Test Bank for Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care, 9th Edition (Chapters 1-74)

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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e1Table of ContentsTable of Contents1Chapter 01: Overview of Professional NursingConcepts for Medical-Surgical Nursing Chapter 02:Overview of Health Concepts for Medical-SurgicalNursingChapter 03: Common HealthProblems of Older AdultsChapter 04: Assessment andCare of Patients with PainChapter 05: GeneticConcepts for Medical-Surgical NursingChapter 06: Rehabilitation Concepts for Chronicand Disabling Health Problems Chapter 07: End-of-Life CareChapter 08: Concepts of Emergency and TraumaNursingChapter 09: Care of Patients withCommon Environmental EmergenciesChapter 10: Concepts of Emergency andDisaster PreparednessChapter 11: Assessment and Care of Patients withFluid and Electrolyte Imbalances Chapter 12:Assessment and Care of Patients with Acid-BaseImbalancesChapter 13: Infusion TherapyChapter 14:Care ofPreoperativePatientsChapter 15:Care ofIntraoperative PatientsChapter 16:Care ofPostoperative PatientsChapter 17:InflammationandImmunityChapter 18: Care of Patients with Arthritis andOther Connective Tissue Diseases Chapter 19:Care of Patients with HIV DiseaseChapter 20: Care of Patients withHypersensitivity (Allergy) and AutoimmunityChapter 21: Cancer DevelopmentChapter 22:Care ofPatientswith CancerChapter 23:Care ofPatientswithInfectionChapter24:Assessmentofthe

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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e2Skin,Hair,andNailsChapter25:CareofPatientswithSkinProblemsChapter26:CareofPatientswithBurnsChapter 27: Assessment of the Respiratory SystemChapter 28: Care of Patients RequiringOxygen Therapy or Tracheostomy Chapter 29:Care of Patients with Noninfectious UpperRespiratory Problems Chapter 30: Care ofPatients with Noninfectious Lower RespiratoryProblems Chapter 31: Care of Patients withInfectious Respiratory ProblemsChapter 32: Care of Critically IllPatients with Respiratory ProblemsChapter 33: Assessment of theCardiovascular SystemChapter 34: Care ofPatients withDysrhythmias Chapter35: Care of Patientswith Cardiac ProblemsChapter 36: Care ofPatients with VascularProblems Chapter 37:Care of Patients withShockChapter 38: Care of Patientswith Acute CoronarySyndromes Chapter 39:Assessment of the HematologicSystemChapter 40: Care ofPatients with HematologicProblems Chapter 41:Assessment of theNervous SystemChapter 42: Care of Patients withProblems of the CNS: The Brain Chapter43: Care of Patients with Problems of theCNS: The Spinal CordChapter 44: Care of Patients with Problems ofthe Peripheral Nervous System Chapter 45:Care of Critically Ill Patients with NeurologicProblemsChapter 46: Assessment of the Eye and VisionChapter 47: Care of Patients with Eye and VisionProblemsChapter 48: Assessment and Care of Patientswith Ear and Hearing Problems Chapter 49:Assessment of the Musculoskeletal SystemChapter 50: Care of Patients with MusculoskeletalProblems38132032384450566268768394103109116122138147152157167174179196213220226233245256269278287

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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e3298310317327331343353364374380394397403410415Chapter51:CareofPatientswithMusculoskeletalTraumaChapter52:AssessmentoftheGastrointestinalSystemChapter53: Care of Patients withOral Cavity ProblemsChapter 54: Care of Patientswith Esophageal ProblemsChapter 55: Care of Patientswith Stomach DisordersChapter 56: Care of Patients withNoninflammatory Intestinal DisordersChapter 57: Care of Patients withInflammatory Intestinal Disorders Chapter58: Care of Patients with Liver ProblemsChapter 59: Care of Patients with Problems of theBiliary System and Pancreas Chapter 60: Care ofPatients with Malnutrition: Undernutrition andObesity Chapter 61: Assessment of the EndocrineSystemChapter 62: Care of Patients with Pituitary andAdrenal Gland ProblemsChapter 63: Care of Patients with Problems of theThyroid and Parathyroid Glands Chapter 64: Care ofPatients with Diabetes MellitusChapter 65: Assessment ofthe Renal/Urinary SystemChapter 66: Care of Patientswith Urinary ProblemsChapter 67: Care of Patientswith Kidney DisordersChapter 68: Care of Patients with Acute KidneyInjury and Chronic Kidney Disease Chapter 69:Assessment of the Reproductive SystemChapter 70: Care ofPatients with BreastDisorders Chapter 71:Care of Patients withGynecologic ProblemsChapter 72: Care of Patients withMale Reproductive ProblemsChapter 73: Care of TransgenderPatientsChapter 74: Care of Patients with SexuallyTransmitted Diseases424435441445454461471481489497506512520527549557568575587

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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e4591598605614618

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Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical NursingMULTIPLE CHOICE1. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse bestdemonstrates this concept?a. Assesses for cultural influences affecting health careb. Ensures that all the clients basic needs are metc. Tells the client and family about all upcoming testsd. Thoroughly orients the client and family to the roomANS: ACompetency in client-focused care is demonstrated when the nurse focuses on communication, culture, respectcompassion, client education, and empowerment. By assessing the effect of the clients culture on health care, thisnurse is practicing client-focused care. Providing for basic needs does not demonstrate this competence. Simplytelling the client about all upcoming tests is not providing empowering education. Orienting the client and family tothe room is an important safety measure, but not directly related to demonstrating client-centeredcare.DIF: Understanding/Comprehension REF: 3KEY: Patient-centered care| culture MSC: Integrated Process: CaringNOT: Client Needs Category: Psychosocial Integrity2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76 mmHg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?a. Call the Rapid Response Team.b. Document and continue to monitor.c. Notify the primary care provider.d. Repeat blood pressure measurement in 15 minutes.ANS: AThe purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before theysuffereither respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse shouldcall theRRT. Changes in blood pressure, mental status, heart rate, and pain are particularly significant.Documentation is vital, but the nurse must do more than document. The primary care provider should benotified, but this is not the priority over calling the RRT. The clients blood pressure should be reassessedfrequently, but the priority is getting the rapid care to the client.DIF: Applying/Application REF: 3KEY: Rapid Response Team (RRT)| medical emergencies MSC:Integrated Process: Communication and DocumentationNOT: Client Needs Category: Physiological Integrity: Physiological Adaptation3. A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide tohelp 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 the client to beactivein his or her health care as a partner is the most critical. The other actions are very limited in scope anddo notprovide the broad protection that being active and involved does.DIF: Understanding/Comprehension REF: 3KEY: Patient safety

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MSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control4. A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor advises thestudent that which is the priority when 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 the priority. Up to98,000 deaths result each year from errors in hospital care, according to the 2000 Institute of Medicine report.Manymore clients have suffered injuries and less serious outcomes. Every nurse has the responsibility to guard theclients safety.DIF: Understanding/Comprehension REF: 2KEY: Patient safetyMSC: Integrated Process: Nursing Process: InterventionNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control5. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain isthe most important thing the client can do to protect against errors?a.Bring a list of all medications and what they are for.b. Keep the doctors phone number by the telephone.c. Make sure all providers wash hands before entering the room.d. Write down the name of each caregiver who comes in the room.ANS: AMedication errors are the most common type of health care mistake. The Joint Commissions Speak Upcampaignencourages clients to help ensure their safety. One recommendation is for clients to know all theirmedications andwhy they take them. This will help prevent medication errors.DIF: Applying/Application REF: 4KEY: Speak Up campaign| patient safety MSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control6. Which action by the nurse working with a client best demonstrates respect for autonomy?a. Asks if the client has questions before signing a consentb. Gives the client accurate information when questionedc. Keeps the promises made to the client and familyd. Treats the client fairly compared to other clientsANS: AAutonomy is self-determination. The client should make decisions regarding care. When the nurse obtains asignature on the consent form, assessing if the client still has questions is vital, because without fullinformationthe client cannot practice autonomy. Giving accurate information is practicing with veracity.Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.DIF: Applying/Application REF: 4KEY: Autonomy| ethical principles MSC: Integrated Process: CaringNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care7.A student nurse asks the faculty to explain best practices when communicating with a person from thelesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. What answer by the faculty ismost accurate?a. Avoid embarrassing the client by asking questions.b. Dont make assumptions about their health needs.c. Most LGBTQ people do not want to share information.

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d. No differences exist in communicating with this population.ANS: BMany members of the LGBTQ community have faced discrimination from health care providers and may bereluctant to seek health care. The nurse should never make assumptions about the needs of members of thispopulation. Rather, respectful questions are appropriate. If approached with sensitivity, the client with any healthcare need is more likely to answer honestly.DIF: Understanding/Comprehension REF: 4KEY: LGBTQ| diversityMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Psychosocial Integrity8. A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and has pain thatis unrelieved by the prescribed narcotic pain medication. Which statement is part of the SBAR format forcommunication?a. A: I would like you to order a different pain medication.b. B: This client has allergies to morphine and codeine.c. R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds.d. S: This client had a vaginal hysterectomy 2 days ago.ANS: BSBAR is a recommended form of communication, and the acronym stands for Situation, Background,Assessment, and Recommendation. Appropriate background information includes allergies to medications theon-call physician might order. Situation describes what is happening right now that must be communicated; theclientssurgery 2 days ago would be considered background. Assessment would include an analysis of the clientsproblem; asking for a different pain medication is a recommendation. Recommendation is a statement of what isneeded or what outcome is desired; this information about the surgeons preference might be better placed inbackground.DIF: Applying/Application REF: 5KEY: SBAR| communicationMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care9.A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistivepersonnel (UAP). Four hours later, the nurse notes the clients blood pressure is much higher than previousreadings, and the clients mental status has changed. What action by the nurse would most likely haveprevented this negative outcome?a. Determining if the UAP knew how to take blood pressureb. Double-checking the UAP by taking another blood pressurec. Providing more appropriate supervision of the UAPd. Taking the blood pressure instead of delegating the taskANS: CSupervision is one of the five rights of delegation and includes directing, evaluating, and following up ondelegated tasks. The nurse should either have asked the UAP about the vital signs or instructed the UAP to reportthem right away. An experienced UAP should know how to take vital signs and the nurse should not have toassess this at this point. Double-checking the work defeats the purpose of delegation. Vital signs arewithin thescope of practice for a UAP and are permissible to delegate. The only appropriate answer is that thenurse did notprovide adequate instruction to the UAP.DIF: Applying/Application REF: 6KEY: Supervision| delegation| unlicensed assistive personnel MSC:Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care10. A nurse is talking with a client who is moving to a new state and needs to find a new doctor and hospitalthere. What advice by the nurse is best?

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a. Ask the hospitals there about standard nurse-client ratios.b. Choose the hospital that has the newest technology.c. Find a hospital that is accredited by The Joint Commission.d. Use a facility affiliated with a medical or nursing school.ANS: CAccreditation by The Joint Commission (TJC) or other accrediting body gives assurance that the facility has afocuson safety. Nurse-client ratios differ by unit type and change over time. New technology doesntnecessarily meanthe hospital is safe. Affiliation with a health professions school has several advantages, butsafety is mostimportant.DIF: Understanding/Comprehension REF: 2 KEY:The Joint Commission (TJC)| accreditationMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control11. A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in qualityimprovement (QI) projects. What response by the precepting nurse is best?a. All staff nurses are required to participate in quality improvement here.b. Even being new, you can implement activities designed to improve care.c. Its easy to identify what indicators should be used to measure quality.d. You should ask to be assigned to the research and quality committee.ANS: BThe preceptor should try to reassure the nurse that implementing QI measures is not out of line for a newlylicensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how thatis possible and is dismissive. Identifying indicators of quality is not an easy, quick process and would notbe thebest place to suggest a new nurse to start. Asking to be assigned to the QI committee does not give the nurseinformation about how to implement QI in daily practice.DIF: Applying/Application REF: 6KEY: Quality improvementMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of CareMULTIPLE RESPONSE1. A nurse is interested in making interdisciplinary work a high priority. Which actions by the nurse bestdemonstrate this skill? (Select all that apply.)a. Consults with other disciplines on client careb. Coordinates discharge planning for home safetyc. Participates in comprehensive client roundingd. Routinely asks other disciplines about client progresse. Shows the nursing care plans to other disciplinesANS: A, B, C, DCollaborating with the interdisciplinary team involves planning, implementing, and evaluating client care as a teamwith all other disciplines included. Simply showing other caregivers the nursing care plan is not activelyinvolvingthem or collaborating with them.DIF: Applying/Application REF: 4KEY: Collaboration| interdisciplinary teamMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care2.A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels ofcompetency. Which areas should the manager assess to determine if the nursing staff demonstrate competencyaccording to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality?(Select all that apply.)

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a. Collaborating with an interdisciplinary teamb. Implementing evidence-based carec. Providing family-focused cared. Routinely using informatics in practicee. Using quality improvement in client careANS: A, B, D, EThe IOM report lists five broad core competencies that all health care providers should practice. These includecollaborating with the interdisciplinary team, implementing evidence-based practice, providing client-focusedcare,using informatics in client care, and using quality improvement in client care.DIF: Remembering/Knowledge REF: 3KEY: Competencies| Institute of Medicine (IOM) MSC:Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control3. The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (Select allthat apply.)a. Cost-saving measuresb. Nurses expertisec. Client preferencesd. Research findingse.Values of the clientANS: B, C, D, EEBP consists of utilizing current evidence, the clients values and preferences, and the nurses expertise whenplanning care. It does not include cost-saving measures.DIF: Remembering/Knowledge REF: 6KEY: Evidence-based practice (EBP)MSC: Integrated Process: Nursing Process: PlanningNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care4. A nurse manager wants to improve hand-off communication among the staff. What actions by the managerwould best help achieve this goal? (Select all that apply.)a. Attend hand-off rounds to coach and mentor.b. Conduct audits of staff using a new template.c. Create a template of topics to include in report.d. Encourage staff to ask questions during hand-off.e. Give raises based on compliance with reporting.ANS: A, B, C, DA good tool for standardizing hand-off reports and other critical communication is the SHARE model. SHAREstands for standardize critical information, hardwire within your system, allow opportunities to ask questions,reinforce quality and measurement, and educate and coach. Attending hand-off report gives the manageropportunities to educate and coach. Conducting audits is part of reinforcing quality. Creating a template ishardwiring within the system. Encouraging staff to ask questions and think critically about the information isallowing opportunities to ask questions. The manager may need to tie raises into compliance if the staff isresistive and other measures have failed, but this is not part of the SHARE model.DIF: Applying/Application REF: 5 KEY:SHARE| hand-off communicationMSC: Integrated Process: Nursing Process: InterventionNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

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Chapter 02: Overview of Health Concepts for Medical-Surgical NursingMULTIPLE CHOICE1. Acid-base balance occurs when the pH level of the blood is between:a. 7.3 and 7.5b. 7.35 and 7.45c. 7.4 and 7.5d. 7.25 and 7.35ANS: BAcid-base balance is the maintenance of arterial blood pH between 7.35 and 7.45 through hydrogen ionproductionand elimination.DIF: Understanding/Comprehension REF: 13KEY: AssessmentMSC: Physiological Adaptation | Fluid and Electrolyte Imbalances NOT:Describe common fluid, electrolyte, and acid-base imbalances.2. The nurse would expect a patient with respiratory acidosis to have an excessive amount ofa. Hydrogen ions.b.Bicarbonate.c.Oxygen.d.Phosphate.ANS: ARespiratory acidosis occurs when the arterial blood pH level falls below 7.35 and is caused by either too manyhydrogen ions in the body (respiratory acidosis) or too little bicarbonate (metabolic acidosis). Excessive oxygenand phosphate are not characteristic of respiratory acidosis.DIF: Understanding/Comprehension REF: 13KEY: AssessmentMSC: Physiological Adaptation | Fluid and Electrolyte Imbalances NOT:Describe common fluid, electrolyte, and acid-base imbalances.3. The best way for an individual to maintain acid-base balance is toa. avoid or quit smoking.b. exercise regularly.c. eat healthy and well-balanced meals.d.All of the above.ANS: DMaintaining a healthy lifestyle is the best way to maintain acid-base balance. For example, most cases of COPDcan be prevented by avoiding or quitting smoking, while regular exercise and a healthy diet candecrease theincidence of type-2 diabetes.DIF: Patient education REF: 14KEY:AssessmentMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance4. The process to control cellular growth, replication, and differentiation to maintain homeostasis is called:a. cellular regulation.b. cellular impairment.c. cellular reproduction.d. cellular tumor.ANS: ACellular Regulation is the term used to describe both the positive and negative aspects of cellular function

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within the body.DIF: Understanding/Comprehension REF: 14KEY: AssessmentMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance5. A defining characteristic of malignant (cancerous) cells is:a. they cannot spread to other tissues or organs.b. they can invade healthy cells, tissues, and organs.c.they are not usually a health risk.d.none of the above.ANS: BMalignant (cancerous) cells have no comparison to the original cells from which they are derived, and theyhavethe ability to invade healthy cells, tissues, and other organs through tumor formation and invasion. On theotherhand, Benign cells do not have the ability to spread to other tissues or organs.DIF: Understanding/Comprehension REF: 14KEY: AssessmentMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance6. Specialized cells that circulate in the body to promote clotting are called:a.anticoagulants.b.proteins.c.emboli.d.platelets.ANS: DClotting is a complex, multi-step process through which blood forms a protein-based clot to prevent excessivebleeding. Platelets (thrombocytes) are the specialized cells that circulate in the blood and are activated when aninjury occurs. Once activated, these cells become sticky, causing them to clump together to form a temporary,localized, solid plug.DIF: Understanding/Comprehension REF: 15KEY: AssessmentMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance7. An increase in platelet stickiness can lead to:a.hypercoagulabilityb.thromobocytopeniac.embolusd. atrial fibrillationANS: AHypercoagulability refers to an increase in clotting ability caused by an excess of platelets or excessive platelystickiness, which can impair blood flow. The opposite end of the spectrum involves an inability to formadequateclots, which often occurs when there is an inadequate number of circulating platelets or a reduction inplateletstickiness.DIF: Understanding/Comprehension REF: 15KEY: AssessmentMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance8.Signs and symptoms ofthromobsis include localized redness, swelling, and warmth:a.arterial

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b.venousc.partiald.atrialANS: BVenous thrombosis is a clot formation in either superficial or deep veins, usually in the leg, and can beobservedlocally.DIF: Understanding/Comprehension REF: 16KEY: AssessmentMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance9. A serious condition which is not locally observable and is typically manifested by decreased blood flow to adistal extremity is known asthrombosis.a.arterialb.venousc.partiald.atrialANS: AArterial thrombosis is manifested by decreased blood flow (perfusion) to a distal extremity or internal organ.Forexample, the distal leg can become pale and cool in the case of a femoral arterial clot due to blockage of bloodto the leg. This is an emergent condition and requires immediate intervention.DIF: Understanding/Comprehension REF: 16KEY: AssessmentMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance10. A high-level thinking process that allows an individual to make decisions and judgments is known as:a.amnesiab.personalityc.reasoningd.memoryANS: CReasoning is the high-level cognitive thinking process that helps individuals make decisions and judgments.Personality is the way an individual feels and behaves, while Memory is the ability of an individual to retain andrecall information. Amnesia refers to a loss of memory caused by brain trauma, congenital disorders, oracutehealth problems.DIF: Understanding/Comprehension REF: 16KEY: AssessmentMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Psychosocial Integrity11. A form of inadequate cognition in older adults which is manifested by an acute, fluctuating confusionalstate is known as:a.dementiab.deleriumc.amnesiad.depressionANS: BDelerium is the form of acute, fluctuating confusion which lasts from a few hours to less than 1 month and that maybe treatable. Dementia is a chronic state of confusion that may last from a few months to many years and that maynot be reversible. Amnesia refers to a loss of memory caused by brain trauma, congenital disorders,or acute healthproblems.

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DIF: Understanding/Comprehension REF: 16KEY: AssessmentMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Psychosocial Integrity12. The most common causes of decreased comfort for a patient are pain and.a.light-headednessb.nauseac. emotional stressd.depressionANS: CPain and emotional stress are the two leading causes of discomfort for a patient. For example, patients who arehaving surgery are often anxious and feel stressed about the procedure. This emotional stress may negativelyimpactthe outcome of surgery.DIF: Understanding/Comprehension REF: 17KEY: AssessmentMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Safe and Effective Care Environment13.The inability to pass stool is known as.a.constipationb.obstipationc.diarrhead.incontinenceANS: BObstipation is the inability to pass stool during bowel elimination. Constipation refers to the condition wherestoolcan be hard, dry, and difficult to pass through the rectum. Diarrhea is at the opposite end of the continuum fromconstipation, and occurs when stool is watery and without solid form. Elimination is thegeneral term to describethe excretion of waste from the body by the gastrointestinal tract and by the urinarysystem.DIF: Understanding/Comprehension REF: 18KEY: AssessmentMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance14. Hypokalemia can occur in patients with prolonged diarrhea and is caused by a decrease in:a.calciumb.magnesiumc.sodiumd.potassiumANS: DHypokalemia occurs when there is a decrease in serum potassium. It can be a life-threatening condition because itoften causes rhythm abnormalities. An excess of potassium is referred to as Hyperkalemia.DIF: Understanding/Comprehension REF: 18KEY: AssessmentMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance15. The minimum hourly urinary output in a patient should be at least:a.5 mL per hourb. 10 mL per hourc. 30 mL per hourd. 60 mL per hour

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ANS: C30 mL per hour is the minimum hourly urinary output in a normal healthy adult. A decrease in urinary output iasign of diminished kidney activity and fluid deficit.DIF: Understanding/Comprehension REF: 20KEY: AssessmentMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance16. The best indicator of fluid volume changes in the body is:a. skin drynessb. weight changesc. blood pressured.pulse rateANS: CChanges in weight are the best indicator of fluid volume changes in the body. Monitoring blood pressure,checking pulse rate and quality, and assessing skin and mucous membranes for dryness are strong secondaryindicators.DIF: Understanding/Comprehension REF: 20KEY: AssessmentMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance17. Immunity which occurs when antibodies are passed from the mother to the fetus through the placenta orthrough breast milk is called:a. natural passiveb. artifical passivec. natural actived. artifical activeANS: AArtifical passive immunity occurs via a specific transfusion. Natural active immunity occurs when an antigen entersthe body and the body creates antibodies to fight off the antigen. Artifical active immunity occurs viavaccination orimmunization.DIF: Understanding/Comprehension REF: 21-22KEY: AssessmentMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance18. A major serum protein that is below normal in patients who have inadequate nutrition is:a.Albuminb.Globulinc.Fibrinogend.TransferrinANS: AA serum laboratory test to measure Albumin is the most common assessment for generalized malnutrition.DIF: Understanding/Comprehension REF: 25KEY: AssessmentMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance

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Chapter 03: Common Health Problems of Older AdultsMULTIPLE CHOICE1. A nurse working with older adults in the community plans programming to improve morale and emotionalhealth in this population. What activity would best meet this goal?a. Exercise program to improve physical functionb. Financial planning seminar series for older adultsc. Social events such as dances and group dinnersd. Workshop on prevention from becoming an abuse victimANS: AAll activities would be beneficial for the older population in the community. However, failure in performingonesown activities of daily living and participating in society has direct effects on morale and life satisfaction.Thosewho lose the ability to function independently often feel worthless and empty. An exercise program designed tomaintain and/or improve physical functioning would best address this need.DIF: Applying/Application REF: 32KEY: Independence| autonomy| older adultMSC: Integrated Process: Nursing Process: PlanningNOT: Client Needs Category: Psychosocial Integrity2. A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipationand only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurseperform first?a. Auscultate bowel sounds.b. Check skin turgor.c. Perform an oral assessment.d. Weigh the client.ANS: CPoorly fitting dentures and other dental problems are often manifested by a preference for soft foods andconstipation from the lack of fiber. The nurse should perform an oral assessment to determine if theseproblemsexist. The other assessments are important, but will not yield information specific to the clients foodpreferences asthey relate to constipation.DIF: Applying/Application REF: 30KEY:Nutrition| dentures| older adultMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort3. A nursing faculty member working with students explains that the fastest growing subset of the olderpopulation 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 comprising those 85 to 99years of age. The young old are between 65 and 74 years of age; the middle old are between 75 and 84 years ofage; and the elite old are over 100 years of age.DIF: Remembering/Knowledge REF: 29KEY: Adulthood| aging| old old MSC: Integrated Process: Teaching/LearningNOT:Client Needs Category: Health Promotion and Maintenance4. A nurse is working with an older client admitted with mild dehydration. What teaching does the nurseprovide to best address this issue?

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a.Cut some sodium out of your diet.b. Dehydration can cause incontinence.c. Have something to drink every 1 to 2 hours.d. Take your diuretic in the morning.ANS: COlder adults often lose their sense of thirst. Since they should drink 1 to 2 liters of water a day, the best remedyis tohave the older adult drink something each hour or two, whether or not he or she is thirsty. Cutting some sodiumfrom the diet will not address this issue. Although dehydration can cause incontinence from theirritation ofconcentrated urine, this information will not help prevent the problem of dehydration. Instructingthe client to take adiuretic in the morning rather than in the evening also will not directly address this issue.DIF: Applying/Application REF: 31KEY: Dehydration| older adult| hydration MSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Physiological Integrity: Physiological Adaptation5. A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by theclient demonstrates a need for further review?a. Barley soupb. Black beansc.White riced. Whole wheat breadANS: COlder adults need 25 to 50 grams of fiber a day. White rice is low in fiber. Foods high in fiber include barley,beans,and whole wheat products.DIF: Applying/Application REF: 31 KEY:Nutrition| fiber| older adultMSC: Integrated Process: Nursing Process: EvaluationNOT: Client Needs Category: Physiological Integrity: Physiological Adaptation6.A home health care nurse is planning an exercise program with an older client who lives at homeindependently but whose mobility issues prevent much activity outside the home. Which exercise regimenwould be most beneficial to this adult?a. Building strength and flexibilityb. Improving exercise endurancec. Increasing aerobic capacityd. Providing personal trainingANS: AThis older adult is mostly homebound. Exercise regimens for homebound clients include things to increasefunctional ability for activities of daily living. Strength and flexibility will help the client to be able to maintainindependence longer. The other plans are good but will not specifically maintain the clients functional abilities.DIF: Applying/Application REF: 32KEY: Exercise| functional ability| older adultMSC: Integrated Process: Nursing Process: PlanningNOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential7. An older adult recently retired and reports being depressed and lonely. What information should the nurseassess as a priority?a. History of previous depressionb. Previous stressful eventsc. Role of work in the adults lifed. Usual leisure time activitiesANS: COften older adults lose support systems when their roles change. For instance, when people retire, they may

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lose their entire social network, leading them to feeling depressed and lonely. The nurse should first assess therolethat work played in the clients life. The other factors can be assessed as well, but this circumstance is commonlyseen in the older population.DIF: Applying/Application REF: 32 KEY:Depression| older adultMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Psychosocial Integrity8. A nurse is assessing coping in older women in a support group for recent widows. Which statement by aparticipant best indicates potential for successful coping?a.I have had the same best friend for decades.b.I think I am coping very well on my own.c. My kids come to see me every weekend.d.Oh, I have lots of friends at the senior center.ANS: AFriendship and support enhance coping. The quality of the relationship is what is most important, however.People who have close, intimate, stable relationships with others in whom they confide are more likely to copewithcrisis.DIF: Remembering/Knowledge REF: 32 KEY:Coping| relationships| older adultMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Psychosocial Integrity9. A home health care nurse has conducted a home safety assessment for an older adult. There are five concretesteps leading out from the front door. Which intervention would be most helpful in keeping the older adultsafe on the steps?a.Have the client use a walker or cane on the steps.b. Install contrasting color strips at the edge of each step.c. Instruct the client to use the garage door instead.d.Tell the client to use a two-footed gait on the steps.ANS: BAs a person ages, he or she may experience a decreased sense of touch. The older adult may not be aware ofwhere his or her foot is on the step. Installing contrasting color strips at the end of each step will help increaseawareness. If the client does not need an assistive device, he or she should not use one just on stairs. Using analternative door may be necessary but does not address making the front steps safer. A two-footed gait may nothelpif the client is unaware of where the foot is on the step.DIF: Applying/Application REF: 33 KEY:Safety| falls| older adultMSC: Integrated Process: Nursing Process: ImplementationNOT: 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 theclient is stabilized and comfortable, what assessment by the nurse is most important?a. Assess for orthostatic hypotension.b. Determine if there are new medications.c. Evaluate the client for gait abnormalities.d. Perform a delirium screening test.ANS: BMedication side effects and adverse effects are common in the older population. Something as simple as a newantibiotic can cause confusion and memory loss. The nurse should determine if the client is taking any newmedications. Assessments for orthostatic hypotension, gait abnormalities, and delirium may be important oncemoreis known about the clients condition.

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DIF: Applying/Application REF: 33KEY: Medications| medication safety| older adult MSC:Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies11.An older adult client takes medication three times a day and becomes confused about which medicationshould be taken at which time. The client refuses to use a pill sorter with slots for different times, saying Thoseare for old people. What action by the nurse would be most helpful?a. Arrange medications by time in a drawer.b. Encourage the client to use easy-open tops.c. Put color-coded stickers on the bottle caps.d. Write a list of when to take each medication.ANS: CColor-coded stickers are a fast, easy-to-remember system. One color is for morning meds, one for eveningmeds,and the third color is for nighttime meds. Arranging medications by time in a drawer might be helpful if the persondoesnt 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 reminderis always with themedication.DIF: Applying/Application REF: 34KEY: Medications| medication safety| older adultMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control12. An older adult client is in the hospital. The client is ambulatory and independent. What intervention by thenurse would be most helpful in preventing falls in this client?a.Keep the light on in the bathroom at night.b. Order a bedside commode for the client.c. Put the client on a toileting schedule.d. Use siderails to keep the client in bed.ANS: AAlthough this older adult is independent and ambulatory, being hospitalized can create confusion. Getting up inadark, unfamiliar environment can contribute to falls. Keeping the light on in the bathroom will help reducethelikelihood of falling. The client does not need a commode or a toileting schedule. Siderails used to keep theclient inbed are considered restraints and should not be used in that fashion.DIF: Applying/Application REF: 41 KEY:Falls| safety| older adultMSC: Integrated Process: Nursing Process: ImplementationNOT: 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 for pain.Theclient is allergic to morphine and reports pain and muscle spasms. When the nurse calls the surgeon,whichmedication should he or she suggest in place of the morphine?a. Cyclobenzaprine (Flexeril)b. Hydromorphone hydrochloride (Dilaudid)c. Ketorolac (Toradol)d. Meperidine (Demerol)ANS: BCyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) are all on the Beerslistof potentially inappropriate medications for use in older adults and should not be suggested. The nurse shouldsuggest hydromorphone hydrochloride.DIF: Remembering/Knowledge REF: 36 KEY:Medications| Beers list| older adultMSC: Integrated Process: Communication and Documentation

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NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies14. A nurse admits an older client from a home environment where she lives with her adult son and daughter-in-law. The client has urine burns on her skin, no dentures, and several pressure ulcers. What action by thenurse is most appropriate?a. Ask the family how these problems occurred.b. Call the police department and file a report.c. Notify Adult Protective Services.d. Report the findings as per agency policy.ANS: DThese findings are suspicious for abuse. Health care providers are mandatory reporters for suspected abuse.Thenurse should notify social work, case management, or whomever is designated in policies. That person can thenassess the situation further. If the police need to be notified, that is the person who will notify them. AdultProtectiveServices is notified in the community setting.DIF: Applying/Application REF: 39 KEY:Abuse| older adultMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care15. A nurse caring for an older client in the hospital is concerned the client is not competent to give consent forupcoming surgery. What action by the nurse is best?a. Call Adult Protective Services.b. Discuss concerns with the health care team.c.Do not allow the client to sign the consent.d. Have the clients family sign the consent.ANS: BIn this situation, each facility will have a policy designed for assessing competence. The nurse should bringtheseconcerns to an interdisciplinary care team meeting. There may be physiologic reasons for the client to betemporarily too confused or incompetent to give consent. If an acute condition is ruled out, the staff shouldfollow the legal procedure and policies in their facility and state for determining competence. The key is to bringthe concerns forward. Calling Adult Protective Services is not appropriate at this time. Signing the consentshould wait until competence is determined unless it is an emergency, in which case the next of kin can sign ifthere are grave doubts as to the clients ability to provide consent.DIF: Applying/Application REF: 36 KEY:Competence| autonomy| older adultMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of CareMULTIPLE RESPONSE1. A nursing student working in an Adult Care for Elders unit learns that frailty in the older population includeswhich components? (Select all that apply.)a.Dementiab.Exhaustionc. Slowed physical activityd.Weaknesse.Weight gainANS: B, C, DFrailty is a syndrome consisting of unintentional weight loss, slowed physical activity and exhaustion, andweakness. Weight gain and dementia are not part of this cluster of manifestations.DIF: Remembering/Knowledge REF: 29 KEY:Frailty| frail elderly| older adultMSC: Integrated Process: Nursing Process: Assessment

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NOT: Client Needs Category: Health Promotion and Maintenance2. A home health care nurse assesses an older client for the intake of nutrients needed in larger amounts than inyounger adults. Which foods found in an older adults kitchen might indicate an adequate intake of thesenutrients? (Select all that apply.)a.1% milkb.Carrotsc. Lean ground beefd.Orangese. Vitamin D supplementsANS: A, B, D, EOlder adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk has calcium; carrots havevitamin A; the vitamin D supplement has vitamin D; and oranges have vitamin C. Lean ground beef ishealthierthan more fatty cuts, but does not contain these needed nutrients.DIF: Applying/Application REF: 30KEY: Nutrition| nutritional requirements| older adults MSC:Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort3. A nurse working with older adults assesses them for common potential adverse medication effects. For whatdoes the nurse assess? (Select all that apply.)a.Constipationb.Dehydrationc.Maniad. Urinary incontinencee.WeaknessANS: A, B, ECommon adverse medication effects include constipation/impaction, dehydration, and weakness. Mania andincontinence are not among the common adverse effects, although urinary retention is.DIF: Remembering/Knowledge REF: 34 KEY:Medications| adverse effectsMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies4. A nurse manager institutes the Fulmer Spices Framework as part of the routine assessment of older adults inthe hospital. The nursing staff assesses for which factors? (Select all that apply.)a.Confusionb. Evidence of abusec.Incontinenced. Problems with behaviore. Sleep disordersANS: A, C, ESPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion, and evidence offalls.DIF: Remembering/Knowledge REF: 40 KEY:SPICES| older adultMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential5. A visiting nurse is in the home of an older adult and notes a 7-pound weight loss since last months visit.What actions should the nurse perform first? (Select all that apply.)a. Assess the clients ability to drive or transportation alternatives.b. Determine if the client has dentures that fit appropriately.

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c. Encourage the client to continue the current exercise plan.d. Have the client complete a 3-day diet recall diary.e. Teach the client about proper nutrition in the older population.ANS: A, B, DAssessment is the first step of the nursing process and should be completed prior to intervening. Asking abouttransportation, dentures, and normal food patterns would be part of an appropriate assessment for the client.There is no information in the question about the older adult needing to lose weight, so encouraging him or hertocontinue the current exercise regimen is premature and may not be appropriate. Teaching about proper nutritionis a good idea, but teaching needs to be tailored to the clients needs, which the nurse does not yet know.DIF: Applying/Application REF: 30 KEY:Nutrition| older adultMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Physiological Adaptation6. A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does theregistered nurse (RN) delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)a. Assess skin redness when turning.b. Document Braden Scale results.c. Keep the clients skin dry.d. Obtain a pressure-relieving mattress.e. Turn the client every 2 hours.ANS: C, D, EThe nurses aide or UAP can assist in keeping the clients skin dry, order a special mattress on direction of the RN,and turn the client on a schedule. Assessing the skin is a nursing responsibility, although the aide should bedirected to report any redness noticed. Documenting the Braden Scale results is the RNs responsibility asthe RN isthe one who performs that assessment.DIF: Applying/Application REF: 42KEY: Skin breakdown| older adult| delegation| unlicensed assistive personnelMSC:Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care7. A nurse admits an older client to the hospital who lives at home with family. The nurse assesses that theclient is malnourished. What actions by the nurse are best? (Select all that apply.)a. Contact Adult Protective Services or hospital social work.b. Notify the provider that the client needs a tube feeding.c. Perform and document results of a Braden Scale assessment.d. Request a dietary consultation from the health care provider.e. Suggest a high-protein oral supplement between meals.ANS: C, D, EMalnutrition in the older population is multifactorial and has several potential adverse outcomes. Appropriate actionsby the nurse include assessing the clients risk for skin breakdown with the Braden Scale, requesting aconsultationwith a dietitian, and suggesting a high-protein meal supplement. There is no evidence that the client is beingabused or needs a feeding tube at this time.DIF: Applying/Application REF: 40KEY: Nutrition| malnutrition| older adult| Braden Scale MSC:Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

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Chapter 04: Assessment and Care of Patients with PainMULTIPLE CHOICE1. A student asks the nurse what is the best way to assess a clients pain. Which response by the nurse is best?a. Numeric pain scaleb. Behavioral assessmentc. Objective observationd. Clients self-reportANS: DMany ways to measure pain are in use, including numeric pain scales, behavioral assessments, and otherobjective observations. However, the most accurate way to assess pain is to get a self-report from the client.DIF: Remembering/Knowledge REF: 46 KEY:Pain| pain assessmentMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Health Promotion and Maintenance2.A new nurse reports to the precepting nurse that a client requested pain medication, and when the nursebrought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe painthe client described. What response by the experienced nurse is best?a. Being able to sleep doesnt mean pain doesnt exist.b. Have you ever experienced any type of pain?c. The client should be assessed for drug addiction.d. Youre right; I would put the medication back.ANS: AA clients description is the most accurate assessment of pain. The nurse should believe the client and providepainrelief. Physiologic changes due to pain vary from client to client, and assessments of them should notsupersedethe clients descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain isjudgmental and flippant, and does not provide useful information. This amount of information does not warrant anassessment for drug addiction. Putting the medication back and ignoring the clients report of painserves no usefulpurpose.DIF: Understanding/Comprehension REF: 49KEY: Pain| pain assessmentMSC: Integrated Process: Communication and DocumentationNOT:Client Needs Category: Health Promotion and Maintenance3. The nurse in the surgery clinic is discussing an upcoming surgical procedure with a client. What informationprovided by the nurse is most appropriate for the clients long-term outcome?a. At least you know that the pain after surgery will diminish quickly.b. Discuss acceptable pain control after your operation with the surgeon.c. Opioids often cause nausea but you wont have to take them for long.d. The nursing staff will give you pain medication when you ask them for it.ANS: BThe best outcome after a surgical procedure is timely and satisfactory pain control, which diminishes thelikelihood of chronic pain afterward. The nurse suggests that the client advocate for himself and discussacceptable pain control with the surgeon. Stating that pain after surgery is usually short lived does not providetheclient with options to have personalized pain control. To prevent or reduce nausea and other side effects fromopioids, a multimodal pain approach is desired. For acute pain after surgery, giving pain medications around theclock instead of waiting until the client requests it is a better approach.DIF: Applying/Application REF: 47 KEY:Pain| acute painMSC: Integrated Process: Teaching/Learning

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NOT: Client Needs Category: Health Promotion and Maintenance4. A nurse is assessing pain on a confused older client who has difficulty with verbal expression. What painassessment 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 Pain Scale-Revised ispreferredby both cognitively intact and cognitively impaired adults.DIF: Applying/Application REF: 51 KEY:Pain assessment| FACESMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Health Promotion and Maintenance5. The nurse is assessing a clients pain and has elicited information on the location, quality, intensity, effect onfunctioning, aggravating and relieving factors, and onset and duration. What question by the nurse would bebest to ask the client for completing a comprehensive pain assessment?a. Are you worried about addiction to pain pills?b. Do you attach any spiritual meaning to pain?c. How high would you say your pain tolerance is?d. What pain rating would be acceptable to you?ANS: DA comprehensive pain assessment includes the items listed in the question plus the clients opinion on afunctional goal, such as what pain rating would be acceptable to him or her. Asking about addiction is notwarranted in an initial pain assessment. Asking about spiritual meanings for pain may give the nurse importantinformation, but getting the basics first is more important. Asking about pain tolerance may give the client theideathat pain tolerance is being judged.DIF: Applying/Application REF: 50 KEY:Pain assessmentMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential6. A nurse is assessing pain in an older adult. What action by the nurse is best?a. Ask only yes-or-no questions so the client doesnt get too tired.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 or because they do notwantto be a bother. Sitting down conveys time, interest, and availability. Ask only one question at a time andallow theclient enough time to answer it. Yes-or-no questions are an example of poor communicationtechnique. Giving theclient a pain scale, then leaving, might give the impression that the nurse does not havetime for the client. Plus theclient may not know how to use it. There is no normal pain from aging.DIF: Applying/Application REF: 53 KEY:Pain assessment| older adultMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Psychosocial Integrity7. The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tinychanges in physical condition and is on the light constantly asking for more pain medication. When assessingthis clients pain, what statement or question by the nurse is most appropriate?

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a. Help me understand how pain is affecting you right now.b.I wish I could do more; is there anything I can get for you?c. You cannot have more pain medication for 3 hours.d. Why do you think the medication is not helping your pain?ANS: AThis is an example of therapeutic communication. A client who is preoccupied with physical symptoms and isdemanding may have some psychosocial impact from the pain that is not being addressed. The nurse isprovidingthe client the chance to explain the emotional effects of pain in addition to the physical ones. Saying the nursewishes he or she could do more is very empathetic, but this response does not attempt to learn moreabout the pain.Simply telling the client when the next medication is due also does not help the nurse understand the clientssituation. Why questions are probing and often make clients defensive, plus the client may not have an answerfor this question.DIF: Applying/Application REF: 54 KEY:Pain| pain assessmentMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Psychosocial Integrity8. A nurse on the medical-surgical unit has received a hand-off report. Which client should the nurse see first?a. Client being discharged later on a complicated analgesia regimenb. Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scalec. Postoperative client who received oral opioid analgesia 45 minutes agod. Client who has returned from physical therapy and is resting in the reclinerANS: BAcute pain often serves as a physiologic warning signal that something is wrong. The client with new-onsetabdominal pain needs to be seen first. The postoperative client needs 45 minutes to an hour for the oralmedication to become effective and should be seen shortly to assess for effectiveness. The client going homerequires teaching, which should be done after the first two clients have been seen and cared for, as thisteachingwill take some time. The client resting comfortably can be checked on quickly before spending timeteaching theclient who is going home.DIF: Analyzing/Analysis REF: 46KEY: Acute pain| pain assessmentMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care9. A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanceddementia. The client scores a zero. What action by the nurse is best?a. Assess physiologic indicators and vital signs.b. Do not give pain medication as no pain is indicated.c. Document the findings and continue to monitor.d. Try a small dose of analgesic medication for pain.ANS: AAssessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for thispopulation. The nurse should next look at physiologic indicators of pain and vital signs for clues to the presenceof pain. Even a low score on this index does not mean the client does not have pain; he or she may be holdingvery still to prevent more pain. Documenting pain is important but not the most important action inthis case. Thenurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult to assess foreffectiveness. However, if the client has a condition that could reasonably cause pain (i.e., recentsurgery), the nursedoes need to treat the client for pain.DIF: Applying/Application REF: 55KEY: Pain assessment| Checklist of Nonverbal Pain IndicatorsMSC:Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

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10. A student nurse asks why several clients are getting more than one type of pain medication instead of veryhigh doses of one medication. What response by the registered nurse is best?a. A multimodal approach is the preferred method of control.b. Doctors are much more liberal with pain medications now.c. Pain is so complex it takes different approaches to control it.d. Clients are consumers and they demand lots of pain medicine.ANS: CPain is a complex phenomenon and often responds best to a regimen that uses different types of analgesia. Thisiscalled a multimodal approach. Using this terminology, however, may not be clear to the student if theterminology is not understood. Doctors may be more liberal with pain medications, but that is not the bestreasonfor this approach. Saying that clients are consumers who demand medications sounds as if the nurse isdiscountingtheir pain experiences.DIF: Understanding/Comprehension REF: 55KEY: Pain| pharmacologic pain management| multimodal pain management MSC:Integrated Process: Teaching/LearningNOT: Client Needs Category: Physiological Adaptation: Pharmacological and Parenteral Therapies11. A client who had surgery has extreme postoperative pain that is worsened when trying to participate inphysical therapy. What intervention for pain management does the nurse include in the clients care plan?a. As-needed pain medication after therapyb. Client-controlled analgesia with a basal ratec. Pain medications prior to therapy onlyd. Round-the-clock analgesia with PRN analgesicsANS: DSevere pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough painassociated with specific procedures is managed with additional medication. An as-needed regimen willnot controlpostoperative pain. A client-controlled analgesia pump might be a good idea but needs basal(continuous) andbolus (intermittent) settings to accomplish adequate pain control. Pain control needs to becontinuous, not justadministered prior to therapy.DIF: Applying/Application REF: 55KEY: Pharmacologic pain management| painMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies12. A nurse on the postoperative inpatient unit receives a hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client should the nurse see first?a. Client who appears to be sleeping soundlyb. Client with no bolus request in 6 hoursc. Client who is pressing the button every 10 minutesd. Client with a respiratory rate of 8 breaths/minANS: DContinuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratoryrateof 8 breaths/min is below normal, so the nurse should first check this client. The client sleeping soundly couldeither be overly sedated or just comfortable and should be checked next. Pressing the button every 10minutesindicates the client has a high level of pain, but the device has a lockout determining how often a boluscan bedelivered. Therefore, the client cannot overdose. The nurse should next assess that clients pain. The client whohas not needed a bolus of pain medicine in several hours has well-controlled pain.DIF: Applying/Application REF: 56KEY: Patient-controlled analgesia (PCA) pump| pharmacologic pain management MSC:Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care13. A registered nurse (RN) and nursing student are caring for a client who is receiving pain medication via

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patient-controlled analgesia (PCA). What action by the student requires the RN to intervene?a. Assesses the clients pain level per agency policyb. Monitors the clients respiratory rate and sedationc. Presses the button when the client cannot reach itd. Reinforces client teaching about using the PCA pumpANS: CThe client is the only person who should press the PCA button. If the client cannot reach it, the student shouldeither reposition the client or the button, and should not press the button for the client. The RN should interveneat this point. The other actions are appropriate.DIF: Applying/Application REF: 56KEY: Patient-controlled analgesia (PCA)| pharmacologic pain management MSC:Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control14. A client is put on twice-daily acetaminophen (Tylenol) for osteoarthritis. What finding in the clients healthhistory would lead the nurse to consult with the provider over the choice of medication?a. 25pack-year smoking historyb.Drinking 3 to 5 beers a dayc. Previous peptic ulcerd. Taking warfarin (Coumadin)ANS: BThe major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each daymay indicate underlying liver disease, which should be investigated prior to taking chronic acetaminophen. Thenurse should relay this information to the provider. Smoking is not related to acetaminophen side effects.Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.DIF: Applying/Application REF: 56KEY: Acetaminophen| pharmacologic pain management MSC:Integrated Process: Communication and DocumentationNOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies15. A nurse is preparing to give a client ketorolac (Toradol) intravenously for pain. Which assessment findingswould lead the nurse to consult with the provider?a. Bilateral lung cracklesb. Hypoactive bowel soundsc. Self-reported pain of 3/10d.Urine output of 20 mL/2 hrANS: DDrugs in this category can affect renal function. Clients should be adequately hydrated and demonstrate goodrenalfunction prior to administering ketorolac. A urine output of 20 mL/2 hr is well below normal, and thenurseshould consult with the provider about the choice of drug. Crackles and hypoactive bowel sounds are not related. Apain report of 3 does not warrant a call to the physician. The medication may be part of a round-the- clock regimento prevent and control pain and would still need to be given. If the medication is PRN, the nursecan ask the clientif he or she still wants it.DIF: Applying/Application REF: 58KEY: Pharmacologic pain management| opioid analgesics| prostaglandins MSC:Integrated Process: Communication and DocumentationNOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies16. A hospitalized client uses a transdermal fentanyl (Duragesic) patch for chronic pain. What action by thenurse is most important for client safety?a. Assess and record the clients pain every 4 hours.b. Ensure the client is eating a high-fiber diet.c. Monitor the clients bowel function every shift.

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d. Remove the old patch when applying the new one.ANS: DThe old fentanyl patch should be removed when applying a new patch so that accidental overdose does notoccur.The other actions are appropriate, but not as important for safety.DIF: Applying/Application REF: 59KEY: Pharmacologic pain management| opioid analgesics| transdermal patch MSC:Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies17. A hospitalized client has a history of depression for which sertraline (Zoloft) is prescribed. The client alsohas a morphine allergy and a history of alcoholism. After surgery, several opioid analgesics are prescribed.Which one would the nurse choose?a. Hydrocodone and acetaminophen (Lorcet)b. Hydromorphone (Dilaudid)c. Meperidine (Demerol)d. Tramadol (Ultram)ANS: BHydromorphone is a good alternative to morphine for moderate to severe pain. The nurse should not chooseLorcet because it contains acetaminophen (Tylenol) and the client has a history of alcoholism. Tramadolshouldnot be used due to the potential for interactions with the clients sertraline. Meperidine is rarely used andis oftenrestricted.DIF: Analyzing/Analysis REF: 61KEY: Pharmacologic pain management| opioid analgesics MSC:Integrated Process: Nursing Process: AnalysisNOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies18.A client has received an opioid analgesic for pain. The nurse assesses that the client has a PaseroScalescore of 3 and a respiratory rate of 7 shallow breaths/min. The clients oxygen saturation is 87%. Whatactionshould the nurse perform first?a. Apply oxygen at 4 L/min.b. Attempt to arouse the client.c. Give naloxone (Narcan).d. Notify the Rapid Response Team.ANS: BThe Pasero Opioid-Induced Sedation Scale is used to assess for unwanted opioid-associated sedation. A PaseroScalescore of 3 is unacceptable but is managed by trying to arouse the client in order to take deep breaths andstayingwith the client until he or she is more alert. Administering oxygen will not help if the clients respiratoryrate is 7breaths/min. Giving naloxone and calling for a Rapid Response Team would be appropriate for a higher PaseroScale score.DIF: Applying/Application REF: 65KEY: Pasero Opioid-Induced Sedation Scale| pharmacologic pain management| opioid analgesics MSC: IntegratedProcess: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care19. An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medicationwould the nurse plan to educate the client?a. Desipramine (Norpramin)b. Duloxetine (Cymbalta)c. Morphine sulfated. Nortriptyline (Pamelor)ANS: BAntidepressants and anticonvulsants often are used for neuropathic pain relief. Morphine would not be used for

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this client. However, older adults do not tolerate tricyclic antidepressants very well, which eliminatesdesipramineand nortriptyline. Duloxetine would be the best choice for this older client.DIF: Applying/Application REF: 66KEY: Neuropathic pain| pharmacologic pain management MSC:Integrated Process: Nursing Process: AnalysisNOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies20. An emergency department (ED) manager wishes to start offering clients nonpharmacologic pain controlmethodologies as an adjunct to medication. Which strategy would be most successful with this clientpopulation?a. Listening to music on a headsetb. Participating in biofeedbackc. Playing video gamesd. Using guided imageryANS: AListening to music on a headset would be the most successful cognitive-behavioral pain control method forseveral reasons. First, in the ED, the nurse does not have time to teach clients complex modalities such asguidedimagery or biofeedback. Second, clients who are anxious and in pain may not have good concentration, limiting theusefulness of video games. Playing music on a headset only requires the client to wear the headset and can bebeneficial without strong concentration. A wide selection of music will make this appealing to morepeople.DIF: Understanding/Comprehension REF: 68KEY: Distraction| nonpharmacologic pain management MSC:Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort21. An older client who lives alone is being discharged on opioid analgesics. What action by the nurse is mostimportant?a. Discuss the need for home health care.b. Give the client follow-up information.c. Provide written discharge instructions.d. Request a home safety assessment.ANS: DAll these activities are appropriate when discharging a client whose needs will continue after discharge. Ahomesafety assessment would be most important to ensure the safety of this older client.DIF: Remembering/Knowledge REF: 69KEY:Safety| older adult| opioid analgesicsMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control22. A nurse is caring for four clients receiving pain medication. After the hand-off report, which client shouldthe nurse see first?a. Client who is crying and agitatedb. Client with a heart rate of 104 beats/minc. Client with a Pasero Scale score of 4d.Client with a verbal pain report of 9ANS: CThe Pasero Opioid-Induced Sedation Scale has scores ranging from S to 1 to 4. A score of 4 indicatesunacceptable somnolence and is an emergency. The nurse should see this client first. The nurse can delegatevisiting with the crying client to a nursing assistant; the client may be upset and might benefit from talking or acomforting presence. The client whose pain score is 9 needs to be seen next, or the nurse can delegate thisassessment to another nurse while working with the priority client. A heart rate of 104 beats/min is slightly abovenormal, and that client can be seen after the other two clients are cared for.

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DIF: Applying/Application REF: 65KEY: Pasero Opioid-Induced Sedation Scale| pharmacologic pain management MSC:Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care23. A nurse is caring for a client on an epidural patient-controlled analgesia (PCA) pump. What action by thenurse is most important to ensure client safety?a. Assess and record vital signs every 2 hours.b. Have another nurse double-check the pump settings.c. Instruct the client to report any unrelieved pain.d. Monitor for numbness and tingling in the legs.ANS: BPCA-delivered analgesia creates a potential risk for the client. Pump settings should always be double- checked.Assessing vital signs should be done per agency policy and nurse discretion, and may or may not need to be thisfrequent. Unrelieved pain should be reported but is not vital to client safety. Monitoring fornumbness and tinglingin the legs is an important function but will manifest after something has occurred to theclient; monitoring does notprevent the event from occurring.DIF: Applying/Application REF: 56KEY: Patient-controlled analgesia (PCA)| pharmacologic pain management MSC:Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control24. A postoperative client is reluctant to participate in physical therapy. What action by the nurse is best?a.Ask the client about pain goals and if they are being met.b. Ask the client why he or she is being uncooperative with therapy.c. Increase the dose of analgesia given prior to therapy sessions.d. Tell the client that physical therapy is required to regain function.ANS: AA comprehensive pain management plan includes the clients goals for pain control. Adequate pain control isnecessary to allow full participation in therapy. The first thing the nurse should do is to ask about the clients paingoals and if they are being met. If not, an adjustment to treatment can be made. If they are being met, thenurse canassess for other factors influencing the clients behavior. Asking the client why he or she is being uncooperative isnot the best response for two reasons. First, why questions tend to put people on thedefensive. Second, labelingthe behavior is inappropriate. Simply increasing the pain medication may not beadvantageous. Simply telling theclient that physical therapy is required does not address the issue.DIF: Applying/Application REF: 67 KEY:Pain goals| painMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential25. A client is being discharged from the hospital after surgery on hydrocodone and acetaminophen (Lorcet).What discharge instruction is most important for this client?a. Call the doctor if the Lorcet does not relieve your pain.b. Check any over-the-counter medications for acetaminophen.c. Eat more fiber and drink more water to prevent constipation.d. Keep your follow-up appointment with the surgeon as scheduled.ANS: BAll instructions are appropriate for this client. However, advising the client to check over-the-countermedications for acetaminophen is an important safety measure. Acetaminophen is often found in commonover-the-counter medications and should be limited to 3000 mg/day.DIF: Applying/Application REF: 56KEY: Pharmacologic pain management| opioid analgesics MSC:Integrated Process: Teaching/Learning

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NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral TherapiesMULTIPLE RESPONSE1. A faculty member explains to students the process by which pain is perceived by the client. Which processesdoes the faculty member include in the discussion? (Select all that apply.)a.Inductionb.Modulationc. Sensory perceptiond.Transductione.TransmissionANS: B, C, D, EThe four processes involved in making pain a conscious experience are modulation, sensory perception,transduction, and transmission.DIF: Remembering/Knowledge REF: 47KEY: Pain transmission| pain MSC: Integrated Process: Teaching/Learning NOT:Client Needs Category: Physiological Integrity: Physiological Adaptation2. A faculty member explains the concepts of addiction, tolerance, and dependence to students. Whichinformation is accurate? (Select all that apply.)a. Addiction is a chronic physiologic disease process.b. Physical dependence and addiction are the same thing.c. Pseudoaddiction can result in withdrawal symptoms.d. Tolerance is a normal response to regular opioid use.e. Tolerance is said to occur when opioid effects decrease.ANS: A, D, EAddiction, tolerance, and dependence are important concepts. Addiction is a chronic, treatable disease with aneurologic and biologic basis. Tolerance occurs with regular administration of opioid analgesics and is seenwhen the effect of the analgesic decreases (either therapeutic effect or side effects). Dependence and addictionarenot the same; dependence occurs with regular administration of analgesics and can result in withdrawalsymptoms when they are discontinued abruptly. Pseudoaddiction is the mistaken diagnosis of addictive disease.DIF: Remembering/Knowledge REF: 59KEY: Dependence| tolerance| addiction MSC: Integrated Process: Teaching/Learning NOT:Client Needs Category: Physiological Integrity: Physiological Adaptation3. A postoperative client has an epidural infusion of morphine and bupivacaine (Marcaine). What actions doesthe nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)a.Ask the client to point out any areas of numbness or tingling.b. Determine how many people are needed to ambulate the client.c.Perform a bladder scan if the client is unable to void after 4 hours.d. Remind the client to use the incentive spirometer every hour.e. Take and record the clients vital signs per agency protocol.ANS: C, D, EThe UAP can assess and record vital signs, perform a bladder scan and report the results to the nurse, and remindthe client to use the spirometer. The nurse is legally responsible for assessments and should ask theclient aboutareas of numbness or tingling, and assess if the client is able to bear weight and walk.DIF: Applying/Application REF: 63KEY: Epidural| pharmacologic pain management| opioid analgesics MSC:Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care4. A client with a broken arm has had ice placed on it for 20 minutes. A short time after the ice was removed,

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