgical procedure is timely and satisfactory pain control, whichdiminishes the likelihood of chronic pain afterward. The nurse suggests that the clientadvocate for himself and discuss acceptable pain control with the surgeon. Stating that painafter surgery is usually short lived does not provide the client with options to havepersonalized pain control. To prevent or reduce nausea and other side effects from opioids,a multimodal pain approach is desired. For acute pain after surgery, giving pain medicationsaround the clock instead of waiting until the client requests it is a better approach.DIF: Applying/Application REF: 26 KEY: Pain| acute painMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance4. A nurse is assessing pain on a confused older client who has difficulty with verbalexpression. What pain assessment tool would the nurse choose for this assessment?a. Numeric rating scaleb. Verbal Descriptor Scalec. FACES Pain Scale-Revisedd. Wong-Baker FACES Pain ScaleANS: CAll are valid pain rating scales; however, some research has shown that the FACES PainScale-Revised is preferred by both cognitively intact and cognitively impaired adults.DIF: Applying/Application REF: 30KEY: Pain assessment| FACESMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Health Promotion and Maintenance5. The nurse is assessing a clients pain and has elicited information on the location, quality,intensity, effect on functioning, aggravating and relieving factors, and onset and duration.What question by the nurse would be best to ask the client for completing a comprehensivepain assessment?a. Are you worried about addiction to pain pills?b. Do you attach any spiritual meaning to pain?c. How high would you say your pain tolerance is?d. What pain rating would be acceptable to you?ANS: DA comprehensive pain assessment includes the items listed in the question plus the clientsopinion on a functional goal, such as what pain rating would be acceptable to him or her.Asking about addiction is not warranted in an initial pain assessment. Asking about spiritualmeanings for pain may give the nurse important information, but getting the basics first ismore important. Asking about pain tolerance may give the client the idea that pain toleranceis being judged.DIF: Applying/Application REF: 29 KEY: Pain assessmentMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential6. A nurse is assessing pain in an older adult. What action by the nurse is best?a. Ask only yes-or-no questions so the client doesnt get too tired.

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b. Give the client a picture of the pain scale and come back later.c. Question the client about new pain only, not normal pain from aging.d. Sit down, ask one question at a time, and allow the client to answer.ANS: DSome older clients do not report pain because they think it is a normal part of aging orbecause they do not want to be a bother. Sitting down conveys time, interest, andavailability. Ask only one question at a time and allow the client enough time to answer it.Yes-or-no questions are an example of poor communication technique. Giving the client apain scale, then leaving, might give the impression that the nurse does not have time for theclient. Plus the client may not know how to use it. There is no normal pain from aging.DIF: Applying/Application REF: 32KEY: Pain assessment| older adultMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Psychosocial Integrity7. The nurse receives a hand-off report. One client is described as a drug seeker who isobsessed with even tiny changes in physical condition and is on the light constantly askingfor more pain medication. When assessing this clients pain, what statement or question bythe nurse is most appropriate?a. Help me understand how pain is affecting you right now.b. I wish I could do more; is there anything I can get for you?c. You cannot have more pain medication for 3 hours.d. Why do you think the medication is not helping your pain?ANS: AThis is an example of therapeutic communication. A client who is preoccupied with physicalsymptoms and is demanding may have some psychosocial impact from the pain that is notbeing addressed. The nurse is providing the client the chance to explain the emotionaleffects of pain in addition to the physical ones. Saying the nurse wishes he or she could domore is very empathetic, but this response does not attempt to learn more about the pain.Simply telling the client when the next medication is due also does not help the nurseunderstand the clients situation. Why questions are probing and often make clientsdefensive, plus the client may not have an answer for this question.DIF: Applying/Application REF: 33KEY: Pain| pain assessmentMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Psychosocial Integrity8. A nurse on the medical-surgical unit has received a hand-off report. Which client shouldthe nurse see first?a. Client being discharged later on a complicated analgesia regimenb. Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scalec. Postoperative client who received oral opioid analgesia 45 minutes agod. Client who has returned from physical therapy and is resting in the reclinerANS: BAcute pain often serves as a physiologic warning signal that something is wrong. The clientwith new-onset abdominal pain needs to be seen first. The postoperative client needs 45minutes to an hour for the oral medication to become effective and should be seen shortlyto assess for effectiveness. The client going home requires teaching, which should be done

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after the first two clients have been seen and cared for, as this teaching will take some time.The client resting comfortably can be checked on quickly before spending time teaching theclient who is going home.DIF: Analyzing/Analysis REF: 25KEY: Acute pain| pain assessmentMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care9. A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbalclient with advanced dementia. The client scores a zero. What action by the nurse is best?a. Assess physiologic indicators and vital signs.b. Do not give pain medication as no pain is indicated.c. Document the findings and continue to monitor.d. Try a small dose of analgesic medication for pain.ANS: AAssessing pain in a nonverbal client is difficult despite the use of a scale specificallydesigned for this population. The nurse should next look at physiologic indicators of painand vital signs for clues to the presence of pain. Even a low score on this index does notmean the client does not have pain; he or she may be holding very still to prevent morepain. Documenting pain is important but not the most important action in this case. Thenurse can try a small dose of analgesia, but without having indices to monitor, it will bedifficult to assess for effectiveness. However, if the client has a condition that couldreasonably cause pain (i.e., recent surgery), the nurse does need to treat the client for pain.DIF: Applying/Application REF: 34KEY: Pain assessment| Checklist of Nonverbal Pain IndicatorsMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Physiological Adaptation10. A student nurse asks why several clients are getting more than one type of painmedication instead of very high doses of one medication. What response by the registerednurse is best?a. A multimodal approach is the preferred method of control.b. Doctors are much more liberal with pain medications now.c. Pain is so complex it takes different approaches to control it.d. Clients are consumers and they demand lots of pain medicine.ANS: CPain is a complex phenomenon and often responds best to a regimen that uses differenttypes of analgesia. This is called a multimodal approach. Using this terminology, however,may not be clear to the student if the terminology is not understood. Doctors may be moreliberal with pain medications, but that is not the best reason for this approach. Saying thatclients are consumers who demand medications sounds as if the nurse is discounting theirpain experiences.DIF: Understanding/Comprehension REF: 34KEY: Pain| pharmacologic pain management| multimodal pain managementMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Physiological Adaptation: Pharmacological and ParenteralTherapies

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11. A client who had surgery has extreme postoperative pain that is worsened when tryingto participate in physical therapy. What intervention for pain management does the nurseinclude in the clients care plan?a. As-needed pain medication after therapyb. Client-controlled analgesia with a basal ratec. Pain medications prior to therapy onlyd. Round-the-clock analgesia with PRN analgesicsANS: DSevere pain related to surgery or tissue trauma is best managed with round-the-clockdosing. Breakthrough pain associated with specific procedures is managed with additionalmedication. An as-needed regimen will not control postoperative pain. A client-controlledanalgesia pump might be a good idea but needs basal (continuous) and bolus (intermittent)settings to accomplish adequate pain control. Pain control needs to be continuous, not justadministered prior to therapy.DIF: Applying/Application REF: 34KEY: Pharmacologic pain management| painMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Physiological Integrity: Pharmacological and ParenteralTherapies12. A nurse on the postoperative inpatient unit receives a hand-off report on four clientsusing patient-controlled analgesia (PCA) pumps. Which client should the nurse see first?a. Client who appears to be sleeping soundlyb. Client with no bolus request in 6 hoursc. Client who is pressing the button every 10 minutesd. Client with a respiratory rate of 8 breaths/minANS: DContinuous delivery of opioid analgesia can lead to respiratory depression and extremesedation. A respiratory rate of 8 breaths/min is below normal, so the nurse should firstcheck this client. The client sleeping soundly could either be overly sedated or justcomfortable and should be checked next. Pressing the button every 10 minutes indicatesthe client has a high level of pain, but the device has a lockout determining how often abolus can be delivered. Therefore, the client cannot overdose. The nurse should nextassess that clients pain. The client who has not needed a bolus of pain medicine in severalhours has well-controlled pain.DIF: Applying/Application REF: 35KEY: Patient-controlled analgesia (PCA) pump| pharmacologic pain managementMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care13. A registered nurse (RN) and nursing student are caring for a client who is receiving painmedication via patient-controlled analgesia (PCA). What action by the student requires theRN to intervene?a. Assesses the clients pain level per agency policyb. Monitors the clients respiratory rate and sedationc. Presses the button when the client cannot reach itd. Reinforces client teaching about using the PCA pumpANS: C

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The client is the only person who should press the PCA button. If the client cannot reach it,the student should either reposition the client or the button, and should not press the buttonfor the client. The RN should intervene at this point. The other actions are appropriate.DIF: Applying/Application REF: 35KEY: Patient-controlled analgesia (PCA)| pharmacologic pain managementMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Safety and InfectionControl14. A client is put on twice-daily acetaminophen (Tylenol) for osteoarthritis. What finding inthe clients health history would lead the nurse to consult with the provider over the choice ofmedication?a. 25pack-year smoking historyb. Drinking 3 to 5 beers a dayc. Previous peptic ulcerd. Taking warfarin (Coumadin)ANS: BThe major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking3 to 5 beers each day may indicate underlying liver disease, which should be investigatedprior to taking chronic acetaminophen. The nurse should relay this information to theprovider. Smoking is not related to acetaminophen side effects. Acetaminophen does notcause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.DIF: Applying/Application REF: 35KEY: Acetaminophen| pharmacologic pain managementMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Physiological Integrity: Pharmacological and ParenteralTherapies15. A nurse is preparing to give a client ketorolac (Toradol) intravenously for pain. Whichassessment findings would lead the nurse to consult with the provider?a. Bilateral lung cracklesb. Hypoactive bowel soundsc. Self-reported pain of 3/10d. Urine output of 20 mL/2 hrANS: DDrugs in this category can affect renal function. Clients should be adequately hydrated anddemonstrate good renal function prior to administering ketorolac. A urine output of 20 mL/2hr is well below normal, and the nurse should consult with the provider about the choice ofdrug. Crackles and hypoactive bowel sounds are not related. A pain report of 3 does notwarrant a call to the physician. The medication may be part of a round-the-clock regimen toprevent and control pain and would still need to be given. If the medication is PRN, thenurse can ask the client if he or she still wants it.DIF: Applying/Application REF: 37KEY: Pharmacologic pain management| opioid analgesics| prostaglandinsMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Physiological Integrity: Pharmacological and ParenteralTherapies

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16. A hospitalized client uses a transdermal fentanyl (Duragesic) patch for chronic pain.What action by the nurse is most important for client safety?a. Assess and record the clients pain every 4 hours.b. Ensure the client is eating a high-fiber diet.c. Monitor the clients bowel function every shift.d. Remove the old patch when applying the new one.ANS: DThe old fentanyl patch should be removed when applying a new patch so that accidentaloverdose does not occur. The other actions are appropriate, but not as important for safety.DIF: Applying/Application REF: 38KEY: Pharmacologic pain management| opioid analgesics| transdermal patchMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Physiological Integrity: Pharmacological and ParenteralTherapies17. A hospitalized client has a history of depression for which sertraline (Zoloft) isprescribed. The client also has a morphine allergy and a history of alcoholism. Aftersurgery, several opioid analgesics are prescribed. Which one would the nurse choose?a. Hydrocodone and acetaminophen (Lorcet)b. Hydromorphone (Dilaudid)c. Meperidine (Demerol)d. Tramadol (Ultram)ANS: BHydromorphone is a good alternative to morphine for moderate to severe pain. The nurseshould not choose Lorcet because it contains acetaminophen (Tylenol) and the client has ahistory of alcoholism. Tramadol should not be used due to the potential for interactions withthe clients sertraline. Meperidine is rarely used and is often restricted.DIF: Analyzing/Analysis REF: 40KEY: Pharmacologic pain management| opioid analgesicsMSC: Integrated Process: Nursing Process: AnalysisNOT: Client Needs Category: Physiological Integrity: Pharmacological and ParenteralTherapies18. A client has received an opioid analgesic for pain. The nurse assesses that the clienthas a Pasero Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The clientsoxygen saturation is 87%. What action should the nurse perform first?a. Apply oxygen at 4 L/min.b. Attempt to arouse the client.c. Give naloxone (Narcan).d. Notify the Rapid Response Team.ANS: BThe Pasero Opioid-Induced Sedation Scale is used to assess for unwanted opioid-associated sedation. A Pasero Scale score of 3 is unacceptable but is managed by trying toarouse the client in order to take deep breaths and staying with the client until he or she ismore alert. Administering oxygen will not help if the clients respiratory rate is 7 breaths/min.Giving naloxone and calling for a Rapid Response Team would be appropriate for a higherPasero Scale score.

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DIF: Applying/Application REF: 44KEY: Pasero Opioid-Induced Sedation Scale| pharmacologic pain management| opioidanalgesics MSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care19. An older adult has diabetic neuropathy and often reports unbearable foot pain. Aboutwhich medication would the nurse plan to educate the client?a. Desipramine (Norpramin)b. Duloxetine (Cymbalta)c. Morphine sulfated. Nortriptyline (Pamelor)ANS: BAntidepressants and anticonvulsants often are used for neuropathic pain relief. Morphinewould not be used for this client. However, older adults do not tolerate tricyclicantidepressants very well, which eliminates desipramine and nortriptyline. Duloxetine wouldbe the best choice for this older client.DIF: Applying/Application REF: 45KEY: Neuropathic pain| pharmacologic pain managementMSC: Integrated Process: Nursing Process: AnalysisNOT: Client Needs Category: Physiological Integrity: Pharmacological and ParenteralTherapies20. An emergency department (ED) manager wishes to start offering clientsnonpharmacologic pain control methodologies as an adjunct to medication. Which strategywould be most successful with this client population?a. Listening to music on a headsetb. Participating in biofeedbackc. Playing video gamesd. Using guided imageryANS: AListening to music on a headset would be the most successful cognitive-behavioral paincontrol method for several reasons. First, in the ED, the nurse does not have time to teachclients complex modalities such as guided imagery or biofeedback. Second, clients who areanxious and in pain may not have good concentration, limiting the usefulness of videogames. Playing music on a headset only requires the client to wear the headset and can bebeneficial without strong concentration. A wide selection of music will make this appealingto more people.DIF: Understanding/Comprehension REF: 47KEY: Distraction| nonpharmacologic pain managementMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort21. An older client who lives alone is being discharged on opioid analgesics. What action bythe nurse is most important?a. Discuss the need for home health care.b. Give the client follow-up information.c. Provide written discharge instructions.d. Request a home safety assessment.

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