Test Bank For Medical-Surgical Nursing: Patient-Centered Collaborative Care (2 Volume Set), 8th Edition
Prepare effectively with Test Bank For Medical-Surgical Nursing: Patient-Centered Collaborative Care (2 Volume Set), 8th Edition—a comprehensive set of questions to help you ace your exams.
Christopher Lee
Contributor
4.6
152
7 months ago
Preview (31 of 973)
Sign in to access the full document!
Chapter 1: Introduction to
Medical-Surgical Nursing
Practice Ignatavicius: Medical-
Surgical Nursing, 8th Edition
Chapter 1: Introduction to Medical-Surgical Nursing Practice
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. 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 client’s 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
2. 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
Medical-Surgical Nursing
Practice Ignatavicius: Medical-
Surgical Nursing, 8th Edition
Chapter 1: Introduction to Medical-Surgical Nursing Practice
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. 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 client’s 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
2. 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
Chapter 1: Introduction to
Medical-Surgical Nursing
Practice Ignatavicius: Medical-
Surgical Nursing, 8th Edition
Chapter 1: Introduction to Medical-Surgical Nursing Practice
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. 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 client’s 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
2. 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
Medical-Surgical Nursing
Practice Ignatavicius: Medical-
Surgical Nursing, 8th Edition
Chapter 1: Introduction to Medical-Surgical Nursing Practice
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. 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 client’s 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
2. 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
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
3. A nurse is caring for a postoperative client on the surgical unit. The client’s 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
client’s 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
4. 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
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
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
3. A nurse is caring for a postoperative client on the surgical unit. The client’s 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
client’s 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
4. 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
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
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
3. A nurse is caring for a postoperative client on the surgical unit. The client’s 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
client’s 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
4. 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
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
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
3. A nurse is caring for a postoperative client on the surgical unit. The client’s 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
client’s 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
4. 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
client’s 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
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 doctor’s 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 Commission’s 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
culture, respect, compassion, client education, and empowerment. By assessing the effect of the
client’s 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
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 doctor’s 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 Commission’s 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. Don’t make assumptions about their health needs.
c. Most LGBTQ people do not want to share information.
d. No differences exist in communicating with this population.
ANS: 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 doesn’t 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
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. Don’t make assumptions about their health needs.
c. Most LGBTQ people do not want to share information.
d. No differences exist in communicating with this population.
ANS: 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 doesn’t 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 client’s surgery 2 days ago would be considered
background. Assessment would include an analysis of the client’s 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 surgeon’s 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 client’s blood pressure is much
higher than previous readings, and the client’s 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 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.”
background. Assessment would include an analysis of the client’s 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 surgeon’s 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 client’s blood pressure is much
higher than previous readings, and the client’s 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 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.”
Loading page 6...
b. “Even being new, you can implement activities designed to improve care.”
c. “It’s 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
11. 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?
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 doesn’t 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
MULTIPLE RESPONSE
c. “It’s 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
11. 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?
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 doesn’t 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
MULTIPLE RESPONSE
Loading page 7...
1. 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.)
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
2. 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
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.)
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
2. 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
Loading page 8...
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. The nurse utilizing evidence-based practice (EBP) considers which factors when planning care?
(Select all that apply.)
a. Cost-saving measures
b. Nurse’s expertise
c. Client preferences
d. Research findings
e. Values of the client
ANS: B, C, D, E
EBP consists of utilizing current evidence, the client’s values and preferences, and the nurse’s
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.
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. The nurse utilizing evidence-based practice (EBP) considers which factors when planning care?
(Select all that apply.)
a. Cost-saving measures
b. Nurse’s expertise
c. Client preferences
d. Research findings
e. Values of the client
ANS: B, C, D, E
EBP consists of utilizing current evidence, the client’s values and preferences, and the nurse’s
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.
Loading page 9...
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
KEY: SHARE| hand-off communication
MSC: Integrated Process: Nursing Process: Intervention
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
Loading page 10...
Chapter 2: Common Health
Problems of Older Adults
Chapter 2: Common Health Problems of Older Adults
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. 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: 9
KEY: Adulthood| aging| old old MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
2. 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 one’s 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
Problems of Older Adults
Chapter 2: Common Health Problems of Older Adults
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. 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: 9
KEY: Adulthood| aging| old old MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
2. 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 one’s 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
Loading page 11...
and empty. An exercise program designed to maintain and/or improve physical functioning would
best address this need.
DIF: Applying/Application REF: 12
KEY: Independence| autonomy| older adult
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Psychosocial Integrity
3. 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 client’s food preferences as they relate to constipation.
DIF: Applying/Application REF: 10
KEY: Nutrition| dentures| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
4. 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.
best address this need.
DIF: Applying/Application REF: 12
KEY: Independence| autonomy| older adult
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Psychosocial Integrity
3. 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 client’s food preferences as they relate to constipation.
DIF: Applying/Application REF: 10
KEY: Nutrition| dentures| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
4. 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.
Loading page 12...
DIF: Applying/Application REF: 11
KEY: Nutrition| fiber| older adult
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A nurse is working with an older client admitted with mild dehydration. What teaching does the
nurse provide to best address this issue?
a. “Cut some sodium out of your diet.”
b. “Dehydration can cause incontinence.”
c. “Have something to drink every 1 to 2 hours.”
d. “Take your diuretic in the morning.”
ANS: 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: 11
KEY: Dehydration| older adult| hydration MSC: Integrated Process: Teaching/Learning
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 client’s functional abilities.
KEY: Nutrition| fiber| older adult
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A nurse is working with an older client admitted with mild dehydration. What teaching does the
nurse provide to best address this issue?
a. “Cut some sodium out of your diet.”
b. “Dehydration can cause incontinence.”
c. “Have something to drink every 1 to 2 hours.”
d. “Take your diuretic in the morning.”
ANS: 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: 11
KEY: Dehydration| older adult| hydration MSC: Integrated Process: Teaching/Learning
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 client’s functional abilities.
Loading page 13...
DIF: Applying/Application REF: 12
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 adult’s 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 lose their entire social network, leading them to feeling depressed and lonely. The nurse
should first assess the role that work played in the client’s life. The other factors can be assessed as
well, but this circumstance is commonly seen in the older population.
DIF: Applying/Application REF: 12
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: 12
KEY: Coping| relationships| older adult
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 adult’s 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 lose their entire social network, leading them to feeling depressed and lonely. The nurse
should first assess the role that work played in the client’s life. The other factors can be assessed as
well, but this circumstance is commonly seen in the older population.
DIF: Applying/Application REF: 12
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: 12
KEY: Coping| relationships| older adult
Loading page 14...
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: 13
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 client’s condition.
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: 13
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 client’s condition.
Loading page 15...
DIF: Applying/Application REF: 13
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 doesn’t 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: 14
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
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 doesn’t 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: 14
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
Loading page 16...
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: 21
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: 16
KEY: Medications| Beers list| older adult
MSC: Integrated Process: Communication and Documentation
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.
used in that fashion.
DIF: Applying/Application REF: 21
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: 16
KEY: Medications| Beers list| older adult
MSC: Integrated Process: Communication and Documentation
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.
Loading page 17...
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: 19 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 client’s 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 client’s
ability to provide consent.
DIF: Applying/Application REF: 16
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
who will notify them. Adult Protective Services is notified in the community setting.
DIF: Applying/Application REF: 19 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 client’s 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 client’s
ability to provide consent.
DIF: Applying/Application REF: 16
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
Loading page 18...
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: 9
KEY: Frailty| frail elderly| older adult
MSC: Integrated Process: Nursing Process: Assessment
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 adult’s 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: 10
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: 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: 9
KEY: Frailty| frail elderly| older adult
MSC: Integrated Process: Nursing Process: Assessment
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 adult’s 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: 10
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
Loading page 19...
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: 14
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: 20
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 month’s
visit. What actions should the nurse perform first? (Select all that apply.)
a. Assess the client’s ability to drive or transportation alternatives.
b. Determine if the client has dentures that fit appropriately.
c. Encourage the client to continue the current exercise plan.
d. Have the client complete a 3-day diet recall diary.
e. Teach the client about proper nutrition in the older population.
ANS: A, B, 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
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: 14
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: 20
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 month’s
visit. What actions should the nurse perform first? (Select all that apply.)
a. Assess the client’s ability to drive or transportation alternatives.
b. Determine if the client has dentures that fit appropriately.
c. Encourage the client to continue the current exercise plan.
d. Have the client complete a 3-day diet recall diary.
e. Teach the client about proper nutrition in the older population.
ANS: A, B, 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
Loading page 20...
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 client’s needs, which the nurse does not yet know.
DIF: Applying/Application REF: 10
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 client’s 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 client’s 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 RN’s responsibility as the RN is the one who performs that assessment.
DIF: Applying/Application REF: 22
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.
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 client’s needs, which the nurse does not yet know.
DIF: Applying/Application REF: 10
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 client’s 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 client’s 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 RN’s responsibility as the RN is the one who performs that assessment.
DIF: Applying/Application REF: 22
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.
Loading page 21...
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 client’s 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: 20
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
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 client’s 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: 20
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
Loading page 22...
Chapter 3: Assessment and
Care of Patients with Pain
Chapter 3: Assessment and Care of Patients with Pain
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. A student asks the nurse what is the best way to assess a client’s pain. Which response by the
nurse is best?
a. Numeric pain scale
b. Behavioral assessment
c. Objective observation
d. Client’s 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: 25
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 doesn’t mean pain doesn’t exist.”
b. “Have you ever experienced any type of pain?”
c. “The client should be assessed for drug addiction.”
d. “You’re right; I would put the medication back.”
ANS: A
A client’s 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
Care of Patients with Pain
Chapter 3: Assessment and Care of Patients with Pain
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. A student asks the nurse what is the best way to assess a client’s pain. Which response by the
nurse is best?
a. Numeric pain scale
b. Behavioral assessment
c. Objective observation
d. Client’s 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: 25
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 doesn’t mean pain doesn’t exist.”
b. “Have you ever experienced any type of pain?”
c. “The client should be assessed for drug addiction.”
d. “You’re right; I would put the medication back.”
ANS: A
A client’s 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
Loading page 23...
them should not supersede the client’s 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 client’s report of pain serves no useful purpose.
DIF: Understanding/Comprehension REF: 28
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 client’s 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 won’t 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: 26 KEY: Pain| acute pain
MSC: Integrated Process: Teaching/Learning
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
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 client’s report of pain serves no useful purpose.
DIF: Understanding/Comprehension REF: 28
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 client’s 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 won’t 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: 26 KEY: Pain| acute pain
MSC: Integrated Process: Teaching/Learning
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
Loading page 24...
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: 30
KEY: Pain assessment| FACES
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance
5. The nurse is assessing a client’s 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 client’s 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: 29 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 doesn’t 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
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: 30
KEY: Pain assessment| FACES
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance
5. The nurse is assessing a client’s 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 client’s 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: 29 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 doesn’t 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
Loading page 25...
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: 32
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 client’s pain, what statement or question by the nurse is most
appropriate?
a. “Help me understand how pain is affecting you right now.”
b. “I wish I could do more; is there anything I can get for you?”
c. “You cannot have more pain medication for 3 hours.”
d. “Why do you think the medication is not helping your pain?”
ANS: 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 client’s 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: 33
KEY: Pain| pain assessment
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Psychosocial Integrity
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: 32
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 client’s pain, what statement or question by the nurse is most
appropriate?
a. “Help me understand how pain is affecting you right now.”
b. “I wish I could do more; is there anything I can get for you?”
c. “You cannot have more pain medication for 3 hours.”
d. “Why do you think the medication is not helping your pain?”
ANS: 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 client’s 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: 33
KEY: Pain| pain assessment
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Psychosocial Integrity
Loading page 26...
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: 25
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.
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: 25
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.
Loading page 27...
DIF: Applying/Application REF: 34
KEY: Pain assessment| Checklist of Nonverbal Pain Indicators
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
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: 34
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
client’s 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
KEY: Pain assessment| Checklist of Nonverbal Pain Indicators
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
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: 34
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
client’s 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
Loading page 28...
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: 34
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 client’s pain. The client who has not needed a bolus of pain
medicine in several hours has well-controlled pain.
DIF: Applying/Application REF: 35
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 patient-controlled analgesia (PCA). What action by the student requires the RN to
intervene?
a. Assesses the client’s pain level per agency policy
b. Monitors the client’s respiratory rate and sedation
c. Presses the button when the client cannot reach it
d. Reinforces client teaching about using the PCA pump
control. Pain control needs to be continuous, not just administered prior to therapy.
DIF: Applying/Application REF: 34
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 client’s pain. The client who has not needed a bolus of pain
medicine in several hours has well-controlled pain.
DIF: Applying/Application REF: 35
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 patient-controlled analgesia (PCA). What action by the student requires the RN to
intervene?
a. Assesses the client’s pain level per agency policy
b. Monitors the client’s respiratory rate and sedation
c. Presses the button when the client cannot reach it
d. Reinforces client teaching about using the PCA pump
Loading page 29...
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: 35
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
client’s health history would lead the nurse to consult with the provider over the choice of
medication?
a. 25–pack-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: 35
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
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: 35
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
client’s health history would lead the nurse to consult with the provider over the choice of
medication?
a. 25–pack-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: 35
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
Loading page 30...
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: 37
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 client’s pain every 4 hours.
b. Ensure the client is eating a high-fiber diet.
c. Monitor the client’s bowel function every shift.
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: 38
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)
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: 37
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 client’s pain every 4 hours.
b. Ensure the client is eating a high-fiber diet.
c. Monitor the client’s bowel function every shift.
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: 38
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)
Loading page 31...
28 more pages available. Scroll down to load them.
Preview Mode
Sign in to access the full document!
100%