Fundamentals Exam 1 (Potter & Perry Chapter Practice 465Questions) and Verified Answers |, Exams of Nursing

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A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility: A. Decreased peristalsis B. Decreased heart rate C. Increased blood pressure D. Increased urinary output - CORRECT ANSWERS Answer: A Rationale: Immobility disrupts normal metabolic functioning: decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis. A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient? A. Encouraging use of an overhead trapeze for positioning and transfer. B. Frequent family visits C. Assisting the patient to a wheelchair once per day D. Ensuring that there is an order for physical therapy - CORRECT ANSWERS Answer: A Rationale: The trapeze bar allows the patient to pull with the upper extremities to raise the trunk off the bed, aid in transfer from bed to wheelchair, or perform upper-arm exercises. It increases independence and maintains upper body strength to help in performing activities of daily living. An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility? A. Loss of appetite B. Gum soreness

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C. Difficulty swallowing D. Left-ankle joint stiffness - CORRECT ANSWERS Answer: D Rationale: Patients whose mobility is restricted require range-of-motion (ROM) exercises daily to reduce the hazards of immobility. Temporary immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness. Two weeks of joint immobilization without ROM can quickly result in contractures. The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend? A. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert B. Hot dog on whole wheat bun with a side salad and an apple for dessert C. Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert D. Turkey salad on toast with tomato and lettuce and honey bun for dessert - CORRECT ANSWERS Answer: A Rationale: Teach patient and/or caregiver the current recommended dietary allowances for calcium and review foods high in calcium (e.g., milk fortified with vitamin D, leafy green vegetables, yogurt, and cheese). A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken: A. Myoclonus B. Pathological fractures C. Pressure ulcers D. Pruritus - CORRECT ANSWERS Answer: C Rationale: Immobility is a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore preventive nursing interventions are imperative.

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To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had abdominal surgery? A. Turn, cough, and deep breathe every 30 minutes while awake B. Ambulate patient to chair in the hall C. Passive range of motion 4 times a day D. Immobility is not a concern the first postoperative day - CORRECT ANSWERS Answer: B Rationale: Prevention of complications of immobility begins when the patient becomes immobilized. Every 30 minutes is not necessary and disruptive to the healing process. Active patient participation in exercises is more beneficial to preventing venous stasis. Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest? A. Isometric exercises B. Administration of low-dose heparin C. Suctioning every 4 hours D. Use of incentive spirometer every 2 hours while awake - CORRECT ANSWERS Answer: D Rationale: Incentive spirometry opens the airway, preventing atelectasis. *What is the correct order in which elastic stockings should be applied?

1. Identify patient using two identifiers.
2. Smooth any creases or wrinkles.
3. Slide the remainder of the stocking over the patient's heel and up the leg
4. Turn the stocking inside out until heel is reached.
5. Assess the condition of the patient's skin and circulation of the legs.
6. Place toes into foot of the stocking.
7. Use tape measure to measure patient's legs to determine proper stocking size.*

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A. 1, 5, 7, 4, 6, 2, 3

B. 1, 7, 5, 4, 6, 2, 3

C. 1, 5, 7, 4, 6, 3, 2

D. 1, 5, 4, 7, 6, 3, 2 - CORRECT ANSWERS Answer: C Which of the following are physiological outcomes of immobility? A. Increased metabolism B. Reduced cardiac workload C. Decreased lung expansion D. Decreased oxygen demand - CORRECT ANSWERS Answer: C Rationale: Physiologic outcomes of immobility include decreased metabolism, increased cardiac workload, decreased lung expansion, and increased oxygen demand. An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.) A. B/P = 128/ B. Respirations 26/min on room air C. HR 114 D. Crackles over lower lobes heard on auscultation E. Pain reported as 3 on scale of 0 to 10 after medication - CORRECT ANSWERS Answer: B, C, D Rationale: Patients who are immobile are at high risk for developing pulmonary complications. The most common respiratory complications are atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions). Ultimately the distribution of mucus in the bronchi increases, particularly when the patient is in the supine, prone, or lateral position.

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A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements reflect understanding of what was taught? (Select all that apply.) A. "I usually go swimming with my family at the YMCA 3 times a week." B. "I need to ask my doctor if I should have a bone mineral density check this year." C. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." D. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill." E. "My lactose intolerance should not be a concern when considering my calcium intake." - CORRECT ANSWERS Answer: A, B, C Rationale: Patients at risk for or diagnosed with osteoporosis have special health promotion needs. Encourage patients at risk to be screened for osteoporosis and assess their diets for calcium and vitamin D intake. Multivitamins do not always have the needed amount of calcium for every individual. A patient needs to know his or her requirement and make a decision based on that. A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for the following signs of bleeding: (Select all that apply.) A. Bruising B. Pale yellow urine C. Bleeding gums D. Coffee ground-like vomitus E. Light brown stool - CORRECT ANSWERS Answer: A, C, D Rationale: Because bleeding is a potential side effect of these medications, continually assess the patient for signs of bleeding such as hematuria, bruising, coffee ground-like vomitus or gastrointestinal aspirate, guaiac-positive stools, and bleeding gums.

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The nurse evaluates that the NAP has applied a patient's sequential compression device (SCD) appropriately when which of the following is observed? (Select all that apply.) A. Initial patient measurement is made around the calves B. Inflation pressure averages 40 mm Hg C. Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve. D. Stockings are removed every 2 hours during application. E. Yellow light indicates SCD device is functioning. - CORRECT ANSWERS Answer: B & C Rationale: The most effective way to prevent deep vein thrombosis is through an aggressive program of prophylaxis. A properly functioning SCD inflates with a pressure around 40 mm Hg. Inflation pressure averages 40 mm Hg, and the patient's leg should be placed in the SCD sleeve with the back of knee aligned with the popliteal opening on the sleeve. Measurement involves length of leg, not calf. A green light indicates the SCD device is functioning. The effects of immobility on the cardiac system include which of the following? (Select all that apply.) A. Thrombus formation B. Increased cardiac workload C. Weak peripheral pulses D. Irregular heartbeat E. Orthostatic hypotension - CORRECT ANSWERS Answer: A, B, E Rationale: The three major changes are orthostatic hypotension, increased cardiac workload, and thrombus formation. The nurse puts elastic stocking on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to...? - CORRECT ANSWERS Answer: Promote venous return to the heart Rationale: Elastic stockings (sometimes called antiembolitic stockings) aid in maintaining external pressure on the muscles of the lower extremities and thus promote venous return. Increase in

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venous return helps reduce the stasis of blood thereby, reducing the risk for deep vein thrombosis in the lower extremities. Which assessment finding is expected for a patient who was just chased by an attacker? A. Blood sugar 45 mg/dL B. Blood pressure 180/ C. Pulse rate 55 beats/minute D. Hyperactive bowel sounds - CORRECT ANSWERS B In the early part of the twentieth century, the fight-or-flight response was described. This arousal of the sympathetic nervous system prepares a person for action by increasing heart rate; diverting blood from the intestines to the brain and striated muscles; and increasing blood pressure, heart rate, respiratory rate, and blood glucose levels. The young child cries and tries to run away when after being told that a flu shot is to be administered. Which term best describes the psychological reaction of the child? A. Primary appraisal B. Ineffective denial C. Adventitious crisis D. Developmental Crisis - CORRECT ANSWERS a When a person encounters an event, there is an immediate process of primary appraisal or rating of the event. If this appraisal results in the event being identified as a potential harm, loss, threat, or challenge, the person has stress. Ineffective denial is not indicated as the child realized the injection would be administered shortly and became upset. An adventitious crisis is a major disaster such as an earthquake or fire. A developmental crisis is when new coping strategies are needed to deal with stages of maturation such as getting married or having a child. The patient is severely injured in an accident but does not feel the pain until several hours afterward. Which type of hormone reduced the patient's sense of pain as part of the stress response?

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a. Endorphins b. Mineralocorticoids c. Prostaglandins d. Bradykinins - CORRECT ANSWERS a Endorphins are hormones that interact with the opiate receptors in the brain to reduce the perception of pain and produce a sense of well-being. Mineralocorticoids control salt and water balance within the body. Prostaglandins cause vasodilation and inhibit platelet function. Bradykinins play a role in inflammation causing vasodilation and pain. Which hormone is the most important factor for the physiological response to stress? a. Cortisol b. Glucagon c. Histamine d. Vasopressin - CORRECT ANSWERS a Corticotropin stimulates the adrenal gland to increase the production of corticosteroids, including cortisol, the primary hormone impacting the stress response. Cortisol increases blood glucose, enhances the brain's use of glucose, and increases the availability of substances for tissue repair. Vasopressin increases reabsorption of water by the kidneys and induces vasoconstriction, thereby raising blood pressure. Glucagon raises blood sugar levels. Histamine causes allergic reactions. The new mother experiences insomnia, irritability, and lack of appetite after several weeks in the neonatal care unit with her critically ill infant. Which stage of the general adaptation syndrome (GAS) is the new mother experiencing? a. Alarm b. Resistance c. Adaptation d. Exhaustion - CORRECT ANSWERS D

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If the stressor remains and adaptation does not happen, the person enters the third stage of the GAS, exhaustion. The exhaustion stage occurs when the body is no longer able to resist the effects of the stressor and the struggle to maintain adaptation drains all available energy. During the alarm reaction, rising hormone levels result in increased blood volume, blood glucose levels, heart rate, blood flow to muscles, and mental alertness. During the resistance stage, the body stabilizes and responds in an opposite manner to the alarm reaction. In the adaptation stage, antiinflammatory adrenocortical hormones are released, and healing occurs. The new mother experiences insomnia, irritability, and lack of appetite after several weeks in the neonatal care unit with her critically ill infant. Which nursing diagnosis is most appropriate for the new mother? a. Stress overload related to ongoing stress and worry about her critically ill infant b. Chronic low self-esteem related to lack of success at beginning of motherhood c. Disturbed sensory perception related to change in problem-solving abilities d. Disturbed personal identity related to inability to distinguish day shift from night - CORRECT ANSWERS a Stress overload related to ongoing stress and worry about her critically ill infant is the appropriate nursing diagnosis for the new mother. The new mother is at the exhaustion stage of the GAS due to the excessive demands of caring for her critically ill infant. The new mother does not demonstrate chronic low self-esteem, disturbed sensory perceptions, or disturbed personal identity. The nurse manager is overwhelmed as the unit prepares for an accreditation inspection. Which type of factor is causing the stress for the nurse manager? a. Situational b. Maturational c. Sociocultural d. Conventional - CORRECT ANSWERS a Situational factors include work stress that happens with work overload (patient load, distractions, conflicting priorities), heavy physical work, long hour work shifts, patient concerns (dealing with death and medical treatment), and interpersonal problems with other health care

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professionals and staff. Coping strategies vary with the individual and the situation. Maturational factors involve stressors and coping strategies that vary with life stage. Sociocultural factors include prolonged poverty, physical handicap, and chronic illness. Conventional factors are not a cause of stress. Which situation demonstrates an allostatic stress load? a. The nursing student uses meditation to cope with mild test anxiety. b. The patient develops anaphylactic shock after being stung by a bee. c. The nurse develops hypertension after working too many double shifts. d. The patient's heart rate returns to normal after a painful procedure is completed. - CORRECT ANSWERS c An allostatic load is the negative physiological effect of long-term extreme stress on the body. An allostatic load is demonstrated by the nurse's development of hypertension after working too many double shifts. Mild test anxiety, recovery after a stressful experience, and anaphylactic shock are not examples of allostatic stress. The patient is frustrated after being treated poorly by providers due to lack of health insurance. Which type of factor is causing the stress for the patient? a. Rational b. Situational c. Maturational d. Sociocultural - CORRECT ANSWERS d Sociocultural factors include prolonged poverty, physical handicap, and chronic illness. Situational factors include work-related stress. Coping strategies vary with the individual and the situation. Maturational factors involve stressors and coping strategies that vary with life stage. Rational factors are not a cause of stress. Which position is best suited for a nurse who preferred to study until the early hours of the morning during nursing school?

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a. Full-time 8-hour day/evening rotation b. Part-time 12-hour day/night rotation position c. Full-time 12-hour night position d. Full-time 8-hour day position - CORRECT ANSWERS c In general, people doing shift work need to maintain as consistent a sleep and mealtime schedule as possible. Some nurses often ease their coping with shift work by knowing their own circadian rhythms. A nurse who typically thinks well at night and tends to sleep late in the morning will adapt better to night shift than to day shift. Rotating shifts prevent establishment of a consistent sleep and mealtime schedule. The patient is overwhelmed by the stresses of being a spouse, new parent, and full-time employee. The nurse encourages the patient to use a housekeeper, babysitter, friends, or relatives to help reduce personal responsibilities and obligations. Which stress-relieving technique was recommended for the patient? a. Assertiveness training b. Engaging support systems c. Mindfulness stress reduction d. Progressive muscle relaxation - CORRECT ANSWERS b The nurse encourages engagement of support systems to relieve the patient's overwhelming duties. The patient will be better able to cope if a support system can assist with some of the patient's personal responsibilities and obligations. Assertiveness training teaches individuals to communicate effectively regarding their needs and desires. The ability to resolve conflict with others through assertiveness training reduces stress. When a group leader teaches assertiveness, the effects of interacting with other people increase the benefits of the experience. Progressive muscle relaxation diminishes physiological tension through a systematic approach to releasing tension in major muscle groups. Mindfulness stress reduction is a form of meditation to reduce symptoms of stress. The patient's spouse is overwhelmed and exhausted trying to provide the ongoing care required by the patient. Which nursing diagnosis is most appropriate for the patient's spouse?

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a. Activity intolerance related to fatigue and generalized weakness b. Readiness for enhanced comfort related to change in personal health status c. Caregiver role strain related to amount and complexity of patient health needs d. Risk for compromised human dignity related to loss of control of bodily functions - CORRECT ANSWERS c The patient's spouse is demonstrating caregiver role strain by feeling overwhelmed and exhausted trying to meet the patient's needs. The patient's spouse is not experiencing activity intolerance and is not at risk for compromised human dignity. The patient's spouse is exhausted and overwhelmed so readiness for enhanced comfort is not appropriate. Which intervention is appropriate for the nurse to reduce compassion fatigue? a. Increase nursing responsibilities at work. b. Hang out with co-workers when not at work. c. Strengthen relationships outside of the hospital. d. Take control over new areas at work to reduce stress. - CORRECT ANSWERS c Compassion fatigue occurs as a result of chronic stress and is often associated with the human service professions. Make a clear separation between work and home life. Strengthening friendships outside of the workplace, socially isolating oneself for personal "recharging" of emotional energy, and spending off-duty hours in interesting activities all help reduce burnout. Identify the limits and scope of your responsibilities at work. Recognize the areas over which you have control and the ability to change and those for which you do not have responsibility. A patient telephones a crisis intervention hotline. The nurse assigned to this center assesses that the patient is experiencing a crisis. What is the most appropriate action for the nurse to take? a. Define the problem at hand and ensure that the patient is safe. b. Take control of the situation and tell the patient what needs to be done. c. Ask the patient how he would like to handle the crisis and follow through. d. Ask the patient to list all of his problems and prioritize which to deal with first. - CORRECT ANSWERS a

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Crisis intervention begins with defining the problem, ensuring patient safety, and providing support. First determine that a patient is safe and is not at risk for injury to self or others, and then use crisis intervention to examine alternatives, make plans, and obtain a commitment to positive action from the patient. Ideally these last three steps are completed collaboratively with a patient, but a patient in crisis may be unable to participate actively and may need a very directive approach or a crisis interventionist. Emphasize focusing on the specific problem, and help a patient to avoid all- encompassing, catastrophic interpretations. The patient refuses to believe the physician's diagnosis and insists on a second opinion from a specialist. Which ego-defense mechanism is used by the patient? a. Denial b. Dissociation c. Deterioration d. Displacement - CORRECT ANSWERS a The patient develops an inability to swallow after many years of emotional abuse. The physicians can find no medical reason for the patient's dysphagia. Which ego-defense mechanism is used by the patient? a. Displacement b. Dissociation c. Compensation d. Conversion - CORRECT ANSWERS d A young child begins wetting the bed again after the parents bring home a new baby sister. Which ego-defense mechanism is used by the child? a. Regression b. Conversion c. Identification

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d. Compensation - CORRECT ANSWERS a The patient concentrates on the mind-numbing details of the spouse's funeral to delay dealing with the overwhelming pain of the loss. Which ego-defense mechanism is used by the patient? a. Conversion b. Dissociation c. Compensation d. Reimbursement - CORRECT ANSWERS b The nurse is caring for a patient who has just been diagnosed with amyotrophic lateral sclerosis (ALS). Which assessment findings justify the diagnosis of ineffective denial related to fear of loss of body function and death for the patient? (Select all that apply.) a. The patient attempts to hide shortness of breath from the nurse. b. The patient has fallen twice after insisting that a walker is not needed. c. The patient uses a gastrostomy tube for nutrition when unable to swallow. d. The patient attends support group meetings for families and patients with ALS. e. The patient insists that an uneven sidewalk caused a fall rather than leg weakness. - CORRECT ANSWERS a b e Which interventions are appropriate to assist the patient who is exhausted and depressed from providing care to the spouse with advanced dementia? (Select all that apply.) a. Assist the patient to identify and utilize support systems. b. Teach the patient how to maintain a sleep and activity log. c. Arrange for intervals of respite care for the patient's spouse. d. Help the patient to find personal time to rest and recuperate. e. Educate the patient about advanced directive and living will options. - CORRECT ANSWERS a c d

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The patient grieves the security of a solid supportive marriage after the spouse has an affair. Which type of loss was experienced by the patient? a. Actual b. Perceived c. Situational d. Maturational - CORRECT ANSWERS B Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had a loss. For example, a person perceives she is less loved by her parents and experiences a loss of self-esteem. People experience an actual loss when they can no longer touch, hear, see, or have near them valued people or objects. Examples include job loss. People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. Situational loss occurs as a result of an unpredictable life event. A situational loss often involves multiple losses. A divorce, for example, begins with the loss of a life companion, but often leads to financial strain and changes in living arrangements. The patient leaves behind nightly dinners with the family, babysitting assistance from friends, and the warmth of the local church community when moving across the country. Which type of loss was experienced by the patient? a. Conditional b. Perceived c. Situational d. Maturational - CORRECT ANSWERS C Situational loss occurs as a result of an unpredictable life event. A situational loss often involves multiple losses. A divorce, for example, begins with the loss of a life companion, but often leads to financial strain, changes in living arrangements. Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had a loss. For example, a person perceives she is less loved by her parents and experiences a loss of self-esteem. People experience maturational losses as they go through a lifetime of normal

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developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. There is no such thing as a conditional loss. The patient concentrates on the mind-numbing details of the spouse's funeral to delay dealing with the overwhelming pain of the loss. Which stage of grief is currently being experienced by the patient? a. Anger b. Denial c. Bargaining d. Acceptance e. Depression - CORRECT ANSWERS B Individuals in the denial stage cannot believe or understand that a loss has occurred and shut down their feelings until they are able to process the grief a little at a time. In the anger stage, a person resists the loss, is angry about the situation, and sometimes becomes angry with God. During bargaining, the individual postpones awareness of the loss and tries to prevent the loss from happening by making deals or promises. A person realizes the full significance of the loss during the depression stage. When depressed, the person feels overwhelmingly lonely or sad and withdraws from interactions with others. During the stage of acceptance, the individual begins to accept the reality and inevitability of loss and looks to the future. Which action demonstrates that the patient is experiencing the disorganization and despair stage of mourning? a. The patient puts the parent's estate and financial matters in order. b. The patient cannot eat or sleep for weeks after the loss of the parent. c. The patient sues the hospital for malpractice for not saving the parent's life. d. The patient falls sobbing to the floor when learning that the parent just died. - CORRECT ANSWERS C

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Expressing anger at the hospital for not saving the parent's life is an example of the disorganization and despair stage. Expressions of anger and hostility at an individual or institution responsible for the loss are seen with the disorganization and despair stage. The person may also take long periods to reflect on how and why the loss occurred. Falling sobbing to the floor and inability to eat or sleep demonstrate the yearning and searching stage. Putting the parent's financial estate in order demonstrates completion of a necessary monetary task after death. Which action demonstrates that the patient is experiencing the reorganization stage of mourning after having a stillborn baby? a. The patient volunteers at a local infant loss support group. b. The patient sits for hours and hours just looking at the empty crib. c. The patient has panic attack with shortness of breath and chest pain. d. The patient turns to alcohol to numb the overwhelming pain of the loss. - CORRECT ANSWERS a During the final phase of reorganization, which usually requires a year or more, the person accepts unaccustomed roles, acquires new skills, and builds new relationships. In the numbing phase, a person has periods of extremely intense emotion and reports feeling "stunned" or "unreal." The numbing phase lasts from several hours to a week. The yearning and searching phase evokes emotional outbursts, tearful sobbing, and acute distress. To move forward, people need to experience this painful phase of grief. During the phase of disorganization and despair, an individual spends much time thinking about how and why the loss occurred. The person often expresses anger at anyone he or she believes to be responsible. Gradually this phase gives way to an acceptance that the loss is permanent. Which nursing diagnosis is most appropriate for a patient who is having difficulty with accepting the reality of a lung cancer diagnosis by attempting to hide periods of shortness of breath from the nurse? a. Ineffective denial related to threat of unpleasant reality of lung cancer b. Noncompliance related to failure to adhere to prescribed treatment plan c. Effective therapeutic regimen management related to illness symptom reduction

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d. Readiness for enhanced decision making related to realignment of personal values - CORRECT ANSWERS a Which nursing diagnosis is most appropriate for a patient whose friends and family have grown distant after the death of the patient's spouse? a. Impaired verbal communication related to alteration in sensory perception b. Risk for loneliness related to insufficient interactions with friends and family c. Health-seeking behavior related to desire for increased control of personal health d. Readiness for enhanced spiritual well-being related to expressed desire for prayer - CORRECT ANSWERS b The patient is at risk for loneliness because the patient's friends and family have grown distant after the death of the patient's spouse. The patient does not demonstrate any sensory perception, desire for increased control, or expressed desire for prayer based on the information presented. Which action by the patient demonstrates reminiscence of a lost parent? a. The patient obtains a copy of the parent's will and inventories all assets. b. The patient returns to school to start a new career in business administration. c. The patient sues the hospital for malpractice after reviewing the medical record. d. The patient creates a scrapbook to remember special times spent with the parent. - CORRECT ANSWERS d The patient demonstrates reminiscence by taking the time to remember the lost loved one through creation of a scrapbook. Suing the hospital for malpractice does not remember individual characteristics of the loved one or shared experiences. Returning to school indicates that the patient has reached the acceptance stage of grief and is moving on to new activities. Obtaining the will and completing inventory of assets demonstrates completion of necessary monetary tasks after death.

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The patient is the caregiver to the spouse with advanced dementia. The patient mourns the loss of the spouse's mind and personality even though the body is still physically functioning. Which type of grief is being experienced by the patient? a. Normal b. Anticipatory c. Complicated d. Disenfranchised - CORRECT ANSWERS b Which behavior supports inclusion of the nursing diagnosis complicated grieving related to sudden death of a sibling in the patient's care plan? a. The patient donates the sibling's clothes to a local charity. b. The patient withdraws from relationships with friends and family. c. The patient adopts the sibling's dog and arranges for veterinary care. d. The patient arranges for the gravestone to be placed at the sibling's burial site. - CORRECT ANSWERS b The female patient grieves the loss of her child to adoption and finds it difficult to cope because the pregnancy was kept a secret from the family and community. Which type of grief is being experienced by the patient? a. Delayed b. Complicated c. Anticipatory d. Disenfranchised - CORRECT ANSWERS d Disenfranchised grief occurs in situations in which others view a person's loss as insignificant or invalid or when the patient's friends and family are unaware of the loss. Complicated grief happens when a person has difficulty progressing through the loss experience. The person does not accept the reality of the loss, and the intense feelings associated with acute grief do not go away. Normal or uncomplicated grief consists of commonly expected emotional and behavioral reactions to a

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loss (e.g., resentment, sorrow, anger, crying, loneliness, and temporary withdrawal from activities). The process of "letting go" before an actual loss or death has occurred is called anticipatory grief. The chart lists the patient's daughter as having medical durable power of attorney for the patient. How does this impact the patient's care? a. The daughter is an attorney and plans to sue to the nursing staff and hospital for malpractice after the patient's death. b. The daughter can provide consent for medical procedures if the patient becomes unresponsive or disoriented. c. The patient's daughter must be consulted before asking the patient to consent to medical procedures. d. The patient's daughter will translate medical terminology used by health care providers when communicating with the patient. - CORRECT ANSWERS b Which attitude of the nurse will facilitate effective care for hospice patients? a. The patient needs the nurse's presence and personal connection. b. Remaining silent signifies a noncaring attitude toward the patient. c. Reminiscing with the patient only makes a difficult situation worse. d. The patient does not recognize the impact of the loss if no tears are shed. - CORRECT ANSWERS a Which treatment would be refused by a patient who has requested palliative care? a. Therapeutic touch b. Supplemental oxygen c. Narcotic pain medications d. Knee-replacement surgery - CORRECT ANSWERS d

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Which assistance is provided to the patient and family by the hospice care providers? a. Education about resuscitation techniques if the patient stops breathing b. Options for ending the patient's life when the pain becomes too severe c. Financial support for funeral and burial services after the patient's death d. Volunteers to stay with the patient to give the family a break from caregiving - CORRECT ANSWERS d Which of the following is true for a patient to receive home hospice care? a. Caregiver support is available during normal business hours. b. A primary caregiver must be living in the home with the patient. c. If the patient goes to the hospital, all prehospital orders are canceled. d. In the hospital, the home hospice care person must provide personal care. - CORRECT ANSWERS b For a patient to receive home hospice care, a primary caregiver must be living in the home. The primary caregiver receives support from professional and volunteer hospice team members who are available 24 hours a day. If a patient receiving home hospice care goes to the hospital for the management of acute symptoms, a hospice nurse coordinates care between the home and hospital settings, but does not provide actual patient care. Which intervention is appropriate for the nursing diagnosis hopelessness related to disease progression? Withhold negative information about the patient's disease processes. Help the patient set realistic goals and then help the patient achieve them. Impress on the family the importance of limiting visiting hours to provide rest. Assure the patient that he will be well cared for and does not need to do anything. - CORRECT ANSWERS b To help patients feel more hopeful, remind them of their strengths and reinforce their expressions of courage, positive thinking, and realistic goal setting. Patients feel more hopeful when they have a

Chapter Practice 465 Questions) and Verified

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sense of control. Family members of dying people identified the importance of maintaining connections. When people have strong relationships and a sense of emotional connectedness to others, they know that help is available. Offer information to patients about their illness, correct misinformation, and clarify patient's perceptions. The nurse is caring for a patient who generally copes well after losing a child many years ago but becomes despondent each year on the anniversary of the death. Which is the best statement by the nurse? "That kind of reaction is very rare after so long a time. It would be best to avoid the cemetery on dates that might trigger this type of reaction." "What happens to you is understandable and common in people who have lost loved ones." "I find that hard to believe. We all grieve basically the same way, and I know that I would not react that way after such a long time." "The fact that you reacted so strongly is concerning to me. This could be the beginning of some psychological issues." - CORRECT ANSWERS b The patient is on a ventilator and has a heartbeat, but is brain dead. What should the nurse do? Explain that as long as the heart is beating, the patient is still alive. Provide a private area for the family to discuss organ donation options. Inform the family that the organs will be harvested when he is off the ventilator. Stress the importance of leaving the patient on the ventilator to harvest the corneas. - CORRECT ANSWERS b A nurse is caring for a patient who is depressed because her children have gone away to college. Which type of loss is experienced by the patient? a. Perceived

Chapter Practice 465 Questions) and Verified

Answers | 100% Correct | Grade A+

b. Situational c. Conditional d. Maturational - CORRECT ANSWERS d The nurse is caring for a patient who has just passed away. Which is the priority action of the nurse? Ask the family to leave the room so that postmortem care can be provided. Have the patient's family members sign consent forms for organ donation. Remove all drainage tubes and IV lines in case an autopsy is to be performed. Provide postmortem care in a manner consistent with religious or cultural beliefs. - CORRECT ANSWERS d Which behaviors support inclusion of the nursing diagnosis compromised family coping related to loss of home in a fire in the care plan? (Select all that apply.) The children missed school and the parents missed work during the first few days after the fire. All of the family members were able to stay at the home of a neighbor for the first week after the fire. The parents have not been able to speak to each other without screaming in anger for the last 2 weeks. The children still have occasional nightmares about the fire and the damage to the family home. The parents are so preoccupied with insurance frustration that they have not noticed that the oldest child is failing school. - CORRECT ANSWERS c, e Inability to speak to each other without screaming and not noticing the needs of other family members demonstrate the appropriateness of compromised family coping as a nursing diagnosis. It is expected that the family members would miss work and school for the first few days after the fire. The family is fortunate that they were able to stay with a neighbor. Occasional nightmares are to be expected following a house fire and do not demonstrate compromised family coping skills. Which assessment findings lead the nurse to inform the family that the patient's death is imminent? (Select all that apply.)

Chapter Practice 465 Questions) and Verified

Answers | 100% Correct | Grade A+

The patient's pupils are fixed and dilated bilaterally. The patient is lethargic, drifting in and out of consciousness. The patient's breathing is harsh and congested with periods of apnea. The patient had only 40 mL in the urinary catheter bag for the last 8 hours. The patient's temperature is 102.6° F (39.2° C) but the hands and feet are cool and mottled. - CORRECT ANSWERS b c d e

1. A patient needs to learn to use a walker. Which domain is required for learning this skill? A. Affective domain B. Cognitive domain C. Attentional domain D. Psychomotor domain - CORRECT ANSWERS D. Psychomotor domain Pg. 339 Using a walker requires the integration of mental and muscular activity.
2. The nurse is planning to teach a patient about the importance of exercise. When is the best time for teaching to occur? (Select all that apply.) A. When there are visitors in the room B. When the patient's pain medications are working C. Just before lunch, when the patient is most awake and alert D. When the patient is talking about current stressors in his or her life - CORRECT ANSWERS B. When the patient's pain medications are working

Chapter Practice 465 Questions) and Verified

Answers | 100% Correct | Grade A+

C. Just before lunch, when the patient is most awake and alert Plan teaching when the patient is most attentive, receptive, alert, and comfortable.

3. A patient newly diagnosed with cervical cancer is going home. The patient is avoiding discussion of her illness and postoperative orders. What is the nurse's best plan in teaching this patient? A. Teach the patient's spouse B. Focus on knowledge the patient will need in a few weeks C. Provide only the information that the patient needs to go home D. Convince the patient that learning about her health is necessary - CORRECT ANSWERS C. Provide only the information that the patient needs to go home This patient is in denial; thus it is appropriate to only give her information that is needed immediately.
4. The school nurse is about to teach a freshman-level high school health class about nutrition. What is the best instructional approach to ensure that the students meet the learning outcomes? A. Provide information using a lecture B. Use simple words to promote understanding C. Develop topics for discussion that require problem solving D. Complete an extensive literature search focusing on eating disorders - CORRECT ANSWERS C. Develop topics for discussion that require problem solving Adolescents learn best when they are able to use problem solving to help them make choices.