| Content |
MULTIPLE CHOICE
1. A man is terminally ill with end-stage prostate cancer. Which is the best statement about this man’s wellness?
| a. |
Wellness can only be achieved with aggressive medical interventions. |
| b. |
Wellness is not a real option for this client because he is terminally ill. |
| c. |
Wellness is defined as the absence of disease. |
| d. |
Nursing interventions can help empower a client to achieve a higher level of wellness. |
ANS: D
Nursing interventions can help empower a client to achieve a higher level of wellness; a nurse can foster wellness in his or her clients. Wellness is defined by the individual and is multidimensional. It is not just the absence of disease. A wellness perspective is based on the belief that every person has an optimal level of health independent of his or her situation or functional level. Even in the presence of chronic illness or while dying, a movement toward wellness is possible if emphasis of care is placed on the promotion of well-being in a supportive environment.
PTS: 1 DIF: Apply REF: p. 7 TOP: Nursing Process: Diagnosis
MSC: Health Promotion and Maintenance
2. In differentiating between health and wellness in health care, which of the following statements is true?
| a. |
Health is a broad term encompassing attitudes and behaviors. |
| b. |
The concept of illness prevention was never considered by previous generations. |
| c. |
Wellness and self-actualization develop through learning and growth. |
| d. |
Wellness is impossible when one’s health is compromised. |
ANS: A
Health is a broad term that encompasses attitudes and behaviors; holistically, health includes wellness, which involves one’s whole being. The concept of illness prevention was never considered by previous generations; throughout history, basic self-care requirements have been recognized. Wellness and self-actualization develop through learning and growth—as basic needs are met, higher level needs can be satisfied in turn, with ever-deepening richness to life. Wellness is possible when one’s health is compromised—even with chronic illness, with multiple disabilities, or in dying, movement toward a higher level of wellness is possible.
PTS: 1 DIF: Understand REF: p. 7 TOP: Nursing Process: Evaluation
MSC: Health Promotion and Maintenance
3. Which racial or ethnic group has the highest life expectancy in the United States?
| a. |
Native Americans |
| b. |
African Americans |
| c. |
Hispanic Americans |
| d. |
Asian and Pacific Island Americans |
ANS: C
As shown in Figure 1.4, Hispanic men and women have the highest life expectancy of all. In 2011, for those of Hispanic origin of any race, the overall life expectancy at 65 years of age was 20.7 more years in 2011 (19.1 years for men and 21.8 years for women).
PTS: 1 DIF: Understand REF: p. 6
TOP: Nursing Process: Assessment MSC: Safe, Effective Care Environment
4. Historical influences that have shaped the lives of the majority of the in-between cohort in the United States today include which of the following?
| a. |
Influenza epidemic of 1918 |
| b. |
World War I |
| c. |
Child rearing in the Depression |
| d. |
World War II |
ANS: D
Those who are in the in-between cohort in 2016 were born between 1915 and 1945. The men were likely to have fought in World War II. The last of the Holocaust survivors are in this group. A person who survived the influenza epidemic would be at least 98 years old in 2016 and therefore would be considered old-old or a centenarian. Most of those who are of the in-between cohort had not reached childbearing age by the end of the Depression. Individuals in the in-between cohort would not have been old enough to fight in World War II.
PTS: 1 DIF: Understand REF: p. 5
TOP: Nursing Process: Assessment MSC: Safe, Effective Care Environment
5. According to researchers, which characteristic do most centenarians share?
| a. |
Female |
| b. |
Hispanic |
| c. |
Living in rural areas |
| d. |
Located in the Midwestern states |
ANS: A
Based on the U.S. census report of 2010, centenarians were overwhelmingly white, female, and living in the urban areas of the Southern states.
PTS: 1 DIF: Remember REF: p. 5
TOP: Nursing Process: Assessment MSC: Safe, Effective Care Environment
6. Which nursing intervention is a holistic approach to an older adult?
| a. |
Performs glucose testing during the weekly worship service |
| b. |
Wheels ambulatory adults to exercise when running late |
| c. |
Assigns female nurses to older women who are Islamic |
| d. |
Allows older adults in a nursing home to eat meals alone |
ANS: C
The nurse uses a holistic approach to the care of an older female adult who is Islamic because the woman and her family are more likely to be willing participants in a therapeutic regimen that respects a tenet of their culture. Interrupting an older adult’s worship with glucose testing can be interpreted as a lack of respect for spiritual needs. The nurse can provide for and respect the physical and spiritual aspects of the older adult’s life by testing for glucose before the service begins. In transporting ambulatory adults to the exercise program in wheelchairs to save time, the nurse disregards the need for self-esteem and exercise, both important aspects of physical well-being. Ambulatory adults can walk with assistance, if needed, to exercise programs and can benefit from the additional activity and independence. The nurse can be tempted to allow an older adult to eat meals alone in his or her room if this will motivate the person to eat or if the older adult has dysphasia and is embarrassed. However, although focusing on physical needs, the nurse ignores psychosocial and other aspects of health and well-being.
PTS: 1 DIF: Understand REF: p. 7 TOP: Nursing Process: Evaluation
MSC: Health Promotion and Maintenance
7. An older man who resides in a nursing home has a total cholesterol level of 245 mg/dL. Which nursing intervention is most likely to assist this man in achieving his highest level of wellness?
| a. |
Instruct him about increasing dietary fiber. |
| b. |
Ask the health care provider for a low-fat diet. |
| c. |
Schedule a consultation for him with the dietitian. |
| d. |
Review a menu with him to choose suitable foods. |
ANS: D
The nurse collaborates with the older adult to choose suitable foods, which is likely to be an effective nursing intervention to help an older adult with hyperlipidemia achieve optimal health and well-being; it gives him some control over the regimen and thus engages him in the process of lowering serum cholesterol. Informing the older man about dietary fiber offers no control to him because he is not part of the decision. Nursing interventions developed with the older adult’s collaboration are most likely to help the older adult achieve health and wellness. Collaborating with the health care provider for a low-fat diet is a reasonable approach to help this man with hyperlipidemia to achieve health and wellness. However, he is more likely to have motivation and enthusiasm for a therapeutic regimen over which he has had some control. Scheduling a consultation with a dietitian is a reasonable approach to an older adult with hyperlipidemia and is a part of a multifaceted approach to optimizing his health. However, the older adult is more likely to engage in a regimen over which he has input.
PTS: 1 DIF: Analyze REF: p. 7 TOP: Nursing Process: Planning
MSC: Health Promotion and Maintenance
8. Which approach requires the nurse to integrate and balance all aspects of an individual’s life into the plan of care?
| a. |
Holistic nursing |
| b. |
Healthy People 2020 |
| c. |
Maslow’s hierarchy of human needs |
| d. |
Orem’s self-care requirements |
ANS: A
Holistic nursing integrates all aspects of an individual’s life into the plan of care by balancing an individual’s internal and external environment with psychosocial, spiritual, cultural, and physical processes. Healthy People 2020, an updated document from 2000 that outlines the goals for achieving health in this country, is a mandate for health care professionals to follow with 467 objectives in 28 focus areas. Maslow’s hierarchy of human needs provides a basis for understanding individuals in context and for ranking nursing assessments, diagnoses, goals, and interventions in order of importance. Dorothea Orem’s self-care requirements lists human needs, including the need for air, fluids, nutrition, hygiene, elimination, activity, comfort, relief from suffering, and skin integrity. The nurse helps individuals meet these needs to achieve optimal health and wellness.
PTS: 1 DIF: Remember REF: p. 7
TOP: Nursing Process: Assessment MSC: Safe, Effective Care Environment
9. The nurse plans activities for older women born between 1920 and 1930 and who reside in an assisted-living facility. Which is the best intervention for the nurse to implement?
| a. |
Have them bake cookies twice a week. |
| b. |
Conduct interviews for specific interests. |
| c. |
Arrange dog and cat visits from volunteers. |
| d. |
Take them to the library for guest speakers. |
ANS: B
The nurse conducts individual interviews with the women to determine their interests and to avoid generalizing; as people live longer, they become more and more unique. Because most of these women are in their 80s and 90s were born between 1920 and 1930 and have generally spent their lives as homemakers, the nurse presumes to know what activities they will enjoy. The nurse avoids arranging group activities until individual interests are determined. In addition, the nurse must assess for allergies and individual fears of animals before exposing an older adult to a pet visit. Unless it is organized on a voluntary basis, the nurse avoids arranging visits by guest speakers. In addition, the nurse will assess each older woman before an outside visit to avoid embarrassing events, including incontinence and hearing and vision problems.
PTS: 1 DIF: Analyze REF: p. 5
TOP: Nursing Process: Implementation MSC: Safe, Effective Care Environment
10. Which of the following issues in the care of older adults are identified in Healthy People 2020?
| a. |
Delineating nursing staffing levels in long term care |
| b. |
Eradicating pressure ulcers in all care settings |
| c. |
Identifying minimum levels of training for people who care for older adults |
| d. |
Instituting mandatory training in identification of elder abuse for all caregivers of older adults |
ANS: C
Identifying minimum training levels for people who care for older adults is one of the issues identified in Healthy People 2020. The rest of the issues are not discussed in Healthy People 2020.
PTS: 1 DIF: Remember REF: p. 8 TOP: Teaching and Learning
MSC: Health Promotion and Maintenance |
Chapter 01: Community Health Nursing
Stanhope: Community Health Nursing in Canada, 3rd Canadian Edition
MULTIPLE CHOICE
1. Which of the following best describes community health nursing?
| a. |
Giving care with a focus on the aggregate’s needs |
| b. |
Giving care with a focus on the group’s needs |
| c. |
Focusing on the health care of individual clients in the community |
| d. |
Working with an approach of unique client care |
ANS: C
By definition, community health nursing is the health care of individual clients in the community.
DIF: Cognitive Level: Knowledge/Remember REF: p. 3
OBJ: 1.6
TOP: Client Need: Safe and Effective Care Environment - Management of Care
2. Which of the following best describes primary health care?
| a. |
A comprehensive way to address issues of social justice |
| b. |
Giving the care to manage acute or chronic conditions |
| c. |
Giving direct care to ill individuals within their family setting |
| d. |
Having the goal of health promotion and disease prevention |
ANS: A
By definition, primary health care is comprehensive and addresses issues of social justice and equity. Social justice in the context of health refers to ensuring fairness and equality in health services so that vulnerable individuals in society have easy access to health care.
DIF: Cognitive Level: Knowledge/Remember REF: p. 10
OBJ: 1.4 TOP: Client Need: Health Promotion and Maintenance
3. The health of which of the following is the primary focus of public health nurses (PHNs)?
| a. |
Families |
| b. |
Groups |
| c. |
Individuals |
| d. |
Populations |
ANS: D
PHNs use knowledge of nursing, social sciences, and public health sciences for the promotion and protection of health and for the prevention of disease among populations.
DIF: Cognitive Level: Knowledge/Remember REF: p. 13, Table 1-4 | p. 20
OBJ: 1.5 TOP: Client Need: Health Promotion and Maintenance
4. Which change is the primary explanation for life expectancy increasing so notably since the early 1900s?
| a. |
An increase in findings from medical laboratory research |
| b. |
Incredible advances in surgical techniques and procedures |
| c. |
Improved sanitation and other public health activities |
| d. |
Increased use of antibiotics to fight infections |
ANS: C
Improvement in control of infectious diseases through immunizations, sanitation, and other public health activities led to the increase in life expectancy since the early 1900s.
DIF: Cognitive Level: Knowledge/Remember REF: pp. 12-13
OBJ: 1.5 TOP: Client Need: Health Promotion and Maintenance
5. Which community health nursing practice area receives funding from the private sector?
| a. |
Telenurses |
| b. |
Corrections nurses |
| c. |
Nurse entrepreneurs |
| d. |
Street or outreach nurses |
ANS: C
The nurse entrepreneur receives private funding, whereas all of the other community health nurse (CHN) roles are with provincially or federally funded positions.
DIF: Cognitive Level: Knowledge/Remember REF: p. 22, Table 1-4 Examples
OBJ: 1.6
TOP: Client Need: Safe and Effective Care Environment - Management of Care
6. A PHN strives to prevent disease and disability, often in partnership with other community groups. Which statement is an appropriate summary of the PHN’s role?
| a. |
The PHN asks the political leaders what interventions should be chosen. |
| b. |
The PHN assesses the community and decides on appropriate interventions. |
| c. |
The PHN uses data from the main health care institutions in the community to determine needed health services. |
| d. |
The PHN works with community members to carry out public health functions. |
ANS: D
It is crucial that the PHN work with members of the community to carry out core public health functions.
DIF: Cognitive Level: Application/Apply REF: p. 13, How To box
OBJ: 1.5 TOP: Client Need: Health Promotion and Maintenance
7. Which of the following is used as a measurement of population health?
| a. |
Health status indicators |
| b. |
The levels of prevention |
| c. |
The number of memberships at the local fitness centre |
| d. |
Reported provincial alcohol and tobacco sales in any given month |
ANS: A
Population health refers to the health outcomes of a population as measured by determinants of health and health outcomes.
DIF: Cognitive Level: Knowledge/Remember REF: p. 16
OBJ: 1.2 TOP: Client Need: Health Promotion and Maintenance
8. A registered nurse (RN), has just been employed as a CHN. Which question would be most relevant to her practice as she begins her position?
| a. |
“Which community groups are at greatest risk for problems?” |
| b. |
“Which patients should I see first as I begin my day?” |
| c. |
“With which physicians will I be collaborating most closely?” |
| d. |
“Who is the nursing assistant to whom I can refer patients?” |
ANS: A
CHNs apply the nursing process to the entire community; asking which groups are at greatest risk reflects a community-oriented perspective. The other possible responses focus on particular individuals.
DIF: Cognitive Level: Application/Apply REF: p. 15
OBJ: 1.6 TOP: Client Need: Health Promotion and Maintenance
9. The CHN working with women at the senior citizens’ centre reminds them that the only way the centre will be able to afford a driver and a van service for those who cannot drive themselves is to continue to write letters to their local city council representatives, requesting funding for such a service. What is the CHN doing?
| a. |
Ensuring that the women do not expect the CHN herself to do anything about their problem |
| b. |
Demonstrating that she understands the women’s concerns and needs |
| c. |
Expressing empathy, support, and concern |
| d. |
Helping the women engage in political action locally |
ANS: D
CHNs have an imperative to work with the members of the community to carry out public health functions such as political action.
DIF: Cognitive Level: Application/Apply REF: p. 13, How To box
OBJ: 1.5 | 1.6
TOP: Client Need: Safe and Effective Care Environment - Management of Care
10. Which activity is an example of the “advocate” role of the CHN?
| a. |
Organizing home care support for a newly discharged older adult client |
| b. |
Acting as a member of a community action group for provision of accessible transit choices |
| c. |
Doing prenatal assessments |
| d. |
Facilitating a self-help group for smoking cessation |
ANS: B
An advocate provides a voice to client concerns when acting as a member of a community action group for provision of accessible transit choices.
DIF: Cognitive Level: Application/Apply REF: p. 19, Table 1-3
OBJ: 1.6
TOP: Client Need: Safe and Effective Care Environment - Management of Care
11. In which scenario is the PHN most comprehensively fulfilling collaborative practice responsibilities?
| a. |
The PHN meets with several groups about community recreation issues. |
| b. |
The PHN spends the day attending meetings at various health agencies. |
| c. |
The PHN talks to several people about their particular health concerns. |
| d. |
The PHN watches television, including a telecast of a city council meeting on the local cable station. |
ANS: B
Any of these might represent a PHN communicating, cooperating, or collaborating with community residents or groups about health concerns. However, the PHN who spends the day attending meetings at various health agencies is most comprehensively fulfilling requirements effectively, since health is broader than recreation, individual concerns are not as important as aggregate priorities, and watching television is only one-way communication.
DIF: Cognitive Level: Synthesis/Synthesize REF: pp. 15-16
OBJ: 1.5
TOP: Client Need: Safe and Effective Care Environment - Management of Care
12. A CHN often has to make resource allocation decisions. In such cases, which approach will most help the CHN to arrive at the decision?
| a. |
Choosing a moral or ethical principle |
| b. |
Choosing the cheapest, most economical approach |
| c. |
Choosing the most rational outcome |
| d. |
Choosing the needs of the aggregate, rather than the needs of a few individuals |
ANS: D
Although all of the answers represent components of the CHN’s decision-making process, the predominant needs of the population outweigh the expressed needs of one person or a few people.
DIF: Cognitive Level: Application/Apply REF: pp. 7-8
OBJ: 1.3
TOP: Client Need: Safe and Effective Care Environment - Management of Care
13. Which situation most closely represents the focus of public health nursing?
| a. |
Assessing the services and effectiveness of the school health clinic |
| b. |
Caring for patients after their outpatient surgeries |
| c. |
Giving care to schoolchildren at the school clinic and to the children’s families |
| d. |
Treating paediatric patients at an outpatient clinic |
ANS: A
A public health or population-focused approach would consider the entire group of children receiving care, to see if services are effective in achieving the goal of improving the health of the school population.
DIF: Cognitive Level: Application/Apply REF: p. 13, How To box
OBJ: 1.5 TOP: Client Need: Health Promotion and Maintenance
14. Which public health service best represents primary prevention?
| a. |
Developing a health education program about the dangers of smoking |
| b. |
Providing a diabetes clinic for adults in low-income neighbourhoods |
| c. |
Providing an influenza vaccination program in a community retirement village |
| d. |
Teaching school-aged children about the positive effects of exercise |
ANS: C
Although all the services listed are appropriate and valuable, providing influenza vaccines to healthy adults represents the primary level of health prevention.
DIF: Cognitive Level: Application/Apply REF: p. 14
OBJ: 1.5 TOP: Client Need: Health Promotion and Maintenance
15. What term is used interchangeably with the term subpopulations?
| a. |
Groups |
| b. |
Aggregates |
| c. |
Clients |
| d. |
Communities |
ANS: B
Generally, subpopulations are referred to as aggregates within the larger community population.
DIF: Cognitive Level: Knowledge/Remember REF: p. 16
OBJ: 1.2 TOP: Client Need: Health Promotion and Maintenance
|
Chapter 1
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A nurse is educating a nursing student about nursing history. The nurse explains that throughout ancient history, nursing care was provided by family members and
| 1. |
Nurses. |
| 2. |
Physicians. |
| 3. |
Male priests. |
| 4. |
Female priests. |
____ 2. A nurse is teaching a student about the history of nursing. The nurse informs the student that in 1836, the first school of nursing was established in Kaiserworth, Germany, by
| 1. |
Jean Watson. |
| 2. |
Clara Barton. |
| 3. |
Theodor Fliedner. |
| 4. |
Florence Nightingale. |
____ 3. A nurse teaches a student nurse that in 1897, the Nurses Associated Alumnae of the United States was formed in an effort to
| 1. |
Set standards and rules in nursing education. |
| 2. |
Keep nurses aware of the newest medical information. |
| 3. |
Oversee training to protect patients from incompetent nurses. |
| 4. |
Keep nurses updated on the newest information about nursing education. |
____ 4. The purpose of the National League for Nursing is to
| 1. |
Set standards and rules in nursing education. |
| 2. |
Keep nurses aware of the newest medical information. |
| 3. |
Oversee training to protect patients from incompetent nurses. |
| 4. |
Keep nurses updated on the newest information about nursing education. |
____ 5. All states required practical nurses to be licensed in the year
| 1. |
1940. |
| 2. |
1945. |
| 3. |
1950. |
| 4. |
1955. |
____ 6. The title licensed practical nurse (LPN) is used in all states except California and
| 1. |
Texas. |
| 2. |
Maine. |
| 3. |
Alaska. |
| 4. |
Arizona. |
____ 7. The National Council Licensure Examination for Practical Nursing (NCLEX-PN) is
| 1. |
Taken in order to practice as a nurse. |
| 2. |
Given as an entrance examination for nursing school. |
| 3. |
Individualized based on where an examinee resides. |
| 4. |
Taken in order to practice as a certified nursing assistant (CNA). |
____ 8. A nurse recruiter is seeking a graduate nurse who has been educated more extensively on management and leadership. The graduate nurse who most likely fits this description is the
| 1. |
Diploma nurse. |
| 2. |
Associate degree nurse (ADN). |
| 3. |
Licensed practical/vocational nurse (LPN/LVN). |
| 4. |
Baccalaureate degree nurse (BSN). |
____ 9. Which statement about the Nurse Practice Act is accurate?
| 1. |
The Nurse Practice Act clarifies who can supervise a physician. |
| 2. |
The Nurse Practice Act is the law that governs the actions of nurses. |
| 3. |
The Nurse Practice Act is determined by the National League of Nursing. |
| 4. |
The Nurse Practice Act specifies the tasks of the unlicensed assistive personnel. |
____ 10. A nurse educates a nursing student about the Nurse Practice Act. The nursing student demonstrates understanding when he or she states:
| 1. |
“The Nurse Practice Act is the same in every state.” |
| 2. |
“The Nurse Practice Act does not specify who can supervise a nurse.” |
| 3. |
“The Nurse Practice Act is determined by the American Nurses Association.” |
| 4. |
“The Nurse Practice Act establishes the scope of practice for each level of nurse.” |
____ 11. While caring for a patient, a nurse performs a nursing action that is not within his or her scope of practice. The nurse has violated the
| 1. |
Ethics Committee. |
| 2. |
Nurse Practice Act. |
| 3. |
State Department of Health. |
| 4. |
National League for Nursing Education. |
____ 12. The Nurse Practice Act is enforced by the
| 1. |
State Board of Nursing. |
| 2. |
County Health Department. |
| 3. |
State Department of Health. |
| 4. |
National League for Nursing. |
____ 13. A nurse is caring for a resident in a long-term setting. The nurse best demonstrates a caring approach when
| 1. |
Performing all activities of daily living for the resident. |
| 2. |
Asking the resident’s spouse to bring a family picture for the resident’s room. |
| 3. |
Answering the resident’s questions quickly without allowing time for clarification. |
| 4. |
Encouraging the resident’s spouse to decide which activities the resident should do. |
____ 14. A nurse is caring for multiple patients on a medical unit. The nurse can best practice the art of nursing with an emphasis on caring by
| 1. |
Providing identical care to each patient. |
| 2. |
Individualizing care provided to each patient. |
| 3. |
Viewing the patients in terms of a cellular disorder. |
| 4. |
Viewing the patients as seriously ill and needing a cure. |
____ 15. A nurse is educating a student nurse about the responsibilities of a student nurse. The nurse recognizes that additional teaching is needed when the student nurse states:
| 1. |
“I will check laboratory results for my patients often.” |
| 2. |
“I am responsible for noting abnormal assessment findings.” |
| 3. |
“I will frequently check the patient’s chart for diagnostic test results.” |
| 4. |
“It is not within my scope of practice to notify someone of abnormal findings.” |
____ 16. A nursing instructor teaches a student nurse about the importance of joining a professional organization. The nursing instructor recognizes that further instruction is necessary when the student nurse states,
| 1. |
“Professional organizations allow me to have a collective voice.” |
| 2. |
“Professional organizations limit my ability to influence laws and policies.” |
| 3. |
“Professional behavior is demonstrated by joining a professional organization.” |
| 4. |
“By joining a professional organization, I will have opportunities for leadership.” |
| Test Bank Foundations of Maternal-Newborn and Women’s Health Nursing 7th Edition
Chapter 01: Maternity and Women’s Health Care Today
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. A nurse educator is teaching a group of nursing students about the history of family-centered
maternity care. Which statement should the nurse include in the teaching session?
a. The Sheppard-Towner Act of 1921 promoted family-centered care.
b. Changes in the pharmacologic management of labor prompted family-centered care.
c. Demands by physicians for family involvement in childbirth increased the practice
of family-centered care.
d. Parental requests that infants be allowed to remain with them rather than in a
nursery initiated the practice of family-centered care.
ANS: D
As research began to identify the benefits of early, extended parent-infant contact, parents began to insist that the infant remain with them. This gradually developed into the practice of
rooming-in and finally to family-centered maternity care. The Sheppard-Towner Act provided
funds for state-managed programs for mothers and children but did not promote
family-centered care. The changes in pharmacologic management of labor were not a factor in
family-centered maternity care. Family-centered care was a request by parents, not physicians.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
2. Expectant parents ask a prenatal nurse educator, “Which setting for childbirth limits the amount of parent-infant interaction?” Which answer should the nurse provide for these parents in order to assist them in choosing an appropriate birth setting?
a. Birth center
b. Homebirth
c. Traditional hospital birth
d. Labor, birth, and recovery room
ANS: C
In the traditional hospital setting, the mother may see the infant for only short feeding periods,
and the infant is cared for in a separate nursery. Birth centers are set up to allow an increase in parent-infant contact. Home births allow the greatest amount of parent-infant contact. The labor, birth, recovery, and postpartum room setting allows for increased parent-infant contact.
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
3. Which statement best describes the advantage of a labor, birth, recovery, and postpartum
(LDRP) room?
a. The family is in a familiar environment.
b. They are less expensive than traditional hospital rooms.
c. The infant is removed to the nursery to allow the mother to rest.
d. The woman’s support system is encouraged to stay until discharge.
ANS: D
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test BankNU
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Sleeping equipment is provided in a private room. A hospital setting is never a familiar
environment to new parents. An LDRP room is not less expensive than a traditional hospital
room. The baby remains with the mother at all times and is not removed to the nursery for
routine care or testing. The father or other designated members of the mother’s support system
are encouraged to stay at all times.
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
4. Which nursing intervention is an independent function of the professional nurse?
a. Administering oral analgesics
b. Requesting diagnostic studies
c. Teaching the patient perineal care
d. Providing wound care to a surgical incision
ANS: C
Nurses are now responsible for various independent functions, including teaching, counseling,
and intervening in nonmedical problems. Interventions initiated by the physician and carried
out by the nurse are called dependent functions. Administrating oral analgesics is a dependent
function; it is initiated by a physician and carried out by a nurse. Requesting diagnostic
studies is a dependent function. Providing wound care is a dependent function; however, the
physician prescribes the type of wound care through direct orders or protocol.
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Safe and Effective Care Environment
5. Which response by the nurse is the most therapeutic when the patient states, “I’m so afraid to
have a cesarean birth”?
a. “Everything will be OK.”
b. “Don’t worry about it. It will be over soon.”
c. “What concerns you most about a cesarean birth?”
d. “The physician will be in later and you can talk to him.”
ANS: C
The response, “What concerns you most about a cesarean birth” focuses on what the patient is
saying and asks for clarification, which is the most therapeutic response. The response,
“Everything will be ok” is belittling the patient’s feelings. The response, “Don’t worry about
it. It will be over soon” will indicate that the patient’s feelings are not important. The
response, “The physician will be in later and you can talk to him” does not allow the patient to
verbalize her feelings when she wishes to do that.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
6. In which step of the nursing process does the nurse determine the appropriate interventions for
the identified nursing diagnosis?
a. Planning
b. Evaluation
c. Assessment
d. Intervention
ANS: A
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test BankNU
RS
IN
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B.CO
M
The third step in the nursing process involves planning care for problems that were identified
during assessment. The evaluation phase is determining whether the goals have been met.
During the assessment phase, data are collected. The intervention phase is when the plan of
care is carried out.
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Safe and Effective Care Environment
7. Which goal is most appropriate for the collaborative problem of wound infection?
a. The patient will not exhibit further signs of infection.
b. Maintain the patient’s fluid intake at 1000 mL/8 hour.
c. The patient will have a temperature of 98.6F within 2 days.
d. Monitor the patient to detect therapeutic response to antibiotic therapy.
ANS: D
In a collaborative problem, the goal should be nurse-oriented and reflect the nursing
interventions of monitoring or observing. Monitoring for complications such as further signs
of infection is an independent nursing role. Intake and output is an independent nursing role.
Monitoring a patient’s temperature is an independent nursing role.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Safe and Effective Care Environment
8. Which nursing intervention is written correctly?
a. Force fluids as necessary.
b. Observe interaction with the infant.
c. Encourage turning, coughing, and deep breathing.
d. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM.
ANS: D
Interventions might not be carried out if they are not detailed and specific. “Force fluids” is
not specific; it does not state how much or how often. Encouraging the patient to turn, cough,
and breathe deeply is not detailed or specific. Observing interaction with the infant does not
state how often this procedure should be done. Assisting the patient to ambulate for 10
minutes within a certain timeframe is specific.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Safe and Effective Care Environment
9. The patient makes the statement: “I’m afraid to take the baby home tomorrow.” Which
response by the nurse would be the most therapeutic?
a. “You’re afraid to take the baby home?”
b. “Don’t you have a mother who can come and help?”
c. “You should read the literature I gave you before you leave.”
d. “I was scared when I took my first baby home, but everything worked out.”
ANS: A
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test BankNU
RS
IN
GT
B.CO
M
This response uses reflection to show concern and open communication. The other choices are
blocks to communication. Asking if the patient has a mother who can come and assist blocks
further communication with the patient. Telling the patient to read the literature before leaving
does not allow the patient to express her feelings further. Sharing your own birth experience is
inappropriate.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
10. The nurse is writing an expected outcome for the nursing diagnosis—acute pain related to
tissue trauma, secondary to vaginal birth, as evidenced by patient stating pain of 8 on a scale
of 10. Which expected outcome is correctly stated for this problem?
a. Patient will state that pain is a 2 on a scale of 10.
b. Patient will have a reduction in pain after administration of the prescribed
analgesic.
c. Patient will state an absence of pain 1 hour after administration of the prescribed
analgesic.
d. Patient will state that pain is a 2 on a scale of 10, 1 hour after the administration of
the prescribed analgesic.
ANS: D
The outcome should be patient-centered, measurable, realistic, and attainable and within a
specified timeframe. Patient stating that her pain is now 2 on a scale of 10 lacks a timeframe.
Patient having a reduction in pain after administration of the prescribed analgesic lacks a
measurement. Patient stating an absence of pain 1 hour after the administration of prescribed
analgesic is unrealistic.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
11. Which nursing diagnosis should the nurse identify as a priority for a patient in active labor?
a. Risk for anxiety related to upcoming birth
b. Risk for imbalanced nutrition related to NPO status
c. Risk for altered family processes related to new addition to the family
d. Risk for injury (maternal) related to altered sensations and positional or physical
changes
ANS: D
The nurse should determine which problem needs immediate attention. Risk for injury is the
problem that has the priority at this time because it is a safety problem. Risk for anxiety,
imbalanced nutrition, and altered family processes are not the priorities at this time.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment | Medical-Surgical Nursing: Making Connections to Practice 1st edition Hoffman, Sullivan Test Bank
Chapter 1: Foundations for Medical-Surgical Nursing
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The medical-surgical nurse identifies a clinical practice issue and wants to determine if there is sufficient evidence to support a change in practice. Which type of study provides the strongest evidence to support a
practice change?
1) Randomized control study
2) Quasi-experimental study
3) Case-control study
4) Cohort study
____ 2. The medical-surgical unit recently implemented a patient-centered care model. Which action implemented by
the nurse supports this model?
1) Evaluating care
2) Assessing needs
3) Diagnosing problems
4) Providing compassion
____ 3. Which action should the nurse implement when providing patient care in order to support The Joint
Commission’s (TJC) National Patient Safety Goals (NPSG)?
1) Silencing a cardiorespiratory monitor
2) Identifying each patient using one source
3) Determining patient safety issues upon admission
4) Decreasing the amount of pain medication administered
____ 4. Which interprofessional role does the nurse often assume when providing patient care in an acute care
setting?
1) Social worker
2) Client advocate
3) Care coordinator
4) Massage therapist
____ 5. The medical-surgical nurse wants to determine if a policy change is needed for an identified clinical problem.
Which is the first action the nurse should implement?
1) Developing a question
2) Disseminating the findings
3) Conducting a review of the literature
4) Evaluating outcomes of practice change
____ 6. The nurse is evaluating the level of evidence found during a recent review of the literature. Which evidence
carries the lowest level of support for a practice change?
1) Level IV
2) Level V
3) Level VI
4) Level VII
____ 7. The nurse is reviewing evidence from a quasi-experimental research study. Which level of evidence should
the nurse identify for this research study?
1) Level ITestBankWorld.org
2) Level II
3) Level III
4) Level IV
____ 8. Which level of evidence should the nurse identify when reviewing evidence from a single descriptive research
study?
1) Level IV
2) Level V
3) Level VI
4) Level VII
____ 9. Which statement should the nurse make when communicating the “S” in the SBAR approach for effective
communication?
1) “The patient presented to the emergency department at 0200 with lower left abdominal
pain.”
2) “The patient rated the pain upon admission as a 9 on a 10-point numeric scale.”
3) “The patient has no significant issues in the medical history.”
4) “The patient was given a prescribed opioid analgesic at 0300.”
____ 10. The staff nurse is communicating with the change nurse about the change of status of the patient. The nurse
would begin her communication with which statement if correctly using the SBAR format?
1) “The patient’s heartrate is 110.”
2) “I think this patient needs to be transferred to the critical care unit.”
3) “The patient is a 68-year-old male patient admitted last night.”
4) “The patient is complaining of chest pain.”
____ 11. Which nursing action exemplifies the Quality and Safety Education for Nursing (QSEN) competency of
safety?
1) Advocating for a patient who is experiencing pain
2) Considering the patient’s culture when planning care
3) Evaluating patient learning style prior to implementing discharge instructions
4) Assessing the right drug prior to administering a prescribed patient medication
____ 12. Which type of nursing is the root of all other nursing practice areas?
1) Pediatric nursing
2) Geriatric nursing
3) Medical-surgical nursing
4) Mental health-psychiatric nursing
____ 13. Which did the Nursing Executive Center of The Advisory Board identify as an academic-practice gap for new
graduate nurses?
1) Patient advocacy
2) Patient education
3) Disease pathophysiology
4) Therapeutic communication
____ 14. Which statement regarding the use of the nursing process in clinical practice is accurate?
1) “The nursing process is closely related to clinical decision-making.”
2) “The nursing process is used by all members of the interprofessional team to plan care.”
3) “The nursing process has 4 basic steps: assessment, planning, implementation,
evaluation.”
4) “The nursing process is being replaced by the implementation of evidence-based practice.”TestBankWorld.org
____ 15. Which is the basis of nursing care practices and protocols?
1) Assessment
2) Evaluation
3) Diagnosis
4) Research
____ 16. Which is a common theme regarding patient dissatisfaction related to care provided in the hospital setting?
1) Space in hospital rooms
2) Medications received to treat pain
3) Time spent with the health-care team
4) Poor quality food received from dietary
____ 17. The nurse manager is preparing a medical-surgical unit for The Joint Commission (TJC) visit With the nurse
manager presenting staff education focusing on TJC benchmarks, which of the following topics would be
most appropriate?
1) Implementation of evidence-based practice
2) Implementation of patient-centered care
3) Implementation of medical asepsis practices
4) Implementation of interprofessional care
____ 18. Which aspect of patient-centered care should the nurse manager evaluate prior to The Joint Commission site
visit for accreditation?
1) Visitation rights
2) Education level of staff
3) Fall prevention protocol
4) Infection control practices
____ 19. The medical-surgical nurse is providing patient care. Which circumstance would necessitate the nurse
verifying the patient’s identification using at least two sources?
1) Prior to delivering a meal tray
2) Prior to passive range of motion
3) Prior to medication administration
4) Prior to documenting in the medical record
____ 20. The nurse is providing care to several patients on a medical-surgical unit. Which situation would necessitate
the nurse to use SBAR during the hand-off process?
1) Wound care
2) Discharge to home
3) Transfer to radiology
4) Medication education
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. The staff nurse is teaching a group of student nurses the situations that necessitate hand-off communication.
Which student responses indicate the need for further education related to this procedure? Select all that
apply.
1) “A hand-off is required prior to administering a medication.”
2) “A hand-off is required during change of shift.”
3) “A hand-off is required for a patient is transferred to the surgical suite.”TestBankWorld.org
4) “A hand-off is required whenever the nurse receives a new patient assignment.”
5) “A hand-off is required prior to family visitation.”
____ 22. Which actions by the nurse enhance patient safety during medication administration? Select all that apply.
1) Answering the call bell while transporting medications for a different patient
2) Identifying the patient using two sources prior to administering the medication
3) Holding a medication if the patient’s diagnosis does not support its use
4) Administering the medication two hours after the scheduled time
5) Having another nurse verify the prescribed dose of insulin the patient is to receive
____ 23. The medical-surgical nurse assumes care for a patient who is receiving continuous cardiopulmonary
monitoring. Which actions by the nurse enhance safety for this patient? Select all that apply.
1) Silencing the alarm during family visitation
2) Assessing the alarm parameters at the start of the shift
3) Responding to the alarm in a timely fashion
4) Decreasing the alarm volume to enhance restful sleep
5) Adjusting alarm parameters based on specified practitioner prescription
____ 24. The nurse is planning an interprofessional care conference for a patient who is approaching discharge from
the hospital. Which members of the interprofessional team should the nurse invite to attend? Select all that
apply.
1) Physician
2) Pharmacist
3) Unit secretary
4) Social worker
5) Home care aide
____ 25. The nurse manager wants to designate a member of the nursing team as the care coordinator for a patient who
will require significant care during the hospitalization. Which skills should this nurse possess in order to
assume this role? Select all that apply.
1) Effective clinical reasoning
2) Effective communication skills
3) Effective infection control procedures
4) Effective documentation
5) Effective intravenous skillsTestBankWorld.org
Chapter 1: Foundations for Medical-Surgical Nursing
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 1, Foundations for Medical Surgical Practice
Chapter learning objective: Discussing the incorporation of evidence-based practices into medical-surgical
nursing
Chapter page reference: 003-004
Heading: Evidence-Based Nursing Care
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Evidence-Based Practice
Difficulty: Easy
Feedback
1 Systematic reviews of randomized control studies (Level I) are the highest level of
evidence because they include data from selected studies that randomly assigned
participants to control and experimental groups. The lower the numerical rating of the
level of evidence indicates the highest level of evidence; therefore, this type of study
provides the strongest evidence to support a practice change.
2 Quasi-experimental studies are considered Level III; therefore, this study does not
provide the strongest evidence to support a practice change.
3 Case-control studies are considered Level IV; therefore, this study does not provide the
strongest evidence to support a practice change.
4 Cohort studies are considered Level IV; therefore, this study does not provide the
strongest evidence to support a practice change.
PTS: 1 CON: Evidence-Based Practice
2. ANS: 4
Chapter number and title: 1, Foundations of Medical-Surgical Practice
Chapter learning objective: Explaining the importance of patient-centered care in the management of
medical-surgical patients
Chapter page reference: 004-005
Heading: Patient-Centered Care in the Medical-Surgical Setting
Integrated Processes: Caring
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Nursing Roles
Difficulty: Moderate
Feedback
1 Evaluation is a step in the nursing process; however, this is not an action that supports
the patient-centered care model.
2 Assessment is a step in the nursing process; however, this is not an action that supports
the patient-centered care model.TestBankWorld.org
3 Diagnosis is a step in the nursing process; however, this is not an action that supports
the patient-centered care model.
4 Compassion is a competency closely associated with patient-centered care; therefore,
this action supports the patient-centered model of care.
PTS: 1 CON: Nursing Roles
3. ANS: 3
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Discussing implications to medical-surgical nurses of Quality and Safety
Education for Nurses (QSEN) competencies
Chapter page reference: 005-006
Heading: Patient Safety Outcomes
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Application [Applying]
Concept: Safety
Difficulty: Moderate
Feedback
1 Safely using alarms is a NPSG identified by TJC. Silencing a cardiorespiratory monitor
is not nursing action that supports this NPSG.
2 Patient identification using two separate resources is a NPSG identified by TJC.
Identifying a patient using only one source does not support this NPSG.
3 Identification of patient safety risks is a NPSG identified by the TJC. Determining
patient safety issues upon admission supports this NPSG.
4 Safe use of medication is a NPSG identified by the TJC. Decreasing the amount of pain
medication administered does not support this NPSG.
PTS: 1 CON: Safety
4. ANS: 3
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Describing the role and competencies of medical-surgical nursing
Chapter page reference: 006-007
Heading: Interprofessional Collaboration and Communication
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Nursing Roles
Difficulty: Easy
Feedback
1 The nurse does not often assume the interprofessional role of social worker when
providing patient care in an acute care setting.
2 The nurse does not often assume the interprofessional role of client advocate role when
providing patient care in an acute care setting.
3 The nurse often assumes the interprofessional role of care coordinator when providing
patient care in an acute care setting.
4 The nurse does not often assume the interprofessional role of massage therapist when
providing patient care in an acute care setting.TestBankWorld.org
PTS: 1 CON: Nursing Roles
5. ANS: 1
Chapter number and title: 1, Foundations of Medical-Surgical Practice
Chapter learning objective: Discussing the incorporation of evidence-based practices into medical-surgical
nursing
Chapter page reference: 003
Heading: Box 1.3 Steps of Evidence-Based Practice
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Evidence-Based Practice
Difficulty: Difficult
Feedback
1 The first step of evidence-based practice is to develop a question based on the clinical
issue.
2 The last step of evidence-based practice is to disseminate findings.
3 The second step of evidence-based practice is to conduct a review of the literature, or
current evidence, available.
4 The fifth step of evidence-based practice is to evaluate the outcomes associated with the
practice change.
PTS: 1 CON: Evidence-Based Practice
6. ANS: 4
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Discussing the incorporation of evidence-based practices into medical-surgical
nursing
Chapter page reference: 004
Heading: Box 1.4 Evaluating Levels of Evidence
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Evidence-Based Practice
Difficulty: Easy
Feedback
1 The lower the numeric value of the evidence the greater the support for a change in
practice. Level IV evidence does not carry the lowest level of support for a practice
change.
2 The lower the numeric value of the evidence the greater the support for a change in
practice. Level V evidence does not carry the lowest level of support for a practice
change.
3 The lower the numeric value of the evidence the greater the support for a change in
practice. Level VI evidence does not carry the lowest level of support for a practice
change.
4 The lower the numeric value of the evidence the greater the support for a change in
practice. Level VII evidence carries the lowest level of support for a practice change.
|
Chapter 05: Comfort and Sedation
Sole: Introduction to Critical Care Nursing, 7th Edition
MULTIPLE CHOICE
1.Nociceptors differ from other nerve receptors in the body in that they:
| a. |
adapt very little to continual pain response. |
| b. |
inhibit the infiltration of neutrophils and eosinophils. |
| c. |
play no role in the inflammatory response. |
| d. |
transmit only the thermal stimuli. |
ANS: A
Nociceptors are stimulated by mechanical, chemical, or thermal stimuli. Nociceptors differ from other nerve receptors in the body in that they adapt very little to the pain response. The body continues to experience pain until the stimulus is discontinued or therapy is initiated. This is a protective mechanism so that the body tissues being damaged will be removed from harm. Nociceptors usually initiate inflammatory responses near injured capillaries. As such, the response promotes infiltration of injured tissues with neutrophils and eosinophils.
DIF: Cognitive Level: Remember/Knowledge REF: p. 54
OBJ:Discuss the physiology of pain and anxiety.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
2.A postsurgical patient is on a ventilator in the critical care unit. The patient has been tolerating the ventilator well and has not required any sedation. On assessment, the nurse notes the patient is tachycardic and hypertensive with an increased respiratory rate of 28 breaths/min. The patient has been suctioned recently via the endotracheal tube, and the airway is clear. The patient responds appropriately to the nurse’s commands. The nurse should:
| a. |
assess the patient’s level of pain. |
| b. |
decrease the ventilator rate. |
| c. |
provide sedation as ordered. |
| d. |
suction the patient again. |
ANS: A
Pulse, respirations, and blood pressure frequently result from activation of the sympathetic nervous system by the pain stimulus. Because the patient is postoperative, the patient should be assessed for the presence of pain and need for pain medication. Decreasing the ventilator rate will not help in this situation. Providing sedation may calm the patient but will not solve the problem if the physiological changes are from pain. The patient has just been suctioned and the airway is clear. There is no need to suction again.
DIF: Cognitive Level: Analyze/Analysis REF: p. 55
OBJ: Describe the positive and negative effects of pain and anxiety in critically ill patients.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
3.The assessment of pain and anxiety is a continuous process. When critically ill patients exhibit signs of anxiety, the nurse’s first priority is to
| a. |
administer antianxiety medications as ordered. |
| b. |
administer pain medication as ordered. |
| c. |
identify and treat the underlying cause. |
| d. |
reassess the patient hourly to determine whether symptoms resolve on their own. |
ANS: C
When patients exhibit signs of anxiety or agitation, the first priority is to identify and treat the underlying cause, which could be hypoxemia, hypoglycemia, hypotension, pain, or withdrawal from alcohol and drugs. Treatment is not initiated until assessment is completed. Medication may not be needed if the underlying cause can be resolved.
DIF: Cognitive Level: Apply/Application REF: p. 70 | Table 5-11
OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
4.Both the electroencephalogram (EEG) monitor and the Bispectral Index Score (BIS) or Patient State Index (PSI) analyzer monitors are used to assess patient sedation levels in critically ill patients. The BIS and PSI monitors are simpler to use because they
| a. |
can be used only on heavily sedated patients. |
| b. |
can be used only on pediatric patients. |
| c. |
provide raw EEG data and a numeric value. |
| d. |
require only five leads. |
ANS: C
The BIS and PSI have very simple steps for application, and results are displayed as raw EEG data and the numeric value. A single electrode is placed across the patient’s forehead and is attached to a monitor. These monitors can be used in both children and adults and in patients with varying levels of sedation.
DIF: Cognitive Level: Understand/Comprehension REF: p. 60
OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
5.The nurse is caring for a patient who requires administration of a neuromuscular blocking agent to facilitate ventilation with nontraditional modes. The nurse understands that neuromuscular blocking agents provide:
| a. |
antianxiety effects. |
| b. |
complete analgesia. |
| c. |
high levels of sedation. |
| d. |
no sedation or analgesia. |
ANS: D
Neuromuscular blocking (NMB) agents do not possess any sedative or analgesic properties. Patients who receive NMBs must also receive sedatives and pain medication.
DIF: Cognitive Level: Remember/Knowledge REF: p. 72
OBJ: Discuss assessment and management challenges in subsets of critically ill patients.
TOP:Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
6.The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis?
| a. |
Glasgow Coma Scale score of 3 |
| b. |
Train-of-four yields two twitches |
| c. |
Bispectral index of 60 |
| d. |
CAM-ICU positive |
ANS: B
A train-of-four response of two twitches (out of four) using a peripheral nerve stimulator indicates adequate paralysis. The Glasgow Coma Scale does not assess paralysis; it is an indicator of consciousness. The bispectral index provides an assessment of sedation. The CAM-ICU is a tool to assess delirium.
DIF: Cognitive Level: Remember/Knowledge REF: p. 73
OBJ: Discuss assessment and management challenges in subsets of critically ill patients.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
7.The nurse is concerned that the patient will pull out the endotracheal tube. As part of the nursing management, the nurse obtains an order for
| a. |
arm binders or splints. |
| b. |
a higher dosage of lorazepam. |
| c. |
propofol. |
| d. |
soft wrist restraints. |
ANS: D
The priority in caring for agitated patients is safety. The least restrictive methods of keeping the patient safe are appropriate. If possible, the tube or device causing irritation should be removed, but if that is not possible, the nurse must prevent the patient from pulling it out. Restraints are associated with an increased incidence of agitation and delirium. Therefore, restraints should not be used unless as a last resort for combative patients. The least amount of sedation is also recommended; therefore, neither increasing the dosage of lorazepam nor adding propofol is indicated and would be likely to prolong mechanical ventilation.
DIF: Cognitive Level: Apply/Application REF: p. 61
OBJ:Identify nonpharmacological and pharmacological strategies to promote comfort and reduce anxiety.TOP:Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment
8.The primary mode of action for neuromuscular blocking agents used in the management of some ventilated patients is
| a. |
analgesia. |
| b. |
anticonvulsant therapy. |
| c. |
paralysis. |
| d. |
sedation. |
ANS: C
These agents cause respiratory muscle paralysis. They do not provide analgesia or sedation. They do not have anticonvulsant properties.
DIF: Cognitive Level: Remember/Knowledge REF: p. 72
OBJ: Discuss assessment and management challenges in subsets of critically ill patients.
TOP:Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
9.The most important nursing intervention for patients who receive neuromuscular blocking agents is to
| a. |
administer sedatives in conjunction with the neuromuscular blocking agents. |
| b. |
assess neurological status every 30 minutes. |
| c. |
avoid interaction with the patient, because he or she won’t be able to hear. |
| d. |
restrain the patient to avoid self-extubation. |
ANS: A
Neuromuscular blocking agents cause paralysis only; they do not cause sedation. Therefore, concomitant administration of sedatives is essential. Neurological status is monitored according to unit protocol. Nurses should communicate with all critically ill patients, regardless of their status. If the patient is paralyzed, restraining devices may not be needed.
DIF: Cognitive Level: Apply/Application REF: p. 72
OBJ: Discuss assessment and management challenges in subsets of critically ill patients.
TOP:Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
10.The best way to monitor agitation and effectiveness of treating it in the critically ill patient is to use a/the:
| a. |
Confusion Assessment Method (CAM-ICU). |
| b. |
FACES assessment tool. |
| c. |
Glasgow Coma Scale. |
| d. |
Richmond Agitation Sedation Scale. |
ANS: D
Various sedation scales are available to assist the nurse in monitoring the level of sedation and assessing response to treatment. The Richmond Agitation Sedation Scale is a commonly used tool that has been validated. The CAM-ICU assesses for delirium. The FACES scale assesses pain. The Glasgow Coma Scale assesses neurological status.
DIF: Cognitive Level: Remember/Knowledge REF: p. 59 | Table 5-5
OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
11.The nurse is caring for a patient receiving intravenous ibuprofen for pain management. The nurse recognizes which laboratory assessment to be a possible side effect of the ibuprofen?
| a. |
Creatinine: 3.1 mg/dL |
| b. |
Platelet count 350,000 billion/L |
| c. |
White blood count 13, 550 mm3 |
| d. |
ALT 25 U/L |
ANS: A
Ibuprofen can result in renal insufficiency, which may be noted in an elevated serum creatinine level. Thrombocytopenia (low platelet count) is another possible side effect. This platelet count is elevated. An elevated white blood count indicates infection. Although ibuprofen is cleared primarily by the kidneys, it is also important to assess liver function, which would show elevated liver enzymes, not low values such as shown here.
DIF: Cognitive Level: Analyze/Analysis REF: p. 71
OBJ:Identify nonpharmacological and pharmacological strategies to promote comfort and reduce anxiety.TOP:Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity
12.The nurse is assessing pain levels in a critically ill patient using the Behavioral Pain Scale. The nurse recognizes __________ as indicating the greatest level of pain.
| a. |
brow lowering |
| b. |
eyelid closing |
| c. |
grimacing |
| d. |
relaxed facial expression |
ANS: C
The Behavioral Pain Scale issues the most points, indicating the greatest amount of pain, to assessment of facial grimacing.
DIF: Cognitive Level: Understand/Comprehension REF: p. 58 | Table 5-3
OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
13.The nurse wishes to assess the quality of a patient’s pain. Which of the following questions is appropriate to obtain this assessment if the patient is able to give a verbal response?
| a. |
“Is the pain constant or intermittent?” |
| b. |
“Is the pain sharp, dull, or crushing?” |
| c. |
“What makes the pain better? Worse?” |
| d. |
“When did the pain start?” |
ANS: B
If the patient can describe the pain, the nurse can assess quality, such as sharp, dull, or crushing. The other responses relate to continuous or intermittent presence, what provides relief, and duration.
DIF: Cognitive Level: Understand/Comprehension REF: p. 56
OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
14.The nurse is assessing the patient’s pain using the Critical Care Pain Observation Tool. Which of the following assessments would indicate the greatest likelihood of pain and need for nursing intervention?
| a. |
Absence of vocal sounds |
| b. |
Fighting the ventilator |
| c. |
Moving legs in bed |
| d. |
Relaxed muscles in upper extremities |
ANS: B
Fighting the ventilator is rated with the greatest number of points for compliance with the ventilator, and could indicate pain or anxiety. Absence of vocal sounds (e.g., no crying) and relaxed muscles do not indicate pain and are not given a point value. The patient may be moving the legs as a method of range of motion, not necessarily in response to pain. The patient needs to be assessed for restlessness if the movement is excessive.
DIF: Cognitive Level: Apply/Application REF: p. 59 | Table 5-4
OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
15.The nurse is caring for four patients on the progressive care unit. Which patient is at greatest risk for developing delirium?
| a. |
36-year-old recovering from a motor vehicle crash; being treated with an evidence-based alcohol withdrawal protocol. |
| b. |
54-year-old postoperative aortic aneurysm resection with a 40 pack-year history of smoking |
| c. |
86-year-old from nursing home with dementia, postoperative from colon resection, still being mechanically ventilated |
| d. |
95-year-old with community-acquired pneumonia; family has brought in eyeglasses and hearing aid |
ANS: C
From this list, the 86-year-old postoperative nursing home resident is at greatest risk due to advanced age, cognitive impairment, and some degree of respiratory failure. The 96-year-old has been provided eyeglasses and a hearing aid, which will decrease the risk of delirium. Smoking is a possible risk for delirium. The 36-year-old is receiving medications as part of an alcohol withdrawal protocol, which should decrease the risk for delirium.
DIF: Cognitive Level: Analyze/Analysis REF: p. 61 | Table 5-8
OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
16.The nurse is caring for a patient with hyperactive delirium. The nurse focuses interventions toward keeping the patient:
| a. |
comfortable. |
| b. |
nourished. |
| c. |
safe. |
| d. |
sedated. |
ANS: C
The greatest priority in managing delirium is to keep the patient safe. Sedation may contribute to the development of delirium. Comfort and nutrition are important, but they are not priorities.
DIF: Cognitive Level: Understand/Comprehension REF: p. 61
OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce anxiety, and prevent delirium. TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment
17.The nurse is caring for a critically ill trauma patient who is expected to be hospitalized for an extended period. Which of the following nursing interventions would improve the patient’s well-being and reduce anxiety the most?
| a. |
Arrange for the patient’s dog to be brought into the unit (per protocol). |
| b. |
Provide aromatherapy with scents such as lavender that are known to help anxiety. |
| c. |
Secure the harpist to come and play soothing music for an hour every afternoon. |
| d. |
Wheel the patient out near the unit aquarium to observe the tropical fish. |
ANS: A
Nonpharmacological approaches are helpful in reducing stress and anxiety, and each of these activities has the potential for improving the patient’s well-being. The patient is likely to benefit most from the presence of his or her own dog rather than the other activities, however; if unit protocol does not allow the patient’s own dog, the nurse should investigate the use of therapy animals or the other options.
DIF: Cognitive Level: Apply/Application REF: p. 64
OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce anxiety, and prevent delirium. TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Psychological Integrity
18.The nurse recognizes that which patient is likely to benefit most from patient-controlled analgesia (PCA)?
| a. |
Patient with a C4 fracture and quadriplegia |
| b. |
Patient with a femur fracture and closed head injury |
| c. |
Postoperative patient who had elective bariatric surgery |
| d. |
Postoperative cardiac surgery patient with mild dementia |
ANS: C
The patient undergoing bariatric surgery (an elective procedure) is the best candidate for PCA as this patient should be awake, cognitively intact, and will have the acute pain related to the surgical procedure. The quadriplegic would be unable to operate the PCA pump. The cardiac surgery patient with mild dementia may not understand how to operate the pump. Likewise, the patient with the closed head injury may not be cognitively intact.
DIF: Cognitive Level: Analyze/Analysis REF: p. 71 | Box 5-6
OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce anxiety, and prevent delirium. TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity
19.The nurse is caring for a patient receiving a benzodiazepine intermittently. The nurse understands that the best way to administer such drugs is to:
| a. |
administer around the clock, rather than as needed, to ensure constant sedation. |
| b. |
administer the medications through the feeding tube to prevent complications. |
| c. |
give the highest allowable dose for the greatest effect. |
| d. |
titrate to a predefined endpoint using a standard sedation scale. |
ANS: D
The best approach for administering benzodiazepines (and all sedatives) is to administer and titrate to a desired endpoint using a standard sedation scale. Administering around the clock as well as giving the highest allowable dose without basing it on an assessment target may result in excessive sedation. For greatest effect, most benzodiazepines are given intravenously.
DIF: Cognitive Level: Apply/Application REF: p. 72
OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce anxiety, and prevent delirium. TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity
20.The nurse is concerned about the risk of alcohol withdrawal syndrome in a postoperative patient. Which statement by the nurse indicates understanding of management of this patient?
| a. |
“Alcohol withdrawal is common; we see it all of the time in the trauma unit.” |
| b. |
“There is no way to assess for alcohol withdrawal.” |
| c. |
“This patient will require less pain medication.” |
| d. |
“We have initiated the alcohol withdrawal protocol.” |
ANS: D
The most important treatment of alcohol withdrawal syndrome is prevention. Many units have protocols that are initiated early to prevent the syndrome. Alcohol withdrawal syndrome is common; however, this statement does not indicate knowledge of management. The patient experiencing alcohol withdrawal may exhibit a variety of symptoms, such as disorientation, agitation, and tachycardia. Patients with substance abuse require increased dosages of pain medications.
DIF: Cognitive Level: Understand/Comprehension REF: p. 74
OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce anxiety, and prevent delirium. TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity
MULTIPLE RESPONSE
1.Nonpharmacological approaches to pain and/or anxiety that may best meet the needs of critically ill patients include: (Select all that apply.)
| a. |
anaerobic exercise. |
| b. |
art therapy. |
| c. |
guided imagery. |
| d. |
music therapy. |
| e. |
animal therapy. |
ANS: C, D, E
Guided imagery is a powerful technique for controlling pain and anxiety, especially that associated with painful procedures. Similar to guided imagery, a music therapy program offers patients a diversionary technique for pain and anxiety relief. Likewise animal therapy has many benefits for the critically ill patient. Anaerobic exercise is not a nonpharmacological approach for managing pain and anxiety. Most critically ill patients are not able to participate in art therapy.
DIF: Cognitive Level: Remember/Knowledge REF: pp. 62-64
OBJ:Identify nonpharmacological and pharmacological strategies to promote comfort and reduce anxiety.TOP:Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
2.Which of the following statements regarding pain and anxiety are true? (Select all that apply.)
| a. |
Anxiety is a state marked by apprehension, agitation, autonomic arousal, and/or fearful withdrawal. |
| b. |
Critically ill patients often experience anxiety, but they rarely experience pain. |
| c. |
Pain and anxiety are often interrelated and may be difficult to differentiate because their physiological and behavioral manifestations are similar. |
| d. |
Pain is defined by each patient; it is whatever the person experiencing the pain says it is. |
| e. |
While anxiety is unpleasant, it does not contribute to mortality or morbidity of the critically ill patient. |
ANS: A, C, D
Pain is defined by each patient, anxiety is associated with marked apprehension, and pain and anxiety are often interrelated. Critically ill patients commonly have both pain and anxiety. Anxiety does increase both morbidity and mortality in critically ill patients, especially those with cardiovascular disease.
DIF: Cognitive Level: Understand/Comprehension REF: p. 53
OBJ: Define pain and anxiety. TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity
3.Which of the following factors predispose the critically ill patient to pain and anxiety? (Select all that apply.)
| a. |
Inability to communicate |
| b. |
Invasive procedures |
| c. |
Monitoring devices |
| d. |
Nursing care |
| e. |
Preexisting conditions |
ANS: A, B, C, D, E
All of these factors predispose the patient to pain or anxiety.
DIF: Cognitive Level: Remember/Knowledge REF: pp. 53-54
OBJ: Identify factors that place the critically ill patient at risk for developing pain and anxiety.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
4.Choose the items that are common to both pain and anxiety. (Select all that apply.)
| a. |
Cyclical exacerbation of one another |
| b. |
Require good nursing assessment for proper treatment |
| c. |
Response only to real phenomena |
| d. |
Subjective in nature |
| e. |
Perception may be influenced by prior experience |
ANS: A, B, D, E
Both pain and anxiety are subjective in nature. One can exacerbate the other in a vicious cycle that often requires good nursing assessment to manage the precipitating problem and break the cycle. Anxiety is a response to a real or perceived fear. Pain is a response to real or “phantom” phenomenon but always involves transmission of nerve impulses. Both relate to the patient’s perceptions of pain and fear. Previous experiences of both pain and/or anxiety can influence the patient’s perception of both. Anxiety is a response to real or perceived fear, and pain is a response to a real or “phantom” phenomenon.
DIF: Cognitive Level: Understand/Comprehension REF: pp. 53-54
OBJ: Identify factors that place the critically ill patient at risk for developing pain and anxiety.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
5.Anxiety differs from pain in that: (Select all that apply.)
| a. |
it is confined to neurological processes in the brain. |
| b. |
it is linked to reward and punishment centers in the limbic system. |
| c. |
it is subjective. |
| d. |
there is no actual tissue injury. |
| e. |
it can be increased by noise and light. |
ANS: A, B, D, E
Unlike pain, anxiety is linked to the reward and punishment centers in the limbic system of the brain. It is totally neurological and does not involve tissue injury. Like pain, it is a subjective phenomenon. Noise, light, and other stimuli can increase the intensity of anxiety. Both anxiety and pain are subjective in nature.
DIF: Cognitive Level: Understand/Comprehension REF: pp. 53-55
OBJ:Discuss the physiology of pain and anxiety.
TOP: Nursing Process Step: Assessment
6.Factors in the critical care unit that may predispose the client to increased pain and anxiety include: (Select all that apply.)
| a. |
an endotracheal tube. |
| b. |
frequent vital signs. |
| c. |
monitor alarms. |
| d. |
room temperature. |
| e. |
hostile environment. |
ANS: A, B, C, D, E
Anxiety is likely to result from loss of control, the inability to communicate, continuous noise and lighting, excessive stimulation (including repeated vital sign measurements), lack of mobility, and uncomfortable room temperatures. Increased anxiety levels often lead to increased pain perception. Environments that are perceived as hostile also contribute.
DIF: Cognitive Level: Understand/Comprehension REF: pp. 53-54
OBJ: Identify factors that place the critically ill patient at risk for developing pain and anxiety.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
7.In the healthy individual, pain and anxiety: (Select all that apply.)
| a. |
activate the sympathetic nervous system (SNS). |
| b. |
decrease stress levels. |
| c. |
help remove one from harm. |
| d. |
increase performance levels. |
| e. |
limit sympathetic nervous system activity. |
ANS: A, C, D
In the healthy person, pain and anxiety are adaptive mechanisms used to increase performance levels or to remove one from potential harm. The “fight or flight” response occurs in response to pain and/or anxiety and involves the activation of the sympathetic nervous system. Pain and anxiety, however, can induce significant stress. The SNS is activated, not limited, by pain and/or anxiety.
DIF: Cognitive Level: Remember/Knowledge REF: p. 55
OBJ: Describe the positive and negative effects of pain and anxiety in critically ill patients.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
8.The nurse is caring for a patient who is intubated and on a ventilator following extensive abdominal surgery. Although the patient is responsive, the nurse is not able to read the patient’s lips as the patient attempts to mouth the words. Which of the following assessment tools would be the most appropriate for the nurse to use when assessing the patient’s pain level? (Select all that apply.)
| a. |
The FACES scale |
| b. |
Pain Intensity Scale |
| c. |
The PQRST method |
| d. |
The Visual Analogue Scale |
| e. |
The CAM tool |
ANS: A, D |
