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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Document preview page 1

Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 1

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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43)

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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 1 preview imageTest Bank For ClinicalNursing Skills andTechniques10th Edition by AnneGriffin Perry, Patricia A.PotterChapter 1-43 CompleteGuide
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 2 preview image
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 3 preview imageComplete Test Bank For Clinical Nursing Skills and Techniques 10th Edition by AnneGriffin Perry, Patricia A. Potter Chapter 1-43 Complete GuideTable Of ContentChapter 1. Using Evidence in Nursing PracticeChapter 2. Communication and CollaborationChapter 3. Admitting, Transfer, and DischargeChapter 4. Documentation and InformaticsChapter 5. Vital SignsChapter 6. Health AssessmentChapter 7. Specimen CollectionChapter 8. Diagnostic ProceduresChapter 9. Medical AsepsisChapter 10. Sterile TechniqueChapter 11. Safe Patient Handling and Mobility (SPHM)Chapter 12. Exercise and MobilityChapter 13. Support Surfaces and Special BedsChapter 14. Patient SafetyChapter 15. Disaster PreparednessChapter 16. Pain ManagementChapter 17. End-of-Life CareChapter 18. Personal Hygiene and Bed MakingChapter 19. Care of the Eye and EarChapter 20. Safe Medication PreparationChapter 21. Nonparenteral MedicationsChapter 22. Parenteral MedicationsChapter 23. Oxygen TherapyChapter 24. Performing Chest PhysiotherapyChapter 25. Airway ManagementChapter 26. Cardiac CareChapter 27. Closed Chest Drainage SystemsChapter 28. Emergency Measures for Life SupportChapter 29. Intravenous and Vascular Access TherapyChapter 30. Blood TherapyChapter 31. Oral NutritionChapter 32. Enteral NutritionChapter 33. Parenteral NutritionChapter 34. Urinary EliminationChapter 35. Bowel Elimination and Gastric IntubationChapter 36. Ostomy CareChapter 37. Preoperative and Postoperative CareChapter 38. Intraoperative CareChapter 39. Wound Care and IrrigationsChapter 40. Impaired Skin Integrity Prevention and CareChapter 41. Dressings, Bandages, and BindersChapter 42. Home Care SafetyChapter 43. Home Care Teaching
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 4 preview imageChapter 01: Using Evidence in Nursing PracticePerry et al.: Clinical Nursing Skills & Techniques, 10th EditionMULTIPLE CHOICE1.Evidence-based practice is a problem-solving approach to making decisions about patient carethat is grounded in:a.the latest information found in textbooks.b.systematically conducted research studies.c.tradition in clinical practice.d.quality improvement and risk-management data.ANS:BThe best evidence comes from well-designed, systematically conducted research studiesdescribed in scientific journals. Portions of a textbook often become outdated by the time it ispublished. Many health care settings do not have a process to help staff adopt new evidence inpractice, and nurses in practice settings lack easy access to risk-management data, relyinginstead on tradition or convenience. Some sources of evidence do not originate from research.These include quality improvement and risk-management data; infection control data;retrospective or concurrent chart reviews; and clinicians‘ expertise. Althoughnon–research-based evidence is often very valuable, it is important that you learn to rely moreon research-based evidence.DIF:CognitiveLevel: ComprehensionOBJ:Discuss the benefits of evidence-based practice.TOP:Evidence-Based PracticeKEY: Nursing Process Step: AssessmentMSC: NCLEX: Safe and Effective Care Environment (management of care)2.When evidence-based practice is used, patient care will be:a.standardized for all.b.unhampered by patient culture.c.variable according to the situation.d.safe from the hazards of critical thinking.ANS:CUsing your clinical expertise and considering patients‘ cultures, values, and preferencesensures that you will apply available evidence in practice ethically and appropriately. Evenwhen you use the best evidence available, application and outcomes will differ; as a nurse,you will develop critical thinking skills to determine whether evidence is relevant andappropriate.DIF:CognitiveLevel: ApplicationOBJ:Discuss the benefits of evidence-based practice.TOP:Evidence-Based PracticeKEY: Nursing Process Step: AssessmentMSC: NCLEX: Safe and Effective Care Environment (management of care)3.When a PICOT question is developed, the letter that corresponds with the usual standard ofcare is:a.P.b.I.c.
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 5 preview imagec.CHOICE BLANKd.O.ANS:CC = Comparison of interest. What standard of care or current intervention do you usually usenow in practice?P = Patient population of interest. Identify your patient by age, gender, ethnicity, disease, orhealth problem.I = Intervention of interest. What intervention (e.g., treatment, diagnostic test, and prognosticfactor) do you think is worthwhile to use in practice?O = Outcome. What result (e.g., change in patient‘s behavior, physical finding, and change inpatient‘s perception) do you wish to achieve or observe as the result of an intervention?DIF:CognitiveLevel: KnowledgeOBJ:Develop a PICO question.TOP:PICOKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment (management of care)4.A well-developed PICOT question helps the nurse:a.search for evidence.b.include all five elements of the sequence.c.find as many articles as possible in a literature search.d.accept standard clinical routines.ANS:AThe more focused a question that you ask is, the easier it is to search for evidence in thescientific literature. A well-designed PICOT question does not have to include all fiveelements, nor does it have to follow the PICOT sequence. Do not be satisfied with clinicalroutines. Always question and use critical thinking to consider better ways to provide patientcare.DIF:CognitiveLevel: AnalysisOBJ:Describe the six steps of evidence-based practice.TOP:Evidence-Based PracticeKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment (management of care)5.The nurse is not sure that the procedure the patient requires is the best possible for thesituation. Utilizing which of the following resources would be the quickest way to reviewresearch on the topic?a.CINAHLb.PubMedc.MEDLINEd.The Cochrane DatabaseANS:DThe Cochrane Community Database of Systematic Reviews is a valuable source ofsynthesized evidence (i.e., pre-appraised evidence). The Cochrane Database includes the fulltext of regularly updated systematic reviews and protocols for reviews currently happening.MEDLINE, CINAHL, and PubMed are among the most comprehensive databases andrepresent the scientific knowledge base of health care.DIF:CognitiveLevel: SynthesisOBJ:Describe the six steps of evidence-based practice.TOP:Evidence-Based PracticeKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment (management of care)
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 6 preview image6.The nurse is getting ready to develop a plan of care for a patient who has a specific need. Thebest source for developing this plan of care would probably be:a.The Cochrane Database.b.MEDLINE.c.NGC.d.CINAHL.ANS:CThe National Guidelines Clearinghouse (NGC) is a database supported by the Agency forHealthcare Research and Quality (AHRQ). It contains clinical guidelines—systematicallydeveloped statements about a plan of care for a specific set of clinical circumstances involvinga specific patient population. The NGC is a valuable source when you want to develop a planof care for a patient. The Cochrane Community Database of Systematic Reviews, MEDLINE,and CINAHL are all valuable sources of synthesized evidence (i.e., pre-appraised evidence).DIF:CognitiveLevel: SynthesisOBJ:Describe the six steps of evidence-based practice.TOP:Evidence-Based PracticeKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment (management of care)7.The nurse has done a literature search and found 25 possible articles on the topic that she isstudying. To determine which of those 25 best fit her inquiry, the nurse first should look at:a.the abstracts.b.the literature reviews.c.the ―Methods‖ sections.d.the narrative sections.ANS:AAn abstract is a brief summary of an article that quickly tells you whether the article isresearch based or clinically based. An abstract summarizes the purpose of the study or clinicalquery, the major themes or findings, and the implications for nursing practice. The literaturereview usually gives you a good idea of how past research led to the researcher‘s question.The ―Methods‖ or ―Design‖ section explains how a research study is organized and conductedto answer the research question or to test the hypothesis. The narrative of a manuscript differsaccording to the type of evidence-based article—clinical or research.DIF:CognitiveLevel: ApplicationOBJ:Discuss elements to review when critiquing the scientific literature.TOP:Randomized Controlled TrialsKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment (management of care)8.The nurse wants to determine the effects of cardiac rehabilitation program attendance on thelevel of postmyocardial depression for individuals who have had a myocardial infarction. Thetype of study that would best capture this information would be a:a.randomized controlled trial.b.qualitative study.c.case control study.d.descriptive study.ANS:B
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 7 preview imageQualitative studies examine individuals‘ experiences with health problems and the contexts inwhich these experiences occur. A qualitative study is best in this case of an individual nursewho wants to examine the effectiveness of a local program. Randomized controlled trialsinvolve close monitoring of control groups and treatment groups to test an intervention againstthe usual standard of care. Case control studies typically compare one group of subjects with acertain condition against another group without the condition, to look for associations betweenthe condition and predictor variables. Descriptive studies focus mainly on describing theconcepts under study.DIF:CognitiveLevel: SynthesisOBJ:Discuss ways to apply evidence in nursing practice.TOP:Randomized Controlled TrialsKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment (management of care)9.Six months after an early mobility protocol was implemented, the incidence of deep veinthrombosis in patients was decreased. This is an example of what stage in the EBP process?a.Asking a clinical questionb.Applying the evidencec.Evaluating the practice decisiond.Communicating your resultsANS:CAfter implementing a practice change, your next step is to evaluate the effect. You do this byanalyzing the outcomes data that you collected during the pilot project. Outcomes evaluationtells you whether your practice change improved conditions, created no change, or worsenedconditions.DIF:CognitiveLevel: ApplicationOBJ:Discuss ways to apply evidence in nursing practice.TOP:Evidence-Based PracticeKEY: Nursing Process Step: EvaluationMSC: NCLEX: Safe and Effective Care Environment (safety and infection control)MULTIPLE RESPONSE1.To use evidence-based practice appropriately, you need to collect the most relevant and bestevidence and to critically appraise the evidence you gather. This process also includes: (Selectall that apply.)a.asking a clinical question.b.applying the evidence.c.evaluating the practice decision.d.communicating your results.ANS:A, B, C, DEBP comprises six steps (Melnyk and Fineout-Overholt, 2010):1. Ask a clinical question.2. Search for the most relevant and best evidence that applies to the question.3. Critically appraise the evidence you gather.4. Apply or integrate evidence along with one‘s clinical expertise and patient preferences andvalues in making a practice decision or change.5. Evaluate the practice decision or change.6. Communicate your results.
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 8 preview imageDIF:CognitiveLevel: AnalysisOBJ:Describe the six steps of evidence-based practice.TOP:Evidence-Based PracticeKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment (management of care)2.In a clinical environment, evidence-based practice has the ability to improve: (Select all thatapply.)a.the quality of care provided.b.patient outcomes.c.clinician satisfaction.d.patients‘ perceptions.ANS:A, B, C, DEBP has the potential to improve the quality of care that nurses provide, patient outcomes, andclinicians‘ satisfaction with their practice. Your patients expect nursing professionals to beinformed and to use the safest and most appropriate interventions. Use of evidence enhancesnursing, thereby improving patients‘ perceptions of excellent nursing care.DIF:CognitiveLevel: ApplicationOBJ:Discuss the benefits of evidence-based practice.TOP:Randomized Controlled TrialsKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment (management of care)3.During the application stage of evidence-based practice change, it is important to consider:(Select all that apply.)a.cost.b.the need for new equipment.c.management support.d.adequate staff.ANS:A, B, C, DOne important step for an individual or an interdisciplinary EBP committee is to consider theresources needed for a practice change project. Are added costs or new equipment involvedwith a practice change? Do you have adequate staff to make the practice change work asplanned? Do management and medical staff support you in the change? If the barriers topractice change are excessive, adopting a practice change can be difficult, if not impossible.DIF:CognitiveLevel: ApplicationOBJ:Describe the six steps of evidence-based practice.TOP:Evidence-Based PracticeKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment (management of care)COMPLETION1._________________ is a guide for making accurate, timely, and appropriate clinicaldecisions.ANS:Evidence-based practiceEvidence-based practice is a guide for making accurate, timely, and appropriate clinicaldecisions.
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 9 preview imageDIF:CognitiveLevel: KnowledgeOBJ:Define the key terms listed.TOP:Evidence-Based PracticeKEY: Nursing Process Step: AssessmentMSC: NCLEX: Safe and Effective Care Environment (management of care)2.Evidence-based practice requires good ______________.ANS:nursing judgmentEvidence-based practice requires good nursing judgment; it does not consist of findingresearch evidence and blindly applying it.DIF:CognitiveLevel: ComprehensionOBJ:Discuss the benefits of evidence-based practice.TOP:Evidence-Based PracticeKEY: Nursing Process Step: AssessmentMSC: NCLEX: Safe and Effective Care Environment (management of care)3.While caring for patients, the professional nurse must question ________________.ANS:what does not make senseAlways think about your practice when caring for patients. Question what does not makesense to you, and question what you think needs clarification.DIF:CognitiveLevel: AnalysisOBJ:Describe the six steps of evidence-based practice.TOP:Evidence-Based PracticeKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment (management of care)4.A systematic review explains whether the evidence that you are searching for exists andwhether there is good cause to change practice. In _____________, all entries includeinformation on systematic reviews.ANS:The Cochrane DatabaseA systematic review explains whether the evidence that you are searching for exists andwhether there is good cause to change practice. In The Cochrane Database, all entries includeinformation on systematic reviews.DIF:CognitiveLevel: AnalysisOBJ:Describe the six steps of evidence-based practice.TOP:Evidence-Based PracticeKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment (management of care)5.The researcher explains how to apply findings in a practice setting for the types of subjectsstudied in the _________________ section of a research article.ANS:―Clinical Implications‖Clinical Implications
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 10 preview imageA research article includes a section that explains whether the findings from the study have―clinical implications.‖ The researcher explains how to apply findings in a practice setting forthe types of subjects studied.DIF:CognitiveLevel: ApplicationOBJ:Discuss elements to review when critiquing the scientific literature.TOP:Randomized Controlled TrialsKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment (management of care)6.____________________ is the extent to which a study‘s findings are valid, reliable, andrelevant to your patient population of interest.ANS:Scientific rigorScientific rigor is the extent to which a study‘s findings are valid, reliable, and relevant toyour patient population of interest.DIF:CognitiveLevel: ApplicationOBJ:Define the key terms listed.TOP:Randomized Controlled TrialsKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment (management of care)7.Patient fall rates are an example of an ______________.ANS:outcome measurementData collected within a health care agency offer important trending information about clinicalconditions and problems. Staff in the agency review the data periodically to identify problemareas and to seek solutions.DIF:CognitiveLevel: ApplicationOBJ:Define the key terms listed.TOP:Quality ImprovementKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment (management of care)Chapter 02: Communication and CollaborationPerry et al.: Clinical Nursing Skills & Techniques, 10th EditionMULTIPLE CHOICE1.The patient is a 54-year-old man who has made a living as a construction worker. He droppedout of high school at age 16 and has been a laborer ever since. He never saw any need for―book learning,‖ and has lived his life ―my way‖ since he was a teenager. He has smoked apack of cigarettes a day for 40 years and follows no special diet, eating a lot of ―fast food‖while on the job. He now is admitted to the coronary care unit for complaints of chest painand is scheduled for a cardiac catheterization in the morning. Which of the following wouldbe the best way for the nurse to explain why he needs the procedure?a.―The doctor believes that you have atherosclerotic plaques occluding the majorarteries in your heart, causing ischemia and possible necrosis of heart tissue.‖b.―There may be a blockage of one of the arteries in your heart, causing the chest
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 11 preview imagediscomfort. He needs to know where it is to see how he can treat it.‖c.―We have pamphlets here that can explain everything. Let me get you one.‖d.―It‘s just like a clogged pipe. All the doctor has to do is ‗Roto-Rooter‘ it to get itcleaned out.‖ANS:BTo send an accurate message, the sender of verbal communication must be aware of differentdevelopmental perspectives as well as cultural differences between sender and receiver, suchas the use of dialect or slang.DIF:CognitiveLevel: ApplicationOBJ:Explain the communication process.TOP:Verbal CommunicationKEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity2.The nurse is assessing a patient who says that she is feeling fine. The patient, however, iswringing her hands and is teary eyed. The nurse should respond to the patient in which of thefollowing ways?a.―You seem anxious today. Is there anything on your mind?‖b.―I‘m glad you‘re feeling better. I‘ll be back later to help you with your bath.‖c.―I can see you‘re upset. Let me get you some tissue.‖d.―It looks to me like you‘re in pain. I‘ll get you some medication.‖ANS:AWhen assessing a patient‘s needs, assess both the verbal and the nonverbal messages andvalidate them. In this case, if you see a patient wringing her hands and sighing, it isappropriate to ask, ―You seem anxious today. Is there anything on your mind?‖ It is notenough to accept only the verbal message if nonverbal signals conflict, and it is inappropriateto jump to conclusions about what the nonverbal signals mean.DIF:CognitiveLevel: ApplicationOBJ:Explain the communication process.TOP:Nonverbal CommunicationKEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity3.Nonverbal communication incorporates messages conveyed by:a.touch.b.cadence.c.tone quality.d.use of jargon.ANS:ANonverbal communication describes all behaviors that convey messages without the use ofwords. This type of communication includes body movement, physical appearance, personalspace, and touch. Cadence, tone quality, and the use of jargon are all part of verbalcommunication.DIF:CognitiveLevel: KnowledgeOBJ:Explain the communication process.TOP:Nonverbal CommunicationKEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity4.The patient is an elderly male who had hip surgery 3 days ago. He states that his hip hurts, buthe does not like how the medicine makes him feel. He believes that he can tolerate the painbetter than he can tolerate the medication. What would be the best response from the nurse?
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 12 preview imagea.Explain the need for the pain medication using a slower rate of speech.b.Explain the need for the pain medication using a simpler vocabulary.c.Explain the need for the pain medication, but ask the patient if he would like thedoctor called and the medication changed.d.Explain in a loud manner the need for the pain medication.ANS:CSuggesting, which is presenting alternative ideas for patient consideration relative to problemsolving, can be effective in helping the patient maintain control by increasing the patient‘sperceived options or choices. Nurses often use elder-speak, which includes a slower rate ofspeech, greater repetition, and simpler grammar than normal adult speech, when caring forolder adults. However, many older patients perceive this type of communication aspatronizing.DIF:CognitiveLevel: ApplicationOBJ:Identify the purpose of therapeutic communication, communication in various phases of thenurse-patient relationship, and special issues related to communication.TOP:Communication with the ElderlyKEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity5.When comparing therapeutic communication versus social communication, the professionalnurse realizes that therapeutic communication:a.allows equal opportunity for personal disclosure.b.allows both participants to have personal needs met.c.is goal directed and patient centered.d.provides an opportunity to compare intimate details.ANS:CTherapeutic communication empowers patients to make decisions but differs from socialcommunication in that it is patient centered and goal directed with limited disclosure from theprofessional. Social communication involves equal opportunity for personal disclosure, andboth participants seek to have personal needs met. Nurses do not share with patients intimatedetails of their personal lives.DIF:CognitiveLevel: ApplicationOBJ:Develop skills for therapeutic communication in various phases of the nurse-patientrelationship.TOP:Establishing the Nurse-Patient RelationshipKEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity6.The nurse is explaining a procedure to a 2-year-old child. Which is the best approach to use?a.Showing the needles and bandages in advanceb.Telling the patient exactly what discomfort to expectc.Using dolls and stories to demonstrate what will be doned.Asking the child to draw pictures of what he or she thinks will happenANS:CSome age-appropriate communication techniques for a 2-year-old child include storytellingand drawing. Showing the child needles or telling the child about discomfort would increaseanxiety. Having a child draw what he expects does not explain what is going to happen.DIF:CognitiveLevel: Application
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 13 preview imageOBJ:Develop skills for therapeutic communication in various phases of the nurse-patientrelationship.TOP:Establishing the Nurse-Patient Relationship—Pediatric ConsiderationsKEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity7.The nurse is about to go over the patient‘s preoperative teaching per hospital protocol. Shefinds the patient sitting in bed wringing her hands, which are sweaty, and acting slightlyagitated. The patient states, ―I‘m scared that something will go wrong tomorrow.‖ Howshould the nurse respond?a.Redirect her focus to dealing with the patient‘s anxiety.b.Tell the patient that everything will be all right and continue teaching.c.Tell the patient that she will return later to do the teaching.d.Give the patient antianxiety medication.ANS:AAnxiety interferes with comprehension, attention, and problem-solving abilities and thusinterferes with the patient‘s care and treatment. To ensure the effectiveness of treatment, thenurse should try to help the patient understand the source of the anxiety. Ignoring the anxiety,medicating for it, and postponing the discussion are all inappropriate.DIF:CognitiveLevel: ApplicationOBJ:Develop therapeutic communication skills for communicating with anxious, angry, anddepressed patients.TOP:Establishing the Nurse-Patient RelationshipKEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity8.The nurse is attempting to teach the patient and his family about his care after discharge. Thepatient and the family demonstrate signs of anxiety during the teaching session. The nurseshould consider doing what?a.Using more gestures or picturesb.Focusing on the physical complaintsc.Getting another staff member to speak to the patientd.Repeating information to the patient and the family at a later timeANS:DRemember that patients and their family members who are under stress often require repeatedexplanations. Increasing gestures and pictures is additional stimulation that may increaseanxiety. Physical complaints should be acknowledged, but dwelling on them can also increasethe patient‘s anxiety. Involving another staff member would cause a break in the continuity ofcare.DIF:CognitiveLevel: ApplicationOBJ:Develop therapeutic communication skills for communicating with anxious, angry, anddepressed patients.TOP:Establishing the Nurse-Patient RelationshipKEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 14 preview image9.The patient is an elderly man who was brought to the hospital from an assisted-livingcommunity with complaints of anorexia and general malaise. The nurse at the assisted-livingcommunity reported that the patient was very ritualistic in his behavior and fastidious in hisdress and always took a shower in the evening before bed. The patient became very angry andupset when the patient care technician asked him to take his bath in the morning. What doesthis behavior tell the nurse?a.The patient is exhibiting anxiety because of a change in his rituals.b.The patient is suffering from sensory overstimulation.c.The patient is basically an angry person.d.The patient has to follow hospital protocol.ANS:APatients often become ritualistic and intent on performing activities a certain way. Anxietydevelops as a result of a specific event or a general pattern of change.DIF:CognitiveLevel: AnalysisOBJ:Develop therapeutic communication skills for communicating with anxious, angry, anddepressed patients.TOP:Gerontological Considerations—AnxietyKEY: Nursing Process Step: DiagnosisMSC: NCLEX: Psychosocial Integrity10.The nurse is preparing to give an intramuscular injection to the patient in room 320. Thepatient care technician comes to the medication room and tells the nurse that the patient inroom 316 is very angry with his roommate and is threatening to hit him. How should the nurserespond?a.Tell the patient care technician to calm the patient down until she can get there.b.Have the angry patient‘s roommate moved to another location.c.Tell the angry patient to calm down until she can get there.d.Tell the angry patient that he has to act civilized in the hospital, and that‘s that.ANS:BA potentially violent patient needs to be in an environment with decreased stimuli and to haveprotection from injury to self and against others. Encourage other people, particularly thosewho provoke anger, to leave the room or area. De-escalation is a skill that cannot be delegatedto nursing assistive personnel (NAP).DIF:CognitiveLevel: ApplicationOBJ:Develop therapeutic communication skills for communicating with anxious, angry, anddepressed patients.TOP:Communicating with the Angry PatientKEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity11.Which behavior should the nurse who is communicating with a potentially violent patientemploy?a.Sit closer to the patient.b.Speak loudly and firmly.c.Use slow, deliberate gestures.d.Always block the door to prevent escape.ANS:C
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 15 preview imageMake sure that gestures are slow and deliberate rather than sudden and abrupt. There is lesschance for misinterpretation of the message, and slow, deliberate gestures are less threatening.Keep an adequate distance between yourself and the patient to reduce your risk of injury andto avoid making the patient feel pressured. Try to talk in a comfortable, reassuring voice.Position yourself closest to the door to facilitate escape from a potentially violent situation.Do not block the exit; if the patient feels unable to escape, this may cause a violent outburst.DIF:CognitiveLevel: ApplicationOBJ:Develop therapeutic communication skills for communicating with anxious, angry, anddepressed patients.TOP:Communicating with the Angry PatientKEY: Nursing Process Step: InterventionMSC: NCLEX: Psychosocial Integrity12.The patient is sitting at the bedside. He has not been eating and is just staring out of thewindow. The nurse approaches the patient and asks, ―What are you thinking about?‖ Whattype of communication technique is this?a.Restatingb.Clarificationc.Broad openingsd.ReflectionANS:CBroad openings encourage patients to select topics for discussion. They affirm the value of thepatient‘s initiative. Restating is repeating a main thought that the patient has expressed.Clarification is attempting to put into words vague ideas or asking the patient to explain whathe or she means. Reflection is directing back to the patient ideas, feelings, questions, orcontent.DIF:CognitiveLevel: KnowledgeOBJ:Explain the communication process.TOP:Therapeutic Communication TechniquesKEY: Nursing Process Step: DiagnosisMSC: NCLEX: Psychosocial Integrity13.A patient tells the nurse, ―I want to die.‖ Which response is the most appropriate for the nurseto make?a.―Why would you say that?‖b.―Tell me more about how you are feeling.‖c.―The doctor should be told how you feel.‖d.―You have too much to live for to think that way.‖ANS:BBroad openings encourage the patient to select topics for discussion and indicate acceptanceby the nurse and the value of the patient‘s initiative. ―Why‖ questions can cause defensivenessand can hinder communication. Saying you will inform the doctor leads the conversationaway from the patient‘s feelings. Saying the patient has too much to live for is falsereassurance and negates the patient‘s feelings.DIF:CognitiveLevel: ApplicationOBJ:Explain the communication process.TOP:Therapeutic Communication TechniquesKEY: Nursing Process Step: InterventionMSC: NCLEX: Psychosocial Integrity
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 16 preview image14.The patient states, ―I don‘t know what my family will think about this.‖ The nurse wishes touse the communication technique of clarification. Which of the following statements would fitthat need best?a.―You don‘t know what your family will think?‖b.―I‘m not sure that I understand what you mean.‖c.―I think it would be helpful if we talk more about your family.‖d.―I sense that you may be anxious about something.‖ANS:BThe definition ofclarificationis attempting to put into words vague ideas or unclear thoughtsof the patient to enhance the nurse‘s understanding, or asking the patient to explain what he orshe means. Repeating main thoughts expressed by patients is known as ―restating.‖ Usingquestions or statements that help patients expand on a topic of importance is known as―focusing.‖ Asking a patient to verify the nurse‘s understanding of what the patient is thinkingor feeling is known as ―sharing perceptions.‖DIF:CognitiveLevel: ApplicationOBJ:Explain the communication process.TOP:Therapeutic Communication TechniquesKEY: Nursing Process Step: InterventionMSC: NCLEX: Psychosocial Integrity15.A patient tells the nurse, ―I think that I must be really sick. All of these tests are being done.‖Which response by the nurse uses the specific communication technique of reflection?a.―I sense that you are worried.‖b.―I think that we should talk about this more.‖c.―You think that you must be very sick because of all the tests.‖d.―I‘ve noticed that this is an underlying issue whenever we talk.‖ANS:CReflecting is directing back to the patient ideas, feelings, questions, or content, validating thenurse‘s understanding of what the patient is saying, and signifying empathy, interest, andrespect for the patient. Asking the patient to confirm your sense of his or her anxiety is―sharing perceptions.‖ Stating that ―we should talk about this more,‖ that is, putting forthquestions or statements to expand on a topic, is ―focusing.‖ Pointing out underlying issues orproblems that occur repeatedly is known as ―theme identification.‖DIF:CognitiveLevel: ApplicationOBJ:Explain the communication process.TOP:Therapeutic Communication TechniquesKEY: Nursing Process Step: InterventionMSC: NCLEX: Psychosocial Integrity16.The patient is admitted to the hospital with complaints of headache, nausea, and dizziness.She states that she has a final exam in the morning and needs to do well on it to pass thecourse, but she can‘t seem to get into it. She appears nervous and distracted, and is unable torecall details. She most likely is showing manifestations of _____ anxiety.a.mildb.moderatec.severed.panic state ofANS:C
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 17 preview imageSevere anxiety manifests as a focus on fragmented details, as well as headache, nausea,dizziness, inability to see connections between details, and poor recall. Mild anxiety manifestsas increased auditory and visual perception, increased awareness of relationships, andincreased alertness and ability to problem-solve. Moderate anxiety manifests as selectiveinattention, decreased perceptual field, focus only on relevant information, muscle tension,and diaphoresis. Panic state of anxiety manifests as an inability to notice surroundings,feelings of terror, and inability to cope with any problem.DIF:CognitiveLevel: AnalysisOBJ:Develop therapeutic communication skills for communicating with anxious, angry, anddepressed patients.TOP:Manifestations of AnxietyKEY: Nursing Process Step: DiagnosisMSC: NCLEX: Physiological Integrity17.The patient is admitted to the emergency department for trauma received in a fist fight. Hestates that he could not control himself. He says that his wife left him for another man. Hethinks it was because he was always too tired after working to do things. He says he has towork, and there is nothing he could do to change things. He says that he feels trapped in hisjob, but he knows nothing else. What was the altercation with the other man probably amanifestation of?a.Mild anxietyb.Depressionc.Severe anxietyd.Moderate anxietyANS:BSymptoms of depressioninclude apathy, sadness, sleep disturbances, hopelessness,helplessness, worthlessness, guilt, anger, fatigue, thoughts of death, decreased libido,ruminations of inadequacy, psychomotor agitation, verbal berating of self, spontaneouscrying, dependency, and passiveness. Mild anxiety manifests as increased auditory and visualperception, increased awareness of relationships, increased alertness, and an increased abilityto problem-solve. Moderate anxiety manifests as selective inattention, decreased perceptualfield, focus only on relevant information, muscle tension, and diaphoresis. Severe anxietymanifests as a focus on fragmented details, headache, nausea, dizziness, an inability to seeconnections between details, and poor recall.DIF:CognitiveLevel: AnalysisOBJ:Develop therapeutic communication skills for communicating with anxious, angry, anddepressed patients.TOP:Manifestations of DepressionKEY: Nursing Process Step: DiagnosisMSC: NCLEX: Psychosocial IntegrityMULTIPLE RESPONSE1.Verbal communication includes which of the following? (Select all that apply.)a.Speechb.Personal spacec.Body movementd.WritingANS:A, D
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 18 preview imageVerbal communication includes both spoken word and written word. Nonverbalcommunication describes all behaviors that convey messages without the use of words. Thistype of communication includes body movement, physical appearance, personal space, andtouch.DIF:CognitiveLevel: AnalysisOBJ:Explain the communication process.TOP:Verbal CommunicationKEY: Nursing Process Step: AssessmentMSC: NCLEX: Psychosocial Integrity2.In caring for patients of different cultures, it is important for the nurse to: (Select all thatapply.)a.use appropriate linguistic services.b.display empathy and respect.c.use accurate health history-taking techniques.d.use patient-centered communication.ANS:A, B, C, DThe following factors are essential in providing effective care for culturally and linguisticallydiverse patients: (1) use of appropriate linguistic services (e.g., interpreter or bilingual healthcare workers) and/or other communication strategies, (2) display of empathy and respect forculturally and linguistically diverse patients, (3) use of accurate health history-takingtechniques for diagnostic and treatment purposes and health teaching, and (4) use ofpatient-centered communication behaviors, including participatory decision making. It also ishelpful to speak plainly and to avoid mimicking a patient‘s accent or dialect.DIF:CognitiveLevel: ComprehensionOBJ:Identify the purpose of therapeutic communication, communication in various phases of thenurse-patient relationship, and special issues related to communication.TOP:Cultural CommunicationKEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity3.The nurse observes that the patient is pacing in his room with clenched fists. When asked―What‘s wrong?‖ the patient states, ―There‘s nothing wrong. I just want out of here.‖ He thenbangs his fist on the table and yells, ―I‘ve had it!‖ How should the nurse respond? (Select allthat apply.)a.Tell the patient that he needs to calm down.b.Pause to collect her own thoughts.c.Block the doorway.d.Notify the proper authorities.ANS:B, DAwareness and control of your own reaction and responses will facilitate more constructiveinteraction. Maintain an open exit. Position yourself closest to the door to facilitate escapefrom a potentially violent situation. Do not block the exit so the patient feels escape isunattainable; this may cause a violent outburst. An angry patient loses the ability to processinformation rationally and therefore may impulsively express anger through intimidation.If astrong likelihood of imminent harm to another is present upon discharge, notify the properauthorities (e.g., nurse manager).DIF:CognitiveLevel: SynthesisOBJ:Develop therapeutic communication skills for communicating with anxious, angry, and
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 19 preview imagedepressed patients.TOP:Communicating with the Angry PatientKEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial IntegrityCOMPLETION1.The nurse is starting her first set of morning rounds. As she interacts with the patient, herquestions revolve around his reactions to his disease process. She also asks if there is anythingthat she can do to make him more comfortable. This type of interaction is known as_______________.ANS:therapeutic communicationTherapeutic communication is an application of the process of communication to promote thewell-being of the patient.DIF:CognitiveLevel: AnalysisOBJ:Identify guidelines to use in therapeutic communication.TOP:Therapeutic CommunicationKEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity2.An active process of receiving information that nonverbally communicates to the patient thenurse‘s interest and acceptance is classified as _____________.ANS:listeningDefinition:An active process of receiving information and examining one‘s reaction tomessages received.Therapeutic value:Nonverbally communicates to the patient the nurse‘sinterest and acceptance.DIF:CognitiveLevel: KnowledgeOBJ:Explain the communication process.TOP:Therapeutic Communication TechniquesKEY: Nursing Process Step: DiagnosisMSC: NCLEX: Psychosocial Integrity3.The patient is talking about his fear of having surgery but is being vague and is using a lot ofjargon. The nurse states, ―I‘m not sure what you mean. Could you tell me again?‖ This is anexample of __________________.ANS:clarificationClarification is attempting to put into words vague ideas or unclear thoughts of the patient toenhance the nurse‘s understanding, or asking the patient to explain what he or she means. Thismay help to clarify the patient‘s feelings, ideas, and perceptions, and may provide an explicitcorrelation between them and the patient‘s actions.DIF:CognitiveLevel: ApplicationOBJ:Explain the communication process.TOP:Therapeutic Communication TechniquesKEY: Nursing Process Step: DiagnosisMSC: NCLEX: Psychosocial Integrity
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 20 preview image4.Directing the conversation back to patient ideas, feelings, questions, or content is known as___________________.ANS:reflectionReflection or directing back to the patient ideas, feelings, questions, or content validates thenurse‘s understanding of what the patient is saying and signifies empathy, interest, and respectfor the patient.DIF:CognitiveLevel: KnowledgeOBJ:Explain the communication process.TOP:Therapeutic Communication TechniquesKEY: Nursing Process Step: DiagnosisMSC: NCLEX: Psychosocial Integrity5.The patient tells the nurse that his mother left him when he was 5 years old. The nurseresponds by saying, ―You say that your mother left you when you were 5 years old?‖ This isan example of _______________.ANS:restatingRestating is a technique whereby the nurse repeats the main thought that the patient hasexpressed. It indicates that the nurse is listening, and validates, reinforces, or calls attention tosomething important that has been said.DIF:CognitiveLevel: ApplicationOBJ:Explain the communication process.TOP:Therapeutic Communication TechniquesKEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity6.The patient has been agitated for the entire morning but refuses to say why he is angry.Instead, whenever the nurse speaks to him, he smiles at her while clenching his fist at thesame time. The nurse states, ―I can see that you‘re smiling, but I sense that you are really veryangry.‖ This is an example of ___________________.ANS:sharing perceptionsSharing perceptions is asking the patient to verify the nurse‘s understanding of what thepatient is thinking or feeling. It conveys to the patient the nurse‘s understanding and has thepotential for clearing up confusing communication.DIF:CognitiveLevel: ApplicationOBJ:Explain the communication process.TOP:Therapeutic Communication TechniquesKEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity7.Lack of verbal communication for a therapeutic reason is known as ___________________.ANS:
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 21 preview imagetherapeutic silenceLack of verbal communication for a therapeutic reason is known as therapeutic silence. Itallows the patient time to think and gain insights, slows the pace of the interaction, andencourages the patient to initiate conversation, while conveying the nurse‘s support,understanding, and acceptance.DIF:CognitiveLevel: ComprehensionOBJ:Explain the communication process.TOP:Therapeutic SilenceKEY: Nursing Process Step: AssessmentMSC: NCLEX: Psychosocial Integrity8.Anxiety that is the source of inattention, decreased perceptual field, and diaphoresis isclassified as ____________________.ANS:moderate anxietyModerate anxiety is characterized by selective inattention, decreased perceptual field, theability to focus only on relevant information, muscle tension, and/or diaphoresis.DIF:CognitiveLevel: ComprehensionOBJ:Develop therapeutic communication skills for communicating with anxious, angry, anddepressed patients.TOP:AnxietyKEY: Nursing Process Step: DiagnosisMSC: NCLEX: Psychosocial IntegrityChapter 03: Admitting, Transfer, and DischargePerry et al.: Clinical Nursing Skills & Techniques, 10th EditionMULTIPLE CHOICE1.The patient is scheduled to go home after having coronary angioplasty. What would be themost effective way to provide discharge teaching to this patient?a.Provide him with information on health care websites.b.Provide him with written information on what he has to do.c.Sit and carefully explain what is required before his follow-up.d.Use a combination of verbal and written information.ANS:DFor discharge teaching, use a combination of verbal and written information. This mosteffectively provides patients with standardized care information, which has been shown toimprove patient knowledge and satisfaction.
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 22 preview imageDIF:CognitiveLevel: ApplicationOBJ:Identify the ongoing needs of patients in the process of discharge planning.TOP:Admission to DischargeProcessKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment2.While preparing for the patient‘s discharge, the nurse uses a discharge planning checklist andnotes that the patient is concerned about going home because she has to depend on her familyfor care. The nurse realizes that successful recovery at home is often based on:a.the patient‘s willingness to go home.b.the family‘s perceived ability to care for the patient.c.the patient‘s ability to live alone.d.allowing the patient to make her own arrangements.ANS:BDischarge from an agency is stressful for a patient and family. Before a patient is discharged,the patient and family need to know how to manage care in the home and what to expect withregard to any continuing physical problems. Family caregiving is a highly stressfulexperience. Family members who are not properly prepared for caregiving are frequentlyoverwhelmed by patient needs, which can lead to unnecessary hospital readmissions.DIF:CognitiveLevel: AnalysisOBJ:Identify the ongoing needs of patients in the process of discharge planning.TOP:Medication ReconciliationKEY: Nursing Process Step: AssessmentMSC: NCLEX: Psychosocial Integrity3.The patient arrives in the emergency department complaining of severe abdominal pain andvomiting, and is severely dehydrated. The physician orders IV fluids for the dehydration andan IV antiemetic for the patient. However, the patient states that she is fearful of needles andadamantly refuses to have an IV started. The nurse explains the importance of and rationalefor the ordered treatment, but the patient continues to refuse. What should the nurse do?a.Summon the nurse technician to hold the arm down while the IV is inserted.b.Use a numbing medication before inserting the IV.c.Document the patient‘s refusal and notify the physician.d.Tell the patient that she will be discharged without care unless she complies.
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 23 preview imageANS:CThe Patient Self-Determination Act, effective December 1, 1991, requires all Medicare- andMedicaid-recipient hospitals to provide patients with information about their right to accept orreject medical treatment. The patient has the right to refuse treatment. Refusal should bedocumented and the health care provider consulted about alternate treatment.DIF:CognitiveLevel: ApplicationOBJ:Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission,transfer, and discharge from an acute care facility.TOP:Patient Self-Determination ActKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment4.An unconscious patient is admitted through the emergency department. How and when isidentification of the patient made?a.Determined only when the patient is ableb.Postponed until family members arrivec.Given an anonymous name under the ―blackout‖ procedured.Determined before treatment is startedANS:BIf a patient is unconscious, identification often is not made until family members arrive.Delaying treatment can cause deterioration of the patient‘s condition. Blackout procedures areintended mainly to protect crime victims.DIF:CognitiveLevel: ApplicationOBJ:Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission,transfer, and discharge from an acute care facility.TOP:The Unconscious PatientKEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity5.During admission of a patient, the nurse notes that the patient speaks another language andmay have difficulty understanding English. What should the nurse do to facilitatecommunication?a.Use hand gestures to explain.
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 24 preview imageb.Request and wait for an interpreter.c.Work with the family to gather information.d.Complete as much of the admission assessment as possible using simple phrases.ANS:BIf the patient does not speak English or has a severe hearing impairment, the clerk must haveaccess to an interpreter to assist during the admission procedure. Translation services arepreferable to using family members to ensure correct translation of medical terminology.Hand gestures and simple phrases may not be adequate for everything that will be discussed atthe time of admission.DIF:CognitiveLevel: ApplicationOBJ:Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission,transfer, and discharge from an acute care facility.TOP:The Patient Who Does Not Speak EnglishKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment6.The patient has been admitted to the emergency department after being beaten and raped. Sheis agitated and is frightened that her attacker may find her in the hospital and try to kill her.What should the nurse tell her?a.She is safe in the hospital, and she needs to provide her name.b.She can be admitted to the hospital without anyone knowing it.c.Her records will be used as evidence in the trial.d.Since she has come to the hospital, she has to be examined by the doctor.ANS:BA patient who has been a victim of crime can be admitted anonymously under an agency‘s―blackout‖ or ―do not publish‖ procedure. HIPAA places limits on the institution‘s ability touse or disclose the patient‘s PHI. The Patient Self-Determination Act prohibits the hospitalfrom requiring her to submit to an examination.DIF:CognitiveLevel: AnalysisOBJ:Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission,transfer, and discharge from an acute care facility.TOP:Victim of Crime
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 25 preview imageKEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity7.The patient is admitted to the ICU after having been in a motor vehicle accident. He wasintubated in the emergency department and needs to receive two units of packed red bloodcells. He is conscious but is indicating that he is in pain by guarding his abdomen. To admitthis patient, the nurse first will focus on:a.examining the patient and treating the pain.b.orienting the family to the ICU visitation policy.c.making sure that the consent forms are signed.d.informing the patient of his HIPAA rights.ANS:AWhen a critically ill patient reaches a hospital‘s nursing division, the patient immediatelyundergoes extensive examination and treatment procedures. Little time is available for thenurse to orient the patient and family to the division, or to learn of their fears or concerns.DIF:CognitiveLevel: AnalysisOBJ:Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission,transfer, and discharge from an acute care facility.TOP:Role of the NurseKEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity8.The nurse is admitting the patient to the medical unit. The patient indicates that he has hadseveral surgeries in the past and has been a diabetic for the past 15 years. He also stated thathe is allergic to Morphine. What does this information prompt the nurse to do next?a.Provide the patient with an allergy armband and document his allergies.b.Postpone routine admission procedures immediately.c.Ask the patient if he wants a smoking room.d.Have all family or friends leave the room.ANS:A
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 26 preview imageProvide the patient with an allergy armband listing allergies to foods, drugs, latex, or othersubstances; document allergies according to hospital policy. Postpone routine admissionprocedures only if the patient is having acute physical problems. Smoking is prohibitedthroughout the hospital, and family or friends can remain if the patient wishes to have themassist with changing into a hospital gown or pajamas.DIF:CognitiveLevel: AnalysisOBJ:Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission,transfer, and discharge from an acute care facility.TOP:AllergiesKEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity9.At what age is separation anxiety a common problem?a.School-aged childrenb.Preschoolersc.Middle infancyd.NewbornsANS:CSeparation anxiety is most common from middle infancy throughout the toddler years,especially from ages 16 to 30 months. Preschoolers are better able to tolerate brief periods ofseparation, but their protest behaviors are more subtle than those of younger children (e.g.,refusal to eat, difficulty sleeping, withdrawing from others). School-aged children are able tocope with separation but have an increased need for parental security and guidance.DIF:CognitiveLevel: SynthesisOBJ:Explain the role of the patient‘s family in the admission, transfer, or DischargeProcess.TOP:Pediatric ConsiderationsKEY: Nursing Process Step: AssessmentMSC: NCLEX: Psychosocial Integrity10.The patient is being transferred from the emergency department to another institution fortreatment. Which of the following cannot be delegated to nursing assistive personnel (NAP)?a.Helping the patient get dressedb.Gathering IV equipment to go with the patient
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 27 preview imagec.Escorting the patient to the transport aread.Assessing the patient‘s respiratory status before transportANS:DThe assessment and decision making conducted during transfers cannot be delegated tonursing assistive personnel. NAP can assist the patient with dressing, can gather and securethe patient‘s personal belongings and any necessary equipment, and can escort the patient tothe nursing unit or transport area.DIF:CognitiveLevel: ApplicationOBJ:Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission,transfer, and discharge from an acute care facility.TOP:DelegationKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment11.When does the plan for patient discharge from a health care facility begin?a.At admissionb.After a medical diagnosis has been determinedc.When the patient‘s physical needs are identifiedd.After a home environment assessment is completedANS:APlanning for discharge begins at admission and continues throughout the patient‘s stay in theagency. Separating the processes of admission and discharge is a critical error; the two aresimultaneous and continuous.DIF:CognitiveLevel: ComprehensionOBJ:Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission,transfer, and discharge from an acute care facility.TOP:Discharge PlanningKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment12.The phase of the DischargeProcess where medical attention dominates discharge planningefforts is known as the _____ phase.a.transitional
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 28 preview imageb.continuingc.acuted.multidisciplinaryANS:CThe DischargeProcess occurs in three phases: acute, transitional, and continuing care. In theacute phase, medical attention dominates discharge planning efforts. During the transitionalphase, the need for acute care is still present, but its urgency declines and patients begin toaddress and plan for their future health care needs. In the continuing care phase, patientsparticipate in planning and implementing continuing care activities needed after discharge.There is no multidisciplinary stage; the discharge planning process is comprehensive andmultidisciplinary.DIF:CognitiveLevel: ComprehensionOBJ:Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission,transfer, and discharge from an acute care facility.TOP:Discharge PlanningKEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity13.Once a patient‘s discharge has been completed, which activity may be delegated to assistivepersonnel?a.Provision of prescriptions to the patientb.Completion of the discharge summaryc.Gathering of the patient‘s personal care itemsd.Provision of instructions on community health resourcesANS:CThe assessment, care planning, and instruction included in discharging patients cannot bedelegated to nursing assistive personnel. The nurse may direct the NAP to gather and securethe patient‘s personal items and any supplies that accompany the patient.DIF:CognitiveLevel: ApplicationOBJ:Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission,transfer, and discharge from an acute care facility.TOP:Discharge PlanningKEY: Nursing Process Step: Implementation
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 29 preview imageMSC: NCLEX: Safe and Effective Care Environment14.The nurse is providing discharge instruction to an 80-year-old patient and her daughter. Thepatient lives in a two-story home. When asked if the patient has difficulty climbing stairs, thepatient says ―No,‖ but the nurse notices a look of surprise on the daughter‘s face. What shouldthe nurse do in this circumstance?a.Speak with the daughter separately.b.Cancel the discharge immediately.c.Order a visiting nurse consult.d.Notify the physician.ANS:APatients and family members often disagree on the health care needs of a patient afterdischarge. Identifying these discrepancies early leads to more accurate development of thedischarge plan. It is often necessary to talk with the patient and family separately to learnabout their true concerns or doubts.DIF:CognitiveLevel: ApplicationOBJ:Explain the role of the patient‘s family in the admission, transfer, or DischargeProcess.TOP:Discharge PlanningKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment15.The patient has decided that he would like to create an advance directive. The nurse is asked ifshe would be a witness. What is the best response for the nurse to make to this request?a.Agree to be a witness.b.Refuse to be a witness.c.Contact social work.d.Contact the physician.ANS:CA social worker often fulfills this requirement. Witnesses for an advance directive documentshould not be medical personnel, and direct refusal does not meet the nurse‘s obligation tomeet the patient‘s needs. Referral to a department that can ensure this service is required.DIF:CognitiveLevel: Application
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 30 preview imageOBJ:Explain the purpose and importance of advance directives.TOP:Advance DirectivesKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe and Effective Care EnvironmentMULTIPLE RESPONSE1.The patient is being admitted to the intensive care department with multiple fractures andinternal bleeding. Which of the following are considered roles of the nurse in this situation?(Select all that apply.)a.Anticipate physical and social deficits to resuming normal activities.b.Involve the family and significant others in the plan of care.c.Assist in making health care resources available to the patient.d.Identify the psychological needs of the patient.ANS:A, B, C, DThe nurse identifies patients‘ ongoing health care needs; anticipates physical, psychological,and social deficits that have implications for resuming normal activities; involves family andsignificant others in a plan of care; provides health education; and assists in making healthcare resources available to the patient. Separating the processes of admission and discharge isa critical error; the two are simultaneous and continuous.DIF:CognitiveLevel: ApplicationOBJ:Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission,transfer, and discharge from an acute care facility.TOP:Admission to DischargeProcessKEY: Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity2.Under the Health Insurance Portability and Accountability Act (HIPAA), a patient must:(Select all that apply.)a.provide his true name before he can be treated.b.be informed of his privacy rights.c.have his personal health information used for treatment or payment only.d.be informed as to who can look at and receive health information.
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Test Bank for Clinical Nursing Skills and Techniques, 10th Edition (Chapters 1-43) - Page 31 preview imageANS:B, C, DHIPAA is a federal law designed to protect the privacy of patient health information, referredto as PHI, or protected health information. Three key concepts of HIPAA are (1) institutionsare required to inform patients of the privacy rights they have and how the institution willhandle their PHI; and (2) the institution and health care providers are to use or disclose thepatient‘s PHI only for the purpose of treatment or payment or for health care operations.DIF:CognitiveLevel: KnowledgeOBJ:Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission,transfer, and discharge from an acute care facility.TOP:HIPAAKEY: NursingProcess Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment3.The patient is admitted to the unit for a cardiac catheterization. Which of the following can bedelegated to nursing assistive personnel (NAP)? (Select all that apply.)a.Obtaining admission vital signsb.Preparing the patient‘s roomc.Gathering and securing personal care itemsd.Orienting patient and family to the nursing unitANS:B, C, DThe nursing assessment conducted during admission to a health care facility cannot bedelegated to NAP. You cannot delegate admission vital signs as they provide a baseline for allfurther comparisons. The nurse directs NAP to (1) prepare the patient‘s room with necessaryequipment before admission; (2) gather and secure the patient‘s personal care items; (3) escortand orient the patient and family to the nursing unit; and (4) collect ordered specimens.DIF:CognitiveLevel: AnalysisOBJ:Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission,transfer, and discharge from an acute care facility.TOP:Delegation ConsiderationsKEY: NursingProcess Step: ImplementationMSC: NCLEX: Safe and Effective Care Environment4.Which of the following are considered ―advance directives‖? (Select all that apply.)
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