Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 8th Edition

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Lewis: Medical-Surgical Nursing, 8th EditionChapter 1: Contemporary Nursing PracticeTest BankMULTIPLE CHOICE1.The nurse has admitted a patient with a new diagnosis of pneumonia and explainedto the patient that together they will plan thepatient’scare and set goals for discharge.The patient says,“Howis that different from what the doctordoes?”Which responseby the nurse is most appropriate?a.“Theroleofthenurseistoadministermedicationsandothertreatmentsprescribedbyyourb.“Thenurse’sjobistohelpthedoctorbycollectingdataandcommunicatingwhentherearec.“Nursesperformmanyoftheproceduresdonebyphysicians,butnursesarehereinthehostimethandoctors.”d.“Inadditiontocaringforyouwhileyouaresick,thenurseswillassistyoutodevelopanintomaintainyourhealth.”ANS: DThis response is consistent with the American Nurses Association (ANA) definitionof nursing, which describes the role of nurses in promoting health. The otherresponses describe some of the dependent and collaborative functions of the nursingrole but do not accurately describe thenurse’srole in the health care system.DIF: Cognitive Level: Comprehension REF: 3TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment2.When providing patient care using evidence-based practice, the nurse usesa.clinicaljudgmentbasedonexperience.b.evidencefromaclinicalresearchstudy.c.evidence-basedguidelinesinadditiontoclinicalexpertise.d.evaluationofdatashowingthatthepatientoutcomesaremet.ANS: CEvidence-based practice (EBP) is the use of the best research-based evidencecombined with clinician expertise. Clinical judgment based on thenurse’sclinicalexperience is part of EBP, but clinical decision making also should incorporatecurrent research and research-based guidelines. Evidence from one clinical researchstudy does not provide an adequate substantiation for interventions. Evaluation of

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patient outcomes is important, but interventions should be based on research fromrandomized control studies with a large number of subjects.DIF: Cognitive Level: Comprehension REF: 6-8 TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment3.The nurse primarily uses the nursing process in the care of patientsa.toexplainnursinginterventionstootherhealthcareprofessionalsb.asaproblem-solvingtooltoidentifyandtreatpatients’healthcareneedsc.asascientific-basedprocessofdiagnosingthepatient’shealthcareproblemsd.toestablishnursingtheorythatincorporatesthebiopsychosocialnatureofhumansANS: BThe nursing process is a problem-solving approach to the identification and treatmentofpatients’problems. Diagnosis is only one phase of the nursing process. Theprimary use of the nursing process is in patient care, not to establish nursing theory orexplain nursing interventions to other health care professionals.DIF: Cognitive Level: Comprehension REF: 10TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment4.The nurse plans an every 2-hour turning schedule to prevent skin breakdown for acritically ill patient in the intensive care unit. In this case, the nursing action isconsidered to bea.dependent.b.cooperative.c.independent.d.collaborative.ANS: DWhen implementing collaborative nursing actions, the nurse is responsible primarilyfor monitoring for complications of acute illness or providing care to prevent or treatcomplications. Independent nursing actions are focused on health promotion, illnessprevention, and patient advocacy. A dependent action would require a physician orderto implement. Cooperative nursing functions are not described as one of the formalnursing functions.DIF: Cognitive Level: Application REF: 10-11TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

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5.A patient who has been admitted to the hospital for surgery tells the nurse,“Ido notfeel right about leaving my children with myneighbor.”Which action should thenurse take next?a.Reassurethepatientthatthesefeelingsarecommonforparents.b.Havethepatientcallthechildrentoensurethattheyaredoingwell.c.Calltheneighbortodeterminewhetheradequatechildcareisbeingprovided.d.Gathermoredataaboutthepatient’sfeelingsaboutthechildcarearrangements.ANS: DSince a complete assessment is necessary in order to identify a problem and choose anappropriate intervention, thenurse’sfirst action should be to obtain more information.The other actions may be appropriate, but more assessment is needed before the bestintervention can be chosen.DIF: Cognitive Level: Application REF: 11TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity6.A patient with a stroke is paralyzed on the left side of the body and has developed apressure ulcer on the left hip. The best nursing diagnosis for this patient isa.impairedphysicalmobilityrelatedtoleft-sidedparalysis.b.riskforimpairedtissueintegrityrelatedtoleft-sidedweakness.c.impairedskinintegrityrelatedtoalteredcirculationandpressure.d.ineffectivetissueperfusionrelatedtoinabilitytomoveindependently.ANS: CThepatient’smajor problem is the impaired skin integrity as demonstrated by thepresence of a pressure ulcer. The nurse is able to treat the cause of altered circulationand pressure by frequently repositioning the patient. Although left-sided weakness is aproblem for the patient, the nurse cannot treat the weakness. The“riskfor”diagnosisis not appropriate for this patient, who already has impaired tissue integrity. Thepatient does have ineffective tissue perfusion, but the impaired skin integrity diagnosisindicates more clearly what the health problem is.DIF: Cognitive Level: Application REF: 11 TOP: Nursing Process: DiagnosisMSC: NCLEX: Physiological Integrity

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7.A patient with an infection has a nursing diagnosis of deficient fluid volume relatedto excessive diaphoresis. An appropriate patient outcome identified by the nurse isthat thea.patienthasabalancedintakeandoutput.b.patient’sbeddingischangedwhenitbecomesdamp.c.patientunderstandstheneedforincreasedfluidintake.d.patient’sskinremainscoolanddrythroughouthospitalization.ANS: AThis statement gives measurable data showing resolution of the problem of deficientfluid volume that was identified in the nursing diagnosis statement. The otherstatements would not indicate that the problem of deficient fluid volume was resolved.DIF: Cognitive Level: Application REF: 13 TOP: Nursing Process: PlanningMSC: NCLEX: Physiological Integrity8.A nursing activity that is carried out during the evaluation phase of the nursingprocess isa.determiningifinterventionshavebeeneffectiveinmeetingpatientoutcomes.b.documentingthenursingcareplanintheprogressnotesinthemedicalrecord.c.decidingwhetherthepatient’shealthproblemshavebeencompletelyresolved.d.askingthepatienttoevaluatewhetherthenursingcareprovidedwassatisfactory.ANS: AEvaluation consists of determining whether the desired patient outcomes have beenmet and whether the nursing interventions were appropriate. The other responses donot describe the evaluation phase.DIF: Cognitive Level: Comprehension REF: 16 TOP: Nursing Process: EvaluationMSC: NCLEX: Safe and Effective Care Environment9.During the assessment phase of the nursing process, the nursea.obtainsdatawithwhichtodiagnosepatientproblems.b.usespatientdatatodevelopprioritynursingdiagnoses.c.teachesinterventionstorelievepatienthealthproblems.d.helpsthepatientidentifyrealisticoutcomestohealthproblems.ANS: A

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During the assessment phase, the nurse gathers information about the patient. Theother responses are examples of the intervention, diagnosis, and planning phases ofthe nursing process.DIF: Cognitive Level: Knowledge REF: 11TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment10.An example of a correctly written nursing diagnosis statement isa.alteredtissueperfusionrelatedtoheartfailure.b.riskforimpairedtissueintegrityrelatedtosacralredness.c.ineffectivecopingrelatedtoresponsetobiopsytestresults.d.alteredurinaryeliminationrelatedtourinarytractinfection.ANS: CThis diagnosis statement includes a NANDA nursing diagnosis and an etiology thatdescribes apatient’sresponse to a health problem that can be treated by nursing. Theuse of a medical diagnosis (as in the responses beginning“Altered tissueperfusion”and“Alteredurinaryelimination”)is not appropriate. The response beginning“Riskfor impaired tissueintegrity”uses the defining characteristics as the etiology.DIF: Cognitive Level: Comprehension REF: 11-13 TOP: Nursing Process: DiagnosisMSC: NCLEX: Safe and Effective Care Environment11.The nurse writes a complete nursing diagnosis statement by includinga.aproblemandthesuggestedpatientgoalsoroutcomes.b.aproblem,itscause,andobjectivedatathatsupporttheproblem.c.aproblemwithallitspossiblecausesandtheplannedinterventions.d.aproblemwithitsetiologyandthesignsandsymptomsoftheproblem.ANS: DThe PES format is used when writing nursing diagnoses. The subjective, as well asobjective, data should be included in the defining characteristics. Interventions andoutcomes are not included in the nursing diagnosis statement.DIF: Cognitive Level: Knowledge REF: 11-13 TOP: Nursing Process: DiagnosisMSC: NCLEX: Safe and Effective Care Environment12.Using the Situation-Background-Assessment-Recommendation (SBAR) format, inwhich order should the nurse make these statements to communicate a change inpatient status to a health care provider?

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a.Mr.Awasadmitted2daysagowithheartfailureandhasbeenreceivingfurosemide(Lasixbuthisurineoutputhasbeenlow.b.Ithinkthatheneedstobeevaluatedimmediatelyandmayneedintubationandmechanicalc.Thisisthenurseonthesurgicalunit.IamcallingaboutMr.Ainroom3.Afterassessinghconcernedabouthisshortnessofbreath.d.Today,hehascracklesaudiblethroughouttheposteriorchestandhisO2saturationis89%veryunstable.ANS: CA, D, BThe order of thenurse’sstatements follows the SBAR format.DIF: Cognitive Level: Application REF: 5-6TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment13.Which of these nursing actions for the patient with heart failure is appropriate forthe nurse to delegate to experienced nursing assistive personnel (NAP)?a.Assessforshortnessofbreathorfatigueafterambulation.b.Instructthepatientabouttheneedtoalternateactivityandrest.c.Obtainthepatient’sbloodpressureandpulserateafterambulation.d.Determinewhetherthepatientisreadytoincreasetheactivitylevel.ANS: CNAP education includes accurate vital sign measurement. Assessment and patientteaching require RN education and scope of practice and cannot be delegated.DIF: Cognitive Level: Application REF: 15-16 | eFig. 1-1OBJ: Special Questions: Delegation TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment14.Which action by a newly graduated RN working on the postsurgical unit indicatesthat more education about delegation and assignment is needed?a.ThenursedelegatesmeasurementofpatientoralintakeandurineoutputtoNAP.b.Thenursedelegatesassessmentofapatient’sbowelsoundstoexperiencedNAP.c.ThenurseassignsanLPN/LVNtoadministeroralmedicationstoseveralpatients.d.Thenurseassignsa“float”RNfrompediatricstocareforapatientwithdiabetes.ANS: BAssessment requires RN education and scope of practice and cannot be delegated toNAP. The other actions by the new RN are appropriate.

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DIF: Cognitive Level: Application REF: 15-16 | eFig. 1-1OBJ: Special Questions: Delegation TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment15.Which of these tasks is appropriate for the registered nurse to delegate to alicensed practical/vocational nurse?a.Performasteriledressingchangeforaninfectedwound.b.Completetheinitialadmissionassessmentandplanofcare.c.Teachapatientabouttheeffectsofprescribedmedications.d.Documentpatientteachingaboutaroutinesurgicalprocedure.ANS: AThe education and scope of practice of the LPN/LVN include activities such as steriledressing changes. Patient teaching and the initial assessment and development of theplan of care are nursing actions that require RN-level education and scope of practice.DIF: Cognitive Level: Comprehension REF: 15OBJ: Special Questions: Delegation TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care EnvironmentChapter 2: Health Disparities andCulturally Competent CareLewis: Medical-Surgical Nursing, 8th EditionChapter 2: Health Disparities and Culturally Competent CareTest BankMULTIPLE CHOICE1.The nurse obtains information about all these areas during the health interview for anew patient. Which area will be the focus of patient teaching?a.Ageandgenderb.Hispanic/Latinoethnicityc.Familyhistoryofdiabetesd.RefinedcarbohydrateintakeANS: DBehaviors are strongly linked to many health care problems. Thepatient’scarbohydrate intake is a behavior that the patient can change. The other information

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will be useful as the nurse develops an individualized plan for improving thepatient’shealth, but will not be the focus of patient education.DIF: Cognitive Level: Application REF: 20-21 TOP: Nursing Process: PlanningMSC: NCLEX: Health Promotion and Maintenance2.When developing strategies to decrease health care disparities, the nurse working ina clinic located in a neighborhood with many Vietnamese individuals will includea.improvingpublictransportation.b.obtaininglow-costmedications.c.updatingequipmentandsuppliesfortheclinic.d.educatingstaffaboutVietnamesehealthbeliefs.ANS: DHealth care disparities are due to stereotyping, biases, and prejudice of health careproviders; the nurse can decrease these through staff education. The other strategiesalso may be addressed by the nurse but will not impact health disparities.DIF: Cognitive Level: Application REF: 21-23 | 32 TOP: Nursing Process: PlanningMSC: NCLEX: Health Promotion and Maintenance3.Which information will the nurse need to collect when assessing the health status ofa community?a.Averageincomeofcommunitymembersb.Morningtrafficpatternsinthecommunityc.Medianlifeexpectancyforthecommunityd.OccupationsofindividualsinthecommunityANS: CHealth status is the aggregate of all health measures for individuals in a communityand includes data such as life expectancy, birth and death rates, and mortality fromvarious diseases. Although income, traffic patterns, and occupations are factors thatimpact acommunity’shealth status, they are not health measures.DIF: Cognitive Level: Comprehension REF: 20-21TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance4.A family member of an elderly Hispanic patient admitted to the hospital tells thenurse that the patient has traditional beliefs about health and illness. The best actionby the nurse is to

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a.avoidaskinganyquestionsunlessthepatientinitiatesconversation.b.askthepatientwhetheritisimportantthatculturalhealersarecontacted.c.explaintheusualhospitalroutinesformealtimes,care,andfamilyvisits.d.obtainfurtherinformationaboutthepatient’sculturalbeliefsfromthedaughter.ANS: BBecause the patient has traditional health care beliefs, it is appropriate for the nurse toask whether the patient would like a visit by acurandero(a)or other cultural healers.There is no cultural reason for the nurse to avoid asking the patient questions, andquestions may be necessary to obtain necessary health information. The patient (ratherthan the daughter) should be consulted about personal cultural beliefs. The hospitalroutines for meals, care, and visits should be adapted to thepatient’spreferencesrather than expecting the patient to adapt to the hospital schedule.DIF: Cognitive Level: Application REF: 26TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity5.When caring for a patient who is Native American, the best initial action by thenurse is toa.avoidalleyecontactwiththepatient.b.observethepatient’suseofeyecontact.c.lookdirectlyatthepatientwheninteracting.d.askthefamilyaboutthepatient’sculturalbeliefs.ANS: BObservation of thepatient’suse of eye contact will be most useful in determining thebest way to communicate effectively with the patient. Looking directly at the patientor avoiding eye contact may be appropriate, depending on thepatient’sindividualcultural beliefs. The nurse should assess the patient, rather than asking familymembers about thepatient’sbeliefs.DIF: Cognitive Level: Application REF: 24 | 27-28TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity6.A new RN graduate is assessing a newly admitted non–English-speaking Chinesepatient who complains of severe headaches. The charge nurse should intervene if thenewRN’sfirst action is toa.sitdownatthebedside.

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b.palpatethepatient’sscalp.c.callforamedicalinterpreter.d.avoideyecontactwiththepatient.ANS: BMany people of Asian ethnicity believe that touching aperson’shead is disrespectful;the RN should ask permission before touching thepatient’shead. The other actionsare appropriate.DIF: Cognitive Level: Application REF: 29TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity7.If an interpreter is not available when a patient speaks a language different from thenurse’slanguage, it is appropriate for the nurse toa.usespecificmedicaltermsintheLatinform.b.talkslowlysothateachwordisclearlyheard.c.repeatimportantwordssothatthepatientrecognizestheirimportance.d.usesimplegesturestodemonstratemeaningwhiletalkingtothepatient.ANS: DThe use of gestures will enable some information to be communicated to the patient.The other actions will not improve communication with the patient.DIF: Cognitive Level: Comprehension REF: 34TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity8.When planning care for a hospitalized patient who uses culturally based treatments,the most appropriate action by the nurse is toa.coordinatetheuseoffolktreatmentswithorderedmedicaltherapies.b.discouragetheuseofculturallybasedtreatmentsforWesterndiseases.c.teachthepatientthatfolkremedieswillinterferewithWesterntreatments.d.askthepatienttodiscontinuetheculturaltreatmentsduringhospitalization.ANS: AMany culturally based therapies can be accommodated along with the use of Westerntreatments and medications. The nurse should attempt to use both traditional folktreatments and the ordered Western therapies as much as possible. Some culturallybased treatments can be effective in treating“Western”diseases. Not all folk remedies

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interfere with Western therapies. It may be appropriate for the patient to continuesome culturally based treatments while he or she is hospitalized.DIF: Cognitive Level: Comprehension REF: 30-31 TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity9.The best example of culturally appropriate nursing care when caring for a newlyadmitted patient isa.havingfamilymembersprovidemostofthepatient’spersonalcare.b.maintainingapersonalspaceofatleast2feetwhenassessingthepatient.c.askingpermissionbeforetouchingapatientduringthephysicalassessment.d.consideringthepatient’sethnicityasthemostimportantfactorinplanningcare.ANS: CMany cultures consider it disrespectful to touch a patient without asking permission,so asking a patient for permission is always culturally appropriate. The other actionsmay be appropriate for some patients but are not appropriate across all cultural groupsor for all individual patients.DIF: Cognitive Level: Comprehension REF: 29TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity10.While talking with the nursing supervisor, a staff nurse expresses frustration that aNative American patient always has several family members at the bedside. The mostappropriate action by the nursing supervisor is toa.remindthenursethatfamilysupportisimportanttothisfamilyandpatient.b.havethenurseexplaintothefamilythattoomanyvisitorswilltirethepatient.c.suggestthatthenurseaskfamilymemberstoleavetheroomduringpatientcare.d.askaboutthenurse’spersonalbeliefsaboutfamilysupportduringhospitalization.ANS: DThe first step in providing culturally competent care is to understandone’sownbeliefs and values related to health and health care. Asking the nurse about personalbeliefs will help to achieve this step. Reminding the nurse that this cultural practice isimportant to the family and patient will not decrease thenurse’sfrustration. Theremaining responses (suggest that the nurse ask family members to leave the room,and have the nurse explain to family that too many visitors will tire the patient) are notculturally appropriate for this patient.

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DIF: Cognitive Level: Application REF: 31TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity11.An 82-year-old Asian American patient tells the nurse that she has lived in theUnited States for 50 years. The patient speaks English but lives in a predominantlyAsian neighborhood. The nurse will need toa.includeafolkhealerwhenplanningthepatient’scare.b.askthepatientaboutanyspecialculturalbeliefsorpractices.c.avoidmakingdirecteyecontactwiththepatientduringcare.d.involvethepatient’soldestsoninmakinghealthcaredecisions.ANS: BFurther assessment of thepatient’shealth care preferences is needed before makingfurther plans for culturally appropriate care. The other responses indicate stereotypingof the patient, based on ethnicity, and would not be appropriate initial actions.DIF: Cognitive Level: Application REF: 25 | 32 TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity12.When planning health care for a community with a large number of recentimmigrants from China, the most important intervention for the nurse to include isa.pregnancytesting.b.tuberculosisscreening.c.contraceptiveteaching.d.colonoscopyinformation.ANS: BTuberculosis (TB) is endemic in many parts of Asia, and the incidence of TB is muchhigher in immigrants from China than in the general U.S. population. Teaching aboutcontraceptive use, colonoscopy, and testing for pregnancy also may be appropriate forsome patients but is not generally indicated for all members of this community.DIF: Cognitive Level: Application REF: 29-30 TOP: Nursing Process: PlanningMSC: NCLEX: Physiological Integrity13.When doing an admission assessment for a patient, the nurse notices that thepatient pauses before answering questions about the health history. The mostappropriate action by the nurse is toa.stopdoingtheassessmentandreturnlater.

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b.waitforthepatienttoanswerthequestions.c.askthepatientwhythequestionsrequiresomuchtimetoanswer.d.givethepatientanassessmentformlistingthequestionsandapen.ANS: BPatients from some cultures take time to consider a question carefully beforeanswering. The nurse will show respect for the patient and help develop a trustingrelationship by allowing the patient time to give a thoughtful answer. Asking thepatient why the answers are taking so much time, stopping the assessment, andhanding the patient a form indicate that the nurse does not have time for the patient.DIF: Cognitive Level: Application REF: 28TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity14.Which of these strategies should be a priority when the nurse is planning care for ahypertensive patient who is uninsured?a.Followevidence-basednationalguidelines.b.Assistwithdietarychangesasthefirstaction.c.Teachabouttheimpactofexerciseonhypertension.d.Obtainlessexpensiveantihypertensivemedications.ANS: AThe use of standardized evidence-based guidelines will reduce the incidence of healthcare disparities among various socioeconomic groups. The other strategies also maybe appropriate, but the priority concern should be that the patient receives care thatmeets the accepted standard.DIF: Cognitive Level: Application REF: 32OBJ: Special Questions: Prioritization TOP: Nursing Process: PlanningMSC: NCLEX: Health Promotion and Maintenance15.A Hispanic patient complains of abdominal cramping caused byempacho.Thenurse’sfirst action should be toa.askthepatientwhattreatmentsarelikelytohelp.b.givethepatientmedicationtodecreasethecramping.c.massagethepatient’sabdomenuntilthepainisgone.d.offertocontactacurandero(a)tomakeavisittothepatient.ANS: A

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Further assessment of thepatient’scultural beliefs is appropriate before implementingany interventions for a culture-bound syndrome such asempacho.Althoughmedication, a visit by acurandero(a),or massage may be helpful, more informationabout thepatient’sbeliefs is needed to determine which intervention(s) will be mosthelpful.DIF: Cognitive Level: Application REF: 25 | 31-32OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity16.When performing a cultural assessment with a patient of a different culture, thenurse’sfirst action should be toa.waituntilaculturalhealerisavailabletohelpwiththeassessment.b.obtainalistofanyculturalremediesthatthepatientcurrentlyuses.c.askthepatientaboutanyaffiliationwithaparticularculturalgroup.d.tellthepatientwhatthenursealreadyknowsaboutthepatient’sculture.ANS: CAn early step in performing a cultural assessment is to determine whether the patientfeels an affiliation with any cultural group. The other actions may be appropriate if thepatient does identify with a particular culture.DIF: Cognitive Level: Application REF: 32OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity17.The nurse working in a clinic in a primarily African American community notes ahigher incidence of uncontrolled hypertension in clinic patients than the nationalaverage. To correct this health disparity, which action should the nurse take first?a.Initiatearegularhome-visitprogrambynursesworkingattheclinic.b.Scheduleteachingsessionsabouthypertensionatcommunityevents.c.Assesstheperceptionsofcommunitymembersaboutthecareattheclinic.d.Obtainlow-costantihypertensivedrugsusingfundingfromgovernmentgrants.ANS: CBefore other actions are taken, additional assessment data are needed to determine thereason for the disparity. The other actions also may be appropriate, but additionalassessment is needed before the next action is selected.

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DIF: Cognitive Level: Application REF: 31-32OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Health Promotion and MaintenanceChapter 3: Health HistoryandPhysical ExaminationLewis: Medical-Surgical Nursing, 8th EditionChapter 3: Health History and Physical ExaminationTest BankMULTIPLE CHOICE1.A patient who is having difficulty breathing is admitted to the hospital. The bestapproach for the nurse to use to obtain a complete health history is toa.obtainsubjectivedataaboutthepatientfromfamilymembers.b.omitsubjectivedatacollectionandobtainthephysicalexamination.c.usethehealthcareprovider’smedicalhistorytoobtainsubjectivedata.d.scheduleseveralshortsessionswiththepatienttogathersubjectivedata.ANS: DIn an emergency situation, the nurse may need to ask only the most pertinentquestions for a specific problem and obtain more information later. A complete healthhistory will include subjective information that is not available in the health careprovider’smedical history. Family members may be able to provide some subjectivedata, but only the patient will be able to give subjective information about theshortness of breath. Since the subjective data about thepatient’srespiratory status willbe essential, obtaining the physical examination alone will not provide sufficientinformation.DIF: Cognitive Level: Application REF: 38TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance2.Immediate surgery is planned for a patient with acute abdominal pain. The questionused by the nurse that will elicit the most complete information about thepatient’scoping-stress tolerance pattern isa.“Canyoutellmehowintenseyourpainisnow?”b.“Whatdoyouthinkcausedthisabdominalpain?”

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c.“Howdoyoufeelaboutyourselfandyourhospitalization?”d.“Arethereothermajorproblemsthatareaconcernrightnow?”ANS: DThe coping-stress tolerance pattern includes information about other major stressorsconfronting the patient. The health perception–health management pattern includesinformation about thepatient’sideas about risk factors. Feelings about self and thehospitalization are assessed in the self-perception–self-concept pattern. Intensity ofpain is part of the cognitive-perceptual pattern.DIF: Cognitive Level: Comprehension REF: 41-42TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity3.During the health history interview, a patient tells the nurse about periodic faintingspells. Which question by the nurse will be most helpful in determining the setting inwhich the fainting spells occur?a.“Howfrequentlydoyouhavethefaintingspells?”b.“Whereareyouwhenyouhavethefaintingspells?”c.“Dothespellstendtooccuratanyspecialtimeofday?”d.“Doyouhaveanyothersymptomsalongwiththespells?”ANS: BInformation about the setting is obtained by asking where the patient was and what thepatient was doing when the symptom occurred. The other questions from the nurse areappropriate for obtaining information about chronology, frequency, and associatedclinical manifestations.DIF: Cognitive Level: Comprehension REF: 39TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance4.The nurse records the following general survey of a patient:“Thepatient is a 68-year-old male Asian attended by his wife and two daughters. Alert and oriented. Doesnot make eye contact with the nurse and responds slowly, but appropriately, toquestions. No apparent disabilities or distinguishingfeatures.”Additional informationthat should be added to this general survey includesa.nutritionalstatus.b.intakeandoutput.c.reasonsforcontactwiththehealthcaresystem.

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d.commentsoffamilymembersabouthiscondition.ANS: AThe general survey also describes thepatient’sgeneral nutritional status. The otherinformation will be obtained when doing the complete nursing history andexamination but is not obtained through the initial scanning of a patient.DIF: Cognitive Level: Application REF: 44TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance5.A nurse is performing a health history and physical examination for a patient withright-sided rib fractures. The pertinent negative finding is that the patienta.statesthattherehavebeennootherhealthproblemsrecently.b.denieshavingpainwhentheareaoverthefracturesispalpated.c.hasseveralbruisedandswollenareasontherightanteriorchest.d.refusestotakeadeepbreathbecauseoftheassociatedchestpain.ANS: BThe nurse expects that a patient with rib fractures will have pain over the fracturedarea. The first statement is neither a positive nor a negative finding with regard to therib fractures. The bruising and swelling and pain with breathing are positive findings.DIF: Cognitive Level: Application REF: 42TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance6.As the nurse assesses thepatient’sneck, the patient says,“Myneck is so stiff I canhardly moveit.”This finding indicates the nurse should perform a(n)a.focusedassessment.b.screeningassessment.c.emergencyassessment.d.comprehensiveassessment.ANS: AThe focused assessment is needed when a patient has clinical manifestations thatindicate a problem. An emergency assessment is done when the nurse needs to obtaininformation about life-threatening problems quickly while simultaneously takingaction to maintain vital function. The screening examination or assessment is used toassess for possible problems such as colorectal cancer in patients who are age 50 or

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older. A comprehensive assessment is a detailed health history and physicalexamination.DIF: Cognitive Level: Application REF: 45-46TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance7.The nurse is preparing to perform a focused abdominal assessment for a patient whohas high-pitched bowel sounds. Which equipment will be needed?a.Flashlightb.Stethoscopec.Tonguebladesd.PercussionhammerANS: BA stethoscope is used to auscultate bowel sounds. The other equipment may be usedfor a comprehensive assessment, but will not be needed for a focused abdominalassessment.DIF: Cognitive Level: Comprehension REF: 43 | 45TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance8.When the nurse is planning for the physical examination of an alert 86-year-oldpatient, adaptations to the examination technique should includea.speakingslowlywhendirectingthepatient.b.avoidingtheuseoftouchasmuchaspossible.c.usingslightlymorepressureforpalpationoftheliver.d.organizingthesequencetominimizepositionchanges.ANS: DOlder patients may have age-related changes in mobility that make it more difficult tochange position. There is no need to avoid the use of touch when examining olderpatients. Less pressure should be used over the liver. Since the patient is alert, there isno indication that there is any age-related difficulty in understanding directions fromthe nurse.DIF: Cognitive Level: Application REF: 45TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

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9.While the nurse is taking the health history, a patient states,“Myfather andgrandfather both had heart attacks and were unable to be very activeafterwards.”Thisstatement is related to the functional health pattern ofa.activity-exercise.b.cognitive-perceptual.c.coping-stresstolerance.d.healthperception–healthmanagement.ANS: DThe information in the patient statement relates to risk factors that may causecardiovascular problems in the future. Identification of risk factors falls into the healthperception–health maintenance pattern.DIF: Cognitive Level: Comprehension REF: 40-41TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance10.A patient is seen in the emergency department with chest pain and hypotension.Which type of assessment should the nurse do at this time?a.Focusedassessmentb.Subjectiveassessmentc.Emergencyassessmentd.ComprehensiveassessmentANS: CSince the patient is hemodynamically unstable, an emergency assessment is needed.Comprehensive and focused assessments may be needed after the patient is stabilized.Subjective information is needed, but objective data such as vital signs also areessential for the unstable patient.DIF: Cognitive Level: Comprehension REF: 46TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance11.When caring for a patient who was admitted a few hours previously with nauseaand vomiting, which nursing action can the RN delegate to an LPN/LVN?a.Askthepatientaboutanycurrentnausea.b.Finishdocumentingtheadmissionassessment.c.Determinethepatient’sprioritynursingdiagnoses.d.Obtainthehealthhistoryfromthepatient’scaregiver.

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ANS: AThe RN may delegate parts of the focused assessment to an LPN/LVN. Obtaining thehealth history, documentation of the admission assessment, and determining nursingdiagnoses require RN education and scope of practice.DIF: Cognitive Level: Application REF: 46OBJ: Special Questions: Delegation TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment12.When assessing the circulation to the lower leg of a patient who has had kneesurgery, which action should the nurse take first?a.Feelforthetemperatureofthefoot.b.Visuallyinspectthecolorofthefoot.c.Checkthepatient’spedalpulsesusingthefingertips.d.Compressthenailbedstodeterminecapillaryrefilltime.ANS: BInspection is the first of the major techniques used in the physical examination.Palpation and auscultation are used later in the examination.DIF: Cognitive Level: Application REF: 43OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Health Promotion and Maintenance13.When assessing apatient’sabdomen during the admission assessment, which ofthese actions should the nurse take first?a.Feelforanymasses.b.Palpatetheabdomen.c.Percusstheliverborders.d.Listentothebowelsounds.ANS: DWhen assessing the abdomen, auscultation is done before palpation or percussionbecause palpation and percussion can cause changes in bowel sounds and alter thefindings. All of the techniques are appropriate, but auscultation should be done first.DIF: Cognitive Level: Comprehension REF: 43OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Health Promotion and Maintenance

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14.When admitting a patient who has just arrived on the medical unit with severeabdominal pain, what should the nurse do first?a.Completeonlybasicdemographicdatabeforeaddressingthepatient’sabdominalpain.b.Medicatethepatientfortheabdominalpainbeforeattendingtothehealthhistoryandexamc.Informthepatientthattheabdominalpainwillbetreatedassoonasthehealthhistoryiscod.TaketheinitialvitalsignsandthendealwiththeabdominalpainbeforecompletingtheheaANS: DThe patient priority in this situation will be to decrease the pain level because thepatient will be unlikely to cooperate in providing demographic data or the healthhistory until the nurse addresses the pain. However, obtaining information about vitalsigns is essential before using either pharmacologic or nonpharmacologic therapies forpain control. The vital signs may indicate hemodynamic instability that would need tobe addressed immediately.DIF: Cognitive Level: Application REF: 39OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Physiological IntegrityChapter 4: Patient and CaregiverTeachingLewis: Medical-Surgical Nursing, 8th EditionChapter 4: Patient and Caregiver TeachingTest BankMULTIPLE CHOICE1.A patient with newly diagnosed breast cancer has a nursing diagnosis of deficientknowledge about breast cancer. When the nurse is planning teaching for the patient,which is the most important initial learning goal?a.Thepatientwillselectthemostappropriatebreastcancertherapy.b.Thepatientwillstatewaysofpreventingtherecurrenceofthetumor.c.Thepatientwilldemonstratecopingskillsneededtomanagethedisease.d.Thepatientwillchoosemethodstominimizeadverseeffectsoftreatment.ANS: A

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Adults learn best when given information that can be used immediately. The firstaction the patient will need to take after a cancer diagnosis is to choose a treatmentoption. The other goals may be appropriate as treatment progresses.DIF: Cognitive Level: Application REF: 50 TOP: Nursing Process: PlanningMSC: NCLEX: Health Promotion and Maintenance2.After the nurse implements diet instruction for a patient with heart disease, thepatient can explain the information but fails to make the recommended dietarychanges. Thenurse’sevaluation is thata.learningdidnotoccurbecausethepatient’sbehaviordidnotchange.b.choosingnottofollowthedietisthebehaviorthatresultedfromlearning.c.thenursingresponsibilityforhelpingthepatientmakedietarychangeshasbeenfulfilled.d.theteachingmethodswereineffectiveinhelpingthepatientlearnthedietaryinformation.ANS: BAlthough the patient behavior has not changed, thepatient’sability to explain theinformation indicates that learning has occurred and the patient is choosing at thistime to continue with the previous diet. The patient may be in the contemplation orpreparation state in the Transtheoretical Model. The nurse should reinforce the needfor change and continue to provide information and assistance with planning forchange.DIF: Cognitive Level: Application REF: 50-51 TOP: Nursing Process: EvaluationMSC: NCLEX: Health Promotion and Maintenance3.A 43-year-old is diagnosed with type 2 diabetes mellitus after being admitted to thehospital with an infected foot wound. When applying principles of adult learning,which teaching strategy by the nurse is most likely to be effective?a.Discusstheimportanceofbloodglucosecontrolinmaintenanceoflong-termhealth.b.Demonstratethecorrectmethodforcleaningandredressingthewoundtothepatient.c.Assurethepatientthatthenurseisanexpertonmanagementofdiabetescomplications.d.WaituntilafterdischargeandhaveahomehealthnurseteachaboutfootcareanddiabetesANS: BPrinciples of adult education indicate that readiness and motivation to learn are highwhen facing new tasks (such wound care) and when demonstration and practice ofskills are available. Although a home health referral may be needed for this patient,

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teaching should not be postponed until discharge. Adult learners are independent; thenurse should act as a facilitator for learning, rather than as the expert. Adults learnbest when the topic is of immediate usefulness; long-term goals may not be verymotivating.DIF: Cognitive Level: Application REF: 50 TOP: Nursing Process: PlanningMSC: NCLEX: Health Promotion and Maintenance4.A patient admitted to the hospital with hyperglycemia and newly diagnoseddiabetes mellitus is scheduled for discharge the second day after admission. Whenimplementing patient teaching, which is the best action for the nurse to take?a.Instructabouttheincreasedriskforcardiovasculardisease.b.Providedetailedinformationaboutdietarycontrolofglucose.c.Teachglucoseself-monitoringandmedicationadministration.d.Giveinformationabouttheeffectsofexerciseonglucosecontrol.ANS: CWhen time is limited, the nurse should focus on the priorities of teaching. In thissituation, the patient should know how to test blood glucose and administermedications to control glucose levels. The patient will need further teaching about therole of diet, exercise, various medications, and the many potential complications ofdiabetes, but these topics can be addressed through planning for appropriate referrals.DIF: Cognitive Level: Application REF: 52TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance5.When using the Transtheoretical Model of Health Behavior Change during patientteaching, the nurse identifies that the patient who states,“Itold my wife that I wasgoing to start exercising, and I think I will join a fitnessclub,”is in the stage ofa.preparation.b.termination.c.maintenance.d.contemplation.ANS: AThepatient’sstatement indicating that the plan for change is being shared withsomeone else indicates that the preparation stage has been achieved. Contemplation ofa change would be indicated by a statement like“Iknow I shouldexercise.”

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Maintenance of a change occurs when the patient practices the behavior regularly.Termination would be indicated when the change is a permanent part of the lifestyle.DIF: Cognitive Level: Comprehension REF: 50-51TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance6.While admitting a patient to the medical unit, the nurse learns that the patient doesnot read well. This information will guide the nurse in determininga.thedegreeofpatientmotivationandreadinesstolearn.b.whatinformationthepatientwillbeabletounderstand.c.thatthefamilymustbeincludedintheteachingprocess.d.whichinstructionalstrategiesshouldbeusedinteaching.ANS: DThe information that the patient is illiterate indicates that the nurse should avoid theuse of written materials in teaching and choose other strategies. The patient does notindicate a lack of motivation or an inability to understand new information. Thepatient’slack of reading ability does not necessarily imply that the family must beincluded in the teaching process.DIF: Cognitive Level: Comprehension REF: 54 TOP: Nursing Process: PlanningMSC: NCLEX: Health Promotion and Maintenance7.When assessing the learning needs for a patient who has coronary heart disease, thenurse finds that the patient has recently made dietary changes to decrease fat intakeand has stopped smoking. The best initial statement by the nurse at this time isa.“Althoughthoseareimportant,itisessentialthatyoumakeotherchanges,too.”b.“Areyouhavinganydifficultyinmaintainingthechangesyouhavealreadymade?”c.“Youhavealreadyaccomplishedsomechangesthatareimportantinhearthealth.”d.“Whichadditionalchangesinyourlifestylewouldyouliketoimplementatthistime?”ANS: CPositive reinforcement of thelearner’sachievements is critical in making lifestylechanges. This patient is in the action stage of the Transtheoretical Model, whenreinforcement of the changes being made is an important nursing intervention. Theother responses are also appropriate, but are not the best initial response.DIF: Cognitive Level: Application REF: 51 | 55TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

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8.To assess apatient’sreadiness to learn before planning teaching activities, whichquestion should the nurse ask?a.“Whatkindofworkandleisureactivitiesdoyoudo?”b.“Whatinformationdoyouthinkyouneedrightnow?”c.“Doyouhaveanyreligiousbeliefsthatareinconsistentwiththetreatment?”d.“Canyoudescribethetypesofactivitiesthathelpyoulearnnewinformation?”ANS: BMotivation and readiness to learn depend on what the patient values and perceives asimportant. The other questions are also important in developing the teaching plan, butdo not address what information most interests the patient at present.DIF: Cognitive Level: Application REF: 55TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance9.The nurse develops a nursing diagnosis of ineffective health maintenance related tolow motivation based on the finding that the diabetic patienta.doesnotperformcapillarybloodglucosetestsasdirected.b.occasionallyforgetstotakethedailyprescribedmedication.c.saysthatdietaryintakedoesnotseemtoimpactfatiguelevel.d.cannotidentifysignsorsymptomsofhighandlowbloodglucose.ANS: CThepatient’smotivation to follow a diabetic diet will be decreased if the patient feelsthat dietary changes do not impact symptoms. The other responses do not indicate thatthe ineffective health maintenance is caused by lack of motivation.DIF: Cognitive Level: Application REF: 55 TOP: Nursing Process: DiagnosisMSC: NCLEX: Health Promotion and Maintenance10.A patient with poor circulation to the feet requires teaching about foot care. Whichlearning goal should the nurse include in the teaching plan?a.Thenursewilldemonstratethepropertechniquefortrimmingtoenails.b.Thepatientwilllistthreewaystoprotectthefeetfrominjurybydischarge.c.Thenursewillinstructthepatientonappropriatefootcarebeforedischarge.d.Thepatientwillunderstandtherationaleforproperfootcareafterinstruction.ANS: B

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Learning goals should state clear, measurable outcomes of the learning process.Options a and c describe actions that the nurse will take, rather than behaviors thatindicate that patient learning has occurred. Option d is too vague and nonspecific tomeasure whether learning has occurred.DIF: Cognitive Level: Application REF: 55-56 TOP: Nursing Process: PlanningMSC: NCLEX: Health Promotion and Maintenance11.When the nurse is planning teaching for a patient who needs to improve skills inbeing more assertive, the most effective teaching strategy will bea.roleplaying.b.peerteaching.c.printedmaterials.d.lecture-discussion.ANS: ARole-playing allows the patient to practice assertive behavior and receive feedbackabout how the behavior is perceived. Lecture-discussion, peer-teaching, and printedmaterials are more useful for other learning needs.DIF: Cognitive Level: Comprehension REF: 57 TOP: Nursing Process: PlanningMSC: NCLEX: Health Promotion and Maintenance12.Thepatient’steaching plan includes this goal:“Thepatient will select a 2-gramsodium diet from the hospital menu for the next 3days.”Which evaluation methodwill be best for the nurse to use when determining whether teaching was effective?a.Checkthesodiumcontentofthepatient’smenuchoicesoverthenext3daysb.Askthepatienttoidentifywhichfoodsonthehospitalmenusarehighinsodium.c.Havethepatientlistfavoritefoodsthatarehighinsodiumandfoodsthatcouldbesubstitufavorites.d.Comparethepatient’ssodiumintakeoverthenext3dayswiththesodiumintakebeforethimplemented.ANS: AAll of the answers address thepatient’ssodium intake, but the desired patientbehaviors in the learning objective are most clearly addressed by evaluation of thepatient’smenu choices.DIF: Cognitive Level: Application REF: 58-59 TOP: Nursing Process: EvaluationMSC: NCLEX: Health Promotion and Maintenance

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13.The nurse is preparing written handouts to be used as part of the standardizedteaching plan for patients who have been recently diagnosed with diabetes. Which ofthe following statements would be appropriate to include in the handouts?a.Polyphagia,polydipsia,andpolyuriaarecommonsymptomsofdiabetesmellitus.b.Theuseoftherightfoodscanhelpinkeepingbloodglucoseatanear-normallevel.c.Somediabeticscontrolbloodglucosewithoralmedicationsornutritionalinterventions.d.Diabetesmellitusischaracterizedbychronichyperglycemiaandtheassociatedsymptoms.ANS: BReading level for patient teaching materials should be at the 5th grade level. The otherresponses have words with three or more syllables, use many medical terms, and/orare too long.DIF: Cognitive Level: Application REF: 56 | 58 TOP: Nursing Process: PlanningMSC: NCLEX: Health Promotion and Maintenance14.The nurse in the hospital has implemented a teaching plan to assist a patient withrheumatoid arthritis in accomplishing daily activities independently. To evaluate thepatient’slong-term response to the teaching, the best action by the nurse will be toa.makeareferraltothehomehealthnursingdepartmentforhomevisits.b.checkthepatient’sabilitytobathewithoutanyassistancethenextday.c.havethepatientdemonstratethelearnedskillsattheendoftheteachingsession.d.arrangeaphysicaltherapyvisitbeforethepatientisdischargedfromthehospital.ANS: AThepatient’slong-term response may need to be assessed after discharge; a homehealth referral would allow this to occur. The other actions allow evaluation of thepatient’sshort-term response to teaching.DIF: Cognitive Level: Application REF: 58-59 TOP: Nursing Process: EvaluationMSC: NCLEX: Health Promotion and Maintenance15.When assessing a 22-year-old male patient, the nurse learns that he smokes a packof cigarettes daily. The patient tells the nurse,“Ienjoy smoking and have no plans toquit.”Which nursing diagnosis is most appropriate?a.Healthseekingbehaviorsrelatedtocigaretteuseb.Ineffectivehealthmaintenancerelatedtotobaccousec.Readinessforenhancedself-healthmanagementrelatedtosmoking

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d.Deficientknowledgerelatedtolong-termeffectsofcigarettesmokingANS: BThepatient’sstatement indicates that he is not considering smoking cessation.Ineffective health maintenance is defined as the inability to identify, manage, and/orseek out help to maintain health.DIF: Cognitive Level: Application REF: 55 TOP: Nursing Process: DiagnosisMSC: NCLEX: Health Promotion and Maintenance16.A 73-year-old Hispanic/Latino patient is seen at the health clinic and diagnosedwith protein malnutrition. The priority action in thenurse’steaching plan will be toa.suggesttheuseofliquidsupplementsasawaytoincreaseproteinintake.b.encouragethepatienttoincreasethedietaryintakeofmeat,cheese,andmilk.c.askthepatienttorecordtheintakeofallfoodsandbeveragesfora3-dayperiod.d.focusontheuseofcombinationsofbeansandricetoimprovedailyproteinintake.ANS: CAssessment is the first step in assisting a patient with health changes. The otheranswers may be appropriate for the patient, but the nurse will not be able to determinethis until the assessment of the patient is complete.DIF: Cognitive Level: Application REF: 53OBJ: Special Questions: Prioritization TOP: Nursing Process: PlanningMSC: NCLEX: Health Promotion and Maintenance17.A newly diagnosed diabetic patient tells the nurse,“Iwant to know how to givemy owninsulin.”Which action will the nurse take first when implementing thestandardized diabetic teaching plan?a.Demonstratehowtodrawupandadministerinsulin.b.Discusstheuseofexercisetodecreaseinsulinneeds.c.Teachaboutdifferencesbetweenthevarioustypesofinsulin.d.Providehandoutsabouttherapeuticandadverseeffectsofinsulin.ANS: AAdult education is most effective when focused on information that the patient thinksis needed right now. All of the indicated information will need to be included whenplanning teaching for this patient, but the teaching will be most effective if the nursestarts with the patient’sstated priority topic.

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DIF: Cognitive Level: Application REF: 50 | 55OBJ: Special Questions: Prioritization TOP: Nursing Process: ImplementationMSC: NCLEX: Health Promotion and Maintenance18.Which action should the nurse take first when teaching apatient’sspouse how tomanage the blood pressure (BP) for a patient with newly diagnosed high BP?a.Teachthecaregiverhowtotakethepatient’sBPusingamanualbloodpressurecuff.b.Havethedieticianmeetwiththepatientandcaregivertodiscusslowsodiumdietarychoicec.Askthepatientandcaregivertoselectimportantinformationfromalistofhypertensionted.Providewritteninformationabouttreatmentandcomplicationsofhypertensionforthepaticaregiver.ANS: CSince adults learn best when given information that they view as being neededimmediately, asking the caregiver and patient to prioritize learning needs is likely tobe the most successful approach to home management of health problems. The otheractions also may be appropriate, depending on what learning needs the caregiver andpatient have, but the initial action should be to assess what the learners feel isimportant.DIF: Cognitive Level: Application REF: 50 | 53OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Health Promotion and MaintenanceChapter 5: Chronic Illness and OlderAdultsLewis: Medical-Surgical Nursing, 8th EditionChapter 5: Chronic Illness and Older AdultsTest BankMULTIPLE CHOICE1.When caring for a patient with type 2 diabetes who has been hospitalized withsevere hyperglycemia, which topic will be most important to include in dischargeteaching?a.Effectofendogenousinsulinontransportationofglucoseintocellsb.Functionoftheliverinformationofglycogenandgluconeogenesis

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c.Impactofthepatient’sfamilyhistoryonlikelihoodofdevelopingdiabetesd.SymptomsindicatingthatthepatientshouldcontactthehealthcareproviderANS: DOne of the tasks for patients with chronic illnesses is to prevent and manage a crisis.The patient needs instruction on recognition of symptoms of hyperglycemia andappropriate actions to take if these symptoms occur. The other information also maybe included in patient teaching, but is not as essential in thepatient’sself-managementof the illness.DIF: Cognitive Level: Application REF: 63TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity2.Which question will provide the most useful information when the nurse isperforming a comprehensive geriatric assessment of an older adult who is beingassessed for admission to an assisted-living facility?a.“Haveyouhadanyrecentinfections?”b.“Howfrequentlydoyouseeadoctor?”c.“Doyouhaveahistoryofheartdisease?”d.“Areyouabletoprepareyourownmeals?”ANS: DThepatient’sfunctional abilities, rather than the presence of acute or chronic illness,are more useful in determining how well the patient might adapt to an assisted-livingsituation. The other questions also will provide helpful information but are not asuseful in providing a basis for determining patient needs or for developinginterventions for the older patient.DIF: Cognitive Level: Application REF: 73TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance3.The nurse is planning care for an alert and active 85-year-old patient who takesmultiple medications for chronic cardiac and respiratory disease and lives with adaughter who works during the day. Which nursing diagnosis is most appropriate?a.Riskforinjuryrelatedtodrug-druginteractionsb.Socialisolationrelatedtoweaknessandfatiguec.Compromisedfamilycopingrelatedtothepatient’smanycareneedsd.Caregiverrolestrainrelatedtoneedtoadjustfamilyemploymentschedule

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