Download Nursing 311: Care of Older Adults Test Bank and more Exams Nursing in PDF only on Docsity! NURSING 311: CARE OF OLDER ADULTS: CULTURE, SPIRITUALITY, COMMUNICATION, SEXUALITY, INFECTION CONTROL TEST BANK WITH VERIFIED ANSWERS 9 TH EDITION/2023 Qualified Virginia State University Care of Surgical Patients Potter et al.: Fundamentals of Nursing, 9th Edition 1. The nurse is caring for a surgical patient, when the family member asks what perioperative nursing means. How should the nurse respond? a. Perioperative nursing occurs in preadmission testing. b. Perioperative nursing occurs primarily in the postanesthesia care unit. Perioperative nursing includes activities before, during, and after c. surgery. Perioperative nursing includes activities only during the surgical d. procedure. NURSING 311: CARE OF OLDER ADULTS: CULTURE, SPIRITUALITY, COMMUNICATION, SEXUALITY, INFECTION CONTROL TEST BANK WITH VERIFIED ANSWERS 9 TH EDITION/2023 Qualified Virginia State University ANS: C Perioperative nursing care occurs before, during, and after surgery. Preadmission testing occurs before surgery and is considered preoperative. Nursing care provided during the surgical procedure is considered intraoperative, and in the postanesthesia care unit, it is considered postoperative. All of these are parts of the perioperative phase, but each individual phase does not explain the term completely. 2. The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and reviews the patient’s laboratory tests and allergies and prepares the patient for surgery. In which perioperative nursing phase is the nurse working? a. Perioperative b. Preoperative c. Intraoperative d. Postoperative ANS: B Reviewing the patient’s laboratory tests and allergies is done before surgery in the preoperative phase. Perioperative means before, during, and after surgery. Intraoperative means during the surgical procedure in the operating suite; postoperative means after the surgery and could occur in the postanesthesia care unit, in the ambulatory surgical area, or on the hospital unit. 3. The nurse is caring for a patient in the postanesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. How will the nurse classify this procedure? a. Major NURSING 311: CARE OF OLDER ADULTS: CULTURE, SPIRITUALITY, COMMUNICATION, SEXUALITY, INFECTION CONTROL TEST BANK WITH VERIFIED ANSWERS 9 TH EDITION/2023 Qualified Virginia State University 5. The patient has presented to the ambulatory surgery center to have a colonoscopy. The patient is scheduled to receive moderate sedation (conscious sedation) during the procedure. How will the nurse interpret this information? a. The procedure results in loss of sensation in an area of the body. b. The procedure requires a depressed level of consciousness. c. The procedure will be performed on an outpatient basis. d. The procedure necessitates the patient to be immobile. ANS: B Moderate sedation (conscious sedation) is used routinely for procedures that do not require complete anesthesia but rather a depressed level of consciousness. Not all patients who are treated on an outpatient basis receive moderate sedation. Regional anesthesia such as local anesthesia provides loss of sensation in an area of the body. General anesthesia is used for patients who need to be immobile and to not remember the surgical procedure. 6. The nurse is caring for a patient in the postanesthesia care unit who has undergone a left total knee arthroplasty. The anesthesia provider has indicated that the patient received a left femoral peripheral nerve block. Which assessment will be an expected finding for this patient? a. Sensation decreased in the left leg b. Patient report of pain in the left foot c. Pulse decreased at the left posterior tibia d. Left toes cool to touch and slightly cyanotic NURSING 311: CARE OF OLDER ADULTS: CULTURE, SPIRITUALITY, COMMUNICATION, SEXUALITY, INFECTION CONTROL TEST BANK WITH VERIFIED ANSWERS 9 TH EDITION/2023 Qualified Virginia State University ANS: A Induction of regional anesthesia results in loss of sensation in an area of the body—in this case, the left leg. The peripheral nerve block influences the portions of sensory pathways that are anesthetized in the targeted area of the body. Decreased pulse, toes cool to touch, and cyanosis are indications of decreased blood flow and are not expected findings. Reports of pain in the left foot may indicate that the block is not working or is subsiding and is not an expected finding in the immediate postoperative period. 7. The nurse is preparing a patient for surgery. Which goal is a priority for assessing the patient before surgery? a. Plan for care after the procedure. b. Establish a patient’s baseline of normal function. c. Educate the patient and family about the procedure. d. Gather appropriate equipment for the patient’s needs. ANS: B The goal of the preoperative assessment is to identify a patient’s normal preoperative function and the presence of any risks to recognize, prevent, and minimize possible postoperative complications. Gathering appropriate equipment, planning care, and educating the patient and family are all important interventions that must be provided for the surgical patient; they are part of the nursing process but are not the priority reason/goal for completing an assessment of the surgical patient. 8. The nurse is completing a medication history for the surgical patient in preadmission testing. Which medication should the nurse instruct the patient to hold (discontinue) in preparation for surgery according to protocol? NURSING 311: CARE OF OLDER ADULTS: CULTURE, SPIRITUALITY, COMMUNICATION, SEXUALITY, INFECTION CONTROL TEST BANK WITH VERIFIED ANSWERS 9 TH EDITION/2023 Qualified Virginia State University a. Warfarin b. Vitamin C NURSING 311: CARE OF OLDER ADULTS: CULTURE, SPIRITUALITY, COMMUNICATION, SEXUALITY, INFECTION CONTROL TEST BANK WITH VERIFIED ANSWERS 9 TH EDITION/2023 Qualified Virginia State University d. Coughing ANS: C After general anesthesia, circulation slows, and when the rate of blood slows, a greater tendency for clot formation is noted. Immobilization results in decreased muscular contractions in the lower extremities; these NURSING 311: CARE OF OLDER ADULTS: CULTURE, SPIRITUALITY, COMMUNICATION, SEXUALITY, INFECTION CONTROL TEST BANK WITH VERIFIED ANSWERS 9 TH EDITION/2023 Qualified Virginia State University promote venous stasis. Coughing, diaphragmatic breathing, and incentive spirometry are utilized to decrease atelectasis and pneumonia. 12. The nurse is caring for a preoperative patient. The nurse teaches the principles and demonstrates leg exercises for the patient. The patient is unable to perform leg exercises correctly. What is the nurse’s best next step? a. Encourage the patient to practice at a later date. b. Assess for the presence of anxiety, pain, or fatigue. c. Ask the patient why exercises are not being done. d. Evaluate the educational methods used to educate the patient. ANS: B If the patient is unable to perform leg exercises, the nurse should look for circumstances that may be impacting the patient’s ability to learn. In this case, the patient can be anticipating the upcoming surgery and may be experiencing anxiety. The patient may also be in pain or may be fatigued; both of these can affect the ability to learn. Evaluation of educational methods may be needed, but in this case, principles and demonstrations are being utilized. Asking anyone “why” can cause defensiveness and may not help in attaining the answer. The nurse is aware that the patient is unable to do the exercises. Moving forward without ascertaining that learning has occurred will not help the patient in meeting goals. 13. Which nursing assessment will indicate the patient is performing diaphragmatic breathing correctly? Hands placed on the border of the rib cage with fingers extended will a. touch as the chest wall contracts. NURSING 311: CARE OF OLDER ADULTS: CULTURE, SPIRITUALITY, COMMUNICATION, SEXUALITY, INFECTION CONTROL TEST BANK WITH VERIFIED ANSWERS 9 TH EDITION/2023 Qualified Virginia State University Hands placed on the chest wall with fingers extended will separate as b. the chest wall contracts. The patient will feel upward movement of the diaphragm during c. inspiration. The patient will feel downward movement of the diaphragm during d. expiration. ANS: A Positioning the hands along the borders of the rib cage allows the patient to feel movement of the chest and abdomen as the diaphragm descends and the lungs expand. As the patient takes a deep breath and slowly exhales, the middle fingers will touch while the chest wall contracts. The fingers will separate as the chest wall expands. The patient will feel normal downward movement of the diaphragm during inspiration and normal upward movement during expiration. 14. The nurse is caring for a postoperative patient with an abdominal incision. The nurse provides a pillow to use during coughing. Which activity is the nurse promoting? a. Pain relief b. Splinting c. Distraction d. Anxiety reduction ANS: B Deep breathing and coughing exercises place additional stress on the suture line and cause discomfort. Splinting incisions with hands and a pillow provides firm support and reduces incisional pull. Providing a pillow during coughing does not provide distraction or reduce anxiety. Providing a pillow does not provide pain relief. Coughing can increase anxiety because it can cause pain. Analgesics provide pain relief. NURSING 311: CARE OF OLDER ADULTS: CULTURE, SPIRITUALITY, COMMUNICATION, SEXUALITY, INFECTION CONTROL TEST BANK WITH VERIFIED ANSWERS 9 TH EDITION/2023 Qualified Virginia State University Instruct the patient to place the right hand over the incisional area to splint it, providing support and minimizing pulling during turning. Closing one’s eyes, holding one’s breath, and holding the nurse’s shoulders do not help support the incision during a turn. 17. The nurse is preparing to assist the patient in using the incentive spirometer. Which nursing intervention should the nurse provide first? a. Perform hand hygiene. b. Explain use of the mouthpiece. c. Instruct the patient to inhale slowly. d. Place in the reverse Trendelenburg position. ANS: A Performing hand hygiene reduces microorganisms and should be performed first. Placing the patient in the correct position such as high Fowler’s for the typical postoperative patient or reverse Trendelenburg for the bariatric patient would be the next step in the process. Demonstration of use of the mouthpiece followed by the instruction to inhale slowly would be the last step in this scenario. 18. The nurse and the nursing assistive personnel (NAP) are caring for a group of postoperative patients who need turning, coughing, deep breathing, incentive spirometer, and leg exercises. Which task will the nurse assign to the NAP? a. Teach postoperative exercises. b. Do nothing associated with postoperative exercises. c. Document in the medical record when exercises are completed. d. Inform the nurse if the patient is unwilling to perform exercises. NURSING 311: CARE OF OLDER ADULTS: CULTURE, SPIRITUALITY, COMMUNICATION, SEXUALITY, INFECTION CONTROL TEST BANK WITH VERIFIED ANSWERS 9 TH EDITION/2023 Qualified Virginia State University ANS: D The nurse can delegate to the NAP to encourage patients to practice postoperative exercises regularly after instruction and to inform the nurse if the patient is unwilling to perform these exercises. The skills of NURSING 311: CARE OF OLDER ADULTS: CULTURE, SPIRITUALITY, COMMUNICATION, SEXUALITY, INFECTION CONTROL TEST BANK WITH VERIFIED ANSWERS 9 TH EDITION/2023 Qualified Virginia State University demonstrating and teaching postoperative exercises and documenting are not within the scope of practice for the nursing assistant. Doing nothing is not appropriate. 19. The nurse is providing preoperative teaching for the ambulatory surgery patient who will be having a cyst removed from the right arm. Which will be the best explanation for diet progression after surgery? “Start with clear liquids, soup, and crackers. Advance to a normal diet a. as tolerated.” “Stay with ice chips for several hours. After that, you can have b. whatever you want.” “Stay on clear liquids for 24 hours. Then you can progress to a normal c. diet.” “Start with clear liquids for 2 hours and then full liquids for 2 hours. d. Then progress to a normal diet.” ANS: A Patients usually receive a normal diet the first evening after surgery unless they have undergone surgery on GI structures. Implement diet intake while judging the patient’s response. For example, provide clear liquids such as water, apple juice, broth, or tea after nausea subsides. If the patient tolerates liquids without nausea, advance the diet as ordered. There is no need to stay on ice chips for several hours or clear liquids for 24 hours after this procedure. Putting a time frame on the progression is too prescriptive. Progression should be adjusted for the patient’s needs. 20. The nurse explains the pain relief measures available after surgery during preoperative teaching for a surgical patient. Which comment from the patient indicates the need for additional education on this topic? a. “I will be asked to rate my pain on a pain scale.” NURSING 311: CARE OF OLDER ADULTS: CULTURE, SPIRITUALITY, COMMUNICATION, SEXUALITY, INFECTION CONTROL TEST BANK WITH VERIFIED ANSWERS 9 TH EDITION/2023 Qualified Virginia State University waiting in the waiting room; however, it is certainly not a requirement for actually completing the surgery that someone comes to this appointment. 22. The nurse is reviewing the surgical consent with the patient during preoperative education and finds the patient does not understand what procedure will be completed. What is the nurse’s best next step? a. Notify the health care provider about the patient’s question. b. Explain the procedure that will be completed. c. Continue with preoperative education. d. Ask the patient to sign the form. ANS: A Surgery cannot be legally or ethically performed until the patient fully understands the need for a procedure and all the implications. It is the surgeon’s responsibility to explain the procedure, associated risks, benefits, alternatives, and possible complications. It is important for the nurse to pause with preoperative education to notify the health care provider of the patient’s questions. It is not within the nurse’s scope to explain the procedure. The nurse can certainly reinforce what the health care provider has explained, but the information needs to come from the health care provider. It is not prudent to ask a patient to sign a form for a procedure that he/she does not understand. 23. During preoperative assessment for a 7:30 AM (0730) surgery, the nurse finds the patient drank a cup of coffee this morning. The nurse reports this information to the anesthesia provider. Which action does the nurse anticipate next? a. A delay in or cancellation of surgery NURSING 311: CARE OF OLDER ADULTS: CULTURE, SPIRITUALITY, COMMUNICATION, SEXUALITY, INFECTION CONTROL TEST BANK WITH VERIFIED ANSWERS 9 TH EDITION/2023 Qualified Virginia State University b. Questions regarding components of the coffee c. Additional questions about why the patient had coffee Instructions to determine what education was provided in the d. preoperative visit ANS: A The recommendations before nonemergent procedures requiring general and regional anesthesia or sedation/ analgesia include fasting from intake of clear liquids for 2 or more hours. A delay in or cancellation of surgery will be in order for this case. Questions regarding components of the coffee, asking why, and evaluating the preoperative education may all be items to be addressed, especially from a performance improvement perspective, but at this time in caring for this patient, a delay or cancellation is in order to prevent aspiration. 24. The nurse has administered a preoperative medication to the patient going to surgery. Which action will the nurse take next? a. Notify the operating suite that the medication has been given. b. Instruct the patient to call for help to go to the restroom. c. Waste any unused medication according to policy. d. Ask the patient to sign the consent for surgery. ANS: B Once a preoperative medication has been administered, instruct the patient to call for help when getting out of bed to prevent falls. For patient safety, explain the purpose of a preoperative medication and its effects. Notifying the operating suite that the medication has been given may be part of a facilities procedure but is not the best next step. It is important to have the patient sign consents before the NURSING 311: CARE OF OLDER ADULTS: CULTURE, SPIRITUALITY, COMMUNICATION, SEXUALITY, INFECTION CONTROL TEST BANK WITH VERIFIED ANSWERS 9 TH EDITION/2023 Qualified Virginia State University patient has received medication that may make him/her drowsy. Wasting unused medication according to policy is important but is not the best next step. 25. The nurse has completed a preoperative assessment for a patient going to surgery and gathers assessment data. Which will be the most important next step for the nurse to take? A&E I Comprehensive Testbank 25 a. Count the sterile surgical instruments. b. Empty the urinary drainage bag. c. Check the surgical dressing. d. Apply a warm blanket. ANS: D The temperature in the preoperative holding area and in adjacent operating suites is usually cold. Offer the patient an extra warm blanket. Counts are taken by the circulating and scrub nurses in the operating room. Emptying a urinary drainage bag and checking the surgical dressing occur in the postanesthesia care unit, not in the holding area. 29. The nurse is caring for a patient in the operating suite. Which outcome will be most appropriate for this patient at the end of the intraoperative phase? a. The patient will be free of burns at the grounding pad. b. The patient will be free of nausea and vomiting. c. The patient will be free of infection. d. The patient will be free of pain. ANS: A A primary focus of intraoperative care is to prevent injury and complications related to anesthesia, surgery, positioning, and equipment use, including use of the electrical cautery grounding pad for the prevention of burns. The perioperative nurse is an advocate for the patient during surgery and protects the patient’s dignity and rights at all times. Signs and symptoms of infection do not have the time to present during the intraoperative phase. During the intraoperative phase, the patient is anesthetized and unconscious and typically has an endotracheal tube that prevents conversation. Nausea, vomiting, and pain typically begin in the postoperative phase of the experience. A&E I Comprehensive Testbank 26 30. The nurse is concerned about the skin integrity of the patient in the intraoperative phase of surgery. Which action will the nurse take to minimize skin breakdown? a. Encouraging the patient to bathe before surgery b. Securing attachments to the operating table with foam padding c. Periodically adjusting the patient during the surgical procedure d. Measuring the time a patient is in one position during surgery ANS: B Although it may be necessary to place a patient in an unusual position, try to maintain correct alignment and protect the patient from pressure, abrasion, and other injuries. Special mattresses, use of foam padding, and attachments to the operating suite table provide protection for the extremities and bony prominences. Bathing before surgery helps to decrease the number of microbes on the skin. Periodically adjusting the patient during the surgical procedure is impractical and can present a safety issue with regard to maintaining sterility of the field and maintaining an airway. Measuring the time the patient is in one position may help with monitoring the situation but does not prevent skin breakdown. 31. The nurse is assessing a postoperative patient with a history of obstructive sleep apnea for airway obstruction. Which assessment finding will best alert the nurse to this complication? a. Drop in pulse oximetry readings b. Moaning with reports of pain c. Shallow respirations d. Disorientation A&E I Comprehensive Testbank 27 ANS: A One of the greatest concerns after general anesthesia is airway obstruction, especially in patients with obstructive sleep apnea. A drop in oxygen saturation by pulse oximetry is a sign of airway obstruction in patients with obstructive sleep apnea. Weak pharyngeal/laryngeal muscle tone from anesthetics; secretions in the pharynx, bronchial tree, or trachea; and laryngeal or subglottic edema also contribute to airway obstruction. In the postanesthetic patient, the tongue is a major cause of airway obstruction. Shallow respirations are indicative of respiratory depression. Moaning and reports of pain are common in all surgical patients and are an expected event. Disorientation is common when first awakening from anesthesia but can be a sign of hypoxia. 32. The nurse is caring for a patient in the operating suite who is experiencing hypercarbia, tachypnea, tachycardia, premature ventricular contractions, and muscle rigidity. Which condition does the nurse suspect the patient is experiencing? a. Malignant hyperthermia b. Fluid imbalance c. Hemorrhage d. Hypoxia ANS: A A life-threatening, rare complication of anesthesia is malignant hyperthermia. Malignant hyperthermia causes hypercarbia, tachycardia, tachypnea, premature ventricular contractions, unstable blood pressure, cyanosis, skin mottling, and muscular rigidity. It often occurs during anesthesia induction. Hypoxia would manifest with decreased oxygen saturation as one of its signs and symptoms. Fluid imbalance would be assessed with intake and output and can manifest with tachycardia and blood pressure fluctuations but does not have muscle rigidity. Hemorrhage can manifest with tachycardia and decreased blood pressure, along with a thready pulse. Usually some sign or symptom of blood loss is noted (e.g., drains, incision, orifice, and abdomen). 33. The nurse is caring for a postoperative patient who has had a minimally invasive carpel A&E I Comprehensive Testbank a. This is done to complete the first action in a head-to-toe assessment. This is done to compare and monitor for vital sign variation during b. transport. This is done to ensure that the medical-surgical nurse checks on the c. postoperative patient. This is done to follow hospital policy and procedure for care of the d. surgical patient. ANS: B Before the PACU nurse leaves the acute care area, the staff nurse assuming care for the patient takes a complete set of vital signs to compare with PACU findings. Minor vital sign variations normally occur after transporting the patient. The PACU nurse reviews the patient’s information with the medical-surgical nurse, including the surgical and PACU course, physician orders, and the patient’s condition. While vital signs may or may not be the first action in a head-to-toe assessment, this is not the rationale for this situation. While following policy or ascertaining that the floor nurse checks on the patient are good reasons for safe care, they are not the best rationale for obtaining vital signs. 37. The nurse is caring for a patient who will undergo a removal of a lung lobe. Which level of care will the patient require immediately post procedure? a. Acute care—medical-surgical unit b. Acute care—intensive care unit c. Ambulatory surgery d. Ambulatory surgery—extended stay ANS: B Patients undergoing extensive surgery and requiring anesthesia of long duration recover slowly. If a patient is undergoing major surgery such as a procedure on the lung, a stay in the hospital and specifically in the intensive care unit is required to monitor for potential risks to well-being. This patient would require more care than can be provided on a medical-surgical unit. It is not appropriate for this type of patient to go home after the procedure or to stay in an extended stay area of an ambulatory surgery area because of the complexity and associated risks. 38. The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient who had cataract surgery is coughing. A patient who had vascular repair of the right leg is not doing right leg b. exercises. A patient after knee surgery is wearing intermittent pneumatic c. compression devices and receiving heparin. A patient after surgery has vital signs taken every 15 minutes twice, d. every 30 minutes twice, hourly for 2 hours then every 4 hours. ANS: A For patients who have had eye, intracranial, or spinal surgery, coughing may be contraindicated because of the potential increase in intraocular or intracranial pressure. The nurse will need to see this patient first to control the cough and intraocular pressure. All the rest are normal postoperative patients. Leg exercise should not be performed on the operative leg with vascular surgery. A patient after knee surgery should receive heparin and be wearing intermittent pneumatic compression devices; while the nurse will check on the patient, it does not have to be first. Monitoring vital signs after surgery is required and this is the standard schedule. 39. The nurse demonstrates postoperative exercises for a patient. In which order will the nurse instruct the patient to perform the exercises? 1. Turning 2. Breathing 3. Coughing 4. Leg exercises a. 4, 1, 2, 3 b. 1, 2, 3, 4 c. 2, 3, 4, 1 d. 3, 1, 4, 2 ANS: A The sequence of exercises is leg exercises, turning, breathing, and coughing. MULTIPLE RESPONSE 1. The nurse is participating in a “time-out.” In which activities will the nurse be involved? (Select all that apply.) a. Verify the correct site. b. Verify the correct patient. c. Verify the correct procedure. d. Perform “time-out” after surgery. e. Perform the actual marking of the operative site. ANS: A, B, C Very young and old patients are at risk during surgery because of immature or declining physiological status. Normal tissue repair and resistance to infection depend on adequate nutrients. Obesity increases surgical risk by reducing respiratory and cardiac function. During pregnancy, the concern is for the mother and the developing fetus. Because all major systems of the mother are affected during pregnancy, risks for operative complications are increased. Race and ambulatory surgery are not risks associated with a surgical procedure. 5. The nurse is providing preoperative education and reviews with the patient what it will be like to be in the surgical environment. Which points should the nurse include in the teaching session? (Select all that apply.) a. The operative suite will be very dark. b. The family is not allowed in the operating suite. c. The operating table or bed will be comfortable and soft. d. The nurses will be there to assist you through this process. The surgical staff will be dressed in special clothing with hats and e. masks. ANS: B, D, E The surgical staff is dressed in special clothing, hats, and masks—all for infection control. Families are not allowed in the operating suite for several reasons, which include infection control and sterility. The nurse is there as the coordinator and patient advocate during a surgical procedure. The rooms are very bright so everyone can see, and the operating table is very uncomfortable for the patient. 6. The operating room nurse is providing a hand-off report to the postanesthesia care unit (PACU) nurse. Which components will the operating room nurse include? (Select all that apply.) a. IV fluids b. Vital signs c. Insurance data d. Family location e. Anesthesia provided f. Estimated blood loss ANS: A, B, E, F The surgical teams report will include topics such as the type of anesthesia provided, vital sign trends, intraoperative medications, IV fluids, estimated blood and urine loss, and pertinent information about the surgical wound (e.g., dressings, tubes, drains). When the patient enters the PACU, the nurse and members of the surgical team discuss his or her status. A standardized approach or tool for hand-off communications assists in providing accurate information about a patient’s care, treatment and services, current condition, and any recent or anticipated changes. The hand-off is interactive, multidisciplinary, and done at the patient’s bedside, allowing for a communication exchange that gives caregivers the chance to dialogue and ask questions. Insurance data and family location are unnecessary. 7. The nurse is caring for a group of postoperative patients on the surgical unit. Which patient assessments indicate the nurse needs to follow up? (Select all that apply.) a. Patient with abdominal surgery has patent airway. b. Patient with knee surgery has approximated incision. c. Patient with femoral artery surgery has strong pedal pulse. d. Patient with lung surgery has 20 mL/hr of urine output via catheter. e. Patient with bladder surgery has bloody urine within the first 12 hours. Patient with appendix surgery has thready pulse and blood pressure is f. 90/60. ANS: D, F Thready pulse, low blood pressure, and urine output of 20 mL/hr need to have follow-up by the nurse. Hemorrhage results in a fall in blood pressure; elevated heart and respiratory rates; thready pulse; cool, clammy, pale skin; and restlessness. Notify the surgeon if these changes occur. If the patient has a urinary catheter, there should be a continuous flow of urine of approximately 30 to 50 mL/hr in adults; this patient requires follow-up since the output is 20 mL/hr. All the rest are normal findings. A patent airway, a strong distal pulse, and approximated incision are all normal findings. Surgery involving portions of the urinary tract normally causes bloody urine for at least 12 to 24 hours, depending on the type of surgery. Chapter 05: Chronic Illness and Older Adults Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. When caring for an older patient with hypertension who has been hospitalized after a transient ischemic (TIA), which topic is the most important for the nurse to include in the discharge teaching? a) Effect of atherosclerosis on blood vessels b) Mechanism of action of anticoagulant drug therapy c) Symptoms indicating that the patient should contact the health care provider d) Impact of the patient’s family history on likelihood of developing a serious stroke ANS: C One of the tasks for patients with chronic illnesses is to prevent and manage a crisis. The patient ANS: B 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. 5. Which intervention should the nurse implement to provide optimal care for an older patient who is hospitalized with pneumonia? a) Plan for transfer to a long-term care facility. b) Minimize activity level during hospitalization. c) Consider the preadmission functional abilities. d) Use an approved standardized geriatric nursing care plan. ANS: C The plan of care for older adults should be individualized and based on the patient’s current functional abilities. A standardized geriatric nursing care plan will not address individual patient needs and strengths. A patient’s 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. 6. The nurse cares for an older adult patient who lives in a rural area. Which intervention should the nurse plan to implement to meet this patient’s needs? a) Suggest that the patient move closer to health care providers. b) Obtain extra medications for the patient to last for 4 to 6 months. c) Ensure transportation to appointments with the health care provider. d) Assess the patient for chronic diseases that are unique to rural areas. 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. 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) Make a schedule for the patient as a reminder of when to take each medication. c) Instruct the patient to avoid taking over-the-counter (OTC) medications or supplements. d) Ask the patient to 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 and herbal medications also need to be considered in order to prevent drug–drug interactions. Use of a medication schedule will help the patient take medications as scheduled, but will not prevent drug–drug interactions. 8. A patient who has just moved to a long-term care facility has a nursing diagnosis of relocation stress syndrome. Which action should the nurse include in the plan of care? a) Remind the patient that making changes is usually stressful. b) Discuss the reason for the move to the facility with the patient. c) Restrict family visits until the patient is accustomed to the facility. d) Have staff members write notes welcoming the patient to the facility. ANS: D TestBankWorld.org Having staff members write notes will make the patient feel more welcome and comfortable at the long-term care facility. Discussing the reason for the move and reminding the patient that change is usually stressful will not decrease the patient’s stress about the move. Family member visits will decrease the patient’s sense of stress about the relocation. 9. An older patient complains of having “no energy” and feeling increasingly weak. The patient has had a 12-lb weight loss over the past year. Which action should the nurse take initially? a) Ask the patient about daily dietary intake. b) Schedule regular range-of-motion exercise. c) Discuss long-term care placement with the patient. d) Describe normal changes associated with aging to the patient. 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 or instrumental ADLs. 13. The home health nurse visits an older patient with mild forgetfulness. Which new information is of most concern to the nurse? a) The patient tells the nurse that a close friend recently died. b) The patient has lost 10 lb (4.5 kg) during the past month. c) The patient is cared for by a daughter during the day and stays with a son at night. d) The patient’s son uses a marked pillbox to set up the patient’s 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-yr-old would have friends who have died. 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.” 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 don’t go on daily walks anymore since I had pneumonia 3 months ago.” d) “I set up my medications in a marked pillbox so I don’t 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. 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) Request the patient empty the bladder. 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 patient’s 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. c) Explain the reasons for the need to live in LTC to the patient. d) Request that the patient be placed in a private room at the facility. ANS: B The stress of relocation is likely to be less when the patient has input into the choice of the facility. The age of the long-term care facility does not indicate a better fit for the patient or better quality of care. Although some patients may prefer a private room, others may adjust better when given a well-suited roommate. The patient should understand the reasons for the move but will make the best adjustment when involved with the choice to move and the choice of the facility. 20. The nurse manages the care of older adults in an adult health day care center. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? TestBankWorld.org a) Obtain information about food and medication allergies from patients. b) Take blood pressures daily and document in individual patient records. c) Choose social activities based on the individual patient needs and desires. d) Teach family members how to cope with patients who are cognitively impaired. ANS: B Measurement and documentation of vital signs are included in UAP education and scope of practice. Obtaining patient health history, planning activities based on the patient assessment, and patient education are all actions that require critical thinking and will be done by the registered nurse. MULTIPLE RESPONSE 1. Which nursing actions will the nurse take to assess for possible malnutrition in an older adult patient (select all that apply)? a) Assess for depression. b) Review laboratory results. c) Determine food preferences. d) Inspect teeth and oral mucosa. e) Ask about transportation needs. ANS: A, B, D, E The laboratory results, especially albumin and cholesterol levels, may indicate chronic poor protein intake or high-fat or high-cholesterol intake. Transportation affects the patient’s ability to shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor condition may decrease the ability to chew and swallow. Food likes and dislikes are not necessarily associated with malnutrition. Chapter 09: Cultural Awareness Potter et al.: Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE 1. A nurse is working at a health fair screening people for liver cancer. Which population group should the nurse monitor most closely for liver cancer? a. Hispanic b. Asian Americans c. Non-Hispanic Caucasians d. Non-Hispanic African-Americans ANS: B While Asian Americans generally have lower cancer rates than the non-Hispanic Caucasian population, they also have the highest incidence rates of liver cancer for both sexes compared with Hispanic, non-Hispanic Caucasians, or non-Hispanic African-Americans. 2. A nurse is caring for an immigrant with low income. Which information should the nurse consider when planning care for this patient? a. There is a decreased frequency of morbidity. b. There is an increased incidence of disease. c. There is an increased level of health. d. There is a decreased mortality rate. ANS: B Populations with health disparities (immigrant with low income) have a significantly increased incidence of disease or increased morbidity and mortality when compared with the general population. Although Americans’ health overall has improved during the past few decades, the c. Understanding organizational forces d. Developing cultural skills ANS: A Becoming more aware of your biases and attitudes about human behavior is the first step in providing patient- centered care, leading to culturally competent care. It is helpful to think about cultural competence as a lifelong process of learning about others and also about yourself. Learning about the world view, developing cultural skills, and understanding organizational forces are not the first steps. 7. A nurse is performing a cultural assessment using the ETHNIC mnemonic for communication. Which area will the nurse assess for the “H”? a. Health b. Healers c. History d. Homeland ANS: B The “H” in ETHNIC stands for healers: Has the patient sought advice from alternative health practitioners? While health, history, and homeland are important, they are not components of “H.” 8. The nurse is caring for a patient of Hispanic descent who speaks no English. The nurse is working with an interpreter. Which action should the nurse take? a. Use long sentences when talking. b. Look at the patient when talking. A&E I Comprehensive Testbank 56 c. Use breaks in sentences when talking. d. Look at only nonverbal behaviors when talking. ANS: B Direct your questions to the patient. Look at the patient, instead of looking at the interpreter. Pace your speech by using short sentences, but do not break your sentences. Observe the patient’s nonverbal and verbal behaviors. 9. Which action indicates the nurse is meeting a primary goal of cultural competent care for patients? a. Provides care to transgender patients b. Provides care to restore relationships c. Provides care to patients that is individualized d. Provides care to surgical patients ANS: A Although cultural competence and patient-centered care both aim to improve health care quality, their focus is slightly different. The primary aim of cultural competence care is to reduce health disparities and increase health equity and fairness by concentrating on people of color and other marginalized groups, like transgender patients. Patient-centered care, rather than cultural competence care, provides individualized care and restores an emphasis on personal relationships; it aims to elevate quality for all patients. 10. The nurse is caring for a Chinese patient using the Teach-Back technique. Which action by the nurse indicates successful implementation of this technique? a. Asks, “Does this make sense?” b. Asks, “Do you think you can do this at home?” c. Asks, “What will you tell your spouse about changing the dressing?” A&E I Comprehensive Testbank 57 d. Asks, “Would you tell me if you don’t understand something so we can go over it?” ANS: C The Teach-Back technique asks open-ended questions, like what will you tell your spouse about changing the dressing, to verify a patient’s understanding. When using the Teach-Back technique do not ask a patient, “Do you understand?” or “Do you have any questions?” Does this make sense and do you think you can do this at home are closed-ended questions. Would you tell me if you don’t understand something so we can go over it is not verifying a patient’s understanding about the teaching. 11. A nurse is using core measures to reduce health disparities. Which group should the nurse focus on to cause the most improvement in core measures? a. Caucasians b. Poor people c. Alaska Natives d. American Indians ANS: B To improve results, the nurse should focus on the highest disparity. Poor people received worse care than high- income people for about 60% of core measures. American Indians and Alaska Natives received worse care than Caucasians for about 30% of core measures. 12. A nurse is designing a form for lesbian, gay, bisexual, and transgender (LGBT) patients. Which design should the nurse use? a. Use partnered rather than married. A&E I Comprehensive Testbank 60 16. A nurse works at a hospital that uses equity-focused quality improvement. Which strategy is the hospital using? a. Document staff satisfaction. b. Focus on the family. c. Implement change on a grand scale. d. Reduce disparities. ANS: D Organizations can implement equity-focused quality improvement by recognizing disparities and committing to reducing them. Staff diversity is a priority for equity-focused quality improvement, not staff satisfaction. While the family is important, the focus is on the patients. Organizations should start by implementing a change on a small scale (pilot testing), learning from each test, and refining the intervention through performance improvement cycles (e.g., plan, do, study, and act). 17. A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful in the role of providing culturally congruent care? a. Provides care that fits the patient’s valued life patterns and set of meanings b. Provides care that is based on meanings generated by predetermined criteria c. Provides care that makes the nurse the leader in determining what is needed d. Provides care that is the same as the values of the professional health care system ANS: A The goal of transcultural nursing is to provide culturally congruent care, or care that fits the person’s life patterns, values, and system of meaning. Patterns and meanings are generated from people themselves, rather than from predetermined criteria. Discovering patients’ cultural values, A&E I Comprehensive Testbank 61 beliefs, and practices as they relat to nursing and health care requires you to assume the role of learner (not become the leader) and to partner with your patients and their families to determine what is needed to provide meaningful and beneficial nursing care. Culturally congruent care is sometimes different from the values and meanings of the professional health care system. 18. A nurse is assessing the patient’s meaning of illness. Which area of focus by the nurse is priority? a. On the way a patient reacts to disease b. On the malfunctioning of biological processes c. On the malfunctioning of psychological processes d. On the way a patient reacts to family/social interactions ANS: A To provide culturally congruent care, you need to understand the difference between disease and illness. Illness is the way that individuals and families react to disease, whereas disease is a malfunctioning of biological or psychological processes. The way a patient interacts to family/social interactions is communication processes and family dynamics. MULTIPLE RESPONSE 1. A nurse is using Campinha-Bacote’s model of cultural competency. Which areas will the nurse focus on to become competent? (Select all that apply.) a. Cultural skills b. Cultural desire c. Cultural transition d. Cultural knowledge A&E I Comprehensive Testbank 62 e. Cultural encounters ANS: A, B, D, E Campinha-Bacote’s model of cultural competency has five interrelated components: cultural awareness; cultural knowledge; cultural skills; cultural encounters; and cultural desire. Cultural transition is not a component of this model. 2. A nurse is using the RESPECT mnemonic to establish rapport, the “R” in RESPECT. Which actions should the nurse take? (Select all that apply.) a. Connect on a social level. b. Help the patient overcome barriers. c. Consciously attempt to suspend judgment. d. Stress that they will be working together to address problems. e. Know limitations in addressing medical issues across cultures. ANS: A, C The “R” in RESPECT stands for rapport and includes the following behaviors: connect on a social level; seek the patient’s point of view; and consciously attempt to suspend judgment. The “S” stands for support and includes the behavior of helping the patient overcome barriers. The “P” stands for partnership and includes the following behaviors: be flexible with regard to issues of control and stress that you will be working together to address medical problems. The “C” stands for cultural competence and includes the behavior of knowing your limitations in addressing medical issues across cultures. 3. A nurse is using the explanatory model to determine the etiology of an illness. Which questions should the nurse ask? (Select all that apply.) a. How should your sickness be treated? A&E I Comprehensive Testbank 65 Every older adult is unique, and the nurse needs to approach each one as a unique individual. The nursing care of older adults poses special challenges because of great variation in their physiological, cognitive, and psychosocial health. Aging does not automatically lead to disability and dependence. Chronological age often has little relation to the reality of aging for an older adult. 3. Which information from a co-worker on a gerontological unit will cause the nurse to intervene? a. Most older people have dependent functioning. b. Most older people have strengths we should focus on. c. Most older people should be involved in care decision. d. Most older people should be encouraged to have independence. ANS: A Most older people remain functionally independent despite the increasing prevalence of chronic disease; therefore, this misconception should be addressed. It is critical for you to respect older adults and actively involve them in care decisions and activities. You also need to identify an older adult’s strengths and abilities during the assessment and encourage independence as an integral part of your plan of care. 4. A nurse suspects an older-adult patient is experiencing caregiver neglect. Which assessment findings are consistent with the nurse’s suspicions? a. Flea bites and lice infestation b. Left at a grocery store c. Refuses to take a bath d. Cuts and bruises ANS: A A&E I Comprehensive Testbank 66 Caregiver neglect includes unsafe and unclean living conditions, soiled bedding, and animal or insect infestation. Abandonment includes desertion at a hospital, nursing facility, or public location such as a shopping center. Self-neglect includes refusal or failure to provide oneself with basic necessities such as food, water, clothing, shelter, personal hygiene, medication, and safety. Physical abuse includes hitting, beating, pushing, slapping, kicking, physical restraint, inappropriate use of drugs, fractures, lacerations, rope burns, and untreated injuries. 5. A nurse is teaching a group of older-adult patients. Which teaching strategy is best for the nurse to use? Provide several topics of discussion at once to promote independence a. and making choices. Avoid uncomfortable silences after questions by helping patients b. complete their statements. Ask patients to recall past experiences that correspond with their c. interests. d. Speak in a high pitch to help patients hear better. ANS: C Teaching strategies include the use of past experiences to connect new learning with previous knowledge, focusing on a single topic to help the patient concentrate, giving the patient enough time in which to respond because older adults’ reaction times are longer than those of younger persons, and keeping the tone of voice low; older adults are able to hear low sounds better than high-frequency sounds. 6. An older patient has fallen and suffered a hip fracture. As a consequence, the patient’s family is concerned about the patient’s ability to care for self, especially during this convalescence. What should the nurse do? a. Stress that older patients usually ask for help when needed. Inform the family that placement in a nursing center is a permanent b. solution. Tell the family to enroll the patient in a ceramics class to maintain A&E I Comprehensive Testbank 67 c. quality of life. Provide information and answer questions as family members make d. choices among care options. ANS: D Nurses help older adults and their families by providing information and answering questions as they make choices among care options. Some older adults deny functional declines and refuse to ask for assistance with tasks that place their safety at great risk. The decision to enter a nursing center is never final, and a nursing center resident sometimes is discharged to home or to another less-acute residence. What defines quality of life varies and is unique for each person. 7. What is the best suggestion a nurse could make to a family requesting help in selecting a local nursing center? Have the family members evaluate nursing home staff according to a. their ability to get tasks done efficiently and safely. Make sure that nursing home staff members get patients out of bed b. and dressed according to staff’s preferences. Explain that it is important for the family to visit the center and c. inspect it personally. Suggest a nursing center that has standards as close to hospital d. standards as possible. ANS: C A&E I Comprehensive Testbank 70 ANS: B Include information about the prevention of sexually transmitted infections when appropriate. Open-ended questions inviting an older adult to explain sexual activities or concerns elicit more information than a list of closed-ended questions about specific activities or symptoms. You need to provide privacy for any discussion of sexuality and maintain a nonjudgmental attitude. Sexuality and the need to express sexual feelings remain throughout the human life span. 12. A nurse is teaching a health promotion class for older adults. In which order will the nurse list the most common to least common conditions that can lead to death in older adults? 1. Chronic obstructive lung disease 2. Cerebrovascular accidents 3. Heart disease 4. Cancer a. 4, 1, 2, 3 b. 3, 4, 1, 2 c. 2, 3, 4, 1 d. 1, 2, 3, 4 ANS: B Heart disease is the leading cause of death in older adults followed by cancer, chronic lung disease, and stroke (cerebrovascular accidents). 13. A nurse is observing skin integrity of an older adult. Which finding will the nurse document as a normal finding? a. Oily skin A&E I Comprehensive Testbank 71 b. Faster nail growth c. Decreased elasticity d. Increased facial hair in men ANS: C Loss of skin elasticity is a common finding in the older adult. Other common findings include pigmentation changes, glandular atrophy (oil, moisture, and sweat glands), thinning hair (facial hair: decreased in men, increased in women), slower nail growth, and atrophy of epidermal arterioles. 14. An older-adult patient in no acute distress reports being less able to taste and smell. What is the nurse’s best response to this information? Notify the health care provider immediately to rule out cranial nerve a. damage. Schedule the patient for an appointment at a smell and taste disorders b. clinic. c. Perform testing on the vestibulocochlear nerve and a hearing test. d. Explain to the patient that diminished senses are normal findings. ANS: D Diminished taste and smell senses are common findings in older adults. Scheduling an appointment at a smell and taste disorders clinic, testing the vestibulocochlear nerve, or an attempt to rule out cranial nerve damage is unnecessary at this time as per the information provided. 15. A nurse is assessing an older adult for cognitive changes. Which symptom will the nurse report as normal? A&E I Comprehensive Testbank 72 a. Disorientation b. Poor judgment c. Slower reaction time d. Loss of language skills ANS: C Slower reaction time is a common change in the older adult. Symptoms of cognitive impairment, such as disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are not normal aging changes and require further investigation of underlying causes. 16. An older patient with dementia and confusion is admitted to the nursing unit after hip replacement surgery. Which action will the nurse include in the plan of care? a. Keep a routine. b. Continue to reorient. c. Allow several choices. d. Socially isolate patient. ANS: A Patients with dementia need a routine. Continuing to reorient a patient with dementia is nonproductive and not advised. Patients with dementia need limited choices. Social interaction based on the patient’s abilities is to be promoted. 17. A nurse is helping an older-adult patient with instrumental activities of daily living. The nurse will be assisting the patient with which activity? a. Taking a bath A&E I Comprehensive Testbank 75 footwear such as smooth bottom socks also contributes to falls. 21. A nurse’s goal for an older adult is to reduce the risk of adverse medication effects. Which action will the nurse take? a. Review the patient’s list of medications at each visit. b. Teach that polypharmacy is to be avoided at all cost. c. Avoid information about adverse effects. d. Focus only on prescribed medications. ANS: A Strategies for reducing the risk for adverse medication effects include reviewing the medications with older adults at each visit; examining for potential interactions with food or other medications; simplifying and individualizing medication regimens; taking every opportunity to inform older adults and their families about all aspects of medication use; and encouraging older adults to question their health care providers about all prescribed and over- the-counter medications. Although polypharmacy often reflects inappropriate prescribing, the concurrent use of multiple medications is often necessary when an older adult has multiple acute and chronic conditions. Older adults are at risk for adverse drug effects because of age- related changes in the absorption, distribution, metabolism, and excretion of drugs. Work collaboratively with the older adult to ensure safe and appropriate use of all medications—both prescribed medications and over-the-counter medications and herbal options. 22. An older-adult patient has developed acute confusion. The patient has been on tranquilizers for the past week. The patient’s vital signs are normal. What should the nurse do? A&E I Comprehensive Testbank 76 Take into account age-related changes in body systems that affect a. pharmacokinetic activity. Increase the dose of tranquilizer if the cause of the confusion is an b. infection. c. Note when the confusion occurs and medicate before that time. d. Restrict phone calls to prevent further confusion. ANS: A Some sedatives and tranquilizers prescribed for acutely confused older adults sometimes cause or exacerbate confusion. Carefully administer drugs used to manage confused behaviors, taking into account age-related changes in body systems that affect pharmacokinetic activity. When confusion has a physiological cause (such as an infection), specifically treat that cause, rather than the confused behavior. When confusion varies by time of day or is related to environmental factors, nonpharmacological measures such as making the environment more meaningful, providing adequate light, etc., should be used. Making phone calls to friends or family members allows older adults to hear reassuring voices, which may be beneficial. 23. Which assessment finding of an older adult, who has a urinary tract infection, requires an immediate nursing intervention? a. Confusion b. Presbycusis c. Temperature of 97.9° F d. Death of a spouse 2 months ago ANS: A Confusion is a common manifestation in older adults with urinary tract infection; however, the cause requires further assessment. There may be another reason for the confusion. Confusion is A&E I Comprehensive Testbank 77 not a normal finding in the older adult, even though it is commonly seen with concurrent infections. Difficulty hearing, presbycusis, is an expected finding in an older adult. Older adults tend to have lower core temperatures. Coping with the death of a spouse is a psychosocial concern to be addressed after the acute physiological concern in this case. 24. Which patient statement is the most reliable indicator that an older adult has the correct understanding of health promotion activities? a. “I need to increase my fat intake and limit protein.” “I still keep my dentist appointments even though I have partials b. now.” c. “I should discontinue my fitness club membership for safety reasons.” “I’m up-to-date on my immunizations, but at my age, I don’t need the d. influenza vaccine.” ANS: B General preventive measures for the nurse to recommend to older adults include keeping regular dental appointments to promote good oral hygiene, eating a low-fat, well-balanced diet, exercising regularly, and maintaining immunizations for seasonal influenza, tetanus, diphtheria and pertussis, shingles, and pneumococcal disease. 25. A 72-year-old woman was recently widowed. She worked as a teller at a bank for 40 years and has been retired for the past 5 years. She never learned how to drive. She lives in a rural area that does not have public transportation. Which psychosocial change does the nurse focus on as a priority? a. Sexuality b. Retirement A&E I Comprehensive Testbank 80 c. Those who like different kinds of people d. Those who maintain perceptual biases ANS: B Nurses who develop critical thinking skills make the best communicators. Just liking people does not make an effective communicator because it is important to apply critical thinking standards to ensure sound effective communication. Just learning psychomotor skills does not ensure that the nurse will use those techniques, and communication involves more than psychomotor skills.Critical thinking helps the nurse overcome perceptual biases or human tendencies that interfere with accurately perceiving and interpreting messages from others. Nurses who maintain perceptual biases do not make good communicators. 2. A nurse believes that the nurse-patient relationship is a partnership and that both are equal participants. Which term should the nurse use to describe this belief? a. Critical thinking b. Authentic c. Mutuality d. Attend ANS: C Effective interpersonal communication requires a sense of mutuality, a belief that the nurse- patient relationship is a partnership and that both are equal participants. Critical thinking in nursing, based on established standards of nursing care and ethical standards, promotes effective communication and uses standards such as humility, self-confidence, independent attitude, and fairness. To be authentic (one’s self) and to respond appropriately to the other person are important for interpersonal relationships but do not mean mutuality. Attending is giving all of your attention to the patient. 3. A nurse wants to present information about flu immunizations to the older adults in the community. Which type of communication should the nurse use? A&E I Comprehensive Testbank 81 a. Public b. Small group c. Interpersonal d. Intrapersonal ANS: A Public communication is interaction with an audience. Nurses have opportunities to speak with groups of consumers about health-related topics, present scholarly work to colleagues at conferences, or lead classroom discussions with peers or students. When nurses work on committees or participate in patient care conferences, they use a small group communication process. Interpersonal communication is one-on-one interaction between a nurse and another person that often occurs face to face. Intrapersonal communication is a powerful form of communication that you use as a professional nurse. This level of communication is also called self- talk. 4. A nurse is using therapeutic communication with a patient. Which technique will the nurse use to ensure effective communication? Interpersonal communication to change negative self-talk to positive a. self-talk b. Small group communication to present information to an audience c. Electronic communication to assess a patient in another city d. Intrapersonal communication to build strong teams ANS: C A&E I Comprehensive Testbank 82 Electronic communication is the use of technology to create ongoing relationships with patients and their health care team. Intrapersonal communication is self-talk. Interpersonal communication is one-on-one interaction between a nurse and another person that often occurs face to face. Public communication is used to present information to an audience. Small group communication is interaction that occurs when a small number of persons meet. When nurses work on committees or participate in patient care conferences, they use a small group communication process. 5. A nurse is standing beside the patient’s bed. Nurse: How are you doing? Patient: I don’t feel good. Which element will the nurse identify as feedback? a. Nurse b. Patient c. How are you doing? d. I don’t feel good. ANS: D “I don’t feel good” is the feedback because the feedback is the message the receiver returns. The sender is the person who encodes and delivers the message, and the receiver is the person who receives and decodes the message. The nurse is the sender. The patient is the receiver. “How are you doing?” is the message. 6. A nurse is sitting at the patient’s bedside taking a nursing history. Which zone of personal space is the nurse using? a. Socio-consultative b. Personal c. Intimate A&E I Comprehensive Testbank 85 superficial, and not deeply personal. Nonjudgmental acceptance of the patient is an important characteristic of the relationship. Acceptance conveys a willingness to hear a message or acknowledge feelings; it is not a technique that involves personal stories. SBAR is a popular communication tool that helps standardize communication among health care providers. SBAR stands for Situation, Background, Assessment, and Recommendation. 10. Before meeting the patient, a nurse talks to other caregivers about the patient. Which phase of the helping relationship is the nurse in with this patient? a. Preinteraction b. Orientation c. Working d. Termination ANS: A The time before the nurse meets the patient is called the preinteraction phase. This phase can involve things such as reviewing available data, including the medical and nursing history, talking to other caregivers who have information about the patient, or anticipating health concerns or issues that can arise. The orientation phase occurs when the nurse and the patient meet and get to know one another. This phase can involve things such as setting the tone for the relationship by adopting a warm, empathetic, caring manner. The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. The termination phase occurs during the ending of the relationship. This phase can involve things such as reminding the patient that termination is near. 11. During the initial home visit, a home health nurse lets the patient know that the visits are expected to end in about a month. Which phase of the helping relationship is the nurse in with this patient? a. Preinteraction b. Orientation A&E I Comprehensive Testbank 86 c. Working d. Termination ANS: B Letting the patient know when to expect the relationship to be terminated occurs in the orientation phase. Preinteraction occurs before the nurse meets the patient. Working occurs when the nurse and the patient work together to solve problems and accomplish goals. Termination occurs during the ending of the relationship. 12. A nurse and a patient work on strategies to reduce weight. Which phase of the helping relationship is the nurse in with this patient? a. Preinteraction b. Orientation c. Working d. Termination ANS: C The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. Preinteraction occurs before the nurse meets the patient. Orientation occurs when the nurse and the patient meet and get to know each other. Termination occurs during the ending of the relationship. 13. A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the nurse’s action? a. To promote autonomy b. To use common courtesy c. To establish trustworthiness A&E I Comprehensive Testbank 87 d. To standardize communication ANS: D SBAR is a popular communication tool that helps standardize communication among health care providers. Common courtesy is part of professional communication but is not the purpose of SBAR. Being trustworthy means helping others without hesitation. Autonomy is being self- directed and independent in accomplishing goals and advocating for others. 14. A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Which piece of data will the nurse use for “B” when using SBAR? a. Having chest pain b. Pulse rate of 108 c. History of angina d. Oxygen is needed ANS: C The B in SBAR stands for background information. The background information in this situation is the history of angina. Having chest pain is the Situation (S). Pulse rate of 108 is the Assessment (A). Oxygen is needed is the Recommendation (R). 15. A patient just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy? a. “Tomorrow will be better.” b. “This must be hard news to hear.” A&E I Comprehensive Testbank 90 a. “You will be okay. Your surgeon will talk to you in the morning.” b. “Why can’t you sleep? You have the best surgeon in the hospital.” c. “Don’t worry. The surgeon ordered a sleeping pill to help you sleep.” “It must be difficult not to know what the surgeon will find. What can d. I do to help?” ANS: D “It must be difficult not to know what the surgeon will find. What can I do to help?” is using therapeutic communication techniques of empathy and asking relevant questions. False reassurances (“You will be okay” and “Don’t worry”) tend to block communication. Patients frequently interpret “why” questions as accusations or think the nurse knows the reason and is simply testing them. 20. Which situation will cause the nurse to intervene and follow up on the nursing assistive personnel’s (NAP) behavior? The nursing assistive personnel is calling the older-adult patient a. “honey.” The nursing assistive personnel is facing the older-adult patient when b. talking. The nursing assistive personnel cleans the older-adult patient’s glasses c. gently. The nursing assistive personnel allows time for the older-adult patient d. to respond. ANS: A The nurse needs to intervene to correct the use of “honey.” Avoid terms of endearment such as “honey,” “dear,” “grandma,” or “sweetheart.” Communicate with older adults on an adult level, and avoid patronizing or speaking in a condescending manner. Facing an older-adult patient, making sure the older adult has clean glasses, and allowing time to respond facilitate communication with older-adult patients and should be encouraged, not stopped. 21. A confused older-adult patient is wearing thick glasses and a hearing aid. Which A&E I Comprehensive Testbank 91 intervention is the priorityto facilitate communication? a. Focus on tasks to be completed. b. Allow time for the patient to respond. c. Limit conversations with the patient. d. Use gestures and other nonverbal cues. ANS: B Allowing time for patients to respond will facilitate communication, especially for a confused, older patient. Focusing on tasks to be completed and limiting conversations do not facilitate communication; in fact, they block communication. Using gestures and other nonverbal cues is not effective for visually impaired (thick glasses) patients or for patients who are confused. 22. The staff is having a hard time getting an older-adult patient to communicate. Which technique should the nurse suggest the staff use? a. Try changing topics often. b. Allow the patient to reminisce. c. Ask the patient for explanations. d. Involve only the patient in conversations. A&E I Comprehensive Testbank 92 ANS: B Encouraging older adults to share life stories and reminisce about the past has a therapeutic effect and increases their sense of well-being. Avoid sudden shifts from subject to subject. It is helpful to include the patient’s family and friends and to become familiar with the patient’s favorite topics for conversation. Asking for explanations is a nontherapeutic technique. 23. A nurse is implementing nursing care measures for patients’ special communication needs. Which patient will need the most nursing care measures? a. The patient who is oriented, pain free, and blind b. The patient who is alert, hungry, and has strong self-esteem c. The patient who is cooperative, depressed, and hard of hearing d. The patient who is dyspneic, anxious, and has a tracheostomy ANS: D Facial trauma, laryngeal cancer, or endotracheal intubation often prevents movement of air past vocal cords or mobility of the tongue, resulting in inability to articulate words. An extremely breathless person needs to use oxygen to breathe rather than speak. Persons with high anxiety are sometimes unable to perceive environmental stimuli or hear explanations. People who are alert, have strong self-esteem, and are cooperative and pain free do not cause communication concerns. Although hunger, blindness, and difficulty hearing can cause communication concerns, dyspnea, tracheostomy, and anxiety all contribute to communication concerns. 24. A patient is aphasic, and the nurse notices that the patient’s hands shake intermittently. Which nursing action is most appropriate to facilitate communication? a. Use a picture board. b. Use pen and paper. c. Use an interpreter. A&E I Comprehensive Testbank 95 communicate the need for more information before making a decision. Faith and supportiveness are attributes of caring, not critical thinking standards. 2. A nurse is implementing nursing care measures for patients with challenging communication issues. Which types of patients will need these nursing care measures? (Select all that apply.) a. A child who is developmentally delayed b. An older-adult patient who is demanding c. A female patient who is outgoing and flirty d. A male patient who is cooperative with treatments e. An older-adult patient who can clearly see small print f. A teenager frightened by the prospect of impending surgery ANS: A, B, C, F Challenging communication situations include patients who are flirtatious, demanding, frightened, or developmentally delayed. A child who has received little environmental stimulation possibly is behind in language development, thus making communication more challenging. Patients who are cooperative and have good eyesight (see small print) do not cause challenging communication situations. MATCHING A nurse is using AIDET to communicate with patients and families. Match the letters of the acronym to the behavior a nurse will use. a. Nurse describes procedures and tests. b. Nurse lets the patient know how long the procedure will last. c. Nurse recognizes the person with a positive attitude. A&E I Comprehensive Testbank 96 d. Nurse thanks the patient. e. Nurse tells the patient “I am an RN and will be managing your care.” 1.A 2.I 3.D 4.E 5.T 1.ANS:C2.ANS:E3.ANS:B4.ANS:A5.ANS:D Chapter 25: Patient Education Potter et al.: Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE 1. A nurse is teaching a patient’s family member about permanent tube feedings at home. Which purpose of patient education is the nurse meeting? a. Health promotion b. Illness prevention c. Restoration of health d. Coping with impaired functions ANS: D Teach family members to help the patient with health care management (e.g., giving medications through gastric tubes and doing passive range-of-motion exercises) when coping with impaired functions. Not all patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations. Health promotion involves healthy people staying healthy, while illness prevention is prevention of diseases. Restoration of health occurs if the teaching is about a temporary tube feeding, not a permanent tube feeding. A&E I Comprehensive Testbank 97 2. A nurse is teaching a group of healthy adults about the benefits of flu immunizations. Which type of patient education is the nurse providing? a. Health analogies b. Restoration of health c. Coping with impaired functions d. Promotion of health and illness prevention ANS: D As a nurse, you are a visible, competent resource for patients who want to improve their physical and psychological well-being. In the school, home, clinic, or workplace, you promote health and prevent illness by providing information and skills that enable patients to assume healthier behaviors. Injured and ill patients need information and skills to help them regain or maintain their level of health; this is referred to as restoration of health. Not all patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations; this is known as coping with impaired functions. Analogies supplement verbal instruction with familiar images that make complex information more real and understandable. For example, when explaining arterial blood pressure, use an analogy of the flow of water through a hose. 3. A nurse’s goal is to provide teaching for restoration of health. Which situation indicates the nurse is meeting this goal? Teaching a family member to provide passive range of motion for a a. stroke patient