Exam 1 Review Questions Flashcards

Question

Which of the following is a traditional definition of nursing by American Nurses Association (ANA)? ## Footnote a) Discussing what nurses would do for themselves if they had the necessary strength, will, or knowledge b) Diagnosing and treating human responses to actual or potential health problems c) Putting the patient in the best condition for nature to act upon him or her d) Helping people to carry out activities contributing to health, recovery, or a peaceful death

Answer 1

b) Diagnosing and treating human responses to actual or potential health problems Rationale: The ANA traditionally defined nursing as “the diagnosis and treatment of human responses to actual or potential health problems.” Florence Nightingale described the role of the nurse as putting “the patient in the best condition for nature to act upon him.” Virginia Henderson envisioned the role of a nurse as helping people (sick or healthy) to carry out the activities that contribute to their health, recovery, or a peaceful death as well as the activities that they would do for themselves if they had the necessary strength, will, or knowledge.

Answer 2

a) “Do you have a video about my disease? I don’t like to read.” Rationale: Experiential readiness refers to past experiences that influence a patient's ability to learn. Emotional readiness refers to the patient's acceptance of an existing illness or the threat of an illness and its influence on the ability to learn. Physical readiness refers to the patient's ability to cope with physical problems and focus attention upon learning.

Answer 3

d) The nurse planning to teach adults age 65 about congestive heart failure (CHF) management Rationale: Eighty percent of people older than 65 years of age have one or more chronic illness and many are limited in their activity. These chronic illnesses may be managed with numerous medications and complicated by periodic acute episodes, making adherence to a regimen difficult. Problems of teenagers, generally, are time limited and specific and require promoting adherence to treatment to return to health. In general, the compliance of children to a regimen depends on the compliance of their parents. Middle-aged adults, in general, have fewer health problems, thus promoting adherence to a regimen.

Answer 4

d) Standards of Professional Performance Rationale: Reviewing and integrating evidence and research findings into practice is included in the Standards of Professional Performance. The ANA Code of Ethics establishes nursing responsibilities and care-maintaining ethical obligations. Nursing’s Standards of Practice describe basic competencies in delivering nursing care using the nursing process. The ANA Social Policy Statement defines nursing’s value and accountability to society.

Answer 5

b) The concept of health wellness-illness continuum Rationale: The concept of a health-illness continuum allows for a greater range in describing a person's health than the definition provided by the WHO. On the health–illness continuum, even people with a chronic illness or disability may attain a high level of wellness if they are successful in meeting their health potential within the limits of their chronic illness or disability. The WHO definition does not allow for any variations in the degrees of wellness and illness. Hood and Leddy discuss wellness as having four components. Risk reduction is a strategy of health promotion.

Answer 6

c) Algorithm Rationale: Algorithms are used in acute situations to determine treatment based on patient information or response to treatment. Nursing care plans utilize the nursing process (assessment, analysis, planning, implementation, and evaluation) to direct nursing care. Care maps along with clinical guidelines, and multidisciplinary action plans (MAPs) facilitate coordination of care and education throughout hospitalization and after discharge. Bundles are set of three to five evidence-based practices used to improve patient outcomes.

Answer 7

a) Patient refusal of a lifesaving blood transfusion related to religious preference, d) Institutional participation in gene chip technology directed at disease prevention, e) Placing a 21-year-old cystic fibrosis patient on the double lung transplant list Rationale: Dilemmas that center on death and dying are prevalent in medical-surgical nursing practice. Allocation of organs to patients with an otherwise poor prognosis is an appropriate ethical issue for an ethics review committee. Advances in genetics and genetic testing provide controversial ethical dilemmas such as gene chip technology. Administering fertilization injections to infertile couples is an accepted medical intervention. The American Nurses Association (ANA) advocates for the placement of restraints “only when no other viable option is available.” The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) have published standards on the use of restraints.

Answer 8

c) Ethics Rationale: Ethics is the formal, systematic study of moral beliefs. Veracity is the obligation to tell the truth and not to lie or deceive others. Fidelity is promise keeping. Morality is the adherence to informal personal values.

Answer 9

c) Critical thinking Rationale: The center of the process of clinical reasoning and clinical judgment is critical thinking. Critical thinking goes beyond basic problem solving into a realm of inquisitive exploration. Critical thinkers validate the information presented to make sure that it is accurate (not just supposition or opinion).

Answer 10

a) Works in the acute care setting, b) Provides nursing care in community health settings, c) Delegates task to other health care personnel, e) Manages care at the point of care, f) Educated at the master’s level in nursing Rationale: The clinical nurse leader (CNL) must have earned a minimal degree in nursing at the master’s level, can work in acute care as well as community-based settings, and provides point-of-care case management. It is within the scope of practice for the CNL to delegate tasks to health care personnel outside of nursing. The CNL is accountable for improving individual care outcomes and processes in a quality, cost-effective manner, therefore reducing the occurrence of fragmented patient care.

Answer 11

c) Assessment Rationale: Analysis of data is included as part of the assessment. Diagnosis is the identification of patient problems. Implementation is the actualization of the plan of care through nursing interventions. Evaluation is the determination of the patient's responses to the nursing interventions and the extent to which the outcomes have been achieved.

Answer 12

Correct Response: b) Individualized nursing practice, e) Using the nursing process, f) Caring Rationale: Teaching pursed-lip breathing to a patient with COPD is individualized based on the patient’s diagnosis. The nurse demonstrates caring by providing education to support desired patient outcomes. The nurse uses the nursing process of assessment and analysis to determine the need to teach the client pursed-lip breathing. The nurse’s actions do not indicate work place environment changes or interdisciplinary collaboration. Evidence-based nursing is not an ANA tenet characteristic of all nursing practice.

Answer 13

d) Improved Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores Rationale: HCAHPS survey measure patients’ satisfaction with the quality of the nursing care they receive, including their satisfaction with their communication with the nurses, the responsiveness of the hospital staff, the quietness of the environment, their pain management, communication about their medications, and their discharge information. Institute for Healthcare Improvement (IHI) is a nonprofit organization whose mission is adapted from the IOM’s six aims for improvement. IHI is not a funding source for hospitals. Accreditation from The Joint Commission has a larger scope outside of pain management measures. QSEN prepares future nurses with the knowledge, skills, and attitudes (KSA) required to continuously improving the quality and safety of the health care system.

Answer 14

a) Instruct the patient to take frequent rest periods., b) Refer patient to seek psychosocial counseling., c) Provide patient education related to multiorgan infections. Rationale: Independent HIV nursing management involves managing the patient's psychosocial and educational needs. Diagnosis of opportunistic infections and medication prescription based on viral load are areas of interdependent concerns in disease management.

Answer 15

d) “Gabapentin or Neurontin can also be used for leg pain associated with diabetes.” Rationale: The therapeutic response for the nurse is to provide education related to the patient’s wife’s question. By providing education the nurse is facilitating informed decision making on part of the patient and his family. Teaching is an independent function of the nurse. It is certainly within the responsibility of the nurse to discuss the method of action of the patient's medications with the wife. This is part of patient teaching and if the husband is aware, it is not a HIPAA violation.

Answer 16

b) Uphold the patient’s wishes, ensuring patient confidentiality Rationale: Information related to the patient’s past medical history is not significant in providing care to the patient in this situation. The Health Insurance Portability and Accountability Act (HIPAA) provides for the maintenance of patient confidentiality. There is no medical reason for the patient’s past medical history to be revealed at this time. The patient has the right to decide when and if her past medical history needs to be shared with her husband. Documentation of all past medical history in the electronic health record is appropriate. Consultation with a nurse not assigned to the patient violates patient confidentiality. The level of experience of the nurse is not pertinent.

Answer 17

a) Decrease health care cost, d) Improve patient outcomes, e) Establish best nursing practices Rationale: EBP are developed from valid and reliable research studies that improve patient outcomes, establish best nursing practice, and decrease health care cost through decreased readmission and shortened lengths of stay. EBP does not validate nursing diagnosis. The health-illness continuum is used to describe a person’s health status; EBP does not delineate the health-illness continuum. Information from EBP may be used to gather information to increase one’s knowledge related to ethical issues; however EBP would be only one aspect in the answering of ethical questions.

Answer 18

a) Input disability Rationale: Reinforcement is an appropriate educational strategy with clients experiencing input disabilities. It is important to allow ample time to learn and to provide reinforcement. Individuals with output disabilities benefit from review of information. Individuals with developmental disabilities benefit from repetition of simple explanations. Individuals with perceptual disabilities benefit from highlighting of significant information for easy reference.

Answer 19

d) Self-monitoring for signs and symptoms of illness Rationale: Common examples of behaviors facilitating health include self-monitoring for signs and symptoms of illness, increased daily activities and exercise, and taking prescribed medications.

Answer 20

b) It is unethical and illegal for me to discuss your mother’s medical information with you. Rationale: Providing a firm response in explaining the need to protect patient information is one strategy to aid the nurse in ethical decision-making. The U.S. Department of Health and Human Services (DHHS) provides for patient confidentiality. Violations of a patient’s confidentiality could result in criminal or civil litigation. While it is unethical/illegal to discuss biopsy results with the daughter, statements by the nurse indicating biopsy results are back but cannot be shared indirectly provide the daughter with confidential information. Encouraging the daughter to ask her mother about the biopsy results indirectly provides the daughter with information that the mother knows the biopsy results.

Answer 21

c) Routine screening and follow-up appointments Rationale: Because Carla is at a risk for developing hypertension, routine screening is important for early detection. Follow-up appointments should be made if she has an initial elevation in blood pressure reading in the physician's office. Lifestyle modifications for clients with newly diagnosed primary hypertension are recommended. If the patient is diagnosed with hypertension, drug therapy can be administered, in addition to providing patient teaching.

Answer 22

a) Autonomy Rationale: It is important to weigh carefully the risk of limiting a person's autonomy and increasing the risk of injury by using restraints against the risk of not using restraints.

Answer 23

b) Implementation Rationale: The implementation phase ends when the teaching strategies have been completed and when the patient's responses to the actions have been recorded. Assessment in the teaching-learning process is directed toward the systematic collection of data about the person's learning needs and readiness to learn, as well as the family's learning needs. Planning has to do with specifying the expected outcomes and assigning priorities to the diagnoses. Evaluation determines how effectively the patient has responded to teaching and to what extent the goals have been achieved.

Answer 24

a) Supporting evidence with facts Rationale: Intellectual skills used in critical thinking include supporting evidence with facts, priority setting with timely decision making, and determination of patient-specific outcomes. Bias is not used to achieve goals.

Answer 25

d) “I will see you next year for my prostate exam.” Rationale: Prostate examinations should be done yearly. PSA levels are assessed every 1–2 years after age 50. Colonoscopy examinations are every 3–5 years

Answer 26

d) The nurse prepares for endotracheal intubation and mechanical ventilation for the patient Rationale: This patient is experiencing respiratory alkalosis related to heatstroke. The pH level is elevated in hyperventilation; the patient’s hyperventilation will “blow off” more CO2, leading to lower pCO2 levels. Decreased pCO2 is caused by hyperventilation. Decreased CO2 levels are seen in renal failure. Renal failure is a sign of heatstroke. With rapid breathing SO2 can be increased with deep or rapid breathing. Acute airway management is indicated to improve tissue oxygenation. Airway support meets the patient’s physiologic need for a clear airway. Spiritual support is a higher level (self-actualization) on Maslow’s hierarchy. Providing IV management for circulatory support is a basic physiologic need; however, airway management is priority.

Answer 27

c) Providing a foundation for evaluation and quality improvement Rationale: Accurate and thorough documentation shows trends and patterns in patient status and provides a foundation for evaluation and quality improvement. In nursing, critical thinking makes judgment based on evidence. The nursing process requires knowledge, skill, and experience and involves purposeful and outcome-directed thinking.

Answer 28

a) The person has the ability to resist relapsing back to unhealthy behavior Rationale: The termination stage of the Transtheoretical Model of Change occurs when a person has the ability to resist relapsing back to unhealthy behavior. Operationalizing a plan of action, constructing a plan to change behavior, and not thinking about making a change are not part of the termination stage

Answer 29

c) The nurse gathers evidenced-based information related to texting and driving and coordinates the education with the school nurse. Rationale: Health education is an independent function of nursing practice and is included in all state nurse practice acts. Teaching, as a function of nursing, is included in all state nurse practice acts. As an independent nursing function a physician order or approval is not required. Health education is a primary responsibility of the nursing profession. Health education by the nurse focuses on: promoting, maintaining, and restoring health; preventing illness; and assisting people to adapt to the residual effects of illness. Prior parental consent is not required for education related to health/safety promotion.

Answer 30

b) Assess patient for dependent edema Rationale: Initial assessments of swollen ankles and feet are symptoms of dependent edema. Hence, the priority assessment method adopted by the nurse should be oriented towards gathering as much relevant information as possible related to edema. Taking the patient's weight, organizing activities to provide frequent rest periods, and assessing oxygen saturation level are also nursing interventions to be used under appropriate circumstances.

Answer 31

d) Nurse practitioner (NP) Rationale: The nurse practitioner (NP) is considered an expanded nursing role. Nurses who function in these roles provide direct care to patients through independent practice, in a practice within a health care agency, or by collaborating with a physician. A CNA, respiratory therapist, and social worker are not examples of an expanded nursing role.

Answer 32

b) Analysis Rationale: Analysis is used to identify patient problems indicated by data. Interpretation is used to determine the significance of data that is gathered. Inference is used by the nurse to draw conclusions. Explanation is the justification of actions or interventions used to address patient problems and to help a patient move toward desired outcomes

Answer 33

b) Maintenance Rationale: A person is in the maintenance stage of the Transtheoretical Model of Change when there is work to prevent relapse and to sustain the gains made from the actions taken. Removing the ashtrays and not keeping the usual after work routine assist the patient to maintain gains made from the smoking cessation program.

Answer 34

d) Participation in disease prevention and health promotion activities Rationale: Nurses work in various settings, such as adhering to facility policies and state nurse practice acts. A nurse participates in disease prevention and health promotion activities for patients, family members, and communities. In the health care delivery system, balancing work with leisure activities is not the function of a nurse. A nurse does not participate in the diagnosis and treatment of a disease. A nurse also does not participate in treatment decisions regarding health restoration.

Answer 35

b) Inform him about the various methods that are available to assist with smoking cessation., c) Ask him to follow a diet that is low in saturated fats and sodium and high in fiber., d) Advise him to begin an exercise regimen based on the approval of the physician. Rationale: Nurses play a vital role in the management of patients with hypertension. The nurse is an educator and provides the essential tools for the patient to manage hypertension to prevent complications. First and foremost, information must be provided to the patient about the importance of lifestyle changes, such as smoking cessation, exercise, diet, stress reduction, and alcohol moderation. Information about the importance and technique of blood pressure monitoring is important but takes place after the nurse informs the patient about lifestyle changes.

Answer 36

d) Informing Rationale: Informing is helpful in health teaching or patient education about relevant aspects of the patient's well-being and self-care. Silence involves periods of no verbal communication among participants for therapeutic reasons. Reflection validates the nurse's understanding of what the patient is saying and signifies empathy, interest, and respect for the patient. Humor promotes insight by bringing repressed material to consciousness, resolving paradoxes, tempering aggression, and revealing new options.

Answer 37

b) “The nurse case manager contacted my insurance company and has arranged for the home health nurse and physical therapist to visit me as soon as I get home.” Rationale: Coordination of care between nurses, other health care personnel, and insurance companies are roles of the nurse case manager. Nurse case managers coordinate patient care from the time of hospital admission to the time of discharge and often following discharge from an acute care setting. Care coordination provided by the nurse care manager is not episodic.

Answer 38

d) Obtain a translator to assist with interpretation during admission assessment Rationale: Translation services should be provided for non-English-speaking patients. Asking the patient’s wife violates the patient’s confidentiality. Physical findings alone are not sufficient; the nurse must understand the patient’s interpretation of the physical findings to provide culturally competent nursing care. Completion of the admission assessment in privacy and documenting the language barrier does not address the need for interpretation of the patient’s history, perception, and description of assessment findings.

Answer 39

d) The Joint Commission Rationale: One of The Joint Commission National Patient Safety Goals (NPSGs) prioritizes the reduction of healthcare-associated infections (HAIs). The NCSBN priorities focus on matters related to the public health, safety, and welfare, including the development of licensing examinations in nursing. IOM emphasis relates to assuring that patient care is safe, effective, patient centered, timely, efficient, and equitable. The Agency for Healthcare Research and Quality (AHRQ) highlights patients’ satisfaction with care.

Answer 40

c) Purchasing a self-monitoring cuff Rationale: Because this patient finds it time consuming to visit the doctor just for a blood pressure reading, as the nurse, you can suggest the use of an automatic cuff at a local pharmacy, or purchasing a self-monitoring cuff. Discussing methods for stress reduction, advising a smoking cessation and administering glycemic control would constitute patient education in managing hypertension.

Answer 41

c) Utilitarian theory Rationale: Utilitarian theory is based on the concept of the greatest good for the greatest number of people. Formalist theory argues that moral standards exist independently of the ends or consequences. Deontological theory argues that moral standards exist independently of the ends or consequences. Adaptation theory is not an ethics theory.

Answer 42

a) Proactiveness Rationale: Alfaro-LeFevre (2009) idntified critical thinkers as individuals with the following characteristics: active thinker, fair-minded, open-minded, persistent, empathic, flexible, good communicators, honest, organized, and proactive, insightful, and independent in thought. By planning ahead for the need for increased security related to the prescription drug drop-off, the nurse is being proactive.

Answer 43

b) Use slow, directed, and deliberate speech Rationale: When teaching persons with a hearing impairment, the nurse should use slow, directed, and deliberate speech. Use of large-print materials, arrangement of materials in a clockwise position would be used for persons with a visual impairment. Demonstrating information and having the person perform a return demonstration would be appropriate for a person with a developmental disability.

Answer 44

a) Increased cost of treatment Rationale: Nonadherence to therapeutic regimens is a significant problem for elderly people, leading to increased morbidity, mortality, and cost of treatment. There is an increasing rate of persons with chronic illness. Elderly people may also have problems that affect adherence to therapeutic regimens, such as the side effects of medications and financial constraints

Answer 45

b) Planning Rationale: Planning encompasses specifying expected outcomes. Assessment is directed toward the systematic collection of data about the person's learning needs and readiness to learn. In the implementation phase, the patient, the family, and the members of the nursing and health care team carry out activities outlined in the teaching plan

Answer 46

a) Instructing the patient to use an electric razor, b) Monitoring the platelet count, c) Instructing the patient to use a soft toothbrush, f) Monitoring for signs of abnormal bleeding Rationale:Utilizing critical thinking skills the nurse knows to implement individualized interventions to reduce the patient’s risk of bleeding. Hence, the nurse must frequently assess platelet counts, monitor for signs of abnormal bleeding, and instruct the patient and family about ways to minimize bleeding, such as using a soft toothbrush and/or an electric razor. Medications, such as aspirin, that may interfere with clotting should be avoided and blood draws and injections should be kept to a minimum.

Answer 47

c) Providing fertility counseling to a young family with a 2-year-old child with cystic fibrosis Rationale: Cystic fibrosis is an autsomal recessive genetic disorder. Parents of a child diagnosed with cystic fibrosis have a 50% chance of having another child with cystic fibrosis. Once the nurse assesses the family history it is appropriate nursing action to for the nurse to make a referral for genetic testing or counseling. Although ADHD may have a genetic component, there is no genetic-related issue in this situation. Lead poisoning is not a genetic disorder. There is no indication that any of the children in the blended family have a genetic-related problem.

Answer 48

b) Evidence-based practice Rationale: Evidence-based practices are derived from valid and reliable research studies, which also take into account the health care setting, patient preferences and values, and clinical judgment. Knowledge, skills, and attitude are key elements in the Quality and Safety Education for Nurses (QSEN). IOM reports assure that quality benchmarks are established. Core measures gauge how well hospitals provide patient care requiring a specific treatment.

Answer 49

c) Increase in the culturally diverse population Rationale: The population has become more culturally diverse as increasing numbers of people from different national backgrounds enter the country. The number of homeless people has significantly increased. There is a decrease in birth rates and an increase in life span.

Answer 50

b) The patient who wishes to stop smoking agrees to cut back on one cigarette a day for the first week of treatment and then decrease smoking by two cigarettes the following week of treatment. Rationale: A well-designed learning contract is realistic and positive. In a typical learning contract, a series of measurable goals is established, beginning with small, easily attainable objectives and progressing to more advanced goals. By reducing a specific amount of cigarettes each week the patient is more likely to meet the smaller attainable goals and remain motivated to stop smoking. Smaller measurable goals related to the reduction of alcohol intake are more realistic. Learning contracts need to be more specific and incremental. A better statement would be to lose 2 pounds the first week and gradually increase weight loss plans over time. The patient wishing to begin an exercise program would benefit from and more likely to remain motivated by smaller goals of walking for 20 minutes three times per week for the first week and gradually increasing exercise intensity, duration, and frequency.

Answer 51

a) Individual cultural assessment Rationale: BMI assessment is an appropriate assessment for this client but does not address specific lifestyle changes. A physical assessment is appropriate for this patient; however, the information gathered does not focus on education directed at a change in lifestyle. Because people with different cultural backgrounds have different values and lifestyles, choices about health care vary. Before beginning health teaching, nurses must conduct an individual cultural assessment instead of relying only on generalized assumptions about a particular culture. A patient’s social and cultural patterns must be appropriately incorporated into the teaching-learning interaction The Braden scale is used to assess risk factors related to skin breakdown.

Answer 52

b) The nurse continues to collect information from Sara’s mother knowing the informant will not always be the patient. Explanation: The informant, or the person providing the health history, may not always be the patient. The nurse assesses the reliability of the mother and the usefulness of the information provided. It is within the scope of the nurse to collect the health history.

Answer 53

d) Percussion Explanation: Percussion translates the application of physical force into sound. Palpation refers to examination by nonforceful touching. Auscultation refers to the skill of listening to sounds produced within the body created by movement of air or fluid. Manipulation refers to the use of the hands to determine motion of a body part.

Answer 54

a) The nurse informs the patient that the therapist will have access to his EMR., b) The nurse allows the patient to view his or her electronic medical record (EMR) at the bedside., c) The hospital provides a copy of the medical record to the patient., d) The patient requests a correction to the medical record on file. Explanation: HIPAA includes the rights of patients to obtain and examine a copy of their health records, and to request corrections. HIPPA provides the patient the right to know why requested information is sought and how it will be used. The act requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information. Sharing patient information with the patient’s son or daughter or sharing computer passwords is a violation of this privacy.

Answer 55

a) 40 inches Explanation: A waist circumference greater than 40 inches for men or 35 inches for women indicates excess abdominal fat. Those with a high waist circumference are at increased risk for diabetes, dyslipidemia, hypertension, cardiovascular disease, and atrial fibrillation.

Answer 56

d) “Good morning, Mr. Jones. The last time you were here you were planning a vacation. Tell me about your trip.” Explanation: During the introduction, the nurse should address the patient by his or her surname. The nurse should avoid tiring older patients by allowing rest periods during the physical examination; however, this is not the most important aspect of establishing a rapport with the patient. Ensuring that the patient is comfortable by keeping the room warm and free from drafts is important during the interview. However, facilitating rapport is done by taking a personal interest in the patient and allowing him or her to contribute to the assessment. Effective communication promotes respect and trust and reduces patient anxiety. The nurse should start by establishing rapport with the patient and family members. Inquiring about the patient’s family, jobs, or interest helps place the patient at ease and may build rapport. Rapport is facilitated by making eye contact. The nurse needs to position the computer to maintain eye-to-eye contact with the patient.

Answer 57

c) “Patient appears older than stated age.” Explanation: The first fundamental technique is inspection or observation. General inspection begins with the first contact with the patient. Percussion translates the application of physical force into sound. Light and deep palpation can be used on the abdomen. Auscultation is the skill of listening to sounds produced within the body created by the movement of air or fluid.

Answer 58

a) 18.5 to 20 Explanation: People who have a BMI lower than 18.5 (or who are 80% or less of their desirable body weight for height) are at increased risk for problems associated with poor nutritional status. Additionally, higher mortality rates in hospitalized patients and community-dwelling elderly are associated with individuals who have low BMI. People who have a BMI of 25 to 29 are considered overweight. People who have a BMI of 30 to 39 are considered obese. People who have a BMI above 40 are considered morbidly obese.

Answer 59

a) Body image Explanation: The patient is often less anxious when the interview progresses from information that is less personal to information that is more personal. Educational level, occupation, housing, religion, and language are relatively impersonal and readily revealed by the patient.

Answer 60

d) Access a government-sponsored Web site that provides culturally appropriate food guides. Explanation: Culturally sensitive materials are available for making appropriate dietary recommendations. Providing extra time for the patient will not increase the likelihood that the patient will adhere or understand nutritional counseling. Food records are used to determine individual eating patterns and do not take cultural preferences into consideration. Specific nutrients may need to be added on an individual and culturally acceptable basis, but only as a result of an in-depth nutritional assessment.

Answer 61

a) A 3- to 7day food record ``` Explanation: Physical measurements (BMI, waist circumference) and biochemical, clinical, and dietary data are used in combination to determine a patient’s nutritional status, but information obtained through these assessments will not help determine the possibility of allergies to food. The food record is used most often in nutritional status studies. A 3- to 7-day food record can be used to associate allergic reactions with specific food intake. ```

Answer 62

a) 100 pounds for 5 feet of height Explanation: To calculate a woman’s ideal body weight, the nurse allows 100 pounds for 5 feet of height and adds 5 pounds for each additional inch over 5 feet. The nurse allows 106 pounds for 5 feet of height in calculating the ideal body weight for a man. The nurse adds 6 pounds for each additional inch over 5 feet in calculating the ideal body weight for a man. Eighty pounds for 5 feet of height is too little.

Answer 63

a) High serum albumin Explanation: Low serum albumin and prealbumin levels are most often used as measures of protein deficiency in adults. A lower than normal 24-hour urine creatinine may indicate loss of lean body mass and protein malnutrition. The total lymphocyte count may be reduced in people who are acutely malnourished as a result of stress and low-caloric feeding.

Answer 64

a) Protects patient privacy while visually inspecting the abdomen, warms the stethoscope prior to listening for bowel sounds, using the fingertips lightly palpates the four abdominal quadrants, and taps the four abdominal quadrants. Explanation: The proper sequence for the abdominal assessment is inspection, auscultation, palpation, and percussion. When the abdomen is examined, auscultation is performed before palpation and percussion to avoid altering bowel sounds.

Answer 65

a) The patient who presents with a respiratory rate of 22 and a productive cough and reports shortness of breath with stair climbing Explanation: The assessment technique of percussion is most beneficial in patients suspected of disease processes in the chest and abdomen. The technique of percussion translates the application of physical force into sound. It is a skill requiring practice that yields much information about disease processes in the chest and abdomen. A patient with a rash and fever is likely to be experiencing a disease process of the integumentary system; the nurse is most likely to rely on the assessment technique of inspection in this situation. Percussion is not the primary assessment technique in a musculoskeletal assessment. The symptoms of dry skin and thinning hair could be indicative of thyroid disease

Answer 66

a) Assess the patient’s children for signs/symptoms of diabetes., b) Offer appropriate genetics information and resources., e) Obtain history of known diseases or disorders from both maternal and paternal family members., f) Ask the patient to list three complications of diabetes. Explanation: Listing three complications of diabetes allows the nurse to assess the patient’s understanding of the disease process. Offering appropriate genetics information and resources is indicated in this situation. Referral for risk assessment when a hereditary disease or disorder is present so the family can discuss inheritance risk with other family members is appropriate. Information should be obtained about both maternal and paternal sides of family for three generations. Nutritional counseling is dependent on an individualized nutritional assessment.

Answer 67

b) 1, 800 Explanation: It is estimated that there are more than 1,800 types of complementary and alternative therapies, including special diets, prayer, visualization or guided imagery, massage, meditation, herbal products, and many others. Marijuana is used to manage symptoms, especially pain, in a number of chronic conditions.

Answer 68

c) State near the end of the interview, “Some patients with HIV are worried about future sexual relationships.” Explanation: Collecting written information is important; however obtaining the verbal sexual history provides an opportunity to discuss sexual matters openly and gives the patient permission to express sexual concerns to an informed professional. Interviewers are frequently uncomfortable with such questions and ignore this area of the patient profile or conduct a very cursory interview about this subject. The nurse needs to assure the sexuality assessment is addressed. It is within the scope of nursing to obtain the sexual history. Sexual assessment can be approached at the end of the interview, at the time interpersonal or lifestyle factors are assessed. Direct questions are usually less threatening when prefaced with introductory statements.

Answer 69

a) Tissue growth Explanation: A positive nitrogen balance exists when nitrogen intake exceeds nitrogen output and indicates tissue growth. A negative nitrogen balance exists with fever, starvation, and burn injury.

Answer 70

a) Pain Explanation: The “fifth vital sign” is considered pain. Speech, strength, and posture are important assessment parameters, but none of these is considered the fifth vital sign.

Answer 71

a) The nurse recognizes that the patient’s obesity may be specifically related to his endocrine disorder. The nurse performs a thorough nutritional assessment. Explanation: Food records, 24-hour diet recall, and dietary education directed at weight loss do not account for the patient’s medical condition as a factor in the patient’s weight or nutritional status, although each method helps estimate whether or not food intake is adequate and appropriate. Certain signs and symptoms that suggest possible nutritional deficiency, such as muscle wasting, poor skin integrity, loss of subcutaneous tissue, and obesity, are easy to note because they are specific; these symptoms should be studied further.

Answer 72

d) Overinflated lung tissue Explanation: Hyperresonance is audible when overinflated lung tissue is percussed, such as in a person with emphysema. Percussion over the liver produces a dull sound. Percussion of the thigh produces a flat sound. Tympany is the drumlike sound produced by percussing the air-filled stomach.

Answer 73

a) “How has the stroke affected your ability to perform your daily activities?” Explanation: An emphasis on functional assessment is viewed as being more holistic than the traditional health or medical history. A patient’s functional status is the ability of the patient to function normally and perform his or her usual physical, mental, and social activities. Questions related to blood pressure readings, family history, and medication regimen indicate a traditional or medical model versus a holistic health assessment.

Answer 74

b) 30 to 39 Explanation: Those persons with a BMI of 30 to 39 are considered obese. Persons with a BMI of less than 24 are at risk for problems associated with poor nutritional status. Persons with a BMI of 25 to 29 are considered overweight. Those with a BMI of greater than 40 are considered morbidly obese.

Answer 75

a) Join hands with the patient and remain at the bedside until the patient finishes the prayer. Explanation: It is important that the spiritual beliefs of people and families be acknowledged, valued, and respected for the comfort and guidance they provide. Leaving the room based on the nurse’s spiritual beliefs does not convey respect for the patient. It is within the scope of the nurse to support the patient’s request for prayer and conveys respect for the patient’s spirituality. The patient needs to remain in control of the prayer, speaking it as he or she is accustomed to doing it

Answer 76

d) Self-concept Explanation: Self-concept, a person’s view of himself or herself, is an image that develops over many years. Self-concept can be threatened very easily by changes in physical function or appearance related to the impact of certain medical conditions such as COPD. Biographical information includes the person’s name, address, age, gender, marital status, occupation, and ethnic origins. The chief complaint is the issue that caused the patient to seek the care of the health care provider but does not address the patient’s view of himself or herself. Past coping patterns and perceptions of current stresses and anticipated outcomes are explored to identify the person’s overall ability to handle stress.

Answer 77

b) Catheter hub Explanation: The primary sources of microorganisms for catheter-related infections are the skin and the catheter hub. The catheter site is covered with an occlusive gauze dressing that is usually changed every other day.

Answer 78

a) Digestive enzymes and sodium bicarbonate Explanation: The nurse should attempt to unclog the tube with digestive enzymes activated with sodium bicarbonate. Although historically both cranberry juice and cola have sometimes been used to unclog feeding tubes, evidence has shown that their acidic nature worsens the clog by causing precipitation of proteins. Meat tenderize diluted with saline is not applicable.

Answer 79

d) Acidic Explanation: The pH of gastric aspirate is acidic (1 to 5)

Answer 80

c) 1 hour Explanation: The semi-Fowler’s position is necessary for an NG feeding with the patient’s head elevated at least 30 to 45 degrees to reduce the risk for reflux and pulmonary aspiration. This position is maintained for at least 1 hour after completion of an intermittent tube feeding and is maintained at all times for patients receiving continuous tube feedings.

Answer 81

d) Reassess the residual gastric content in 1 hour. Explanation: If the gastric residual exceeds 100 mL for 2 hours in a row, the physician should be notified. One observation of a residual gastric content over 100 mL does not have to be reported to the physician. If the observation occurs two times in succession, the physician should be notified. If the amount of gastric residual exceeds 100 mL, the tube feeding should be withheld at that time, but not indefinitely.

Answer 82

d) Feedings stopped too abruptly Explanation: Rebound hypoglycemia occurs when the feedings are stopped too abruptly. Hyperglycemia is caused by glucose intolerance. Fluid overload is caused by fluids infusing too rapidly. An air embolism can occur from a cap missing on a port.

Answer 83

b) Continuous feedings Explanation: Continuous feedings should be administered to a patient who is at risk of diarrhea due to hypertonic feeding solutions. Bolus or intermittent feedings cause sudden distention of the small intestine, while cyclic feedings are not advised.

Answer 84

c) X-ray confirmation Explanation: Radiologic identification of tube placement in the stomach is the most reliable method. Gastric fluid may be grassy green, brown, clear, or odorless, whereas an aspirate from the lungs may be off-white or tan. Hence, checking aspirate is not the best method of determining NG tube placement in the stomach. Gastric pH values are typically lower or more acidic than that of the intestinal or respiratory tract, but not always. Air auscultation is not a reliable method for determining NG tube placement in the stomach when used alone.

Answer 85

d) Every 48 hours Explanation: The nurse should include changing the central line dressing every 48 hours in the plan of care

Answer 86

c) Respiratory rate of 30 Explanation: The nurse determines that the patient may be having pulmonary complications when the respiratory rate is 30, indicating tachypnea. Other signs/symptoms of pulmonary complications include coughing during food or medication administration, difficulty clearing the airway, and fever

Answer 87

b) Feeding Explanation: Placement of the tube must be verified prior to any feeding. A gastric sump and nasoenteric tube are used for gastrointestinal decompression. Nasoenteric tubes are used for feeding. Gastric sump tubes are used to decompress the stomach and keep it empty

Answer 88

b) 30 minutes Explanation: Tube feedings administered via intermittent gravity drip should be administered over 30 minutes or longer.

Answer 89

d) Daily when not in use Explanation: Daily instillation of normal saline and dilute heparin flush when a nontunneled central catheter is not in use will maintain the line’s patency. Continuous infusion maintains the patency of the line. Normal saline and heparin flushes should be used after each time blood is drawn in order to prevent clotting of blood within the line. Normal saline and heparin flush are not needed when a line is being discontinued.

Answer 90

d) Urinary output 20 mL/hr Explanation: The nurse should notify the physician when the patient has a urinary output of 20 mL/hr as this is a decreased urinary rate. Decreased urinary output, lethargy, lightheadedness, hypotension, and increased heart rate are signs and symptoms of fluid volume deficit. A heart rate of 100, BP of 118/72, and moist mucous membranes are findings that are within acceptable ranges/limits and do not indicate a fluid volume deficit.

Answer 91

a) Dobbhoff Explanation: The Dobbhoff tube is a nasoentreric feeding tube. Nasogastric tubes include Levin, a gastric sump (Salem), and Sengstaken-Blakemore tubes

Answer 92

d) The potential for aspiration Explanation: Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the patient receiving continuous tube feedings. Tube feedings preserve GI integrity by intraluminal delivery of nutrients. Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. Tube feedings maintain fat metabolism and lipoprotein synthesis.

Answer 93

c) Nontunneled central catheter Explanation: Nontunneled central catheters are used for short-term (less than 6 weeks) IV therapy in acute care settings. The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored; it allows the patient freedom of movement and provides easy access to the dressing site. PICC lines may be used for intermediate terms (3 to 12 months). Tunneled central catheters are for long-term use and may remain in place for many years. Implanted ports are devices also used for long-term home IV therapy (e.g., Port-A-Cath, Mediport, Hickman Port, P.A.S. Port).

Answer 94

b) Place patient in semi-Fowler’s position during, and 60 minutes after, an intermittent feeding. Explanation: To minimize the risk of aspiration, it is important to place the patient in a semi-Fowler’s position during, and 60 minutes after, an intermittent feeding because proper positioning prevents regurgitation. Checking tube placement and gastric residual prior to feedings is another important measure because it prevents improper infusion and vomiting. If aspiration is suspected, feeding should be stopped as cessation prevents further problems and allows for treatment of the immediate problem. Changing tube feeding container and tubing, monitoring weight daily, and administering 15 to 30 mL of water before and after medications and feedings are measures to maintain tube function.

Answer 95

c) Every shift Explanation: Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding. Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities. Checking for placement every 12 or 24 hours does not meet the standard of care due the patient receiving continuous tube feedings.

Answer 96

d) Hang 10% dextrose and water Explanation: If the PN solution runs out and no PN is available, the nurse should hang 10% dextrose and water until the PN becomes available

Answer 97

d) Monitor the feeding closely. Explanation: High residual volumes (\>200 mL) should alert the nurse to monitor the patient more closely. Increasing the feeding rate will increase the residual volume. Lowering the head of the bed increases the patient’s risk for aspiration.

Answer 98

a) Enteric-coated tablets Explanation: Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change in the form of medication is necessary for patients with tube feedings. Simple compressed tablets may be crushed and dissolved in water for patients receiving oral medications by feeding tube. Buccal or sublingual tablets are absorbed by mucous membranes and may be given as intended to the patient undergoing tube feedings. The nurse may make an opening in the capsule and squeeze out contents for administration by feeding tube.

Answer 99

c) Loose, watery stools Explanation: When the patient indicates that loose watery stools are a sign/symptom of metabolic complications, the nurse evaluates that the patient understands the teaching of metabolic complications. Signs and symptoms of metabolic complications from PN include neuropathies, mentation changes, diarrhea, nausea, skin changes, and decreased urine output.

Answer 100

b) Tunneled central catheters Explanation: Hickman and Groshong catheters are examples of tunneled central catheters. MediPort is an implanted port. A percutaneous subclavian Arrow is an example of a nontunneled central catheter. A PICC line is used for intermediate-term IV therapy for the hospital, long-term care, or the home setting.

Answer 101

c) Pneumothorax Explanation: A pneumothorax is caused by improper catheter placement and inadvertent puncture of the pleura. Air embolism can occur from a missing cap on a port. Sepsis can be caused by the separation of dressings. Fluid overload is caused by fluids infusing too rapidly.

Answer 102

1, 2, 3, 5 By aspirating stomach contents the residual volume can be determined and the pH checked. pH \<3.5 verifies gastric placement. suction should be turned off befor the tubing is disconnected to check for residual volume; in addition, suction should remain off for 30-60 mintes following med admin to allow for med absorption.

Answer 103

3 If a clent has a NG tube connected to suction, the nurse should wait 30-60 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. The client should not be palced in the supine position b/c of the risk for aspiration. Aspirating the NG tube will remove the med just adminstered. Low intermittent suction also will remove the med just administered.

Answer 104

1 If the NG tube is in the somatch, the pH of the contents will be acidic.Gastric aspirates have acidic pH values and should be 3.5 or lower.

Answer 105

3 Measuring the length of a NG tube needed is done by placing the tube at the tip of the client's nose and extending the tube to the earlobe and then down to the xiphoid process. The average length for anadult is about 22-26 inches. The remaining options identify incorrect procedures for measuing the length of the tube.

Answer 106

1 Unless specifcally indicated, residual amounts more than 100 ml require holding the feeding. In addition the feeding is not discarded unless its contents are abnormal in color or characteristics

Answer 107

4 During the insertion of a NG tube, if the client experieces difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. It is not necessary to notify the NCP immediately or remove the tube completely. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.

Answer 108

3 The incident report should contain the client's name, age, and diagnosis. The report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the siuation. The correct option is the only one that describes the facts as observed by the nurse. Options 1,2,4, are interpreations of the situation and are not factual information as observed by the nurse

Answer 109

4 Living wills, also know =n as natural death acts in some states, are required to be in writing and signed by the pt. The pt's signature must be witnessed by specified individuals or notorized. Laws and gudielines regarding living wills vary from state to state, and it is the responsibility of the nurse to know the laws. Many states prohibit any employee, including the nurse of a facility where the client is recieving care, from being a witness. Optino 2 is nontherapeutic and not a helpful resounrces. The nurse should seek the assistance of a nursing supervisor

Answer 110

4 The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends w/o the pt's permission. Pt should be assured that info is kept confidential unless it places the nurse under a legal obligation. Options 1, 2, 3 do not address the legal implications of the situation and do not ensure a safe environement for the pt.

Answer 111

4 In team nursing, nursing personnel are led by a RN leader in providng care to a group of pts. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing