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Chapter 01: Aspects of Medical-Surgical Nursing

Linton: Medical-Surgical Nursing, 7th Edition

MULTIPLE CHOICE

1. What provides direction for individualized care and assures the delivery of accurate, safe

care through a definitive pathway that promotes the client’s and the support persons’

progress toward positive outcomes?

a. Physician’s orders

b. Progress notes

c. Nursing care plan

d. Client health history

ANS: C

The nursing care plan provides direction for individualized care and assures the delivery of

accurate, safe care through a definitive pathway that promotes the client’s and the support

persons’ progress toward positive outcomes.

DIF: Cognitive Level: Comprehension REF: p. 2 OBJ: 1 TOP: Nursing Care Plan KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk

2. The nurse is performing behaviors and actions that assist clients and significant others in

meeting their needs and the identified outcomes of the plan of care. What is the correct

term for these nursing behaviors?

a. Assessments

b. Interventions

c. Planning

d. Evaluation

ANS: B

Caring interventions are those nursing behaviors and actions that assist clients and

significant others in meeting their needs and the identified outcomes of the plan of care.

DIF: Cognitive Level: Comprehension REF: p. 3 OBJ: 1 TOP: Interventions KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk

3. The nurse understands the importance of being answerable for all actions and the

possibility of being called on to explain or justify them. What term best describes this

concept?

a. Reliability

b. Maturity

c. Accountability

d. Liability

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ANS: C

Accountability means that a person is answerable for his or her actions and may be called

on to explain or justify them.

DIF: Cognitive Level: Comprehension REF: pp. 6-7 OBJ: 3 | 5 | 7

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TOP: Accountability KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Reduction of Risk

MULTIPLE RESPONSE

1. The nurse manager is providing an inservice about conflict resolution. What modes of

conflict resolution should be addressed? ( Select all that apply. )

a. Suppression

b. Accommodation

c. Compromise

d. Avoidance

e. Collaboration

f. Competition

ANS: B, C, D, E, F

The modes of conflict resolution include accommodation, collaboration, compromise,

avoidance, and competition.

DIF: Cognitive Level: Knowledge REF: p. 7|p. 8|Table 1. OBJ: 7 TOP: Conflict Resolution KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

2. What are the characteristics of an effective leader? ( Select all that apply. )

a. Effective communication

b. Rigid rules and regulations

c. Delegates appropriately

d. Acts as a role model

e. Consistently handles conflict

f. Focuses on individual development

ANS: A, C, D, E

Characteristics of an effective leader include effective communication, consistency in

managing conflict, knowledge and competency in all aspects of delivery of care, effective

role model for staff, uses participatory approach in decision making, shows appreciation

for a job well done, delegates work appropriately, sets objectives and guides staff, displays

caring, understanding, and empathy for others, motivates and empowers others, is

proactive and flexible, and focuses on team development.

DIF: Cognitive Level: Comprehension REF: p. 6 OBJ: 5 TOP: Leadership KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

COMPLETION

1. is defined as the process by which information is exchanged between

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individuals verbally, nonverbally, and/or in writing or through information technology.

ANS:

Communication

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Communication is defined as the process by which information is exchanged between

individuals verbally, nonverbally, and/or in writing or through information technology.

DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: 2 TOP: Communication KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

2. is the collection and processing of relevant data for the purpose of appraising

the client’s health status.

ANS:

Assessment

Assessment is the collection and processing of relevant data for the purpose of appraising

the client’s health status.

DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: 1 | 2 TOP: Assessment KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

3. is concerned with the ethical questions that arise in the context of health care.

ANS:

Bioethics

Bioethics is concerned with the ethical questions that arise in the context of health care.

DIF: Cognitive Level: Knowledge REF: p. 4 OBJ: 3 TOP: Bioethics KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

4. Place the corresponding letter to each stage of conflict in the correct order.

(Place the events in the appropriate sequence with capital letters. Do not separate

answers with a space or punctuation. Example: ABCD.)

a. Outcomes

b. Conceptualization

c. Frustration

d. Action

ANS:

CBDA

The stages of conflict in order are frustration, conceptualization, action, and outcomes.

DIF: Cognitive Level: Comprehension REF: p. 7 OBJ: 7 TOP: Conflict KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

5. Place the corresponding letter to each key step in solving an ethical dilemma in the correct

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order. (Place the events in the appropriate sequence. Do not separate answers

with a space or punctuation. Example: ABCD.)

a. Negotiate a plan.

b. Clarify values.

c. Ask if it is an ethical dilemma.

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d. Verbalize the problem.

e. Gather information.

f. Identify possible courses of action.

g. Evaluate the plan over time.

ANS:

CEBDFAG

The key step of solving an ethical dilemma in order are ask the question, is it an ethical

dilemma, gather information, clarify values, verbalize the problem, identify possible

course of action, negotiate a plan, and evaluate the plan over time.

DIF: Cognitive Level: Analysis REF: p. 4 OBJ: 3 TOP: Ethical Dilemma KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

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Chapter 02: Medical-Surgical Practice Settings

Linton: Medical-Surgical Nursing, 7th Edition

MULTIPLE CHOICE

1. While a home health nurse is making the entry to a service assessment on a homebound

patient, the spouse of the patient asks whether Medicare will cover the patient’s ventilator

therapy and insulin injections. What is the best response by the nurse?

a. “Yes, Medicare will cover both the ventilator therapy and the insulin injections.”

b. “No, Medicare will not cover either of these ongoing therapies.”

c. “Medicare will cover the ventilator therapy, but it does not cover the insulin

injections.”

d. “Medicare will cover the ongoing insulin therapy, but it does not cover a highly

technical skill such as ventilator therapy.”

ANS: C

Medicare will cover skilled nursing tasks such as ventilator therapy, but common tasks

that can be taught to the family or the patient are not covered.

DIF: Cognitive Level: Application REF: pp. 12-13 OBJ: 3 | 4 TOP: Medicare Coverage for Home Health KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

2. The wife of a patient asks the nurse whether her husband would be considered for

placement in a skilled nursing care facility when he is discharged from the general

hospital. The patient is incontinent, has mild dementia but is able to ambulate with a

walker, and must have help to eat and dress himself. What is the nurse’s most appropriate

response?

a. “Yes, your husband would qualify for a skilled care facility because of his inability

to feed and dress himself.”

b. “No, your husband’s disabilities would not qualify him for a skilled facility.”

c. “Yes, your husband qualifies for placement in a skilled care facility because of his

dementia.”

d. “Yes, anyone who is willing to pay can be placed in a skilled nursing facility.”

ANS: B

Placement in a skilled nursing facility must be authorized by a physician. A clear need for

rehabilitation must be evident, or severe deficits in self-care that have a potential for

improvement and require the services of a registered nurse, a physical therapist, or a

speech therapist must exist.

DIF: Cognitive Level: Analysis REF: p. 13 OBJ: 6 TOP: Placement Qualifications for Skilled Nursing Facility KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Safe, Effective Care Environment

3. A nurse has noted that a newly admitted resident to an extended care facility stays in her

room, does not take active part in activities, and leaves the meal table after having eaten

very little. The nurse should analyze this relocation response as

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a. regression.

b. social withdrawal.

c. depersonalization.

d. passive aggressive.

ANS: B

Social withdrawal is a frequent response to relocation.

DIF: Cognitive Level: Application REF: p. 21 OBJ: 10 TOP: Relocation Response KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

4. A nurse clarifies to a new patient in a rehabilitation center what rehabilitation means.

What statement made by the patient indicates a correct understanding?

a. “I will return to my previous level of functioning.”

b. “I will be counseled into a new career.”

c. “I will develop better coping skills to accept his disability.”

d. “I will attain the greatest degree of independence possible.”

ANS: D

The rehabilitation process works to promote independence at whatever level the patient is

capable of achieving.

DIF: Cognitive Level: Comprehension REF: p. 15 OBJ: 7 TOP: Rehabilitation Goals KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care

5. A nurse assesses a patient who needs to be reminded to take premeasured oral

medications, wash, go to meals, and undress and come to bed at night, but coming and

going as he pleases is considered safe for him. What facility placement would be most

appropriate for this patient?

a. Skilled care

b. Intermediate care

c. Sheltered housing

d. Domiciliary care

ANS: D

Domiciliary care provides room, board, and supervision, and residents may come and go

as they please. Sheltered housing does not provide 24-hour care.

DIF: Cognitive Level: Comprehension REF: p. 19 OBJ: 3 | 9 TOP: “Levels of Care, Criteria for Domiciliary Residence” KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

6. A nurse is making a list of the members of the rehabilitation team, so the different types of

services available to patients may be taught to a group of families. Which lists should be

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used?

a. Physical therapist, nurse, family members, and personal physician

b. Occupational therapist, dietitian, nurse, and patient

c. Rehabilitation physician, laboratory technician, patient, and family

d. Vocational rehabilitation specialist, patient, and psychiatrist

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ANS: A

The rehabilitation team usually consists of all of the choices except the laboratory

technician, dietitian, and psychiatrist. (The mental health role is represented by the

psychologist.)

DIF: Cognitive Level: Comprehension REF: p. 17 OBJ: 7 TOP: Rehabilitation Team Members KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

7. A nurse explains the level of disability to a patient who was injured in a construction

accident that resulted in the loss of both his right arm and right leg. This loss has affected

his quality of life and ability to return to previous employment. At what level should the

client be classified as being disabled?

a. I

b. II

c. III

d. IV

ANS: B

The patient is limited in the use of his right arm for feeding himself, dressing himself, and

driving his car, which are three main activities of daily living. He may be able to work if

workplace modifications are made.

DIF: Cognitive Level: Application REF: p. 15 OBJ: 8 TOP: Levels of Disability KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

8. A nurse explains that in 1990, the Americans with Disabilities Act (ADA) was passed. For

which extended services for the disabled persons did this act provide?

a. Covering the costs for the rehabilitation of disabled World War I servicemen by

providing job training

b. Extending protection to the disabled in the military sector, such as wheelchair

ramps on military bases

c. Extending protection to the disabled in private areas, such as accessibility to public

restaurant bathrooms and telephones

d. Affording disabled persons full access to all health care services

ANS: C

The ADA of 1990 extended the previous legislative Acts of 1920, 1935, and 1973. The

ADA now covers private sector individuals and public businesses in particular.

DIF: Cognitive Level: Comprehension REF: p. 16 OBJ: 8 TOP: Americans with Disabilities Act (ADA) of 1990 KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

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9. A frail patient in a long-term care facility asks the nurse if a bath is to be given this

morning. What is the best reply by the nurse to encourage independence and give the

patient the most flexibility?

a. “Based on your room number, you get bathed on Monday, Wednesday, and Friday.

Today is Tuesday.”

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b. “If you want to eat breakfast in the dining room with the others, you may sponge

yourself off in your bathroom.”

c. “When your daughter comes this evening, ask her if she can give you a bath.”

d. “I will bring a basin of water for a sponge off for right now. After breakfast, we

will talk about a bath schedule.”

ANS: D

The resident should be provided as much flexibility as possible and support for

independence.

DIF: Cognitive Level: Application REF: p. 22 OBJ: 11 TOP: Maintenance of Autonomy in Extended Care Facility KEY: Nursing Process Step: Implementation MSC: NCLEX Physiological Integrity: Basic Care and Comfort

10. A computer programmer who lost both legs is being retained by his employer, who has

made arrangements for a ramp and a special desk to accommodate the patient’s

wheelchair. What is the disability level of the computer programmer?

a. I

b. II

c. III

d. IV

ANS: B

Level II allows for workplace accommodation, which is the desk modification in this case.

DIF: Cognitive Level: Analysis REF: p. 15 OBJ: N/A TOP: Reasonable Accommodation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

11. A partially paralyzed forklift operator is to be retrained by vocational rehabilitation

services for less demanding office work. What law provides for this rehabilitation?

a. Vocational Rehabilitation Act of 1920

b. Social Security Act of 1935

c. Rehabilitation Act of 1973

d. Americans with Disabilities Act of 1990

ANS: C

The Rehabilitation Act of 1973 provided a comprehensive approach and expanded

resources for public vocational training.

DIF: Cognitive Level: Comprehension REF: p. 16 OBJ: 7 TOP: Rehabilitation Legislation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

12. The home health care nurse performs all the following actions. Which is the only action

that is reimbursable under Medicare payment rules?

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a. Observing a spouse cleaning and changing a dressing

b. Taking a frail couple for a walk to provide exercise

c. Watching a patient measure out all medications

d. Teaching a patient to self-administer insulin

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ANS: D

Medicare reimburses skilled techniques that are clearly spelled out; these include teaching

but not return demonstration–type actions by patient or family.

DIF: Cognitive Level: Comprehension REF: pp. 12-13 OBJ: 4 TOP: Medicare Reimbursable Actions KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

13. A patient with multiple sclerosis must be fed, bathed, and dressed. How should the nurse

assess this patient?

a. Disabled

b. Disadvantaged

c. Handicapped

d. Impaired

ANS: D

Feeding oneself, dressing, and bathing are activities of daily living. The patient is impaired

in this scenario.

DIF: Cognitive Level: Analysis REF: p. 15 OBJ: 7 TOP: Principles of Rehabilitation | Defining Levels of Loss of Functioning Independently KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

14. Which law initially provided for rehabilitation of disabled Americans?

a. Vocational Rehabilitation Act of 1920

b. Social Security Act of 1935

c. Rehabilitation Act of 1973

d. Americans with Disabilities Act of 1990

ANS: A

The U.S. government has passed four pieces of legislation to identify and meet the needs

of disabled individuals with each one being more inclusive. The first one was passed in

DIF: Cognitive Level: Knowledge REF: p. 16 OBJ: 8 TOP: Rehabilitation Legislation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

15. A client was admitted to a long-term residential care facility. On what should the

admitting nurse tell the family the concepts of long-term care are based?

a. Amount of activities the resident can do for herself

b. Maintenance care with an emphasis on incontinence

c. Successful adaptation to the regulations of the home

d. Maintenance of as much function as possible

ANS: D

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Maintenance of function and encouraging autonomy and independence are some of the

basic concepts of long-term care.

DIF: Cognitive Level: Comprehension REF: p. 18 OBJ: 11 TOP: Principles of Nursing Home Care KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

16. A 58-year-old patient with diabetes is recuperating from a broken hip and is concerned

about how to pay for rehabilitation. The nurse should inform this patient that funds for

rehabilitation are available from which resource?

a. Vocational Rehabilitation Act of 1920

b. Rehabilitation Act of 1973

c. Disabled American Veterans Act of 1990

d. Title V, Health of Crippled Americans 1935

ANS: B

The Rehabilitation Act of 1973 assists in paying for rehabilitation for those who are

younger than 65 years of age and who will benefit from vocational rehabilitation through

teaching.

DIF: Cognitive Level: Comprehension REF: p. 16 OBJ: 8 TOP: Legislation for Funding Health Care KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

17. What is an example of a description of community health nursing?

a. Visiting patients in their homes after hospital discharge to assess their personal

health status

b. Asking a nursing assistant (NA) to identify the health services most needed in the

patient’s personal life

c. Meeting with residents of low-income housing to identify their health care needs

d. Developing a hospital-based home health care service

ANS: C

Whereas community-based nursing looks at identified community needs and provides care

at all levels of wellness and illness, community health nursing seeks to provide services to

groups to modify or create systems of care.

DIF: Cognitive Level: Comprehension REF: pp. 10-11 OBJ: 2 TOP: Defining Community-Based Nursing versus Community Health Nursing KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care

18. Home health nurses have some different nursing activities than those of community health

nurses. Which statement best describes the home health nurse’s activities?

a. Conducting health education classes in a senior citizens’ common residence

building

b. Conducting blood pressure screening on a regular basis at a local mall

c. Visiting and assessing the home care and further teaching needs of a patient who

has been recently discharged from the hospital

d. Acting as a nurse consultant to a chronic psychiatric section in a state institution

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ANS: C

The home health nurse works with individuals in the home; the other descriptors are

community nurse activities.

DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: 1 | 5

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TOP: Activities of the Home Health Nurse KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

19. Based on guidelines from the Americans with Disability Act (ADA), which question is an

appropriate choice for the director of nurses to ask a nurse with an artificial leg who is

applying for a staff position in an extended care facility?

a. “How long have you had your prosthesis?”

b. “How many flights of stairs are you able to climb without assistance?”

c. “Are you able to lift a load of 45 lb?”

d. “Has your disability caused you to miss work?”

ANS: C

Queries to disabled job applicants can be made relative to specific job functions, but they

cannot be asked relative to the severity of the disability or the degree of disability in

general.

DIF: Cognitive Level: Application REF: p. 16 OBJ: 7 | 8 TOP: ADA KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

20. A nurse reminds a resident in a long-term care facility that he has autonomy in many

aspects of his institutionalization. What is an example of autonomy?

a. Selection of medication times

b. Availability of his own small electrical appliances

c. Smoking in the privacy of his own room

d. Application of advance directives

ANS: D

The application of advance directives is an autonomous decision. Agency protocols

relative to medication times, access to private electrical devices, and smoking are rarely

waived; these policies are not in the control of the resident.

DIF: Cognitive Level: Comprehension REF: p. 22 OBJ: 10 TOP: Autonomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

MULTIPLE RESPONSE

1. What care skills are safe and appropriate for the licensed practical nurse (LPN) to teach

family members in the home health care setting? ( Select all that apply. )

a. Insulin injection

b. Sterile dressing changes

c. Venipunctures

d. Periodic Foley catheter insertions

e. Instillation of eye drops

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f. Changing dressings on small wounds

ANS: A, E, F

Insulin injections, instillation of eye drops, and small wound dressing changes are safe to

teach a nonprofessional caregiver. Sterile dressings, venipunctures, and inserting Foley

catheters are considered skilled, and the costs for these are reimbursed by Medicare.

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DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: 3 TOP: Skills Taught by Home Health Nurse KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

2. The nursing care plan in a long-term care facility calls for the documentation of regressive

behavior of a newly admitted 82-year-old resident who has had congestive heart failure

and osteoarthritis. Of these behaviors observed by the nurse, which should be documented

as regression? ( Select all that apply. )

a. Talks nonstop to staff and other residents.

b. Wets and soils self several times a day.

c. Wakes in the middle of the night and is unable to return to sleep.

d. Wears the same clothes day after day.

e. Cries frequently for no apparent reason.

ANS: B, D, E

Behaviors that are infantile or immature in the absence of dementia are considered

regressive. Frequent episodes of crying and inattention to personal hygiene are regressive

in nature. Excessive talking and wakefulness may be related to relocation anxiety, but they

are not considered regressive.

DIF: Cognitive Level: Analysis REF: pp. 20-21 OBJ: 10 TOP: Impact of Relocation KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

3. From what do most quality-of-care problems in home health care result? ( Select all that

apply. )

a. Patient’s noncompliance

b. Family’s reluctance to participate in the care

c. Inadequate documentation

d. Limited funding

e. Defective communication among care team members

ANS: C, E

Inadequate communication and incomplete documentation create most of the

quality-of-care problems.

DIF: Cognitive Level: Comprehension REF: pp. 11-12 OBJ: 2 TOP: Communication in Home Health Setting KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

4. An 80-year-old man is newly admitted to a long-term care facility and suddenly becomes

incontinent of urine at night. What nursing interventions should be used to help restore

self-toileting? ( Select all that apply. )

a. Waking the resident every 2 hours and escorting him to the bathroom

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b. Leaving a night-light on

c. Discouraging the use of long-legged pajama bottoms

d. Placing a urinal at the bedside

e. Keeping the room uncluttered

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ANS: B, C, D, E

Providing light in an uncluttered room, encouraging clothing that does not impede

self-toileting, and making the urinal available increase independence and alleviate

situations that make self-toileting difficult. Waking a resident not only disturbs his or her

rest, but doing so also increases dependency on the staff.

DIF: Cognitive Level: Application REF: pp. 11-12 OBJ: 10 | 11 TOP: Independence in Long-Term Care Center KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

COMPLETION

1. The nurse clarifies that an impairment that creates a measurable diminished capacity to

work is a(n).

ANS:

disability

When there is a measurable impairment that changes the individual’s lifestyle, it is

referred to as a disability.

DIF: Cognitive Level: Knowledge REF: p. 15 OBJ: N/A TOP: Rehabilitation Concepts KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care

2. What should the home health nurse do when teaching a family member the skill of

injecting insulin effectively? Prioritize these nursing interventions for this situation.

(Place the events in the appropriate sequence. Do not separate answers with a

space or punctuation. Example: ABCD.)

a. Offer instruction at an appropriate pace.

b. Write down the steps of the procedure.

c. Assess the level of knowledge of the family member.

d. Inquire about the preferred learning style.

e. Evaluate the family member’s performance.

ANS:

CBDAE

Effective teaching depends on assessing the level of knowledge, breaking down the skill in

steps, offering instruction in the preferred style, pacing the instruction appropriately, and

evaluating the performance.

DIF: Cognitive Level: Application REF: p. 14 OBJ: 1 TOP: Home Health Teaching KEY: Nursing Process Step: Planning

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MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

3. Prioritize the steps in solving an ethical dilemma. (Place the events in the

appropriate sequence. Do not separate answers with a space or punctuation. Example:

ABCD.)