Davis Advantage Basic Nursing- Thinking Doing and Caring 3rd Edition Treas Wilkinson Test Bank (1)

www.mynursingtestprep.com2) Check the graphic data for vital signs. 3) Examine the history and physical. 4) Look for an advance directive. ANS: 4 The advance directive, which should be located in a special section of the patients medical record, should be examined first because the patients symptoms indicate that he may need to be resuscitated. The advanced directive contains information about the patients wishes for intensity of care and actions that should be taken in the event of a life- threatening event. The discharge plan contains data from utilization review, case managers, or discharge planners on anticipated needs after discharge. Graphic data are to record assessment done frequently, such as vital signs. The history and physical provide a detailed summary of the patients current problem, past medical and social history, medications taken by the patient, review of systems, and physical examination data. PTS:1DIF:EasyREF:p. 386 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 2. A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system? 1) It involves a cooperative effort among various disciplines. 2) The system requires diligence in maintaining a current problem list. 3) Data may be fragmented and scattered throughout the chart. 4) It allows the nurse to provide information in an unorganized manner. ANS: 3 A major disadvantage of a source-oriented medical record is that data may be fragmented and scattered throughout the chart. The problem-oriented medical record requires a cooperative effort among disciplines and diligence in maintaining a current problem list. Narrative charting allows the nurse to provide information in a disorganized manner. PTS:1DIF:ModerateREF:p. 387 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 3. The patients medical record contains the following documentation: 06/05/05 0200 Received patient from the E.D. BP 80/52, HR 118, RR 24, temp 104F. Arouses to verbal stimuli but drifts off to sleep. Normal saline infusing in left arm via18 gauge IV catheter at 250 mL/hr. Urinary catheter draining scant dark amber urine. Pt receiving O2 at 6 L/min via nasal cannula. Lungs with coarse crackles at the left base. Loose cough present. Pt unable to expectorate secretions.Ann. Davids, RN Which type of charting has the nurse used? 1) Narrative 2) Focus 3) SOAP 4) PIE ANS: 1

www.mynursingtestprep.comThe nurse used narrative charting when documenting the condition of this newly admitted patient. This format is free text description of the patient status and nursing care. Focus charting highlights the patients concerns, problems, and strengths in a three-column format. SOAP is an acronym for subjective data, objective data, assessment, and plan. This charting format is used to address single problems or to write summative notes. PIE is an acronym for problem, interventions, and evaluation. This charting method also addresses problems. PTS:1DIF:EasyREF:p. 392 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis 4. The department of nursing at a local hospital is considering changing to charting by exception (CBE). Which statement provides a rationale to support making this change? CBE 1) Reduces the time nurses spend charting 2) Addresses the patients concerns holistically 3) Establishes an ongoing care plan from admission 4) Is most useful when constructing a timeline of events ANS: 1 An advantage of CBE is that it reduces the amount of time that nurses must spend documenting. CBE assumes that unless a separate entry is made, all standards have been met with a normal response. Focus charting addresses the patients concerns holistically. PIE charting establishes an ongoing care plan from admission. Narrative charting is especially useful when attempting to construct timelines of events. PTS:1DIF:ModerateREF:p. 387 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 5. A patient is admitted to the emergency department with a stroke. After being stabilized, the patients needs are best met if the nurse documents a care plan that provides for 1) Acute interventions 2) Patient teaching 3) Discharge needs 4) Family health data ANS: 3 The patients potential discharge needs should be evaluated when the patient first enters the healthcare facility. After the patient is admitted, discharge needs should be continually reevaluated and documented throughout the patients hospitalization. PTS:1DIF:ModerateREF:p. 395 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 6. The patients health record contains the following providers order: furosemide 40 mg intravenously STAT. If the nurse later needed to know when the medication had been given and the patients response to the medication, where would he look? 1) Progress notes

www.mynursingtestprep.com2) Graphic record 3) Narrative notes 4) MAR ANS: 3 The nursing narrative note will contain documentation about the time the medication was administered and the patients response to the medicine. In contrast, the MAR will only contain documentation about when the medication was given, not the patients response. The physicians progress note contains documentation about why the furosemide was ordered. The graphic record will not contain charting about the medication but will contain information about the patients output. PTS: 1 DIF: Easy REF: dm 386-387; 396; 401 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 7. A client who cannot manage a patient-controlled analgesia pump is prescribed morphine 4 mg intravenously q 1 hour PRN pain. When should the nurse administer the medication? 1) Every hour around-the-clock 2) Immediately after taking off the order 3) As needed, but not more than once per hour 4) 1 hour after the last administered dose ANS: 3 PRN is the abbreviation for as needed. The nurse should administer the medication after assessing that the patient needs the medication or the patient requests it and at least 1 hour has elapsed since the last dose. STAT medications must be administered immediately. PTS:1DIF:ModerateREF:p. 399 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 8. The nurse administers heparin 5000 units subcutaneously at 2100 and documents in the medication administration record that the dose was administered. What other information is important for the nurse document? 1) Injection site 2) Previous site of administration 3) Patient response to medication 4) Heart rate prior to administration ANS: 1 After administering an injection, the nurse must document the injection site to prevent the patient from receiving repeated injections in the same location. Heparin 5000 units subQ was prescribed for the patient. The previous route of administration is already documented on the MAR from the previous dose and would not be noted in the entry for the current dose. The patients response to medication is recorded in the nurses narrative note in the traditional paper for the electronic health record. When the nurse signs out that the drug

www.mynursingtestprep.comwas given in the medication administration record, she is validating that she administered the drug according to the physicians order. Heparin does not affect heart rate. PTS:1DIF:ModerateREF:p. 399 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 9. A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery for colon cancer. Which integrated plan of care (IPOC) would be most appropriate for the nurse to implement? 1) Hypertension 2) Rheumatoid arthritis 3) Postoperative colon resection 4) Follow all three plans ANS: 3 The postoperative colon resection integrated plan of care should be followed; however, modifications should be made to meet the patients other health needs. Therefore, portions of the hypertension and rheumatoid arthritis integrated plan of care may be added to the postoperative colon resection plan of care. PTS: 1 DIF: Difficult REF: p. 400; ESG, KEY: Nursing process: Planning | Client need: Physiological integrity | Cognitive level: Application 10. The nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone order for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order? 1) 09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain. Kay Andrews, RN 2) 09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews, RN 3) 09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain V.O.: Dr. D. Kelly/Kay Andrews, RN 4) 09/02/13 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RN ANS: 2 Correct documentation of a telephone order is as follows: 09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews, RN (date, time, medication, route, frequency of dose, circumstances under which it is to be given, prescribers name and title, nurses name and title.) The other options demonstrate incomplete documentation of a telephone order. PTS:1DIF:ModerateREF:dm 403-404 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 11. A patient refuses a dose of medication. How should the nurse document the event? 1) Patient is uncooperative and refuses the prescribed dose of digoxin. 2) Patient refuses the 0900 dose of digoxin.

www.mynursingtestprep.com3) Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin. 4) 0900 dose of digoxin not given. ANS: 2 Patient refuses the 0900 dose of digoxin objectively describes the event in which the patient refuses to take his 0900 dose of digoxin. 0900 dose of digoxin not given provides no explanation as to why the medication was not given. The other two options offer judgmental information, which should be avoided when charting. PTS:1DIF:ModerateREF:p. 399 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 12. The nurse makes a mistake while documenting in the patients health record. Which action should the nurse take? 1) Use an opaque white fluid to cover the documentation error. 2) Completely cover the documentation error with black ink. 3) Draw a line through the error and initial the change. 4) Use correction tape to make the documentation correct. ANS: 3 The nurse should draw a single line through the documentation error and place her initials next to the change. In some institutions, the nurse must also write the words error or mistaken entry above the error. The nurse should never use opaque cover-up liquid or correction tape. It is not acceptable to alter the patients health record as though the error was not made. Making note of the correction in documentation makes it clear to others what happened. PTS:1DIF:ModerateREF:p. 407 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 13. At 1000 on 11/14/10, the nurse takes a telephone order for metoprolol 5 mg intravenously now. What is the latest date and time the nurse will expect the prescriber to countersign the order? 1) 11/14/13 at 1200 2) 11/14/13 at 2200 3) 11/15/13 at 1000 4) 11/16/13 at 1000 ANS: 3 The prescriber must countersign all verbal and telephone orders within 24 hours. PTS:1DIF:ModerateREF:p. 404 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 14. The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order? 1)

www.mynursingtestprep.comRepeat the order to the prescriber even if she believes she understood the order correctly. 2) Immediately notify the pharmacy of the order and verify it with a pharmacist. 3) Ask the unit secretary to listen to the prescriber on the phone to verify the order. 4) Transcribe the order onto note paper and verify the dosage in a drug handbook. ANS: 1 The nurse should repeat the order to the prescriber even if she believes she understood it entirely. If possible, she should have a second nurse (not the unit secretary) listen to the order to verify accuracy. Only the prescribing provider, not the pharmacist, can verify the order. The nurse should transcribe the order directly on the patients chart. Transcribing it on a piece of paper and then copying it again introduces one more chance of error. PTS:1DIF:ModerateREF:p. 404 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 15. A resident in a long-term care facility receiving Medicare funds requires care for a stage 2 pressure ulcer. How often must the nurse document this patients care? 1) Every 2 weeks 2) Every shift 3) Every week 4) Every 3 months ANS: 2 When a patient requires Medicare-reimbursed services, such as wound care, documentation is required every shift. Those who require assistance with medications, nutrition, and activities of daily living must have a summary written by a registered nurse or licensed practical nurse every 2 weeks. A summary must also be recorded on a weekly basis for those who require wound care. The Minimum Data Set must be updated every 3 months. PTS:1DIF:ModerateREF:p. 401 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 16. What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident of a long-term care facility? 1) 14 days 2) 3 days 3) 2 days 4) 24 hours ANS: 1 Federal regulations require that a resident be evaluated using the Minimum Data Set within 14 days of admission to a long-term care facility. PTS:1DIF:EasyREF:p. 401 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall

www.mynursingtestprep.com17. A client is admitted to a long-term care facility. The nurse knows that federal law requires the use of 1) The Minimum Data Set (MDS) for assessment 2) Situation-background-assessment-recommendation (SBAR) for reporting 3) Healthcare Financing Administration guidelines prior to surgery 4) Joint Commission guidelines for discharge planning ANS: 1 Federal regulations require that a resident be evaluated using the Minimum Data Set (MDS) within 14 days of admission to a long-term care facility. SBAR is a technique used for communicating and organizing a hand-off report. HCFA guidelines govern home healthcare documentation. Joint Commission guidelines do apply to long-term care facilities, but only the MDS assessment is mandated by federal law. PTS:1DIF:EasyREF:p. 401 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall 18. The surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM. Which action indicates that the nurse is following the surgeons order? The nurse 1) Performs oral care 2) Assists the patient out of bed 3) Assists the patient with bathing 4) Changes the patients operative dressings ANS: 2 OOB is the abbreviation for out of bed. The nurse is following the physicians order when she assists the patient out of bed in the morning. OOB does not indicate that the nurse should perform oral care, assist with bathing, or change the patients postoperative dressings. PTS:1DIF:EasyREF:p. 391 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 19. What is the purpose of completing an occurrence report? 1) Provide a legal defense should the patient seek legal action after an unusual occurrence 2) Track problems and identify areas for quality improvement 3) Report errors to the Food and Drug Administration 4) Report medical errors to the Joint Commission ANS: 2 Occurrence reports are used to track problems and identify areas for quality improvement. Occurrence reports are not used to provide legal defense should a patient seek legal action or to report errors to the FDA or Joint Commission. PTS:1DIF:ModerateREF:p. 400 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

www.mynursingtestprep.com20. The nursing instructor is teaching the student about occurrence reports. Which statement by the student indicates an understanding of the purpose of occurrence reports? 1) Occurrence reports track problems and identify areas for quality improvement. 2) Occurrence reports are required by the Food and Drug Administration to report drug errors. 3) The Joint Commission requires occurrence reports for all client falls. 4) Occurrence reports provide legal information should the patient seek legal action after an unusual occurrence. ANS: 1 Occurrence reports are used to track problems and identify areas for quality improvement. Occurrence reports are not used to provide legal information should a patient seek legal action. As an internal communication and documentation tool, occurrence reports are not required to be reported to the FDA or Joint Commission. PTS:1DIF:ModerateREF:p. 400 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 21. Which of the following is a disadvantage of paper health records? 1) Assist collaboration 2) Provide cautionary reminders 3) Are sometimes illegible 4) Serve as a resource ANS: 3 A disadvantage of paper documentation systems is that they are sometimes illegible. This increases the risk for medication administration and other errors, as well as taking nurses time to decipher handwriting and call providers. PTS:1DIF:ModerateREF:p. 390 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 22. The nursing assistive personnel (NAP) informs the nurse that a patient has fallen out of bed and is in pain. The nurse assesses the patient and provides care. Identify the correct documentation of the fall. 1) Patient found on floor in pain after falling out of bed. 2) Patient found on floor after falling out of bed; found by NAP Smith. 3) Patient fell out of bed but is currently in bed. 4) Patient reminded to not climb OOB after falling. ANS: 2 Charting must be accurate and succinct. Only chart what you observe. Do not chart what others have observed as your own observation. Avoid judging patients; instead, chart objectively. PTS: 1 DIF: Moderate REF: p. 400

www.mynursingtestprep.comKEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 23. Which set of topics makes up a hand-off report given in a recommended format? 1) Data-action-response 2) Subjective-objective-assessment-plan 3) Situation-background-assessment-recommendation 4) Patient-diagnosis-medications-activity ANS: 3 The SBAR (situation-background-assessment-recommendation) technique is used as a mechanism to give a hand-off report by enabling a focused communication between healthcare team members. DAR is used in Focus Charting, and SOAP is a method for documenting nursing care. The nursing admission assessment is completed and documented at the time of admission. PTS: 1 DIF: Easy REF: p. 402 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. Which statement by the student nurse indicates an understanding of the nursing Kardex? Choose all correct answers. 1) The Kardex pulls data from multiple areas of the patients chart. 2) The Kardex is usually kept at the patients bedside. 3) The Kardex is used to document patient response to interventions. 4) The Kardex summarizes the plan of care and guides nursing care. ANS: 1, 4 The Kardex is a tool that pulls data from multiple areas of the patients health record and helps guide nursing care. Responses to interventions are documented on flow sheets and in nurses notes. Kardexes are paper forms that are kept together in a portable file at the nurses station to allow all team members access to the summary information. The file is portable, so it could be carried to the bedside briefly; however, it is not stored there, as a general rule. PTS:1DIF:ModerateREF:p. 400 KEY: Nursing process: N/A | Client need: Safe-care environment | Cognitive level: Application 2. Which action by the nurse breaches patient confidentiality? Select all that apply. 1) Leaving patient data displayed on a computer screen where others may view it 2) Remaining logged on to the computer system after documenting patient care 3) Faxing a patient report to the nurses station where the patient is being transferred 4)

www.mynursingtestprep.comInforming the nurse manager of a change in the patients condition ANS: 1, 2 Leaving patient data displayed on a computer screen where others may view them breaches patient confidentiality. The nurse should log off the computer immediately after use. Faxing a report to the nurses station receiving a patient does not breach patient confidentiality because it is located at the nurses station out of others view. Anyone directly involved in the patients care has the right to know about the patients condition without breaching patient confidentiality. PTS:1DIF:ModerateREF:p. 408 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 3. Which statement by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply. 1) I can wait until the end of the shift to document my care. 2) Charting every 2 hours is the most appropriate way to document nursing care. 3) I find it easier to chart before I go to lunch and then after my shift report. 4) I should chart as soon as possible after nursing care is given. ANS: 1, 2, 3 Documentation should be performed as soon as possible after the nurse makes an assessment or provides care. The longer the nurse waits, the less accurate the documentation will be. Leaving documentation until the end of the shift may cause important details to be omitted or mistaken. It is not necessary to complete documentation on a strict schedule, such as every 2 to 4 hours. Even waiting until lunch or reporting after the shift is over is too long of a period of time for accurate documentation. In addition, the objectivity of documentation might be influenced by the discussion that occurs during report. PTS: 1 DIF: Moderate REF: p. 405-406 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 4. The nurse who understands the electronic health record (EHR) can do which of the following? Select all that apply. 1) Facilitate evidence-based nursing practice 2) Promote efficient use of the nurses documentation time 3) Reduce the opportunity for interdisciplinary collaboration 4) Ensure improved client safety and outcomes ANS: 1, 2, 4 Electronic health records (EHR) have many advantages, including the facilitation of evidence-based nursing practice, efficient use of the nurses documentation time, and improved client safety and outcomes. The EHR does not impair interdisciplinary collaboration; rather, the EHR fosters communication and collaboration among healthcare team members. PTS:1DIF:EasyREF:p. 388 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

www.mynursingtestprep.com5. In performing a hand-off report, the nurse should communicate information on which of the following? Select all that apply. 1) Teaching performed 2) Any change in client status 3) Treatments administered 4) Hygiene measures performed ANS: 1, 2, 3 Hand-off reports include any client teaching done, therapies and treatments administered, and changes in the clients status. Hygiene care is routinely done in inpatient settings and is usually recorded on a flow sheet. Hand-off reports should be succinct and not contain routine information. PTS: 1 DIF: Easy REF: p. 402 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall True/False Indicate whether the statement is true or false. 1. The nursing Kardex is part of the patients permanent health record. ANS: F The Kardex is not part of the patients permanent medical record. It is a tool that helps guide nursing care. It changes as different care is required. Chapter 18 Measuring Vital Signs Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A clients vital signs at the beginning of the shift are as follows: oral temperature 99.3F (37C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four hours later the clients oral temperature is 102.2F (39C). Based on the temperature change, the nurse should anticipate the clients heart rate would be how many beats/min? 1) 62 2) 82 3) 102 4) 122 ANS: 3 Heart rate increases about 10 beats per minute for each degree of temperature to meet increased metabolic needs and compensate for peripheral dilation. PTS:1DIF:ModerateREF:p. 426 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 2. The nurse is assessing vital signs for a client after surgical procedure on the left leg. IV fluids are infusing. It would be most important for the nurse to 1) Compare the left pedal pulse with the right pedal pulse 2)

www.mynursingtestprep.comCount the clients respiratory rate for 1 full minute 3) Take the blood pressure in the arm without an IV 4) Take an oral temperature with an electronic thermometer ANS: 1 For a client having surgery on the leg, the most important data would be whether the circulation has been compromised because of the surgery. This can be done only by comparing one leg with the other. The nurse would, of course, count the respiratory rate for 1 full minute and take the BP in the arm without the IV. Oral temperatures are commonly obtained using electronic thermometers. PTS:1DIF:ModerateREF:p. 449-450 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 3. The nurse hears rhonchi when auscultating a clients lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds? 1) Have the client take several deep breaths. 2) Request the client take a deep breath and cough. 3) Take the clients blood pressure and apical pulse. 4) Count the clients respiratory rate for 1 minute. ANS: 2 Rhonchi are caused by secretions in the large airways and may clear with coughing. This is how you differentiate between rhonchi and other adventitious sounds. Deep breathing will not help to clear rhonchi. Taking the blood pressure and apical pulse and counting the respiratory rate are not effective for clearing rhonchi and would not be sufficient for the nurse to identify whether the sounds were, indeed, rhonchi. PTS:1DIF:ModerateREF:p. 431 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 4. Which of the following sets of vital signs are all within normal limits for patients at rest? 1) Infant: T 98.8F (rectal), HR 160, RR 16, BP 120/54 2) Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/68 3) Adult: T 99.6F (oral), HR 48, RR 22, BP 130/84 4) Older adult: T 98.6F (oral), HR 110, RR 28, BP 170/95 ANS:2 All of the adolescents vital signs are within normal parameters for the age. The infants temperature is below normal for a rectal reading because the core temperature is approximately 1 degree higher than readings from other sites. The heart rate (HR) for an infant is high, the respiratory rate (RR) is low, and the blood pressure (BP) is high for the age. For the typical adult, the temperature is high, the HR is low, the RR is high, and the BP is elevated for the age. For the older adult, the temperature is high-end normal, the HR is high, the RR is high, and the BP is high for the age.

www.mynursingtestprep.comPTS:1DIFifficultREF:p. 414; for adult vital signs ESG Table 19-1, Comparison of Normal Vital Signs for Various Ages KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 5. The nurse assesses the following changes in a clients vital signs. Which client situation should be reported to the primary care provider? 1) Decreased blood pressure (BP) after standing up 2) Decreased temperature after a period of diaphoresis 3) Increased heart rate after walking down the hall 4) Increased respiratory rate when the heart rate increases ANS: 1 A drop in the clients blood pressure when standing indicates orthostatic hypotension, and the cause should be investigated. The changes in vital signs indicated in the other options are normal changes for the situations. PTS:1DIF:ModerateREF:p. 439 for hypotension information but should read content about all of the vital signs KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 6. The clients temperature is 101.1F. Which is the correct conversion to centigrade? 1) 38.0C 2) 38.4C 3) 38.8C 4) 39.2C ANS:2 To convert Fahrenheit to centigrade, subtract 32 from the temperature, and multiply by 5/9. PTS:1DIFifficultREF:p. 419 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application 7. The client has had a fever, ranging from 99.8F orally to 103F orally, over the last 24 hours. The clients fever would be classified as 1) Constant 2) Intermittent 3) Relapsing 4) Remittent ANS: 4 Remittent fevers fluctuate widely over a 24-hour period. Constant fevers stay above normal with only slight fluctuations. Intermittent fevers alternate between normal or subnormal temperatures with periods of fever. Relapsing fevers alternate between periods of fever and periods of normal temperature, each phase lasting 1 to 2 days. PTS:1DIF:ModerateREF:p. 418

www.mynursingtestprep.comKEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 8. A clients vital signs 4 hours ago were temperature (oral) 101.4F (38.6C), heart rate 110 beats/min, respiratory rate 26 breaths/min, and blood pressure 124/78 mm Hg. The temperature is now 99.4F (37.4C). Based only on the expected relationship between temperature and respiratory rate, the nurse might best anticipate the clients respiratory rate to be 1) 16 2) 18 3) 20 4) 22 ANS:2 For every degree Fahrenheit (0.6C) the temperature falls, the respiratory rate may decrease up to 4 breaths per minute. The clients temperature has fallen 2 degrees; multiplied by 4, this is 8. It was 26 breaths/min: 26 8 = 18 breaths/min. Keep in mind, this is an estimate and would vary depending on the patients baseline health, current condition, age, and other factors. PTS:1DIF:EasyREF:p. 430 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 9. Which one of the following clients would probably have a higher than normal respiratory rate? A client who has 1) Had surgery and is receiving a narcotic analgesic 2) Had surgery and lost a unit of blood intraoperatively 3) Lived at a high altitude and then moved to sea level 4) Been exposed to the cold and is now hypothermic ANS: 2 A reduction in hemoglobin from blood loss would increase the respiratory rate. Narcotics and hypothermia slow the respiratory rate. Going from lower altitudes to higher altitudes inhibits oxygen binding, so going to a lower altitude would decrease the respiratory rate or have no effect. Hypothermia decreases the metabolic rate, so the respiratory rate would likely decrease. PTS:1DIF:ModerateREF:p. 430 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 10. For which of the following adult clients should the nurse make follow- up observations and monitor the vital signs closely? A client whose 1) Resting morning blood pressure is 136/86 while the afternoon BP is 128/84 mm Hg 2) Oral temperature is 97.9F in the morning and 99.8F in the evening 3) Heart rate was 76 beats/min before eating and 88 beats/min after eating 4)

www.mynursingtestprep.comRespiratory rate is 16 breaths/min when standing and 18 when lying down ANS: 1 Both the blood pressures would be classified as prehypertension according to the JNC 7 Express guidelines. Body temperature normally increases during the course of a day. Heart rate increases for several hours after eating. Respiratory depth decreases when lying down, so it would be normal for the rate would increase; both rates are within normal limits. PTS:1DIF:ModerateREF:p. 440 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 11. A client who has been hospitalized for an infection states, The nursing assistant told me my vital signs are all within normal limits; that means Im cured. The nurses best response would be which of the following? 1) Your vital signs confirm that your infection is resolved; how do you feel? 2) Ill let your healthcare provider know so you can be discharged. 3) Your vital signs are stable, but there are other things to assess. 4) We still need to keep monitoring your temperature for a while. ANS: 3 Vital signs are one indicator of a clients physiological status, but they are not an absolute indicator of well-being from every aspect. It may be inaccurate to state that the vital signs indicate the infection is resolved; vital signs could stabilize even if the infection remains active. The healthcare providers decision regarding the clients readiness for discharge is not based exclusively on the vital signs but rather is based on a compilation of other sources of information, primarily the clients clinical status, but also cultures, complete blood counts, and various other laboratory and possibly radiologic evidence. Although the nurse will need to continue monitoring the temperature, other clinical signs must also be monitored; therefore, the statement We still need to keep monitoring your temperature . . . is incomplete and less useful than the statement that begins Your vital signs are stable, but . . . PTS:1DIFifficultREF:p. 414 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 12. The nursing instructor asks students how they would assess the fifth vital sign. Which student would be correct? 1) I would have the client rate her pain on a scale of 0 to 10. 2) I would ask the client when she had her last bowel movement. 3) I would take the clients pulse oximetry reading. 4) I would interview the client about history of tobacco use. ANS: 1 Pain is considered to be the fifth vital sign. PTS:1DIF:EasyREF:p. 414 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 13. A clients axillary temperature is 100.8F. The nurse realizes this is outside

www.mynursingtestprep.comnormal range for this client and that axillary temperatures do not reflect core temperature. What should the nurse do to obtain a good estimate of the core temperature? 1) Add 1F to 100.8F to obtain an oral equivalent. 2) Add 2F to 100.8F to obtain a rectal equivalent. 3) Obtain a rectal temperature reading. 4) Obtain a tympanic membrane reading. ANS: 3 Body temperatures, from lowest to highest, are axillary, oral, rectal, and tympanic. For oral, axillary, and rectal temperatures, there is a 1F degree difference between each site and the next higher one. However, mathematical conversions between sites are not reliable and should be used only when a rough estimate is neededfor instance, to decide whether a reading needs to be validated by another site or another thermometer. Rectal temperatures are most reliable and most accurately reflect the core temperature. Tympanic membrane readings are considered by most to be the least accurate and least reliable. PTS:1DIF:ModerateREF:dm 415, 421-422 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 14. In caring for a client who has a fever, it would be important for the nurse to monitor for increased 1) Urine output 2) Sensitivity to pain 3) Blood pressure 4) Respiratory rate ANS: 4 The metabolic rate increases with a fever, increasing a persons respiratory rate. Urine output would more likely decrease, rather than increase, because of increased insensible loss and possible loss of intake because of loss of appetite. Change in pain sensation is not a symptom of a fever. Blood pressure is more likely to decrease with a fever because of peripheral vasodilation. PTS:1DIF:ModerateREF:p. 430 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 15. The nurse is teaching a client how to use a portable blood pressure device to monitor his blood pressure at home. It would be most important for the nurse to 1) Ask the client to demonstrate the use of the blood pressure device 2) Explain the importance of frequent calibration of the device 3) Give the client a chart to record his blood pressure readings 4) Provide written instructions of the information taught ANS: 1 All are important things to include in client education, but self-monitoring of blood

www.mynursingtestprep.compressure is of little value unless it is done using proper technique. Requesting that the client demonstrate the procedure would allow the nurse to evaluate the clients technique. PTS: 1 DIF: Difficult REF: p. 437; not stated directly KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis 16. At last measurement, the clients vital signs were as follows: oral temperature 98F (36.7C), heart rate 76 beats/min, respiratory rate 16 breaths/min, and blood pressure (BP) 118/60 mm Hg. Four hours later, the vital signs are as follows: oral temperature 103.2F (38.5C), heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood pressure 120/66 mm Hg. Which should be the nurses first intervention at this time? 1) Ask the client if he has had a warm drink in the last 30 minutes. 2) Notify the primary care provider of the clients temperature. 3) Ask the client if he is feeling chilled. 4) Take the temperature by a different route. ANS: 1 With a fever, the heart rate and respiratory rate are usually elevated. In this case, they are within normal limits, so the nurse should wonder about the accuracy of the temperature reading and validate it in some way. Because having a hot drink is a common cause of false readings, the nurse should determine whether that has occurred before retaking or otherwise validating the reading. PTS: 1 DIF: Moderate REF: p. 421; should know norms for all vital signs, p. 414, to answer question KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 17. A clients average normal temperature is 98F. Which of the following temperatures would be expected during the night in this healthy young adult client who does not have a fever, inflammatory process, or underlying health problems? 1) 97.2F 2) 98.0F 3) 98.6F 4) 99.2F ANS: 1 The lowest temperature occurs during sleep (usually at night) when the metabolic rate is lowest. Temperature normally increases throughout the day until it peaks in the early evening. PTS:1DIF:EasyREF:p. 417 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application 18. The nurse is instructing a client how to appropriately dress an infant in cold weather. Which of the following instructions would be most important for the nurse to include? 1) Be sure to put mittens on the baby. 2) Layer the infants clothing.

www.mynursingtestprep.com3) Place a cap on the infants head. 4) Put warm booties on the baby. ANS: 3 All interventions are correct, but because of the many blood vessels close to the skin surface in the head, infants lose approximately one third of their body heat through the head. Therefore, to prevent heat loss, it is most important to cover the head. PTS:1DIF:ModerateREF:p. 417 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 19. In evaluating a clients blood pressure for hypertension, it would be most important to 1) Use the same type of manometer each time 2) Auscultate all five Korotkoff sounds 3) Measure the blood pressure in both arms 4) Monitor the blood pressure for a pattern ANS: 4 Blood pressure fluctuates a great deal during the day and is influenced by age, sex, activity, and many other factors. Any determination of hypertension must be done after two or more BP readings taken on separate occasions. The type of manometer does not greatly influence the reliability of BP readings, although the mercury manometer is more accurate. Only the first and last Korotkoff sounds are necessary to determine a BP reading. The first time BP is assessed for a patient, the nurse should compare the reading in the left and right arm; however, this is not specific to evaluating for hypertension. PTS:1DIF:ModerateREF:p. 434 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 20. Which of the following pieces of information in the clients health history might indicate a risk for primary hypertension? 1) Consumes a high-protein diet 2) Drinks three to four beers every day 3) Has a family history of kidney disease 4) Does not engage in physical exercise ANS: 2 Heavy alcohol consumption, age, race, high-sodium diet, tobacco use, family history of hypertension, and high cholesterol levels put a client at risk for primary hypertension. Kidney disease is a cause of secondary hypertension. PTS:1DIF:ModerateREF:dm 434-435 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 21. The nurse provides client education regarding hypertension prevention and management. Which of these statements indicates that the client understands the instructions? 1) I dont have to worry if my blood pressure is high once in a while.

www.mynursingtestprep.com2) I guess I will have to make sure I dont drink too much water. 3) I can lose some weight to help lower my blood pressure. 4) I will need to reduce the amount milk and other dairy products I use. ANS: 3 A single lifestyle change, such as weight loss, can lower blood pressure (BP). Whenever the client has an elevated BP, the reading should be monitored even when it occurs just occasionally. Drinking too much alcohol is associated with hypertension, but water consumption is not unless accompanied by high sodium intake. A diet high in calcium is recommended to prevent and manage hypertension; therefore, it is not advisable to limit the intake of dietary calcium found in dairy products. PTS:1DIF:ModerateREF:dm 434-435 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 22. For which of the following patients would it be most important to obtain an apical-radial pulse and calculate the pulse deficit? A patient who 1) Had abdominal surgery 2 hours ago 2) Suffered a fractured hip yesterday 3) Is dehydrated from vomiting 4) Has a heart or lung disease ANS: 4 Conditions that require assessment of pulse deficit include digitalis therapy and blood loss, cardiac or respiratory disease, and other conditions that affect oxygenation status. PTS:1DIF:ModerateREF:p. 427 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 23. Which of the following procedure techniques has the most effect on the accuracy of an apical pulse count? 1) Counting the rate for 1 full minute 2) Exposing only the left side of the chest 3) Determining why assessment of apical pulse is indicated 4) Using your ring finger to palpate the intercostal spaces ANS: 1 Apical pulse is generally indicated for patients with cardiac conditions or who are taking cardiac medications. Often they have irregular heartbeats or slow rates. A more accurate count is obtained when such heartbeats are counted for a full minute. Exposing the chest is, of course, necessary; exposing only the left side protects the patients privacy but does not improve the accuracy. The nurse should know why an apical pulse is indicated, but this would not affect the accuracy of the count. Which finger the nurse uses to palpate depends on which hand is used. Even if the nurse failed to use the index or ring finger, this would be unlikely to affect the accuracy of the counting. PTS:1DIF:ModerateREF:p. 452

www.mynursingtestprep.comKEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 24. Which assessment data best support a report of severe pain in an adult client whose baseline vital signs are within an average normal range? 1) Oral temperature 100F (37.8C) 2) Respiratory rate 26 breaths/min and shallow 3) Apical heart rate 56 beats/min 4) Blood pressure 124/82 mm Hg ANS: 2 Respiratory rate 26 breaths/min and shallow. Acute pain causes an increase in respiratory rate but a decrease in depth. Elevated temperature does not indicate pain. The apical pulse is lower than normal, but because the pulse increases with pain, a rate of 56 beats/min does not indicate pain. A blood pressure of 124/82 mm Hg is within normal limits. Blood pressure usually elevates temporarily with acute pain; it may decrease over time with unremitting chronic pain. PTS:1DIF:EasyREF:p. 430 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 25. During a clinic interview, a client states he has been experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement? 1) Ask the client when in the day dizziness occurs. 2) Help the client to assume a recumbent position. 3) Measure both heart rate and blood pressure with the client standing. 4) Measure vital signs with the client supine, sitting, and standing. ANS: 4 Dizziness upon standing is a symptom of orthostatic hypotension. The nurse should obtain orthostatic vital signs (measure pulse and blood pressure with the patient supine, sitting, and standing) to assess for orthostatic hypotension. The time of day is irrelevant to the diagnosis. If the nurse observes the patient become dizzy upon standing, the first action would be to help the client lie down and then obtain orthostatic vital signs; but this is not necessary when the symptom is not present. The nurse needs to measure both the heart rate and the blood pressure but not only in the standing position. PTS:1DIF:ModerateREF:p. 439 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. Which blood pressure has a pulse pressure within normal limits? Choose all that apply. 1) 104/50 mm Hg 2) 120/62 mm Hg 3) 120/80 mm Hg 4)

www.mynursingtestprep.com130/86 mm Hg ANS: 3, 4 The pulse pressure is the systolic blood pressure (BP) minus the diastolic BP. The pulse pressure is usually approximately one third of the systolic pressure. (120 80 = 40; 40 = 1/3 of 120) (130 86 = 44; 1/3 of 130 = 43.3) PTS:1DIF:ModerateREF:p. 433 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 2. Which of the following interventions would be appropriate for a client who has a fever? Choose all that apply. 1) Put an ice pack on the clients neck and axillae. 2) Provide the client a blanket when he is shivering. 3) Offer the client fluids to drink every 1 to 2 hours. 4) Take the temperature using a tympanic thermometer. ANS: 1, 3 If ice packs are used, they are applied to the groin, neck, or axillae. A fever increases metabolic needs, so fluids are necessary to prevent dehydration. A blanket would help with heat retention. A tympanic thermometer is not appropriate when an accurate temperature is needed, as when a client has a fever. PTS:1DIF:EasyREF:p. 423 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 3. Comparing the changes in vital signs as a person ages, which statement is correct? Select all that apply. 1) Blood pressure decreases less than heart rate and respiratory rate. 2) Respiratory rate remains fairly stable throughout a persons life. 3) Blood pressure increases; heart rate and respiratory rate decline. 4) Men have higher blood pressure than women until after menopause. ANS: 3, 4 Heart rate and respiratory rate tend to decrease as people age, whereas the blood pressure increases because of increased vascular resistance. Mens blood pressure tends to be higher than womens until after menopause, when womens blood pressure typically increases. PTS: 1 DIF: Moderate REF: dm 430, 434 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Analysis 4. Which of these steps in taking a blood pressure is correct? Choose all that apply. 1) Use a bladder that encircles 40% of the arm. 2) Wrap the cuff snugly around the clients arm. 3) Ask the client to hold the arm at heart level. 4) Have the client sit with feet flat on the floor.

www.mynursingtestprep.comANS: 2, 4 The cuff should be wrapped snugly around the clients arm. Crossed legs or dangling legs can increase blood pressure, so feet should be flat on the floor. The bladder should encircle 80% of the arm. Holding the arm out can cause an erroneously higher blood pressure measurement; the arm should be supported. PTS: 1 DIF: Moderate REF: dm 457-460 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension 5. When assessing the quality of a clients pedal pulses, what is the nurse assessing? Choose all that apply. 1) Rhythm of the pulses 2) Strength of the pulses 3) Bilateral equality of pulses 4) Rate compared with apical pulse ANS: 2, 3 The quality of a pulse refers to the pulse volume (strength) and bilateral equality of the pulses. PTS:1DIF:EasyREF:dm 427-428 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 6. All of the following clinical signs may be present with hypoxia. However, only two are specific indicators of hypoxia (that is, if they are present, it means that the patient is probably hypoxic). Which ones are specific indicators of hypoxia? Choose all that apply. 1) Feelings of anxiety 2) Crackles in the lung bases 3) Increased heart rate 4) Improved breathing in upright position ANS: 1, 3 Apprehension, confusion, dizziness, and an increased heart rate are all specific manifestations of hypoxia. Although they are not listed in this question, cyanosis of the tongue and oral mucosa are also good indicators of hypoxia because those areas are not affected by cold or reduced circulation as are the nails, lips, and skin. Crackles and orthopnea are abnormal respiratory findings, but they do not necessarily indicate poor oxygenation. PTS:1DIFifficultREF:p. 432 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis Matching Match the breath sound with the appropriate description. 1) High-pitched sound heard on inspiration in infants 2) High-pitched, continuous musical sound 3)

High-pitched popping or low-pitched bubbling sounds 4) Low-pitched continuous sounds that clear with coughing 5) Labored, snoring sound 1. Crackles 2. Rhonchi 3. Stridor 4. Wheezes 5. Stertor • ANS: 3 PTS: 1 DIF: Moderate REF: dm 431-432; descriptions www.mynursingtestprep.com of the various breath sounds are as stated KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application • ANS: 4 PTS: 1 DIF: Moderate REF: dm 431-432; descriptions of the various breath sounds are as stated KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application • ANS: 1 PTS: 1 DIF: Moderate REF: V1, dm 431-432; descriptions of the various breath sounds are as stated KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application • ANS: 2 PTS: 1 DIF: Moderate REF: V1, dm 431-432; descriptions of the various breath sounds are as stated KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application • ANS: 5 PTS: 1 DIF: Moderate REF: V1, dm 431-432; descriptions of the various breath sounds are as stated KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application Other 1. How will each of the errors affect a clients blood pressure reading? • Blood pressure cuff too narrow • Blood pressure cuff too wide • Assessing immediately after smoking • Assessing immediately after eating • Assessing when the client is in mild-to-moderate pain • Assessing when the client experiences severe pain • Assessing immediately after exercise ANS: A: erroneously high; B: erroneously low; C: temporarily high; D: temporarily high; E: temporarily high; F: temporarily low; G: temporarily high. Improper cuff size causes errors in blood pressure (BP) readings: Too narrow a cuff increases the BP reading, while too wide a cuff decreases it. Tobacco use, eating, mild/ moderate pain, and exercise all stimulate and increase BP. Severe pain can lower BP, whereas mild to moderate pain can increase blood pressure. PTS: 1 DIF: Moderate REF: dm 434-435| p. 436; for cuff size implications KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall Essay Describe where to auscultate the apical pulse for an average-size adult. ANS: Auscultate at approximately 3 inches to the left of adult sternum at the fourth, fifth, or sixth intercostal spaces in the midclavicular line. Apical pulse is heard at the apex of the heart. The position of the apex of the heart is different for a child than an adult. Chapter 15 Communication & Therapeutic Relationships

www.mynursingtestprep.comMultiple Choice Identify the choice that best completes the statement or answers the question. 1.Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment? 1) Small group 2) Interpersonal 3) Group 4) Intrapersonal ANS:2 The nurse uses interpersonal communication when interviewing the patient about his health history during the admission assessment. Small-group communication occurs when a person engages in an exchange of ideas with two or more people at the same time. Group communication is interaction that occurs among several people. Intrapersonal communication is conscious internal dialogue. PTS:1DIF:ModerateREF:p. 464 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension 2.During admission to the unit, a patient states, Im not worried about the results of my tests. Im sure Ill be all right. As he observes the patient, the nurse notes that the patient is shaky and tearful and does not make eye contact. Unfortunately, the nurse is called away to an emergency before he has time to complete this discussion. Which of the following actions is most appropriate for the nurse to establish when returning to the patient? Patient will 1) Explain the reason for his incongruent statements 2) Engage in diversional activities to cope with stress 3) Express his concerns to his primary care provider 4) Discuss his concerns and fears with the nurse ANS:4 The nurse has observed a mismatch between verbal and nonverbal communication. Unfortunately, an emergency has required the nurse to leave the patient. To resolve this mismatch, the nurse will set a goal to have the patient discuss his concerns and fears at their next interaction. It is inappropriate to ask the patient to explain why his verbal message did not match the nonverbal message because this will inhibit further conversation. It may be appropriate to have the patient discuss his concerns with his primary care provider; however, we do not have enough information to suggest this course of action. For example, if the patient is upset about some other matter, this action would not be appropriate. Similarly, it is not appropriate to suggest diversional activities until the reason for the mismatch between his words and behavior is identified. PTS: 1 DIF: Moderate REF: p. 476 KEY: Nursing process: Planning | Client need: PSI | Cognitive level:Application 3.The nurse is preparing a patient for a computed tomography (CT) scan of the abdomen. Which statement by the nurse is best (all contain correct information)? 1) You will need to remain NPO for the 4 hours prior to your CT scan.

www.mynursingtestprep.com2) You cannot have anything to eat or drink for 4 hours before your test. 3) You will need to be NPO and drink this contrast media before your test. 4) You may need to void before you go down to the department for your CT scan. ANS:2 Telling the patient that he cannot have anything to eat or drink for a specific time before his test is the best statement. It uses terms that the patient can understand. The other options use medical jargon that many patients may not understand. PTS:1DIF:ModerateREF:p. 465 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 4.The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows she should use touch cautiously, especially when communicating with which patient? 1) Middle-aged woman just diagnosed with terminal lung cancer 2) Middle-aged man experiencing the acute phase of myocardial infarction 3) Older adult with a history of dementia admitted for dehydration 4) Young adult in the rehabilitative phase after arthroscopic surgery ANS:3 The nurse should use touch especially cautiously when communicating with a person who suffers from impaired mental health, such as dementia, because the patient may have difficulty interpreting the meaning of touch. In general, touch can be used with most patients, such as patients with cancer, an acute MI, or general orthopedic surgery, and with all age groups. However, the nurse should always be conscious of the situation, environment, and receptivity of the patient. PTS:1DIF:ModerateREF:p. 467 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis 5.The nurse manager of the medical intensive care unit formed a group to help her staff cope with stress more effectively. Which of the comments by group members will lead the manager to evaluate the group as successful? 1) This was a good idea to form a group; Ive been wanting to get to know some of the people working the other shifts. 2) It really helps me to share feelings about how hard it is to see pain and suffering every day. 3) I now have a group to help me when I need to work through situations in my own life causing me stress. 4) It feels good to have a chance to get away from the unit and talk on a regular basis. ANS:2 Work-related social support groups assist members of a profession to cope with the stress associated with their work. The focus of the group is to share feelings about the stress of

www.mynursingtestprep.comthe work environment. Although this may also be an opportunity to meet other staff members, get away from the unit, or share personal and family problems, these are not the primary focus of the group. PTS:1DIF:ModerateREF:p. 473 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application 6.A patient who speaks little English is admitted to the hospital after experiencing severe abdominal pain. Which nursing diagnosis is preferred for this patient? 1) Impaired Communication 2) Readiness for Enhanced Communication 3) Impaired Verbal Communication 4) Sensory Alteration ANS:1 Impaired Communication is the preferred nursing diagnosis when the patient is unfamiliar with the dominant language. Impaired Verbal Communication is an appropriate diagnosis for the patient with expressive or receptive aphasia. Readiness for Enhanced Communication is appropriate when the patient expresses willingness to enhance communication. Sensory Alteration is appropriate when there is a change in the characteristics of the patients incoming stimuli. PTS:1DIFifficultREF:p. 474 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 7. A young adult with a severe episode of asthma bronchoconstriction comes to the emergency department with signs of respiratory distress. When the nurse performs the admission assessment, she notes that the patient is not able to say where she is or the time. Which nursing diagnosis is probably most suitable for this patient? 1) Chronic Confusion 2) Acute Confusion 3) Impaired Verbal Communication 4) Readiness for Enhanced Communication ANS: 2 This patient is experiencing Acute Confusion caused by lack of oxygen related to his respiratory distress. As a young adult with an acute episode of asthma, this patient would not likely have a history of confusion; therefore, without more data, Chronic Confusion is not an appropriate diagnosis for this patient. Impaired Verbal Communication is an appropriate diagnosis for the patient with expressive or receptive aphasia, but not with confusion. Readiness for Enhanced Communication is appropriate when the patient expresses willingness to enhance communication. PTS:1DIFifficultREF:p. 474 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 8.A patient experiences expressive aphasia after a stroke. Which expected outcome is appropriate for this patient? 1)

www.mynursingtestprep.comUses alternative methods of communication 2) Communicates effectively using a translator 3) Interprets messages accurately 4) Follows commands when asked ANS:1 An appropriate outcome for a patient with expressive aphasia is uses alternative methods of communication. Expressive aphasia means the patient cannot verbalize his intended message, but the patient may be able to understand and to communicate in other ways. Communicates effectively using a translator is an appropriate outcome for a patient who is unfamiliar with the dominant language. Interprets messages accurately and follows commands when asked are appropriate outcomes for the patient with receptive, not expressive, aphasia. PTS:1DIF:ModerateREF:p. 475 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 9.Which intervention by the nurse first helps to establish a trusting nurse- patient relationship? 1) Avoiding topics that may provoke emotional responses from the patient 2) Listening to the patient while performing care activities 3) Performing care interventions quietly and respectfully 4) Greeting the patient by name whenever entering the patients room ANS:4 The nurse can establish a trusting nurse-patient relationship by always greeting the patient by name, listening actively, responding honestly to the patients concerns, providing explanations for care interventions, and providing care competently and consistently. PTS:1DIF:ModerateREF:p. 476 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 10.A physician tells a patient that she has cancer and that she should have surgery as soon as possible. The patient is not certain she wants to pursue this treatment approach but responds by saying, Ill do whatever you think I should do. Which communication style is this patient using? 1) Assertive 2) Aggressive 3) Passive aggressive 2 4) Passive ANS:4 This patient is using a passive communication style to avoid conflict with others while allowing the other person to be in control. An aggressive approach forces others to relinquish control. The goal of the aggressive approach is to win and be in control. With assertive communication, the person expresses beliefs or feelings without infringing on

www.mynursingtestprep.comanothers rights. The passive aggressive approach uses a submissive style of communication but is aggressive in the sense that it manipulates the receiver to help the sender win. This allows the sender to be in control without conflict. PTS:1DIF:ModerateREF:p. 470 KEY: Nursing process: Analysis | Client need: PSI | Cognitive level: Application 11.Which statement by the nurse manager demonstrates an assertive approach when communicating with the staff nurse about a patient care issue? 1) You must assess and document pain status for every patient. 2) Why havent you been assessing and documenting pain for every patient? 3) Will you please assess and document pain status for every patient? 4) Explain why you havent been assessing and documenting pain for every patient. ANS:1 By stating that pain must be assessed and documented for every patient, the nurse manager is using an assertive approach. An assertive approach uses the statement of facts, not judgments. Asking why the nurse has not been assessing and documenting pain is judgmental and elicits a defensive response by the nurse. Asking the nurse whether she will assess and document pain for every patient invites a negative response and does not use an assertive approach. Asking the nurse to explain why she has not been assessing and documenting pain is also judgmental. PTS:1DIF:ModerateREF:dm 470-471 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis 12.A patient comes to the emergency department complaining of severe, substernal chest pain. He is restless and anxious. Which statement by the nurse appropriately offers reassurance? 1) Ill give you some medication to help relieve the pain. 2) If you lie still and relax, youll be fine in a little while. 3) Please try not to think about the pain as best as you can. 4) Dont worry; were going to take good care of you. ANS:1 By telling the patient that she is going to give him some medication to help relieve his pain, the nurse is offering him realistic reassurance. The other options offer false reassurance and minimize patient concerns. PTS:1DIF:ModerateREF:p. 479 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 13.Which statement by the nurse indicates that the nurse-patient relationship is entering the termination phase? 1) Ill be admitting you to our nursing unit as soon as I obtain your health history. 2) You seem upset today. Would you like to talk about whatever is bothering you? 3)

www.mynursingtestprep.comIm leaving for the day. Is there anything I can do for you before I leave? 4) Hello. My name is Leslie, and Im going to be your nurse today. ANS:3 When the nurse states, Im leaving for the day. Is there anything I can do for you before I leave? the nurse-patient relationship is entering the termination phase. The termination phase is the conclusion of the relationship, which can occur at the end of a nurses shift. The pre-interaction phase occurs before the nurse meets the patient. The statement Ill be admitting you to our floor as soon as I obtain your history demonstrates the pre- interaction phase of the nurse-patient relationship. The nurse introduces herself to the patient during the orientation phase. During the working phase of the nurse-patient relationship, feelings are explored. This phase is demonstrated by the statement, You seem upset today. Would you like to talk about whatever is bothering you? PTS:1DIF:ModerateREF:p. 472 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 14.A health center that is interested in purchasing IV infusion pumps organizes a group of nurses to evaluate pumps provided by a variety of vendors. Which type of group has been organized? 1) Short term 2) Ongoing 3) Self-help 4) Work-related social support ANS:1 The organized group is a short-term group. Short-term groups focus on the task at hand, which in this case is evaluating infusion pumps. Ongoing groups address issues that are recurrent. Self-help groups are voluntary organizations composed of people with a common need. Work-related social support groups assist members of a profession to cope with the stress associated with their work. PTS:1DIF:ModerateREF:p. 473 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 15.The nurse must insert a nasogastric (NG) tube into a patient with a bowel obstruction. Before inserting the tube, the nurse must explain the procedure to the patient. Which explanation by the nurse is best, assuming that all provide correct information? 1) Im going to insert an NG tube and connect it to low Gomco to keep your stomach empty. 2) Im going to insert a tube through your nose into your stomach to prevent you from vomiting. 3) Im going to insert an NG tube through your nares to suction your secretions and prevent emesis. 4) Lie still, please; I need to elevate the head of the bed and insert this tube. ANS:2

www.mynursingtestprep.comBecause patients are typically confused by medical terminology, the nurse should use language that the patient can understand. NG tube, Gomco, suction secretions, nares, and emesis are all medical jargon that the patient might not understand. Moreover, the nurse should explain all procedures before performing them to help minimize the patients anxiety. Lie still, please . . . offers no explanation of why the NG tube is being inserted, and it conveys that the nurse is impatient. PTS:1DIF:ModerateREF:p. 465 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 16.A patient had surgery 6 hours ago. When the nurse enters the room to turn him, she notes that he is restless and grimacing. Considering the patients nonverbal communication, what action should the nurse take first? 1) Administer pain medication to the patient. 2) Turn and reposition the patient. 3) Assess to determine the cause of the grimacing. 4) Leave the patients room so he can rest quietly. ANS:3 The nurse should assess the patient to determine whether he is having pain. The nurse should not assume by the patients nonverbal communication that the patient is in pain and administer pain medication; the nurse should validate the message being sent. The nurse should not turn and reposition the patient without assessing him. Leaving the patient without addressing his nonverbal cues is neglectful. PTS:1DIF:ModerateREF:dm 466-467 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis 17.A patient who speaks only French was admitted to the hospital after a motor vehicle accident. Assuming that the nurse does not speak French, what is the best way to communicate with this patient? 1) Use sign language for communicating. 2) Ask a family member to serve as a translator. 3) Request the services of a hospital translator. 4) Speak in English, but speak very slowly. ANS:3 The nurse should request the services of a hospital translator to communicate with the patient who does not speak English. A family member should not be used as a translator unless there are no other options because it is often culturally unacceptable to have a family member ask personal questions. Also, considering the patients right to confidentiality, it is not appropriate to share private information about the patient with family members unless permission is obtained. Using sign language can be an effective strategy for hearing-impaired persons. Speaking slowly in English is not useful if the patient does not understand the language. PTS:1DIF:ModerateREF:p. 475 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 18.After a physician discusses cancer treatment options with a patient, the patient

www.mynursingtestprep.comasks the nurse which treatment he should choose. Which response by the nurse is best? 1) If I were you, Id go with chemotherapy. 2) What do you think about radiation therapy? 3) Why dont you see what your wife thinks. 4) Ill give you some information about each option. ANS:4 The nurse should avoid giving a personal opinion; instead offer the patient more information so he can make an informed decision. Responses such as, If I were you, Id go with chemotherapy and Why dont you see what your wife thinks do not respect the patients right to make his own decisions. What do you think about radiation therapy, is leading the patient without exploring the other options. PTS:1DIF:EasyREF:dm 478-479 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 19.Which of the following is a nonverbal behavior that enhances communication? 1) Keeping a neutral expression on the face 2) Maintaining a distance of 6 to 12 inches 3) Sitting down to speak with the patient 4) Asking mostly open-ended questions ANS:3 Sitting down to speak with the patient enhances communication because it communicates a willingness to listen. A concerned expression, not a neutral one, demonstrates interest and attention. Maintaining a distance of 18 inches to 4 feet, not 6 to 12 inches, while speaking allows most patients to feel comfortable, thereby enhancing communication. When the interpersonal distance is too close, patients might feel uncomfortable. Asking open-ended questions is a verbal communication strategy, not a nonverbal behavior. PTS:1DIF:ModerateREF:p. 467 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Comprehension 20.A patient being admitted in hypertensive crisis informs the nurse that he stopped taking his blood pressure medication 3 weeks ago. Which response by the nurse is best? 1) Youre lucky you didnt have a stroke; you really need to take your medication. 2) Tell me more about your experience with your high blood pressure medication. 3) Why did you stop taking your high blood pressure medication? 4) Its very important to take your blood pressure medication. ANS:2 The nurse can gather more information about the patients reasons for stopping his blood pressure medication by asking him to tell her more about his experience with the medication. Telling the patient he is lucky he did not have a stroke suggests criticism. Asking the patient why he stopped taking his high blood pressure medication may cause

www.mynursingtestprep.comthe patient to become defensive and halt further communication. Telling the patient that it is very important to take his blood pressure medication is patronizing and also suggests criticism; at the very least, it fails to elicit more communication from the patient. PTS:1DIF:ModerateREF:dm 477-478 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 21.The wife of an elderly patient begins crying after she is informed that he has a terminal illness. Which intervention by the nurse is best? 1) Sit quietly with the patients wife while she composes her thoughts. 2) Inform his wife that a chaplain is available if she would like to speak to him. 3) Remind his wife that her husband has lived a long and happy life. 4) Tell his wife there are always options and suggest she not give up hope. ANS:1 The nurse can intervene best by sitting quietly with the patients wife, allowing her to compose her thoughts. Silence communicates acceptance. After processing the bad news, the wife can provide the nurse with further information, such as whether she would like to consult with a chaplain. Telling the wife there are always options offers false reassurance and would probably discourage her from further communication. PTS:1DIFifficultREF:p. 476 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 22.A patient newly diagnosed with breast cancer tells the nurse, Im worried I wont live to see my children grow up. Which response by the nurse best conveys concern and active listening? 1) There have been many advances in breast cancer treatment; hope for the best. 2) Breast cancer is a serious disease; I can understand why youre worried. 3) Youre strong and have youth on your side to fight the breast cancer. 4) Id be worried, too; Ive seen a lot of patients die from breast cancer. ANS:2 Restating the patients concern by saying, Breast cancer is a serious disease; I can understand why youre worried conveys concern and active listening. Stating that there have been many advances in breast cancer treatment minimizes the patients concern. Stating that the patient is young and should have no trouble surviving breast cancer minimizes the patients concern and offers false reassurance. Stating that the nurse has seen a lot of patients die from breast cancer could frighten the patient and cause emotional harm. PTS:1DIF:ModerateREF:p. 476 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 23.A nurse has sound, scientific evidence to support changing a procedure that would reduce catheter-related infections on the unit. The unit manager states, nevertheless, that she is unwilling to make the change because it would be too costly. Which response by the nurse represents assertive communication?

www.mynursingtestprep.com1) This is a widely used practice. If you read more research, youd probably wonder why we arent already doing it. 2) There is extensive evidence to support the new method, but I dont want to create an issue. 3) Is the budget more important to the hospital than reducing infections and patient suffering? 4) Id like to help gather information regarding the cost of new materials versus the savings in treating infections. ANS:4 The statement pertaining to helping to gather information about of the cost of materials is an assertive response. It does not threaten the authority of the nurse manager and introduce another element preventing change that is unrelated to the procedure itself. It states the nurses position and wishes clearly with an I statement, and it does not invite negative responses. The statement beginning with This is a widely used practice is aggressive and implies criticism and a judgment that the nurse manager does not read as much as she should. The statement ending with I wouldnt want to create chaos is passive and submissive. The statement beginning with Is the budget more important . . . is aggressive and judgmental. PTS:1DIF:ModerateREF:dm 470-471 KEY: Nursing process: Implementation | Client need: PSI | Cognitive level: Application 24.When using the SBAR model to communicate with a physician, what information does the nurse offer first? 1) Statement of the problem and its probable cause 2) Nurses name, patients name, and reason for the communication 3) History of information related to and leading up to the situation 4) A solution to the problem or what is needed from the physician ANS:2 SBAR is an acronym for Situation, Background, Assessment, and Recommendation. The nurses name, and so forth, are part of the Situation. Statement of the problem and cause are the Assessment. History of the factors leading up to the current situation make up the Background. What the nurse thinks will correct the problem is categorized under Recommendation. PTS: 1 DIF: Difficult REF: p. 471 KEY:Nursing process: Implementation | Client need: PSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1.Which statement about communication is true? (Choose all that apply.) Communication is 1) Used to meet physical and psychosocial needs 2) Most basically described as talking and listening 3)

www.mynursingtestprep.comThe process of sending and receiving information 4) The basis for forming relationships ANS:1, 3, 4 People use communication to fulfill basic human needs at all levels: physical, psychosocial, emotional, and spiritual needs. Communication is a process of sending and receiving messages. It forms the basis for sharing meaning and building effective relationships among individuals, families, and the healthcare team. Communication involves more than just talking and listening. And simply because messages are verbalized does not mean listening and understanding are achieved. PTS:1DIF:EasyREF:dm 463-464 KEY:Nursing process: N/A |Client need: PSI | Cognitive level: Recall 2.Which statement by the nurse demonstrates that active listening has occurred? Choose all that apply. 1) I listened to my patient while I was changing his IV site. 2) I made eye contact and listened to my patient to find out his concerns. 3) I took notes when I listened to my patient describe his symptoms. 4) I sat with my patient and his wife to talk about their fears before the surgery. ANS:2, 4 The nurse demonstrates active listening by facing the patient, making eye contact, and listening while he expresses concerns. Arranging time to sit with the patient and his wife to discuss fears about an upcoming surgery also indicates active listening. Listening to the patient while performing activities, such as hanging an IV infusion or bathing him, distracts the nurse from active listening. Although taking detailed notes can help the nurse to accurately recall the patients words, this activity while listening to the patient speak can also be a distraction and could reduce eye contact and nonverbal cues of care and concern. PTS:1DIF:ModerateREF:p. 476 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application 3.A patient tells the nurse, Im having a lot of pain in my hip. Which response by the nurse is open-ended and would stimulate the patient to provide the most complete data? Choose all that are correct. 1) Is your pain severe? 2) Tell me about your pain. 3) When did you first notice this pain? 4) How would you describe your pain? ANS:2, 4 The responses Tell me about your pain and How would you describe your pain? are open-ended responses that stimulate conversation. Although it is important information, the question Is your pain severe? prompts a yes or no response. When did you first notice this pain?also important informationis likely to stimulate a brief, factual answer. Such questions allow the nurse to control the patients response. Limiting the response might

www.mynursingtestprep.comlead to an incomplete assessment. Chapter 19 Health Assessment Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A mother brings her 6-month-old infant to the clinic for a well-baby checkup. How should the nurse proceed when weighing the patient? 1) Have the mother remain outside the room. 2) Ask the mother to remove the infants clothing and diaper. 3) Weigh the infant wearing only the diaper. 4) Place the infant supine on the scale with his knees extended. ANS: 2 The nurse should ask the mother to remove the infants clothing and diaper before weighing and measuring the infant. An older child can be examined in his underwear; infants should be undressed. Infants are typically more comfortable with the parent close by, so the mother should remain in the room. The infant should be supine with knees extended on the examination table when being measured, not when being weighed. PTS: 1 DIF: Moderate REF: p. 517 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application 2. Where should the nurse assess skin color changes in the dark-skinned patient? 1) Nailbeds 2) Any exposed area 3) Oral mucosa 4) Palms of the hands ANS: 3 In dark-skinned patients, look for color changes in the conjunctiva or oral mucosa. They should be pink and moist. In dark-skinned patients, skin color changes may not be apparent in nailbeds, palms of the hands, and other exposed areas. PTS: 1 DIF: Easy REF: dm 497-498, 519 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 3. While the nurse assesses a newborn of African American descent, the mother points out a blue-black Mongolian spot on the newborns back and asks, Whats that? Is something wrong with my baby? Which response by the nurse is best? 1) Ill ask the physician to look at the spot. 2) Those spots are quite common and typically fade with time. 3) You may want a plastic surgeon to look at that. 4) That spot is benign so its nothing you need to worry about. ANS: 2 The best response by the nurse is to explain that Mongolian spots are common in dark-

www.mynursingtestprep.comskinned newborns and typically fade over time. The nurse should report the finding in the patient health record, but there is no need to notify the physician immediately. It is inappropriate for the nurse to recommend that the mother take her newborn to a plastic surgeon; Mongolian spots do not require treatment. Although it contains correct information, nothing you need to worry about is condescending. PTS: 1 DIF: Moderate REF: p. 497 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application 4. An older adult comes to the clinic complaining of pain in the left foot. While assessing the patient, the nurse notes smooth, shiny skin that contains no hair on the clients lower legs. Which condition does this finding suggest? 1) Venous insufficiency 2) Hyperthyroidism 3) Arterial insufficiency 4) Dehydration ANS: 3 Peripheral arterial insufficiency is associated with smooth, thin, shiny skin with little or no hair. Venous insufficiency leads to thick, rough skin that is commonly hyperpigmented. Hyperthyroidism is associated with abnormally warm skin. Decreased turgor would be seen in dehydration. PTS: 1 DIF: Moderate REF: p. 498 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application 5. Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with travelers diarrhea? 1) Edema 2) Hyperhidrosis 3) Pallor 4) Tenting ANS: 4 Tenting, skin that takes several seconds to return to normal after lifting up a fold, may be a sign of dehydration. Edema, an excessive amount of fluid in the tissues, may be a sign of heart failure, kidney disease, peripheral vascular disease, or low albumin levels. Hyperhidrosis is a term for excessive sweating, which may be a sign of thyrotoxicosis. Pallor, abnormal loss of skin color, may be a sign of anemia or blood loss. PTS:1DIF:ModerateREF:p. 498 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 6. A female patient has excessive facial hair. The nurse should document this finding as: 1) Alopecia. 2) Albinism. 3)

www.mynursingtestprep.comHirsutism. 4) Lanugo. ANS: 3 The nurse should document this finding as hirsutism, excess facial or trunk hair. Hair loss should be documented as alopecia. Albinism is a condition caused by lack of pigment in which the patient has white hair and very pale skin. Lanugo is the fine, downy growth of hair that covers the body of a newborn. PTS: 1 DIF: Moderate REF: p. 499 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 7. The nurse should assess skin temperature by using the: 1) Dorsum of the hand. 2) Pad of the fingertip. 3) Palm of the hand. 4) Dorsum of the wrist. ANS: 1 The dorsum of the hand should be used to assess skin temperature. The nurse should compare the temperature of the hands with that of the feet and compare the right side of the body with the left. PTS: 1 DIF: Easy REF: p. 497 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 8. While assessing an older adult patient, the nurse notes clubbing of the fingers. This finding is a sign of: 1) Fungal infection. 2) Poor circulation. 3) Iron deficiency. 4) Long-term hypoxia. ANS: 4 Clubbing (when the nail plate angle is 180 or more) is associated with long-term hypoxic states such as chronic lung disease. A thick nail with yellowing indicates a fungal infection. Spoon-shaped nails may result from iron-deficiency anemia. Brittle nails are commonly seen with malnutrition and hyperthyroidism. PTS: 1 DIF: Moderate REF: p. 500 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 9. A 6-week-old infant is brought to the pediatricians office for a well-baby checkup. The nurse notes a flattening of the skull. Flattening of the skull in the infant might suggest: 1) The baby has been lying in the same position for several hours a day. 2) A disorder associated with excessive growth hormone. 3)

www.mynursingtestprep.comAn accumulation of excessive cerebrospinal fluid. 4) Temporomandibular joint syndrome. ANS: 1 Abnormal flattening of the skull in infants may result from placing the baby in the same position for several hours every day. A large head in an adolescent or adult may be associated with acromegaly, a disorder associated with excess growth hormone. In infants and children, a head that is growing disproportionately faster than the body may be a sign of hydrocephalus, which is fluid collection in the cavity within the brain. Irregular jaw movement and cracking of the jaw in adults may indicate temporomandibular joint (TMJ) syndrome. PTS: 1 DIF: Moderate REF: p. 500 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 10. The nurse notes ptosis in a patient who just arrived in the emergency department. The nurse quickly triages the patient because she knows that this finding, along with other symptoms, might suggest: 1) Hyperthyroidism. 2) Stroke. 3) Glaucoma. 4) Macular degeneration. ANS: 2 Ptosis, or drooping of the eyelid, may be seen in a patient who experienced Bells palsy or a stroke. Exophthalmos is associated with hyperthyroidism. Mydriasis may be seen with glaucoma. Macular degeneration has no outward signs. PTS: 1 DIF: Moderate REF: p. 500 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application 11. Small hemorrhages are noted under the nailbed of a patient with a history of intravenous drug abuse. This finding is associated with: 1) Low albumin levels. 2) Zinc deficiency. 3) Renal disease. 4) Bacterial endocarditis. ANS: 4 Small hemorrhages under the nailbed, known as splinter hemorrhages, are associated with bacterial endocarditis, a complication of IV drug abuse. A distal band of reddish- pink covering 20% to 60% of the nail (half and half nails) is seen in patients with low albumin levels and renal disease. White spots may indicate zinc deficiency. PTS: 1 DIF: Difficult REF: p. 499 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 12. A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease. Which finding might the nurse expect when assessing the patients nails?

www.mynursingtestprep.com1) Soft, boggy nails 2) Brittle nails 3) Thickened nails 4) Thick nails with yellowing ANS: 1 Soft, boggy nails are seen with poor oxygenation. Brittle nails are seen with hypothyroidism, malnutrition, calcium, and iron deficiency. Thickened nails may result from poor circulation. A thick nail with yellowing is an indication of fungal infection known as onychomycosis. PTS: 1 DIF: Moderate REF: p. 500 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 13. A patients ankles appear swollen. When the nurse assesses the edema, the skin depresses 6 mm, and the depression lasts 2 minutes. The nurse should document this finding as: 1) Trace edema. 2) +1 edema. 3) +2 edema. 4) +3 edema. ANS: 4 To assess edema, the nurse presses firmly with her fingertip for 5 seconds over a bony area. Trace appears as a minimal depression; +1 appears as a 2-mm depression with a rapid return of skin to position; +2 reveals a 4-mm depression, which disappears in 10 to 15 seconds; +3 displays a 6-mm depression that lasts 1 to 2 minutes; and +4 demonstrates an 8-mm depression that persists for 2 to 3 minutes. The area is grossly edematous. PTS: 1 DIF: Moderate REF: p. 521 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 14. Which abnormal laboratory value is associated with icteric sclerae? 1) Bleeding time 2) Bilirubin 3) Hemoglobin 4) Glucose ANS: 2 Icteric sclerae are associated with elevated bilirubin levels. Low hemoglobin would indicate anemia. High hemoglobin is polycythemia, which is like thick blood. Low glucose is hypoglycemia, and high sugar is hyperglycemia. PTS: 1 DIF: Easy REF: p. 500 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Recall

www.mynursingtestprep.com15. The left pupil of a patient fails to accommodate. This finding may reflect an abnormality in which cranial nerve? 1) CN III 2) CN V 3) CN VIII 4) CN X ANS: 1 CN III, the oculomotor nerve, is responsible for accommodation. Failure of a pupil to accommodate reflects an abnormality in this cranial nerve. CN V, the trigeminal nerve, controls the corneal reflex, chewing, and biting. CN VIII, the acoustic nerve, plays a role in hearing and the sense of balance. CN X, the vagus nerve, affects heart rate, peristalsis, swallowing, and the gag reflex. PTS: 1 DIF: Moderate REF: p. 501 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 16. When testing near vision, the nurse should position printed text how many inches away from the patient? 1) 20 2) 18 3) 16 4) 14 ANS: 4 Test near vision by having the client read text from a distance of 14 inches. PTS: 1 DIF: Easy REF: p. 501 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 17. A 48-year-old patient comes to the physicians office complaining of diminished near vision, which the nurse confirms with testing. She should document this finding as: 1) Myopia. 2) Diplopia. 3) Presbyopia. 4) Mydriasis. ANS: 3 Diminished near vision in a patient over age 40 or so years is known as presbyopia. Diminished distant vision is known as myopia. Double vision is known as diplopia. Mydriasis or enlarged pupils may be seen with glaucoma. PTS: 1 DIF: Moderate REF: p. 501 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 18. Which portion of the ear is responsible for maintaining equilibrium? 1)

External ear 2) Inner ear 3) Middle ear 4) Ossicles ANS: 2 The inner ear is responsible for hearing and equilibrium. The middle ear, which contains the ossicles (auditory structures), conducts sound waves to the inner ear. The external ear collects and conveys sound waves to the middle ear. www.mynursingtestprep.com PTS: 1 DIF: Easy REF: p. 502 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 19. Which statement best describes the procedure used to assess capillary refill? 1) Briefly press the tip of the nail with firm, steady pressure, then release and observe for changes in color. 2) Press firmly with your fingertip for 5 seconds over a bony area, release pressure, and observe the skin for the reaction. 3) Tap on the skin with short strokes from your fingers. 4) Lift a fold of skin, and allow it to return to its normal position. ANS: 1 To assess capillary refill, the nurse should briefly press the tip of the nail with firm, steady pressure, then release, and observe for changes in skin color. Tap on the skin . . . describes the procedure for performing percussion. Lift a fold of skin . . . demonstrates the procedure for assessing for tenting. The nurse should press firmly with her fingertip for 5 seconds over a bony area, then release her finger, and observe the skin for the reaction to grade edema. PTS: 1 DIF: Moderate REF: p. 528 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 20. Which of the following is an abnormal capillary refill finding that the nurse should report? 1) • second 2) • seconds 3) • seconds 4) • seconds ANS: 4 Normal capillary refill is less than 3 seconds; therefore, the nurse should report a capillary refill of 4 seconds. PTS: 1 DIF: Easy REF: p. 528 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 21. Which of the following is a correct developmental outcome for an infant? The infants anterior fontanel (soft spot) typically fuses:

www.mynursingtestprep.com1) At about 8 weeks. 2) At about 14 months. 3) By 6 months of age. 4) Before 1 year of age. ANS: 2 The large soft spot on the top of the head, known as the anterior fontanel, typically fuses at about 12 to 18 months. The infant should be able to hold up his head by age 6 months. The posterior fontanel fuses at about 8 weeks of age. PTS: 1 DIF: Moderate REF: p. 529 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension 22. The nurse assesses a 4-year-old childs vision as 20/40. This finding is considered: 1) Myopia. 2) Hyperopia. 3) Normal. 4) Presbyopia. ANS: 3 Children typically do not have 20/20 vision until the ages of 6 or 7 years. A finding of 20/60 in a 4-year-old child is considered normal, so of course 20/40 is normal as well. Myopia is diminished distant vision, which is associated with Snellen chart reading of 20/100. Hyperopia is diminished near vision and is represented by a large fraction, such as 20/15; when found in people over age 45 it is known as presbyopia. PTS: 1 DIF: Moderate REF: p. 531 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Analysis 23. Which test should the patient undergo when the Weber test is positive? 1) Romberg test 2) Rinne test 3) Pure tone audiometry 4) Tympanometry ANS: 2 If the Weber test is positive, the patient should undergo the Rinne test to assess the type of hearing loss. The Romberg test is performed to test equilibrium. Pure tone audiometry uses a machine to hear sounds at different volumes while the patient wears a headset. Tympanometry assesses pressure in the ear; it does not assess hearing. PTS: 1 DIF: Moderate REF: p. 502 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall

www.mynursingtestprep.com24. The nurse is performing an otoscopic examination on an adult patient. She has the patient tilt his head to the side not being examined and looks into the ear canal to make sure a foreign body is not present. Which step should she perform next? 1) Straighten the ear canal by pulling the helix up and back. 2) Insert the speculum into the ear canal slowly. 3) Test the mobility of the tympanic membrane. 4) Straighten the ear canal by pulling the helix down and back. ANS: 1 Next, the nurse should straighten the ear canal by pulling the helix up and back. In a preschool child, the nurse should straighten the ear canal by pulling the helix down and back. After straightening the ear canal, the nurse should slowly insert the speculum and observe the ear canal. PTS: 1 DIF: Moderate REF: p. 538 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application 25. An 85-year-old patient is brought to the emergency department with lethargy and hypotension. When the nurse assesses the patients tongue, she notes that it appears dry and furry. This finding suggests: 1) Fungal infection. 2) Dehydration. 3) Allergy. 4) Iron deficiency. ANS: 2 A dry, furry tongue is associated with dehydration. A black, hairy tongue is characteristic of a fungal infection. Absence of papillae, reddened mucosa, and ulcerations may indicate allergy. Patients who have a deficiency of iron may have a smooth, red tongue. PTS: 1 DIF: Moderate REF: p. 503 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 26. Which assessment should the nurse perform if she notes a palpable thyroid gland? 1) Illuminate the thyroid gland for the presence of fluid. 2) Auscultate the thyroid gland for bruits. 3) Percuss the thyroid gland for mass size. 4) Measure the thyroid gland to assess change. ANS: 2 Normally, the thyroid gland is smooth, firm, and nontender. It is often nonpalpable. If the thyroid gland is palpable, the nurse should auscultate it for bruits. It is not necessary to measure or illuminate the thyroid gland. The thyroid gland should not be percussed.

www.mynursingtestprep.comPTS: 1 DIF: Moderate REF: p. 548 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 27. While palpating the anterior chest, the nurse notes crackling in the skin around the patients chest tube insertion site. The nurse recognizes this finding is: 1) Tactile fremitus. 2) Egophony. 3) Bronchophony. 4) Crepitus. ANS: 4 The nurse should document this finding as crepitus, crackling skin caused by air leaking into the subcutaneous tissues. Tactile fremitus involves palpating for vibrations as the client says 99, which indicates the presence of fluid in the chest. Bronchophony is present if the words 1, 2, 3 are clearly heard over the lungs as the nurse listens while the patient says those words. Egophony is present if the sound heard is ay when the nurse listens over the lung fields as the patient says eee. PTS: 1 DIF: Easy REF: dm 554-555 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 28. Bronchovesicular breath sounds are best heard over which area? 1) Midline over the trachea just below the larynx 2) Fourth intercostal space, in the midclavicular line 3) First and second intercostal spaces next to the sternum 4) At the base of the lungs near the diaphragm ANS: 3 Bronchovesicular breath sounds are best heard over the first and second intercostal spaces adjacent to the sternum on the anterior chest. PTS: 1 DIF: Moderate REF: p. 557 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 29. High-pitched breath sounds produced by airway narrowing are known as: 1) Rales. 2) Crackles. 3) Rhonchi. 4) Wheezing. ANS: 4 Wheezing is a high-pitched sound produced by narrowing of an airway. Rales and crackles are crackling sounds that indicate atelectasis, pulmonary edema, or pneumonia. Rhonchi are low-pitched snoring or rumbling sounds that result from mucous secretions in the large airways. PTS: 1 DIF: Easy REF: ESG,

www.mynursingtestprep.comKEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 30. The nurse notes a small pulsation at the fifth intercostal space midclavicular line. This should be documented as a: 1) Thrill. 2) Murmur. 3) Normal finding. 4) Heave. ANS: 3 A small pulsation at the fifth intercostal space midclavicular line is known as the point of maximal impulse (PMI) and is considered a normal finding. A thrill is a vibration or pulsation palpated in any area except the PMI. A murmur occurs when structural defects in the hearts chambers or valves cause turbulent blood flow. A heave, which is a visible palpation, is associated with an enlarged ventricle. PTS: 1 DIF: Moderate REF: p. 507 KEY: Nursing process: Implementation | Client need: PHSI | Cognitive level: Application 31. The nurse notes an S3 heart sound while performing an assessment on a patient admitted with an acute myocardial infarction. The nurse notifies the physician of the finding, which most likely suggests: 1) Heart failure. 2) Coronary artery disease. 3) Hypertension. 4) Pulmonic stenosis. ANS: 1 A third heart sound, commonly referred to as S3, is heard with heart failure or volume overload. S4 heart sound may be auscultated with coronary artery disease, hypertension, and pulmonic stenosis. PTS: 1 DIF: Difficult REF: p. 507 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 32. The admission assessment form indicates that the patient has pedal pulses that are rated 1 in amplitude. This documentation indicates that the patients pulses are: 1) Bounding. 2) Normal. 3) Full. 4) Diminished. ANS: 4 Pulses documented as 1 are diminished and barely palpable; 2 are normal; 3 are full and increased; and 4 are bounding.

www.mynursingtestprep.comPTS: 1 DIF: Moderate REF: p. 563 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 33. A patients jugular venous pressure measures 5 cm. This finding indicates: 1) A normal finding. 2) Hypovolemia. 3) Heart failure. 4) Dehydration. ANS: 3 Normal jugular venous pressure is less than 3 cm. A jugular venous pressure of 5 cm is elevated and suggests heart failure. PTS: 1 DIF: Moderate REF: p. 559 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Comprehension 34. The nurse is caring for a patient who underwent abdominal surgery 24 hours ago and has a nasogastric tube to intermittent suction. How should the nurse proceed when performing an abdominal assessment on this patient? 1) Avoid palpating the patients abdomen. 2) Turn off the suction before auscultating bowel sounds. 3) Listen for bowel sounds for 2 minutes in each quadrant. 4) Percuss the abdomen before auscultating bowel sounds. ANS: 2 The sound of suction attached to a nasogastric tube can be mistaken for bowel sounds; therefore, the nurse should discontinue the suction or clamp off the tube while auscultating bowel sounds. Light palpation can be performed in the postoperative patient. The nurse should listen for bowel sounds for at least 5 minutes before determining that they are absent. Auscultation should be performed before percussion in examining the abdomen. PTS: 1 DIF: Moderate REF: p. 509 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 35. Abdominal palpation should be avoided in a child who has which disorder? 1) Appendicitis 2) Wilms tumor 3) Crohns disease 4) Small bowel obstruction ANS: 2 Abdominal palpation should be avoided in the child who has Wilms tumor, large diffuse pulsation, or a history of organ transplant. Abdominal palpation can be performed with appendicitis, Crohns disease, and small bowel obstruction. PTS: 1 DIF: Moderate REF: p. 568 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall

www.mynursingtestprep.com36. A father brings his 18-month-old child to the pediatric clinic for a well-baby checkup. The father tells the nurse that he is concerned because his childs legs are bowed. Which response by the nurse is appropriate? 1) Your child will most likely require physical therapy. 2) You should consider having your child seen by an orthopedic surgeon. 3) This is a normal finding in children for 1 year after they begin walking. 4) Your child is walking fine, so you dont need to worry. ANS: 3 Genu varum, or bowlegs, is a normal finding in children for 1 year after they begin walking and the bones of the legs become more ossified with development and weight- bearing. However, assessment over time is important to be sure the gait and positioning develop normally. The nurse should allay the fathers concerns by providing him with this information. The child shows no signs, in the scenario above, that physical therapy is needed. It is not appropriate for the nurse to recommend an orthopedic surgeon; physician referrals are given by the physician or advanced practice nurse when appropriate. Your child is walking fine . . . is condescending and does not appropriately address the fathers concerns. PTS: 1 DIF: Moderate REF: p. 571 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application 37. The nurse asks the patient to spread his fingers and then bring them together again. Which of the following is the nurse testing when asking to bring his fingers together? 1) Abduction 2) Adduction 3) Flexion 4) Extension ANS: 2 Asking the patient to spread his fingers tests abduction; asking him to bring them together assesses adduction. Asking the patient to make a fist tests flexion, whereas asking him to extend the hand tests extension. PTS: 1 DIF: Moderate REF: p. 576 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 38. An adult admitted to the hospital after a stroke does not respond to verbal stimuli. What should the nurse do next to try to provoke a response? 1) Apply pressure to the mandible at the jaw. 2) Rub the patients sternum. 3) Squeeze the trapezius muscle. 4) Gently shake the patients shoulder.

www.mynursingtestprep.comANS: 4 If the patient does not respond to verbal stimuli, the nurse should try tactile stimuli by gently shaking the patients shoulder. If the patient does not respond to tactile stimuli, the nurse should try painful stimuli by squeezing the trapezius muscle, rubbing the sternum, applying pressure on the mandible at the angle of the jaw, or applying pressure over the moon of the nail. But do not start out with painful stimulation before you are sure the patient is not going to react to a less invasive approach. PTS: 1 DIF: Moderate REF: p. 579 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 39. Which assessment question helps assess immediate memory? 1) How did you get to the hospital today? 2) Can you repeat the numbers 2, 7, 9 for me? 3) Do you recall the three items I mentioned earlier? 4) What was your birth date including the year? ANS: 2 The nurse can assess immediate memory by asking the patient to repeat a series of three numbers and gradually increasing the length of the series until the patient cannot repeat the series correctly. The nurse can assess recent memory by asking the patient how he got to the hospital or by asking the patient to repeat three items that the nurse mentioned earlier in the examination. The nurse can assess remote memory by asking the patient his birth date or the date of a significant historical event. PTS: 1 DIF: Moderate REF: p. 580 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application 40. Assuming that all are accurate, which documentation about a patients level of consciousness is best? 1) Patient is lethargic and slept when undisturbed. 2) Patient responds to tactile stimulation; falls back to sleep immediately after tactile and verbal stimulation are stopped. 3) Patient slept throughout the day, missing his meals and bath. 4) Patient appears to be tired as he slept throughout the day except when bathed. ANS: 2 The option that includes the most detailed information provides the most accurate description of the patients level of consciousness. The other documentation provides little information about the level of consciousness. From those descriptions, the patient might have a decreased level of consciousness or could simply be exhausted. PTS: 1 DIF: Moderate REF: p. 510; High-level question; answer not stated verbatim KEY: Nursing process: Implementation | Client need: PHSI | Cognitive level: Analysis 41. Based on developmental stage, how should the nurse modify the comprehensive physical examination of an older adult? 1) Work rapidly to finish as quickly as possible. 2)

www.mynursingtestprep.comSequence the exam to limit position changes. 3) Demonstrate equipment before using it. 4) Omit portions of the exam that may be tiring. ANS: 2 Because older adults may tire easily and because they may have stiff muscles and arthritic joints, the nurse should arrange the sequence of the exam to limit position changes. The nurse should work efficiently; however, speed is not the goal, and the nurse should observe the patients energy level and stop for periods of rest as needed. It is appropriate to demonstrate equipment for school-age children but is not usually necessary for older adults, who have probably experienced other physical examinations. Because this is a comprehensive exam, it is not appropriate to omit portions of the exam because they may be tiring. As discussed, the patient should rest and then the nurse should return to the examination. PTS: 1 DIF: Moderate REF: p. 515 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 42. The nurse applies resistance to the top of the clients foot and asks him to pull his toes toward his knee. The nurse observes active motion against some, but not against full, resistance. How should the nurse document this finding? 1) 5: Normal 2) 4: Slight weakness 3) 3: Weakness 4) 2: Poor ROM ANS: 2 The nurse should document 4: Slight weakness. The following is the muscle strength rating scale: Rating Criteria Classification 5 Active motion against full resistance Normal 4 Active motion against some resistance Slight weakness 3 Active motion against gravity Weakness 2 Passive ROM Poor ROM 1 Slight flicker of contraction Severe weakness 0 No muscular contraction

www.mynursingtestprep.comParalysis PTS: 1 DIF: Difficult REF: dm 577-578 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday. Which finding(s) require(s) further assessment? Select all that apply. 1) Blood pressure 110/64 mm Hg 2) Pulse rate 118 beats/minute 3) Respiratory rate 35 breaths/minute 4) Oral temperature 98.6F (37C) ANS: 2, 3 The pulse rate of 118 beats/minute and the respiratory rate of 35 breaths/minute are abnormally elevated and require further assessment. Blood pressure 110/64 mm Hg and oral temperature 98.6F (37C) are considered normal and do not require further assessment. PTS: 1 DIF: Easy REF: p. 517 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 2. Which disorder(s) might limit a patients visual field? Select all that apply. 1) Diabetes 2) Advanced glaucoma 3) Peripheral vascular disease 4) Cataracts ANS: 1, 2, 4 Poorly controlled diabetes, cataracts, macular degeneration, and advanced glaucoma may limit the visual field. Peripheral vascular disease may be associated with diabetes, but it occurs in the extremities, not the eyes. Chapter 20 Promoting Asepsis & Preventing Infection Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which of the following behaviors indicates the highest potential for spreading infections among clients? The nurse: 1) disinfects dirty hands with antibacterial soap. 2) allows alcohol-based rub to dry for 10 seconds. 3) washes hands only when leaving each room. 4)