Test Bank For Medical-Surgical Nursing: Patient-Centered Collaborative Care (2 Volume Set), 8th Edition

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Chapter 1: Introduction toMedical-Surgical NursingPractice Ignatavicius: Medical-Surgical Nursing, 8th EditionChapter 1: Introduction to Medical-Surgical Nursing PracticeIgnatavicius: Medical-Surgical Nursing, 8th EditionMULTIPLE CHOICE1. A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptoradvises the student 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 to 98,000 deaths result each year from errors in hospital care, according to the 2000 Institute ofMedicine report. Many more clients have suffered injuries and less serious outcomes. Every nursehas the responsibility to guard the client’s safety.DIF: Understanding/Comprehension REF: 2 KEY: Patient safetyMSC: Integrated Process: Nursing Process: InterventionNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control2. A nurse is orienting a new client and family to the inpatient unit. What information does the nurseprovide to help the client promote his or her own safety?a. Encourage the client and family to be active partners.b. Have the client monitor hand hygiene in caregivers.c. Offer the family the opportunity to stay with the client.d. Tell the client to always wear his or her armband.ANS: A

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Each action could be important for the client or family to perform. However, encouraging the clientto be active in his or her health care as a partner is the most critical. The other actions are verylimited in scope and do not provide the broad protection that being active and involved does.DIF: Understanding/Comprehension REF: 3 KEY: Patient safetyMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control3. A nurse is caring for a postoperative client on the surgical unit. The client’s blood pressure was142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?a. Call the Rapid Response Team.b. Document and continue to monitor.c. Notify the primary care provider.d. Repeat blood pressure measurement in 15 minutes.ANS: AThe purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating beforethey suffer either respiratory or cardiac arrest. Since the client has manifested a significant change,the nurse should call the RRT. Changes in blood pressure, mental status, heart rate, and pain areparticularly significant. Documentation is vital, but the nurse must do more than document. Theprimary care provider should be notified, but this is not the priority over calling the RRT. Theclient’s blood pressure should be reassessed frequently, but the priority is getting the rapid care to theclient.DIF: Applying/Application REF: 3KEY: Rapid Response Team (RRT)| medical emergenciesMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Physiological Integrity: Physiological Adaptation4. 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: A

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Competency in client-focused care is demonstrated when the nurse focuses on communication,culture, respect, compassion, client education, and empowerment. By assessing the effect of theclient’s culture on health care, this nurse is practicing client-focused care. Providing for basic needsdoes not demonstrate this competence. Simply telling the client about all upcoming tests is notproviding empowering education. Orienting the client and family to the room is an important safetymeasure, but not directly related to demonstrating client-centered care.DIF: Understanding/Comprehension REF: 3KEY: Patient-centered care| culture MSC: Integrated Process: CaringNOT: Client Needs Category: Psychosocial Integrity5. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurseexplain is the most important thing the client can do to protect against errors?a. Bring a list of all medications and what they are for.b. Keep the doctor’s phone number by the telephone.c. Make sure all providers wash hands before entering the room.d. Write down the name of each caregiver who comes in the room.ANS: AMedication errors are the most common type of health care mistake. The Joint Commission’s SpeakUp campaign encourages clients to help ensure their safety. One recommendation is for clients toknow all their medications and why 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 nurseobtains a signature on the consent form, assessing if the client still has questions is vital, becausewithout full information the client cannot practice autonomy. Giving accurate information is

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practicing with veracity. Keeping promises is upholding fidelity. Treating the client fairly isproviding 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 fromthe lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. What answer bythe faculty is most accurate?a. Avoid embarrassing the client by asking questions.b. Don’t make assumptions about their health needs.c. Most LGBTQ people do not want to share information.d. No differences exist in communicating with this population.ANS: BMany members of the LGBTQ community have faced discrimination from health care providers andmay be reluctant to seek health care. The nurse should never make assumptions about the needs ofmembers of this population. Rather, respectful questions are appropriate. If approached withsensitivity, the client with any health care need is more likely to answer honestly.DIF: Understanding/Comprehension REF: 4 KEY: 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 haspain that is unrelieved by the prescribed narcotic pain medication. Which statement is part of theSBAR format for communication?a. A: “I would like you to order a different pain medication.”b. B: “This client has allergies to morphine and codeine.”c. R: “Dr. Smith doesn’t like nonsteroidal anti-inflammatory meds.”d. S: “This client had a vaginal hysterectomy 2 days ago.”ANS: BSBAR is a recommended form of communication, and the acronym stands for Situation,Background, Assessment, and Recommendation. Appropriate background information includesallergies to medications the on-call physician might order. Situation describes what is happening

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right now that must be communicated; the client’s surgery 2 days ago would beconsideredbackground. Assessment would include an analysis of the client’s problem; asking for a differentpain medication is a recommendation. Recommendation is a statement of what is needed or whatoutcome is desired; this information about the surgeon’s 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 unlicensedassistive personnel (UAP). Four hours later, the nurse notes the client’s blood pressure is muchhigher than previous readings, and the client’s mental status has changed. What action by the nursewould most likely have prevented 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 followingup on delegated tasks. The nurse should either have asked the UAP about the vital signs or instructedthe UAP to report them right away. An experienced UAP should know how to take vital signs andthe nurse should not have to assess this at this point. Double-checking the work defeats the purposeof delegation. Vital signs are within the scope of practice for a UAP and are permissible to delegate.The only appropriate answer is that the nurse did not provide adequate instruction to the UAP.DIF: Applying/Application REF: 6KEY: Supervision| delegation| unlicensed assistive personnelMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care10. A newly graduated nurse in the hospital states that, since she is so new, she cannot participate inquality improvement (QI) projects. What response by the precepting nurse is best?a. “All staff nurses are required to participate in quality improvement here.”

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b. “Even being new, you can implement activities designed to improve care.”c. “It’s easy to identify what indicators should be used to measure quality.”d. “You should ask to be assigned to the research and quality committee.”ANS: BThe preceptor should try to reassure the nurse that implementing QI measures is not out of line for anewly licensed nurse. Simply stating that all nurses are required to participate does not help the nurseunderstand how that is possible and is dismissive. Identifying indicators of quality is not an easy,quick process and would not be the best place to suggest a new nurse to start. Asking to be assignedto the QI committee does not give the nurse information about how to implement QI in dailypractice.DIF: Applying/Application REF: 6KEY: Quality improvementMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care11. A nurse is talking with a client who is moving to a new state and needs to find a new doctor andhospital there. What advice by the nurse is best?a. Ask the hospitals there about standard nurse-client ratios.b. Choose the hospital that has the newest technology.c. Find a hospital that is accredited by The Joint Commission.d. Use a facility affiliated with a medical or nursing school.ANS: CAccreditation by The Joint Commission (TJC) or other accrediting body gives assurance that thefacility has a focus on safety. Nurse-client ratios differ by unit type and change over time. Newtechnology doesn’t necessarily mean the hospital is safe. Affiliation with a health professions schoolhas several advantages, but safety is most important.DIF: Understanding/Comprehension REF: 2KEY: The Joint Commission (TJC)| accreditationMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection ControlMULTIPLE RESPONSE

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1. A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levelsof competency. Which areas should the manager assess to determine if the nursing staff demonstratecompetency according to the Institute of Medicine (IOM) report Health Professions Education: ABridge to Quality? (Select all that apply.)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 include collaborating with the interdisciplinary team, implementing evidence-based practice,providing client-focused care, using informatics in client care, and using quality improvement inclient 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 Control2. A nurse is interested in making interdisciplinary work a high priority. Which actions by the nursebest demonstrate 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 clientcare as a team with all other disciplines included. Simply showing other caregivers the nursing careplan is not actively involving them or collaborating with them.DIF: Applying/Application REF: 4KEY: Collaboration| interdisciplinary team

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MSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care3. The nurse utilizing evidence-based practice (EBP) considers which factors when planning care?(Select all that apply.)a. Cost-saving measuresb. Nurse’s expertisec. Client preferencesd. Research findingse. Values of the clientANS: B, C, D, EEBP consists of utilizing current evidence, the client’s values and preferences, and the nurse’sexpertise when planning 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 themanager would best help achieve this goal? (Select all that apply.)a. Attend hand-off rounds to coach and mentor.b. Conduct audits of staff using a new template.c. Create a template of topics to include in report.d. Encourage staff to ask questions during hand-off.e. Give raises based on compliance with reporting.ANS: A, B, C, DA good tool for standardizing hand-off reports and other critical communication is the SHAREmodel. SHARE stands for standardize critical information, hardwire within your system, allowopportunities to ask questions, reinforce quality and measurement, and educate and coach. Attendinghand-off report gives the manager opportunities to educate and coach. Conducting audits is part ofreinforcing quality. Creating a template is hardwiring within the system. Encouraging staff to askquestions and think critically about the information is allowing opportunities to ask questions. Themanager may need to tie raises into compliance if the staff is resistive and other measures havefailed, but this is not part of the SHARE model.

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DIF: Applying/Application REF: 5KEY: 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 2: Common HealthProblems of Older AdultsChapter 2: Common Health Problems of Older AdultsIgnatavicius: Medical-Surgical Nursing, 8th EditionMULTIPLE CHOICE1. A nursing faculty member working with students explains that the fastest growing subset of theolder population is which group?a. Elite oldb. Middle oldc. Old oldd. Young oldANS: CThe old old is the fastest growing subset of the older population. This is the group comprising those85 to 99 years of age. The young old are between 65 and 74 years of age; the middle old are between75 and 84 years of age; and the elite old are over 100 years of age.DIF: Remembering/Knowledge REF: 9KEY: Adulthood| aging| old old MSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance2. A nurse working with older adults in the community plans programming to improve morale andemotional health 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 inperforming one’s own activitiesof daily living and participating in society has direct effects onmorale and life satisfaction. Those who lose the ability to function independently often feel worthless

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and empty. An exercise program designed to maintain and/or improve physical functioning wouldbest address this need.DIF: Applying/Application REF: 12KEY: Independence| autonomy| older adultMSC: Integrated Process: Nursing Process: PlanningNOT: Client Needs Category: Psychosocial Integrity3. A nurse caring for an older client on a medical-surgical unit notices the client reports frequentconstipation and only wants to eat softer foods such as rice, bread, and puddings. What assessmentshould the nurse perform 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 foodsand constipation from the lack of fiber. The nurse should perform an oral assessment to determine ifthese problems exist. The other assessments are important, but will not yield information specific tothe client’s food preferences as they relate to constipation.DIF: Applying/Application REF: 10KEY: Nutrition| dentures| older adultMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort4. A nurse caring for an older adult has provided education on high-fiber foods. Which menuselection by the client demonstrates a need for further review?a. Barley soupb. Black beansc. White riced. Whole wheat breadANS: COlder adults need 25 to 50 grams of fiber a day. White rice is low in fiber. Foods high in fiberinclude barley, beans, and whole wheat products.

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DIF: Applying/Application REF: 11KEY: Nutrition| fiber| older adultMSC: Integrated Process: Nursing Process: EvaluationNOT: Client Needs Category: Physiological Integrity: Physiological Adaptation5. A nurse is working with an older client admitted with mild dehydration. What teaching does thenurse provide to best address this issue?a. “Cut some sodium out of your diet.”b. “Dehydration can cause incontinence.”c. “Have something to drink every 1 to 2 hours.”d. “Take your diuretic in the morning.”ANS: COlder adults often lose their sense of thirst. Since they should drink 1 to 2 liters of water a day, thebest remedy is to have the older adult drink something each hour or two, whether or not he or she isthirsty. Cutting “some” sodium from the diet will not address this issue. Although dehydration cancause incontinence from the irritation of concentrated urine, this information will not help prevent theproblem of dehydration. Instructing the client to take a diuretic in the morning rather than in theevening also will not directly address this issue.DIF: Applying/Application REF: 11KEY: Dehydration| older adult| hydration MSC: Integrated Process: Teaching/LearningNOT: 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 exerciseregimen would 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 toincrease functional ability for activities of daily living. Strength and flexibility will help the client tobe able to maintain independence longer. The other plans are good but will not specifically maintainthe client’s functional abilities.

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DIF: Applying/Application REF: 12KEY: 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 shouldthe nurse assess as a priority?a. History of previous depressionb. Previous stressful eventsc. Role of work in the adult’s lifed. Usual leisure time activitiesANS: COften older adults lose support systems when their roles change. For instance, when people retire,they may lose their entire social network, leading them to feeling depressed and lonely. The nurseshould first assess the role that work played in the client’s life. The other factors can be assessed aswell, but this circumstance is commonly seen in the older population.DIF: Applying/Application REF: 12KEY: 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. Whichstatement by a participant best indicates potential for successful coping?a. “I have had the same best friend for decades.”b. “I think I am coping very well on my own.”c. “My kids come to see me every weekend.”d. “Oh, I have lots of friends at the senior center.”ANS: 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 aremore likely to cope with crisis.DIF: Remembering/Knowledge REF: 12KEY: Coping| relationships| older adult

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MSC: 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 arefive concrete steps leading out from the front door. Which intervention would be most helpful inkeeping the older adult safe on the steps?a. Have the client use a walker or cane on the steps.b. Install contrasting color strips at the edge of each step.c. Instruct the client to use the garage door instead.d. Tell the client to use a two-footed gait on the steps.ANS: BAs a person ages, he or she may experience a decreased sense of touch. The older adult may not beaware of where his or her foot is on the step. Installing contrasting color strips at the end of each stepwill help increase awareness. If the client does not need an assistive device, he or she should not useone just on stairs. Using an alternative door may be necessary but does not address making the frontsteps safer. A two-footed gait may not help if the client is unaware of where the foot is on the step.DIF: Applying/Application REF: 13KEY: 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 the client is stabilized and comfortable, what assessment by the nurse is most important?a. Assess for orthostatic hypotension.b. Determine if there are new medications.c. Evaluate the client for gait abnormalities.d. Perform a delirium screening test.ANS: BMedication side effects and adverse effects are common in the older population. Something as simpleas a new antibiotic can cause confusion and memory loss. The nurse should determine if the client istaking any new medications. Assessments for orthostatic hypotension, gait abnormalities, anddelirium may be important once more is known about the client’s condition.

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DIF: Applying/Application REF: 13KEY: Medications| medication safety| older adultMSC: 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 whichmedication should be taken at which time. The client refuses to use a pill sorter with slots fordifferent times, saying “Those are for old people.” What action by the nurse would 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 forevening meds, and the third color is for nighttime meds. Arranging medications by time in a drawermight be helpful if the person doesn’t accidentally put them back in the wrong spot. Easy-open topsare not related. Writing a list might be helpful, but not if it gets misplaced. With stickers on themedication bottles themselves, the reminder is always with the medication.DIF: Applying/Application REF: 14KEY: 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. Whatintervention by the nurse would be most helpful in preventing falls in this client?a. Keep the light on in the bathroom at night.b. Order a bedside commode for the client.c. Put the client on a toileting schedule.d. Use siderails to keep the client in bed.ANS: AAlthough this older adult is independent and ambulatory, being hospitalized can create confusion.Getting up in a dark, unfamiliar environment can contribute to falls. Keeping the light on in thebathroom will help reduce the likelihood of falling. The client does not need a commode or a

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toileting schedule. Siderails used to keep the client in bed are considered restraints and should not beused in that fashion.DIF: Applying/Application REF: 21KEY: 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 forpain. The client is allergic to morphine and reports pain and muscle spasms. When the nurse calls thesurgeon, which medication should he or she suggest in place of the morphine?a. Cyclobenzaprine (Flexeril)b. Hydromorphone hydrochloride (Dilaudid)c. Ketorolac (Toradol)d. Meperidine (Demerol)ANS: BCyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) are all onthe Beers list of potentially inappropriate medications for use in older adults and should not besuggested. The nurse should suggest hydromorphone hydrochloride.DIF: Remembering/Knowledge REF: 16KEY: Medications| Beers list| older adultMSC: Integrated Process: Communication and DocumentationNOT: 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 anddaughter-in-law. The client has urine burns on her skin, no dentures, and several pressure ulcers.What action by the nurse is most appropriate?a. Ask the family how these problems occurred.b. Call the police department and file a report.c. Notify Adult Protective Services.d. Report the findings as per agency policy.ANS: DThese findings are suspicious for abuse. Health care providers are mandatory reporters for suspectedabuse. The nurse should notify social work, case management, or whomever is designated in policies.

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That person can then assess the situation further. If the police need to be notified, that is the personwho will notify them. Adult Protective Services is notified in the community setting.DIF: Applying/Application REF: 19 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 giveconsent for upcoming surgery. What action by the nurse is best?a. Call Adult Protective Services.b. Discuss concerns with the health care team.c. Do not allow the client to sign the consent.d. Have the client’s family sign the consent.ANS: BIn this situation, each facility will have a policy designed for assessing competence. The nurse shouldbring these concerns to an interdisciplinary care team meeting. There may be physiologic reasons forthe client to be temporarily too confused or incompetent to give consent. If an acute condition isruled out, the staff should follow the legal procedure and policies in their facility and state fordetermining competence. The key is to bring the concerns forward. Calling Adult Protective Servicesis not appropriate at this time. Signing the consent should wait until competence is determined unlessit is an emergency, in which casethe next of kin can sign if there are grave doubts as to the client’sability to provide consent.DIF: Applying/Application REF: 16KEY: 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 olderpopulation includes which components? (Select all that apply.)a. Dementiab. Exhaustionc. Slowed physical activityd. Weakness

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e. Weight gainANS: B, C, DFrailty is a syndrome consisting of unintentional weight loss, slowed physical activity andexhaustion, and weakness. Weight gain and dementia are not part of this cluster of manifestations.DIF: Remembering/Knowledge REF: 9KEY: Frailty| frail elderly| older adultMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Health Promotion and Maintenance2. A home health care nurse assesses an older client for the intake of nutrients needed in largeramounts than in younger adults. Which foods found in an older adult’s kitchen might indicate anadequate intake of these nutrients? (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 have vitamin A; the vitamin D supplement has vitamin D; and oranges have vitamin C. Leanground beef is healthier than more fatty cuts, but does not contain these needed nutrients.DIF: Applying/Application REF: 10KEY: Nutrition| nutritional requirements| older adultsMSC: 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 what does the nurse assess? (Select all that apply.)a. Constipationb. Dehydrationc. Maniad. Urinary incontinencee. Weakness

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ANS: A, B, ECommon adverse medication effects include constipation/impaction, dehydration, and weakness.Mania and incontinence are not among the common adverse effects, although urinary retention is.DIF: Remembering/Knowledge REF: 14KEY: 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 olderadults in the 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, andevidence of falls.DIF: Remembering/Knowledge REF: 20KEY: 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 month’svisit. What actions should the nurse perform first? (Select all that apply.)a. Assess the client’s ability to drive or transportation alternatives.b. Determine if the client has dentures that fit appropriately.c. Encourage the client to continue the current exercise plan.d. Have the client complete a 3-day diet recall diary.e. Teach the client about proper nutrition in the older population.ANS: A, B, DAssessment is the first step of the nursing process and should be completed prior to intervening.Asking about transportation, dentures, and normal food patterns would be part of an appropriate

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assessment for the client. There is no information in the question about the older adult needing tolose weight, so encouraging him or her to continue the current exercise regimen is premature andmay not be appropriate. Teaching about proper nutrition is a good idea, but teaching needs to betailoredto the client’s needs, which the nurse does not yet know.DIF: Applying/Application REF: 10KEY: 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 doesthe registered nurse (RN) delegate to the unlicensed assistive personnel (UAP)? (Select all thatapply.)a. Assess skin redness when turning.b. Document Braden Scale results.c. Keep the client’s skin dry.d. Obtain a pressure-relieving mattress.e. Turn the client every 2 hours.ANS: C, D, EThe nurses’ aide or UAP can assist in keeping the client’s skin dry, order a special mattress ondirection of the RN, and turn the client on a schedule. Assessing the skin is a nursing responsibility,although the aide should be directed to report any redness noticed. Documenting the Braden Scaleresults is the RN’s responsibility as the RN is the one who performs that assessment.DIF: Applying/Application REF: 22KEY: 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 assessesthat the client is malnourished. What actions by the nurse are best? (Select all that apply.)a. Contact Adult Protective Services or hospital social work.b. Notify the provider that the client needs a tube feeding.c. Perform and document results of a Braden Scale assessment.d. Request a dietary consultation from the health care provider.

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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 actions by the nurse include assessing the client’s risk for skin breakdown with theBraden Scale, requesting a consultation with a dietitian, and suggesting a high-protein mealsupplement. There is no evidence that the client is being abused or needs a feeding tube at this time.DIF: Applying/Application REF: 20KEY: Nutrition| malnutrition| older adult| Braden ScaleMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

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Chapter 3: Assessment andCare of Patients with PainChapter 3: Assessment and Care of Patients with PainIgnatavicius: Medical-Surgical Nursing, 8th EditionMULTIPLE CHOICE1. A student asks the nurse what is the best way to assess a client’s pain. Which response by thenurse is best?a. Numeric pain scaleb. Behavioral assessmentc. Objective observationd. Client’s self-reportANS: DMany ways to measure pain are in use, including numeric pain scales, behavioral assessments, andother objective observations. However, the most accurate way to assess pain is to get a self-reportfrom the client.DIF: Remembering/Knowledge REF: 25KEY: 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 thenurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep withthe severe pain the client described. What response by the experienced nurse is best?a. “Being able to sleep doesn’t mean pain doesn’t exist.”b. “Have you ever experienced any type of pain?”c. “The client should be assessed for drug addiction.”d. “You’re right; I would put the medication back.”ANS: AA client’s description is the most accurate assessment of pain. The nurse should believe the client andprovide pain relief. Physiologic changes due to pain vary from client to client, and assessments of

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them should not supersede the client’s descriptions, especially if the pain is chronic in nature. Askingif the new nurse has had pain is judgmental and flippant, and does not provide useful information.This amount of information does not warrant an assessment for drug addiction. Putting themedication back and ignoring the client’s report of pain serves no useful purpose.DIF: Understanding/Comprehension REF: 28KEY: 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. Whatinformation provided by the nurse is most appropriate for the client’s long-term outcome?a. “At least you know that the pain after surgery will diminish quickly.”b. “Discuss acceptable pain control after your operation with the surgeon.”c. “Opioids often cause nausea but you won’t have to take them for long.”d. “The nursing staff will give you pain medication when you ask them for it.”ANS: BThe best outcome after a surgical procedure is timely and satisfactory pain control, which diminishesthe likelihood of chronic pain afterward. The nurse suggests that the client advocate for himself anddiscuss acceptable pain control with the surgeon. Stating that pain after surgery is usually short liveddoes not provide the client with options to have personalized pain control. To prevent or reducenausea and other side effects from opioids, a multimodal pain approach is desired. For acute painafter surgery, giving pain medications around the clock instead of waiting until the client requests itis a better approach.DIF: Applying/Application REF: 26 KEY: Pain| acute painMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance4. A nurse is assessing pain on a confused older client who has difficulty with verbal expression.What pain assessment tool would the nurse choose for this assessment?a. Numeric rating scaleb. Verbal Descriptor Scalec. FACES Pain Scale-Revisedd. Wong-Baker FACES Pain Scale

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ANS: CAll are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred by both cognitively intact and cognitively impaired adults.DIF: Applying/Application REF: 30KEY: Pain assessment| FACESMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Health Promotion and Maintenance5. The nurse is assessing a client’s pain and has elicited information on the location, quality,intensity, effect on functioning, aggravating and relieving factors, and onset and duration. Whatquestion by the nurse would be best to ask the client for completing a comprehensive painassessment?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 client’s opinionon a functional goal, such as what pain rating would be acceptable to him or her. Asking aboutaddiction is not warranted in an initial pain assessment. Asking about spiritual meanings for painmay give the nurse important information, but getting the basics first is more important. Askingabout pain tolerance may give the client the idea that pain tolerance is being judged.DIF: Applying/Application REF: 29 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 doesn’t get too tired.b. Give the client a picture of the pain scale and come back later.c. Question the client about new pain only, not normal pain from aging.d. Sit down, ask one question at a time, and allow the client to answer.ANS: DSome older clients do not report pain because they think it is a normal part of aging or because they

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do not want to be a bother. Sitting down conveys time, interest, and availability. Ask only onequestion at a time and allow the client enough time to answer it. Yes-or-no questions are an exampleof poor communication technique. Giving the client a pain scale, then leaving, might give theimpression that the nurse does not have time for the client. Plus the client may not know how to useit. There is no normal pain from aging.DIF: Applying/Application REF: 32KEY: 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 witheven tiny changes in physical condition and is “on the light constantly” asking for more painmedication. When assessing this client’s pain, what statement or question by the nurse is mostappropriate?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 physicalsymptoms and is “demanding” may have some psychosocial impact from the pain that is not beingaddressed. The nurse is providing the client the chance to explain the emotional effects of pain inaddition to the physical ones. Saying the nurse wishes he or she could do more is very empathetic,but this response does not attempt to learn more about the pain. Simply telling the client when thenext medication is due also does not help the nurse understand the client’s situation. “Why”questions are probing and often make clients defensive, plus the client may not have an answer forthis question.DIF: Applying/Application REF: 33KEY: Pain| pain assessmentMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Psychosocial Integrity

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8. A nurse on the medical-surgical unit has received a hand-off report. Which client should the nursesee 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 withnew-onset abdominal pain needs to be seen first. The postoperative client needs 45 minutes to anhour for the oral medication to become effective and should be seen shortly to assess foreffectiveness. The client going home requires teaching, which should be done after the first twoclients have been seen and cared for, as this teaching will take some time. The client restingcomfortably can be checked on quickly before spending time teaching the client who is going home.DIF: Analyzing/Analysis REF: 25KEY: 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 withadvanced dementia. The client scores a zero. What action by the nurse is best?a. Assess physiologic indicators and vital signs.b. Do not give pain medication as no pain is indicated.c. Document the findings and continue to monitor.d. Try a small dose of analgesic medication for pain.ANS: AAssessing pain in a nonverbal client is difficult despite the use of a scale specifically designed forthis population. The nurse should next look at physiologic indicators of pain and vital signs for cluesto the presence of pain. Even a low score on this index does not mean the client does not have pain;he or she may be holding very still to prevent more pain. Documenting pain is important but not themost important action in this case. The nurse can try a small dose of analgesia, but without havingindices to monitor, it will be difficult to assess for effectiveness. However, if the client has acondition that could reasonably cause pain (i.e., recent surgery), the nurse does need to treat theclient for pain.

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DIF: Applying/Application REF: 34KEY: Pain assessment| Checklist of Nonverbal Pain IndicatorsMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Physiological Adaptation10. A student nurse asks why several clients are getting more than one type of pain medicationinstead of very high doses of one medication. What response by the registered nurse is best?a. “A multimodal approach is the preferred method of control.”b. “Doctors are much more liberal with pain medications now.”c. “Pain is so complex it takes different approaches to control it.”d. “Clients are consumers and they demand lotsof pain medicine.”ANS: CPain is a complex phenomenon and often responds best to a regimen that uses different types ofanalgesia. This is called a multimodal approach. Using this terminology, however, may not be clearto the student if the terminology is not understood. Doctors may be more liberal with painmedications, but that is not the best reason for this approach. Saying that clients are consumers whodemand medications sounds as if the nurse is discounting their pain experiences.DIF: Understanding/Comprehension REF: 34KEY: Pain| pharmacologic pain management| multimodal pain managementMSC: 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 toparticipate in physical therapy. What intervention for pain management does the nurse include in theclient’s 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 pain associated with specific procedures is managed with additional medication. Anas-needed regimen will not control postoperative pain. A client-controlled analgesia pump might be a

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good idea but needs basal (continuous) and bolus (intermittent) settings to accomplish adequate paincontrol. Pain control needs to be continuous, not just administered prior to therapy.DIF: Applying/Application REF: 34KEY: 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 usingpatient-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. Arespiratory rate of 8 breaths/min is below normal, so the nurse should first check this client. Theclient sleeping soundly could either be overly sedated or just comfortable and should be checkednext. Pressing the button every 10 minutes indicates the client has a high level of pain, but the devicehas a lockout determining how often a bolus can be delivered. Therefore, the client cannot overdose.The nurse should next assess that client’s pain. The client who has not needed a bolus of painmedicine in several hours has well-controlled pain.DIF: Applying/Application REF: 35KEY: Patient-controlled analgesia (PCA) pump| pharmacologic pain managementMSC: 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 painmedication via patient-controlled analgesia (PCA). What action by the student requires the RN tointervene?a. Assesses the client’s pain level per agency policyb. Monitors the client’s respiratory rate and sedationc. Presses the button when the client cannot reach itd. Reinforces client teaching about using the PCA pump

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ANS: CThe client is the only person who should press the PCA button. If the client cannot reach it, thestudent should either reposition the client or the button, and should not press the button for the client.The RN should intervene at this point. The other actions are appropriate.DIF: Applying/Application REF: 35KEY: Patient-controlled analgesia (PCA)| pharmacologic pain managementMSC: 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 theclient’s health history would lead the nurse to consult with the provider over the choice ofmedication?a. 25–pack-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 5beers each day may indicate underlying liver disease, which should be investigated prior to takingchronic acetaminophen. The nurse should relay this information to the provider. Smoking is notrelated to acetaminophen side effects. Acetaminophen does not cause bleeding, so a previous pepticulcer or taking warfarin would not be a problem.DIF: Applying/Application REF: 35KEY: Acetaminophen| pharmacologic pain managementMSC: 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. Whichassessment findings would 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 hr

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ANS: DDrugs in this category can affect renal function. Clients should be adequately hydrated anddemonstrate good renal function prior to administering ketorolac. A urine output of 20 mL/2 hr iswell below normal, and the nurse should consult with the provider about the choice of drug. Cracklesand hypoactive bowel sounds are not related. A pain report of 3 does not warrant a call to thephysician. The medication may be part of a round-the-clock regimen to prevent and control pain andwould still need to be given. If the medication is PRN, the nurse can ask the client if he or she stillwants it.DIF: Applying/Application REF: 37KEY: Pharmacologic pain management| opioid analgesics| prostaglandinsMSC: 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 actionby the nurse is most important for client safety?a. Assess and record the client’s pain every 4 hours.b. Ensure the client is eating a high-fiber diet.c. Monitor the client’s bowel function every shift.d. Remove the old patch when applying the new one.ANS: DThe old fentanyl patch should be removed when applying a new patch so that accidental overdosedoes not occur. The other actions are appropriate, but not as important for safety.DIF: Applying/Application REF: 38KEY: Pharmacologic pain management| opioid analgesics| transdermal patchMSC: 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. Theclient also has a morphine allergy and a history of alcoholism. After surgery, several opioidanalgesics are prescribed. Which one would the nurse choose?a. Hydrocodone and acetaminophen (Lorcet)b. Hydromorphone (Dilaudid)c. Meperidine (Demerol)

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