TEST BANK FOR FUNDAMENTALS OF NURSING 11TH EDITION POTTER PERRY (A COMPREHENSIVE STUDY GU, Exams of Nursing

Download TEST BANK FOR FUNDAMENTALS OF NURSING 11TH EDITION POTTER PERRY (A COMPREHENSIVE STUDY GU and more Exams Nursing in PDF only on Docsity! TEST BANK FOR FUNDAMENTALS OF NURSING 11TH EDITION POTTER PERRY (A COMPREHENSIVE STUDY GUIDE 2022) Chapter 1 • Which nurse most likely kept records on sanitation techniques and the effects on health? ANS: Florence Nightingale • The nurse prescribes strategies and alternatives to attain expected outcome. Which standard of nursing practice is the nurse following? ANS: Planning • An experienced medical­surgical nurse chooses to work in obstetrics. Which level of proficiency is the nurse upon initial transition to the obstetrical floor? ANS: Novice • A nurse assesses a patient’s fluid status and decides that the patient needs to drink more fluids. The nurse then encourages the patient to drink more fluids. Which concept is the nurse demonstrating? ANS: Autonomy • A nurse prepares the budget and policies for an intensive care unit. Which role is the nurse implementing? ANS: manager • The nurse has been working in the clinical setting for several years as an advanced practice nurse. However, the nurse has a strong desire to pursue research and theory development. To fulfill this desire, which program should the nurse attend? ANS: Doctor of Philosophy degree (PhD) • A nurse attends a workshop on current nursing issues provided by the American Nurses Association. Which type of education did the nurse receive? ANS: Continuing Education • A nurse identifies gaps between local and best practices. Which Quality and Safety Education for Nurses (QSEN) competency is the nurse demonstrating? ANS: Quality improvement • A nurse has compassion fatigue. What is the nurse experiencing? ANS: Burnout and secondary traumatic stress • A patient is scheduled for surgery. When getting ready to obtain the informed consent, the patient tells the nurse, “ I have no idea what is going to happen. I couldn’t ask any questions.” The nurse does not allow the patient to sign the permit and notifies the health care provider of the situation. Which role is the nurse displaying? ANS: Patient advocate’ • The patient requires routine gynecological services after giving birth to her son, and while seeing the nurse­midwife, the patient asks for a referral to a pediatrician for the newborn. Which action should the nurse­midwife take initially? ANS: offer to provide the newborn care • The nurse has a goal of becoming a certified registered nurse anesthetist (CRNA). Which activity is appropriate for a CRNA? ANS: works under the guidance of an anesthesiologist • A nurse teaches a group of nursing students about nurse practice acts. Which information is most important to include in the teaching session about nurse practice acts? ANS: Protects the public • A bill has been submitted to the State House of Representatives that is designed to reduce the cost of health care by increasing the patient­to­nurse ratio from a maximum of 2:1 in intensive care units to 3:1. What should the nurse realize? ANS: The individual nurse can influence legislative decisions • A nurse is using a guide that provides principles of right and wrong to provide care to patients. Which guide is the nurse using? ANS: Code of ethics • A graduate of a baccalaureate degree program is ready to start working as an RN in the emergency department. Which action must the nurse take first? ANS: Pass the National Council Licensure Examination • While providing care to a patient, the nurse is responsible, both professionally and legally. Which concept does this describe? ANS: Accountability • A nurse is teaching the staff about Benner’s levels of proficiency. In which order should the nurse place the levels from beginning level to ending level? ANS: Novice, Advanced beginner, Competent, Proficient, Expert (2,5,4,3,1) Chapter 2 • The nurse is caring for a patient whose insurance coverage is Medicare. The nurse should consider which information when planning care for this patient? ANS: Diagnosis­related groups (DRGs) provide a fixed reimbursement of cost • A nurse is teaching the staff about managed care. Which information should the nurse include in the teaching session? ANS: Managed care causes providers to focus on prevention TEST BANK FOR FUNDAMENTALS OF NURSING 11TH EDITION POTTER PERRY (A COMPREHENSIVE STUDY GUIDE 2022) • A nurse observes an outbreak of lice in a certain school district. The nurse collects data and identifies a common practice of sharing lockers, caps, and hair brushes. The nurse shares the information with the school. Which community­based nursing competency did the nurse use? ANS: Epidemiologist • A nurse is providing screening at a health fair. Which finding indicates the person may be a vulnerable patient who is most likely to develop health problems? ANS: One who has excessive risks • The instructor is teaching student nurses about identifying members of vulnerable populations when the nursing student asks. “Why is it that not all poor people are considered members of vulnerable populations?” How should the nurse respond? ANS: “Members of vulnerable groups frequently have a combination of risks factors” • The nurse is making a home visit to a Korean mother after the birth of girl. The spouse is pressing different parts of the patient’s hand and lower arm to relieve a headache. What is the nurse’s next action? ANS: ask the mother and/or spouse to explain the procedure • A nurse is assessing the social system of a community. Which area should the nurse assess? ANS: Volunteer programs • The nurse is working with a 16­year­old pregnant female who tells the nurse that she needs an abortion. The nurse, acting as a counselor, provides the patient with information on alternatives to abortion, but after several sessions, the patient still insists on having the abortion. What should the nurse, in the counselor role, do next? ANS: Provide referral to an abortion service • Before a patient with beginning stage of Alzheimer’s disease is discharged, the communitybased nurse is making a visit to the patient’s home. The patient’s daughter and family live in the home with the patient. What is the major focus of the visit? ANS: Demonstrate techniques for providing care • While conducting a community assessment, the nurse seeks data on the average household income and the number of residents on public assistance. In doing so, the nurse is evaluating which component of a community assessment? ANS: Structure • The nurse uses statistics on increased incidence of communicable disease to influence legislatures to pass a bill for mandatory vaccinations to enroll in school. Which type of nursing will the nurse use in this process? ANS: Public Health Nursing Chapter 6 • A nurse is teaching about the goals of Healthy People 2020. Which information should the nurse include in the teaching session? ANS: Eliminate health disparities in America • A nurse is following the goals of Healthy People 2020 to provide care. Which action should the nurse take? ANS: Create social and physical environments that promote good health • A nurse is using the World Health Organization definition of health to provide care. Which area will the nurse focus on while providing care? ANS: Making sure to involve the whole person • A nurse is preparing a smoking cessation class for family members of patients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the benefits of not smoking. Which health care model is the nurse following? ANS: Health Belief Model • A nurse is using Maslow’s hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first? ANS: Not eating • The patient is reporting moderate incisional pain that was not relieved by the last dose of pain medication. The patient is not due for another dose of medication for another 2 ½ hours. The nurse repositions the patient, asks what type of music the patient likes, and sets the television to the channel playing that type of music. Which health care model is the nurse using? ANS: Holistic health model • A nurse is assessing internal variables that are affecting the patient’s health status. Which area should the nurse assess? ANS: Perception of functioning • The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about employment status and displays a nonjudgmental attitude. What is the rationale for the nurse’s actions? ANS: A person’s compliance is affected by economic status TEST BANK FOR FUNDAMENTALS OF NURSING 11TH EDITION POTTER PERRY (A COMPREHENSIVE STUDY GUIDE 2022) • The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. Which concept is the nurse fostering? ANS: Passive health promotion • The nurse is working in a clinic that is designed to provide health education and immunizations. Which type of preventive care is the nurse providing? ANS: primary prevention • The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. The patient is placed on oxygen, has labs and blood gasses drawn, and is given an electrocardiogram and breathing treatments. Which level of preventive care is this patient receiving? ANS: Secondary prevention • A patient is admitted to a rehabilitation facility following a stroke. The patient has right­sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. Which level of preventive care is the patient receiving? ANS: Tertiary prevention • Upon completing a history, the nurse finds that a patient has risks factors for lung disease. How should the nurse interpret this finding? ANS: The chances of getting the disease are increased • The nurse is caring for a patient who has been trying to quit smoking. The patient has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate? ANS: The patient will return to the contemplation or precontemplation phase. • The nurse is working in a drug rehabilitation clinic and is in the process of admitting a patient for “detox.” What should the nurse do next? ANS: Identify the patient’s stage of change • A female patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. The patient is visiting the weight loss clinic/ health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. Which stage is the patient displaying? ANS: Contemplation • A nurse is performing a cultural assessment using the ETHNIC mnemonic for communication. Which area will the nurse assess for the “H”? ANS: Healers • 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? ANS: Look at the patient when talking • Which action indicates the nurse is meeting a primary goal of cultural competent care for patients? ANS: Provides care to transgender patients • The nurse is caring for a Chinese patient using the Teach­Back technique. Which action by the nurse indicates successful implementation of this technique? ANS: Asks, “What will you tell your spouse about changing the dressing?” • 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? ANS: Poor People • A nurse is designing a form for lesbian, gay, bisexual, and transgender (LGBT) patients. Which design should the nurse use? ANS: Use partnered rather than married • A nurse is assessing population groups for the risk of suicide requiring medical attention. Which group should the nurse monitor most closely? ANS: Young Bisexuals • A nurse is assessing a patient’s ethnohistory. Which question should the nurse ask? ANS: How different is your life here from back home? • A nurse is teaching patients about health care information. Which patient will the nurse assess closely for health literacy? ANS: A patient 68 years old A nurse works at a hospital that uses equity­focused quality improvement. Which strategy is the hospital using? ANS: reduce disparities • 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? ANS: Provides care that fits the patient’s valued life patterns and set of meanings • A nurse is assessing the patient’s meaning of illness. Which area of focus by the nurse is priority? ANS: On the way a patient reacts to disease Chapter 10 • A nurse is assessing the family unit to determine the family’s ability to adapt to the change of a member having surgery. Which area is the nurse monitoring? ANS: Family resiliency • A nurse reviews the current trends affecting the family. Which trend will the nurse find? ANS: More grandparents are raising their grandchildren • A spouse brings the children in to visit their mother in the hospital. The nurse asks how the family is doing. The husband states, “None of her jobs are getting done, and I don’t do those jobs, so the house and the kids are falling apart.” How will the nurse interpret this finding? ANS: The family structure is rigid. • A nurse cares for the family’s as well as the patient’s needs using available resources. Which approach is the nurse using? ANS: Family as a system • A nurse is caring for a patient who needs constant care in the home setting and for whom most of the care is provided by the patient’s family. Which action should the nurse take to help relieve stress? ANS: Provide education • A nurse is working with a patient. When the nurse asks about family members, the patient states that it includes my spouse, children, and aunt and uncle. How will the nurse describe the type of family? ANS: Extended • A nurse is assessing a child that lives in car with family members who presents to the emergency department. Which area should the nurse assess closely? ANS: Ears • The nurse is interviewing a patient who is being admitted to the hospital. The patient’s family went home before the nurse’s interview. The nurse asks the patient, “Who decides when to come to the hospital?” What is the rationale for the nurse’s action? ANS: To assess the family structure • A nurse is caring for a patient from a motor vehicle accident. Which action by the unlicensed assistive personnel will cause the nurse to intervene? ANS: Tells the family not to leave the bedside • A nurse is using the family as context approach to provide care to a patient. What should the nurse do next? ANS: Assess how much the family provides the patient’s basic needs. • The nurse is caring for a patient in hospice. The nurse notes that the patient is getting adequate care, but the spouse is not sleeping well. The nurse also assesses the need for better family nutrition and meals assistance. The nurse discusses these needs with the patient and family and develops a plan of care with them using community resources. Which approach is the nurse using? ANS: Family as system • The nurse is caring for an older adult patient who has no apparent family. When questioned about family and the definition of family, the patient states,” I have no family. They’re all gone.” When asked, “Who prepares your meals?” the patient states, “I do, or I go out.” Which approach should the nurse use for this patient? ANS: Family as context • The nurse is caring for an older adult patient at home who requires teaching for dressing changes. The spouse and adult child are also involved in changing the dressing. Which statement by the nurse will most likely elicit a positive response from the patient and family? ANS: “You’re hesitant about changing the dressing like I was before I was shown an easier way; would you like to see?” ANS: Assessing patient needs, determining nursing diagnoses, Planning priorities of care, implementing nursing interventions, evaluating goals (2,4,3,5,1) Chapter 16 • The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase? ANS: Completes a comprehensive database • A nurse is using the problem­oriented approach to data collection. Which action will the nurse take first? ANS: Focus on the patient’s presenting situation. • After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? ANS: Ask the NAP to record the patient’s vital signs before administering medications. • The nurse is gathering data on a patient. Which data will the nurse report as objective data? ANS: Respirations 16 • A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data? ANS: The patient is apprehensive about discharge • Which method of data collection will the nurse use to establish a patient’s database? ANS: Preforming a physical examination • A nurse is gathering information about the patient’s habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information? ANS: preform a thorough nursing health history • While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do? ANS: consider cultural differences during this assessment • A nurse has already set the agenda during a patient­centered interview what will the nurse do next? ANS: Ask about the chief concerns or problems • The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask? ANS: “What reasons do you think are contributing to your fatigue?” • A nurse is conducting a nursing health history. Which component will the nurse address? ANS: Patient expectations • While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest a night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take? ANS: Ask the patient about usual sleep patterns and the onset of having difficulty resting. • The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using? ANS: Problem­oriented assessment • Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation? ANS: “Validation involves comparing data with other sources for accuracy.” • Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? ANS: The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage • While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first? ANS: Ask the patient to describe the type of reaction. • A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations? ANS: Ask the patient about the facial grimacing with movement • The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview? ANS: The patient’s room with the door closed Chapter 17 • A new nurse is completing an assessment on an 80­year­old patent who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow­up by the charge nurse? ANS: the nurse speaks only to the patient’s daughter • After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions? ANS: To distinguish the nurse’s role from the physician’s role • Which diagnosis will the nurse document in a patient’s care plan that is NANDA­I approved? ANS: Acute pain • A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x­ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write? ANS: impaired gas exchange related to alveolar­capillary membrane changes • The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need revise? ANS: etiology • A nurse is using assessment data gathered about a patient and combing critical thinking to develop a nursing diagnosis. What is the nurse doing? ANS: Diagnostic reasoning • A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care? ANS: Acute pain • The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review? ANS: Diagnosis • A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self­catheterization versus assisted catheterization by home health nurses and family members. The • The following statements are on a patient’s nursing care plan. Which statement will the nurse use as an outcome for a goal of care? ANS: The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift • A charge nurse is reviewing outcome statement using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse? ANS: the patient will feed self at all mealtimes today without reports of shortness of breath • A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for the patient? ANS: Reflex urinary incontinence • The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse? ANS: “ Begin with the highest priority diagnosis, then select appropriate interventions.” • A Patient’s son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do? ANS: Involve the son in the plan of care as much as possible • A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care? ANS: Patient will have one soft, formed bowel movement by end of shift. • The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform? ANS: Interdependent • A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing? ANS: Dependent Which action indicates the nurse is using a PICOT question to improve care for a patient? ANS: Implements interventions based on scientific research • A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Risk for loneliness related to impaired verbal communication? ANS: Provide the patient with a writing board each shift • A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces? ANS: Turn the patient every 2 hours, even hours • A patient has reduced muscle strength following a left­sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls? ANS: Assist patient into and out of bed every 4 hours or as tolerated • Which action will the nurse take after the plan of care for a patient is developed? ANS: Communicate the plan to all heath care professionals involved in the patient’s care. • A nurse is preparing to make a consult. In which order, beginning with the first step, will the nurse take? ANS: Identify the problem, Contact the right professional, with the appropriate knowledge and expertise, provide the consultant with relevant information about the problem, Avoid bias by not providing a lot of information based on opinion to the consultant, Discuss the findings and recommendations(1,4,3,5,2) • A hospital’s wound nurse consultant made a recommendation for nurses on the unit about how to care for the patient’s dressing changes. Which action should the nurses take next? ANS: Include dressing change instructions and frequency in the care plan Chapter 19 • A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse? ANS: implementation • The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching? ANS: Protocols assist the clinician in making decisions and choosing interventions for specific health care problems or conditions • The standing orders for a patient include acetaminophen 650mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next? ANS: Administer the acetaminophen • Which action indicates a nurse is using critical thinking for implementation of nursing care to patients? ANS: Determines whether an intervention is correct and appropriate for the given situation • A nurse is reviewing a patient’s care plan. Which information will the nurse identify as a nursing intervention? ANS: Provide assistance while the patient walks in the hallway twice this shift with crutches • A patient recovering from leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around the room with crutches because of leg discomfort. Which nursing intervention is priority? ANS: Administer pain medication • The nurse is caring for a patient who requires a complex dressing change. While in the patient’s room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing? ANS: Assess the patient’s readiness for the procedure • A patient visiting with family members in the waiting area tells the nurse “ I don’t feel good, especially in the stomach.” What should the nurse do? ANS: As the patient to return to the room, so the nurse can inspect the abdomen • A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially? ANS : Review the patient’s activity orders A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take? ANS: Develop good communication skills ANS: The patient is able to ambulate in the hallway with crutches • The nurse is evaluating whether a patient’s turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule? ANS: Absence of skin breakdown • A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next? ANS: Reassess the patient and situation • A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate? ANS: “Evaluative measures include assessment data used to determine whether patients have met their outcomes and goals.” • The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take? ANS: Measure the wound and observe for redness, swelling or drainage The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse’s next action? ANS: Revise the plan of care and change the dressing now • A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome? ANS: States feels better after talking with family and friends • A nurse is providing education to a patient about self­administering subcutaneous injections. The patient demonstrates the self­injection. Which type of indicator did the nurse evaluate? ANS: Health Behavior • A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement mad by the patient is the best indicator of progress toward the goal? ANS: “ I’ll wear the blue dress. It matches my eyes.” • A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion? ANS: Patient correctly states names of family members in the room • A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse’s priority when evaluating the patient? ANS: Identify factors interfering with goal achievement • A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal? ANS: Lungs clear to auscultation following use of inhaler • A nurse is evaluating an expected outcome for a patient that states heart rate will be less than 80 beats/min by 12/3. Which finding will alert the nurse that the goal has been met? ANS: heart rate 78 beats/min on 12/3 A nurse is modifying a patient’s care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks? ANS: Reassess blood pressure reading, Revise nursing diagnosis, Change goal to blood pressure less than 140/90, Administer new blood pressure medication, Retake blood pressure after medication. (2,1,5,4,3) Chapter 22 • Four patients in labor all request epidural analgesia to manage their pain at the same time. Which ethical principle is most compromised when only one nurse anesthetist is on call? ANS: Justice • The patient reports to the nurse of being afraid to speak up regarding a desire to end care for fear of upsetting spouse and children. Which principle in the nursing code of ethics ensures that the nurse will promote the patient’s cause? ANS: Advocacy • The patient’s son requests to view documentation in the medical record. What is the nurse’s best response to this request? ANS: “You will need your mother’s permission.” • When professionals work together to solve ethical dilemmas, nurses must examine their own values. What is the best rationale for this step? ANS: So different perspectives are respected • A nurse is experiencing an ethical dilemma with a patient. Which information indicates the nurse has a correct understanding of the primary cause of ethical dilemmas? ANS: Presence of conflicting values • The nurse questions a health care provider’s decision to not tell the patient about a cancer diagnosis. Which ethical principle is the nurse trying to uphold for the patient? ANS: Autonomy The nurse finds it difficult to care for a patient whose advance directive states that no extraordinary resuscitation measures should be taken. Which step may help the nurse to find resolution in this assignment? ANS: Scrutinize personal values • The nurse values autonomy above all other principles. Which patient assignment will the nurse find most difficult to accept? ANS: Family elder who is making the decisions for a young­adult female member • A nurse must make an ethical decision concerning vulnerable patient populations. Which philosophy of health care ethics would be particularly useful for this nurse? ANS: Feminist ethics • A nurse agrees with regulations for mandatory immunizations of children. The nurse believes that immunizations prevent diseases as well as prevent spread of the disease to others. Which ethical framework is the nurse using? ANS: Utilitarianism • A pediatric oncology nurse floats to an orthopedic trauma unit. Which action should the nurse manager of the orthopedic unit take to enable safe care to be given by this nurse? ANS: determine patient acuity and care the nurse can safely provide • While recovering form severe illness, a hospitalized patient wants to change a living will, which was signed 9 months ago. Which response by the nurse is most appropriate? ANS: “ Let me check with someone here in the hospital who can assist you? A home health nurse notices that a patient’s preschool children are often playing on the sidewalk and in the street unsupervised and repeatedly takes them back to the home and talks with the patient, but the situation continues. Which immediate action by the nurse is mandated by law? ANS: Contact the appropriate community child protection facility. • A confused patient with urinary catheter, nasogastric tube, and intravenous line keeps touching these needed items for care. The nurse has tried to explain to the patient that these lines should not be touched, but the patient continues. Which is the best action by the nurse at this time? ANS: Try other approaches to prevent the patient from touching these care items • A patient with sepsis as a result of long­term leukemia dies 25 hours after admission to the hospital. A full code was conducted without success. The patient had a urinary catheter, an intravenous line, an oxygen cannula, and nasogastric tube. Which question is the priority for the nurse to ask the family before beginning postmortem care? ANS: “ Is an autopsy going to be done?” • Conjoined twins are in the neonatal department of the community hospital until transfer to the closest medical center. A photographer from the local newspaper gets off the elevator on the neonatal floor and wants to take pictures of the infant. Which initial action should the nurse take? ANS: Tell the cameraman where the hospital’s public relations department is located • A nursing student has been written up several times for being late with providing patient care and for omitting aspects of patient care and not knowing basic procedures that were taught in the skills course one term earlier. The nursing student says, “I don’t understand what the big deal is. As my instructor, you are there to protect me and make sure I don’t make mistakes.” What is the best response from the nursing instructor? ANS: “ you are expected to perform at the level of a professional nurse.” A nurse works full time on the oncology unit at the hospital and works part time on weekendsgiving immunizations at the local pharmacy. While giving an injection on a weekend, the nurse caused injury to the patient’s arm and is now being sued. How will the hospital’s malpractice insurance provide coverage for this nurse? ANS: the hospital’s malpractice insurance covers this nurse only during the time the nurse is working at the hospital • A female nursing student in the final term of nursing school is overheard by a nursing faculty member telling another student that she got to insert a nasogastric tube in the emergency department while working as a nursing assistant. Which advice is best for the nursing faculty member to give to the nursing student? ANS: “You are not allowed to perform any procedures other than those in your job description even with the nurse’s permission.” Chapter 24 • Which types of nurses make the best communicators with patients? ANS: those who develop critical thinking skills • A nurse believes that the nurse­patient relationship is a partnership and that both are equal participants. Which term should the nurse use to describe this belief? ANS: Mutuality • A nurse wants to present information about flu immunization to the older adults in the community. Which type of communication should the nurse use? ANS: Public • A nurse is using therapeutic communication with a patient. Which technique will the nurse use to ensure effective communication? ANS: Electronic communication to assess a patient in another city A nurse is standing bedside the patient’s bed. Nurse: How are you doing? Patient: I don’t feel good. Which element will the nurse identify as feedback? ANS: I don’t’ feel good • A nurse is sitting at the patient’s beside taking a nursing history. Which zone of personal space is the nurse using? ANS: personal • A smiling patient angrily states, ”I will not cough and deep breathe.” How will the nurse interpret this finding? ANS: the patient’s affect is inappropriate • The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which form of communication did the patient use? ANS: nonverbal • A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal story about the care that has been received. Which interaction is the nurse using? ANS: Narrative • 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? ANS: Preinteraction • 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? ANS: Orientation ANS: The student nurse shares patient information with a friend A nurse exchanges information with the oncoming nurse about a patient’s care. Which actiondid the nurse complete? ANS: A verbal report A nurse is auditing and monitoring patient’s health records. Which action is the nurse taking? ANS: Determining the degree to which standards of care are met by reviewing patients’ health records • After providing care, a nurse charts in the patient’s record. Which entry will the nurse document? ANS: Skin pale and cool • A nurse has provided care to patient. Which entry should the nurse document in the patient’s record? ANS: Left knee incision 1 inch in length without redness. Drainage or edema • A nurse is charting on a patient’s record. Which action will the nurse take that is accurate legally? ANS: Chart’s legibly • A nurse wants to find all the pertinent patient information in one record, regardless of the number of times the patient entered the health care system. Which record should the nurse find? ANS: Electronic health record • A nurse has taught the patient how to use crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the “I” in PIE charting? ANS: Demonstrated use of crutches • A nurse wants to find the daily weights of a patient. Which form will the nurse use? ANS: Graphic record flow sheet • A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do? ANS: Document the variance in the patient’s record A nurse needs to begin discharged home. Which information should the nurse include? ANS: Community resources • . A nurse developed the following discharge summary sheet. Which critical information should the nurse add? TOPIC DISCHARGE SUMMARY Medication Diet Activity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge ANS: mode of transportation • A home health nurse is preparing for an initial home visit. Which information should be included in the patient’s home care medical record? ANS: Reports to third­party payers A nurse in a long­term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing? ANS: A minimum data set • A nurse is charting. Which information is critical for the nurse to document? ANS: the patient received a pain medication, Lortab • A nurse is completing an OASIS data set on a patient. The nurse works in which area? ANS: Home Health • A nurse is preparing to document a patient who has chest pain. Which information is critical for the nurse to include? ANS: Sharp pain of 8 on scale of 0 to 10 • A nurse is providing care to a group of patients. Which situation will require the nurse to obtain a telephone order? ANS: At 0100, a patient’s blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood. • A nurse obtained a telephone order form a primary care provider for a patient in pain. Which chart entry should the nurse document? ANS: 12/16/20XX 0915 Morphine, 2mg, IV every 4 hours for incisional pain. TO Dr. Day/ J. Winds, RN, read back. • A nurse is teaching the staff about informatics. Which information the staff indicates the nurse needs to follow up? ANS: If a nurse has computer competency, the nurse is competent in informatics • A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using? ANS: Critical pathway design • A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take? ANS: chart on the computer immediately after care is provided • Which entry will require follow­up by the nurse manager? 0800 Patient states, “Fell out of bed.” Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, “Did not pass out.” Assisted back to bed. Call bell within reach. Bed monitor on. ——————-Jane More, RN The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint? ANS: The patient continues to remove the nasogastric tube The nurse is trying to use alternatives rather than restrain a patient. Which finding will cause the nurse to determine the alternative is working? ANS: The patient folds three washcloths over and over • The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take? ANS: Assess the patient • The nurse is monitoring for the four categories of risk that have been identified in the health care environment. Which examples will alert the nurse that these safety risks are occurring? ANS: Wet floors unmarked, and patient pinching fingers in door, failure to use life for patient, and alarms not functioning properly • Which activity will cause the nurse to monitor for equipment­related accidents? ANS: uses a patient­controlled analgesic pump • A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take? ANS: Keep the patient on fall risk until discharge • A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure­related accident? ANS: Surgical asepsis • A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals? ANS: Uses medication bar coding when administering medications • A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals? ANS: Then patient takes a hypnotic • A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel? ANS: Applying the restraints • A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next? ANS: Remove the restraints • The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority? ANS: Manage all patients using standard precautions The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan? ANS: Risk for Injury A confused patient is restless and continues to try to remove the oxygen cannula and urinarycatheter. What is the priority nursing diagnosis and intervention to implement for this patient? ANS: Risk for injury: Check on patient every 15 minutes • The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient’s application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient’s plan of care? ANS: Deficient knowledge • The nurse enters the patient’s room and notices a small fire in the headlight above the patient’s bed. In which order will the nurse perform the steps, beginning with the first one? ANS: Remove the patient, Pull the alarm, Close doors and windows, Use the fire extinguisher. (2,1,4,3) • The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1­year­old grandchild. Which comment by the grandparent will cause the nurse to intervene? ANS: “ if my grandchild eats a plant, I should provide syrup of ipecac” • A home health nurse is assessing a family’s home after the birth of an infant. A toddler also lives in the home. Which finding will cause the nurse to follow up? ANS: Plastic grocery bags are neatly stored under the counter • Which patient will the nurse see first? ANS: A 56­year­old patient with oxygen using an electric razor for grooming • A home health nurse is teaching a family to prevent electrical shock. Which information will the nurse include in the teaching session? ANS: Disconnect items before cleaning • The nurse has placed a yellow armband on a 70­year­old patient. Which observation by the nurse will indicate the patient has an understanding of this action? ANS: The patient wears the red nonslip footwear • An older­adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient? ANS: Backs wheelchair into elevator, leading with large rear wheels first Chapter 30 • A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely? ANS: Temperature A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss? ANS: Convection • The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address? ANS: African­Americans • A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient’s blood pressure (BP)? ANS: Smoking result in Vasoconstriction, falsely elevating BP • When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding? ANS: This is normal for an infant. • The nurse is caring for an older­adult patient and notes that the temperature is 96.8° F (36° C). How will the nurse interpret this finding? ANS: The patient has a normal temperature. • When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse’s action? ANS: It has no risk of injury to patient or nurse • The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to praise the NAP? ANS: Brachial site • The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn? Ans: 30 to 60 • The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will the nurse take? ANS: Determine whether the toddler has a latex allergy • The nurse is preparing to assess the blood pressure of a 3­year­old. How should the nurse proceed? ANS: Explain the procedure to the child • A nurse is caring for a group of patients. Which patient will the nurse see first? ANS: A calm adolescent with P­95 and R­26 The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take blood pressure 3 times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient? ANS: You will need to recalibrate the machine • The nurse is caring for a patient who reports feeling light­headed and “woozy.” The nurse checks the patient’s pulse and finds that it is irregular. The patient’s blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do? ANS: Perform an apical/radial pulse assessment • A nurse is caring for group of patients. Which patient will the nurse see first? ANS: A 20­year­old male postoperative patient whose blood pressure went from 128/70 to 100/60 • The health care provider prescription reads “Metoprolol (Lopressor) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic.” The patient’s blood pressure is 92/66. The nurse does not give the medication. Which action should the nurse take? ANS: Documents that the medication was not given because of low blood pressure • After taking the patient’s temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse’s action? ANS: Temperatures vary depending on the route used. • When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding? ANS: 138/62 • The nursing assistive personnel (NAP) is taking vital signs and reports that a patient’s blood pressure is abnormally low. What should the nurse do next? ANS: Retake the blood pressure personally and assess the patient’s condition Chapter 33 • A patient describes practicing a complementary and alternative therapy involving breathwork and yoga. The nurse also recommends using energy field therapies. Which techniques did the nurse suggest? ANS: Reiki therapy and therapeutic touch • A teen with an anxiety disorder is referred for biofeedback because the parents do not want their child to take anxiolytics. Which statement from the teen indicates successful learning? ANS: “Biofeedback will help me with my thoughts and physiological responses to stress.” An older­adult patient is newly admitted to a skilled nursing facility with the diagnoses of Alzheimer’s dementia, lipidemia, and hypertension, and a history of pulmonary embolism. Medications brought on admission included lisinopril (Zestril, Prinivil), hydrochlorothiazide (Microzide), warfarin (Coumadin), low­dose aspirin, ginkgo biloba, and echinacea. Which potential interaction will cause the nurse to notify the patient’s health care provider? ANS: Warfarin and ginkgo biloba • A patient asks the nurse for a nonmedical approach for excessive worry and work stress. Which therapy should the nurse recommend? ANS: Meditation • A patient asks the nurse for a nonmedical approach for excessive worry and work stress. Which therapy should the nurse recommend? ANS: Allopathic • During a relaxation therapy skills group, the instructor discusses the cognitive skill of learning to tolerate uncertain and unfamiliar experiences. Which skill is the nurse describing? ANS: Receptivity • A patient asks about the new clinic in town that is staffed by allopathic and complementary practitioners. Which response from the nurse is best? ANS: It is probably an integrative medial clinic • The group leader is overheard saying to the gathering of patients, “Focus on your breathing once again …. Notice how it is regular …. Now focus on your left arm …. Notice how relaxed your left arm feels …. Notice the relaxation going down the left arm to the hand.” A patient asks the nurse what the group is doing. What is the nurse’s best response? ANS: It is progressive relaxation training • A therapeutic touch practitioner scans the patient’s body. What is the purpose of the practitioner’s actions? ANS: To identify energy obstructions • A nurse is teaching a patient about meridians. Which technique is the nurse preparing the patient to receive? ANS: Acupuncture • A Native American patient is asking for a spiritual healer. Which person should the nurse try to contact for the patient? ANS: Shaman • A nurse is using the holistic approach to care. Which goal is the priority? ANS: Incorporate the mind­body­spirit connection • A nurse is using caring­healing relationships to support whole person/whole systems healing. Which type of nursing is the nurse using? ANS: Integrative nursing A nurse is teaching a patient relaxation techniques to decreases stress. Which finding will support the nurse’s evaluation that the therapy is effective? ANS: Decreased heart rate • A severely depressed patient cannot state any positive attributes to life. The nurse patiently sits with this patient and assists the patient to identify several activities the patient is actually looking forward to in life. Which spiritual concept is the nurse trying to promote? ANS: Hope • In preparation for the eventual death of a female hospice patient of the Muslim faith, the nurse organizes a meeting of all hospice caregivers. A plan of care to be followed when this patient dies is prepared. Which information will be included in the plan? ANS: Allow female Muslims to care for the body after death has occurred • Family members gather in the emergency department after learning that a family member was involved in a motor vehicle accident. After learning of the family member’s unexpected death, the surviving family members begin to cry and scream in despair. Which phase does the nurse determine the family is in according to the Attachment Theory? ANS: Yearning and searching • A nursing assistive personnel (NAP) is caring for a dying patient. Which action by the NAP will cause the nurse to intervene? ANS: Making the patient eat • An Orthodox Jewish rabbi has been pronounced dead. The nursing assistive personnel respectfully ask family members to leave the room and go home as postmortem care is provided. Which statement from the supervising nurse is best? ANS: “ Family members stay with the body until burial the next day • A palliative team is caring for a dying patient in severe pain. Which action is the priority? ANS: Enhance the patient’s quality of life • A veteran is hospitalized after surgical amputation of both lower extremities owing to injuries sustained during military service. Which type of loss will the nurse focus the plan of care on for this patient? ANS: Situational loss • “I know it seems strange, but I feel guilty being pregnant after the death of my son last year,” said a woman during her routine obstetrical examination. The nurse spends extra time with this woman, helping her realize bonding with this unborn child will not mean she is replacing the one who died. Which nursing technique does this demonstrate? ANS: Facilitating mourning • A patient has had two family members die during the past 2 days. Which coping strategy is most appropriate for the nurse to suggest to the patient? ANS: Writing in a journal • A female nurse is called into the supervisor’s office regarding her deteriorating work performance since the loss of her spouse 2 years ago. The woman begins sobbing and says that she is “falling apart” at home as well. Which type of grief is the female nurse experiencing? ANS: Complicated grief • A nurse is caring for a patient in the last stages of dying. Which finding indicates the nurse needs to prepare the family for death? ANS: Cheyne­stokes breathing • The mother of a child who died recently keeps the child’s room intact. Family members are encouraging her to redecorate and move forward in life. Which type of grief will the home health nurse recognize the mother is experiencing? ANS: Normal • A nurse is caring for a dying patient. One of the nurse’s goals is to promote dignity and validation of the dying person’s life. Which action will the nurse take to best achieve this goal? ANS: Listen to family stories about the person • A nurse is caring for a dying patient. When is the best time for the nurse to discuss end­oflife care? ANS: During assessment • A nurse is providing postmortem care. Which action will the nurse take? ANS: Leave dentures in the mouth • A nurse lets the transplant coordinator make a request for organ and tissue donation from the patient’s family. What is the primary rationale for the nurse’s action? ANS: The nurse is following a federal law A patient cancels a scheduled appointment because the patient will be attending a Shivah for a family member. Which response by the nurse is best? ANS: “I’m so sorry for your loss” During a follow­up visit, a female patient is describing new onset of marital discord with her terminally ill spouse to the hospice nurse. Which Kübler­Ross stage of dying is the patient experiencing? ANS: Anger • A previously toilet trained toddler has started wetting again. A nurse is gathering a health history from the grandparent. Which health history finding will the nurse most likely consider as the cause of the wetting? ANS: Recent parental death • A patient’s father died a week ago. Both the patient and the patient’s spouse talk about the death. The patient’s spouse is experiencing headaches and fatigue. The patient is having trouble sleeping, has no appetite, and gets choked up most of the time. How should the nurse interpret these findings as the basis for a follow­up assessment? ANS: Both the patient and the spouse are likely grieving Chapter 39 • A nurse observes a patient rising from a chair slowly by pushing on the chair arms. Which type of tension and contraction did the nurse observe? ANS: Eccentric tension and isotonic contraction • A nurse notices that a patient has a structural curvature of the spine associated with vertebral rotation. Which condition will the nurse most likely find documented in the patient’s medical record? ANS: Scoliosis • A nurse is caring for a patient who has some immobility from noninflammatory joint degeneration. The nurse is teaching the patient about this process. Which information will the nurse include in the teaching session? ANS: This involves overgrowth of bone at the articular ends • The nurse is providing care to a patient who is bedridden. The nurse raises the height of the bed. What is the rationale for the nurse’s action? ANS: Prevents a shift in the nurse’s base of support • A nurse is following the no­lift policy when working to prevent personal injury. Which type of personal back injury is the nurse most likely trying to prevent? ANS: Lumbar • The nurse is caring for a patient in the emergency department with an injured shoulder. Which type of joint will the nurse assess? ANS: Synovial • The nurse is caring for a patient with inner ear problems. Which goal is the priority? ANS: Maintain balance • A nurse is teaching a health promotion class about isotonic exercises. Which types of exercises will the nurse give as examples? ANS: Swimming, jogging, and bicycling • A patient’s hygiene schedule of bathing and brushing teeth is largely influenced by family customs. For which age group is the nurse most likely providing care? ANS: Preschooler • The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind? ANS: The patient’s illness may require teaching of new hygiene practices • The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says “I always bathe in the evening.” Which action by the nurse is best? ANS: Defer the bath until evening and pass on the information to the next shift. • A nurse is completing an assessment of the patient. Which principle is a priority? ANS: Critical thinking will always be important • When providing hygiene for an older­adult patient, the nurse closely assesses the skin. What is the rationale for the nurse’s action? ANS: Less frequent bathing may be required • The nurse is bathing a patient and notices movement in the patient’s hair. Which action will the nurse take? ANS: Use gloves to inspect the hair • The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. The driver’s license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next? ANS: Stand to the side of the patient’s eye and observe the cornea • A nurse is assessing a patient’s skin. Which patient is most at risk for impaired skin integrity? ANS: A patient who is diaphoretic The nurse is caring for a patient who is immobile. The nurse frequently checks the patient for impaired skin integrity. What is the rationale for the nurse’s action? ANS: Pressure reduces circulation to affected tissue The nurse is caring for a patient who has diabetes mellitus and circulatory insufficiency, with peripheral neuropathy and urinary incontinence. On which areas does the nurse focus care? ANS: Decreased pain sensation and increased risk of skin impairment • The nurse is caring for a patient who has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment? ANS: Assess surfaces exposed to the edges of the cast for pressure areas • Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage? ANS: Assess for pain during a bath • After performing foot care, the nurse checks the medical record and discovers that the patient has a foot disorder caused by a virus. Which condition did the nurse most likely observe? ANS: Plantar warts • The nurse is caring for a patient who is reporting severe foot pain due to corns. The patient has been using oval corn pads to self­treat the corns, but they seem to be getting worse. Which information will the nurse share with the patient? ANS: Depending on severity, surgery may be needed to remove the corns • The patient is diagnosed with athlete’s foot (tinea pedis). The patient says that he is relieved because it is only athlete’s foot, and it can be treated easily. Which information should the nurse consider when formulating a response to the patient? ANS: Contagious with frequent recurrences • When assessing a patient’s feet, the nurse notices that the toenails are thick and separated from the nail bed. What does the nurse most likely suspect is the cause of this condition? ANS: Fungi • The nurse is providing education about the importance of proper foot care to a patient who has diabetes mellitus. Which primary goal is the nurse trying to achieve? ANS: Prevention of amputation • The nurse is providing oral care to an unconscious patient and notes that the patient has extremely bad breath. Which term will the nurse use when reporting to the oncoming shift? ANS: Halitosis • The nurse is caring for a patient with diabetes. Which task will the nurse assign to the nursing assistive personnel? ANS: Making an occupied bed • The patient is being treated for cancer with weekly radiation therapy to the head and chemotherapy treatments. Which assessment is the priority? ANS: Oral Cavity • The nurse is providing oral care to an unconscious patient. Which action should the nurse take? ANS: Suction the oral cavity • The nurse is teaching the patient about flossing and oral hygiene. Which instruction will the nurse include in the teaching session? ANS: Flossing removes plaque and tarter from the teeth • The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which information will the nurse include in the teaching session? ANS: Head lice may spread to furniture and other people • A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff? ANS: Dandruff • A nurse is providing a bath. In which order will the nurse clean the body, beginning with the first area? ANS: Eyes, Face, Arms and chest, Hands and nails, Abdomen and legs, Perineum, Back and buttocks. ( 2,1,4,5,7,2,6) • The nurse is caring for a patient who has multiple ticks on lower legs and body. What should the nurse do to rid the patient of ticks? ANS: Use blunt tweezers and pull upward with steady pressure • The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area? ANS: Chewing and inner tooth surfaces, Outer tooth surfaces, Roof of mouth, gums and inside cheek, Tongue. (2,3,1,4) • The nurse is caring for an older­adult patient with Alzheimer’s disease who is ambulatory but requires total assistance with activities of daily living (ADLs). The nurse notices that the patient is edentulous. Which area should the nurse assess? ANS: Assess oral cavity • A self­sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel? ANS: Partial bed bath • The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. In which order will the nurse clean the body, starting with the first area? ANS: Neck shoulders and chest, Both arms both hands webs spaces and axilla, Abdomen and groin/perineum, Legs feet and web spaces, Back of neck, back and then buttocks (1,5,2,3,4)