Test Bank for Medical-Surgical Nursing in Canada, 4th Edition

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Chapter 01: Introduction to Medical-Surgical Nursing Practice in CanadaLewis: Medical-Surgical Nursing in Canada, 4th Canadian EditionMULTIPLE CHOICE1.When caring for clients using evidence-informed practice, which of the following does thenurse use?a.Clinical judgement based on experienceb.Evidence from a clinical research studyc.The best available evidence to guide clinical expertised.Evaluation of data showing that the client outcomes are metANS: CEvidence-informed nursing practice is a continuous interactive process involving theexplicit, conscientious, and judicious consideration of the best available evidence toprovide care. Four primary elements are: (a) clinical state, setting, and circumstances; (b)client preferences and actions; (c) best research evidence; and (d) health care resources.Clinical judgement based on the nurse’s clinical experience is part of EIP, but clinicaldecision making also should incorporate current research and research-based guidelines.Evidence from one clinical research study does not provide an adequate substantiation forinterventions. Evaluation of client outcomes is important, but interventions should bebased on research from randomized control studies with a large number of subjects.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Planning2.Which of the following best explains the nurses’ primary use of the nursing process whenproviding care to clients?a.To explain nursing interventions to other health care professionalsb.As a problem-solving tool to identify and treat clients’ health care needsc.As a scientific-based process of diagnosing the client’s health care problemsd.To establish nursing theory that incorporates the biopsychosocial nature of humansANS: BThe nursing process is an assertive problem-solving approach to the identification andtreatment of clients’ problems. Diagnosis is only one phase of the nursing process. Theprimary use of the nursing process is in client care, not to establish nursing theory orexplain nursing interventions to other health care professionals.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Implementation3.The nurse is caring for a critically ill client in the intensive care unit and plans an every2-hour turning schedule to prevent skin breakdown. Which type of nursing function isdemonstrated with this turning schedule?a.Dependentb.Cooperativec.Independentd.CollaborativeANS: D

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When implementing collaborative nursing actions, the nurse is responsible primarily formonitoring for complications of acute illness or providing care to prevent or treatcomplications. Independent nursing actions are focused on health promotion, illnessprevention, and client advocacy. A dependent action would require a physician order toimplement. Cooperative nursing functions are not described as one of the formal nursingfunctions.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Implementation4.The nurse is caring for a client who has been admitted to the hospital for surgery and tellsthe nurse, “I do not feel right about leaving my children with my neighbour.” Whichaction should the nurse take next?a.Reassure the client that these feelings are common for parents.b.Have the client call the children to ensure that they are doing well.c.Call the neighbour to determine whether adequate childcare is being provided.d.Gather more data about the client’s feelings about the childcare arrangements.ANS: DSince a complete assessment is necessary in order to identify a problem and choose anappropriate intervention, the nurse’s first action should be to obtain more information. Theother actions may be appropriate, but more assessment is needed before the bestintervention can be chosen.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Assessment5.The nurse is caring for a client who has left-sided paralysis as the result of a stroke andassesses a pressure injury on the client’s left hip. Which of the following is the mostappropriate nursing diagnosis for this client?a.Impaired physical mobility related to decrease in muscle control (left-sidedparalysis)b.Risk for impaired tissue integrity as evidenced by insufficient knowledge aboutprotecting tissue integrityc.Impaired skin integrity related to pressure over bony prominence (impairedcirculation)d.Ineffective tissue perfusion related to sedentary lifestyleANS: CThe client’s major problem is the impaired skin integrity as demonstrated by the presenceof a pressure injury. The nurse is able to treat the cause of altered circulation and pressureby frequently repositioning the client. Although left-sided weakness is a problem for theclient, the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate forthis client, who already has impaired tissue integrity. The client does have ineffectivetissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what thehealth problem is.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Diagnosis6.The nurse caring for a client with an infection has a nursing diagnosis of deficient fluidvolume related to excessive diaphoresis. Which of the following is an appropriate clientoutcome?a.Client has a balanced intake and output.

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b.Client’s bedding is changed when it becomes damp.c.Client understands the need for increased fluid intake.d.Client’s skin remains cool and dry throughout hospitalization.ANS: AThis statement gives measurable data showing resolution of the problem of deficient fluidvolume that was identified in the nursing diagnosis statement. The other statements wouldnot indicate that the problem of deficient fluid volume was resolved.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Planning7.Which of the following represents a nursing activity that is carried out during theevaluation phase of the nursing process?a.Determining if interventions have been effective in meeting client outcomesb.Documenting the nursing care plan in the progress notes in the medical recordc.Deciding whether the client’s health problems have been completely resolvedd.Asking the client to evaluate whether the nursing care provided was satisfactoryANS: AEvaluation consists of determining whether the desired client outcomes have been met andwhether the nursing interventions were appropriate. The other responses do not describethe evaluation phase.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Evaluation8.Which of the following would the nurse perform during the assessment phase of thenursing process?a.Obtains data with which to diagnose client problemsb.Uses client data to develop priority nursing diagnosesc.Teaches interventions to relieve client health problemsd.Assists the client to identify realistic outcomes to health problemsANS: ADuring the assessment phase, the nurse gathers information about the client. The otherresponses are examples of the intervention, diagnosis, and planning phases of the nursingprocess.DIF:Cognitive Level: KnowledgeTOP:Nursing Process: Assessment9.Which of the following is an example of a correctly written nursing diagnosis statement?a.Altered tissue perfusion related to heart failureb.Risk for impaired tissue integrity related to sacral rednessc.Ineffective coping related to insufficient sense of control.d.Altered urinary elimination related to urinary tract infectionANS: CThis diagnosis statement includes a NANDA nursing diagnosis and an etiology thatdescribes a client’s response to a health problem that can be treated by nursing. The use ofa medical diagnosis (as in the responses beginning “Altered tissue perfusion” and “Alteredurinary elimination”) is not appropriate. The response beginning “Risk for impaired tissueintegrity” uses the defining characteristics as the etiology.

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DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Diagnosis10.Which of the following includes the components required for a complete nursing diagnosisstatement?a.A problem and the suggested client goals or outcomesb.A problem, its cause, and objective data that support the problemc.A problem with all its possible causes and the planned interventionsd.A problem with its etiology and the signs and symptoms of the problemANS: DThe PES format is used when writing nursing diagnoses. The subjective, as well asobjective, data should be included in the defining characteristics. Interventions andoutcomes are not included in the nursing diagnosis statement.DIF:Cognitive Level: KnowledgeTOP:Nursing Process: Diagnosis11.Which of the following refers to a situation that results in unintended harm to the clientand is related to the care or services provided rather than the client’s medical condition?a.Negligenceb.Adverse eventc.Incident reportd.NonmaleficenceANS: BAn adverse event is an event that results in unintended harm to the client and is related tothe care or services provided to the client rather than to the client’s underlying medicalcondition.DIF:Cognitive Level: KnowledgeTOP:Nursing Process: Evaluation12.When using the Five Steps of theevidence-informedpractice (EIP) Process, which of theflowing elements is the final step when constructing a clinical question?a.Comparison of interestb.Population of interestc.Outcome of interestd.Timeframe of interestANS: DThe order of the nurse’s statements follows the PICOT format with the final step being the“T”, or timeframe of interest.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Implementation

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Chapter 02: Cultural Competence and Health Equity in Nursing CareLewis: Medical-Surgical Nursing in Canada, 4th Canadian EditionMULTIPLE CHOICE1.Which of the following terms refers to characteristics of a group whose members share acommon social, cultural, linguistic, or religious heritage?a.Diversityb.Ethnicityc.Ethnocentrismd.Cultural impositionANS: BEthnicity is the common social, cultural, linguistic, or religious heritage of a group ofpeople. Diversity is a presence of persons with differences from the majority or dominantgroup that is assumed to be the norm. Ethnocentrism is a tendency of individuals tobelieve that their way of viewing and responding to the world is the most correct, natural,and superior one. Cultural imposition is imposition of one person's own cultural beliefsand practices, intentionally or unintentionally, on another person or group of people.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Planning2.The nurse is caring for Indigenous clients in a community clinic setting. Which of thefollowing would the nurse include when developing strategies to decrease health caredisparities?a.Improve public transportation.b.Obtain low-cost medications.c.Update equipment and supplies for the clinic.d.Educate staff about Indigenous health beliefs.ANS: DHealth care disparities are due to stereotyping, biases, and prejudice of health careproviders; the nurse can decrease these through staff education. The other strategies alsomay be addressed by the nurse but will not impact health disparities.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Planning3.A family member of an elderly Hispanic client admitted to the hospital tells the nurse thatthe client has traditional beliefs about health and illness. Which of the following actions ismost appropriate for the nurse in this situation?a.Avoid asking any questions unless the client initiates conversation.b.Ask the client whether it is important that cultural healers are contacted.c.Explain the usual hospital routines for meal times, care, and family visits.d.Obtain further information about the client’s cultural beliefs from the daughter.ANS: B

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Because the client has traditional health care beliefs, it is appropriate for the nurse to askwhether the client would like a visit from a cultural healer. Nurses ask key questions withregard to language, diet, religion, and acculturation and eliciting the client’s explanatorymodel of health and illness. There is no cultural reason for the nurse to avoid asking theclient questions, and questions may be necessary to obtain necessary health information.The client (rather than the daughter) should be consulted about personal cultural beliefs.The hospital routines for meals, care, and visits should be adapted to the client’spreferences rather than expecting the client to adapt to the hospital schedule.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Implementation4.When caring for an Indigenous client, which of the following actions is the best initialapproach in relation to eye contact for the nurse to take?a.Avoid all eye contact with the client.b.Observe the client’s use of eye contact.c.Look directly at the client when interacting.d.Ask the family about the client’s cultural beliefs.ANS: BEye contact varies greatly among and within cultures so the nurses’ initial action is toassess the client’s use of eye contact. Although nurses are often taught to maintain directeye contact, clients who are Asian, Arab, or Indigenous may avoid direct eye contact andconsider direct eye contact disrespectful or aggressive. Looking directly at the client oravoiding eye contact may be appropriate, depending on the client’s individual culturalbeliefs. The nurse should assess the client, rather than asking family members about theclient’s beliefs.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Implementation5.A graduate nurse is assessing a newly admitted non–English-speaking Chinese client whocomplains of severe headaches. Which of the following actions by the graduate nursewould cause the charge nurse to intervene during this assessment interview?a.Sit down at the bedside.b.Palpate the client’s scalp.c.Call for a medical interpreter.d.Avoid eye contact with the client.ANS: BMany people of Asian ethnicity believe that touching a person’s head is disrespectful; thenurse should always ask permission before touching any client’s head. The other actionsare appropriate.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Implementation6.The nurse is caring for a client who speaks a language different from the nurse’s languageand there is no interpreter available. Which of the following actions is the mostappropriate for the nurse to implement?a.Use specific medical terms in the Latin form.b.Talk loudly and slowly so that each word is clearly heard.c.Repeat important words so that the client recognizes their importance.d.Use simple gestures to demonstrate meaning while talking to the client.

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ANS: DThe use of gestures will enable some information to be communicated to the client. Theother actions will not improve communication with the client.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Implementation7.According to the ABC(DE)s of cultural competence, awareness of and sensitivity tocultural values is in which of the following domains?a.Skills domainb.Affective domainc.Knowledge domaind.Behavioural domainANS: BThe affectivedomain reflects an awareness of and sensitivity to cultural values, needs, andbiases. The skills domain does not reflect an awareness of and sensitivity to cultural values,needs, and biases. There is no skills or knowledge domain; with ABC(DE) it is affective,behavioural, and cognitive domains as well as dynamics of difference and environment.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Planning8.Which of the following actions represents the best example of culturally appropriatenursing care when caring for a newly admitted client?a.Have family members provide most of the client’s personal care.b.Maintain a personal space of at least 0.5 m when assessing the client.c.Ask permission before touching a client during the physical assessment.d.Consider the client’s ethnicity as the most important factor in planning care.ANS: CMany cultures consider it disrespectful to touch a client without asking permission, soasking a client for permission is always culturally appropriate. The other actions may beappropriate for some clients but are not appropriate across all cultural groups or for allindividual clients.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Implementation9.While talking with the nursing supervisor, a staff nurse expresses frustration that anIndigenous client always has several family members at the bedside. Which of thefollowing actions is the most appropriate action for the nursing supervisor in thissituation?a.Remind the nurse that family support is important to this family and client.b.Have the nurse explain to the family that too many visitors will tire the client.c.Suggest that the nurse ask family members to leave the room during client care.d.Ask about the nurse’s personal beliefs about family support during hospitalization.ANS: D

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The first step in providing culturally competent care is to understand one’s own beliefs andvalues related to health and health care. Asking the nurse about personal beliefs will helpto achieve this step. Reminding the nurse that this cultural practice is important to thefamily and client will not decrease the nurse’s frustration. The remaining responses(suggest that the nurse ask family members to leave the room, and have the nurse explainto family that too many visitors will tire the client) are not culturally appropriate for thisclient.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Implementation10.An elderly Asian Canadian client tells the nurse that she has lived in Canada for 50 years.The client speaks English but lives in a predominantly Asian neighbourhood. Which of thefollowing actions is most appropriate for the nurse?a.Arrange to have a folk healer available when planning the client’s care.b.Ask the client about any special cultural beliefs or practices.c.Avoid making direct eye contact with the client during care.d.Involve the client’s oldest son in making health care decisions.ANS: BFurther assessment of the client’s health care preferences is needed before making furtherplans for culturally appropriate care. The other responses indicate stereotyping of theclient, based on ethnicity, and would not be appropriate initial actions.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Planning11.Which of the following statements is true related to immigrants to Canada?a.Decreased risk of social exclusion related to Canada’s multicultural population.b.New immigrants tend to be in overall better health than the resident population.c.Health status of immigrants is not related to length of time in Canada.d.Unemployment is not associated with poorer health outcomes for immigrants.ANS: BThehealthy immigrant effectindicates that new immigrants tend to be in better overallhealth than the general resident population. This finding is not surprising inasmuch asimmigrants are screened before being granted admittance to Canada. Health status isrelated to length of time in Canada, the health of immigrants, 20 years after immigration,as determined by age-standardized mortality rates, is generally poorer than those of theCanadian-born population. Underemployment, unemployment, and workplace stress placeimmigrants at increased health risks as well as the risk for social exclusion.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Planning12.Which of the following question formats is the most appropriate for the nurse to ask whencommunicating with a client that has limited English proficiency?a.Are you tired and in discomfort?b.You have taken your pills right?c.Are you alright?d.Are you in pain?ANS: D

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When communicating with a client that has limited English proficiency, the best questionsto ask are ones that are in simple language a couple of words, plain simple terms, such as“Are you in pain?” Asking about tiredness and discomfort in the same sentence should beavoided—ask one item at a time and use the term ‘pain’, not discomfort. Asking the client“are you alright” is vague and will elicit a yes or no answer. “You have taken your pillsright?” is accusatory and should be avoided.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Implementation13.An Indigenous client tells the nurse that he thinks his abdominal pain is caused by eatingtoo much seal fat and that strong massage over the stomach will help it. Which of thefollowing statements depicts what the client is describing to the nurse?a.Evidence-informed national guidelinesb.Awareness and knowledge of his own culturec.The explanatory model of health and health practicesd.Knowledge about the difference in modern and folk health practicesANS: CThe explanatory model is a set of beliefs regarding what causes the disease or illness andthe methods that would potentially treat the condition best. Different cultural groups havedifferent beliefs about the causes of illness and the appropriateness of various treatments.The situation is not reflective of national guidelines. There is no comparison betweenmodern and folk health practices. The client is explaining experiences and beliefs’ ratherthan awareness and knowledge.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Assessment14.Which of the following statements represents a health inequity currently experienced inCanada?a.Indigenous adults are less likely to smoke tobacco than other adults in Canada.b.Overall suicide rate among First Nation communities is about twice the rate of thegeneral population.c.Individuals from lower income neighbourhoods undergo preventive healthscreening more that their higher income counterparts.d.Recent immigrants are more likely to have a primary care physician thanCanadian-born individuals.ANS: BSuicide rates are five to seven times higher among Indigenous youth than amongnon-Indigenous youth. Suicide rates among Indigenous youth are among the highest in theworld, at 11 times the national average. Smoking rates are more than two times higheramong the three Indigenous groups than among the non-Indigenous population.Individuals from higher income neighbourhoods undergo preventive health screeningmore than those from lower income neighbourhoods. Recent immigrants are less likely tohave a primary care physician than Canadian-born individuals.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment15.When performing a cultural assessment with a client of a different culture, which of thefollowing actions is the initial action to be taken by the nurse?a.Wait until a cultural healer is available to help with the assessment.

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b.Obtain a list of any cultural remedies that the client currently uses.c.Ask the client about any affiliation with a particular cultural group.d.Tell the client what the nurse already knows about the client’s culture.ANS: CAn early step in performing a cultural assessment is to determine the cultural group withwhich the client identifies. The other actions may be appropriate if the client does identifywith a particular culture.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Assessment16.Equity in health care is concerned with creating equal opportunities for good health foreveryone in which one of the following ways?a.Increase negative effect of social determinants of health.b.Increase awareness of acute care programs.c.Decrease non-modifiable risk factors.d.Reduce exclusion.ANS: DHealth equity is concerned with creating equal opportunities for good health for everyonein two ways: (a) decreasing the negative effect of the social determinants of health and (b)by improving services to enhance access and reduce exclusion.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment

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Chapter 03: Health History and Physical ExaminationLewis: Medical-Surgical Nursing in Canada, 4th Canadian EditionMULTIPLE CHOICE1.An older-adult client who is having difficulty breathing is admitted to the hospital. Whichof the following approaches is the best for the nurse to use to obtain a complete healthhistory?a.Obtain subjective data about the client from family members.b.Omit subjective data collection and obtain the physical examination.c.Use the health care provider’s medical history to obtain subjective data.d.Schedule several short sessions with the client to gather subjective data.ANS: DIn the case of an older-adult client with a low energy level, several short sessions mayhave to be scheduled. Allowing time for the client to volunteer information aboutparticular areas of concern enables the nurse to work with the client to identify existingand potential health problems. In an emergency situation, the nurse may need to ask onlythe most pertinent questions for a specific problem and obtain more information later. Acomplete health history will include subjective information that is not available in thehealth care provider’s medical history. Family members may be able to provide somesubjective data, but only the client will be able to give subjective information about theshortness of breath. Since the subjective data about the client’s respiratory status will beessential, obtaining the physical examination alone will not provide sufficient information.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Assessment2.Immediate surgery is planned for a client with acute abdominal pain. Which of thefollowing questions will elicit the most complete information about the client’scoping-stress tolerance pattern?a.“Can you tell me how intense your pain is now?”b.“What do you think caused this abdominal pain?”c.“How do you feel about yourself and your hospitalization?”d.“Are there other major problems that are a concern right now?”ANS: DThe coping-stress tolerance pattern includes information about other major stressorsconfronting the client. The health perception–health management pattern includesinformation about the client’s ideas about risk factors. Feelings about self and thehospitalization are assessed in the self-perception–self-concept pattern. Intensity of pain ispart of the cognitive–perceptual pattern.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment3.During the health history interview, a client tells the nurse about periodic fainting spells.Which question by the nurse will be most helpful in determining the setting in which thefainting spells occur?a.“How frequently do you have the fainting spells?”b.“Where are you when you have the fainting spells?”c.“Do the spells tend to occur at any special time of day?”

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d.“Do you have any other symptoms along with the spells?”ANS: BInformation about the setting is obtained by asking where the client was and what theclient was doing when the symptom occurred. The other questions from the nurse areappropriate for obtaining information about chronology, frequency, and associated clinicalmanifestations.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment4.The nurse records the following general survey of a client: “The client is a 68-year-oldmale Asian accompanied by his wife and two daughters. Alert and oriented. Does notmake eye contact with the nurse and responds slowly, but appropriately, to questions. Noapparent disabilities or distinguishing features.” Which of the following informationshould be added to this general survey documentation?a.Nutritional statusb.Intake and outputc.Reasons for contact with the health care systemd.Comments of family members about his conditionANS: AThe general survey also describes the client’s general nutritional status. The otherinformation will be obtained when doing the complete nursing history and examination butis not obtained through the initial scanning of a client.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Assessment5.A nurse is performing a health history and physical examination for a client withright-sided rib fractures. Which of the following data is a pertinent negative finding?a.Client states that there have been no other health problems recently.b.Client denies having pain when the area over the fractures is palpated.c.Client has several bruised and swollen areas on the right anterior chest.d.Client refuses to take a deep breath because of the associated chest pain.ANS: BThe nurse expects that a client with rib fractures will have pain over the fractured area.The first statement is neither a positive nor a negative finding with regard to the ribfractures. The bruising and swelling and pain with breathing are positive findings.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Assessment6.As the nurse assesses the client’s neck, the client says, “My neck is so stiff I can hardlymove it.” This client statement indicates the nurse should perform which of the followingassessments?a.Focusedb.Screeningc.Emergencyd.ComprehensiveANS: A

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The focused assessment is needed when a client has clinical manifestations that indicate aproblem. An emergency assessment is done when the nurse needs to obtain informationabout life-threatening problems quickly while simultaneously taking action to maintainvital function. The screening assessment is not recognized as one of the three main typesof assessment. A comprehensive assessment is a detailed health history and physicalexamination.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Assessment7.The nurse is preparing to perform a focused abdominal assessment for a client who hashigh-pitched bowel sounds. Which equipment will be needed?a.Flashlightb.Stethoscopec.Tongue bladesd.Percussion hammerANS: BA stethoscope is used to auscultate bowel sounds. The other equipment may be used for acomprehensive assessment, but will not be needed for a focused abdominal assessment.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment8.When the nurse is planning for the physical examination of an alert older-adult client,which of the following adaptations to the examination technique should be considered?a.Speaking slowly when directing the clientb.Avoiding the use of touch as much as possiblec.Using slightly more pressure for palpation of the liverd.Organizing the sequence to minimize position changesANS: DOlder clients may have age-related changes in mobility that make it more difficult tochange position. There is no need to avoid the use of touch when examining older clients.Less pressure should be used over the liver. Since the client is alert, there is no indicationthat there is any age-related difficulty in understanding directions from the nurse.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Assessment9.While the nurse is taking the health history, a client states, “My father and grandfatherboth had heart attacks and were unable to be very active afterwards.” This statementreflects which of the following functional health patterns?a.Activity—exerciseb.Cognitive—perceptualc.Coping—stress toleranced.Health perception—health managementANS: DThe information in the client statement relates to risk factors that may causecardiovascular problems in the future. Identification of risk factors falls into the healthperception—health maintenance pattern.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment

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10.A client is seen in the emergency department with chest pain and hypotension. Which typeof assessment should the nurse do at this time?a.Focusedb.Subjectivec.Emergencyd.ComprehensiveANS: CSince the client is hemodynamically unstable, an emergency assessment is needed.Comprehensive and focused assessments may be needed after the client is stabilized.Subjective information is needed, but objective data such as vital signs also are essentialfor the unstable client.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment11.The nurse records the following general survey of a client: “The client is a 68-year-oldIndigenous male accompanied by his wife and two daughters. Alert and oriented. Does notmake eye contact with the nurse and responds slowly, but appropriately, to questions. Noapparent disabilities or distinguishing features.” Which of the following areas does thenurse need to assess to complete the general survey?a.Body movementsb.Intake and outputc.Reasons for contact with the health care systemd.Comments of family members about his conditionANS: ATo complete a general survey, the nurse needs to assess the client’s body movements.Intake and output, reasons for contact with the health care system, and comments of familymembers about the client’s condition are not part of the general survey.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Assessment12.When assessing the circulation to the lower leg of a client who has had knee surgery,which action should the nurse take first?a.Feel for the temperature of the foot.b.Visually inspect the colour of the foot.c.Check the client’s pedal pulses using the fingertips.d.Compress the nail beds to determine capillary refill time.ANS: BInspection is the first of the major techniques used in the physical examination. Palpationand auscultation are used later in the examination.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Assessment13.When assessing a client’s abdomen during the admission assessment, which of theseactions should the nurse take first?a.Feel for any masses.b.Palpate the abdomen.c.Percuss the liver borders.d.Listen to the bowel sounds.

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ANS: DWhen assessing the abdomen, auscultation is done before palpation or percussion becausepalpation and percussion can cause changes in bowel sounds and alter the findings. All ofthe techniques are appropriate, but auscultation should be done first.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment14.When admitting a client who has just arrived on the medical unit with severe abdominalpain, what should the nurse do first?a.Complete only basic demographic data before addressing the client’s abdominalpain.b.Medicate the client for the abdominal pain before attending to the health historyand examination.c.Inform the client that the abdominal pain will be treated as soon as the healthhistory is completed.d.Take the initial vital signs and then deal with the abdominal pain beforecompleting the health history.ANS: DThe client priority in this situation will be to decrease the pain level because the client willbe unlikely to cooperate in providing demographic data or the health history until the nurseaddresses the pain. However, obtaining information about vital signs is essential beforeusing either pharmacological or nonpharmacological therapies for pain control. The vitalsigns may indicate hemodynamic instability that would need to be addressed immediately.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Assessment15.The nurse is completing a neurological assessment on an adult client. The nurse shouldimplement which one of the following assessments when assessing the client’s motorstatus?a.Toe walkb.Finger to nosec.Rombergd.Heel to opposite shinANS: AA neurological assessment is completed to observe motor status by assessing gait, toe andheel walk, and drift whereas when assessing coordination, the nurses observes finger tonose, Romberg sign and heel to opposite shin.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Assessment

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Chapter 04: Patient and Caregiver TeachingLewis: Medical-Surgical Nursing in Canada, 4th Canadian EditionMULTIPLE CHOICE1.A client with newly diagnosed breast cancer has a nursing diagnosis of deficientknowledge related to insufficient information (about breast cancer). When the nurse isplanning teaching for the client, which is the most important initial learning goal?a.The client will select the most appropriate breast cancer therapy.b.The client will state ways of preventing the recurrence of the tumour.c.The client will demonstrate coping skills needed to manage the disease.d.The client will choose methods to minimize adverse effects of treatment.ANS: AAdults learn best when given information that can be used immediately. The first actionthe client will need to take after a cancer diagnosis is to choose a treatment option. Theother goals may be appropriate as treatment progresses.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Planning2.After the nurse implements diet instruction for a client with heart disease, the client canexplain the information but fails to make the recommended dietary changes. Which of thefollowing statements reflects the correct evaluation of the intervention?a.Learning did not occur because the client’s behaviour did not change.b.Choosing not to follow the diet is the behaviour that resulted from learning.c.The nursing responsibility for helping the client make dietary changes has beenfulfilled.d.The teaching methods were ineffective in helping the client learn the dietaryinformation.ANS: BAlthough the client behaviour has not changed, the client’s ability to explain theinformation indicates that learning has occurred and the client is choosing at this time tocontinue with the previous diet. The client may be in the contemplation or preparationstate in the Transtheoretical Model. The nurse should reinforce the need for change andcontinue to provide information and assistance with planning for change.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Evaluation3.The nurse is caring for an adult client who has been diagnosed with type 2 diabetesmellitus after being admitted to the hospital with an infected foot wound. When applyingprinciples of adult learning, which teaching strategy by the nurse is most likely to beeffective?a.Discuss the importance of blood glucose control in maintenance of long-termhealth.b.Demonstrate the correct method for cleaning and redressing the wound to theclient.c.Assure the client that the nurse is an expert on management of diabetescomplications.d.Wait until after discharge and have a home health nurse teach about foot care and

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diabetes management.ANS: BPrinciples of adult education indicate that readiness and motivation to learn are high whenfacing new tasks (such as wound care) and when demonstration and practice of skills areavailable. Although a home health referral may be needed for this client, teaching shouldnot be postponed until discharge. Adult learners are independent; the nurse should act as afacilitator for learning, rather than as the expert. Adults learn best when the topic is ofimmediate usefulness; long-term goals may not be very motivating.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Planning4.A client admitted to the hospital with hyperglycemia and newly diagnosed diabetesmellitus is scheduled for discharge the second day after admission. When implementingclient teaching, which is the best action for the nurse to take?a.Instruct about the increased risk for cardiovascular disease.b.Provide detailed information about dietary control of glucose.c.Teach glucose self-monitoring and medication administration.d.Give information about the effects of exercise on glucose control.ANS: CWhen time is limited, the nurse should focus on the priorities of teaching. In this situation,the client should know how to test blood glucose and administer medications to controlglucose levels. The client will need further teaching about the role of diet, exercise,various medications, and the many potential complications of diabetes, but these topicscan be addressed through planning for appropriate referrals.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Implementation5.When using the Transtheoretical Model of Health Behaviour Change during clientteaching, the nurse identifies that the client who states, “I told my wife that I was going tostart exercising, and I think I will join a fitness club,” is in which of the following stages?a.Preparationb.Terminationc.Maintenanced.ContemplationANS: AThe client’s statement indicating that the plan for change is being shared with someoneelse indicates that the preparation stage has been achieved. Contemplation of a changewould be indicated by a statement like “I know I should exercise.” Maintenance of achange occurs when the client practices the behaviour regularly. Termination would beindicated when the change is a permanent part of the lifestyle.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment6.While admitting a client to the medical unit, the nurse learns that the client has difficultyreading. This information will guide the nurse in determining which of the followingstrategies would be the most appropriate when planning for client teaching?a.Assessing the degree of client motivation and readiness to learnb.Deciding what information the client will be able to understand

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c.Ensuring that the family be included in the teaching processd.Choosing which instructional strategies should be used in teachingANS: DThe information that the client has poor health literacy skills indicates that the nurseshould avoid the use of written materials in teaching and choose other strategies. Theclient does not indicate a lack of motivation or an inability to understand new information.The client’s lack of reading ability does not necessarily imply that the family must beincluded in the teaching process.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Planning7.When assessing the learning needs for a client who has coronary heart disease, the nursefinds that the client has recently made dietary changes to decrease fat intake and hasstopped smoking. Which of the following is the most appropriate initial statement by thenurse at this time?a.“Although those are important, it is essential that you make other changes, too.”b.“Are you having any difficulty in maintaining the changes you have alreadymade?”c.“You have already accomplished some changes that are important in heart health.”d.“Which additional changes in your lifestyle would you like to implement at thistime?”ANS: CPositive reinforcement of the learner’s achievements is critical in making lifestyle changes.This client is in the action stage of the Transtheoretical Model, when reinforcement of thechanges being made is an important nursing intervention. The other responses are alsoappropriate, but are not the best initial response.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Implementation8.When assessing a client’s readiness to learn before planning teaching activities, whichquestion should the nurse ask?a.“What kind of work and leisure activities do you do?”b.“What information do you think you need right now?”c.“Do you have any religious beliefs that are inconsistent with the treatment?”d.“Can you describe the types of activities that help you learn new information?”ANS: BMotivation and readiness to learn depend on what the client values and perceives asimportant. The other questions are also important in developing the teaching plan, but donot address what information most interests the client at present.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Assessment9.The nurse is caring for a client with diabetes and develops a nursing diagnosis ofineffective health management related to insufficient knowledge of therapeutic regimen(resulting in low motivation). Which of the following client actions is the basis for thisnursing diagnosis?a.Does not perform capillary blood glucose tests as directedb.Occasionally forgets to take the daily prescribed medication

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c.Says that dietary intake does not seem to impact fatigue leveld.Cannot identify signs or symptoms of high and low blood glucoseANS: CThe client’s motivation to follow a diabetic diet will be decreased if the client feels thatdietary changes do not impact symptoms. The other responses do not indicate that theineffective health maintenance is caused by lack of motivation.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Diagnosis10.A client with poor circulation to the feet requires teaching about foot care. Which learninggoal should the nurse include in the teaching plan?a.The nurse will demonstrate the proper technique for trimming toenails.b.The client will list three ways to protect the feet from injury by discharge.c.The nurse will instruct the client on appropriate foot care before discharge.d.The client will understand the rationale for proper foot care after instruction.ANS: BLearning goals should state clear, measurable outcomes of what is to be accomplishedfrom the learning process. Demonstrating a proper technique or providing instruction areactions that the nurse will take, rather than behaviours that would indicate if client learninghas occurred. Having the client understand the rational for proper foot care afterinstruction is an example of a learning outcome.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Planning11.The nurse is planning a teaching session for a client who needs to improve skills in beingmore assertive. Which of the following is the most effective teaching strategy for thisclient?a.Role-playingb.Peer teachingc.Printed materialsd.Lecture-discussionANS: ARole playing allows the client to practice assertive behaviour and receive feedback abouthow the behaviour is perceived. This strategy is most often used when clients need toexamine their attitudes and behaviours; understand the viewpoints and attitudes of others;or practise carrying out thoughts, ideas, or decisions. Lecture-discussion, peer teaching,and printed materials are more useful for other learning needs.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Planning12.The client’s teaching plan includes this goal: “The client will select a 2-g sodium diet fromthe hospital menu for the next 3 days.” Which evaluation method will be best for the nurseto use when determining whether teaching was effective?a.Check the sodium content of the client’s menu choices over the next 3 days.b.Ask the client to identify which foods on the hospital menus are high in sodium.c.Have the client list favourite foods that are high in sodium and foods that could besubstituted for these favourites.d.Compare the client’s sodium intake over the next 3 days with the sodium intake

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before the teaching was implemented.ANS: AAll of the answers address the client’s sodium intake, but the desired client behaviours inthe learning objective are most clearly addressed by evaluation of the client’s menuchoices.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Evaluation13.The nurse is preparing written handouts to be used as part of the standardized teachingplan for clients who have been recently diagnosed with diabetes and requires an awarenessof literacy levels. Which of the following literacy levels is generally reflective of studentswho graduate from high school?a.1b.2c.3d.4ANS: CPeople with Level 3 literacy have the minimum skills necessary for everyday life in acomplex society, such as graduation from high school. People with Level 1 literacy havevery poor skills; for example, they were unable to determine the correct dose ofmedication from information on the package. People with Level 2 literacy require materialto be simple and clearly laid out, and only tasks that are not too complex are to be includedin learning material. People at this level could read but had poor test results. People withLevels 4 and 5 literacy had higher-order skills in information processing.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Planning14.The nurse in the hospital has implemented a teaching plan to assist a client withrheumatoid arthritis in accomplishing daily activities independently. Which of thefollowing actions is the best approach for the nurse to take in order to evaluate the client’slong-term response to the teaching?a.Make a referral to the home health nursing department for home visits.b.Assess the client’s ability to bathe without any assistance the next day.c.Have the client demonstrate the learned skills at the end of the teaching session.d.Arrange a physical therapy visit before the client is discharged from the hospital.ANS: AThe client’s long-term response may need to be assessed after discharge; long-termevaluation necessitates follow-up by the nurse, outpatient clinic, or outside agency. In thiscase, a home health referral would allow this to occur. The other actions allow evaluationof the client’s short-term response to teaching.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Evaluation15.A young adult client tells the nurse, “I enjoy smoking and have no plans to quit.” Whichstage of the Transtheoretical Model of Health Behaviour Change does this exampleportray?a.Contemplationb.Precontemplation

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c.Preparationd.MaintenanceANS: BThe precontemplation phase indicates that the client is not considering a change and is notready to learn. In the contemplation phase, a change is being considered. The client startsgathering information for the change in the preparation stage. In the maintenance stage,the change has already occurred.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Diagnosis16.An older-adult client is seen at the health clinic and diagnosed with protein malnutrition.Which of the following actions is priority to be included in the teaching plan?a.Suggest the use of liquid supplements as a way to increase protein intake.b.Encourage the client to increase the dietary intake of meat, cheese, and milk.c.Ask the client to record the intake of all foods and beverages for a 3-day period.d.Focus on the use of combinations of beans and rice to improve daily protein intake.ANS: CAssessment is the first step in assisting a client with health changes. The other answersmay be appropriate for the client, but the nurse will not be able to determine this until theassessment of the client is complete.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Planning17.The nurse is caring for a client who has been newly diagnosed with diabetes. The clienttells the nurse, “I want to know how to give my own insulin.” Which initial action will thenurse take when implementing the standardized diabetic teaching plan?a.Demonstrate how to draw up and administer insulin.b.Discuss the use of exercise to decrease insulin needs.c.Teach about differences between the various types of insulin.d.Provide handouts about therapeutic and adverse effects of insulin.ANS: AAdult education is most effective when focused on information that the client thinks isneeded right now. All of the indicated information will need to be included when planningteaching for this client, but the teaching will be most effective if the nurse starts with theclient’s stated priority topic.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Implementation18.Which action should the nurse take first when teaching a client’s spouse how to managethebloodpressure (BP) for a client with newly diagnosed hypertension?a.Teach the caregiver how to take the client’s BP using a manual blood pressurecuff.b.Have the dietitian meet with the client and caregiver to discuss low sodium dietarychoices.c.Ask the client and caregiver to select important information from a list ofhypertension teaching topics.d.Provide written information about treatment and complications of hypertension forthe client and caregiver.

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ANS: CSince adults learn best when given information that they view as being neededimmediately, asking the caregiver and client to prioritize learning needs is likely to be themost successful approach to home management of health problems. The other actions alsomay be appropriate, depending on what learning needs the caregiver and client have, butthe initial action should be to assess what the learners feel is important.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Assessment19.Which of the following determinants of learning is an evaluation of learning?a.Learner needsb.Demonstrated learner behaviourc.State of learner readinessd.Preferred learning styleANS: BDemonstrated learner behaviour is an evaluation of learning. The three determinants oflearning that require learning assessments are learner needs, state of learner readiness, andthe client’s preferred learning style.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment

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Chapter 05: Chronic IllnessLewis: Medical-Surgical Nursing in Canada, 4th Canadian EditionMULTIPLE CHOICE1.The nurse is caring for a client with type 2 diabetes who has been hospitalized with severehyperglycemia. Which of the following topics will be most important to include indischarge teaching?a.Effect of endogenous insulin on transportation of glucose into cellsb.Function of the liver in formation of glycogen and gluconeogenesisc.Impact of the client’s family history on likelihood of developing diabetesd.Symptoms indicating that the client should contact the health care providerANS: DOne of the tasks for clients with chronic illnesses is to prevent and manage a crisis. Theclient needs instruction on recognition of symptoms of hyperglycemia and appropriateactions to take if these symptoms occur. The other information also may be included inclient teaching, but is not as essential in the client’s self-management of the illness.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Implementation2.Which of the following diseases has the highest proportion of chronic illness deaths inCanada?a.Cancerb.Diabetesc.Cardiovascular diseased.Chronic respiratory diseaseANS: CCardiovascular diseases (37%) were responsible for the highest proportion of globaldeaths in 2012, followed by cancers (27%), chronic respiratory diseases (8%), anddiabetes (4%).DIF:Cognitive Level: KnowledgeTOP:Nursing Process: Assessment3.Which of the following is an example of multimorbidity?a.Chronic obstructive pulmonary disease and a urinary tract infectionb.Lung cancer and pneumoniac.Chronic kidney disease and appendicitisd.Diabetes and exacerbation of rheumatoid arthritisANS: DMultimorbidity is the simultaneous occurrence of several chronic medical conditions,which may or may not be related to each other, in the same person. Pneumonia, urinarytract infection, and appendicitis are all acute conditions.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment4.Which of the following factors has a major impact on the development of chronic illness?a.Poverty

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b.Social stabilityc.Urban dwellingd.High school diplomaANS: APoverty and socioeconomic disadvantage are recognized to have a major impact on thedevelopment of chronic illness. Social stability, urban living, and having a high schooleducation are not factors contributing to the development of chronic illness.DIF:Cognitive Level: KnowledgeTOP:Nursing Process: Assessment5.Which of the following statements is true related to nonmodifiable risk factors for chronicillness?a.Cannot be changedb.Requires intervention in order to changec.Can be altered to benefit health outcomesd.Can be changed with client perseveranceANS: ANonmodifiable risk factors cannot be changed. Requiring intervention in order to change,altering, and changed with perseverance all indicate that change is possible.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Planning6.What is the average life expectancy in Canada?a.60 yearsb.70 yearsc.80 yearsd.90 yearsANS: CThe life expectancy in Canada is estimated to be 80 years, specifically in 2010, it was 78.5years for males and 82.7 years for females.DIF:Cognitive Level: KnowledgeTOP:Nursing Process: Planning7.Which of the following types of cancers has a genetic predisposition to its occurrence?a.Lungb.Breastc.Cervixd.TesticlesANS: BGenetic testing can also show an inherited predisposition to several different types ofcancer, including breast and ovarian cancer, melanoma, and colon cancer.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment8.Which of the following models views disability as directly caused by disease or trauma?a.Socialb.Nursingc.Medical

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d.CollaborativeANS: CThe medical model views disability as directly caused by disease, trauma, or anotherhealth condition. Disability, from the medical model perspective, necessitates medical careprovided in the form of individual treatment by providers to “correct” the problem with theindividual. The social model of disability, conversely, sees disability as a socially createdproblem and not an inherent attribute of an individual.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Planning9.Which of the following client statements reflect an outcome expectancy statement?a.“I am not able to exercise.”b.“Exercise helps people lose weight.”c.“Exercise is too hard on my arthritis.”d.“Dietary restrictions work better than exercise to lose weight.”ANS: BAnoutcome expectancyis the individual’s belief that a specific behaviour will lead tocertain outcomes. For example, the client who tells the nurse that exercising helps peopleto lose weight is voicing an outcome expectancy.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Assessment10.What is the most influential source of self-efficacy?a.Masteryb.Affective statesc.Verbal persuasiond.Vicarious experienceANS: AFour primary influences shape an individual's self-efficacy beliefs: mastery; vicariousexperience; verbal persuasion and other social influences; and physiological and affectivestates that help us judge our capability and our vulnerability to dysfunction. Masteryreflects a belief about whether or not “we have what it takes to succeed” and is consideredthe most influential source of self-efficacy.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment11.Which of the following is a characteristic of health-related hardiness known as“challenge”?a.Confidence to appraise a health stressorb.Ability to modify responses to health stressorsc.Viewing a health stressor as an opportunity for growthd.Optimal psychosocial adaptation to a health stressorANS: CChallenge is the anticipation of change. The person with health-related hardiness, whenconfronted with a health stressor, possesses sufficient self-mastery and confidence toappraise and modify responses appropriately (control) and cognitively reappraises thehealth stressor so it is viewed as stimulating and beneficial or an opportunity for growth(challenge).

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DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment12.Which of the following characteristics is true related to chronic illness?a.Abrupt onsetb.Usually single causec.Short latency periodd.Noninfectious originANS: DChronic (or noncommunicable) illnesses are typically characterized as having an uncertainetiology, multiple risk factors, long latency, prolonged duration, and a noninfectious originand can be associated with impairments or functional disability. Abrupt onset, usually asingle cause and cure most likely, are characteristic of acute illness.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment13.Clients with chronic illness want the health care system to provide them with which of thefollowing?a.Less informationb.Less travel timec.Ways to adjust to disease consequencesd.Limited information on ways to cope with their symptomsANS: CClients with chronic illness want the health care system to provide them with ways toadjust to disease consequences such as uncertainty, fear and depression, anger, loneliness,sleep disorders, memory loss, exercise needs, nocturia, sexual dysfunction, and stress.They did not identify wanting less information, shorter travel times, or limited informationon coping strategies but they do also want shorter wait times.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment14.Which of the following models calls for a political response to disability?a.Socialb.Medicalc.Activistd.CollaborativeANS: AThe social model of disability, conversely, sees disability as a socially created problemand not an inherent attribute of an individual (Barnes, 2012). The social model perspectivecalls for a political response, because the problem is created by an unaccommodatingphysical environment brought about by attitudes and other features of the socialenvironment.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment15.According to the World Health Organization’s ICF Bio-Psycho-Social Model, which ofthe following factors is an environmental contextual factor?a.Social backgroundb.Behaviour pattern

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c.Social attitudesd.Coping styleANS: CContextual factors are composed of external environmental factors (e.g., social attitudes,architectural characteristics, and legal and social structures, as well as climate, terrain, andso forth). The other choices represent internal personal factors (e.g., gender, age, copingstyles, social background, education, profession, past and current experience, overallbehaviour pattern, character, and other factors that influence how disability is experiencedby the individual).DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Assessment16.Which of these clients assigned to the nurse is most likely to need planning for long-termnursing management?a.22-year-old with appendicitis who has had an emergency appendectomyb.56-year-old with bilateral knee osteoarthritis who weighs 159 kgc.34-year-old with cholecystitis who has had a laparoscopic cholecystectomyd.62-year-old with acute sinusitis who will require antibiotic therapy for 5 daysANS: BThe client’s osteoarthritis is a chronic problem that will require planning for long-terminterventions such as physical therapy and nutrition counselling. The other clients haveacute problems that are not likely to require long-term management.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Planning17.“Set in motion and continue the trajectory projection and scheme” is a goal ofmanagement in which of the following trajectory phases?a.Pretrajectoryb.Onsetc.Comebackd.DownwardANS: C“Set in motion and continue the trajectory projection and scheme” is a goal ofmanagement in the trajectory phase of comeback. Pretrajectory goal is to prevent the onsetof chronic illness. The onset goal of management is to form an appropriate trajectoryprojection and scheme. The goal of the downward phase is to adapt to increasingdisability.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Planning18.Which one of the following levels is part of the client response to health carerecommendations based on a continuum of self-care?a.Self-esteemb.Adherencec.Deniald.AcceptanceANS: B

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Compliance, adherence, and self-care makeup the three levels of client response to healthcare recommendations on a continuum of self-care. Adherence is now the term mostwidely accepted because it incorporates the notion of the client agreeing with the treatmentplan presented by the health care provider.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Assessment

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Chapter 06: Community-Based Nursing and Home CareLewis: Medical-Surgical Nursing in Canada, 4th Canadian EditionMULTIPLE CHOICE1.A family caregiver tells the home health nurse, “I feel like I can never get away to doanything for myself.” Which action is the most appropriate for the nurse to take?a.Assist the caregiver in finding respite services.b.Assure the caregiver that the work is appreciated.c.Teach the caregiver that family members provide excellent client care.d.Encourage the caregiver to discuss feelings openly with the nurse as-needed.ANS: ARespite services allow family caregivers to have free time. The other actions also may behelpful, but the caregiver’s statement clearly indicates the need for some free time.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Implementation2.A client who was in an automobile accident is assigned a nurse as a case manager. Whichof the following responsibilities is required of the nurse in this role?a.Care for the client during hospitalization for the injuries.b.Assist the client with home care activities during recovery.c.Coordinate the services that the client receives in the hospital and at home.d.Determine the types of medical care the client needs for optimal rehabilitation.ANS: CThe role of the case manager is to coordinate the client’s care through multiple settingsand levels of care to allow the maximal client benefit at the least cost. The case managerdoes not provide direct care in either the acute or home setting. The case managercoordinates and advocates for care but does not determine what types of medical care areneeded, that is done by the health care provider or other provider.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Implementation3.The nurse is conducting a home visit and notes that the caregiver may be experiencingcaregiver burnout. Which of the following assessments would support this finding?a.Anxietyb.Sleeplessnessc.Weight gaind.Increased use of respite careANS: BAssessment of the signs of caregiver burnout (e.g., sleeplessness, difficulty concentrating)is a critical role of the home care nurse. Weight gain is an indication that the caregivers’nutritional intake exceeds requirements. An increased use of respite care could indicate anincreased involvement of the caregiver in outside support and activity groups. Thisassessment finding would require further assessment before linking it to caregiver burnout.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Assessment

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4.An older-adult client who lives alone was hospitalized for a fractured hip and hasrecovered from the surgery but needs to continue to work to improve mobility. Which ofthe following settings would the nurse anticipate that the client be transferred to?a.Another acute care settingb.A transitional care settingc.A residential care facilityd.Their own home with home health nursingANS: DHome health nursing is appropriate for clients who need continued rehabilitation and canimplement this in their own home. The client is no longer in need of the more continuousassessment and care given in acute care settings. There is no indication that the client willneed the permanent and ongoing medical and nursing services available in intermediatecare. The client is not yet independent enough to transfer to a residential care facility.DIF:Cognitive Level: ApplicationTOP:Nursing Process: Planning5.The nurse is describing home care services to a client that requires extended care. Whichof the following statements is true related to home care services?a.Technologically complex therapies must be managed in the hospital.b.The client’s family will be included in planning and the client’s care.c.Home care services are limited to visits by registered nurses or home health aides.d.In order for insurance to cover the home care, the client must be confined to bed.ANS: BFamily members who are providing care are included in planning the client’s care andtreatments. Other disciplines, such as physical and occupational therapy, also provideappropriate home health services. The client must be homebound, but not bed bound, toreceive reimbursement for home care services. High-tech services are increasinglyaccomplished in the home setting where the client is more comfortable and the risks forcomplications such as infection are less.DIF:Cognitive Level: ComprehensionTOP:Nursing Process: Implementation6.Which of the following statements represents a current trend in home health nursing?a.Increased numbers of registered nurses are being employed as home health nurses.b.Decreased numbers of licensed practical nurses are being employed as home healthnurses.c.There are more employment opportunities for newly graduated nurses.d.That a minimum of two years of acute care experience is required beforeemployment as a home health nurse.ANS: C

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