Test Bank for Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care, 9th Edition (Chapters 1-74)
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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 1
Table of Contents
Table of Contents
1
Chapter 01: Overview of Professional Nursing
Concepts for Medical-Surgical Nursing Chapter 02:
Overview of Health Concepts for Medical-Surgical
Nursing
Chapter 03: Common Health
Problems of Older Adults
Chapter 04: Assessment and
Care of Patients with Pain
Chapter 05: Genetic
Concepts for Medical-
Surgical Nursing
Chapter 06: Rehabilitation Concepts for Chronic
and Disabling Health Problems Chapter 07: End-
of-Life Care
Chapter 08: Concepts of Emergency and Trauma
Nursing
Chapter 09: Care of Patients with
Common Environmental Emergencies
Chapter 10: Concepts of Emergency and
Disaster Preparedness
Chapter 11: Assessment and Care of Patients with
Fluid and Electrolyte Imbalances Chapter 12:
Assessment and Care of Patients with Acid-Base
Imbalances
Chapter 13: Infusion Therapy
Chapter 14:
Care of
Preoperative
Patients
Chapter 15:
Care of
Intraoperativ
e Patients
Chapter 16:
Care of
Postoperativ
e Patients
Chapter 17:
Inflammation
and
Immunity
Chapter 18: Care of Patients with Arthritis and
Other Connective Tissue Diseases Chapter 19:
Care of Patients with HIV Disease
Chapter 20: Care of Patients with
Hypersensitivity (Allergy) and Autoimmunity
Chapter 21: Cancer Development
Chapter 22:
Care of
Patients
with Cancer
Chapter 23:
Care of
P
a
t
i
e
n
t
s
w
i
t
h
I
n
f
e
c
t
i
o
n
C
h
a
p
t
e
r
2
4
:
A
s
s
e
s
s
m
e
n
t
o
f
t
h
e
Table of Contents
Table of Contents
1
Chapter 01: Overview of Professional Nursing
Concepts for Medical-Surgical Nursing Chapter 02:
Overview of Health Concepts for Medical-Surgical
Nursing
Chapter 03: Common Health
Problems of Older Adults
Chapter 04: Assessment and
Care of Patients with Pain
Chapter 05: Genetic
Concepts for Medical-
Surgical Nursing
Chapter 06: Rehabilitation Concepts for Chronic
and Disabling Health Problems Chapter 07: End-
of-Life Care
Chapter 08: Concepts of Emergency and Trauma
Nursing
Chapter 09: Care of Patients with
Common Environmental Emergencies
Chapter 10: Concepts of Emergency and
Disaster Preparedness
Chapter 11: Assessment and Care of Patients with
Fluid and Electrolyte Imbalances Chapter 12:
Assessment and Care of Patients with Acid-Base
Imbalances
Chapter 13: Infusion Therapy
Chapter 14:
Care of
Preoperative
Patients
Chapter 15:
Care of
Intraoperativ
e Patients
Chapter 16:
Care of
Postoperativ
e Patients
Chapter 17:
Inflammation
and
Immunity
Chapter 18: Care of Patients with Arthritis and
Other Connective Tissue Diseases Chapter 19:
Care of Patients with HIV Disease
Chapter 20: Care of Patients with
Hypersensitivity (Allergy) and Autoimmunity
Chapter 21: Cancer Development
Chapter 22:
Care of
Patients
with Cancer
Chapter 23:
Care of
P
a
t
i
e
n
t
s
w
i
t
h
I
n
f
e
c
t
i
o
n
C
h
a
p
t
e
r
2
4
:
A
s
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s
s
m
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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 1
Table of Contents
Table of Contents
1
Chapter 01: Overview of Professional Nursing
Concepts for Medical-Surgical Nursing Chapter 02:
Overview of Health Concepts for Medical-Surgical
Nursing
Chapter 03: Common Health
Problems of Older Adults
Chapter 04: Assessment and
Care of Patients with Pain
Chapter 05: Genetic
Concepts for Medical-
Surgical Nursing
Chapter 06: Rehabilitation Concepts for Chronic
and Disabling Health Problems Chapter 07: End-
of-Life Care
Chapter 08: Concepts of Emergency and Trauma
Nursing
Chapter 09: Care of Patients with
Common Environmental Emergencies
Chapter 10: Concepts of Emergency and
Disaster Preparedness
Chapter 11: Assessment and Care of Patients with
Fluid and Electrolyte Imbalances Chapter 12:
Assessment and Care of Patients with Acid-Base
Imbalances
Chapter 13: Infusion Therapy
Chapter 14:
Care of
Preoperative
Patients
Chapter 15:
Care of
Intraoperativ
e Patients
Chapter 16:
Care of
Postoperativ
e Patients
Chapter 17:
Inflammation
and
Immunity
Chapter 18: Care of Patients with Arthritis and
Other Connective Tissue Diseases Chapter 19:
Care of Patients with HIV Disease
Chapter 20: Care of Patients with
Hypersensitivity (Allergy) and Autoimmunity
Chapter 21: Cancer Development
Chapter 22:
Care of
Patients
with Cancer
Chapter 23:
Care of
P
a
t
i
e
n
t
s
w
i
t
h
I
n
f
e
c
t
i
o
n
C
h
a
p
t
e
r
2
4
:
A
s
s
e
s
s
m
e
n
t
o
f
t
h
e
Table of Contents
Table of Contents
1
Chapter 01: Overview of Professional Nursing
Concepts for Medical-Surgical Nursing Chapter 02:
Overview of Health Concepts for Medical-Surgical
Nursing
Chapter 03: Common Health
Problems of Older Adults
Chapter 04: Assessment and
Care of Patients with Pain
Chapter 05: Genetic
Concepts for Medical-
Surgical Nursing
Chapter 06: Rehabilitation Concepts for Chronic
and Disabling Health Problems Chapter 07: End-
of-Life Care
Chapter 08: Concepts of Emergency and Trauma
Nursing
Chapter 09: Care of Patients with
Common Environmental Emergencies
Chapter 10: Concepts of Emergency and
Disaster Preparedness
Chapter 11: Assessment and Care of Patients with
Fluid and Electrolyte Imbalances Chapter 12:
Assessment and Care of Patients with Acid-Base
Imbalances
Chapter 13: Infusion Therapy
Chapter 14:
Care of
Preoperative
Patients
Chapter 15:
Care of
Intraoperativ
e Patients
Chapter 16:
Care of
Postoperativ
e Patients
Chapter 17:
Inflammation
and
Immunity
Chapter 18: Care of Patients with Arthritis and
Other Connective Tissue Diseases Chapter 19:
Care of Patients with HIV Disease
Chapter 20: Care of Patients with
Hypersensitivity (Allergy) and Autoimmunity
Chapter 21: Cancer Development
Chapter 22:
Care of
Patients
with Cancer
Chapter 23:
Care of
P
a
t
i
e
n
t
s
w
i
t
h
I
n
f
e
c
t
i
o
n
C
h
a
p
t
e
r
2
4
:
A
s
s
e
s
s
m
e
n
t
o
f
t
h
e
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 2
S
k
i
n
,
H
a
i
r
,
a
n
d
N
a
i
l
s
C
h
a
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5
:
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s
w
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S
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Pr
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bl
e
m
s
C
h
a
pt
er
2
6:
C
ar
e
of
P
at
ie
nt
s
wi
th
B
ur
n
s
Chapter 27: Assessment of the Respiratory System
Chapter 28: Care of Patients Requiring
Oxygen Therapy or Tracheostomy Chapter 29:
Care of Patients with Noninfectious Upper
Respiratory Problems Chapter 30: Care of
Patients with Noninfectious Lower Respiratory
Problems Chapter 31: Care of Patients with
Infectious Respiratory Problems
Chapter 32: Care of Critically Ill
Patients with Respiratory Problems
Chapter 33: Assessment of the
Cardiovascular System
Chapter 34: Care of
Patients with
Dysrhythmias Chapter
35: Care of Patients
with Cardiac Problems
Chapter 36: Care of
Patients with Vascular
Problems Chapter 37:
Care of Patients with
Shock
Chapter 38: Care of Patients
with Acute Coronary
Syndromes Chapter 39:
Assessment of the Hematologic
System
Chapter 40: Care of
Patients with Hematologic
Problems Chapter 41:
Assessment of the
Nervous System
Chapter 42: Care of Patients with
Problems of the CNS: The Brain Chapter
43: Care of Patients with Problems of the
CNS: The Spinal Cord
Chapter 44: Care of Patients with Problems of
the Peripheral Nervous System Chapter 45:
Care of Critically Ill Patients with Neurologic
Problems
Chapter 46: Assessment of the Eye and Vision
Chapter 47: Care of Patients with Eye and Vision
Problems
Chapter 48: Assessment and Care of Patients
with Ear and Hearing Problems Chapter 49:
Assessment of the Musculoskeletal System
Chapter 50: Care of Patients with Musculoskeletal
Problems
3
8
13
20
32
38
44
50
56
62
68
76
83
94
10
3
10
9
11
6
12
2
13
8
14
7
15
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22
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23
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24
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25
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26
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27
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28
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Pr
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bl
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m
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C
h
a
pt
er
2
6:
C
ar
e
of
P
at
ie
nt
s
wi
th
B
ur
n
s
Chapter 27: Assessment of the Respiratory System
Chapter 28: Care of Patients Requiring
Oxygen Therapy or Tracheostomy Chapter 29:
Care of Patients with Noninfectious Upper
Respiratory Problems Chapter 30: Care of
Patients with Noninfectious Lower Respiratory
Problems Chapter 31: Care of Patients with
Infectious Respiratory Problems
Chapter 32: Care of Critically Ill
Patients with Respiratory Problems
Chapter 33: Assessment of the
Cardiovascular System
Chapter 34: Care of
Patients with
Dysrhythmias Chapter
35: Care of Patients
with Cardiac Problems
Chapter 36: Care of
Patients with Vascular
Problems Chapter 37:
Care of Patients with
Shock
Chapter 38: Care of Patients
with Acute Coronary
Syndromes Chapter 39:
Assessment of the Hematologic
System
Chapter 40: Care of
Patients with Hematologic
Problems Chapter 41:
Assessment of the
Nervous System
Chapter 42: Care of Patients with
Problems of the CNS: The Brain Chapter
43: Care of Patients with Problems of the
CNS: The Spinal Cord
Chapter 44: Care of Patients with Problems of
the Peripheral Nervous System Chapter 45:
Care of Critically Ill Patients with Neurologic
Problems
Chapter 46: Assessment of the Eye and Vision
Chapter 47: Care of Patients with Eye and Vision
Problems
Chapter 48: Assessment and Care of Patients
with Ear and Hearing Problems Chapter 49:
Assessment of the Musculoskeletal System
Chapter 50: Care of Patients with Musculoskeletal
Problems
3
8
13
20
32
38
44
50
56
62
68
76
83
94
10
3
10
9
11
6
12
2
13
8
14
7
15
2
15
7
16
7
17
4
17
9
19
6
21
3
22
0
22
6
23
3
24
5
25
6
26
9
27
8
28
7
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 3
298
310
317
327
331
343
353
364
374
380
394
3
9
7
4
0
3
4
1
0
4
1
5
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C
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a
pt
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5
2:
A
ss
es
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nt
of
th
e
G
as
tr
oi
nt
es
tin
al
S
ys
te
m
C
h
a
pt
er
53: Care of Patients with
Oral Cavity Problems
Chapter 54: Care of Patients
with Esophageal Problems
Chapter 55: Care of Patients
with Stomach Disorders
Chapter 56: Care of Patients with
Noninflammatory Intestinal Disorders
Chapter 57: Care of Patients with
Inflammatory Intestinal Disorders Chapter
58: Care of Patients with Liver Problems
Chapter 59: Care of Patients with Problems of the
Biliary System and Pancreas Chapter 60: Care of
Patients with Malnutrition: Undernutrition and
Obesity Chapter 61: Assessment of the Endocrine
System
Chapter 62: Care of Patients with Pituitary and
Adrenal Gland Problems
Chapter 63: Care of Patients with Problems of the
Thyroid and Parathyroid Glands Chapter 64: Care of
Patients with Diabetes Mellitus
Chapter 65: Assessment of
the Renal/Urinary System
Chapter 66: Care of Patients
with Urinary Problems
Chapter 67: Care of Patients
with Kidney Disorders
Chapter 68: Care of Patients with Acute Kidney
Injury and Chronic Kidney Disease Chapter 69:
Assessment of the Reproductive System
Chapter 70: Care of
Patients with Breast
Disorders Chapter 71:
Care of Patients with
Gynecologic Problems
Chapter 72: Care of Patients with
Male Reproductive Problems
Chapter 73: Care of Transgender
Patients
Chapter 74: Care of Patients with Sexually
Transmitted Diseases
4
2
4
4
3
5
4
4
1
4
4
5
4
5
4
4
6
1
4
7
1
4
8
1
4
8
9
4
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0
6
5
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5
2
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5
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7
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4
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5
5
7
5
6
8
5
7
5
5
8
7
298
310
317
327
331
343
353
364
374
380
394
3
9
7
4
0
3
4
1
0
4
1
5
C
h
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p
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C
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2:
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nt
of
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G
as
tr
oi
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es
tin
al
S
ys
te
m
C
h
a
pt
er
53: Care of Patients with
Oral Cavity Problems
Chapter 54: Care of Patients
with Esophageal Problems
Chapter 55: Care of Patients
with Stomach Disorders
Chapter 56: Care of Patients with
Noninflammatory Intestinal Disorders
Chapter 57: Care of Patients with
Inflammatory Intestinal Disorders Chapter
58: Care of Patients with Liver Problems
Chapter 59: Care of Patients with Problems of the
Biliary System and Pancreas Chapter 60: Care of
Patients with Malnutrition: Undernutrition and
Obesity Chapter 61: Assessment of the Endocrine
System
Chapter 62: Care of Patients with Pituitary and
Adrenal Gland Problems
Chapter 63: Care of Patients with Problems of the
Thyroid and Parathyroid Glands Chapter 64: Care of
Patients with Diabetes Mellitus
Chapter 65: Assessment of
the Renal/Urinary System
Chapter 66: Care of Patients
with Urinary Problems
Chapter 67: Care of Patients
with Kidney Disorders
Chapter 68: Care of Patients with Acute Kidney
Injury and Chronic Kidney Disease Chapter 69:
Assessment of the Reproductive System
Chapter 70: Care of
Patients with Breast
Disorders Chapter 71:
Care of Patients with
Gynecologic Problems
Chapter 72: Care of Patients with
Male Reproductive Problems
Chapter 73: Care of Transgender
Patients
Chapter 74: Care of Patients with Sexually
Transmitted Diseases
4
2
4
4
3
5
4
4
1
4
4
5
4
5
4
4
6
1
4
7
1
4
8
1
4
8
9
4
9
7
5
0
6
5
1
2
5
2
0
5
2
7
5
4
9
5
5
7
5
6
8
5
7
5
5
8
7
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 4
591
598
605
614
6
1
8
591
598
605
614
6
1
8
Chapter 01: Overview of Professional Nursing Concepts for Medical-
Surgical Nursing
MULTIPLE CHOICE
1. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best
demonstrates this concept?
a. Assesses for cultural influences affecting health care
b. Ensures that all the clients basic needs are met
c. Tells the client and family about all upcoming tests
d. Thoroughly orients the client and family to the room
ANS: A
Competency in client-focused care is demonstrated when the nurse focuses on communication, culture, respect
compassion, client education, and empowerment. By 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. Simply
telling the client about all upcoming tests is not providing empowering education. Orienting the client and family to
the room is an important safety measure, but not directly related to demonstrating client-centered care.
DIF: Understanding/Comprehension REF: 3
KEY: Patient-centered care| culture MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76 mm
Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
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: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they suffer
either respiratory or cardiac arrest. Since the client has manifested 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 the nurse must do more than document. The primary care provider should be
notified, but this is not the priority over calling the RRT. The clients blood pressure should be reassessed
frequently, but the priority is getting the rapid care to the client.
DIF: Applying/Application REF: 3
KEY: Rapid Response Team (RRT)| medical emergencies MSC:
Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse is orienting a new client and family to the inpatient unit. What information does the 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: A
Each action could be important for the client or family to perform. However, encouraging the client to be active
in his or her health care as a partner is the most critical. The other actions are very limited in scope and do not
provide the broad protection that being active and involved does.
DIF: Understanding/Comprehension REF: 3
KEY: Patient safety
Surgical Nursing
MULTIPLE CHOICE
1. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best
demonstrates this concept?
a. Assesses for cultural influences affecting health care
b. Ensures that all the clients basic needs are met
c. Tells the client and family about all upcoming tests
d. Thoroughly orients the client and family to the room
ANS: A
Competency in client-focused care is demonstrated when the nurse focuses on communication, culture, respect
compassion, client education, and empowerment. By 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. Simply
telling the client about all upcoming tests is not providing empowering education. Orienting the client and family to
the room is an important safety measure, but not directly related to demonstrating client-centered care.
DIF: Understanding/Comprehension REF: 3
KEY: Patient-centered care| culture MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76 mm
Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
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: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they suffer
either respiratory or cardiac arrest. Since the client has manifested 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 the nurse must do more than document. The primary care provider should be
notified, but this is not the priority over calling the RRT. The clients blood pressure should be reassessed
frequently, but the priority is getting the rapid care to the client.
DIF: Applying/Application REF: 3
KEY: Rapid Response Team (RRT)| medical emergencies MSC:
Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse is orienting a new client and family to the inpatient unit. What information does the 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: A
Each action could be important for the client or family to perform. However, encouraging the client to be active
in his or her health care as a partner is the most critical. The other actions are very limited in scope and do not
provide the broad protection that being active and involved does.
DIF: Understanding/Comprehension REF: 3
KEY: Patient safety
Loading page 6...
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
4. A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor advises the
student that which is the priority when working as a professional nurse?
a. Attending to holistic client needs
b. Ensuring client safety
c. Not making medication errors
d. Providing client-focused care
ANS: B
All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Up to
98,000 deaths result each year from errors in hospital care, according to the 2000 Institute of Medicine report. Many
more clients have suffered injuries and less serious outcomes. Every nurse has the responsibility to guard the
clients safety.
DIF: Understanding/Comprehension REF: 2
KEY: Patient safety
MSC: Integrated Process: Nursing Process: Intervention
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5. A client is going to be admitted for a scheduled surgical procedure. Which action does the 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: A
Medication errors are the most common type of health care mistake. The Joint Commissions Speak Up campaign
encourages clients to help ensure their safety. One recommendation is for clients to know all their medications and
why they take them. This will help prevent medication errors.
DIF: Applying/Application REF: 4
KEY: Speak Up campaign| patient safety MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
6. Which action by the nurse working with a client best demonstrates respect for autonomy?
a. Asks if the client has questions before signing a consent
b. Gives the client accurate information when questioned
c. Keeps the promises made to the client and family
d. Treats the client fairly compared to other clients
ANS: A
Autonomy is self-determination. The client should make decisions regarding care. When the nurse obtains a
signature on the consent form, assessing if the client still has questions is vital, because without full information
the client cannot practice autonomy. Giving accurate information is practicing with veracity.
Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.
DIF: Applying/Application REF: 4
KEY: Autonomy| ethical principles MSC: Integrated Process: Caring
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A student nurse asks the faculty to explain best practices when communicating with a person 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.
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
4. A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor advises the
student that which is the priority when working as a professional nurse?
a. Attending to holistic client needs
b. Ensuring client safety
c. Not making medication errors
d. Providing client-focused care
ANS: B
All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Up to
98,000 deaths result each year from errors in hospital care, according to the 2000 Institute of Medicine report. Many
more clients have suffered injuries and less serious outcomes. Every nurse has the responsibility to guard the
clients safety.
DIF: Understanding/Comprehension REF: 2
KEY: Patient safety
MSC: Integrated Process: Nursing Process: Intervention
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5. A client is going to be admitted for a scheduled surgical procedure. Which action does the 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: A
Medication errors are the most common type of health care mistake. The Joint Commissions Speak Up campaign
encourages clients to help ensure their safety. One recommendation is for clients to know all their medications and
why they take them. This will help prevent medication errors.
DIF: Applying/Application REF: 4
KEY: Speak Up campaign| patient safety MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
6. Which action by the nurse working with a client best demonstrates respect for autonomy?
a. Asks if the client has questions before signing a consent
b. Gives the client accurate information when questioned
c. Keeps the promises made to the client and family
d. Treats the client fairly compared to other clients
ANS: A
Autonomy is self-determination. The client should make decisions regarding care. When the nurse obtains a
signature on the consent form, assessing if the client still has questions is vital, because without full information
the client cannot practice autonomy. Giving accurate information is practicing with veracity.
Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.
DIF: Applying/Application REF: 4
KEY: Autonomy| ethical principles MSC: Integrated Process: Caring
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A student nurse asks the faculty to explain best practices when communicating with a person 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.
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d. No differences exist in communicating with this population.
ANS: B
Many members of the LGBTQ community have faced discrimination from health care providers and may be
reluctant to seek health care. The nurse should never make assumptions about the needs of members of this
population. Rather, respectful questions are appropriate. If approached with sensitivity, the client with any health
care need is more likely to answer honestly.
DIF: Understanding/Comprehension REF: 4
KEY: LGBTQ| diversity
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Psychosocial Integrity
8. A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and has pain that
is unrelieved by the prescribed narcotic pain medication. Which statement is 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: B
SBAR is a recommended form of communication, and the acronym stands for Situation, Background,
Assessment, and Recommendation. Appropriate background information includes allergies to medications the on-
call physician might order. Situation describes what is happening right now that must be communicated; the clients
surgery 2 days ago would be considered background. Assessment would include an analysis of the clients
problem; asking for a different pain medication is a recommendation. Recommendation is a statement of what is
needed or what outcome is desired; this information about the surgeons preference might be better placed in
background.
DIF: Applying/Application REF: 5
KEY: SBAR| communication
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
9. A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive
personnel (UAP). Four hours later, the nurse notes the clients blood pressure 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 pressure
b. Double-checking the UAP by taking another blood pressure
c. Providing more appropriate supervision of the UAP
d. Taking the blood pressure instead of delegating the task
ANS: C
Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on
delegated tasks. The nurse should either have asked the UAP about the vital signs or instructed the UAP to report
them right away. An experienced UAP should know 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 the
scope of practice for a UAP and are permissible to delegate. The only appropriate answer is that the nurse did not
provide adequate instruction to the UAP.
DIF: Applying/Application REF: 6
KEY: Supervision| delegation| unlicensed assistive personnel MSC:
Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
10. A nurse is talking with a client who is moving to a new state and needs to find a new doctor and hospital
there. What advice by the nurse is best?
ANS: B
Many members of the LGBTQ community have faced discrimination from health care providers and may be
reluctant to seek health care. The nurse should never make assumptions about the needs of members of this
population. Rather, respectful questions are appropriate. If approached with sensitivity, the client with any health
care need is more likely to answer honestly.
DIF: Understanding/Comprehension REF: 4
KEY: LGBTQ| diversity
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Psychosocial Integrity
8. A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and has pain that
is unrelieved by the prescribed narcotic pain medication. Which statement is 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: B
SBAR is a recommended form of communication, and the acronym stands for Situation, Background,
Assessment, and Recommendation. Appropriate background information includes allergies to medications the on-
call physician might order. Situation describes what is happening right now that must be communicated; the clients
surgery 2 days ago would be considered background. Assessment would include an analysis of the clients
problem; asking for a different pain medication is a recommendation. Recommendation is a statement of what is
needed or what outcome is desired; this information about the surgeons preference might be better placed in
background.
DIF: Applying/Application REF: 5
KEY: SBAR| communication
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
9. A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive
personnel (UAP). Four hours later, the nurse notes the clients blood pressure 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 pressure
b. Double-checking the UAP by taking another blood pressure
c. Providing more appropriate supervision of the UAP
d. Taking the blood pressure instead of delegating the task
ANS: C
Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on
delegated tasks. The nurse should either have asked the UAP about the vital signs or instructed the UAP to report
them right away. An experienced UAP should know 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 the
scope of practice for a UAP and are permissible to delegate. The only appropriate answer is that the nurse did not
provide adequate instruction to the UAP.
DIF: Applying/Application REF: 6
KEY: Supervision| delegation| unlicensed assistive personnel MSC:
Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
10. A nurse is talking with a client who is moving to a new state and needs to find a new doctor and hospital
there. What advice by the nurse is best?
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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: C
Accreditation by The Joint Commission (TJC) or other accrediting body gives assurance that the facility has a focus
on safety. Nurse-client ratios differ by unit type and change over time. New technology doesnt necessarily mean
the hospital is safe. Affiliation with a health professions school has several advantages, but safety is most
important.
DIF: Understanding/Comprehension REF: 2 KEY:
The Joint Commission (TJC)| accreditation
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
11. A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in quality
improvement (QI) projects. What response by the precepting nurse is best?
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: B
The preceptor should try to reassure the nurse that implementing QI measures is not out of line for a newly
licensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how that
is possible and is dismissive. Identifying indicators of quality is not an easy, quick process and would not be the
best place to suggest a new nurse to start. Asking to be assigned to the QI committee does not give the nurse
information about how to implement QI in daily practice.
DIF: Applying/Application REF: 6
KEY: Quality improvement
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. A nurse is interested in making interdisciplinary work a high priority. Which actions by the nurse best
demonstrate this skill? (Select all that apply.)
a. Consults with other disciplines on client care
b. Coordinates discharge planning for home safety
c. Participates in comprehensive client rounding
d. Routinely asks other disciplines about client progress
e. Shows the nursing care plans to other disciplines
ANS: A, B, C, D
Collaborating with the interdisciplinary team involves planning, implementing, and evaluating client care as a team
with all other disciplines included. Simply showing other caregivers the nursing care plan is not actively involving
them or collaborating with them.
DIF: Applying/Application REF: 4
KEY: Collaboration| interdisciplinary team
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
2. A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of
competency. Which areas should the manager assess to determine if the nursing staff demonstrate competency
according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality?
(Select all that apply.)
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: C
Accreditation by The Joint Commission (TJC) or other accrediting body gives assurance that the facility has a focus
on safety. Nurse-client ratios differ by unit type and change over time. New technology doesnt necessarily mean
the hospital is safe. Affiliation with a health professions school has several advantages, but safety is most
important.
DIF: Understanding/Comprehension REF: 2 KEY:
The Joint Commission (TJC)| accreditation
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
11. A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in quality
improvement (QI) projects. What response by the precepting nurse is best?
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: B
The preceptor should try to reassure the nurse that implementing QI measures is not out of line for a newly
licensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how that
is possible and is dismissive. Identifying indicators of quality is not an easy, quick process and would not be the
best place to suggest a new nurse to start. Asking to be assigned to the QI committee does not give the nurse
information about how to implement QI in daily practice.
DIF: Applying/Application REF: 6
KEY: Quality improvement
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. A nurse is interested in making interdisciplinary work a high priority. Which actions by the nurse best
demonstrate this skill? (Select all that apply.)
a. Consults with other disciplines on client care
b. Coordinates discharge planning for home safety
c. Participates in comprehensive client rounding
d. Routinely asks other disciplines about client progress
e. Shows the nursing care plans to other disciplines
ANS: A, B, C, D
Collaborating with the interdisciplinary team involves planning, implementing, and evaluating client care as a team
with all other disciplines included. Simply showing other caregivers the nursing care plan is not actively involving
them or collaborating with them.
DIF: Applying/Application REF: 4
KEY: Collaboration| interdisciplinary team
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
2. A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of
competency. Which areas should the manager assess to determine if the nursing staff demonstrate competency
according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality?
(Select all that apply.)
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a. Collaborating with an interdisciplinary team
b. Implementing evidence-based care
c. Providing family-focused care
d. Routinely using informatics in practice
e. Using quality improvement in client care
ANS: A, B, D, E
The IOM report lists five broad core competencies that all health care providers should practice. These include
collaborating with the interdisciplinary team, implementing evidence-based practice, providing client-focused care,
using informatics in client care, and using quality improvement in client care.
DIF: Remembering/Knowledge REF: 3
KEY: Competencies| Institute of Medicine (IOM) MSC:
Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
3. The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (Select all
that apply.)
a. Cost-saving measures
b. Nurses expertise
c. Client preferences
d. Research findings
e. Values of the client
ANS: B, C, D, E
EBP consists of utilizing current evidence, the clients values and preferences, and the nurses expertise when
planning care. It does not include cost-saving measures.
DIF: Remembering/Knowledge REF: 6
KEY: Evidence-based practice (EBP)
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A nurse manager wants to improve hand-off communication among the staff. What actions 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, D
A good tool for standardizing hand-off reports and other critical communication is the SHARE model. SHARE
stands for standardize critical information, hardwire within your system, allow opportunities to ask questions,
reinforce quality and measurement, and educate and coach. Attending hand-off report gives the manager
opportunities to educate and coach. Conducting audits is part of reinforcing quality. Creating a template is
hardwiring within the system. Encouraging staff to ask questions and think critically about the information is
allowing opportunities to ask questions. The manager may need to tie raises into compliance if the staff is
resistive and other measures have failed, but this is not part of the SHARE model.
DIF: Applying/Application REF: 5 KEY:
SHARE| hand-off communication
MSC: Integrated Process: Nursing Process: Intervention
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
b. Implementing evidence-based care
c. Providing family-focused care
d. Routinely using informatics in practice
e. Using quality improvement in client care
ANS: A, B, D, E
The IOM report lists five broad core competencies that all health care providers should practice. These include
collaborating with the interdisciplinary team, implementing evidence-based practice, providing client-focused care,
using informatics in client care, and using quality improvement in client care.
DIF: Remembering/Knowledge REF: 3
KEY: Competencies| Institute of Medicine (IOM) MSC:
Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
3. The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (Select all
that apply.)
a. Cost-saving measures
b. Nurses expertise
c. Client preferences
d. Research findings
e. Values of the client
ANS: B, C, D, E
EBP consists of utilizing current evidence, the clients values and preferences, and the nurses expertise when
planning care. It does not include cost-saving measures.
DIF: Remembering/Knowledge REF: 6
KEY: Evidence-based practice (EBP)
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A nurse manager wants to improve hand-off communication among the staff. What actions 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, D
A good tool for standardizing hand-off reports and other critical communication is the SHARE model. SHARE
stands for standardize critical information, hardwire within your system, allow opportunities to ask questions,
reinforce quality and measurement, and educate and coach. Attending hand-off report gives the manager
opportunities to educate and coach. Conducting audits is part of reinforcing quality. Creating a template is
hardwiring within the system. Encouraging staff to ask questions and think critically about the information is
allowing opportunities to ask questions. The manager may need to tie raises into compliance if the staff is
resistive and other measures have failed, but this is not part of the SHARE model.
DIF: Applying/Application REF: 5 KEY:
SHARE| hand-off communication
MSC: Integrated Process: Nursing Process: Intervention
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
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Chapter 02: Overview of Health Concepts for Medical-Surgical Nursing
MULTIPLE CHOICE
1. Acid-base balance occurs when the pH level of the blood is between:
a. 7.3 and 7.5
b. 7.35 and 7.45
c. 7.4 and 7.5
d. 7.25 and 7.35
ANS: B
Acid-base balance is the maintenance of arterial blood pH between 7.35 and 7.45 through hydrogen ion production
and elimination.
DIF: Understanding/Comprehension REF: 13
KEY: Assessment
MSC: Physiological Adaptation | Fluid and Electrolyte Imbalances NOT:
Describe common fluid, electrolyte, and acid-base imbalances.
2. The nurse would expect a patient with respiratory acidosis to have an excessive amount of
a. Hydrogen ions.
b. Bicarbonate.
c. Oxygen.
d. Phosphate.
ANS: A
Respiratory acidosis occurs when the arterial blood pH level falls below 7.35 and is caused by either too many
hydrogen ions in the body (respiratory acidosis) or too little bicarbonate (metabolic acidosis). Excessive oxygen
and phosphate are not characteristic of respiratory acidosis.
DIF: Understanding/Comprehension REF: 13
KEY: Assessment
MSC: Physiological Adaptation | Fluid and Electrolyte Imbalances NOT:
Describe common fluid, electrolyte, and acid-base imbalances.
3. The best way for an individual to maintain acid-base balance is to
a. avoid or quit smoking.
b. exercise regularly.
c. eat healthy and well-balanced meals.
d. All of the above.
ANS: D
Maintaining a healthy lifestyle is the best way to maintain acid-base balance. For example, most cases of COPD
can be prevented by avoiding or quitting smoking, while regular exercise and a healthy diet can decrease the
incidence of type-2 diabetes.
DIF: Patient education REF: 14 KEY:
Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
4. The process to control cellular growth, replication, and differentiation to maintain homeostasis is called:
a. cellular regulation.
b. cellular impairment.
c. cellular reproduction.
d. cellular tumor.
ANS: A
Cellular Regulation is the term used to describe both the positive and negative aspects of cellular function
MULTIPLE CHOICE
1. Acid-base balance occurs when the pH level of the blood is between:
a. 7.3 and 7.5
b. 7.35 and 7.45
c. 7.4 and 7.5
d. 7.25 and 7.35
ANS: B
Acid-base balance is the maintenance of arterial blood pH between 7.35 and 7.45 through hydrogen ion production
and elimination.
DIF: Understanding/Comprehension REF: 13
KEY: Assessment
MSC: Physiological Adaptation | Fluid and Electrolyte Imbalances NOT:
Describe common fluid, electrolyte, and acid-base imbalances.
2. The nurse would expect a patient with respiratory acidosis to have an excessive amount of
a. Hydrogen ions.
b. Bicarbonate.
c. Oxygen.
d. Phosphate.
ANS: A
Respiratory acidosis occurs when the arterial blood pH level falls below 7.35 and is caused by either too many
hydrogen ions in the body (respiratory acidosis) or too little bicarbonate (metabolic acidosis). Excessive oxygen
and phosphate are not characteristic of respiratory acidosis.
DIF: Understanding/Comprehension REF: 13
KEY: Assessment
MSC: Physiological Adaptation | Fluid and Electrolyte Imbalances NOT:
Describe common fluid, electrolyte, and acid-base imbalances.
3. The best way for an individual to maintain acid-base balance is to
a. avoid or quit smoking.
b. exercise regularly.
c. eat healthy and well-balanced meals.
d. All of the above.
ANS: D
Maintaining a healthy lifestyle is the best way to maintain acid-base balance. For example, most cases of COPD
can be prevented by avoiding or quitting smoking, while regular exercise and a healthy diet can decrease the
incidence of type-2 diabetes.
DIF: Patient education REF: 14 KEY:
Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
4. The process to control cellular growth, replication, and differentiation to maintain homeostasis is called:
a. cellular regulation.
b. cellular impairment.
c. cellular reproduction.
d. cellular tumor.
ANS: A
Cellular Regulation is the term used to describe both the positive and negative aspects of cellular function
Loading page 11...
within the body.
DIF: Understanding/Comprehension REF: 14
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
5. A defining characteristic of malignant (cancerous) cells is:
a. they cannot spread to other tissues or organs.
b. they can invade healthy cells, tissues, and organs.
c. they are not usually a health risk.
d. none of the above.
ANS: B
Malignant (cancerous) cells have no comparison to the original cells from which they are derived, and they have
the ability to invade healthy cells, tissues, and other organs through tumor formation and invasion. On the other
hand, Benign cells do not have the ability to spread to other tissues or organs.
DIF: Understanding/Comprehension REF: 14
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
6. Specialized cells that circulate in the body to promote clotting are called:
a. anticoagulants.
b. proteins.
c. emboli.
d. platelets.
ANS: D
Clotting is a complex, multi-step process through which blood forms a protein-based clot to prevent excessive
bleeding. Platelets (thrombocytes) are the specialized cells that circulate in the blood and are activated when an
injury occurs. Once activated, these cells become sticky, causing them to clump together to form a temporary,
localized, solid plug.
DIF: Understanding/Comprehension REF: 15
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
7. An increase in platelet stickiness can lead to:
a. hypercoagulability
b. thromobocytopenia
c. embolus
d. atrial fibrillation
ANS: A
Hypercoagulability refers to an increase in clotting ability caused by an excess of platelets or excessive plately
stickiness, which can impair blood flow. The opposite end of the spectrum involves an inability to form adequate
clots, which often occurs when there is an inadequate number of circulating platelets or a reduction in platelet
stickiness.
DIF: Understanding/Comprehension REF: 15
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
8. Signs and symptoms of thromobsis include localized redness, swelling, and warmth:
a. arterial
DIF: Understanding/Comprehension REF: 14
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
5. A defining characteristic of malignant (cancerous) cells is:
a. they cannot spread to other tissues or organs.
b. they can invade healthy cells, tissues, and organs.
c. they are not usually a health risk.
d. none of the above.
ANS: B
Malignant (cancerous) cells have no comparison to the original cells from which they are derived, and they have
the ability to invade healthy cells, tissues, and other organs through tumor formation and invasion. On the other
hand, Benign cells do not have the ability to spread to other tissues or organs.
DIF: Understanding/Comprehension REF: 14
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
6. Specialized cells that circulate in the body to promote clotting are called:
a. anticoagulants.
b. proteins.
c. emboli.
d. platelets.
ANS: D
Clotting is a complex, multi-step process through which blood forms a protein-based clot to prevent excessive
bleeding. Platelets (thrombocytes) are the specialized cells that circulate in the blood and are activated when an
injury occurs. Once activated, these cells become sticky, causing them to clump together to form a temporary,
localized, solid plug.
DIF: Understanding/Comprehension REF: 15
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
7. An increase in platelet stickiness can lead to:
a. hypercoagulability
b. thromobocytopenia
c. embolus
d. atrial fibrillation
ANS: A
Hypercoagulability refers to an increase in clotting ability caused by an excess of platelets or excessive plately
stickiness, which can impair blood flow. The opposite end of the spectrum involves an inability to form adequate
clots, which often occurs when there is an inadequate number of circulating platelets or a reduction in platelet
stickiness.
DIF: Understanding/Comprehension REF: 15
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
8. Signs and symptoms of thromobsis include localized redness, swelling, and warmth:
a. arterial
Loading page 12...
b. venous
c. partial
d. atrial
ANS: B
Venous thrombosis is a clot formation in either superficial or deep veins, usually in the leg, and can be observed
locally.
DIF: Understanding/Comprehension REF: 16
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
9. A serious condition which is not locally observable and is typically manifested by decreased blood flow to a
distal extremity is known as thrombosis.
a. arterial
b. venous
c. partial
d. atrial
ANS: A
Arterial thrombosis is manifested by decreased blood flow (perfusion) to a distal extremity or internal organ. For
example, the distal leg can become pale and cool in the case of a femoral arterial clot due to blockage of blood
to the leg. This is an emergent condition and requires immediate intervention.
DIF: Understanding/Comprehension REF: 16
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
10. A high-level thinking process that allows an individual to make decisions and judgments is known as:
a. amnesia
b. personality
c. reasoning
d. memory
ANS: C
Reasoning is the high-level cognitive thinking process that helps individuals make decisions and judgments.
Personality is the way an individual feels and behaves, while Memory is the ability of an individual to retain and
recall information. Amnesia refers to a loss of memory caused by brain trauma, congenital disorders, or acute
health problems.
DIF: Understanding/Comprehension REF: 16
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Psychosocial Integrity
11. A form of inadequate cognition in older adults which is manifested by an acute, fluctuating confusional
state is known as:
a. dementia
b. delerium
c. amnesia
d. depression
ANS: B
Delerium is the form of acute, fluctuating confusion which lasts from a few hours to less than 1 month and that may
be treatable. Dementia is a chronic state of confusion that may last from a few months to many years and that may
not be reversible. Amnesia refers to a loss of memory caused by brain trauma, congenital disorders, or acute health
problems.
c. partial
d. atrial
ANS: B
Venous thrombosis is a clot formation in either superficial or deep veins, usually in the leg, and can be observed
locally.
DIF: Understanding/Comprehension REF: 16
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
9. A serious condition which is not locally observable and is typically manifested by decreased blood flow to a
distal extremity is known as thrombosis.
a. arterial
b. venous
c. partial
d. atrial
ANS: A
Arterial thrombosis is manifested by decreased blood flow (perfusion) to a distal extremity or internal organ. For
example, the distal leg can become pale and cool in the case of a femoral arterial clot due to blockage of blood
to the leg. This is an emergent condition and requires immediate intervention.
DIF: Understanding/Comprehension REF: 16
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
10. A high-level thinking process that allows an individual to make decisions and judgments is known as:
a. amnesia
b. personality
c. reasoning
d. memory
ANS: C
Reasoning is the high-level cognitive thinking process that helps individuals make decisions and judgments.
Personality is the way an individual feels and behaves, while Memory is the ability of an individual to retain and
recall information. Amnesia refers to a loss of memory caused by brain trauma, congenital disorders, or acute
health problems.
DIF: Understanding/Comprehension REF: 16
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Psychosocial Integrity
11. A form of inadequate cognition in older adults which is manifested by an acute, fluctuating confusional
state is known as:
a. dementia
b. delerium
c. amnesia
d. depression
ANS: B
Delerium is the form of acute, fluctuating confusion which lasts from a few hours to less than 1 month and that may
be treatable. Dementia is a chronic state of confusion that may last from a few months to many years and that may
not be reversible. Amnesia refers to a loss of memory caused by brain trauma, congenital disorders, or acute health
problems.
Loading page 13...
DIF: Understanding/Comprehension REF: 16
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Psychosocial Integrity
12. The most common causes of decreased comfort for a patient are pain and .
a. light-headedness
b. nausea
c. emotional stress
d. depression
ANS: C
Pain and emotional stress are the two leading causes of discomfort for a patient. For example, patients who are
having surgery are often anxious and feel stressed about the procedure. This emotional stress may negatively impact
the outcome of surgery.
DIF: Understanding/Comprehension REF: 17
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment
13. The inability to pass stool is known as .
a. constipation
b. obstipation
c. diarrhea
d. incontinence
ANS: B
Obstipation is the inability to pass stool during bowel elimination. Constipation refers to the condition where stool
can be hard, dry, and difficult to pass through the rectum. Diarrhea is at the opposite end of the continuum from
constipation, and occurs when stool is watery and without solid form. Elimination is the general term to describe
the excretion of waste from the body by the gastrointestinal tract and by the urinary system.
DIF: Understanding/Comprehension REF: 18
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
14. Hypokalemia can occur in patients with prolonged diarrhea and is caused by a decrease in:
a. calcium
b. magnesium
c. sodium
d. potassium
ANS: D
Hypokalemia occurs when there is a decrease in serum potassium. It can be a life-threatening condition because it
often causes rhythm abnormalities. An excess of potassium is referred to as Hyperkalemia.
DIF: Understanding/Comprehension REF: 18
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
15. The minimum hourly urinary output in a patient should be at least:
a. 5 mL per hour
b. 10 mL per hour
c. 30 mL per hour
d. 60 mL per hour
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Psychosocial Integrity
12. The most common causes of decreased comfort for a patient are pain and .
a. light-headedness
b. nausea
c. emotional stress
d. depression
ANS: C
Pain and emotional stress are the two leading causes of discomfort for a patient. For example, patients who are
having surgery are often anxious and feel stressed about the procedure. This emotional stress may negatively impact
the outcome of surgery.
DIF: Understanding/Comprehension REF: 17
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment
13. The inability to pass stool is known as .
a. constipation
b. obstipation
c. diarrhea
d. incontinence
ANS: B
Obstipation is the inability to pass stool during bowel elimination. Constipation refers to the condition where stool
can be hard, dry, and difficult to pass through the rectum. Diarrhea is at the opposite end of the continuum from
constipation, and occurs when stool is watery and without solid form. Elimination is the general term to describe
the excretion of waste from the body by the gastrointestinal tract and by the urinary system.
DIF: Understanding/Comprehension REF: 18
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
14. Hypokalemia can occur in patients with prolonged diarrhea and is caused by a decrease in:
a. calcium
b. magnesium
c. sodium
d. potassium
ANS: D
Hypokalemia occurs when there is a decrease in serum potassium. It can be a life-threatening condition because it
often causes rhythm abnormalities. An excess of potassium is referred to as Hyperkalemia.
DIF: Understanding/Comprehension REF: 18
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
15. The minimum hourly urinary output in a patient should be at least:
a. 5 mL per hour
b. 10 mL per hour
c. 30 mL per hour
d. 60 mL per hour
Loading page 14...
ANS: C
30 mL per hour is the minimum hourly urinary output in a normal healthy adult. A decrease in urinary output i a
sign of diminished kidney activity and fluid deficit.
DIF: Understanding/Comprehension REF: 20
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
16. The best indicator of fluid volume changes in the body is:
a. skin dryness
b. weight changes
c. blood pressure
d. pulse rate
ANS: C
Changes in weight are the best indicator of fluid volume changes in the body. Monitoring blood pressure,
checking pulse rate and quality, and assessing skin and mucous membranes for dryness are strong secondary
indicators.
DIF: Understanding/Comprehension REF: 20
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
17. Immunity which occurs when antibodies are passed from the mother to the fetus through the placenta or
through breast milk is called:
a. natural passive
b. artifical passive
c. natural active
d. artifical active
ANS: A
Artifical passive immunity occurs via a specific transfusion. Natural active immunity occurs when an antigen enters
the body and the body creates antibodies to fight off the antigen. Artifical active immunity occurs via vaccination or
immunization.
DIF: Understanding/Comprehension REF: 21-22
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
18. A major serum protein that is below normal in patients who have inadequate nutrition is:
a. Albumin
b. Globulin
c. Fibrinogen
d. Transferrin
ANS: A
A serum laboratory test to measure Albumin is the most common assessment for generalized malnutrition.
DIF: Understanding/Comprehension REF: 25
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
30 mL per hour is the minimum hourly urinary output in a normal healthy adult. A decrease in urinary output i a
sign of diminished kidney activity and fluid deficit.
DIF: Understanding/Comprehension REF: 20
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
16. The best indicator of fluid volume changes in the body is:
a. skin dryness
b. weight changes
c. blood pressure
d. pulse rate
ANS: C
Changes in weight are the best indicator of fluid volume changes in the body. Monitoring blood pressure,
checking pulse rate and quality, and assessing skin and mucous membranes for dryness are strong secondary
indicators.
DIF: Understanding/Comprehension REF: 20
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
17. Immunity which occurs when antibodies are passed from the mother to the fetus through the placenta or
through breast milk is called:
a. natural passive
b. artifical passive
c. natural active
d. artifical active
ANS: A
Artifical passive immunity occurs via a specific transfusion. Natural active immunity occurs when an antigen enters
the body and the body creates antibodies to fight off the antigen. Artifical active immunity occurs via vaccination or
immunization.
DIF: Understanding/Comprehension REF: 21-22
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
18. A major serum protein that is below normal in patients who have inadequate nutrition is:
a. Albumin
b. Globulin
c. Fibrinogen
d. Transferrin
ANS: A
A serum laboratory test to measure Albumin is the most common assessment for generalized malnutrition.
DIF: Understanding/Comprehension REF: 25
KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
Loading page 15...
Chapter 03: Common Health Problems of Older Adults
MULTIPLE CHOICE
1. A nurse working with older adults in the community plans programming to improve morale and emotional
health in this population. What activity would best meet this goal?
a. Exercise program to improve physical function
b. Financial planning seminar series for older adults
c. Social events such as dances and group dinners
d. Workshop on prevention from becoming an abuse victim
ANS: A
All activities would be beneficial for the older population in the community. However, failure in performing ones
own activities of daily living and participating in society has direct effects on morale and life satisfaction. Those
who lose the ability to function independently often feel worthless and empty. An exercise program designed to
maintain and/or improve physical functioning would best address this need.
DIF: Applying/Application REF: 32
KEY: Independence| autonomy| older adult
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Psychosocial Integrity
2. A nurse caring for an older client on a medical-surgical unit notices the client reports frequent 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: C
Poorly fitting dentures and other dental problems are often manifested by a preference for soft foods and
constipation from the lack of fiber. The nurse should perform an oral assessment to determine if these problems
exist. The other assessments are important, but will not yield information specific to the clients food preferences as
they relate to constipation.
DIF: Applying/Application REF: 30 KEY:
Nutrition| dentures| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
3. A nursing faculty member working with students explains that the fastest growing subset of the older
population is which group?
a. Elite old
b. Middle old
c. Old old
d. Young old
ANS: C
The old old is the fastest growing subset of the older population. This is the group comprising 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 of age.
DIF: Remembering/Knowledge REF: 29
KEY: Adulthood| aging| old old MSC: Integrated Process: Teaching/Learning NOT:
Client Needs Category: Health Promotion and Maintenance
4. A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse
provide to best address this issue?
MULTIPLE CHOICE
1. A nurse working with older adults in the community plans programming to improve morale and emotional
health in this population. What activity would best meet this goal?
a. Exercise program to improve physical function
b. Financial planning seminar series for older adults
c. Social events such as dances and group dinners
d. Workshop on prevention from becoming an abuse victim
ANS: A
All activities would be beneficial for the older population in the community. However, failure in performing ones
own activities of daily living and participating in society has direct effects on morale and life satisfaction. Those
who lose the ability to function independently often feel worthless and empty. An exercise program designed to
maintain and/or improve physical functioning would best address this need.
DIF: Applying/Application REF: 32
KEY: Independence| autonomy| older adult
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Psychosocial Integrity
2. A nurse caring for an older client on a medical-surgical unit notices the client reports frequent 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: C
Poorly fitting dentures and other dental problems are often manifested by a preference for soft foods and
constipation from the lack of fiber. The nurse should perform an oral assessment to determine if these problems
exist. The other assessments are important, but will not yield information specific to the clients food preferences as
they relate to constipation.
DIF: Applying/Application REF: 30 KEY:
Nutrition| dentures| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
3. A nursing faculty member working with students explains that the fastest growing subset of the older
population is which group?
a. Elite old
b. Middle old
c. Old old
d. Young old
ANS: C
The old old is the fastest growing subset of the older population. This is the group comprising 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 of age.
DIF: Remembering/Knowledge REF: 29
KEY: Adulthood| aging| old old MSC: Integrated Process: Teaching/Learning NOT:
Client Needs Category: Health Promotion and Maintenance
4. A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse
provide to best address this issue?
Loading page 16...
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: C
Older adults often lose their sense of thirst. Since they should drink 1 to 2 liters of water a day, the best remedy is to
have the older adult drink something each hour or two, whether or 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, this information will not help prevent the problem of dehydration. Instructing the client to take a
diuretic in the morning rather than in the evening also will not directly address this issue.
DIF: Applying/Application REF: 31
KEY: Dehydration| older adult| hydration MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the
client demonstrates a need for further review?
a. Barley soup
b. Black beans
c. White rice
d. Whole wheat bread
ANS: C
Older adults need 25 to 50 grams of fiber a day. White rice is low in fiber. Foods high in fiber include barley, beans,
and whole wheat products.
DIF: Applying/Application REF: 31 KEY:
Nutrition| fiber| older adult
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A home health care nurse is planning an exercise program with an older client who lives at 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 flexibility
b. Improving exercise endurance
c. Increasing aerobic capacity
d. Providing personal training
ANS: A
This older adult is mostly homebound. Exercise regimens for homebound clients include things to increase
functional ability for activities of daily living. Strength and flexibility will help the client to be able to maintain
independence longer. The other plans are good but will not specifically maintain the clients functional abilities.
DIF: Applying/Application REF: 32
KEY: Exercise| functional ability| older adult
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
7. An older adult recently retired and reports being depressed and lonely. What information should the nurse
assess as a priority?
a. History of previous depression
b. Previous stressful events
c. Role of work in the adults life
d. Usual leisure time activities
ANS: C
Often older adults lose support systems when their roles change. For instance, when people retire, they may
b. Dehydration can cause incontinence.
c. Have something to drink every 1 to 2 hours.
d. Take your diuretic in the morning.
ANS: C
Older adults often lose their sense of thirst. Since they should drink 1 to 2 liters of water a day, the best remedy is to
have the older adult drink something each hour or two, whether or 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, this information will not help prevent the problem of dehydration. Instructing the client to take a
diuretic in the morning rather than in the evening also will not directly address this issue.
DIF: Applying/Application REF: 31
KEY: Dehydration| older adult| hydration MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the
client demonstrates a need for further review?
a. Barley soup
b. Black beans
c. White rice
d. Whole wheat bread
ANS: C
Older adults need 25 to 50 grams of fiber a day. White rice is low in fiber. Foods high in fiber include barley, beans,
and whole wheat products.
DIF: Applying/Application REF: 31 KEY:
Nutrition| fiber| older adult
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A home health care nurse is planning an exercise program with an older client who lives at 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 flexibility
b. Improving exercise endurance
c. Increasing aerobic capacity
d. Providing personal training
ANS: A
This older adult is mostly homebound. Exercise regimens for homebound clients include things to increase
functional ability for activities of daily living. Strength and flexibility will help the client to be able to maintain
independence longer. The other plans are good but will not specifically maintain the clients functional abilities.
DIF: Applying/Application REF: 32
KEY: Exercise| functional ability| older adult
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
7. An older adult recently retired and reports being depressed and lonely. What information should the nurse
assess as a priority?
a. History of previous depression
b. Previous stressful events
c. Role of work in the adults life
d. Usual leisure time activities
ANS: C
Often older adults lose support systems when their roles change. For instance, when people retire, they may
Loading page 17...
lose their entire social network, leading them to feeling depressed and lonely. The nurse should first assess the role
that work played in the clients life. The other factors can be assessed as well, but this circumstance is commonly
seen in the older population.
DIF: Applying/Application REF: 32 KEY:
Depression| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Psychosocial Integrity
8. A nurse is assessing coping in older women in a support group for recent widows. Which statement 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: A
Friendship and support enhance coping. The quality of the relationship is what is most important, however.
People who have close, intimate, stable relationships with others in whom they confide are more likely to cope with
crisis.
DIF: Remembering/Knowledge REF: 32 KEY:
Coping| relationships| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Psychosocial Integrity
9. 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 be most 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: B
As a person ages, he or she may experience a decreased sense of touch. The older adult may not be aware of
where his or her foot is on the step. Installing contrasting color strips at the end of each step will help increase
awareness. If the client does not need an assistive device, he or she should not use one just on stairs. Using an
alternative door may be necessary but does not address making the front steps safer. A two-footed gait may not help
if the client is unaware of where the foot is on the step.
DIF: Applying/Application REF: 33 KEY:
Safety| falls| older adult
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
10. An older adult is brought to the emergency department because of sudden onset of confusion. After the
client is stabilized and comfortable, what assessment by the nurse is most important?
a. Assess for orthostatic hypotension.
b. Determine if there are new medications.
c. Evaluate the client for gait abnormalities.
d. Perform a delirium screening test.
ANS: B
Medication side effects and adverse effects are common in the older population. Something as simple as a new
antibiotic can cause confusion and memory loss. The nurse should determine if the client is taking any new
medications. Assessments for orthostatic hypotension, gait abnormalities, and delirium may be important once more
is known about the clients condition.
that work played in the clients life. The other factors can be assessed as well, but this circumstance is commonly
seen in the older population.
DIF: Applying/Application REF: 32 KEY:
Depression| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Psychosocial Integrity
8. A nurse is assessing coping in older women in a support group for recent widows. Which statement 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: A
Friendship and support enhance coping. The quality of the relationship is what is most important, however.
People who have close, intimate, stable relationships with others in whom they confide are more likely to cope with
crisis.
DIF: Remembering/Knowledge REF: 32 KEY:
Coping| relationships| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Psychosocial Integrity
9. 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 be most 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: B
As a person ages, he or she may experience a decreased sense of touch. The older adult may not be aware of
where his or her foot is on the step. Installing contrasting color strips at the end of each step will help increase
awareness. If the client does not need an assistive device, he or she should not use one just on stairs. Using an
alternative door may be necessary but does not address making the front steps safer. A two-footed gait may not help
if the client is unaware of where the foot is on the step.
DIF: Applying/Application REF: 33 KEY:
Safety| falls| older adult
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
10. An older adult is brought to the emergency department because of sudden onset of confusion. After the
client is stabilized and comfortable, what assessment by the nurse is most important?
a. Assess for orthostatic hypotension.
b. Determine if there are new medications.
c. Evaluate the client for gait abnormalities.
d. Perform a delirium screening test.
ANS: B
Medication side effects and adverse effects are common in the older population. Something as simple as a new
antibiotic can cause confusion and memory loss. The nurse should determine if the client is taking any new
medications. Assessments for orthostatic hypotension, gait abnormalities, and delirium may be important once more
is known about the clients condition.
Loading page 18...
DIF: Applying/Application REF: 33
KEY: Medications| medication safety| older adult MSC:
Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
11. An older adult client takes medication three times a day and becomes confused about which medication
should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying Those
are for old people. What action by the nurse would be most 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: C
Color-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 by time in a drawer might be helpful if the person
doesnt accidentally put them back in the wrong spot. Easy-open tops are not related. Writing a list might be helpful,
but not if it gets misplaced. With stickers on the medication bottles themselves, the reminder is always with the
medication.
DIF: Applying/Application REF: 34
KEY: Medications| medication safety| older adult
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
12. An older adult client is in the hospital. The client is ambulatory and independent. What intervention 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: A
Although this older adult is independent and ambulatory, being hospitalized can create confusion. Getting up in a
dark, unfamiliar environment can contribute to falls. Keeping the light on in the bathroom will help reduce the
likelihood of falling. The client does not need a commode or a toileting schedule. Siderails used to keep the client in
bed are considered restraints and should not be used in that fashion.
DIF: Applying/Application REF: 41 KEY:
Falls| safety| older adult
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
13. An older client had hip replacement surgery and the surgeon prescribed morphine sulfate 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 of the morphine?
a. Cyclobenzaprine (Flexeril)
b. Hydromorphone hydrochloride (Dilaudid)
c. Ketorolac (Toradol)
d. Meperidine (Demerol)
ANS: B
Cyclobenzaprine (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 and should not be suggested. The nurse should
suggest hydromorphone hydrochloride.
DIF: Remembering/Knowledge REF: 36 KEY:
Medications| Beers list| older adult
MSC: Integrated Process: Communication and Documentation
KEY: Medications| medication safety| older adult MSC:
Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
11. An older adult client takes medication three times a day and becomes confused about which medication
should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying Those
are for old people. What action by the nurse would be most 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: C
Color-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 by time in a drawer might be helpful if the person
doesnt accidentally put them back in the wrong spot. Easy-open tops are not related. Writing a list might be helpful,
but not if it gets misplaced. With stickers on the medication bottles themselves, the reminder is always with the
medication.
DIF: Applying/Application REF: 34
KEY: Medications| medication safety| older adult
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
12. An older adult client is in the hospital. The client is ambulatory and independent. What intervention 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: A
Although this older adult is independent and ambulatory, being hospitalized can create confusion. Getting up in a
dark, unfamiliar environment can contribute to falls. Keeping the light on in the bathroom will help reduce the
likelihood of falling. The client does not need a commode or a toileting schedule. Siderails used to keep the client in
bed are considered restraints and should not be used in that fashion.
DIF: Applying/Application REF: 41 KEY:
Falls| safety| older adult
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
13. An older client had hip replacement surgery and the surgeon prescribed morphine sulfate 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 of the morphine?
a. Cyclobenzaprine (Flexeril)
b. Hydromorphone hydrochloride (Dilaudid)
c. Ketorolac (Toradol)
d. Meperidine (Demerol)
ANS: B
Cyclobenzaprine (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 and should not be suggested. The nurse should
suggest hydromorphone hydrochloride.
DIF: Remembering/Knowledge REF: 36 KEY:
Medications| Beers list| older adult
MSC: Integrated Process: Communication and Documentation
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NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
14. A nurse admits an older client from a home environment where she lives with her adult son and daughter-
in-law. The client has urine burns on her skin, no dentures, and several pressure 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: D
These findings are suspicious for abuse. Health care providers are mandatory reporters for suspected abuse. The
nurse should notify social work, case management, or whomever is designated in policies. That person can then
assess the situation further. If the police need to be notified, that is the person who will notify them. Adult Protective
Services is notified in the community setting.
DIF: Applying/Application REF: 39 KEY:
Abuse| older adult
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
15. A nurse caring for an older client in the hospital is concerned the client is not competent to 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
In this situation, each facility will have a policy designed for assessing competence. The nurse should bring these
concerns to an interdisciplinary care team meeting. There may be physiologic reasons for the client to be
temporarily too confused or incompetent to give consent. If an acute condition is ruled out, the staff should
follow the legal procedure and policies in their facility and state for determining competence. The key is to bring
the concerns forward. Calling Adult Protective Services is not appropriate at this time. Signing the consent
should wait until competence is determined unless it is an emergency, in which case the next of kin can sign if
there are grave doubts as to the clients ability to provide consent.
DIF: Applying/Application REF: 36 KEY:
Competence| autonomy| older adult
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. A nursing student working in an Adult Care for Elders unit learns that frailty in the older population includes
which components? (Select all that apply.)
a. Dementia
b. Exhaustion
c. Slowed physical activity
d. Weakness
e. Weight gain
ANS: B, C, D
Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and exhaustion, and
weakness. Weight gain and dementia are not part of this cluster of manifestations.
DIF: Remembering/Knowledge REF: 29 KEY:
Frailty| frail elderly| older adult
MSC: Integrated Process: Nursing Process: Assessment
14. A nurse admits an older client from a home environment where she lives with her adult son and daughter-
in-law. The client has urine burns on her skin, no dentures, and several pressure 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: D
These findings are suspicious for abuse. Health care providers are mandatory reporters for suspected abuse. The
nurse should notify social work, case management, or whomever is designated in policies. That person can then
assess the situation further. If the police need to be notified, that is the person who will notify them. Adult Protective
Services is notified in the community setting.
DIF: Applying/Application REF: 39 KEY:
Abuse| older adult
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
15. A nurse caring for an older client in the hospital is concerned the client is not competent to 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
In this situation, each facility will have a policy designed for assessing competence. The nurse should bring these
concerns to an interdisciplinary care team meeting. There may be physiologic reasons for the client to be
temporarily too confused or incompetent to give consent. If an acute condition is ruled out, the staff should
follow the legal procedure and policies in their facility and state for determining competence. The key is to bring
the concerns forward. Calling Adult Protective Services is not appropriate at this time. Signing the consent
should wait until competence is determined unless it is an emergency, in which case the next of kin can sign if
there are grave doubts as to the clients ability to provide consent.
DIF: Applying/Application REF: 36 KEY:
Competence| autonomy| older adult
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. A nursing student working in an Adult Care for Elders unit learns that frailty in the older population includes
which components? (Select all that apply.)
a. Dementia
b. Exhaustion
c. Slowed physical activity
d. Weakness
e. Weight gain
ANS: B, C, D
Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and exhaustion, and
weakness. Weight gain and dementia are not part of this cluster of manifestations.
DIF: Remembering/Knowledge REF: 29 KEY:
Frailty| frail elderly| older adult
MSC: Integrated Process: Nursing Process: Assessment
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NOT: Client Needs Category: Health Promotion and Maintenance
2. A home health care nurse assesses an older client for the intake of nutrients needed in larger amounts than in
younger adults. Which foods found in an older adults kitchen might indicate an adequate intake of these
nutrients? (Select all that apply.)
a. 1% milk
b. Carrots
c. Lean ground beef
d. Oranges
e. Vitamin D supplements
ANS: A, B, D, E
Older adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk has calcium; carrots have
vitamin A; the vitamin D supplement has vitamin D; and oranges have vitamin C. Lean ground beef is healthier
than more fatty cuts, but does not contain these needed nutrients.
DIF: Applying/Application REF: 30
KEY: Nutrition| nutritional requirements| older adults MSC:
Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
3. A nurse working with older adults assesses them for common potential adverse medication effects. For what
does the nurse assess? (Select all that apply.)
a. Constipation
b. Dehydration
c. Mania
d. Urinary incontinence
e. Weakness
ANS: A, B, E
Common adverse medication effects include constipation/impaction, dehydration, and weakness. Mania and
incontinence are not among the common adverse effects, although urinary retention is.
DIF: Remembering/Knowledge REF: 34 KEY:
Medications| adverse effects
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A nurse manager institutes the Fulmer Spices Framework as part of the routine assessment of older adults in
the hospital. The nursing staff assesses for which factors? (Select all that apply.)
a. Confusion
b. Evidence of abuse
c. Incontinence
d. Problems with behavior
e. Sleep disorders
ANS: A, C, E
SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion, and evidence of falls.
DIF: Remembering/Knowledge REF: 40 KEY:
SPICES| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A visiting nurse is in the home of an older adult and notes a 7-pound weight loss since last 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.
2. A home health care nurse assesses an older client for the intake of nutrients needed in larger amounts than in
younger adults. Which foods found in an older adults kitchen might indicate an adequate intake of these
nutrients? (Select all that apply.)
a. 1% milk
b. Carrots
c. Lean ground beef
d. Oranges
e. Vitamin D supplements
ANS: A, B, D, E
Older adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk has calcium; carrots have
vitamin A; the vitamin D supplement has vitamin D; and oranges have vitamin C. Lean ground beef is healthier
than more fatty cuts, but does not contain these needed nutrients.
DIF: Applying/Application REF: 30
KEY: Nutrition| nutritional requirements| older adults MSC:
Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
3. A nurse working with older adults assesses them for common potential adverse medication effects. For what
does the nurse assess? (Select all that apply.)
a. Constipation
b. Dehydration
c. Mania
d. Urinary incontinence
e. Weakness
ANS: A, B, E
Common adverse medication effects include constipation/impaction, dehydration, and weakness. Mania and
incontinence are not among the common adverse effects, although urinary retention is.
DIF: Remembering/Knowledge REF: 34 KEY:
Medications| adverse effects
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A nurse manager institutes the Fulmer Spices Framework as part of the routine assessment of older adults in
the hospital. The nursing staff assesses for which factors? (Select all that apply.)
a. Confusion
b. Evidence of abuse
c. Incontinence
d. Problems with behavior
e. Sleep disorders
ANS: A, C, E
SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion, and evidence of falls.
DIF: Remembering/Knowledge REF: 40 KEY:
SPICES| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A visiting nurse is in the home of an older adult and notes a 7-pound weight loss since last 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.
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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, D
Assessment is the first step of the nursing process and should be completed prior to intervening. Asking about
transportation, dentures, and normal food patterns would be part of an appropriate assessment for the client.
There is no information in the question about the older adult needing to lose weight, so encouraging him or her to
continue the current exercise regimen is premature and may not be appropriate. Teaching about proper nutrition
is a good idea, but teaching needs to be tailored to the clients needs, which the nurse does not yet know.
DIF: Applying/Application REF: 30 KEY:
Nutrition| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions 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, E
The nurses aide or UAP can assist in keeping the clients skin dry, order a special mattress on direction of the RN,
and turn the client on a schedule. Assessing the skin is a nursing responsibility, 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 who performs that assessment.
DIF: Applying/Application REF: 42
KEY: Skin breakdown| older adult| delegation| unlicensed assistive personnel MSC:
Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A nurse admits an older client to the hospital who lives at home with family. The nurse assesses that the
client is malnourished. What actions by the nurse are best? (Select all that 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, E
Malnutrition in the older population is multifactorial and has several potential adverse outcomes. Appropriate actions
by the nurse include assessing the clients risk for skin breakdown with the Braden Scale, requesting a consultation
with a dietitian, and suggesting a high-protein meal supplement. There is no evidence that the client is being
abused or needs a feeding tube at this time.
DIF: Applying/Application REF: 40
KEY: Nutrition| malnutrition| older adult| Braden Scale MSC:
Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
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, D
Assessment is the first step of the nursing process and should be completed prior to intervening. Asking about
transportation, dentures, and normal food patterns would be part of an appropriate assessment for the client.
There is no information in the question about the older adult needing to lose weight, so encouraging him or her to
continue the current exercise regimen is premature and may not be appropriate. Teaching about proper nutrition
is a good idea, but teaching needs to be tailored to the clients needs, which the nurse does not yet know.
DIF: Applying/Application REF: 30 KEY:
Nutrition| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions 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, E
The nurses aide or UAP can assist in keeping the clients skin dry, order a special mattress on direction of the RN,
and turn the client on a schedule. Assessing the skin is a nursing responsibility, 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 who performs that assessment.
DIF: Applying/Application REF: 42
KEY: Skin breakdown| older adult| delegation| unlicensed assistive personnel MSC:
Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A nurse admits an older client to the hospital who lives at home with family. The nurse assesses that the
client is malnourished. What actions by the nurse are best? (Select all that 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, E
Malnutrition in the older population is multifactorial and has several potential adverse outcomes. Appropriate actions
by the nurse include assessing the clients risk for skin breakdown with the Braden Scale, requesting a consultation
with a dietitian, and suggesting a high-protein meal supplement. There is no evidence that the client is being
abused or needs a feeding tube at this time.
DIF: Applying/Application REF: 40
KEY: Nutrition| malnutrition| older adult| Braden Scale MSC:
Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
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Chapter 04: Assessment and Care of Patients with Pain
MULTIPLE CHOICE
1. A student asks the nurse what is the best way to assess a clients pain. Which response by the nurse is best?
a. Numeric pain scale
b. Behavioral assessment
c. Objective observation
d. Clients self-report
ANS: D
Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other
objective observations. However, the most accurate way to assess pain is to get a self-report from the client.
DIF: Remembering/Knowledge REF: 46 KEY:
Pain| pain assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance
2. A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse
brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain
the client described. What response by the experienced nurse 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: A
A clients description is the most accurate assessment of pain. The nurse should believe the client and provide pain
relief. Physiologic changes due to pain vary from client to client, and assessments of them should not supersede
the clients descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is
judgmental and flippant, and does not provide useful information. This amount of information does not warrant an
assessment for drug addiction. Putting the medication back and ignoring the clients report of pain serves no useful
purpose.
DIF: Understanding/Comprehension REF: 49
KEY: Pain| pain assessment
MSC: Integrated Process: Communication and Documentation NOT:
Client Needs Category: Health Promotion and Maintenance
3. 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-term outcome?
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.
ANS: B
The best outcome after a surgical procedure is timely and satisfactory pain control, which diminishes the
likelihood of chronic pain afterward. The nurse suggests that the client advocate for himself and discuss
acceptable pain control with the surgeon. Stating that pain after surgery is usually short lived does not provide the
client with options to have personalized 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 medications around the
clock instead of waiting until the client requests it is a better approach.
DIF: Applying/Application REF: 47 KEY:
Pain| acute pain
MSC: Integrated Process: Teaching/Learning
MULTIPLE CHOICE
1. A student asks the nurse what is the best way to assess a clients pain. Which response by the nurse is best?
a. Numeric pain scale
b. Behavioral assessment
c. Objective observation
d. Clients self-report
ANS: D
Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other
objective observations. However, the most accurate way to assess pain is to get a self-report from the client.
DIF: Remembering/Knowledge REF: 46 KEY:
Pain| pain assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance
2. A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse
brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain
the client described. What response by the experienced nurse 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: A
A clients description is the most accurate assessment of pain. The nurse should believe the client and provide pain
relief. Physiologic changes due to pain vary from client to client, and assessments of them should not supersede
the clients descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is
judgmental and flippant, and does not provide useful information. This amount of information does not warrant an
assessment for drug addiction. Putting the medication back and ignoring the clients report of pain serves no useful
purpose.
DIF: Understanding/Comprehension REF: 49
KEY: Pain| pain assessment
MSC: Integrated Process: Communication and Documentation NOT:
Client Needs Category: Health Promotion and Maintenance
3. 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-term outcome?
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.
ANS: B
The best outcome after a surgical procedure is timely and satisfactory pain control, which diminishes the
likelihood of chronic pain afterward. The nurse suggests that the client advocate for himself and discuss
acceptable pain control with the surgeon. Stating that pain after surgery is usually short lived does not provide the
client with options to have personalized 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 medications around the
clock instead of waiting until the client requests it is a better approach.
DIF: Applying/Application REF: 47 KEY:
Pain| acute pain
MSC: Integrated Process: Teaching/Learning
Loading page 23...
NOT: Client Needs Category: Health Promotion and Maintenance
4. A nurse is assessing pain on a confused older client who has difficulty with verbal expression. What pain
assessment tool would the nurse choose for this assessment?
a. Numeric rating scale
b. Verbal Descriptor Scale
c. FACES Pain Scale-Revised
d. Wong-Baker FACES Pain Scale
ANS: C
All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred
by both cognitively intact and cognitively impaired adults.
DIF: Applying/Application REF: 51 KEY:
Pain assessment| FACES
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance
5. 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 comprehensive pain 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: D
A comprehensive pain assessment includes the items listed in the question plus the clients opinion 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 spiritual meanings for pain may give the nurse important
information, but getting the basics first is more important. Asking about pain tolerance may give the client the idea
that pain tolerance is being judged.
DIF: Applying/Application REF: 50 KEY:
Pain assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. 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.
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: D
Some older clients do not report pain because they think it is a normal part of aging or because they do not want
to be a bother. Sitting down conveys time, interest, and availability. 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 a pain scale, then leaving, might give the impression that the nurse does not have time for the client. Plus the
client may not know how to use it. There is no normal pain from aging.
DIF: Applying/Application REF: 53 KEY:
Pain assessment| older adult
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Psychosocial Integrity
7. The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tiny
changes in physical condition and is on the light constantly asking for more pain medication. When assessing
this clients pain, what statement or question by the nurse is most appropriate?
4. A nurse is assessing pain on a confused older client who has difficulty with verbal expression. What pain
assessment tool would the nurse choose for this assessment?
a. Numeric rating scale
b. Verbal Descriptor Scale
c. FACES Pain Scale-Revised
d. Wong-Baker FACES Pain Scale
ANS: C
All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred
by both cognitively intact and cognitively impaired adults.
DIF: Applying/Application REF: 51 KEY:
Pain assessment| FACES
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance
5. 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 comprehensive pain 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: D
A comprehensive pain assessment includes the items listed in the question plus the clients opinion 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 spiritual meanings for pain may give the nurse important
information, but getting the basics first is more important. Asking about pain tolerance may give the client the idea
that pain tolerance is being judged.
DIF: Applying/Application REF: 50 KEY:
Pain assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. 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.
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: D
Some older clients do not report pain because they think it is a normal part of aging or because they do not want
to be a bother. Sitting down conveys time, interest, and availability. 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 a pain scale, then leaving, might give the impression that the nurse does not have time for the client. Plus the
client may not know how to use it. There is no normal pain from aging.
DIF: Applying/Application REF: 53 KEY:
Pain assessment| older adult
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Psychosocial Integrity
7. The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tiny
changes in physical condition and is on the light constantly asking for more pain medication. When assessing
this clients pain, what statement or question by the nurse is most appropriate?
Loading page 24...
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: A
This is an example of therapeutic communication. A client who is preoccupied with physical symptoms and is
demanding may have some psychosocial impact from the pain that is not being addressed. The nurse is providing
the client the chance to explain the emotional effects of pain in addition to the physical ones. Saying the nurse
wishes he or she could do more 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 nurse understand the clients
situation. Why questions are probing and often make clients defensive, plus the client may not have an answer
for this question.
DIF: Applying/Application REF: 54 KEY:
Pain| pain assessment
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Psychosocial Integrity
8. A nurse on the medical-surgical unit has received a hand-off report. Which client should the nurse see first?
a. Client being discharged later on a complicated analgesia regimen
b. Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale
c. Postoperative client who received oral opioid analgesia 45 minutes ago
d. Client who has returned from physical therapy and is resting in the recliner
ANS: B
Acute pain often serves as a physiologic warning signal that something is wrong. The client with new-onset
abdominal pain needs to be seen first. The postoperative client needs 45 minutes to an hour for the oral
medication to become effective and should be seen shortly to assess for effectiveness. The client going home
requires teaching, which should be done 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 the
client who is going home.
DIF: Analyzing/Analysis REF: 46
KEY: Acute pain| pain assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
9. A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client 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: A
Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this
population. The nurse should next look at physiologic indicators of pain and vital signs for clues to the presence
of pain. Even a low score on this index does not mean the client does not have pain; he or she may be holding
very still to prevent more pain. Documenting pain is important but not the most important action in this case. The
nurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult to assess for
effectiveness. However, if the client has a condition that could reasonably cause pain (i.e., recent surgery), the nurse
does need to treat the client for pain.
DIF: Applying/Application REF: 55
KEY: Pain assessment| Checklist of Nonverbal Pain Indicators MSC:
Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
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: A
This is an example of therapeutic communication. A client who is preoccupied with physical symptoms and is
demanding may have some psychosocial impact from the pain that is not being addressed. The nurse is providing
the client the chance to explain the emotional effects of pain in addition to the physical ones. Saying the nurse
wishes he or she could do more 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 nurse understand the clients
situation. Why questions are probing and often make clients defensive, plus the client may not have an answer
for this question.
DIF: Applying/Application REF: 54 KEY:
Pain| pain assessment
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Psychosocial Integrity
8. A nurse on the medical-surgical unit has received a hand-off report. Which client should the nurse see first?
a. Client being discharged later on a complicated analgesia regimen
b. Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale
c. Postoperative client who received oral opioid analgesia 45 minutes ago
d. Client who has returned from physical therapy and is resting in the recliner
ANS: B
Acute pain often serves as a physiologic warning signal that something is wrong. The client with new-onset
abdominal pain needs to be seen first. The postoperative client needs 45 minutes to an hour for the oral
medication to become effective and should be seen shortly to assess for effectiveness. The client going home
requires teaching, which should be done 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 the
client who is going home.
DIF: Analyzing/Analysis REF: 46
KEY: Acute pain| pain assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
9. A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client 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: A
Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this
population. The nurse should next look at physiologic indicators of pain and vital signs for clues to the presence
of pain. Even a low score on this index does not mean the client does not have pain; he or she may be holding
very still to prevent more pain. Documenting pain is important but not the most important action in this case. The
nurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult to assess for
effectiveness. However, if the client has a condition that could reasonably cause pain (i.e., recent surgery), the nurse
does need to treat the client for pain.
DIF: Applying/Application REF: 55
KEY: Pain assessment| Checklist of Nonverbal Pain Indicators MSC:
Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
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10. A student nurse asks why several clients are getting more than one type of pain medication instead of very
high doses of one medication. What response by the registered nurse 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: C
Pain is a complex phenomenon and often responds best to a regimen that uses different types 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 more liberal with pain medications, but that is not the best reason
for this approach. Saying that clients are consumers who demand medications sounds as if the nurse is discounting
their pain experiences.
DIF: Understanding/Comprehension REF: 55
KEY: Pain| pharmacologic pain management| multimodal pain management MSC:
Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Adaptation: Pharmacological and Parenteral Therapies
11. A client who had surgery has extreme postoperative pain that is worsened when trying to participate in
physical therapy. What intervention for pain management does the nurse include in the clients care plan?
a. As-needed pain medication after therapy
b. Client-controlled analgesia with a basal rate
c. Pain medications prior to therapy only
d. Round-the-clock analgesia with PRN analgesics
ANS: D
Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain
associated with specific procedures is managed with additional medication. An as-needed regimen will not control
postoperative pain. A client-controlled analgesia 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 just
administered prior to therapy.
DIF: Applying/Application REF: 55
KEY: Pharmacologic pain management| pain
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
12. A nurse on the postoperative inpatient unit receives a hand-off report on four clients using patient-
controlled analgesia (PCA) pumps. Which client should the nurse see first?
a. Client who appears to be sleeping soundly
b. Client with no bolus request in 6 hours
c. Client who is pressing the button every 10 minutes
d. Client with a respiratory rate of 8 breaths/min
ANS: D
Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate
of 8 breaths/min is below normal, so the nurse should first check this client. The client sleeping soundly could
either be overly sedated or just comfortable and should be checked next. Pressing the button every 10 minutes
indicates the client has a high level of pain, but the device has a lockout determining how often a bolus can be
delivered. Therefore, the client cannot overdose. The nurse should next assess that clients pain. The client who
has not needed a bolus of pain medicine in several hours has well-controlled pain.
DIF: Applying/Application REF: 56
KEY: Patient-controlled analgesia (PCA) pump| pharmacologic pain management MSC:
Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
13. A registered nurse (RN) and nursing student are caring for a client who is receiving pain medication via
high doses of one medication. What response by the registered nurse 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: C
Pain is a complex phenomenon and often responds best to a regimen that uses different types 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 more liberal with pain medications, but that is not the best reason
for this approach. Saying that clients are consumers who demand medications sounds as if the nurse is discounting
their pain experiences.
DIF: Understanding/Comprehension REF: 55
KEY: Pain| pharmacologic pain management| multimodal pain management MSC:
Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Adaptation: Pharmacological and Parenteral Therapies
11. A client who had surgery has extreme postoperative pain that is worsened when trying to participate in
physical therapy. What intervention for pain management does the nurse include in the clients care plan?
a. As-needed pain medication after therapy
b. Client-controlled analgesia with a basal rate
c. Pain medications prior to therapy only
d. Round-the-clock analgesia with PRN analgesics
ANS: D
Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain
associated with specific procedures is managed with additional medication. An as-needed regimen will not control
postoperative pain. A client-controlled analgesia 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 just
administered prior to therapy.
DIF: Applying/Application REF: 55
KEY: Pharmacologic pain management| pain
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
12. A nurse on the postoperative inpatient unit receives a hand-off report on four clients using patient-
controlled analgesia (PCA) pumps. Which client should the nurse see first?
a. Client who appears to be sleeping soundly
b. Client with no bolus request in 6 hours
c. Client who is pressing the button every 10 minutes
d. Client with a respiratory rate of 8 breaths/min
ANS: D
Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate
of 8 breaths/min is below normal, so the nurse should first check this client. The client sleeping soundly could
either be overly sedated or just comfortable and should be checked next. Pressing the button every 10 minutes
indicates the client has a high level of pain, but the device has a lockout determining how often a bolus can be
delivered. Therefore, the client cannot overdose. The nurse should next assess that clients pain. The client who
has not needed a bolus of pain medicine in several hours has well-controlled pain.
DIF: Applying/Application REF: 56
KEY: Patient-controlled analgesia (PCA) pump| pharmacologic pain management MSC:
Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
13. A registered nurse (RN) and nursing student are caring for a client who is receiving pain medication via
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patient-controlled analgesia (PCA). What action by the student requires the RN to intervene?
a. Assesses the clients pain level per agency policy
b. Monitors the clients respiratory rate and sedation
c. Presses the button when the client cannot reach it
d. Reinforces client teaching about using the PCA pump
ANS: C
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 button for the client. The RN should intervene
at this point. The other actions are appropriate.
DIF: Applying/Application REF: 56
KEY: Patient-controlled analgesia (PCA)| pharmacologic pain management MSC:
Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
14. A client is put on twice-daily acetaminophen (Tylenol) for osteoarthritis. What finding in the clients health
history would lead the nurse to consult with the provider over the choice of medication?
a. 25pack-year smoking history
b. Drinking 3 to 5 beers a day
c. Previous peptic ulcer
d. Taking warfarin (Coumadin)
ANS: B
The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day
may indicate underlying liver disease, which should be investigated prior to taking chronic acetaminophen. The
nurse should relay this information to the provider. Smoking is not related to acetaminophen side effects.
Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.
DIF: Applying/Application REF: 56
KEY: Acetaminophen| pharmacologic pain management MSC:
Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
15. A nurse is preparing to give a client ketorolac (Toradol) intravenously for pain. Which assessment findings
would lead the nurse to consult with the provider?
a. Bilateral lung crackles
b. Hypoactive bowel sounds
c. Self-reported pain of 3/10
d. Urine output of 20 mL/2 hr
ANS: D
Drugs in this category can affect renal function. Clients should be adequately hydrated and demonstrate good renal
function prior to administering ketorolac. A urine output of 20 mL/2 hr is well below normal, and the nurse
should consult with the provider about the choice of drug. Crackles and hypoactive bowel sounds are not related. A
pain report of 3 does not warrant a call to the physician. The medication may be part of a round-the- clock regimen
to prevent and control pain and would still need to be given. If the medication is PRN, the nurse can ask the client
if he or she still wants it.
DIF: Applying/Application REF: 58
KEY: Pharmacologic pain management| opioid analgesics| prostaglandins MSC:
Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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.
a. Assesses the clients pain level per agency policy
b. Monitors the clients respiratory rate and sedation
c. Presses the button when the client cannot reach it
d. Reinforces client teaching about using the PCA pump
ANS: C
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 button for the client. The RN should intervene
at this point. The other actions are appropriate.
DIF: Applying/Application REF: 56
KEY: Patient-controlled analgesia (PCA)| pharmacologic pain management MSC:
Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
14. A client is put on twice-daily acetaminophen (Tylenol) for osteoarthritis. What finding in the clients health
history would lead the nurse to consult with the provider over the choice of medication?
a. 25pack-year smoking history
b. Drinking 3 to 5 beers a day
c. Previous peptic ulcer
d. Taking warfarin (Coumadin)
ANS: B
The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day
may indicate underlying liver disease, which should be investigated prior to taking chronic acetaminophen. The
nurse should relay this information to the provider. Smoking is not related to acetaminophen side effects.
Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.
DIF: Applying/Application REF: 56
KEY: Acetaminophen| pharmacologic pain management MSC:
Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
15. A nurse is preparing to give a client ketorolac (Toradol) intravenously for pain. Which assessment findings
would lead the nurse to consult with the provider?
a. Bilateral lung crackles
b. Hypoactive bowel sounds
c. Self-reported pain of 3/10
d. Urine output of 20 mL/2 hr
ANS: D
Drugs in this category can affect renal function. Clients should be adequately hydrated and demonstrate good renal
function prior to administering ketorolac. A urine output of 20 mL/2 hr is well below normal, and the nurse
should consult with the provider about the choice of drug. Crackles and hypoactive bowel sounds are not related. A
pain report of 3 does not warrant a call to the physician. The medication may be part of a round-the- clock regimen
to prevent and control pain and would still need to be given. If the medication is PRN, the nurse can ask the client
if he or she still wants it.
DIF: Applying/Application REF: 58
KEY: Pharmacologic pain management| opioid analgesics| prostaglandins MSC:
Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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.
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d. Remove the old patch when applying the new one.
ANS: D
The old fentanyl patch should be removed when applying a new patch so that accidental overdose does not occur.
The other actions are appropriate, but not as important for safety.
DIF: Applying/Application REF: 59
KEY: Pharmacologic pain management| opioid analgesics| transdermal patch MSC:
Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
17. A hospitalized client has a history of depression for which sertraline (Zoloft) is prescribed. The client also
has a morphine allergy and a history of alcoholism. After surgery, 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: B
Hydromorphone is a good alternative to morphine for moderate to severe pain. The nurse should not choose
Lorcet because it contains acetaminophen (Tylenol) and the client has a history of alcoholism. Tramadol should
not be used due to the potential for interactions with the clients sertraline. Meperidine is rarely used and is often
restricted.
DIF: Analyzing/Analysis REF: 61
KEY: Pharmacologic pain management| opioid analgesics MSC:
Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
18. A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero
Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The clients oxygen 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: B
The 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 to arouse the client in order to take deep breaths and staying
with the client until he or she is more 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 higher Pasero
Scale score.
DIF: Applying/Application REF: 65
KEY: Pasero Opioid-Induced Sedation Scale| pharmacologic pain management| opioid analgesics MSC: Integrated
Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
19. An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medication
would the nurse plan to educate the client?
a. Desipramine (Norpramin)
b. Duloxetine (Cymbalta)
c. Morphine sulfate
d. Nortriptyline (Pamelor)
ANS: B
Antidepressants and anticonvulsants often are used for neuropathic pain relief. Morphine would not be used for
ANS: D
The old fentanyl patch should be removed when applying a new patch so that accidental overdose does not occur.
The other actions are appropriate, but not as important for safety.
DIF: Applying/Application REF: 59
KEY: Pharmacologic pain management| opioid analgesics| transdermal patch MSC:
Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
17. A hospitalized client has a history of depression for which sertraline (Zoloft) is prescribed. The client also
has a morphine allergy and a history of alcoholism. After surgery, 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: B
Hydromorphone is a good alternative to morphine for moderate to severe pain. The nurse should not choose
Lorcet because it contains acetaminophen (Tylenol) and the client has a history of alcoholism. Tramadol should
not be used due to the potential for interactions with the clients sertraline. Meperidine is rarely used and is often
restricted.
DIF: Analyzing/Analysis REF: 61
KEY: Pharmacologic pain management| opioid analgesics MSC:
Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
18. A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero
Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The clients oxygen 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: B
The 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 to arouse the client in order to take deep breaths and staying
with the client until he or she is more 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 higher Pasero
Scale score.
DIF: Applying/Application REF: 65
KEY: Pasero Opioid-Induced Sedation Scale| pharmacologic pain management| opioid analgesics MSC: Integrated
Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
19. An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medication
would the nurse plan to educate the client?
a. Desipramine (Norpramin)
b. Duloxetine (Cymbalta)
c. Morphine sulfate
d. Nortriptyline (Pamelor)
ANS: B
Antidepressants and anticonvulsants often are used for neuropathic pain relief. Morphine would not be used for
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this client. However, older adults do not tolerate tricyclic antidepressants very well, which eliminates desipramine
and nortriptyline. Duloxetine would be the best choice for this older client.
DIF: Applying/Application REF: 66
KEY: Neuropathic pain| pharmacologic pain management MSC:
Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
20. An emergency department (ED) manager wishes to start offering clients nonpharmacologic pain control
methodologies as an adjunct to medication. Which strategy would be most successful with this client
population?
a. Listening to music on a headset
b. Participating in biofeedback
c. Playing video games
d. Using guided imagery
ANS: A
Listening to music on a headset would be the most successful cognitive-behavioral pain control method for
several reasons. First, in the ED, the nurse does not have time to teach clients complex modalities such as guided
imagery or biofeedback. Second, clients who are anxious and in pain may not have good concentration, limiting the
usefulness of video games. Playing music on a headset only requires the client to wear the headset and can be
beneficial without strong concentration. A wide selection of music will make this appealing to more people.
DIF: Understanding/Comprehension REF: 68
KEY: Distraction| nonpharmacologic pain management MSC:
Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
21. An older client who lives alone is being discharged on opioid analgesics. What action by the 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.
ANS: D
All these activities are appropriate when discharging a client whose needs will continue after discharge. A home
safety assessment would be most important to ensure the safety of this older client.
DIF: Remembering/Knowledge REF: 69 KEY:
Safety| older adult| opioid analgesics
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
22. A nurse is caring for four clients receiving pain medication. After the hand-off report, which client should
the nurse see first?
a. Client who is crying and agitated
b. Client with a heart rate of 104 beats/min
c. Client with a Pasero Scale score of 4
d. Client with a verbal pain report of 9
ANS: C
The Pasero Opioid-Induced Sedation Scale has scores ranging from S to 1 to 4. A score of 4 indicates
unacceptable somnolence and is an emergency. The nurse should see this client first. The nurse can delegate
visiting with the crying client to a nursing assistant; the client may be upset and might benefit from talking or a
comforting presence. The client whose pain score is 9 needs to be seen next, or the nurse can delegate this
assessment to another nurse while working with the priority client. A heart rate of 104 beats/min is slightly above
normal, and that client can be seen after the other two clients are cared for.
and nortriptyline. Duloxetine would be the best choice for this older client.
DIF: Applying/Application REF: 66
KEY: Neuropathic pain| pharmacologic pain management MSC:
Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
20. An emergency department (ED) manager wishes to start offering clients nonpharmacologic pain control
methodologies as an adjunct to medication. Which strategy would be most successful with this client
population?
a. Listening to music on a headset
b. Participating in biofeedback
c. Playing video games
d. Using guided imagery
ANS: A
Listening to music on a headset would be the most successful cognitive-behavioral pain control method for
several reasons. First, in the ED, the nurse does not have time to teach clients complex modalities such as guided
imagery or biofeedback. Second, clients who are anxious and in pain may not have good concentration, limiting the
usefulness of video games. Playing music on a headset only requires the client to wear the headset and can be
beneficial without strong concentration. A wide selection of music will make this appealing to more people.
DIF: Understanding/Comprehension REF: 68
KEY: Distraction| nonpharmacologic pain management MSC:
Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
21. An older client who lives alone is being discharged on opioid analgesics. What action by the 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.
ANS: D
All these activities are appropriate when discharging a client whose needs will continue after discharge. A home
safety assessment would be most important to ensure the safety of this older client.
DIF: Remembering/Knowledge REF: 69 KEY:
Safety| older adult| opioid analgesics
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
22. A nurse is caring for four clients receiving pain medication. After the hand-off report, which client should
the nurse see first?
a. Client who is crying and agitated
b. Client with a heart rate of 104 beats/min
c. Client with a Pasero Scale score of 4
d. Client with a verbal pain report of 9
ANS: C
The Pasero Opioid-Induced Sedation Scale has scores ranging from S to 1 to 4. A score of 4 indicates
unacceptable somnolence and is an emergency. The nurse should see this client first. The nurse can delegate
visiting with the crying client to a nursing assistant; the client may be upset and might benefit from talking or a
comforting presence. The client whose pain score is 9 needs to be seen next, or the nurse can delegate this
assessment to another nurse while working with the priority client. A heart rate of 104 beats/min is slightly above
normal, and that client can be seen after the other two clients are cared for.
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DIF: Applying/Application REF: 65
KEY: Pasero Opioid-Induced Sedation Scale| pharmacologic pain management MSC:
Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
23. A nurse is caring for a client on an epidural patient-controlled analgesia (PCA) pump. What action by the
nurse is most important to ensure client safety?
a. Assess and record vital signs every 2 hours.
b. Have another nurse double-check the pump settings.
c. Instruct the client to report any unrelieved pain.
d. Monitor for numbness and tingling in the legs.
ANS: B
PCA-delivered analgesia creates a potential risk for the client. Pump settings should always be double- checked.
Assessing vital signs should be done per agency policy and nurse discretion, and may or may not need to be this
frequent. Unrelieved pain should be reported but is not vital to client safety. Monitoring for numbness and tingling
in the legs is an important function but will manifest after something has occurred to the client; monitoring does not
prevent the event from occurring.
DIF: Applying/Application REF: 56
KEY: Patient-controlled analgesia (PCA)| pharmacologic pain management MSC:
Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
24. A postoperative client is reluctant to participate in physical therapy. What action by the nurse is best?
a. Ask the client about pain goals and if they are being met.
b. Ask the client why he or she is being uncooperative with therapy.
c. Increase the dose of analgesia given prior to therapy sessions.
d. Tell the client that physical therapy is required to regain function.
ANS: A
A comprehensive pain management plan includes the clients goals for pain control. Adequate pain control is
necessary to allow full participation in therapy. The first thing the nurse should do is to ask about the clients pain
goals and if they are being met. If not, an adjustment to treatment can be made. If they are being met, the nurse can
assess for other factors influencing the clients behavior. Asking the client why he or she is being uncooperative is
not the best response for two reasons. First, why questions tend to put people on the defensive. Second, labeling
the behavior is inappropriate. Simply increasing the pain medication may not be advantageous. Simply telling the
client that physical therapy is required does not address the issue.
DIF: Applying/Application REF: 67 KEY:
Pain goals| pain
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
25. A client is being discharged from the hospital after surgery on hydrocodone and acetaminophen (Lorcet).
What discharge instruction is most important for this client?
a. Call the doctor if the Lorcet does not relieve your pain.
b. Check any over-the-counter medications for acetaminophen.
c. Eat more fiber and drink more water to prevent constipation.
d. Keep your follow-up appointment with the surgeon as scheduled.
ANS: B
All instructions are appropriate for this client. However, advising the client to check over-the-counter
medications for acetaminophen is an important safety measure. Acetaminophen is often found in common
over-the-counter medications and should be limited to 3000 mg/day.
DIF: Applying/Application REF: 56
KEY: Pharmacologic pain management| opioid analgesics MSC:
Integrated Process: Teaching/Learning
KEY: Pasero Opioid-Induced Sedation Scale| pharmacologic pain management MSC:
Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
23. A nurse is caring for a client on an epidural patient-controlled analgesia (PCA) pump. What action by the
nurse is most important to ensure client safety?
a. Assess and record vital signs every 2 hours.
b. Have another nurse double-check the pump settings.
c. Instruct the client to report any unrelieved pain.
d. Monitor for numbness and tingling in the legs.
ANS: B
PCA-delivered analgesia creates a potential risk for the client. Pump settings should always be double- checked.
Assessing vital signs should be done per agency policy and nurse discretion, and may or may not need to be this
frequent. Unrelieved pain should be reported but is not vital to client safety. Monitoring for numbness and tingling
in the legs is an important function but will manifest after something has occurred to the client; monitoring does not
prevent the event from occurring.
DIF: Applying/Application REF: 56
KEY: Patient-controlled analgesia (PCA)| pharmacologic pain management MSC:
Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
24. A postoperative client is reluctant to participate in physical therapy. What action by the nurse is best?
a. Ask the client about pain goals and if they are being met.
b. Ask the client why he or she is being uncooperative with therapy.
c. Increase the dose of analgesia given prior to therapy sessions.
d. Tell the client that physical therapy is required to regain function.
ANS: A
A comprehensive pain management plan includes the clients goals for pain control. Adequate pain control is
necessary to allow full participation in therapy. The first thing the nurse should do is to ask about the clients pain
goals and if they are being met. If not, an adjustment to treatment can be made. If they are being met, the nurse can
assess for other factors influencing the clients behavior. Asking the client why he or she is being uncooperative is
not the best response for two reasons. First, why questions tend to put people on the defensive. Second, labeling
the behavior is inappropriate. Simply increasing the pain medication may not be advantageous. Simply telling the
client that physical therapy is required does not address the issue.
DIF: Applying/Application REF: 67 KEY:
Pain goals| pain
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
25. A client is being discharged from the hospital after surgery on hydrocodone and acetaminophen (Lorcet).
What discharge instruction is most important for this client?
a. Call the doctor if the Lorcet does not relieve your pain.
b. Check any over-the-counter medications for acetaminophen.
c. Eat more fiber and drink more water to prevent constipation.
d. Keep your follow-up appointment with the surgeon as scheduled.
ANS: B
All instructions are appropriate for this client. However, advising the client to check over-the-counter
medications for acetaminophen is an important safety measure. Acetaminophen is often found in common
over-the-counter medications and should be limited to 3000 mg/day.
DIF: Applying/Application REF: 56
KEY: Pharmacologic pain management| opioid analgesics MSC:
Integrated Process: Teaching/Learning
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NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
MULTIPLE RESPONSE
1. A faculty member explains to students the process by which pain is perceived by the client. Which processes
does the faculty member include in the discussion? (Select all that apply.)
a. Induction
b. Modulation
c. Sensory perception
d. Transduction
e. Transmission
ANS: B, C, D, E
The four processes involved in making pain a conscious experience are modulation, sensory perception,
transduction, and transmission.
DIF: Remembering/Knowledge REF: 47
KEY: Pain transmission| pain MSC: Integrated Process: Teaching/Learning NOT:
Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A faculty member explains the concepts of addiction, tolerance, and dependence to students. Which
information is accurate? (Select all that apply.)
a. Addiction is a chronic physiologic disease process.
b. Physical dependence and addiction are the same thing.
c. Pseudoaddiction can result in withdrawal symptoms.
d. Tolerance is a normal response to regular opioid use.
e. Tolerance is said to occur when opioid effects decrease.
ANS: A, D, E
Addiction, tolerance, and dependence are important concepts. Addiction is a chronic, treatable disease with a
neurologic and biologic basis. Tolerance occurs with regular administration of opioid analgesics and is seen
when the effect of the analgesic decreases (either therapeutic effect or side effects). Dependence and addiction are
not the same; dependence occurs with regular administration of analgesics and can result in withdrawal
symptoms when they are discontinued abruptly. Pseudoaddiction is the mistaken diagnosis of addictive disease.
DIF: Remembering/Knowledge REF: 59
KEY: Dependence| tolerance| addiction MSC: Integrated Process: Teaching/Learning NOT:
Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A postoperative client has an epidural infusion of morphine and bupivacaine (Marcaine). What actions does
the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Ask the client to point out any areas of numbness or tingling.
b. Determine how many people are needed to ambulate the client.
c. Perform a bladder scan if the client is unable to void after 4 hours.
d. Remind the client to use the incentive spirometer every hour.
e. Take and record the clients vital signs per agency protocol.
ANS: C, D, E
The UAP can assess and record vital signs, perform a bladder scan and report the results to the nurse, and remind
the client to use the spirometer. The nurse is legally responsible for assessments and should ask the client about
areas of numbness or tingling, and assess if the client is able to bear weight and walk.
DIF: Applying/Application REF: 63
KEY: Epidural| pharmacologic pain management| opioid analgesics MSC:
Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A client with a broken arm has had ice placed on it for 20 minutes. A short time after the ice was removed,
MULTIPLE RESPONSE
1. A faculty member explains to students the process by which pain is perceived by the client. Which processes
does the faculty member include in the discussion? (Select all that apply.)
a. Induction
b. Modulation
c. Sensory perception
d. Transduction
e. Transmission
ANS: B, C, D, E
The four processes involved in making pain a conscious experience are modulation, sensory perception,
transduction, and transmission.
DIF: Remembering/Knowledge REF: 47
KEY: Pain transmission| pain MSC: Integrated Process: Teaching/Learning NOT:
Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A faculty member explains the concepts of addiction, tolerance, and dependence to students. Which
information is accurate? (Select all that apply.)
a. Addiction is a chronic physiologic disease process.
b. Physical dependence and addiction are the same thing.
c. Pseudoaddiction can result in withdrawal symptoms.
d. Tolerance is a normal response to regular opioid use.
e. Tolerance is said to occur when opioid effects decrease.
ANS: A, D, E
Addiction, tolerance, and dependence are important concepts. Addiction is a chronic, treatable disease with a
neurologic and biologic basis. Tolerance occurs with regular administration of opioid analgesics and is seen
when the effect of the analgesic decreases (either therapeutic effect or side effects). Dependence and addiction are
not the same; dependence occurs with regular administration of analgesics and can result in withdrawal
symptoms when they are discontinued abruptly. Pseudoaddiction is the mistaken diagnosis of addictive disease.
DIF: Remembering/Knowledge REF: 59
KEY: Dependence| tolerance| addiction MSC: Integrated Process: Teaching/Learning NOT:
Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A postoperative client has an epidural infusion of morphine and bupivacaine (Marcaine). What actions does
the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Ask the client to point out any areas of numbness or tingling.
b. Determine how many people are needed to ambulate the client.
c. Perform a bladder scan if the client is unable to void after 4 hours.
d. Remind the client to use the incentive spirometer every hour.
e. Take and record the clients vital signs per agency protocol.
ANS: C, D, E
The UAP can assess and record vital signs, perform a bladder scan and report the results to the nurse, and remind
the client to use the spirometer. The nurse is legally responsible for assessments and should ask the client about
areas of numbness or tingling, and assess if the client is able to bear weight and walk.
DIF: Applying/Application REF: 63
KEY: Epidural| pharmacologic pain management| opioid analgesics MSC:
Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A client with a broken arm has had ice placed on it for 20 minutes. A short time after the ice was removed,
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Subject
Nursing