| Content | Test Bank for Essentials for Nursing Practice 9th Edition Potter
Chapter 01: Professional Nursing
Potter: Essentials for Nursing Practice, 9th Edition
MULTIPLE CHOICE
1. Which action by the nurse demonstrates implementation of Florence Nightingale’s original
theories about nursing care?
a. The patient is gently bathed and given fresh linens after giving birth.
b. The nurse forms a close therapeutic relationship with the patient.
c. The nurse helps the patient conserve energy for healing processes.
d. The nurse views the patient as a unique, ever-changing energy field.
ANS: A
Florence Nightingale worked to improve sanitation and healing environments for patients.
Gently bathing and providing fresh linens to patients is an example of Nightingale’s theory in
practice. Formation of a close therapeutic relationship with the patient, energy conservation,
and viewing patients as energy fields were not concepts included in Nightingale’s theory of
nursing practice.
DIF: Cognitive Level: Apply (Application)
OBJ: Discuss the influence of social, political, and economic changes on nursing practices.
TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort
2. The nurse is mandated by the state to complete 25 contact hours of nursing education before
the nursing license may be renewed. Which term best describes this requirement?
a. In-service education
b. Advanced education
c. Continuing education
d. Certification education
ANS: C
Continuing education is required for professionals in many states. Continuing education
involves formal, organized educational programs offered by universities, hospitals, state
nurses’ associations, professional nursing organizations, and educational and health care
institutions. In-service education programs are instruction or training provided by a health
care agency or institution designed to increase the knowledge, skills, and competencies of
nurses and other health care professionals employed by the institution. Some roles for RNs in
nursing require advanced graduate degrees, such as a clinical nurse specialist or nurse
practitioner.
DIF: Cognitive Level: Apply (Application)
OBJ: Discuss the importance of education in professional nursing practice.
TOP: Nursing Process: Communication and Documentation
MSC: NCLEX: Management of Care
3. The nurse is caring for a patient who suddenly becomes acutely short of breath. The nurse
elevates the head of the patient’s bed, checks the patient’s pulse oximetry, and administers 2 L
of oxygen before notifying the patient’s physician. Which term best describes the actions of
the nurse?
a. Accountability
Essentials for Nursing Practice 9th Edition Potter Test BankNU
b. Autonomy
c. Licensure
d. Certification
ANS: B
Autonomy is essential to professional nursing and involves the initiation of independent
nursing interventions without medical orders. Accountability means that you are
professionally and legally responsible for the type and quality of nursing care provided. To
obtain licensure in the United States, RN candidates must pass the NCLEX-RN® examination
administered by the individual State Boards of Nursing to obtain a nursing license. Beyond
the NCLEX-RN®, some nurses choose to work toward certification in a specific area of
nursing practice.
DIF: Cognitive Level: Apply (Application)
OBJ: Discuss the characteristics of professionalism in nursing.
TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care
4. Which type of program is appropriate to educate staff about new fall prevention protocols that
are to be implemented on the nursing unit?
a. In-service education
b. Advanced education
c. Continuing education
d. Certification education
ANS: A
In-service education programs are instruction or training provided by a health care agency or
institution designed to increase the knowledge, skills, and competencies of nurses and other
health care professionals employed by the institution. Some roles for RNs in nursing require
advanced graduate degrees, such as a clinical nurse specialist or nurse practitioner. Continuing
education is required for professionals in many states. Continuing education involves formal,
organized educational programs offered by universities, hospitals, state nurses’ associations,
professional nursing organizations, and educational and health care institutions.
DIF: Cognitive Level: Apply (Application)
OBJ: Discuss the importance of education in professional nursing practice.
TOP: Nursing Process: Teaching and Learning
MSC: NCLEX: Management of Care
5. Which program is appropriate for a nurse who wishes to become an expert in ostomy and
wound care?
a. Specialty certification
b. Master of Science program
c. Doctoral degree program
d. Continuing education program
ANS: A
Essentials for Nursing Practice 9th Edition Potter Test BankNU
Specialty certification programs are appropriate for nurses who wish to become experts in
certain areas of nursing care such as perioperative care, wound care, or occupational health.
Master of Science programs prepare nurses for advanced practice roles as educators,
administrators, or clinical nurse leaders. Doctoral programs prepare nurses for advanced
clinical practice and research. Continuing education is required for professionals in many
states. Continuing education involves formal, organized educational programs offered by
universities, hospitals, state nurses’ associations, professional nursing organizations, and
educational and health care institutions.
DIF: Cognitive Level: Apply (Application)
OBJ: Describe the roles and career opportunities for nurses.
TOP: Nursing Process: Teaching and Learning
MSC: NCLEX: Management of Care |
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 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 | Chapter 1. The Concept of Stress Adaptation
Multiple Choice
- A client has experienced the death of a close family member and at the same time becomes unemployed. This situation has resulted in a 6-month score of 110 on the Recent Life Changes Questionnaire. How should the nurse evaluate this client data?
- The client is experiencing severe distress and is at risk for physical and psychological illness.
- A score of 110 on the Miller and Rahe Recent Life Changes Questionnaire indicates no significant threat of stress-related illness.
- Susceptibility to stress-related physical or psychological illness cannot be estimated without knowledge of coping resources and available supports.
- The client may view these losses as challenges and perceive them as opportunities.
ANS: C
The Recent Life Changes Questionnaire is an expanded version of the Schedule of Recent Experiences and the Rahe-Holmes Social Readjustment Rating Scale. A 6-month score of 300 or more, or a year-score total of 500 or more, indicates high stress in a client’s life. However, positive coping mechanisms and strong social support can limit susceptibility to stress-related illnesses.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity
- A physically and emotionally healthy client has just been fired. During a routine office visit he states to a nurse: “Perhaps this was the best thing to happen. Maybe I’ll look into pursuing an art degree.” How should the nurse characterize the client’s appraisal of the job loss stressor?
- Irrelevant
- Harm/loss
- Threatening
- Challenging
ANS: D
The client perceives the situation of job loss as a challenge and an opportunity for growth.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity
- Which client statement should alert a nurse that a client may be responding maladaptively to stress?
- “I’ve found that avoiding contact with others helps me cope.”
- “I really enjoy journaling; it’s my private time.”
- “I signed up for a yoga class this week.”
- “I made an appointment to meet with a therapist.”
ANS: A
Reliance on social isolation as a coping mechanism is a maladaptive method to relieve stress. It can prevent learning appropriate coping skills and can prevent access to needed support systems.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity
- A nursing student finds that she comes down with a sinus infection toward the end of every semester. When this occurs, which stage of stress is the student most likely experiencing?
- Alarm reaction stage
- Stage of resistance
- Stage of exhaustion
- Fight-or-flight stage
ANS: C
At the stage of exhaustion, the student’s exposure to stress has been prolonged and adaptive energy has been depleted. Diseases of adaptation occur more frequently in this stage.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity
- A school nurse is assessing a female high school student who is overly concerned about her appearance. The client’s mother states, “That’s not something to be stressed about!” Which is the most appropriate nursing response?
- “Teenagers! They don’t know a thing about real stress.”
- “Stress occurs only when there is a loss.”
- “When you are in poor physical condition, you can’t experience psychological well-being.”
- “Stress can be psychological. A threat to self-esteem may result in high stress levels.”
ANS: D
Stress can be physical or psychological in nature. A perceived threat to self-esteem can be as stressful as a physiological change.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity
- A bright student confides in the school nurse about conflicts related to attending college or working to add needed financial support to the family. Which coping strategy is most appropriate for the nurse to recommend to the student at this time?
- Meditation
- Problem-solving training
- Relaxation
- Journaling
ANS: B
The student must assess his or her situation and determine the best course of action. Problem-solving training, by providing structure and objectivity, can assist in decision making.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity
- An unemployed college graduate is experiencing severe anxiety over not finding a teaching position and has difficulty with independent problem-solving. During a routine physical examination, the graduate confides in the clinic nurse. Which is the most appropriate nursing intervention?
- Encourage the student to use the alternative coping mechanism of relaxation exercises.
- Complete the problem-solving process for the client.
- Work through the problem-solving process with the client.
- Encourage the client to keep a journal.
ANS: C
During times of high anxiety and stress, clients will need more assistance in problem-solving and decision making.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity
- A school nurse is assessing a distraught female high school student who is overly concerned because her parents can’t afford horseback riding lessons. How should the nurse interpret the student’s reaction to her perceived problem?
- The problem is endangering her well-being.
- The problem is personally relevant to her.
- The problem is based on immaturity.
- The problem is exceeding her capacity to cope.
ANS: B
Psychological stressors to self-esteem and self-image are related to how the individual perceives the situation or event. Self-image is of particular importance to adolescents, who feel entitled to have all the advantages that other adolescents experience.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity
- Meditation has been shown to be an effective stress management technique. When meditation is effective, what should a nurse expect to assess?
- An achieved state of relaxation
- An achieved insight into one’s feelings
- A demonstration of appropriate role behaviors
- An enhanced ability to problem-solve
ANS: A
Meditation produces relaxation by creating a special state of consciousness through focused concentration.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity
- A distraught, single, first-time mother cries and asks a nurse, “How can I go to work if I can’t afford childcare?” What is the nurse’s initial action in assisting the client with the problem-solving process?
- Determine the risks and benefits for each alternative.
- Formulate goals for resolution of the problem.
- Evaluate the outcome of the implemented alternative.
- Assess the facts of the situation.
ANS: D
Before any other steps can be taken, accurate information about the situation must be gathered and assessed.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity | Old’s Maternal-Newborn Nursing and Women’s Health, 11e (Davidson/London/Ladewig)
Chapter 1 Contemporary Maternal-Newborn Nursing
- The nurse is speaking to students about changes in maternal-newborn care. One change is that self-care has gained wide acceptance with clients and the healthcare community due to research findings that suggest that it has which effect?
- Shortens newborn length of stay
- Decreases use of home health agencies
- Decreases healthcare costs
- Decreases the number of emergency department visits
Answer:C
Explanation:
- Length of stay is often determined by third-party payer (insurance company) policies as well as the physiologic stability of the mother and newborn. Home healthcare agencies often are involved in client care to decrease hospital stay time.
- Home healthcare agencies often are involved in client care to decrease hospital stay time.
- Research indicates that self-care significantly decreases healthcare costs.
- Acute emergencies are addressed by emergency departments, and are not delayed by those practicing self-care.
Page Ref: 3
Cognitive Level:Understanding
Client Need/Sub:Health Promotion and Maintenance: Self-Care
Standards: QSEN Competencies: Ⅰ.A.2. Describe strategies to empower patients or families in all aspects of the healthcare process. | AACN Essentials Competencies: Ⅸ.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Health care economic policy; reimbursement structures; accreditation standards; staffing models and productivity; supply chain models | Nursing/Integrated Concepts: Nursing Process: Planning.
Learning Outcome:1 Discuss the impact of the self-care movement on contemporary childbirth.
MNL LO:Recognize contemporary issues related to care of the childbearing family.
- Care delivered by nurse-midwives can be safe and effective and can represent a positive response to the healthcare provider shortage. Nurse-midwives tend to use less technology, which often results in which of the following?
- There is less trauma to the mother.
- More childbirth education classes are available.
- They are instrumental in providing change in the birth environment at work.
- They advocate for more home healthcare agencies.
Answer:A
Explanation:
- Nurse-midwife models of care can be one way to ensure that mothers receive excellent prenatal and intrapartum care.
- It is appropriate for nurse-midwives, in conjunction with doctors and hospitals, to provide childbirth classes for expectant families.
- By working with other staff members and doctors, the nurse-midwife is able to implement changes as needed within the birthing unit.
- Clients are increasingly going home sooner, so there needs to be more follow-up in the home.
Page Ref: 3
Cognitive Level:Understanding
Client Need/Sub:Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: Ⅲ.A.6. Describe how the strength and relevance of available evidence influences the choice of interventions in provision of patient-centered care. | AACN Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning.
Learning Outcome:2 Compare the nursing roles available to the maternal-newborn nurse.
MNL LO:Recognize contemporary issues related to care of the childbearing family.
- The nurse is telling a new client how advanced technology has permitted the physician to do which of the following?
- Treat the fetus and monitor fetal development.
- Deliver at home with a nurse-midwife and doula.
- Have the father act as the coach and cut the umbilical cord.
- Breastfeed a new baby on the delivery table.
Answer:A
Explanation:
- The fetus is increasingly viewed as a patient separate from the mother, although treatment of the fetus necessarily involves the mother.
- A nurse-midwife and a doula are not examples of technological care.
- Fathers being present during labor and coaching their partners represents nontechnological care during childbirth.
- Breastfeeding is not an example of technology impacting care.
Page Ref: 2—3
Cognitive Level:Understanding
Client Need/Sub:Safe and Effective Care Environment: Management of Care
Standards:QSEN Competencies: Ⅰ.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Teamwork: Scope of practice, roles, and responsibilities of health care team members, including overlaps. | Nursing/Integrated Concepts: Nursing Process: Implementation.
Learning Outcome:6 Evaluate the potential impact of some of the special situations in contemporary maternity care.
MNL LO:Recognize contemporary issues related to care of the childbearing family.
- A nurse is examining different nursing roles. Which example best illustrates an advanced practice nursing role?
- A registered nurse who is the manager of a large obstetrical unit
- A registered nurse who is the circulating nurse during surgical deliveries (cesarean sections)
- A clinical nurse specialist working as a staff nurse on a mother-baby unit
- A clinical nurse specialist with whom other nurses consult for her expertise in caring for high-risk infants
Answer:D
Explanation:
- A registered nurse who is the manager of a large obstetrical unit is a professional nurse who has graduated from an accredited program in nursing and completed the licensure examination.
- A registered nurse who is a circulating nurse at surgical deliveries (cesarean sections) is a professional nurse who has graduated from an accredited program in nursing and completed the licensure examination.
- A clinical nurse specialist working as a staff nurse on a mother-baby unit might have the qualifications for an advanced practice nursing staff member but is not working in that capacity.
- A clinical nurse specialist with whom other nurses consult for expertise in caring for high-risk infants is working in an advanced practice nursing role. This nurse has specialized knowledge and competence in a specific clinical area, and is master’s prepared.
Page Ref: 5
Cognitive Level:Understanding
Client Need/Sub:Safe and Effective Care Environment: Management of Care
Standards:QSEN Competencies: Ⅱ.A.2. Describe scopes of practice and roles of healthcare team members. | AACN Essentials Competencies: Ⅵ. 6. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Teamwork: Scope of practice, roles, and responsibilities of health care team members, including overlaps. | Nursing/Integrated Concepts: Nursing Process: Assessment.
Learning Outcome:2 Compare the nursing roles available to the maternal-newborn nurse.
MNL LO:Recognize contemporary issues related to care of the childbearing family.
| Test Bank for Maternal Child Nursing Care 6th Edition Perry
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Chapter 01: 21st Century Maternity Nursing
Perry: Maternal Child Nursing Care, 6th Edition
MULTIPLE CHOICE
1. When providing care for a pregnant woman, the nurse should be aware that one of the most
frequently reported maternal medical risk factors is:
a. diabetes mellitus.
b. mitral valve prolapse (MVP).
c. chronic hypertension.
d. anemia.
ANS: A
The most frequently reported maternal medical risk factors are diabetes and hypertension
associated with pregnancy. Both of these conditions are associated with maternal obesity.
There are no studies that indicate MVP is among the most frequently reported maternal risk
factors. Hypertension associated with pregnancy, not chronic hypertension, is one of the most
frequently reported maternal medical risk factors. Although anemia is a concern in pregnancy,
it is not one of the most frequently reported maternal medical risk factors in pregnancy.
PTS: 1 DIF: Cognitive Level: Knowledge
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
2. To ensure optimal outcomes for the patient, the contemporary maternity nurse must
incorporate both teamwork and communication with clinicians into her care delivery. The
SBAR technique of communication is an easy-to-remember mechanism for communication.
Which of the following correctly defines this acronym?
a. Situation, baseline assessment, response
b. Situation, background, assessment, recommendation
c. Subjective background, assessment, recommendation
d. Situation, background, anticipated recommendation
ANS: B
The situation, background, assessment, recommendation (SBAR) technique provides a
specific framework for communication among health care providers. Failure to communicate
is one of the major reasons for errors in health care. The SBAR technique has the potential to
serve as a means to reduce errors.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment, Planning
MSC: Client Needs: Safe and Effective Care Environment
3. The role of the professional nurse caring for childbearing families has evolved to emphasize:
a. providing care to patients directly at the bedside.
b. primarily hospital care of maternity patients.
c. practice using an evidence-based approach.
d. planning patient care to cover longer hospital stays.
ANS: C
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Professional nurses are part of the team of health care providers who collaboratively care for
patients throughout the childbearing cycle. Providing care to patients directly at the bedside is
one of the nurse’s tasks; however, it does not encompass the concept of the evolved
professional nurse. Throughout the prenatal period, nurses care for women in clinics and
physician’s offices and teach classes to help families prepare for childbirth. Nurses also care
for childbearing families in birthing centers and in the home. Nurses have been critically
important in developing strategies to improve the well-being of women and their infants and
have led the efforts to implement clinical practice guidelines using an evidence-based
approach. Maternity patients have experienced a decreased, rather than an increased, length of
stay over the past two decades.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
4. A 23-year-old African-American woman is pregnant with her first child. Based on the
statistics for infant mortality, which plan is most important for the nurse to implement?
a. Perform a nutrition assessment.
b. Refer the woman to a social worker.
c. Advise the woman to see an obstetrician, not a midwife.
d. Explain to the woman the importance of keeping her prenatal care appointments.
ANS: D
Consistent prenatal care is the best method of preventing or controlling risk factors associated
with infant mortality. Nutritional status is an important modifiable risk factor, but a nutrition
assessment is not the most important action a nurse should take in this situation. The patient
may need assistance from a social worker at some time during her pregnancy, but a referral to
a social worker is not the most important aspect the nurse should address at this time. If the
woman has identifiable high risk problems, her health care may need to be provided by a
physician. However, it cannot be assumed that all African-American women have high risk
issues. In addition, advising the woman to see an obstetrician is not the most important aspect
on which the nurse should focus at this time, and it is not appropriate for a nurse to advise or
manage the type of care a patient is to receive.
PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
5. During a prenatal intake interview, the nurse is in the process of obtaining an initial
assessment of a 21-year-old Hispanic patient with limited English proficiency. It is important
for the nurse to:
a. use maternity jargon in order for the patient to become familiar with these terms.
b. speak quickly and efficiently to expedite the visit.
c. provide the patient with handouts.
d. assess whether the patient understands the discussion.
ANS: D
Nurses contribute to health literacy by using simple, common words; avoiding jargon; and
evaluating whether the patient understands the discussion. Speaking slowly and clearly and
focusing on what is important increase understanding. Most patient education materials are
written at too high a level for the average adult and may not be useful for a patient with
limited English proficiency.
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PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
6. When managing health care for pregnant women at a prenatal clinic, the nurse should
recognize that the most significant barrier to access to care is the pregnant woman’s:
a. age.
b. minority status.
c. educational level.
d. inability to pay.
ANS: D
The most significant barrier to health care access is the inability to pay for services; this is
compounded by the fact that many physicians refuse to care for women who cannot pay.
Although adolescent pregnant patients statistically receive less prenatal care, age is not the
most significant barrier. Significant disparities in morbidity and mortality rates exist for
minority women; however, minority status is not the most significant barrier to access of care.
Disparities in educational level are associated with morbidity and mortality rates; however,
educational level is not the most significant barrier to access of care.
PTS: 1 DIF: Cognitive Level: Knowledge
OBJ: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment
7. When the nurse is unsure about how to perform a patient care procedure, the best action
would be to:
a. ask another nurse.
b. discuss the procedure with the patient’s physician.
c. look up the procedure in a nursing textbook.
d. consult the agency’s procedure manual and follow the guidelines for the
procedure.
ANS: D
It is always best to follow the agency’s policies and procedures manual when seeking
information on correct patient procedures. These policies should reflect the current standards
of care and state guidelines. Each nurse is responsible for her own practice. Relying on
another nurse may not always be safe practice. Each nurse is obligated to follow the standards
of care for safe patient care delivery. Physicians are responsible for their own patient care
activity. Nurses may follow safe orders from physicians, but they are also responsible for the
activities that they as nurses are to carry out. Information provided in a nursing textbook is
basic information for general knowledge. Furthermore, the information in a textbook may not
reflect the current standard of care or individual state or hospital policies.
PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
8. From the nurse’s perspective, what measure should be the focus of the health care system to
reduce the rate of infant mortality further?
a. Implementing programs to ensure women’s early participation in ongoing prenatal
care.
b. Increasing the length of stay in a hospital after vaginal birth from 2 to 3 days.
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c. Expanding the number of neonatal intensive care units (NICUs).
d. Mandating that all pregnant women receive care from an obstetrician.
ANS: A
Early prenatal care allows for early diagnosis and appropriate interventions to reduce the rate
of infant mortality. An increased length of stay has been shown to foster improved self-care
and parental education. However, it does not prevent the incidence of leading causes of infant
mortality rates, such as low birth weight. Early prevention and diagnosis reduce the rate of
infant mortality. NICUs offer care to high risk infants after they are born. Expanding the
number of NICUs would offer better access for high risk care, but this factor is not the
primary focus for further reduction of infant mortality rates. A mandate that all pregnant
women receive obstetric care would be nearly impossible to enforce. Furthermore, certified
nurse-midwives (CNMs) have demonstrated reliable, safe care for pregnant women.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
9. Alternative and complementary therapies:
a. replace conventional Western modalities of treatment.
b. are used by only a small number of American adults.
c. recognize the value of patients’ input into their health care.
d. focus primarily on the disease an individual is experiencing.
ANS: C
Many popular alternative healing modalities offer human-centered care based on philosophies
that recognize the value of the patient’s input and honor the individual’s beliefs, values, and
desires. Alternative and complementary therapies are part of an integrative approach to health
care. An increasing number of American adults are seeking alternative and complementary
health care options. Alternative healing modalities offer a holistic approach to health, focusing
on the whole person, not just the disease.
PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
10. A 38-year-old Hispanic woman delivered a 9-pound, 6-ounce girl vaginally after being in
labor for 43 hours. The baby died 3 days later from sepsis. On what grounds would the
woman potentially have a legitimate legal case for negligence?
a. She is Hispanic.
b. She delivered a girl.
c. The standards of care were not met.
d. She refused fetal monitoring.
ANS: C
Not meeting the standards of care is a legitimate factor for a case of negligence. The patient’s
race is not a factor for a case of negligence. The infant’s gender is not a factor for a case of
negligence. Although fetal monitoring is the standard of care, the patient has the right to
refuse treatment. This refusal is not a case for negligence; however, informed consent should
be properly obtained, and the patient should sign an against medical advice form for refusal of
any treatment that is within the standard of care.
PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Planning
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MSC: Client Needs: Health Promotion and Maintenance
11. A newly graduated nurse is attempting to understand the reason for increasing health care
spending in the United States. Her research finds that these costs are much higher compared
with other developed countries as a result of:
a. a higher rate of obesity among pregnant women.
b. limited access to technology.
c. increased usage of health care services along with lower prices.
d. homogeneity of the population.
ANS: A
Health care is one of the fastest growing sectors of the U.S. economy. Currently, 17.5% of the
gross domestic product is spent on health care. Higher spending in the United States compared
with 12 other industrialized countries is related to higher prices and readily accessible
technology along with greater obesity rates among women. More than one third of women in
the United States are obese. Of the U.S. population, 16% is uninsured and has limited access
to health care. Maternal morbidity and mortality are directly related to racial disparities.
PTS: 1 DIF: Cognitive Level: Analysis OBJ: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
12. The term used to describe legal and professional responsibility for practice for maternity
nurses is:
a. collegiality.
b. ethics.
c. evaluation.
d. accountability.
ANS: D
Accountability refers to legal and professional responsibility for practice. Collegiality refers to
a working relationship with one’s colleagues. Ethics refers to a code to guide practice.
Evaluation refers to examination of the effectiveness of interventions in relation to expected
outcomes.
PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
13. Through the use of social media technology, nurses can link with other nurses who may share
similar interests, insights about practice, and advocate for patients. The most concerning
pitfall for nurses using this technology is:
a. violation of patient privacy and confidentiality.
b. institutions and colleagues may be cast in an unfavorable light.
c. unintended negative consequences for using social media.
d. lack of institutional policy governing online contact.
ANS: A
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The most significant pitfall for nurses using this technology is the violation of patient privacy
and confidentiality. Furthermore, institutions and colleagues can be cast in unfavorable lights
with negative consequences for those posting information. Nursing students have been
expelled from school and nurses have been fired or reprimanded by their Board of Nursing for
injudicious posts. The American Nurses Association has published six principles for social
networking and nurses. All institutions should have policies guiding the use of social media,
and nurses should be familiar with these guidelines.
PTS: 1 DIF: Cognitive Level: Analysis
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
14. An important development that affects maternity nursing is integrative health care, which:
a. seeks to provide the same health care for all racial and ethnic groups.
b. blends complementary and alternative therapies with conventional Western
treatment.
c. focuses on the disease or condition rather than the background of the patient.
d. has been mandated by Congress.
ANS: B
Integrative health care tries to mix the old with the new at the discretion of the patient and
health care providers. Integrative health care is a blending of new and traditional practices.
Integrative health care focuses on the whole person, not just the disease or condition. U.S. law
supports complementary and alternative therapies but does not mandate them.
PTS: 1 DIF: Cognitive Level: Understanding
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
15. The nurse caring for a pregnant patient should be aware that the U.S. birth rate shows which
trend?
a. Births to unmarried women are more likely to have less favorable outcomes.
b. Birth rates for women 40 to 44 years old are beginning to decline.
c. Cigarette smoking among pregnant women continues to increase.
d. The rates of maternal death owing to racial disparity are elevated in the United
States.
ANS: A
Low-birth-weight infants and preterm birth are more likely because of the large number of
teenagers in the unmarried group. Birth rates for women in their early 40s continue to
increase. Fewer pregnant women smoke. In the United States, there is significant racial
disparity in the rates of maternal death.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment
16. Maternity nursing care that is based on knowledge gained through research and clinical
trials is:
a. derived from the Nursing Intervention Classification.
b. known as evidence-based practice.
c. at odds with the Cochrane School of traditional nursing.
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d. an outgrowth of telemedicine.
ANS: B
Evidence-based practice is based on knowledge gained from research and clinical trials. The
Nursing Intervention Classification is a method of standardizing language and categorizing
care. Dr. Cochrane systematically reviewed research trials and is part of the evidence-based
practice movement. Telemedicine uses communication technologies to support health care.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
17. The level of practice a reasonably prudent nurse provides is called:
a. the standard of care.
b. risk management.
c. a sentinel event.
d. failure to rescue.
ANS: A
Guidelines for standards of care are published by various professional nursing organizations.
Risk management identifies risks and establishes preventive practices, but it does not define
the standard of care. Sentinel events are unexpected negative occurrences. They do not
establish the standard of care. Failure to rescue is an evaluative process for nursing, but it does
not define the standard of care.
PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Diagnosis
MSC: Client Needs: Safe and Effective Care Environment
18. While obtaining a detailed history from a woman who has recently emigrated from Somalia,
the nurse realizes that the patient has undergone female genital mutilation (FGM). The nurse’s
best response to this patient is:
a. “this is a very abnormal practice and rarely seen in the United States.”
b. “do you know who performed this so that it can be reported to the authorities?”
c. “we will be able to restore your circumcision fully after delivery.”
d. “the extent of your circumcision will affect the potential for complications.”
ANS: D
“The extent of your circumcision will affect the potential for complications” is the most
appropriate response. The patient may experience pain, bleeding, scarring, or infection and
may require surgery before childbirth. With the growing number of immigrants from countries
where FGM is practiced, nurses will increasingly encounter women who have undergone the
procedure. Although this practice is not prevalent in the United States, it is very common in
many African and Middle Eastern countries for religious reasons. Responding with, “This is a
very abnormal practice and rarely seen in the United States” is culturally insensitive. The
infibulation may have occurred during infancy or childhood. The patient will have little to no
recollection of the event. She would have considered this to be a normal milestone during her
growth and development. The International Council of Nurses has spoken out against this
procedure as harmful to a woman’s health.
PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
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19. To ensure patient safety, the practicing nurse must have knowledge of the current Joint
Commission’s “Do Not Use” list of abbreviations. Which of the following is acceptable for
use?
a. q.o.d. or Q.O.D.
b. MSO4 or MgSO4
c. International Unit
d. Lack of a leading zero
ANS: C
The abbreviations “i.u.” and “I.U.” are no longer acceptable because they could be misread as
“I.V.” or the number “10.” The abbreviation “q.o.d. or Q.O.D.” should be written out as
“every other day.” The period after the “Q” could be mistaken for an “I”; the “o” could also
be mistaken for an “i.” With MSO4 or MgSO4, it is too easy to confuse one medication for
another. These medications are used for very different purposes and could put a patient at risk
for an adverse outcome. They should be written as morphine sulfate and magnesium sulfate.
The decimal point should never be missed before a number to avoid confusion (i.e., 0.4 rather
than .4).
PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
20. Healthy People 2020 has established national health priorities that focus on a number of
maternal-child health indicators. Nurses are assuming greater roles in assessing family health
and providing care across the perinatal continuum. Therefore, it is important for the nurse to
be aware that significant progress has been made in:
a. the reduction of fetal deaths and use of prenatal care.
b. low birth weight and preterm birth.
c. elimination of health disparities based on race.
d. infant mortality and the prevention of birth defects.
ANS: A
Trends in maternal child health indicate that progress has been made in relation to reduced
infant and fetal deaths and increased prenatal care. Notable gaps remain in the rates of low
birth weight and preterm births. According to the March of Dimes, persistent disparities still
exist between African-Americans and non-Hispanic Caucasians. Many of these negative
outcomes are preventable through access to prenatal care and the use of preventive health
practices. This demonstrates the need for comprehensive community-based care for all
mothers, infants, and families.
PTS: 1 DIF: Cognitive Level: Knowledge
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. Which interventions would help alleviate the problems associated with access to health care
for maternity patients? (Select all that apply.)
a. Provide transportation to prenatal visits.
b. Provide child care so that a pregnant woman may keep prenatal visits.
c. Mandate that physicians make house calls.
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d. Provide low-cost or no-cost health care insurance.
e. Provide job training.
ANS: A, B, D
Lack of transportation to visits, lack of child care, and lack of affordable health insurance are
prohibitive factors associated with lack of prenatal care. House calls are not a cost-effective
approach to health care. Although job training may result in employment and income, the
likelihood of significant changes during the time frame of the pregnancy is remote.
PTS: 1 DIF: Cognitive Level: Implementation OBJ: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
MATCHING
Medical errors are a leading cause of death in the United States. The National Quality Forum
has recommended numerous safe practices that nursing can promote to reduce errors. Match
each safe practice with the correct statement.
a. Ask the patient to “teach back.”
b. Comply with CDC guidelines.
c. Ensure that information is documented in a timely manner.
d. Promote interventions that will reduce patient risk.
e. Reduce exposure to radiation.
1. Hand hygiene
2. Informed consent
3. Culture measurement, feedback, and intervention
4. Pediatric imaging
5. Patient care information
1. ANS: B PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
NOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in
2010, outlining 24 safe practices that should be used in all health care settings to reduce the risk of
harm from the environment of care, processes, and systems. These are only a few of the recommended
practices; however, nurses should be familiar with these guidelines.
2. ANS: A PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
NOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in
2010, outlining 24 safe practices that should be used in all health care settings to reduce the risk of
harm from the environment of care, processes, and systems. These are only a few of the recommended
practices; however, nurses should be familiar with these guidelines.
3. ANS: D PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
NOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in
2010, outlining 24 safe practices that should be used in all health care settings to reduce the risk of
harm from the environment of care, processes, and systems. These are only a few of the recommended
practices; however, nurses should be familiar with these guidelines.
4. ANS: E PTS: 1 DIF: Cognitive Level: Application
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OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
NOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in
2010, outlining 24 safe practices that should be used in all health care settings to reduce the risk of
harm from the environment of care, processes, and systems. These are only a few of the recommended
practices; however, nurses should be familiar with these guidelines.
5. ANS: C PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
NOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in
2010, outlining 24 safe practices that should be used in all health care settings to reduce the risk of
harm from the environment of care, processes, and systems. These are only a few of the recommended
practices; however, nurses should be familiar with these guidelines.
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