Test Bank for Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care, 10th Edition (Chapters 1-69)

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Medical Surgical Nursing 10th EditionIgnatavicius Workman Test BankChapter 01: Overview of Professional Nursing Concepts for Medical-Surgical NursingIgnatavicius: Medical-Surgical Nursing, 10th EditionMULTIPLE CHOICE1.A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises thenew nurse that which is theprioritywhen working as a professional nurse?a.Attending to holistic client needsb.Ensuring client safetyc.Not making medication errorsd.Providing client-focused careANS: BAll actions are appropriate for the professional nurse. However, ensuring client safety is thepriority. Health care errors have been widely reported for 25 years, many of which result inclient injury, death, and increased health care costs. There are several national andinternational organizations that have either recommended or mandated safety initiatives.Every nurse has the responsibility to guard the client9s safety. The other actions are importantfor quality nursing, but they are not as vital as providing safety. Not making medication errorsdoes provide safety, but is too narrow in scope to be the best answer.DIF:UnderstandingTOP: Integrated Process: Nursing Process: InterventionKEY: Client safetyMSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control2.A nurse is orienting a new client and family to the medical-surgical unit. What informationdoes the nurse provide to best help the client promote his or her own safety?a.Encourage the client and family to be active partners.b.Have the client monitor hand hygiene in caregivers.c.Offer the family the opportunity to stay with the client.d.Tell the client to always wear his or her armband.ANS: AEach action could be important for the client or family to perform. However, encouraging theclient to be active in his or her health care as a safety partner is the most critical. The otheractions are very limited in scope and do not provide the broad protection that being active andinvolved does.DIF:UnderstandingTOP: Integrated Process: Teaching/LearningKEY: Client safetyMSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control3.A nurse is caring for a postoperative client on the surgical unit. The client9s blood pressurewas 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the nursetakefirst?a.Call the Rapid Response Team.b.Document and continue to monitor.c.Notify the primary health care provider.d.Repeat the blood pressure in 15 minutes.lOMoARcPSD|13445102

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ANS: AThe purpose of the Rapid Response Team (RRT) is to intervene when clients are deterioratingbefore they suffer either respiratory or cardiac arrest. Since the client has manifested asignificant change, the nurse would call the RRT. Changes in blood pressure, mental status,heart rate, temperature, oxygen saturation, and last 2 hours9 urine output are particularlysignificant and are part of the Modified Early Warning System guide. Documentation is vital,but the nurse must do more than document. The primary health care provider would benotified, but this is not more important than calling the RRT. The client9s blood pressurewould be reassessed frequently, but the priority is getting the rapid care to the client.DIF:ApplyingTOP: Integrated Process: Communication and DocumentationKEY: Rapid Response Team (RRT), Clinical judgmentMSC: Client Needs Category: Physiological Integrity: Physiological Adaptation4.A nurse wishes to provide client-centered care in all interactions. Which action by the nursebestdemonstrates this concept?a.Assesses for cultural influences affecting health care.b.Ensures that all theclient9sbasic needs are met.c.Tells the client and family about all upcoming tests.d.Thoroughly orients the client and family to the room.ANS: AShowing respect for the client and family9s preferences and needs is essential to ensure aholistic or <whole-person= approach to care. By assessing the effect of the client9s culture onhealth care, this nurse is practicing client-focused care. Providing for basic needs does notdemonstrate this competence. Simply telling the client about all upcoming tests is notproviding empowering education. Orienting the client and family to the room is an importantsafety measure, but not directly related to demonstrating client-centered care.DIF:UnderstandingTOP: Integrated Process: Culture and SpiritualityKEY: Client-centered care, CultureMSC: Client Needs Category: Psychosocial Integrity5.A client is going to be admitted for a scheduled surgical procedure. Which action does thenurse explain is themostimportant thing the client can do to protect against errors?a.Bring a list of all medications and what they are for.b.Keep theprovider9sphone number by the telephone.c.Make sure that all providers wash hands before entering the room.d.Write down the name of each caregiver who comes in the room.ANS: AMedication reconciliation is a formalprocess in which the client9s actual current medicationsare compared to the prescribed medications at the time of admission, transfer, or discharge.This National client Safety Goal is important to reduce medication errors. The client wouldnot have to be responsible for providers washing their hands, and even if the client does so,this is too narrow to be the most important action to prevent errors. Keeping the provider9sphone number nearby and documenting everyone who enters the room also do not guaranteesafety.DIF:ApplyingTOP: Integrated Process: Teaching/LearningKEY: Client safety, InformaticsMSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection ControllOMoARcPSD|13445102

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6.Which action by the nurse working with a clientbestdemonstrates 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: AAutonomy is self-determination. The client would make decisions regarding care. When thenurse 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 accurateinformation is practicing with veracity. Keeping promises is upholding fidelity. Treating theclient fairly is providing social justice.DIF:ApplyingTOP:Integrated Process: CaringKEY: Ethics, AutonomyMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care7.A nurse asks a more seasoned colleague to explain best practices when communicating with aperson from the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ)community. What answer by the faculty ismostaccurate?a.Avoid embarrassing the client by asking questions.b.Don9tmake assumptions about his or her health needs.c.Most LGBTQ people do not want to share information.d.No differences exist in communicating with this population.ANS: BMany members of the LGBTQ community have faced discrimination from health careproviders and may be reluctant to seek health care. The nurse would never make assumptionsabout the needs of members of this population. Rather, respectful questions are appropriate. Ifapproached with sensitivity, the client with any health care need is more likely to answerhonestly.DIF:UnderstandingTOP: Integrated Process: Teaching/LearningKEY: Health care disparities, LGBTQMSC: Client Needs Category: Psychosocial Integrity8.A nurse is calling the on-call health care provider about a client who had a hysterectomy 2days ago and has pain that is unrelieved by the prescribed opioid pain medication. Whichstatement comprises the background portion of the SBAR format for communication?a.<Iwould like you to order a different painmedication.=b.<Thisclient has allergies to morphine andcodeine.=c.<Dr.Smithdoesn9tlike nonsteroidal anti-inflammatorymeds.=d.<Thisclient had a vaginal hysterectomy 2 daysago.=ANS: BlOMoARcPSD|13445102

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SBAR is a recommended form of communication, and the acronym stands forSituation,Background,Assessment, andRecommendation. Appropriate background informationincludes allergies to medications the on-call health care provider might order.Situationdescribes what is happening right now that must be communicated; the client9s surgery 2 daysago would be considered background.Assessmentwould include an analysisof the client9sproblem; none of the options has assessment information. Asking for a different painmedication is a recommendation.Recommendationis a statement of what is needed or whatoutcome is desired.DIF:ApplyingTOP: Integrated Process: Communication and DocumentationKEY: Teamwork and collaboration, SBARMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care9.A nurse working on a cardiac unit delegated taking vital signs to an experienced assistivepersonnel (AP).Four hours later, the nurse notes that the client9s blood pressure taken by theAP was much higher than previous readings, and the client9s mental status has changed. Whataction by the nurse wouldmostlikely have prevented this negative outcome?a.Determining if the AP knew how to take blood pressureb.Double-checking the AP by taking another blood pressurec.Providing more appropriate supervision of the APd.Taking the blood pressure instead of delegating the taskANS: CSupervision is one of the five rights of delegation and includes directing, evaluating, andfollowing up on delegated tasks. The nurse would either have asked the AP about the vitalsigns or instructed the AP to report them right away. An experienced AP would know how totake vital signs and the nurse would not have to assess this at this point. Double-checking thework defeats the purpose of delegation. Vital signs are within the scope of practice for a APand are permissible to delegate. The only appropriate answer is that the nurse did not provideadequate instruction to the AP.DIF:AnalyzingTOP: Integrated Process: Communication and DocumentationKEY: Teamwork and collaboration, DelegationMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care10.A newly graduated nurse in the hospital states that because of being so new, participation inquality improvement (QI) projects is not wise. What response by the precepting nurse isbest?a.<Allstaff nurses are required to participate in quality improvementhere.=b.<Evenbeing new, you can implement activities designed to improvecare.=c.<It9seasy to identify what indicators would be used to measurequality.=d.<Youshould ask to be assigned to the research andquality committee.=ANS: BThe preceptor would try to reassure the nurse that implementing QI measures is not out of linefor a newly licensed nurse. Simply stating that all nurses are required to participate does nothelp the nurse understand how that is possible and is dismissive. Identifying indicators ofquality is not an easy, quick process and would not be the best place to suggest a new nurse tostart. Asking to be assigned to the QI committee does not give the nurse information abouthow to implement QI in daily practice.DIF:ApplyingTOP: Integrated Process: Communication and DocumentationlOMoARcPSD|13445102

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KEY: Systems thinking, Quality improvementMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care11.A nurse is talking with a co-worker who is moving to a new state and needs to find newemployment there. What advice by the nurse isbest?a.Ask the hospitals there about standard nurse3client ratios.b.Choose the hospital that has the newest technology.c.Find a hospital that has achieved Magnet status.d.Work in a facility affiliated with a medical or nursing school.ANS: CClient Magnet status is awarded by The Joint Commission (TJC) and certifies that nurses candemonstrate how best current evidence guides their practice. New technology doesn9tnecessarily mean that the hospital is safe. Affiliation with a health profession school hasseveral advantages, but safety is most important.DIF:UnderstandingTOP: Integrated Process: Communication and DocumentationKEY: Evidence-based practice, Magnet statusMSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection ControlMULTIPLE RESPONSE1.A nurse manager wishes to ensure that the nurses on the unit are practicing at their highestlevels of competency. Which areas would the manager assess to determine if the nursing staffdemonstrate competency according to the Institute of Medicine (IOM) reportHealthProfessions Education: A Bridge to Quality?(Select all that apply.)a.Collaborating with an interprofessional teamb.Implementing evidence-based carec.Providing family-focused cared.Routinely using informatics in practicee.Using quality improvement in client caref.Formalizing systems thinking when implementing careANS: A, B, D, EThe IOM report lists five broad core competencies that all health care providers shouldpractice. These include collaborating with the interprofessional team, implementingevidence-based practice, providing patient-focused care, using informatics in client care, andusing quality improvement in client care. Systems thinking is required for qualityimprovement but is not a specified part of the IOM report.DIF:RememberingTOP: Integrated Process: Nursing Process: AssessmentKEY: Competencies, Institute of Medicine (IOM)MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control2.A nurse is interested in making interprofessional work a high priority. Which actions by thenursebestdemonstrate 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.lOMoARcPSD|13445102

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e.Shows the nursing care plans to other disciplines.f.Delegate tasks to unlicensed personnel appropriately.ANS: A, B, C, D, FCollaborating with the interprofessional team involves planning, implementing, andevaluating client care as a team with all other involved disciplines included. Simply showingother caregivers the nursing care plan is not actively involving them or collaborating withthem.DIF:ApplyingTOP: Integrated Process: Communication and DocumentationKEY: Teamwork and collaboration, Interprofessional teamMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care3.The nurse utilizing evidence-based practice (EBP) considers which factors when planningcare? (Select all that apply.)a.Cost-saving measuresb.Nurse9sexpertisec.Client preferencesd.Research findingse.Values of the clientf.Plan-do-study-act modelANS: B, C, D, EEBP consists ofutilizing current evidence, the client9s values and preferences, and the nurse9sexpertise when planning care. It does not include cost-saving measures. The PDSA model is asystematic model for quality improvement, but is not a specific component of EBP.DIF:RememberingTOP: Integrated Process: Nursing Process: PlanningKEY: Evidence-based practice (EBP)MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care4.A nurse manager wants to improve hand-off communication among the staff. What actions bythe manager wouldbesthelp achieve this goal? (Select all that apply.)a.Attend hand-off rounds to coach and mentor.b.Create a template of suggested topics to include in report.c.Encourage staff to ask questions during hand-off.d.Give raises based on compliance with reporting.e.Provide education on the SBAR method of communicationANS: A, B, C, EThe SBAR method of communication has been identified as an excellent method ofcommunication between health care professionals. It is a formalized structure consisting ofSituation, Background, Assessment, and Recommendation/Request. Using a formalizedmechanism for communication helps ensure successful hand-off and fewer client errors. Whenestablishing this new format for report, the most helpful actions by the manager would be toprovide initial education on the process, develop a template with suggested topics under eachheading, attend rounds to coach and mentor, and encourage staff to ask questions to clarifyinformation. Basing raises on compliance would not be the most helpful method becauseraises are often determined only once a year and are based on multiple criteria.DIF:ApplyingTOP: Integrated Process: Communication and DocumentationKEY: Teamwork and collaboration, CommunicationlOMoARcPSD|13445102

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MSC: Client Needs Category: Safe and Effective Care Environment: Management of CarelOMoARcPSD|13445102

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Chapter 02: Clinical Judgment and Systems ThinkingIgnatavicius: Medical-Surgical Nursing, 10th EditionMULTIPLE CHOICE1.A nurse asks the charge nurse to explain the difference between critical thinking and clinicaljudgment. What statement by the charge nurse isbest?a.<Clinicaljudgment is often clouded by erroneoushypotheses.=b.<Clinicaljudgment is the observable outcome of criticalthinking.=c.<Criticalthinking requires synthesizing interactions within asituation.=d.<Criticalthinking is the highest level of nursingjudgment.=ANS: BClinical judgment is the observable outcome of critical thinking and decision making. It canbe, but most often is not, clouded by erroneous hypotheses. Recognizing, understanding, andsynthesizing interactions and interdependencies in a set of components designed for a specificpurpose is systems thinking. Critical thinking is not the highest level of nursing judgment.DIF:UnderstandingTOP: Integrated Process: Teaching/LearningKEY: Clinical judgmentMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care2.The nurse understands which information regarding patient-centered care?a.A competency recognizing the client as the source of control of his or her careb.A project addressing challenges in implementing patient-centered carec.Purposeful, informed, and outcome-focused care of clients or familiesd.The ability to use best evidence and practice when making care-related decisionsANS: APatient-centered care is a QSEN competency that recognizes the patient or caregiver as thesource of control and full partner in providing compassionate and coordinated care based onrespect for the patient9s preferences, values, and needs. QSEN is a project addressing thechallenge of preparing future nurses with the knowledge, skills, and attitudes (KSAs)necessary to continuously improve the quality and safety of the health care systems in whichthey work. Critical thinking is the application of purposeful, informed, and outcome-focusedcare. The ability to use best evidence and practice when making care-related decisions isevidence-based practice.DIF:UnderstandingTOP: Integrated Process: Teaching/LearningKEY: Patient-centered careMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care3.A nurse wishes to participate in an activity that will influence health outcomes. What actionby the nursebestmeets this objective?a.Creating a transportation system for health care appointmentsb.Lobbying with a national organization for health care policyc.Organizing a food pantry in an impoverished communityd.Running for election to the county public health boardANS: BlOMoARcPSD|13445102

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All options are good choices for an altruistic nurse wishing to influence health outcomes;however, being involved in policy creation and health care reform is an activity specificallyrecognized to improve health outcomes. This action will also affect a wider population thanthe more local options.DIF:ApplyingTOP: Integrated Process: Communication and DocumentationKEY: Health outcomesMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care4.What factorbestpredicts anurse9swillingness to employ critical thinking?a.Caringb.Knowledgec.Presenced.SkillsANS: AAll attributes are important in nursing, however; the nurse9swillingness to think critically ispredicted by caring behaviors, self-reflection, and insight.DIF:RememberingTOP: Integrated Process: Nursing Process: AssessmentKEY: Critical thinkingMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care5.To demonstrate clinical reasoning skills, what action does the nurse take?a.Collaborating with co-workers to buddy up for lunch breaksb.Delegating frequent vital signs on a new postoperative patientc.Documenting a complete history and physical on an admissiond.Requesting the provider order medication for a client with high potassiumANS: DThe components of clinical reasoning include assessing, analyzing, planning, implementing,and evaluating. This nurse shows the ability to analyze by interpreting the meaning of the labvalue, to plan by anticipating the consequences of the lab value, and to implement by takingaction.DIF:AnalyzingTOP: Integrated Process: Nursing Process: ImplementationKEY: Clinical judgmentMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care6.The new nurse asks the preceptor how context affects clinical judgment. What response by thepreceptor isbest?a.<Contextconsiders the whole of thepatient9sstory andcircumstances.=b.<Itshouldn9t,only nursing knowledge would affect clinicaljudgment.=c.<Outside influences such as environment in which you provide care, influenceyourdecisions.=d.<Thecontext of the situation provides an extra layer of complexity toconsider.=ANS: CThe context of a situation considers and supports clinical judgment. The factors within thislayer4such as environment, time pressure, availability or content of electronic health records,resources, and individual nursing knowledge4have a direct impact on clinical judgment. Theother two options are too vague to provide appropriate information.lOMoARcPSD|13445102

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DIF:UnderstandingTOP: Integrated Process: Teaching/LearningKEY: Clinical judgmentMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care7.Once the nurse has considered all possible collaborative and client problems, what action doesthe nurse take next?a.Act on the observed cues.b.Determine desired outcomes.c.Generate solutions.d.Prioritize the hypotheses.ANS: DAnalyzing cues lead to a list of potential hypotheses. The nurse prioritizes them, determinesthe desired outcomes, generates solutions, and acts. This is part of the six-step clinicaljudgment model.DIF:UnderstandingTOP: Integrated Process: Nursing Process: DiagnosisKEY: Clinical judgmentMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care8.A nurse working in a medical home would do which of the following as part of the job?a.Advocate with insurance companies.b.Coordinate interprofessional care.c.Hold monthly team meetings.d.Provide out-of-network specialty referrals.ANS: BThe medical home concept came into being to decrease the fragmentation of care. On a dailybasis, this nurse would expect to coordinate with the interprofessional care team. Advocatingwith insurance companies would not be a daily function. Monthly team meetings may or maynot be needed. Out of network referrals would not be needed as the interprofessional teamstrives to provide comprehensive care.DIF:RememberingTOP:Integrated Process: Nursing Process: ImplementationKEY: Medical homeMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care9.A nurse is confused on why systems thinking is important since working on the unit involvescaring for a few specific clients. What explanation by the nurse manager isbest?a.<It9sa good way to conduct root-causeanalysis.=b.<Itis important for quality improvement andsafety.=c.<Systemsthinking helps you see the biggerpicture.=d.<Youmay enter management 1 day and need to knowthis.=ANS: BA systems thinking approach to care reinforces the nurse9s role in safety and qualityimprovement while expanding clinical judgment to include the patient9s place within thegreater health care system in the context of care decisions. Root-cause analyses would be asmall portion of systems thinking. It does give the nurse a big-picture view, but this answer isvague. The nurse may or may not ever join management.lOMoARcPSD|13445102

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DIF:UnderstandingTOP: Integrated Process: Teaching/LearningKEY: Systems thinkingMSC: Client Needs Category: Safe and Effective Care Environment: Management of CareMULTIPLE RESPONSE1.The expert nurse understands that critical thinking requires which elements to be present?(Select all that apply.)a.Based on logic, creativity, and intuitionb.Driven by needsc.Focused on safety and qualityd.Grounded in a specific theorye.Guided by standardsf.Requires forming options about evidenceANS: A, B, C, ECritical thinking must be based on logic, creativity, and intuition; driven by patient, family, orcommunity needs; focused on safety and quality; guided by standards, policies, ethics, andlaws; based on principles of nursing process, problem-solving, and the scientific method(requires forming opinions and making decisions based on evidence); centered onidentification of the key problems, issues, and risks; and grounded in strategies that make themost of human potential. It is not dependent on using a specific theory.DIF:UnderstandingTOP: Integrated Process: Nursing Process: PlanningKEY: Critical thinkingMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care2.The nurse manager is conducting an annual evaluation of a staff nurse and is appraising thenurse9s clinical reasoning. What nurse actions does the manager observe to help form thisjudgment? (Select all that apply.)a.Anticipating consequences of actionsb.Delegating appropriatelyc.Interpreting datad.Noticing cuese.Setting prioritiesANS: A, C, D, EThe phases of clinical reasoning include assessing (noticing cues), analyzing (interpretingdata), planning (anticipating consequences and setting priorities), implementing, andevaluating. Delegating appropriately is not included in this model.DIF:ApplyingTOP: Integrated Process: Nursing Process: EvaluationKEY: Clinical reasoningMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care3.According to the WHO, what does primary care involve? (Select all that apply.)a.Empowered people and communitiesb.Essential public functionsc.Multisectoral policy and actiond.Primary caree.Priority consideration of chronic diseaseslOMoARcPSD|13445102

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f.Elimination of chronic diseasesANS: A, B, C, DAccording to the WHO, primary care involves three main areas: empowered people andcommunities, primary care and essential public functions, and multisectoral policy and action.Primary care focuses on both prevention and management of chronic disease.DIF:RememberingTOP: Integrated Process: Teaching/LearningKEY: Primary care, Systems thinkingMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care4.A nurse wishes to work in a community-based practice setting. Which areas would this nurseexplore for employment? (Select all that apply.)a.Hospice facilityb.<Minuteclinic=c.Mobile mammography unitd.Small community hospitale.Telehealthf.Home health careANS: A, B, C, E, FThe multiple avenues providing community-based care include hospice, <minute= orretailclinics, mobile screening and diagnostic services, telehealth, private medical practices,outpatient services, freestanding points of care, home health care, long-term ambulatory care,public health, and free clinics. Inpatient services in a hospital are not considered primary caresites.DIF:RememberingTOP: Integrated Process: NAKEY: Community-based careMSC: Client Needs Category: Safe and Effective Care Environment: Management of CarelOMoARcPSD|13445102

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Chapter 03: Overview of Health Concepts for Medical-Surgical NursingIgnatavicius: Medical-Surgical Nursing, 10th EditionMULTIPLE CHOICE1.A nurse is caring for a client who is acidotic. The nurse asks the charge nurse why the client isbreathing rapidly. What response by the charge nurse isbest?a.Anxiety is causing the client to breathe rapidly.b.The client is trying to get rid of excess body acids.c.The rapid respirations cause buildup of bicarbonate.d.An increased respiratory rate is due to increased metabolism.ANS: BThe client is acidotic, and the respiratory system is attempting to compensate by <blowingoff= excess acid in the form of carbon dioxide. The increased respiratory rate is not due toanxiety or increased metabolism. An increased respiratory rate does not cause a buildup ofbicarbonate.DIF:UnderstandingTOP: Integrated Process: Teaching/LearningKEY: Acid-base balanceMSC: Client Needs Category: Physiological Integrity: Physiological Adaptation2.A client had a recent thromboembolism and must resume work which requires frequent carand plane travel. What self-care measure does the nurse teach to reduce the risk of impairedclotting in this client?a.Get up and walk around at least every 2 hours while traveling.b.Use a soft toothbrush and an electric razor for safety.c.Be sure to sit with the legs elevated as much as possible.d.Increase fiber in the diet so as not to strain to move the bowels.ANS: AClients who are at risk of increased clotting (as evidenced by prior thromboembolic event) cantake several measures to reduce their risk of further problems. One measure is to get up andwalk frequently when sitting for a long period of time. Using a soft toothbrush and an electricrazor and needing to prevent constipation would be important for a client at risk of bleeding.Elevating the legs is not as beneficial as ambulating.DIF:ApplyingTOP: Integrated Process: Teaching/LearningKEY: Clotting, Health teachingMSC: Client Needs Category: Physiological Integrity: Physiological Adaptation3.A nurse is caring for four clients. Which client does the nurse assessfirstfor impairedcognition?a.A 28-year-old client 2 days post-open cholecystectomyb.An 88-year-old client 3 days post-hemorrhagic strokec.A 32-year-old client with a 203pack-year history of smokingd.A 42-year-old client with a serum sodium of 134 mEq/L (134 mmol/L)ANS: BlOMoARcPSD|13445102

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There are many risk factors for impaired cognition including advanced age and diseases anddisorders that affect the brain. The 88-year-old client who is recovering from a stroke has twosuch risk factors and is at highest risk for impaired cognition. The nurse assesses this clientfirst. The other clients have a much lower risk of developing impaired cognition.DIF:AnalyzingTOP: Integrated Process: Nursing Process: AssessmentKEY: Cognition, Nursing assessmentMSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential4.The assistive personnel (AP) reports to the registered nurse that a postoperative client has apulse of 132 beats/min and a blood pressure of 168/90 mm Hg. What response by the nurse ismostappropriate?a.Ask the AP to repeat theclient9svital signs in 15 minutes.b.Assess the client for pain.c.Ask the client if something is bothersome.d.Instruct the AP to reposition the client.ANS: BThe <fight-or-flight= syndrome can occur from sympathetic nervous stimulation due to acutepain. Symptoms can include nausea, vomiting, diaphoresis, tachycardia, tachypnea,hypertension, and dilated pupils. Since this client is postoperative, it is reasonable to believethat he or she might be in pain. The nurse first assesses for pain or discomfort and treats it. Ifthe client is not in pain, the nurse would conduct further assessments to determine the cause ofthe abnormal vital signs.DIF:ApplyingTOP: Integrated Process: Nursing Process: AssessmentKEY: Pain, Nursing assessmentMSC: Client Needs Category: Physiological Integrity: Physiological Adaptation5.A client has urinary incontinence. Which assessment finding indicates that outcomes for apriority nursing diagnosis have been met?a.Client reports satisfaction with undergarments for incontinence.b.Client reports drinking 8 to 9 glasses of water each day.c.Skin in perineal area is intact without redness on inspection.d.Family states that client is more active and socializes more.ANS: CUrinary incontinence can lead to skin breakdown and possibility of infection. Skin that isintact without redness shows that a major goal for this client has been met. Becoming moresocial is a positive finding as many adults with incontinence limit their social activities, butthis psychosocial outcome is not the priority over a physical outcome. Being satisfied withundergarments is also not the priority. Drinking adequate water can sometimes help withincontinence and is important for general health, but is not directly related to an importantgoal for this client.DIF:AnalyzingTOP: Integrated Process: Nursing Process: EvaluationKEY: Tissue integrity, IncontinenceMSC: Client Needs Category: Physiological Integrity: Reduction of Risk PotentiallOMoARcPSD|13445102

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6.The registered nurse asks the nursing assistant why a cardiac client9s morning weight has notyet been done. The nursing assistant says, <I9ll get to it, what9s the big deal?= When decidinghow to respond, the nurse considers what information about weight?a.Decisions on treatment often depend on the daily weight.b.The nursing assistant needs to ensure that tasks are done on time.c.Weight is the most accurate noninvasive indicator of fluid status.d.A change in weight may indicate the need to change IV fluids.ANS: CWeight is the best (noninvasive) indicator of fluid status. Primary health care providers maybase treatment decisions on weight, because the weight reflects fluid balance, but this answerdoes not explain why. IV fluid rates or solutions may change for the same reason. The nursingassistant would perform tasks on a timely basis, but this is not related to information aboutweight.DIF:ApplyingTOP: Integrated Process: Teaching/LearningKEY: Fluid and electrolytesMSC: Client Needs Category: Physiological Integrity: Physiological Adaptation7.The nurse in the emergency department (ED) is caring for four clients. Which client does thenurse assess for gas exchange abnormalitiesfirst?a.Involved in motor vehicle crash, has broken femur.b.Brought in unconscious by roommate after opioid overdose.c.Asthmatic client being discharged after bronchodilator therapy.d.History of COPD, presents to ED after being bitten by a dog.ANS: BOpioid medications can cause respiratory depression, so this client is most at risk for gasexchange problems. Diminished respirations will allow a buildup of carbon dioxide in theblood. The clients with asthma and COPD have the potential for gas exchange problems butthis is not indicated in answer option as he or she is being discharged. The client with abroken femur does not have information suggesting gas exchange problems.DIF:ApplyingTOP: Integrated Process: Nursing Process: AssessmentKEY: Gas exchange, Risk factorsMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care8.The nurse caring for a client with malnutrition assesses which laboratory value as thepriority?a.Albuminb.Prealbuminc.Prothrombin timed.Serum sodiumANS: BBoth albumin and prealbumin are indicators for nutrition. However, prealbumin changes morerapidly with decreased nutrition, so it is the better test. Prothrombin time and serum sodiumare not directly related to nutritional status.DIF:RememberingTOP: Integrated Process: Nursing Process: AssessmentKEY: Nutrition, Laboratory valueslOMoARcPSD|13445102

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9.A nurse is planning primary prevention measures for community-dwelling adults to preventvisual impairment. What action by the nurse willbestmeet this objective?a.Provide glaucoma screening.b.Assess visual acuity.c.Teach clients about instilling eyedrops.d.Offer a healthy lifestyle class.ANS: DPrimary prevention activities are those designed to actually prevent the onset of a disease orhealth problem. Secondary prevention focuses on screening and early diagnosis/detection.Tertiary measures are those that offer treatment and rehabilitation. Encouraging a healthylifestyle through classes may help prevent diabetes, a common cause of visual impairment,and is a primary prevention measure. Assessing for glaucoma and visual acuity is a secondaryprevention measure. Teaching clients how to instill eyedrops is tertiary.DIF:ApplyingTOP: Integrated Process: Nursing Process: PlanningKEY: Sensory perception, Health teachingMSC: Client Needs Category: Health Promotion and Maintenance10.The nurse tells the staff development nurse he/she is very uncomfortable discussing sexualitywith clients, especially those who are older. What suggestion by the staff development nurseismostappropriate?a.<Finda trusted friend and roleplay.=b.<Don9tworry it will geteasier.=c.<Asexual assessment is usually notneeded.=d.<It9shard for me to do,too.=ANS: ADiscussing sexuality and sex is difficult for most people. Since it is important to be able toassess this aspect of people9s lives, the nurse needs to become comfortable. Role-playing witha trusted friend will build confidence and comfort. Saying that it will get easier and that it ishard for the staff development nurse too does not give the nurse any ideas for improvement.Sexuality is important to assess.DIF:ApplyingTOP: Integrated Process: CaringKEY: Sexuality, Nursing assessmentMSC: Client Needs Category: Psychosocial IntegrityMULTIPLE RESPONSE1.A nurse is planning a community education event-related to impaired cellular regulation.What teaching topics would the nurse include in this event? (Select all that apply.)a.Ways to minimize exposure to sunlightb.Resources available for smoking cessationc.Strategies to remain hydrated during hot weatherd.Use of indoor tanning beds instead of sunbathinge.Creative cooking techniques to increase dietary fiberf.How to determine sodium content in food?ANS: A, B, ElOMoARcPSD|13445102

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Disrupted cellular regulation can lead to both benign and malignant tumors (cancer). Ways tominimize the risk of developing cancer include decreasing exposure to sunlight, smokingcessation, and increasing dietary fiber. Tanning beds do not reduce the risk of cancer asopposed to sunbathing. While staying hydrated is a good health measure, it is not related tocellular regulation. Maintaining a normal intake of sodium is also not related to cellularregulation.DIF:ApplyingTOP: Integrated Process: Nursing Process: PlanningKEY: Cellular regulation, Health teachingMSC: Client Needs Category: Health Promotion and Maintenance2.A nurse is caring for clients on an inclient surgical unit. Which clients does the nurse identifyas having a risk for impaired immunity? (Select all that apply.)a.86 years oldb.Has type 2 diabetesc.Taking prednisoned.Has many allergiese.Drinks a beer a dayf.Low socioeconomic statusANS: A, B, C, FRisk factors for impaired immunity include but are not limited to: older adults (diminishedimmunity due to normal aging changes), low socioeconomic groups (inability to obtain properimmunizations), nonimmunized adults, adults with chronic illnesses that weaken the immunesystem, adults taking chronic drug therapy such as corticosteroids and chemotherapeuticagents, adults experiencing substance use disorder, adults who do not practice a healthylifestyle, and adults who have a genetic risk for decreased or excessive immunity. Allergiesand one beer a day are not risk factors.DIF:RememberingTOP: Integrated Process: Nursing Process: PlanningKEY: ImmunityMSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential3.The nurse is caring for a client with severely impaired mobility. What actions does the nurseplace on the care plan to address potential complications? (Select all that apply.)a.Perform a depression screen once a day.b.Consult physical therapy for range of motion.c.Increase fiber in theclient9sdiet.d.Decrease fluid intake.e.Allow client to stay in a position of comfort.ANS: A, B, CThere are many complications of immobility including depression, pressure injuries,constipation, urinary calculi, and muscle atrophy. The nurse would address these by assessingfor depression, consulting physical therapy for activities such as range of motion the client cando, and increase fiber so the client does not become constipated. Decreasing fluid intakewould increase the possibility of calculi and allowing the client to stay in one position wouldincrease the risk of pressure injuries.DIF:ApplyingTOP: Integrated Process: Nursing Process: ImplementationKEY: MobilitylOMoARcPSD|13445102

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MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential4.A client has impaired tissue integrity and a nonhealing wound. The nurse has taught the clientabout diet changes to improve wound healing. What diet selections does the nurse evaluate asgood understanding by the client? (Select all that apply.)a.Chicken breastb.Orange juicec.Boost supplementd.Spinach salade.Cantaloupef.Whole wheat breadANS: A, B, C, DProtein and vitamin C are important for wound healing. Foods high in protein include meatsources such as chicken and nutritional supplements. Foods high in vitamin C include orangejuice and spinach. Cantaloupe is a good source of vitamin A. Whole wheat bread, whilehealthy, does not contribute directly to wound healing.DIF:RememberingTOP: Integrated Process: Nursing Process: EvaluationKEY: NutritionMSC: Client Needs Category: Physiological Integrity: Physiological AdaptationlOMoARcPSD|13445102

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Chapter 04: Common Health Problems of Older AdultsIgnatavicius: Medical-Surgical Nursing, 10th EditionMULTIPLE CHOICE1.A nurse learns that the fastest growing subset of the older population is which group?a.Elite oldb.Middle oldc.Old oldd.Young oldANS: CThe old old is the fastest growing subset of the older population. This is the group comprisingthose 85 to 99 years of age. The young old are between 65 and 74 years of age; the middle oldare between 75 and 84 years of age; and the elite old are over 100 years of age.DIF:RememberingTOP: Integrated Process: Teaching/LearningKEY: Older adultsMSC: Client Needs Category: Health Promotion and Maintenance2.A nurse working with older adults in the community plans programming to improve moraleand emotional health in this population. What activity wouldbestmeet this goal?a.Exercise program to improve physical functionb.Financial planning seminar series for older adultsc.Social events such as dances and group dinnersd.Workshop on prevention from becoming an abuse victimANS: AAll activities would be beneficial for the older population in the community. However, failurein performing one9s own activities of daily living and participating in society has direct effectson morale and life satisfaction. Those who lose the ability to function independently often feelworthless and empty. An exercise program designed to maintain and/or improve physicalfunctioning would best address this need.DIF:ApplyingTOP: Integrated Process: Nursing Process: PlanningKEY: Older adultMSC: Client Needs Category: Psychosocial Integrity3.A nurse caring for an older client on a medical-surgical unit notices the client reports frequentconstipation and only wants to eat softer foods such as rice, bread, and puddings. Whatassessment would the nurse performfirst?a.Auscultate bowel sounds.b.Check skin turgor.c.Perform an oral assessment.d.Weigh the client.ANS: CPoorly fitting dentures and other dental problems are often manifested by a preference for softfoods and constipation from the lack of fiber. The nurse would perform an oral assessment todetermine if these problems exist. The other assessments are important, but will not yieldinformation specific to theclient9s foodpreferences as they relate to constipation.lOMoARcPSD|13445102

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DIF:ApplyingTOP: Integrated Process: Nursing Process: AssessmentKEY: Older adult, NutritionMSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort4.A nurse caring for an older adult has provided education on high-fiber foods. Which menuselection by the client demonstrates a need for further review?a.Barley soupb.Black beansc.White riced.Whole-wheat breadANS: COlder adults need 35 to 50 g of fiber a day. White rice is low in fiber. Foods high in fiberinclude barley, beans, and whole-wheat products.DIF:AnalyzingTOP: Integrated Process: Nursing Process: EvaluationKEY: Older adult, NutritionMSC: Client Needs Category: Physiological Integrity: Physiological Adaptation5.A nurse is working with an older client admitted with mild dehydration. What teaching doesthe nurse provide tobestaddress this issue?a.<Cutsome sodium out ofyour diet.=b.<Dehydrationcan causeincontinence.=c.<Havesomething to drink every 1 to 2hours.=d.<Takeyour diuretic in themorning.=ANS: COlder adults often lose their sense of thirst. Plus older adults have less body water thanyounger people. Since they should drink 1 to 2 L of water a day, the best remedy is to havethe 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 and is vague. Although dehydrationcan cause incontinence from the irritation of concentrated urine, this information will not helpprevent the problem of dehydration. Instructing the client to take a diuretic in the morningrather than in the evening also will not directly address this issue.DIF:ApplyingTOP: Integrated Process: Teaching/LearningKEY: Older adult, Fluid and electrolyte balanceMSC: Client Needs Category: Physiological Integrity: Physiological Adaptation6.A home health care nurse is planning an exercise program with an older adult who lives athome independently but whose mobility issues prevent much activity outside the home.Which exercise regimen would bemostbeneficial to this adult?a.Building strength and flexibilityb.Improving exercise endurancec.Increasing aerobic capacityd.Providing personal trainingANS: AThis older adult is mostly homebound. Exercise regimens for homebound clients includethings to increase functional fitness and ability for activities of daily living. Strength andflexibility will help the client to be able to maintain independence longer. The other plans aregood but will not specifically maintain theclient9s functionalabilities.lOMoARcPSD|13445102

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DIF:ApplyingTOP: Integrated Process: Nursing Process: PlanningKEY: Older adult, Functional abilityMSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential7.An older adult recently retired and reports <being depressed and lonely.= What informationwould the nurse assess as apriority?a.History of previous depressionb.Previous stressful eventsc.Role of work in theadult9slifed.Usual leisure time activitiesANS: CEstablishing and maintaining relationships with others throughout life are especially importantto the older person9s happiness. When people retire, theymay lose much of their socialnetwork, leading them to feeling depressed and lonely. This loss from a sudden change inlifestyle can easily lead to depression. The nurse would first assess the role that work playedin the client9s life. The other factors can be assessed as well, but this circumstance iscommonly seen in the older population.DIF:ApplyingTOP: Integrated Process: Nursing Process: AssessmentKEY: Older adult, DepressionMSC: Client Needs Category: Psychosocial Integrity8.A nurse is assessing coping in older women in a support group for recent widows. Whichstatement by a participantbestindicates potential for successful coping?a.<Ihave had the same best friend fordecades.=b.<Ithink I am coping very well on myown.=c.<Mykids come to see me everyweekend.=d.<Oh,I have lots of friends at the seniorcenter.=ANS: AFriendship and support enhance coping. The quality of the relationship is what is mostimportant, however. People who have close, intimate, stable relationships with others inwhom they confide are more likely to cope with crisis. The person who is <coping well on myown= may actually need resources to help with this transition. Having children visit isimportant but not as important as intimate, long-term friendships. <Friends at the seniorcenter=may refer to good acquaintances and not real friends.DIF:AnalyzingTOP: Integrated Process: Nursing Process: AssessmentKEY: Older adult, CopingMSC: Client Needs Category: Psychosocial Integrity9.A home health care nurse has conducted a home safety assessment for an older adult. Thereare five concrete steps leading out from the front door. Which intervention would bemosthelpful in keeping the older adult safe on the steps?a.Have the client use a walker or cane on the steps.b.Teach the client to hold the handrail when using the stepsc.Instruct the client to use the garage door instead.d.Tell the client to use a two-footed gait on the steps.ANS: BlOMoARcPSD|13445102

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As a person ages, he or she may experience a decreased sense of touch. The older adult maynot be aware of where his or her foot is on the step. Combined with diminished visual acuity,this can create a fall hazard. Holding the handrail would help keep the person safer. If theclient does not need an assistive device, he or she would not use a cane or walker just onstairs. Using an alternative door may be necessary but does not address making the front stepssafer. A two-footed gait may not help if the client is unaware of where the foot is on the step.DIF:ApplyingTOP: Integrated Process: Nursing Process: ImplementationKEY: Older adult, SafetyMSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control10.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 ismostimportant?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: BMedication side effects and adverse effects are common in the older population. Something assimple as a new antibiotic can cause confusion and memory loss. The nurse would determineif the client is taking any new medications. Assessments for orthostatic hypotension, gaitabnormalities, and delirium may be important once more is known about the client9scondition.DIF:ApplyingTOP: Integrated Process: Nursing Process: AssessmentKEY: Older adult, Medication safetyMSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies11.An older adult client takes medication three times a day and becomes confused about whichmedication should be taken at which time. The client refuses to use a pill sorter with slots fordifferent times, saying <Those are for old people.= What action by the nurse would bemosthelpful?a.Arrange medications by time in a drawer.b.Encourage the client to use easy-open tops.c.Put color-coded stickers on the bottle caps.d.Write a list of when to take each medication.ANS: CColor-coded stickers are a fast, easy-to-remember system. One color is for morning meds, onefor evening meds, and the third color is for nighttime meds. Arranging medications by time ina drawer might be helpful if the person doesn9t 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 themedication.DIF:ApplyingTOP: Integrated Process: Nursing Process: ImplementationKEY: Older adult, Medication safetyMSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection ControllOMoARcPSD|13445102

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12.An older adult client is in the hospital. The client is ambulatory and independent. Whatintervention by the nurse would bemosthelpful 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 side rails to keep the client in bed.ANS: AAlthough this older adult is independent and ambulatory, being hospitalized can createconfusion. Getting up in a dark, unfamiliar environment can contribute to falls. Keeping thelight on in the bathroom will help reduce the likelihood of falling. The client does not need acommode or a toileting schedule. Side rails used to keep the client in bed are consideredrestraints and would not be used in that fashion.DIF:ApplyingTOP: Integrated Process: Nursing Process: ImplementationKEY: Older adult, Fall preventionMSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control13.An older client had hip replacement surgery and the surgeon prescribed morphine sulfate forpain. The client is allergic to morphine and reports pain and muscle spasms. When the nursecalls the surgeon, which medication would he or she suggest in place of the morphine?a.Cyclobenzaprineb.Hydromorphone hydrochloridec.Ketorolacd.MeperidineANS: BCyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) areall on the Beers list of potentially inappropriate medications for use in older adults and wouldnot be suggested. The nurse would suggest hydromorphone hydrochloride.DIF:RememberingTOP: Integrated Process: Communication and DocumentationKEY: Older adult, Medication safetyMSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies14.A nurse admits an older adult from a home environment. The client lives with an adult sonand daughter-in-law. The client has urine burns on the skin, no dentures, and several pressureinjuries. What action by the nurse ismostappropriate?a.Ask the family how these problems occurred.b.Call the police department and file a report.c.Notify Adult Protective Services.d.Report the findings as per agency policy.ANS: DThese findings are suspicious for abuse. Health care providers are mandatory reporters forsuspected abuse. The nurse would notify social work, case management, or whomever isdesignated in facility policies. That person can then assess the situation further. If the policeneed to be notified, that is the person who will notify them. Adult Protective Services isnotified in the community setting.DIF:ApplyingTOP: Integrated Process: Communication and DocumentationlOMoARcPSD|13445102

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KEY: Older adult, AbuseMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care15.A nurse caring for an older client in the hospital is concerned the client is not competent togive consent for upcoming surgery. What action by the nurse isbest?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 theclient9sfamily sign the consent.ANS: BIn this situation, each facility will have a policy designed for assessing competence. The nursewould bring these concerns to an interprofessional care team meeting. There may bephysiologic reasons for the client to be temporarily too confused or incompetent to giveconsent. If an acute condition is ruled out, the staff would follow the legal procedure andpolicies in their facility and state for determining competence. The key is to bring theconcerns forward. Calling Adult Protective Services is not appropriate at this time. Signingthe consent would wait until competence is determined unless it is an emergency, in whichcase the next of kin can sign if there are grave doubts as to the client9s ability to provideconsent. Simply not allowing the client to sign does not address the problem.DIF:ApplyingTOP: Integrated Process: Communication and DocumentationKEY: Older adult, AutonomyMSC: Client Needs Category: Safe and Effective Care Environment: Management of CareMULTIPLE RESPONSE1.A nurse working in an Acute Care of the Elderly unit learns that frailty in the older populationincludes which components? (Select all that apply.)a.Dementiab.Exhaustionc.Slowed physical activityd.Weaknesse.Weight gainf.Frequent illnessANS: B, C, DFrailty is a syndrome consisting of unintentional weight loss, slowed physical activity andexhaustion, and weakness. Weight gain and dementia are not part of this syndrome. Frequentillness could occur due to frailty, but is also not part of the syndrome.DIF:RememberingTOP: Integrated Process: Nursing Process: AssessmentKEY: Older adult, FrailtyMSC: Client Needs Category: Health Promotion and Maintenance2.A home health care nurse assesses an older adult for the intake of nutrients needed in largeramounts than in younger adults. Which foods found in an older adult9s kitchen might indicatean adequate intake of these nutrients? (Select all that apply.)a.1% milkb.Carrotsc.Lean ground beeflOMoARcPSD|13445102

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d.Orangese.Vitamin D supplementsf.Cheese sticksANS: A, B, D, EOlder adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk andcheese have calcium; carrots have vitamin A; vitamin D supplement has vitamin D; andoranges have vitamin C. Lean ground beef is healthier than more fatty cuts, but does notcontain these needed nutrients.DIF:UnderstandingTOP: Integrated Process: Nursing Process: AssessmentKEY: Older adults, NutritionMSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort3.A nurse working with older adults assesses them for common potential adverse medicationeffects. For what does the nurse assess? (Select all that apply.)a.Constipationb.Dehydrationc.Maniad.Urinary incontinencee.Weaknessf.AnorexiaANS: A, B, E, FCommon adverse medication effects include constipation/impaction, dehydration, anorexia,and weakness. Mania and incontinence are not among the common adverse effects, althoughurinary retention is.DIF:RememberingTOP: Integrated Process: Nursing Process: AssessmentKEY: Older adult, Adverse medication effectsMSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies4.A nurse manager institutes the Fulmer SPICES Framework as part of the routine assessmentof older adults in the hospital. The nursing staff assesses for which factors? (Select all thatapply.)a.Confusionb.Evidence of abusec.Incontinenced.Problems with behaviore.Sleep disordersANS: A, C, ESPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion,and evidence of falls.DIF:RememberingTOP: Integrated Process: Nursing Process: AssessmentKEY: Older adult, Nursing assessmentMSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential5.A visiting nurse is in the home of an older adult and notes a 7-lb weight loss since lastmonth9svisit. What actions would the nurse performfirst? (Select all that apply.)a.Assess theclient9sability to drive or transportation alternatives.lOMoARcPSD|13445102

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b.Determine if the client has dentures that fit appropriately.c.Encourage the client to continue the current exercise plan.d.Have the client complete a 3-day diet recall diary.e.Teach the client about proper nutrition in the older population.ANS: A, B, DAssessment is the first step of the nursing process and would be completed prior tointervening. Asking about transportation to get food, dentures, and normal food patternswould be part of an appropriate assessment for the client. There is no information in thequestion about the older adult needing to lose weight, so encouraging him or her to continuethe current exercise regimen is premature and may not be appropriate. Teaching about propernutrition isa good idea, but teaching needs to be tailored to the client9s needs, which the nursedoes not yet know.DIF:ApplyingTOP: Integrated Process: Nursing Process: AssessmentKEY: Older adult, NutritionMSC: Client Needs Category: Physiological Integrity: Physiological Adaptation6.A hospitalized older adult has been assessed at high risk for skin breakdown. Which actionsdoes the registered nurse (RN) delegate to the assistive personnel (AP)? (Select all that apply.)a.Assess skin redness when turning.b.Document Braden Scale results.c.Keep theclient9sskin dry.d.Obtain a pressure-relieving mattress.e.Turn the client every 2 hours.ANS: C, D, EThe nurses9 aide or AP can assist in keeping the client9s skin dry, order a special mattress ondirection of the RN, and turn the client on a schedule. Assessing the skin is a nursingresponsibility, although the aide would be directed to report any redness noticed.Documenting the Braden Scale results is the RN9s responsibility as the RN is the one whoperforms that assessment.DIF:ApplyingTOP: Integrated Process: Communication and DocumentationKEY: Older adult, Tissue integrityMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care7.A nurse admits an older adult to the hospital who lives at home with family. The nurseassesses that the client is malnourished. What actions by the nurse arebest? (Select all thatapply.)a.Contact Adult Protective Services or hospital social work.b.Request the primary health care provider prescribes tube feedings.c.Perform and document results of a Braden Scale assessment.d.Request a dietary consultation from the health care provider.e.Suggest a high-protein oral supplement between meals.f.Assess theclient9sown teeth or the dentures for proper fit.ANS: C, D, E, FlOMoARcPSD|13445102

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Malnutrition in the older population is multifactorial and has several potential adverseoutcomes. Appropriate actions by the nurse include assessing the client9s risk for skinbreakdown with the Braden Scale, requesting a consultation with a dietitian, suggesting ahigh-protein meal supplement, and assessing the client9s dentures or own teeth. There is noevidence that the client is being abused or needs a feeding tube at this time.DIF:ApplyingTOP: Integrated Process: Nursing Process: ImplementationKEY: Older adult, NutritionMSC: Client Needs Category: Safe and Effective Care Environment: Management of CarelOMoARcPSD|13445102

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Chapter 05: Assessment and Care of Patients With PainIgnatavicius: Medical-Surgical Nursing, 10th EditionMULTIPLE CHOICE1.A new nurse asks the precepting nurse <What is the best way to assess a client9s pain?= Whichresponse by the nurse isbest?a.Numeric pain scaleb.Behavioral assessmentc.Client9sself-reportd.Objective observationANS: CMany 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 aself-report from the client.DIF:RememberingTOP: Integrated Process: Nursing Process: AssessmentKEY: Pain, Nursing assessmentMSC: Client Needs Category: Health Promotion and Maintenance2.A new nurse reports to the nurse preceptor that a client requested pain medication, and whenthe nurse brought it, the client was sound asleep. The nurse states the client cannot possiblysleep with the severe pain the client described. Which response by the experienced nurse isbest?a.<Beingable tosleep doesn9tmean paindoesn9t exist.=b.<Haveyou ever experienced any type ofpain?=c.<Theclient should be assessed for drugaddiction.=d.<You9reright; I would put the medicationback.=ANS: AA client9s description is the most accurate assessment of pain. The nurse would believe theclient and provide pain relief. Physiologic changes due to pain vary from client to client, andassessments of them would not supersede the client9s descriptions, especially if the pain ischronic in nature. Asking if the new nurse has had pain is judgmental and flippant and doesnot provide useful information. This amount of information does not warrant an assessmentfor drug addiction. Putting the medication back and ignoring the client9s report of pain servesno useful purpose and is unethical.DIF:UnderstandingTOP:Integrated Process: Communication and DocumentationKEY: Pain, Nursing assessmentMSC: Client Needs Category: Health Promotion and Maintenance3.The nurse in the outpatient surgery clinic is discussing an upcoming surgical procedure with aclient. Which information provided by the nurse ismostappropriate for the client9s long-termoutcome?a.<Atleast you know that the pain after surgery will diminishquickly.=b.<Discussacceptable pain control after your operation with thesurgeon.=c.<Opioidsoften cause nausea but youwon9thave to take them forlong.=d.<Thenursing staff will give you pain medication when you ask themfor it.=lOMoARcPSD|13445102

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ANS: BThe best outcome after a surgical procedure is timely and satisfactory pain control, whichdiminishes the likelihood of chronic pain afterward. The nurse suggests that the clientadvocate for himself or herself and discuss acceptable pain control with the surgeon. Statingthat pain after surgery is usually short lived does not provide the client with options to havepersonalized pain control. To prevent or reduce nausea and other side effects from opioids, amultimodal pain approach is desired. For acute pain after surgery, giving pain medicationsaround the clock instead of waiting until the client requests it is a better approach.DIF:ApplyingTOP: Integrated Process: Teaching/LearningKEY: Pain, Acute painMSC: Client Needs Category: Health Promotion and Maintenance4.A nurse is assessing pain on a confused older client who has difficulty with verbal expression.Which pain assessment tool would the nurse choose for this assessment?a.Numeric rating scaleb.Verbal Descriptor Scalec.FACES Pain Scale-Revisedd.Wong-Baker FACES Pain ScaleANS: CAll are valid pain rating scales; however, some research has shown that the FACES PainScale-Revised is preferred by both cognitively intact and cognitively impaired adults. Aconfused client with difficulty speaking would not be a good candidate for the numeric ratingscale or the verbal descriptor scale. The cartoon images on the Wong-Baker FACES PainScale may not be appropriate for an adult client.DIF:ApplyingTOP: Integrated Process: Nursing Process: AssessmentKEY: Pain, Nursing assessmentMSC: Client Needs Category: Health Promotion and Maintenance5.The nurse is assessing aclient9s pain and has elicited information on the location, quality,intensity, effect on functioning, aggravating and relieving factors, and onset and duration.Which question by the nurse would bebestto ask the client for completing a comprehensivepain assessment?a.<Areyou worried about addiction to painpills?=b.<Doyou attach any spiritual meaning topain?=c.<Howhigh would you say your pain toleranceis?=d.<Whatpain rating would be acceptable toyou?=ANS: DA comprehensive pain assessment includesthe items listed in the question plus the client9sopinion on a comfort-function outcome, such as what pain rating would be acceptable to himor her. Asking about addiction is not warranted in an initial pain assessment. Asking aboutspiritual meanings for pain may give the nurse important information, but getting the basicsfirst is more important. Asking about pain tolerance may give the client the idea that paintolerance is being judged.DIF:ApplyingTOP: Integrated Process: Nursing Process: AssessmentKEY: Pain, Nursing assessmentMSC: Client Needs Category: Physiological Integrity: Reduction of Risk PotentiallOMoARcPSD|13445102

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6.A nurse is assessing pain in an older adult. Which action by the nurse isbest?a.Ask only<yes-or-no=questions so the clientdoesn9tget 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: DSome older clients do not report pain because they think it is a normal part of aging orbecause they do not want to be a bother. Sitting down conveys time, interest, and availability.Ask only one question at a time and allow the client enough time to answer it. Yes-or-noquestions are an example of poor communication technique. Giving the client a pain scale,and then leaving, might give the impression that the nurse does not have time for the client.Also, the client may not know how to use it. There is no normal pain from aging.DIF:ApplyingTOP: Integrated Process: Communication and DocumentationKEY: Pain, Nursing assessmentMSC: Client Needs Category: Psychosocial Integrity7.The nurse receives a hand-off report. One client is described as a drug seeker who is obsessedwith even tiny changes in physical condition and is <on the light constantly= asking for morepain medication. When assessing this client9s pain, which statement or question by the nurseismostappropriate?a.<Helpme understand how pain is affecting you rightnow.=b.<Iwish I could do more; is there anything I can getfor you?=c.<Youcannot have more pain medication for 3hours.=d.<Whydo you think the medication is not helpingyour pain?=ANS: AA client who is preoccupied with physical symptoms andis <demanding= may have somepsychosocial impact from the pain that is not being addressed. The nurse is providing theclient 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 doesnot attempt to learn more about the pain. Simply telling the client when the next medication isdue also does not help the nurse understand the client9s situation. <Why= questions areprobing and often make clients defensive, plus the client may not have an answer for thisquestion.DIF:ApplyingTOP: Integrated Process: Communication and DocumentationKEY: Pain, Nursing assessmentMSC: Client Needs Category: Psychosocial Integrity8.A nurse on the medical-surgical unit has received a hand-off report. Which client would thenurse seefirst?a.Client being discharged later on a complicated analgesia regimen.b.Client with new-onset abdominal pain, rated as an 8 on a 0-10 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: BlOMoARcPSD|13445102

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