Fundamentals of Nursing 10th Edition Potter Perry Test Bank LATEST UPDATED (GRADED A++), Exams of Nursing

Download Fundamentals of Nursing 10th Edition Potter Perry Test Bank LATEST UPDATED (GRADED A++) and more Exams Nursing in PDF only on Docsity! Chapter 1. Nursing Today Fundamentals of Nursing 10th Edition Potter Perry Test Bank LATEST UPDATED (GRADED A] Fundamentals of Nursing 10th Edition Potter Perry Test Bank LATEST UPDATED (GRADED A++) MULTIPLE CHOICE 1. Contemporary nursing practice is based on knowledge generated through nursing theories. Florence Nightingales theory introduced the concept that nursing care focuses on: 1 Psychological needs 2 A maximal level of wellness 3 Health maintenance and restoration 4 Interpersonal interactions with the client ANS: 3 Florence Nightingale believed the role of the nurse was to put the clients body in the best state in order to remain free of disease or to recover from disease. Although Florence Nightingale may have addressed meeting the psychological needs of her clients, it is not the focus of her theory. The goal of Nightingales theory is to facilitate the bodys reparative processes by manipulating the clients environment. Florence Nightingale thought the human body had reparative properties of its own if it was cared for in a way to recover from disease. Her theory did not focus on achieving a maximal level of wellness. Florence Nightingale believed the nurse was in charge of the clients health. Although she interacted with her clients by reading to them, her theory of nursing care did not focus upon interpersonal interactions. DIF: A REF: 2 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 2. Nursing education programs in the United States may seek voluntary accreditation by the appropriate accrediting commission council of the: 1 National League for Nursing 2 American Nurses Association 3 Congress for Nursing Practice 4 International Council of Nurses ANS: 1 The National League for Nursing (NLN) is the professional nursing organization concerned with nursing education. The NLN provides accreditation to nursing programs that seek and meet the NLN accreditation requirements. The American Nurses Association (ANA) is concerned with the nursing profession and issues affecting health care, including standards of care. The Congress for Nursing Practice is the part of the ANA concerned with determining the legal aspects of nursing practice, the public recognition of the importance of nursing, and the impact of trends in health care on nursing practice. The International Council of Nurses (ICN) is concerned about issues of health care and the nursing profession, including the provision of an international power base for nurses. DIF: A REF: 8 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 3. Risk for injury during client transfer is minimized most effectively by: 1 Implementation of lift teams 2 Yearly personnel training sessions 3 Using mechanical lifts when possible 4 Use of evidence-based techniques ANS: 4 Injuries to both caregiver and client occur during client transfer. The caregiver is at risk for musculoskeletal injuries. The client is at risk for falls as well as musculoskeletal injuries. There is a shift from ineffective, injury-prone client transfer techniques to evidence-based practices for safe client handling. The implementation of a lift team is directly supported by evidence-based research (EBR). Yearly training sessions are important but the specific training is determined first by EBR. The use of mechanical lifts is directly supported by evidence-based research (EBR). DIF: C REF: 6 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Accident Prevention MULTIPLE RESPONSE 1. Which of the following activities reflect the nurses role in health promotion and wellness? (Select all that apply.) 1 Screening the local homeless population for head lice 2 Monitoring blood pressures at a community health fair 3 Organizing a foot race to benefit national cancer research 4 Consulting a teenage mother on breast-feeding techniques 3 Drug rehabilitation center 4 State-owned psychiatric hospital ANS: 4 A state-owned psychiatric hospital is an example of the secondary level of care in which clients who present with signs and symptoms of disease are diagnosed and treated. A school is an example of preventive or primary care. A nursing home is an example of continuing care. A drug rehabilitation center is an example of restorative care. DIF: A REF: 20 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 4. Which of the following fits within the occupational safety and health categories? 1 Noise exposure 2 Firearms safety 3 Swimming lessons 4 Motorcycle helmets ANS: 1 Exposure to environmental hazards within the workplace, such as noise exposure, is one aspect of occupational safety and health. Firearms do not fit within the occupational safety and health category. Swimming lessons do no fit within the occupational safety and health category. Motorcycle helmets do not fit within the occupational safety and health category. DIF: A REF: 20 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 5. A contractual agreement between a hospital and a corporation to pay the health care expenses of the corporations employees is an example of a(n): 1 PPO 2 HMO 3 Private insurance 4 Third-party payment ANS: 1 A preferred provider organization (PPO) is characterized by a contractual agreement between a set of providers (e.g., hospitals, physicians, or clinics) and a purchaser (e.g., the corporations insurance plan). Comprehensive health services are provided at a discount to the companies under contract. Enrollees are limited to a list of preferred hospitals, physicians, and providers. An enrollee pays more out-of-pocket expenses for using a provider not on the list. A Medicare HMO is the same as a managed care organization (all care provided by a primary care physician) but designed to cover costs of senior citizens. Private insurance is the traditional fee-for-service plan where payment is computed after services are provided based on the number of services used. Third-party payment is when an entity (other than the client or health care provider) reimburses health care expenses. Third-party payers include insurance companies, governmental agencies, and employers. DIF: A REF: 18 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 6. The Medicaid insurance program is best described as: 1 Acute care hospital insurance for the older adult population 2 A funded health care program for older and disabled persons 3 A state-regulated health care program for persons of low income 4 A fee-for-service insurance plan that supports preventive health care ANS: 3 Medicaid is a federally funded, state-operated program of medical assistance to people with low incomes. Individual states determine eligibility and benefits. This option describes Medicare. This option describes Medicare Part A. This option does not describe Medicaid. DIF: A REF: 18 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 7. Quality health care is an innovative approach to delivering health care. The major factor for its success is that it: 1 Focuses on the nursing process 2 Uses outcomes to manage client care 3 Is used exclusively in the acute care setting 4 Allows a high degree of flexibility delivering the care ANS: 2 Health care providers are defining and measuring quality in terms of outcomes. An outcome is a measure of what actually does or does not happen as a result of a process of care. The focus in quality health care is on the outcome, not the process. Quality health care is not used exclusively in the acute care setting. It may be used in various health care settings. Because quality health care is based on achieving outcomes, it does not allow a high degree of flexibility for the nurse in delivering care. DIF: A REF: 27 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 8. Case management is one strategy for coordinating health care services. What best describes this caregiving approach? 1 Continuity of care is the primary concern. 2 This focus of care may be more expensive. 3 The physician is the coordinator of client care. 4 It is designed to provide minimal to moderate levels of care. ANS: 1 With the case management model of care, the case manager coordinates the efforts of all disciplines to achieve the most efficient and appropriate plan of care. Continuity of care is of primary importance. If the efforts of all disciplines are well managed, repetition or delays may be avoided with a resultant shortened hospital stay. Therefore this focus of care may not be more expensive. The physician may or may not be the coordinator of client care. The case manager typically is a nurse or social worker. Case management is not entirely based on the level of care required. DIF: A REF: 21 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care/ Case Management 9. The payment mechanism that Medicare uses within its health care financing is: 1 Capitation 2 Fixed payments 3 Direct contracting 4 Prospective payment ANS: 2 Inpatient hospital services for Medicare clients are reimbursed a set amount for each DRG, regardless of the clients length of stay or use of services in the hospital. Capitation is the payment mechanism in which providers receive a fixed amount per enrollee of a health care plan. 2 Focuses on health maintenance and primary care 3 Allows the individual to go to any physician that he desires 4 Requires a contractual agreement between the health provider and clients employer ANS: 2 In a managed care organization (MCO), a primary care physician provides all care and the focus is on health maintenance and primary care. Medicaid reimburses nursing home funding. In a managed care organization, referral by the primary care physician is necessary for access to specialists and for hospitalization. A PPO is limited to a contractual agreement between a set of providers and one or more purchasers. DIF: A REF: 25 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 15. Which form of health care is of primary importance when dealing with managed care? 1 Health promotion 2 Disease prevention 3 Tertiary treatment 4 Secondary treatment ANS: 1 If people stay healthy, the cost of medical care declines. Systems of managed care focus on containing or reducing costs, increasing client satisfaction, and improving the health or functional status of the individual (Sultz and Young, 2004). Health promotion: Activities that develop human attitudes and behaviors to maintain or enhance well-being. Disease prevention: Activities that protect people from becoming ill because of actual or potential health threats. Tertiary prevention: Care that prevents further progression of disease. Secondary prevention: Early diagnosis and treatment of illness (e.g., screening for hypertension). DIF: C REF: 21 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 16. A nurse is consulting with a homeless family who has a 12-year-old disabled child. The nurse suggests which of the following services to best assist with the childs health care needs? 1 Medicare 2 Medicaid 3 Long-term care insurance 4 An extended care faculty ANS: 2 Medicaid is a federally funded, state-operated program that provides (1) health insurance to low- income families and (2) health assistance to low-income people with long-term care (LTC) disabilities. MULTIPLE CHOICE 1. The student nurse is investigating different types of practice settings. In looking at community health nursing, the student recognizes that it: 1 Is the same as public health nursing 2 Focuses on the incidence of disease 3 Requires graduate-level educational preparation 4 Includes direct care and services to subpopulations ANS: 4 Community health nursing strives to safeguard and improve the health of populations in the community as well as providing direct care services to subpopulations within a community. Public health nursing is concerned with trends and patterns influencing the incidence of disease within populations. A community health nurse may be involved in direct client care for disease within a community. Public health nursing focuses on the needs of populations. Community health nursing has a broader focus, with an emphasis on the health of a community. The community health nurse merges public health knowledge with nursing theory. The community health nurse considers the needs of populations and is prepared to provide direct care services to subpopulations within a community. Nurses who become expert in community health practice may have advanced nursing degrees, yet the baccalaureate-prepared generalist also can become quite competent in formulating and applying population-focused assessments and interventions. DIF: A REF: 34 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. As a community health nurse assisting the client and family with nutritional needs the nurse should first: 1 Identify for the client the best foods to buy 2 Purchase foods at the lowest cost for the client 3 Ask the client and family what they think they should eat 4 Provide information on stores with the most reasonable pricing ANS: 3 Chapter 3. Community-Based Nursing Practice With the goal of helping clients assume responsibility for their own health care, the community health nurse must assess a clients learning needs and readiness to learn within the context of the individual, the systems the individual interacts with, and the resources available for support. Asking the client about what foods he or she thinks should be eaten may help the nurse assess the clients level of knowledge regarding nutrition as well as the clients food preferences. It also enables the client to become a participant in his or her care. Telling the client what foods to buy does not encourage the client to assume responsibility for managing his or her health care. The nurse should first assess the resources available, and then encourage the client to do his or her own shopping. Providing information on food sources and stores with reasonable pricing may be appropriate after the nurse has determined what information the client requires to meet nutritional needs. DIF: C REF: 40 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 3. Which one of the following clients from a vulnerable population currently appears to be at the greatest risk? 1 A physically abused client in a shelter 2 A schizophrenic client in outpatient therapy 3 An older adult taking medication for hypertension 4 A substance abuser who shares drug paraphernalia ANS: 4 A client with substance abuse has health and socioeconomic problems. These clients frequently may avoid health care for fear of judgmental attitudes by health care providers and concern over being turned in to criminal authorities. An abused client in a shelter has sought protection so currently should be at less risk. Although considered to be a member of a vulnerable population, the older adult who takes medication for a chronic disease, such as hypertension, is taking measures to maintain health. A schizophrenic client in outpatient therapy is currently at less risk because he or she is receiving treatment. DIF: C REF: 36 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 4. A client with a history of a gastrointestinal disorder eats a well-balanced diet that keeps his GI symptoms suppressed. Which level of prevention corresponds to his dietary management? 1 Health promotion 2 Primary prevention 3 Tertiary prevention 4 Secondary prevention 8. The client is being discharged from an acute care facility following a total hip replacement. She will need follow-up for her rehabilitation and exercise plan. In addition to a home health care nurse, what referral should be discussed? 1 Dietitian 2 Social worker 3 Physical therapist 4 Respiratory therapist ANS: 3 Directing clients to appropriate resources and improving continuity of care require the nurse to know those resources well. A physical therapist is responsible for the clients movement system and is likely to be needed following hip replacement surgery. A social worker may or may not be necessary. A dietitian may or may not be necessary. A respiratory therapist would not be necessary unless the client experienced a respiratory complication or had a preexisting respiratory condition. DIF: A OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 9. The nurse recognizes which of the following as the largest contributing factor for the rise in the need and use of home care? 1 Government funding of the home care setting has increased greatly. 2 Clients are more acutely ill when discharged from the acute care facility. 3 There are 7 days/week services for the elderly in home care agencies. 4 The existence of more single-income families has increased the need for their elderly relatives to receive care in the home. ANS: 2 Because hospital stays are being shortened to control health care costs, clients are returning home more acutely ill. This is the largest contributing factor for the rise in the need and use of home care. Government funding of home care is not the largest contributing factor for the rise in the need and use of home care. There are 7 days/week services for the elderly in a variety of settings, such as in acute care or long-term care, not just in the home care setting. Being able to provide daily services for the elderly in the home care setting is not the largest contributing factor for the rise in the need and use of home care. The existence of more single-income families is not the largest contributing factor for the rise in the need and use of home care. DIF: C REF: Chapter 2, 22 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 10. One of the overall goals of Healthy People 2010 is to: 1 Increase life expectancy 2 Decrease health care costs 3 Promote managed care organizations 4 Establish the credentials of service providers ANS: 1 The overall goals of Healthy People 2010 are to increase the life expectancy and quality of life and to eliminate health disparities. The initiative of Healthy People 2010 is to improve the delivery of health care services to the general public. The overall goal did not focus on reducing health care costs. Although managed care organizations may increase in number, this was not a goal of the Healthy People 2010 initiative. Establishing the credentials of care providers was not a goal of Healthy People 2010. DIF: A REF: 33 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 11. When assessing members of a vulnerable population, the community health nurse should realize that the primary need is to: 1 Provide culturally competent assessment. 2 Organize in your mind exactly what you need to ask. 3 Create a comfortable, nonthreatening environment. 4 Be alert for indications of mental and physical abuse. ANS: 3 In order to be successful in assessing a member of a vulnerable population, the nurse must first create an environment that is encourages the client to cooperate with and actively participate in the assessment process While it is important that the nurse be cultural considerate of the client, it is not the primary need of those offered as options. While organization to thought is important to the effective use of time needed for an assessment, it is not the primary need of those offered as options. While vulnerable populations may be more susceptible to both mental and physical abuse making observation for signs of abuse important, it is not the primary need of those offered as options DIF: C REF: 35 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 12. The nurse working in a free clinic often utilized by Hispanic immigrants is assessing a client who reports a cough and malaise. The client is hearing impaired, speaks very little English and is currently living in a homeless shelter. The nurses primary concerns should be the clients: 1 Language barrier 2 Risk for tuberculosis 3 Hearing impairment 4 Lack of health care resources ANS: 2 Risk for tuberculosis presents the greatest risk since it is supported by the physical signs, is highly contagious and a risk factor among the homeless and some immigrant populations. The language barrier is a concern since it impacts the communication between the nurse and the client but it is not the primary concern among the options offered. The clients hearing impairment is a concern because it has an impact on the communication between the nurse and the client but it is not the primary concern among the options offered. The clients lack of insurance is a concern because it affects the treatment plan necessary for the clients recovery, but it is not the primary concern among the options offered. DIF: C REF: 36 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 13. A nurse is planning interventions for the clients of a homeless shelter. Which of the activities represents a primary level intervention regarding sexually transmitted diseases? 1 HIV screening for all residents 2 Sex education for teenage residents 3 Treatment for residents diagnosed with AIDS 4 Gynecological referrals for female residences ANS: 2 Primary level interventions are directed a preventing the disease. Educational programming is generally considered a primary intervention. Screening a disease is generally considered a secondary level intervention. Treatment of the disease is generally considered a tertiary level intervention. Referrals are generally considered a secondary intervention. DIF: A REF: 36 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 14. The nurse working in a free clinic is caring for a homeless client diagnosed with paranoid schizophrenia who has reported that, I hurt my foot running away from them. It hurts so bad I can hardly walk now. On assessment the nurse notices bruising on the clients back, arms, and the need for change. While cost to the client is a factor, it is not the primary factor in achieving client compliance provided among the options available since client compliance is primarily a result of the clients understanding of the need for change. An incentive is sometimes necessary, but it is not the primary factor in achieving client compliance provided among the options available, because client compliance is primarily a result of the clients understanding of the need for change. DIF: C REF: 39 OBJ: Analysis TOP: Nursing Process: Planning/Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance 18. The nurse is assessing a client diagnosed with chronic bronchitis who has been experiencing an increase in dyspnea. The client lives within 2 blocks of a factory that emits pollution into the air. In light of this information, the nurse is primarily concerned with: 1 Performing a complete client health history and physical assessment 2 Providing the client with assess to all the required breathing treatments 3 Identifying a correlation between the pollution and the clients increased dyspnea 4 Determining the availability of alternate housing for the client away from the factory ANS: 3 There may be many factors that are affecting the clients breathing. Determining the clients exposure to the pollution and its affects of the clients breathing would be the nurses primary concern for this client. The assessment and history is important but is not the best option available regarding the effects of air pollution on the clients respirations. The availability of required breathing treatments is important but it is not the best option regarding the effects of air pollution of the clients respirations. It may be necessary for the client to consider moving but only if it is determined that the pollution is responsible of the increase in the dyspnea. DIF: A REF: 40 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Which of the following clients is a concern for the community health nurse? (Select all that apply.) 1 The homeless woman with a history of congestive heart failure 2 The elderly gentleman who fell while disembarking from a bus 3 The child of itinerant workers who has a developed asthma 4 A client diagnosed with HIV who recently lost her insurance 5 A 15-year-old who was injured while at a public swimming pool 6 A retired service veteran who has a chronic psychiatric disorder ANS: 1, 3, 4 Community-based health care occurs outside traditional health care institutions, such as hospitals. It provides services for acute and chronic conditions to individuals and families with in the community (Stanhope and Lancaster, 2006). Some of these problems include an increase in homeless and immigrant populations, an increase in sexually transmitted diseases, underimmunization of infants and children, and life-threatening diseases (e.g., clients living with HIV and other emerging infections). All of these clients possess risk factors that are community based DIF: C REF: 40 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 2. A nurse working with clients at or below the poverty level recognizes that the life expectancy of these clients is lower than the general population because of: (select all that apply.) 1 Inadequate nutritional diets 2 High-risk work environments 3 Hazardous living environments 4 Addictive and abusive lifestyles 5 Predisposition to chronic diseases 6 Ineffective decision making abilities ANS: 1, 2, 3, 4 People who live in poverty are more likely to live in hazardous environments, work at high-risk jobs, eat less nutritious diets, abuse substances, and have multiple stressors in their life. When researchers compared the life expectancies of European Americans and African-Americans, the causes of the differences were related to low socioeconomic status rather than ethnicity. Predisposition to chronic disease in part is genetic in nature and research has confirmed no such link between poverty and chronic disease. Decision-making ability is not the only factor affecting decision making. Poverty negatively affects the individuals ability to access recourses and adds stressors such as finding shelter that can alter the decision-making process. MULTIPLE CHOICE Chapter 4. Theoretical Foundations of Nursing Practice 1. In preparing to review different theories, the nurse reviews basic information to assist in understanding the material. Theories are defined as: 1 Mental formulations of objects or events 2 Aspects of reality that can be consciously sensed 3 Statements that describe concepts or connect concepts 4 Concepts or propositions that project a systematic view of phenomena ANS: 4 A theory is a set of concepts, definitions, relationships, and assumptions that project a systematic view of phenomena. Mental formulations of objects or events are called concepts. Aspects of reality that can be consciously sensed are called phenomena. Statements that describe concepts or connect concepts are called assumptions. DIF: A REF: 46 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 2. There are different types of theories that may be used by nurses seeking to study the basis of nursing practice. When the goal of a theory is to speculate on why phenomena occur, it is termed a: 1 Grand theory 2 Prescriptive theory 3 Descriptive theory 4 Middle range theory ANS: 3 Descriptive theories describe phenomena, speculate on why phenomena occur, and describe the consequences of phenomena. Grand theories provide the structural framework for broad, abstract ideas about nursing. Prescriptive theories address nursing interventions and predict the consequence of a specific nursing intervention. Middle range theories address specific phenomena or concepts and reflect practice. DIF: A REF: 47 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance ANS: 4 Determining a clients attitudes toward health behaviors follows a health-and-wellness theoretical model. Focusing on the response of a client to the process of growth and development is consistent with developmental theories. DIF: A REF: 47 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 7. While working on a postoperative unit, the nurse is applying the elements of the self-care theory. The nurse who assists the client to manage or attain self-care in wound management is using the theory developed by: 1 Imogene King 2 Dorothea Orem 3 Virginia Henderson 4 Florence Nightingale ANS: 2 The goal of Orems theory is to help the client perform self-care. The goal of Kings theory is to use communication to help the client reestablish positive adaptation to the environment. The goal of Hendersons theory is to work independently with other health care workers assisting the client to gain independence as quickly as possible. The goal of Nightingales theory is to facilitate the bodys reparative processes by manipulating the clients environment. DIF: A REF: 50 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 8. Martha Rogers theory has a framework for practice that includes the: 1 Manipulation of the clients environment 2 21 nursing problems within 4 major client needs 3 Seven categories of behavior and behavioral balance ANS: 4 4 Unitary human being in continuous interaction with the environment ANS: 1 The framework for practice according to Martha Rogers theory is the unitary human continuously changing and coexisting with the environment. Nightingales theory includes manipulation of the clients environment (i.e., appropriate noise, nutrition, hygiene, light, comfort, socialization, and hope) in the framework for practice. Abdellahs nursing theory includes 21 nursing problems within 4 major client needs in the framework for practice. Johnsons theory includes seven categories of behavior and behavioral balance in the framework for practice. DIF: A REF: 50 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 9. The nurse plans to apply a theory that focused on stress reduction. A theory proposed by which one of the following individuals should be selected? 1 Parse 2 Peplau 3 Neuman 4 Orlando ANS: 3 Stress reduction is the goal of the systems model of nursing practice according to Neumans theory. Parses theory focuses on indivisible beings and the environment co-creating health. Peplaus theory focuses on the interpersonal process as the maturing force for personality. Orlandos theory focuses on the interpersonal process to alleviate distress. DIF: A REF: 49 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 10. A similarity between the theories of Leininger and of Benner and Wrubel is: 1 Caring as a central focus 2 The clients adaptation to demands 3 An emphasis on the maximum level of wellness ANS: 1 Health has different meanings for each client, the clinical setting, and the health care profession (see Chapter 6). Health is dynamic and continuously changing. Your challenge is to provide the best possible care based on the clients level of health and health care needs at the time of care delivery. While the other options may be true, they are not universally true to all individuals because not everyone is involved in a nurse-client relationship, wellness can be affected by internal factors, external factors, or a combination of both, and not everyone is capable of perceiving and defining their own wellness. DIF: C REF: 45 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 13. Which of the following statements by the nurse best defines nursing diagnoses for a client? 1 It is the basis for a clients care plan. 2 It is what we nurses use to plan your care. 3 It is one of a set of standardized client oriented problems. 4 It is the way nurses identify what specific needs a client has. ANS: 4 In medicine, physicians diagnose and treat disease. In contrast, nursing is the diagnosis and treatment of human responses to actual or potential health problems (ANA, 2003). The scope of nursing is broad. For example, a nurse does not medically diagnose the clients heart condition but instead assesses the clients response to the disease and may develop nursing diagnoses of fatigue, change in body image, and altered coping. From these nursing diagnoses, the nurse creates an individualized plan of care for each of the clients health problems. Although the other statements are correct, they are not the best options available because they do not fully explain the function of a nursing diagnosis. DIF: C REF: 45 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 14. The nurse is caring for a client newly diagnosed with type 2 diabetes mellitus. Which of the following nursing interventions best reflects Orems nursing theory? 1 Arranging for a consult with a certified diabetic nurse educator 2 Demonstrating proper documentation of glucose testing results 3 Explaining the role of A1C values in the management of glucose levels 4 Preparing discharge teaching to reinforce proper finger-stick technique ANS: 4 If a nurse uses Orems theory in practice, the nurse assesses and interprets the data to determine the clients self-care needs, self-care deficits, and self-care abilities in the management of a disease. The theory then guides the design of individualized nursing interventions. While the other interventions are appropriate and will ultimately affect effective client self-care/ management of the diabetes, they are not the correct option because they are not directly involved in determining client self-care needs. DIF: C REF: 50 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 15. Swansons theory of caring is best demonstrated when the nurse: 1 Demonstrates efficiency when performing ordered treatments 2 Offers to stay with the client during a painful bedside procedure 3 Administers the clients pain medication promptly when requested 4 Frequently updates a family regarding a clients status during surgery ANS: 2 Swansons theory of caring defines five components of caring: knowing, being with, doing for, enabling, and maintaining belief. These components provide a foundation of knowledge for the direction and delivery of caring nursing practice. This theory provides a basis for identifying and testing nurse caring behaviors to determine if caring improves client health outcomes. Offering to stay with the client is an intervention directly reflected of being with the client. Efficiency is a component of caring but it is not the best option available because it is not exclusively directed toward Swansons theory. Administering pain medication promptly reflects effective nursing care as well as a clients right. It is a component of caring but it is not the best option available because it is not exclusively directed towards Swansons theory. Effective nursing care and caring for the family is important, but it is not the best option available because it is not directed towards the client. DIF: C REF: 46 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 16. Which of the following responses observed in a client recently diagnosed with lung cancer is most directly addressed by the Neuman System Model? 1 The client asks for a consult with the hospital clergy. 2 The client is observed crying after his family has left for the day. 3 The client asks for pictures of his children to be brought to him in the hospital. 4 The client is heard saying, I trust my health team, and Ill do what they suggest. ANS: 2 Examples of phenomena of nursing include caring, self-care, and client responses to stress. In the Neuman Systems Model (1995), phenomena include all client responses, environmental factors, and nursing actions. Crying is reflective of a clients response to stress to a second level need (Maslows) and so is directly related to Neumans model. While consulting with clergy is reflective of a client need, it is higher on Maslows hierarchy and so not the best option available. While requesting family photos is reflective of a client need, it is higher on Maslows hierarchy and so not the best option available. The client stating that he/she will trust the health team is reflective of a client response, it is less reflective of a need and so not the best option available. DIF: C REF: 49 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 17. A client diagnosed with type 2 diabetes mellitus reports poor glucose control since starting her new stressful job. The nurse uses Neumans theory to focus on the: 1 Identification of new stressors and improve dietary choices 2 Acquisition of appropriate interpersonal communication skills 3 Learning of effective coping methods and relaxation techniques 4 Implementation of both aerobic and anaerobic exercise routines ANS: 1 4 An asthmatic clients concern regarding the lack of insurance to pay for her medications ANS: 4 The second level of Maslows hierarchy includes safety and security needs, which involve physical and psychological security. The clients concern about securing the medication needed to minimize the potential for breathing problems has the highest priority of the options available. The fourth level encompasses esteem and self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth. Although important, a clients concern regarding her appearance would not have priority over the other options available. The third level contains love and belonging needs, including friendship, social relationships, and sexual love. Although important, a clients reaction to the loss of a loved one does not have priority over the other options available. The second level of Maslows hierarchy includes safety and security needs, which involve physical and psychological security. While the clients concern for the safety of his belongs is on the same level, it does not take priority over the client whose concern relates to potential breathing problems. DIF: C REF: Chapter 6, 72 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 21. Which of the following statements best expresses the primary goal of nursing practice? 1 To identify client needs in order to facilitate improved health and wellness 2 To tend to the physical and psychosocial needs of both the client and his family 3 To provide effective, research-based nursing care specifically tailored to each clients needs 4 To perform the required treatments and interventions directed towards client recovery from illness ANS: 3 Providing excellent, evidenced-based nursing care is an expectation for all nurses and the care they provide. Although other options are reflective of an appropriate nursing outcome, they are not the best descriptions of nursings primary goal. MULTIPLE CHOICE Chapter 5. Evidence-Based Practice 1. Which of the following research approaches is an example of an exploratory type of research? 1 Establishing facts and relationships of past events 2 Testing how well a program, practice, or policy is working 3 Refining a hypothesis on the relationships among phenomena 4 Portraying the characteristics of persons, situations, or groups ANS: 3 An example of an exploratory type of research is to develop or refine a hypothesis about the relationships among phenomena. An example of a historical type of research is to establish facts and relationships concerning past events. An example of an evaluation type of research is to test how well a program, practice, or policy is working. An example of a descriptive type of research is to accurately portray characteristics of persons, situations, or groups and the frequency with which certain events or characteristics occur. PTS: 1 DIF: A REF: 62 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. The Health Information Portability and Accountability Act (HIPAA), implemented in 2003, may influence nursing research in the area of: 1 The cost of the study 2 Where the study may be published 3 What type of study may be conducted 4 How the data will be obtained and protected ANS: 4 HIPAA regulations identify how protected health information of potential research subjects is to be managed. The researcher must be able to ensure that the data will be protected and used only by the researcher. HIPAA regulations should not influence the area of cost in nursing research. The focus of HIPAA regulations is not on where a study may be published. HIPAA regulations should not influence the type of study conducted. PTS: 1 DIF: A OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. The expected research role for the baccalaureate-prepared nurse is to: 1 Assume the role of a clinical expert 2 Acquire funding for research projects 3 Identify clinical nursing problems in practice 4 Develop methods of inquiry relevant to nursing ANS: 3 Nurses with a baccalaureate degree are prepared to read research critically and use existing standards to determine the readiness of the findings for clinical practice. They also participate in research activities through identification of clinical problems in nursing practice. Nurses with a masters degree assume the role of clinical expert and are able to create a climate in which research-based change can be implemented into practice. Doctorally-prepared nurses are responsible for acquiring funding for research from public and private sources. Doctorally-prepared nurses are prepared to design studies independently including the development of methods of inquiry relevant to nursing. PTS: 1 DIF: A REF: 55 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. When a nurse researcher distributes an explanatory information sheet to subjects solicited for participation in her study, which of the following ethical principles that guide research is this researcher using? 1 Informed consent 2 Freedom from harm 3 Protection of subjects 4 Confidentiality of subjects ANS: 1 As a component of informed consent, research subjects are given full and complete information about the purpose of the study, procedures, data collection, potential harm and benefits, and alternative methods of treatment. Research aspects such as minimizing the risk to participants, allowing reasonable risk to participants in relation to anticipated benefits, and monitoring the research to ensure the safety of participants follow the ethical standard of freedom from harm. In the case of research, institutions have Health Information Portability and Accountability Act (HIPAA) regulations that identify how protected health information of research subjects is to be 3 Correlational research 4 Experimental research ANS: 3 Correlational research explores the interrelationships among variables of interest (such as factors affecting client comfort) without any active intervention by the researcher. Historical research is designed to establish facts and relationships concerning past events. It would not use prospective groups of clients. Evaluation research tests how well a program, practice, or policy is working. In experimental research, the investigator controls the study variable and randomly assigns subjects to different conditions. PTS: 1 DIF: A REF: 62 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. Which of the following research topics best lends itself to the experimental research process method? 1 The effects of therapeutic touch on a geriatric client diagnosed with Alzheimers disease 2 Prioritizing three nursing diagnoses for a newly admitted client with diabetes mellitus 3 Employing humor as an intervention with clients who are recovering from orthopedic surgery 4 Determining the blood pressure patterns of a client who recently experienced a cerebrovascular accident (i.e., stroke) ANS: 3 In experimental research, the investigator controls the study variable (use of humor) and randomly assigns subjects to different conditions (those who receive humor as an intervention, and those who do not). The effect of therapeutic touch on a geriatric client with Alzheimers disease lends itself to the nursing process as a nursing intervention to perhaps assist a client in meeting a goal of preventing social isolation. To use the experimental research process, there would have to be other clients involved (i.e., a group of clients with Alzheimers disease who receive therapeutic touch, and a group of clients with Alzheimers disease who do not receive therapeutic touch) to determine whether or not therapeutic touch had any effect. Prioritizing nursing diagnoses for client care is an example of using the nursing process. Determining the blood pressure patterns of a client who recently had a cerebrovascular accident is a part of the assessment phase of the nursing process. In contrast to an experimental research study, no variable is being controlled by the nurse. PTS: 1 DIF: A REF: 62 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. The nurse is looking at different strategies for learning and incorporating new information into practice. A strategy that uses problem-solving is demonstrated by: 1 Repeatedly practicing vital signs until competence is achieved 2 Seeking information from the nurse manager on the clients status 3 Reviewing Maslows hierarchy either in a textbook or on the internet 4 Trying different types of colostomy dressings for maximum therapeutic effect ANS: 4 Trying various ways of resolving clients health care needs or evaluating health care products, as in trying different types of colostomy dressings for maximum effect, is an example of the problem-solving strategy for knowledge acquisition. Practicing skills is an example of gaining experience to increase ones knowledge. Information-seeking is a strategy used to obtain knowledge from experts in a particular field. Reviewing Maslows hierarchy in a reference textbook or on the internet is another example of acquiring knowledge through information-seeking. PTS: 1 DIF: A REF: 55 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. A nurse researcher has completed a study involving the use of intravenous analgesics for postsurgical discomfort. The description of the 16 clients used for the study would best be written in which part of the research report? 1 Results section 2 Methods section 3 Discussion section 4 Introduction section ANS: 2 A description of the clients used is found in the methods section of the research study. The results section contains a description of the results obtained in the study, including appropriate statistical tests used to analyze the data. The discussion section presents the authors interpretation of the results, including conclusions and implications that can be drawn from the study. The introductory section presents the purpose of the study, a summary of literature, and the hypotheses tested or questions posed. PTS: 1 DIF: A REF: 59 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. A nurse reads about a case study involving the potential positive effects of the early stimulation of posthead-injury clients. Which of the following questions should be a priority consideration before use of the research results? 1 What was the cost of the study? 2 Were ethical principles maintained? 3 Were the results of this study published in other journals? 4 Are the clients in the study similar to clients I work with? ANS: 4 Determination of whether the subjects and environment in the study are similar to the clients for whom the nurse provides care in the particular practice setting is necessary before research can be considered for use in practice. Although cost may be a consideration in determining the feasibility of applying research findings, it is not the priority consideration for research utilization. The research findings would first have to be applicable to the practice setting and client population. Even though research may indicate ethical principles were maintained, it does not necessarily mean that it is feasible to apply the findings in practice. For example, cost issues may limit the use of research findings. The number of journals that published the research results of the study should not be the priority consideration in implementation of its findings. To judge the scientific worth of the study; however, it is important to examine the amount of supportive evidence provided by other scientific studies that have obtained similar results. PTS: 1 DIF: C REF: 59 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. An example of a predictive type of question that a nurse might use for research is which of the following? Reducing health care costs was not a goal for Healthy People 2010. Investigation of substance abuse was not one of the main, overarching goals for Healthy People 2010. Determining acceptable morbidity rates was not one of the main, overarching goals for Healthy People 2010. DIF: A REF: 69 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 3. A nurse is using a holistic approach when caring for a client. To incorporate all of the factors that may influence the client, which of the following nursing responses is most therapeutic? 1 I would like you to perform this exercise once a day. 2 Your physician has left orders that you are to follow. 3 The laboratory tests reveal the need to reduce your daily percentage of fat intake. 4 Adapting to a low-fat diet and increasing your activity will help lower your blood glucose levels. ANS: 4 Using a holistic approach involves consideration of all factors that may impact a clients level of well-being in all dimensions, not just physical health. Factors such as diet and exercise can influence ones level of health. Directing the client to exercise does not address the many factors that may impact ones level of health. This response does not facilitate the client in seeing the connection between lifestyle choices and well-being. Directing the client to follow physicians orders, though important, does not describe a holistic approach of nursing care. A holistic approach may include a discussion of diet and exercise and the effect these factors have on blood glucose level. The aim is for the client to take responsibility for their health and choices that may impact their health. Viewing laboratory test results is a part of the nursing assessment. To approach the client holistically, the nurse would need to also assess the clients diet and activity level. DIF: C REF: 72 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance 4. The client states, Heart disease runs in our family. My blood pressure has always been high. The nurse determines that this is an example of the clients: 1 Risk factors 2 Active strategy 3 Health beliefs 4 Negative health behavior ANS: 1 Risk factors are anything that increases the vulnerability of an individual or group to an illness or accident. This client is identifying the physical risk factor of genetic predisposition to heart disease. An example of an active strategy would be weight reduction or smoking cessation, where the client is actively involved in measures to improve their present and future levels of wellness. Health beliefs are a persons ideas, convictions, and attitudes about health and illness. An example of a health belief would be if the client stated, Heart disease runs in our family. I know I will have heart disease anyway, so why exercise? A negative health behavior is a behavior that may negatively impact ones health. An example of a negative health behavior would be consistently drinking alcohol in excess. DIF: A REF: 77 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 5. A client is discharged following a heart attack. In using the Stages of Health Behavior Change as a guide, the nurse recognizes that the client is most likely to begin to accept information on diet changes and an exercise program during which stage? 1 Action 2 Preparation 3 Maintenance 4 Contemplation ANS: 4 During the contemplation stage, the client is considering a change within the next 6 months. The client may be ambivalent initially, but will more likely accept information as he or she develops more belief in the value of change. During the action stage, the client is actively engaged in strategies to change behavior. During the preparation stage, the client is making small changes in preparation for a change in the next month. At this point, the client believes advantages outweigh disadvantages in behavior change. During the maintenance stage, the client has sustained change over time. DIF: A REF: 78 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 6. When assessing the external variables that influence a clients health beliefs and practices, the nurse must consider his: 1 Income status 2 Religious practices 3 Educational background 4 Reaction to the heart disease ANS: 1 External variables influencing a persons health beliefs and practices include family practices, cultural background, and socioeconomic factors, such as income. Economic variables may affect a clients level of health by increasing the risk for disease and influencing how or at what point the client enters the health care system. A persons compliance with the treatment to maintain or improve health is also affected by economic status. Religious practices are one way that people exercise spirituality. Spirituality is considered to be an internal variable. Educational background is an internal variable that can influence the health beliefs and practices of a client. An example of an internal variable that can influence health beliefs and practices of a client includes emotional factors, such as the reaction to heart disease. DIF: A REF: 74 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 7. A paraplegic client is admitted for an electrolyte imbalance. Based on the levels of prevention, the client is receiving care at the level of: 1 Health promotion 2 Primary prevention 3 Tertiary prevention 4 Secondary prevention ANS: 4 The secondary prevention level focuses on early diagnosis and prompt treatment as well as disability limitations. Adequate treatment for the electrolyte imbalance is sought to prevent further complications. Health promotion is a focus of the primary prevention level. The effects of illness on the client and family have created a change in family dynamics. Family dynamics is the process by which the family functions, makes decisions, gives support to individual members, and copes with everyday changes and challenges. Body image is the subjective concept of physical appearance. The client did not express concerns regarding body image. Self-concept is a mental self-image of strengths and weaknesses in all aspects of personality. The client did not express a change in self-concept. Illness behavior refers to how people monitor their bodies, define and interpret their symptoms, take remedial actions, and use the health care system. The client did not express change in illness behavior. DIF: A REF: 81 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 12. Client assessment provides the nurse with necessary information for the development of an effective plan of care. When determining the influence of an internal variable on the clients health status, the nurse will specifically look for: 1 Anxiety level present 2 Family remedies used 3 Location and type of occupation 4 Available health insurance coverage ANS: 1 Emotional factors, such as the clients degree of anxiety, is an internal variable that can influence the clients health status. An example of an external variable that can influence the clients health status is the use of family remedies. Socioeconomic factors, such as location and type of occupation, are external variables that can influence the clients health status. Available health insurance coverage is an example of an external socioeconomic factor that can influence the clients health status. DIF: C REF: 73-74 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 13. A nurse understands that illness behavior means: 1 Each distinct illness will cause the client to behave in a specific manner 2 Nursing care provides interventions that are behavior oriented 3 The clients behaviors will have a direct impact on his illness 4 When ill, a clients perception of illness will result in unique behaviors ANS: 4 Medical sociologists call the reaction to illness, illness behavior. Nurses who understand how clients react to illness can minimize the effects of illness and assist clients and their families in maintaining or returning to the highest level of functioning. While the other options may be true, they do not define illness behavior. DIF: A REF: 79 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 14. A client tells the nurse that his illness is a result of his failure to live a good life. The nurse recognizes this statement as an example of the clients: 1 Risk factor 2 Health belief 3 Illness behavior 4 Negative health behavior ANS: 2 Health beliefs are a persons ideas, convictions, and attitudes about health and illness. A risk factor is any situation, habit, social or environmental condition, physiological or psychological condition, developmental or intellectual condition, or spiritual or other variable that increases the vulnerability of an individual or group to an illness or accident. Illness behavior is the unique manner in which a client reacts to illness. Negative health behaviors include practices actually or potentially harmful to health, such as smoking, drug or alcohol abuse, poor diet, and refusal to take necessary medications. DIF: A REF: 70 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 15. Which of the following client statements best relates to the third component of the Health Belief Model? 1 My blood cholesterol is only a little high. 2 No one in my family is susceptible to the flu. 3 Ill just avoid the food that causes the problem. 4 By losing weight my blood pressure may come down. ANS: 4 The third componentthe likelihood that a person will take preventive actionresults from the persons perception of the benefits of and barriers to taking action. Preventive action may include lifestyle changes, increased adherence to medical therapies, or a search for medical advice or treatment. The second component is the individuals perception of the seriousness of the illness. The first component of this model involves the individuals perception of susceptibility to an illness. Increased incidence of chronic disease processes. DIF: C REF: 70 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 16. The goal of Penders Health Promotion theory is best reflected in which of the following nursing interventions? 1 Suggesting the client experience a variety of exercise routines before settling on the one to adapt 2 Arranging for a client to attend a support group for individuals who also have severe burn scars 3 Playing soft, classical music when a client diagnosed with Alzheimers becomes physically agitated 4 Providing a client with a history of stress-induced respiratory problems with detailed explanations regarding her care ANS: 1 Health-promoting behaviors should result in improved health, enhanced functional ability, and better quality of life. According to the Basic Human Needs model, certain human needs are more basic than others; that is, some needs must be met before other needs (i.e., fulfilling the physiological needs before the needs of love and belonging). Self-actualization is the highest expression of ones individual potential and allows for continual discovery of self. Maslows model takes into account individual experiences, always unique to the individual. includes health education programs, immunizations, and physical and nutritional fitness activities. This option is the best example because it facilitates the availability of a service to clients to whom it might otherwise be unavailable. This is a good example of primary care, but it is not the best one available because it facilitates a service that is already available. While this is an example of primary care, it is not the best because it does not ensure the facilitation of the needed service. While this is an example of primary care, it is not the best because it does not ensure the facilitation of the needed service. DIF: C REF: 75 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 20. The nurse can best discuss the impact of a known risk factor on a clients health by stating: 1 It doesnt mean youll get the disease just that the odds are greater for you. 2 Now you know that the possibility is there, you can take steps to prevent it. 3 The risk factor can be managed by making a change in your lifestyle. 4 Youre lucky because you have the benefit of being able to do something about it. ANS: 1 The presence of risk factors does not mean that a disease will develop, but risk factors increase the chances that the individual will experience a particular disease or dysfunction. While this response is not incorrect, it does not address the impact of a risk factor on the clients health. This is not always true, and so it is not the best option. This option minimizes the clients concern and does not address the impact of a risk factor on the clients health. DIF: C REF: 77 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 21. When caring for a client with a spouse and two adolescent children, the nurse knows that the family unit must first: 1 Be viewed as a client Chapter 7. Caring in Nursing Practice 2 Change traditional roles 3 Provide support for the ailing mother 4 Seek help to fulfill day-to-day needs ANS: 1 The nurse must view the whole family as a client under stress, planning care to help the family regain the maximal level of functioning and well-being. While the illness of a family member requires role reassignment in order for the family to continue to function, the initial focus is to be viewed as a unit in need of care. While the family should provide support to the ailing member, the initial focus is to be viewed as a unit in need of care. MULTIPLE CHOICE 1. The nurse recognizes that the client symptomatology typical of the acute cancer survival phase includes: 1 Fear and anxiety 2 Despair and anger 3 Lethargy and alopecia 4 Dyspnea and tachycardia ANS: 1 The acute survival phase starts with the diagnosis of cancer. Diagnostic and therapeutic efforts dominate. Fear and anxiety are constant elements of this phase. Despair and anger are more representative of the stages of grief and loss according to Kbler- Ross. Extended survival is the period during which a client has ended the basic, rigorous course of treatment and is dealing with the physical side effects of the treatment, such as lethargy and alopecia. Dyspnea and tachycardia may represent a clients unique individualized symptomatology but they are not recognized as general signs of the acute phase. DIF: A REF: 85 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 2. Since being treated for leukemia in her early twenties, a client has experienced bilateral mastectomies and has been diagnosed with osteoporosis and hypothyroidism. This health history best reflects the lifelong impact of: 1 Cancer on a clients health and wellness 2 Cancer treatments on future health status 3 Specific cancers on the health status of survivors 4 Genetic susceptibility on the reoccurrence of cancer ANS: 2 The impact of cancer treatment on future health status is the correct response. The increased risk for developing a second cancer is due to cancer treatment, genetic or other susceptibility, or an interaction between treatment and susceptibility. The risk for treatment related problems is associated with the complexity of the cancer itself (e.g., type of tumor and stage of disease); the type, variety, and intensity of treatments used; and the age and underlying health status of the client. While cancer itself affects the clients immediate health and wellness status, it is secondary to the long-term effects of the cancer treatments used. Although some health effects are related to specific forms of cancer, this is not the best option available because it is much less likely to be the cause of lifelong health issues. While genetic predisposition is a factor in cancer development it is not the most likely factor affecting lifelong health issues for the cancer survivor. DIF: C REF: 86 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 3. In the geriatric population, the primary reason cancer is diagnosed in its later stage is: 1 Health care benefit coverage is often inadequate 2 Symptoms are often masked by the effects of aging 3 Clients are reluctant to seek help for the early symptoms 4 Symptoms are often attributed to the aging process ANS: 4 Most cancer survivors (61%) are over the age of 65 (IOM, 2006). Often health care providers wrongly attribute the symptoms of cancer or the symptoms from the side effects of treatment to aging. This often leads to late diagnosis or a failure to provide aggressive and effective treatment of symptoms. While the geriatric population may have a problem with adequate health care coverage, it is not the primary cause of delayed cancer diagnosis in that population. While symptoms may be masked by the effects of aging, it is not the primary cause of delayed cancer diagnosis in this population. MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 7. The nurse knows that the primary factor affecting a cancer survivors quality of life is: 1 The clients precancer physical and mental health status 2 The presence of a strong support system 3 The quality and type of cancer treatment received 4 The type and number of cancer-related risk factors the client possesses ANS: 2 Mellon and colleagues (2006) interviewed cancer survivors and their family caregivers, finding that two of the strongest predictors for cancer survivors quality of life (enjoyment of life) were family stressors and social support. Precancer physical and mental health status may affect the survivors physical recovery regarding the treatment but not their quality of life (enjoyment of life). The quality and type of cancer treatment received may affect the survivors chances of survival but not their quality of life (enjoyment of life). The type and number of cancer-related risk factors the client possesses may affect the survivors chances of survival but not their quality of life (enjoyment of life). DIF: C REF: 85-86 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 8. A client, who is a 7-year breast cancer survivor, tells the nurse, My husband will help me bathe when he gets here. The nurse interprets this statement to mean that the client: 1 Is reluctant to have the staff see her chest scar 2 Prefers to protect her modesty and privacy 3 Has a healthy self-image regarding her husband 4 Is not comfortable with the care she is receiving ANS: 3 Self-image and intimacy may be negatively affected after cancer surgery. It is a positive sign that the client is comfortable having her husband perform this task for her. Although the client may be reluctant to have staff see her chest scar, the clients history of cancer surgery should direct you to the more related option. While the client may prefer to protect her modesty and privacy, the clients history of cancer surgery should direct you to the more related option. Although the client may not be comfortable with the care she is receiving, it is not as likely as the other options and the clients history of cancer surgery should direct you to the more related option. DIF: C REF: 88 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 9. The nurse understands the primary focus of education for a client who has just received a diagnosis of cancer is to: 1 Introduce self-care measures to support health 2 Discuss the management of treatment-related side effects 3 Reinforce the explanation of the risks of proposed treatments 4 Formulate long-term lifestyle changes to minimize risk factors ANS: 3 When caring for clients with an initial diagnosis of cancer, the immediate focus of client education should be the reinforcement of their health care providers explanations of the risks related to their cancer as well as the benefits and risks related to the proposed treatment options. This should then be followed by instructions on what they need to self-monitor (i.e., appetite and weight, effects of fatigue and sleeplessness), and what to discuss with health care providers in the future. Potential for treatment effects; such as pain, neuropathy, or cognitive change; also should be addressed since clients are more likely to report their symptoms if they are educated on their likelihood. Survivors need to learn how to manage problems related to persistent symptoms. Because survivors are at an increased risk for developing a second cancer and/or chronic illness, it is important to educate them about lifestyle behaviors that will improve the quality of their life. While introducing self-care measures to support health is an appropriate topic for client education, it should be addressed after the client is informed of the risks related to their cancer as well as the benefits and risks related to the proposed treatment options. Although discussing the management of treatment-related side effects is an appropriate topic for client education, it should be addressed after the client is informed of the risks related to their cancer as well as the benefits and risks related to the proposed treatment options. While formulating long-term lifestyle changes to minimize risk factors is an appropriate topic for client education, it should be addressed after the client is informed of the risks related to the cancer as well as the benefits and risks related to the proposed treatment options. DIF: C REF: 91 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. Which of the following assessment data best confirms the possibility of cognitive impairment in a client with a diagnosis of lung cancer? 1 Client is observed writing questions to ask his oncologist. 2 Client states, I seem to be a little more forgetful lately. 3 Clients wife states, I have to remind him of everything. 4 Client overheard asking son, Where did I put my glasses? ANS: 2 Cognitive changes are a set of physical symptoms very common in survivors that develop from their disease, treatment, the complications of treatment, underlying medical conditions, and psychological responses to the diagnosis of cancer (Nail, 2006). Cognitive changes can occur during all phases of the cancer experience, from small deficits in information processing to acute delirium. Often the cognitive impairments survivors experience are not evident to someone else but are apparent to the person experiencing them, especially in relation to work performance with high cognitive demands (Anderson-Hanley and others, 2003). The clients personal evaluation of his memory is the best indicator of cognitive impairment. While writing down questions to ask the oncologist may be motivated by poor memory, it is not uncommon for clients to prepare a list of questions before a meeting with their health care provider. Although the clients spouse reminding the client of things may indicate impaired cognitive ability, it is not as strong an indicator as a statement from the client. Although not being able to locate an item may indicate impaired memory, it is not uncommon for individuals to misplace personal items. DIF: C REF: 86-87 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 11. Which of the following cancer survivors is at greatest risk for post-treatment symptoms and poor treatment outcomes? 1 An Asian dishwasher 2 A Hispanic truck driver 3 A Caucasian factory worker 4 An African-American carpenter ANS: 1 There is evidence to suggest that survivors among racial and ethnic minorities and other underserved populations have more post-treatment symptoms and poorer treatment outcomes than Caucasians (CDC, 2004). The disparities in health among ethnic groups are related to a complex interplay of economic, social, and cultural factors, with poverty being a key factor. The DIF: Cognitive Level: Apply (application) REF: 63 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse performs a comprehensive geriatric assessment of a patient who is being assessed for admission to an assisted living facility. Which question is the most important for the nurse to ask? a. Have you had any recent infections? b. How frequently do you see a doctor? c. Do you have a history of heart disease? d. Are you able to prepare your own meals? ANS: D The patients functional abilities, rather than the presence of an acute or chronic illness, are more useful in determining how well the patient might adapt to an assisted living situation. The other questions will also provide helpful information but are not as useful in providing a basis for determining patient needs or for developing interventions for the older patient. DIF: Cognitive Level: Apply (application) REF: 71 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. An older patient who takes multiple medications for chronic cardiac and pulmonary diseases is alert and lives with a daughter who works during the day. During a clinic visit, the patient verbalizes to the nurse that she has a strained relationship with her daughter and does not enjoy being alone all day. Which nursing diagnosis should the nurse assign as the priority for this patient? a. Risk for injury related to drug interactions b. Social isolation related to weakness and fatigue c. Compromised family coping related to the patients many care needs d. Caregiver role strain related to need to adjust family employment schedule ANS: A The patients age and multiple medications indicate a risk for injury caused by interactions between the multiple drugs being taken and a decreased drug metabolism rate. Problems with social isolation, caregiver role strain, or compromised family coping are not physiologic priorities. Drug-drug interactions could cause the most harm to the patient and is therefore the priority. DIF: Cognitive Level: Apply (application) REF: 73-74 TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 4. The nurse plans to complete a thorough assessment of an older patient. Which method should the nurse use to gather the most complete information? a. Use a geriatric assessment instrument to evaluate the patient. b. Ask the patient to write down medical problems and medications. c. Interview both the patient and the primary caregiver for the patient. d. Review the patients medical record for a history of medical problems. ANS: A The most complete information about the patient will be obtained through the use of an assessment instrument specific to the geriatric population, which includes information about both medical diagnoses and treatments and about functional health patterns and abilities. A review of the medical record, interviews with the patient and caregiver, and written information by the patient are all included in a comprehensive geriatric assessment. DIF: Cognitive Level: Apply (application) REF: 71 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 5. An older patient is hospitalized with pneumonia. Which intervention should the nurse implement to provide optimal care for this patient? a. Use a standardized geriatric nursing care plan. b. Minimize activity level during hospitalization. c. Plan for transfer to a long-term care facility upon discharge. d. Consider the preadmission functional abilities when setting patient goals. ANS: D The plan of care for older adults should be individualized and based on the patients current functional abilities. A standardized geriatric nursing care plan will not address individual patient needs and strengths. A patients need for discharge to a long-term care facility is variable. Activity level should be designed to allow the patient to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process. DIF: Cognitive Level: Apply (application) REF: 71 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 6. The nurse cares for an older adult patient who lives in a rural area. Which intervention should the nurse plan to implement to best meet this patients needs? a. Suggest that the patient move to an urban area. b. Assess the patient for chronic diseases that are unique to rural areas. c. Ensure transportation to appointments with the health care provider. d. Obtain adequate medications for the patient to last for 4 to 6 months. ANS: C Transportation can be a barrier to accessing health services in rural areas. The patient living in a rural area may lose the benefits of a familiar situation and social support by moving to an urban area. There are no chronic diseases unique to rural areas. Because medications may change, the nurse should help the patient plan for obtaining medications through alternate means such as the mail or delivery services, not by purchasing large quantities of the medications. DIF: Cognitive Level: Apply (application) REF: 66-67 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 7. Which nursing action will be most helpful in decreasing the risk for drug-drug interactions in an older adult? a. Teach the patient to have all prescriptions filled at the same pharmacy. b. Instruct the patient to avoid taking over-the-counter (OTC) medications. c. Make a schedule for the patient as a reminder of when to take each medication. d. Have the patient bring all medications, supplements, and herbs to each appointment. ANS: D The most information about drug use and possible interactions is obtained when the patient brings all prescribed medications, OTC medications, and supplements to every health care appointment. The patient should discuss the use of any OTC medications with the health care provider and obtain all prescribed medications from the same pharmacy, but use of supplements adequate foot care because of a lack of supplies or a suitable place to accomplish care. Older homeless individuals are less likely to use shelters or meal sites. A homeless person may fail to keep appointments for outpatient services because of factors such as fear of institutionalization or lack of transportation. DIF: Cognitive Level: Apply (application) REF: 67 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 12. The home health nurse cares for an older adult patient who lives alone and takes several different prescribed medications for chronic health problems. Which intervention, if implemented by the nurse, would best encourage medication compliance? a. Use a marked pillbox to set up the patients medications. b. Discuss the option of moving to an assisted living facility. c. Remind the patient about the importance of taking medications. d. Visit the patient daily to administer the prescribed medications. ANS: A Because forgetting to take medications is a common cause of medication errors in older adults, the use of medication reminder devices is helpful when older adults have multiple medications to take. There is no indication that the patient needs to move to assisted living or that the patient does not understand the importance of medication compliance. Home health care is not designed for the patient who needs ongoing assistance with activities of daily living (ADLs) or instrumental ADLs (IADLs). DIF: Cognitive Level: Apply (application) REF: 65 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 13. The home health nurse visits an older patient with mild forgetfulness. The nurse is most concerned if which information is obtained? a. The patient tells the nurse that a close friend recently died. b. The patient has lost 10 pounds (4.5 kg) during the last month. c. The patient is cared for by a daughter during the day and stays with a son at night. d. The patients son uses a marked pillbox to set up the patients medications weekly. ANS: B A 10-pound weight loss may be an indication of elder neglect or depression and requires further assessment by the nurse. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an 86-year-old would have friends who have died. DIF: Cognitive Level: Apply (application) REF: 67 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 14. Which statement, if made by an older adult patient, would be of most concern to the nurse? a. I prefer to manage my life without much help from other people. b. I take three different medications for my heart and joint problems. c. I dont go on daily walks anymore since I had pneumonia 3 months ago. d. I set up my medications in a marked pillbox so I dont forget to take them. ANS: C Inactivity and immobility lead rapidly to loss of function in older adults. The nurse should develop a plan to prevent further deconditioning and restore function for the patient. Self- management is appropriate for independently living older adults. On average, an older adult takes seven different medications so the use of three medications is not unusual for this patient. The use of memory devices to assist with safe medication administration is recommended for older adults. DIF: Cognitive Level: Apply (application) REF: 73 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 15. The nurse assesses an older patient who takes diuretics and has a possible urinary tract infection (UTI). Which action should the nurse take first? a. Palpate over the suprapubic area. b. Inspect for abdominal distention. c. Question the patient about hematuria. d. Invite the patient to use the bathroom. ANS: D Before beginning the assessment of an older patient with a UTI and on diuretics, the nurse should have the patient empty the bladder because bladder fullness or discomfort will distract from the patients ability to provide accurate information. The patient may seem disoriented if distracted by pain or urgency. The physical assessment data are obtained after the patient is as comfortable as possible. DIF: Cognitive Level: Apply (application) REF: 71 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 16. Which patient is most likely to need long-term nursing care management? a. 72-year-old who had a hip replacement after a fall at home b. 64-year-old who developed sepsis after a ruptured peptic ulcer c. 76-year-old who had a cholecystectomy and bile duct drainage d. 63-year-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg) ANS: D Osteoarthritis and obesity are chronic problems that will require planning for long-term interventions such as physical therapy and nutrition counseling. The other patients have acute problems that are not likely to require long-term management. DIF: Cognitive Level: Apply (application) REF: 70 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 17. When completing an admission assessment on an older adult, the nurse gives the patient a high fall risk score. Which action should the nurse take first? a. Use a bed alarm system on the patients bed. b. Administer the prescribed PRN sedative medication. c. Ask the health care provider to order a vest restraint. d. Place the patient in a geri-chair near the nurses station. ANS: A The use of the least restrictive restraint alternative is required. Physical or chemical restraints may be necessary, but the nurses first action should be an alternative such as a bed alarm. DIF: Cognitive Level: Apply (application) REF: 75 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment decrease the ability to chew and swallow. Food likes and dislikes are not necessarily associated with malnutrition. MULTIPLE CHOICE 1. The nurse recognizes that ethnicity differs from race in that ethnicity: 1 Refers to subgroups within a race 2 Is a unique factor within a cultural group 3 Includes more than biological identification 4 Is the set of conflicting values between races ANS: 3 Ethnicity refers to a shared identity related to social and cultural heritage, such as values, language, geographical space, and racial characteristics. Race refers to biological attributes. Subcultures refer to subgroups within a race. A variant cultural pattern is a unique factor within a cultural group. Ethnocentrism is the root of biases and prejudices comprising beliefs and attitudes associating negative permanent characteristics with people who are perceived to be different from the valued group. DIF: A REF: 107 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 2. Within transcultural nursing, sensitivity to social organization is the recognition of the clients: 1 Language usage 2 Status and expected role in the family 3 Definition of health and health practices 4 Psychological characteristics and coping mechanisms ANS: 2 Cultural groups consist of units of social organization delineated by kinship, status hierarchy, and appropriate roles for their members. Sensitivity to social organization is the recognition of the clients status and role in the family. Sensitivity to communication patterns would be the recognition of the clients language usage. Culture is the framework used in defining social phenomena such as when a person is considered to be healthy or in need of intervention. The way an individual defines health and health practices needs to be understood by the nurse to best meet the needs of the client. Sensitivity to social organization is not met by recognizing the definition of health for an individual. Psychological characteristics and coping mechanisms may be expressed in a variety of ways across cultures. Sensitivity to social organization is not Chapter 9. Cultural Competence demonstrated by the recognition of psychological characteristics and coping mechanisms of a particular culture. DIF: A REF: 116 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 3. Traditional Western medicine, in contrast to alternative therapy, uses: 1 Acupuncture 2 Herbal therapy 3 Spiritual advising 4 Medication administration ANS: 4 Traditional Western medicine uses medication administration as a method of treatment. Acupuncture is an alternative therapy often used in non-Western cultures such as the Chinese and Southeast Asians. Herbal therapy is an alternative therapy often used in non-Western cultures, but not in traditional Western medicine. Spiritual advising is not used in traditional Western medicine, but it may be seen in the African-American cultural group. DIF: A REF: 110 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 4. The nurse is completing an assessment of an Asian-American client. Recognizing that there are commonly seen problems in individuals from this background, the nurse observes for particular signs and symptoms of: 1 Hypertension 2 Tuberculosis 3 Diabetes mellitus 4 Lactose intolerance ANS: 4 Lactose intolerance is frequently observed among Asians, Africans, and Hispanics. Hypertension is commonly seen in African Americans. Aboriginal Canadians descended from native North American Indians and living on reservations have a higher incidence of tuberculosis. Diabetes mellitus is commonly seen among Ute, Pima, and Papago Indians. DIF: A REF: 116 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 5. The nurse recognizes the following as an appropriate strategy for communicating with clients who are not fluent in English? 1 Speaking in a louder tone of voice 2 Incorporating hand gestures and pictures 3 Responding to the client by his or her first name 4 Interacting with an interpreter for all communication ANS: 2 An appropriate strategy for communicating with clients who are not fluent in English is to incorporate hand gestures and pictures. Speaking in a louder tone of voice will not help the client understand the English language. Responding to the client by his or her first name may demonstrate a lack of respect. The nurse should introduce him or herself and then request the client to introduce himself or herself. An interpreter is not necessary for all communication. However, an interpreter must be used for communicating to the client information about his or her medical condition. It is not acceptable for family members to translate health care information, but they can assist with ongoing interaction during the clients care. DIF: A REF: 113 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 6. One aspect of a culture is invisible, or less observable, to others. A nurse wanting to develop an awareness of the practices of different cultures within that community would have which of the following as an example of this component? 1 Wearing an amulet or charm 2 Using prayer beads or candles 3 Using cotton garments for clothing 4 Believing in supernatural influences ANS: 4 An example of an invisible (less observable) component of a culture is having a belief in supernatural influences. An example of a visible (easily seen) component of culture is the wearing of an amulet or charm. An example of a visible (easily seen) component of culture is 4 Encouraging family members to assist with the clients feeding and hygiene care ANS: 3 Holding back more potent pain medication for a client who had a minor procedure is an example of a cultural imposition of the nurse on a client. Adaptation of the clients room to accommodate extra family members is not an example of cultural imposition on a client, but rather is meeting the clients need by providing culturally congruent care. Seeking information on gender- congruent care for an Egyptian client is an example of the desire to provide culturally congruent care. Encouraging family to assist with the clients care is not an example of cultural imposition on a client. Western culture tends to follow a pattern of caring that focuses on self-care and self- determination, whereas non-Western cultures typically have care provided by others. DIF: A REF: 109 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 11. Following a surgical procedure, an older Chinese woman refuses to perform the range of motion and breathing exercises requested, in addition is hesitant to complete her hygienic care and grooming. The nurse recognizes that this is most likely related to: 1 Dependence on health care providers for care 2 Reliance upon family members to assist with care 3 Lack of personal motivation to participate in self-care 4 Reluctance to cooperate with traditional Western medical treatment ANS: 2 Non-Western cultures traditionally rely heavily on family members to provide care. Although it may be related to dependence on health care providers for care, it is not as likely because non- Western cultures depend on family members to assist with care. While it may be related to lack of personal motivation to participate in self-care, the clients behavior is more likely a result of her cultural background rather than a lack of motivation. While the clients behavior may be a result of reluctance to cooperate with Western medical treatments, it is more likely indicative of her cultural dependence on family members. DIF: C REF: 110 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 12. When faced with a scenario where it is believed that a client from another cultural background is using herbal remedies along with the prescribed medication to treat her arthritis. The nurses first action should be to: 1 Educate the client concerning the danger of taking herbs and the prescribed medication 2 Inquire of the client as to the reason for using herbal remedies along with the prescribed medication 3 Ask the client to identify what herbal remedies are being used along with the prescribed medications 4 Alert the physician to the clients use of herbal remedies in addition to the prescribed medications ANS: 3 Rather than first dismissing the practice as dangerous and incompatible with Western medicine, practitioners need to investigate further whether the practice needs changing. Although educating the client may be appropriate, this cannot be determined until the herb has been identified and it is determined to be harmful in this situation. Asking the client why additional remedies are being used may make the client feel defensive. The nurse needs to first determine what herbs are being used. While alerting the physician is appropriate, it is not the first action to be taken by the nurse. The nurse should initially determine what herbs are being used. DIF: C REF: 110 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 13. Being cared for by a nurse of the opposite gender would be an especially important issue for women from which of the following cultures? 1 Afghan 2 Filipino 3 Native American 4 African American ANS: 1 Modesty is a strong value among Afghan and Arab women. Modesty is not an especially important issue for Filipino women. Modesty is not an especially important issue for Native American women. Modesty is not an especially important issue for African American women. DIF: A REF: 109 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 14. An example of a culture where a male relative will regularly decline to observe the birth process is: 1 Pakistani 2 Hispanic 3 Korean 4 Japanese ANS: 1 Religious beliefs may prohibit the presence of males, including husbands, in the delivery room. This may be observed among devout Muslims, Hindus, and Orthodox Jews. Hispanic men typically do not have religious or cultural beliefs that would prohibit them from the delivery room. Korean men typically do not have religious or cultural beliefs that would prohibit them from the delivery room. Asian men typically do not have religious or cultural beliefs that would prohibit them from the delivery room. DIF: A REF: 111 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 15. The nurse observes a religious charm hanging from the wrist of a client being prepared for surgery. The nurses best initial approach is to: 1 Remove the religious charm 2 Securely tape the charm in place 3 Ask the client to leave the charm with family members 4 Clarify whether the charm may remain in place during the procedure ANS: 4 The nurse should first determine if it is permissible for the item to remain in place during the procedure. Removing the bracelet may create unnecessary stress for the client. Initially the nurse should determine if removal is necessary. Taping the bracelet in place may be appropriate after the nurse determines that the item may remain in place during the procedure. Asking the client to 20. For a client who is a Buddhist and maintains a traditional diet, the nurse will make sure that a sufficient quantity of which of the following is included in the menu? 1 Beef 2 Milk 3 Fish 4 Vegetables ANS: 4 Many Buddhists are vegetarians. The nurse should ensure that a sufficient quantity of vegetables is included in the menu when caring for a Buddhist who maintains a traditional diet. Beef is not a traditional component of a Buddhists diet. A sufficient quantity of milk is not necessary for the traditional Buddhists diet. A sufficient quantity of fish is not necessary for the traditional Buddhists diet. DIF: A REF: 117 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 21. Which of the following factors has the greatest impact on health care available to non- Hispanic white minority groups in the United Sates? 1 Significant language barriers 2 Inappropriately high poverty rates 3 Genetically based disease processes 4 Mistrust of Western medical practices ANS: 2 Racial and ethnic minorities are more likely than non-Hispanic whites to be poor or near poor. In addition, Hispanics, African Americans, and some Asian subgroups are less likely than non- Hispanic whites to have a high school education. In general, racial and ethnic minorities often experience poorer access to care and lower quality of preventive, primary, and specialty care. While language barriers may have an influence on the amount and type of health care services available to and sought out by minority groups, it is poverty that has the greatest negative influence. While genetically based disease processes may have an influence on the amount and type of health care services available to and sought out by minority groups, it is poverty that has the greatest negative influence. Although mistrust of Western medical practices may have an influence on the amount and type of health care services available to and sought out by minority groups, it is poverty that has the greatest negative influence. DIF: C REF: 107 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 22. The nurse who is attempting to practice in a culturally sensitive manner must first realize that recognition of the visible signs of a clients culture: 1 Is essential to the establishment of a nurse-client relationship 2 Provides the basis for a sense of trust between client and nurse 3 Does not ensure understanding of the underlying cultural beliefs 4 Has little impact on the nurses ability to provide therapeutic care ANS: 3 Culture has both visible (easily seen) and invisible (less observable) components. Nurses cannot appreciate the meanings and beliefs associated with these artifacts without further assessment. Recognition of visible signs of a clients culture will assist in the formation of a therapeutic nurse- client relationship because it conveys the nurses interest in the client as a person; it is not essential to the relationship process. Recognition of visible signs of a clients culture will assist in the formation of trust (a component of a therapeutic nurse-client relationship) because it conveys the nurses interest in the client as a person; it is not essential to the trust-establishing process. Recognition of visible signs of a clients culture will assist in the formation of a therapeutic nurse- client relationship, which is vital to the nurses ability to provide therapeutic care because it conveys the nurses interest in the client as a person. DIF: C REF: 107 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 23. Which of the following nursing interventions shows the greatest degree of culturally competent nursing care for a Muslim female client? 1 Notifying the chaplain of the clients religious preference 2 Notifying staff that the clients bath will be done by her sister 3 Drawing the curtains around the clients bed during prayer time 4 Facilitating a dietary consult to meet the clients nutritional concerns ANS: 2 Cultural competence is the process of acquiring specific knowledge, skills, and attitudes that ensure delivery of culturally congruent care. By arranging for the family to assume responsibility for the clients hygiene, the nurse has shown a specific knowledge of the clients needs and acted upon that need. The other options are not as specific or as directly related to nursing care as notifying the staff that the clients bath will be done by her sister. DIF: C REF: 109 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 24. A nursing care assistant fails to report in a timely manner a request for pain medication from an African-American male client who is recovering from a stab wound. The nurses initial action is to evaluate the care assistants: 1 Feelings regarding this particular client 2 Need for administrative disciplinary action 3 Understanding of the need for prompt reporting 4 Employment files for documentation of similar behavior ANS: 1 Personal bias and prejudices when acted upon may interfere with the delivery of appropriate, effective nursing care. While all the options are appropriate, the nurses initial action is to determine the cause of the care assistants negligent behavior. Although all the options are appropriate, the nurses initial action is to determine the cause of the care assistants negligent behavior. DIF: C REF: 109 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 25. An Arab woman arrives in the emergency department reporting vaginal bleeding. It is determined that the client is 5 months pregnant with her second child and has had no prenatal care. The nurse realizes that the most likely reason for this lack of health care is that the client: first discuss the practice with the daughter to learn more of the details regarding the practice. The clients health care provider should be notified, however, the nurses assessment of the areas as reddened areas suggests that other options may have priority. Documentation of the assessment findings is certainly appropriate and is a nursing responsibility, but acquiring an explanation from the daughter who is present would have priority. DIF: C REF: 110 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 29. The nurse, caring for a comatose Muslim client who is dying, realizes that from a cultural standpoint, the most therapeutic intervention is to: 1 Facilitate the clients peaceful, pain-controlled death 2 Become familiar with Muslim death and dying traditions 3 Approach the family to identify and discuss any needs that exist 4 Arrange for a private room so the family can grieve traditionally ANS: 3 Be aware of religious and cultural preferences when helping clients and families prepare for death. Facilitating the clients peaceful, pain-controlled death is an appropriate intervention; it is not necessarily culturally oriented because nursing strives to facilitate a peaceful, pain-free death for all clients. Becoming familiar with cultural tradition is therapeutic and would have priority if the family were not present to be questioned directly regarding their needs. Arranging for a private room may be a therapeutic intervention because most cultures would prefer some degree of privacy when attending to the death of a loved one, but since the family is present the priority intervention is the one that identifies their needs. DIF: C REF: 112-113 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 30. A Hispanic client is diagnosed with inoperable brain cancer. The clients wife insists that any discussion about treatment options be postponed until all local family members are present. The nurse correctly views this as: 1 The familys attempt to facilitate a good death for the client 2 An invasion of the clients right of confidentiality by the family members 3 Appropriate because the cancer may have affected his decision-making abilities 4 A cultural tradition that relieves the ill family member of the burden of decision making ANS: 4 In some cultures, the group assumes decision making for a family member in these situations and is trusted to make the right decision for the individual. Indeed, some groups such as African Americans, Asian Americans, and Hispanics expect their family to make decisions for them, and family members prefer to protect the individual from unnecessary suffering by knowing the reality of imminent death. These cultures value group interdependence and view individual autonomy as an unnecessary burden for a loved one who is ill (Pacquiao, 2002, 2003a). The means by which the family provides a good death is first established through the process of group decision making. It may appear that the clients confidentiality is being invaded by a member of the Western nursing profession; it is a cultural norm for members of many Hispanic families. Although cancer may affect the clients abilities to make decisions, the origin of this behavior is more likely the cultural tradition of group decision making among Hispanics. DIF: C REF: 111 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 31. The nurse realizes that the primary goal of a cultural assessment is to: 1 Minimize client distress resulting from unmet cultural expectations 2 Provide care that is in concert with the clients cultural expectations 3 Identify cultural beliefs and traditions that are important to the client 4 Blend Western nursing practice with the clients cultural expectations ANS: 2 The goal of cultural assessment is to gather significant information from the client that will enable the nurse to implement culturally congruent care. Minimizing distress is an achieved outcome when the goal of culturally congruent care is met. Identifying beliefs and traditions is an assessment goal that helps identify the criteria for individualized, culturally congruent care. Blending Western nursing practice with cultural expectations will result in individualized, culturally congruent care. DIF: C REF: 108 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 32. The nurse caring for members of the Hispanic community recognizes which of the following situations as the best reflection of the cultures view of family caring? 1 A husband calling each evening to tell his wife goodnight 2 Family members taking turns staying with the client at night 3 The daughter bringing her fathers favorite soup to the hospital 4 The eldest son sending a huge floral arrangement to the hospital ANS: 2 In collectivistic groups such as the Hispanic culture, the physical presence of loved ones with the client demonstrates caring. While the other options show caring, it is not the best option reflecting the Hispanic culture. DIF: C REF: 110 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 33. A nurse caring for the Arab community observes a client crying. The woman was recently informed that her radiation treatments may affect her ability to become pregnant. The nurse recognizes that the client is most likely reacting to a cultural attitude regarding: 1 The importance of children to an Arab family 2 The Arab view that infertility is grounds for divorce 3 Infertility is a punishment for unholy living 4 The loss of status among other married Arab women ANS: 2 Infertility in a woman is considered grounds for divorce and rejection among Arabs. Although infertility is grounds for divorce in Arab cultures, it is not the best option for this question. MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 4. What would a nurse expect to find in an assessment of a healthy family? 1 Change is viewed as detrimental to the family. 2 There is a passive response to most stressors. 3 The structure is flexible enough to adapt to crises. 4 Minimum influence is being exerted on the environment. ANS: 3 A healthy family has a flexible structure that allows adaptable performance of tasks and acceptance of help from outside the family system. The structure is flexible enough to allow adaptability but not so flexible that the family lacks cohesiveness and a sense of stability. The healthy family is able to integrate the need for stability with the need for growth and change. It does not view change as detrimental to family processes. The healthy family demonstrates control over the environment and does not passively respond to stressors. The healthy family exerts influence on the immediate environment of home, neighborhood, and school. DIF: A REF: 127 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 5. Initially, the nurse should begin by doing what in completing a clients family assessment? 1 Collecting health data from all the family members 2 Testing the familys ability to cope with normal stressors 3 Evaluating the familys interpersonal communication patterns 4 Determining the clients definition of familiar structure and attitudes ANS: 4 The nurse begins the family assessment by determining the clients definition of and attitude toward family and the extent to which the family may be incorporated into nursing care. The nurse also assesses family form and membership. Gathering health data from the family members is not the starting point for a family assessment. Testing a familys ability to cope is not where the nurse should begin a family assessment. Evaluating communication barriers would not be an initial action of the nurse when completing a clients family assessment. DIF: C REF: 126 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 6. Post discharge, the client is returning to their home environment. In assisting the client with that, specifically in implementing family-centered care, the nurse: 1 Provides personal beliefs regarding problem-solving 2 Assists the family members to assume dependent roles 3 Works with the client to accept responsibility for role in discourse 4 Offers both client and family information about necessary self- care abilities ANS: 4 When implementing family-centered care, the nurse adopts the role of educator and offers information about necessary self-care abilities. In family-centered care, the nurse guides the family in problem solving without providing his/her own beliefs. In family-centered care, the nurse assists clients to assume independent roles by increasing family members abilities in certain areas. In family-centered care, the nurse guides the family in problem solving, not in helping them accept blame. DIF: A REF: 129 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 7. A client is unable to independently perform colostomy care due to arthritis. The nurse should first: 1 Offer to assist the client to learn to manage the care 2 Arrange for home care services to care for the colostomy 3 Inquire as to family members who may be able to assist with the care 4 Suggest that the client attend a colostomy self-help support group ANS: 3 The nurse should first find out if there is anyone else in the family or neighborhood who would or could assist with the colostomy care. Informing the client that management of the colostomy must be learned will not change the fact that the client has arthritis and needs assistance. The nurse should first determine whether there is someone else who could perform the task. If not, the nurse arranges for a home care service referral. A colostomy self-help support group may provide emotional support, but it will not meet the clients need for assistance with colostomy care. DIF: C REF: 131 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 8. The optimum goal of effective communication within the family, according to the nurse observing the family members and their interaction, is: 1 Problem solving and psychological support 2 Role development of individual members 3 Socialization among individual members 4 Better financial conditions for the family ANS: 1 The optimum goal of effective communication within the family is to be able to problem solve and provide psychological support for its members. Role development is not the optimum goal of effective communication within the family. Socialization among individual family members is not the optimum goal of effective communication within the family. Improving financial conditions for the family is not the optimum goal of effective communication within the family. DIF: A REF: 129 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 9. Which of the following is a gerontological principle related to families? 1 Later-life families need not work on developmental tasks. 2 The caregivers are often not members of the clients family. 3 Role reversal is usually expected and well accepted by the older client. 4 Support systems are likely to be different than those of younger age-groups. ANS: 4 It is true that social support systems for older adults are likely to be different from those for clients in younger age-groups. Members of later-life families need to be working on developmental tasks. Caregivers for older adults are usually either spouses or middle-age children. Accepting shifting of generational roles is often difficult for the older client. DIF: A REF: 125 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 10. In assessing the roles and power structure of a clients nuclear family, the nurse should specifically ask the client: