Test Bank for Concepts for Nursing Practice, 3rd Edition (Chapters 1-57)

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TEST BANK FORGiddens:ConceptsforNursingPractice,3rdEdition2024/2025UPDATE WITHRATIONALESConcept01:DevelopmentGiddens:ConceptsforNursingPractice,3rdEditionMULTIPLECHOICE1.The nurse manager of a pediatric clinic could confirm that the new nurse recognized thepurpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it isusedto assessforneeds related toa.anticipatoryguidance.b.low-riskadolescents.c.physicaldevelopment.d.sexualdevelopment.ANS:AThe HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool whichassesses home, education, activities, drugs, sex, and suicide for the purpose of identifyinghigh-risk adolescents and the need for anticipatory guidance. It is used to identify high-risk,notlow-risk,adolescents.Physicaldevelopmentisassessed withanthropometricdata.Sexualdevelopmentisassessedusingphysicalexamination.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance2.The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, theexpectedstageof development for apreschoolerisa.concreteoperational.b.formaloperational.c.preoperational.d.sensorimotor.ANS:CThe expected stage of development for a preschooler (3–4 years old) is pre-operational.Concrete operational describes the thinking of a school-age child (7–11 years old). Formaloperational describes the thinking of an individual after about 11 years of age. Sensorimotordescribestheearliest pattern ofthinking from birth to 2 yearsold.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance3.The school nurse talking with a high school class about the difference between growth and

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developmentwould bestdescribegrowthasa.processesbywhichearlycellsspecialize.b.psychosocialandcognitivechanges.c.qualitativechangesassociatedwithaging.d.quantitative changes in size or weight.ANS:D

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Growth is a quantitative change in which an increase in cell number and size results in anincrease in overall size or weight of the body or any of its parts. The processes by whichearly cells specialize are referred to asdifferentiation.Psychosocial and cognitive changesare referred to asdevelopment.Qualitative changes associated with aging are referred to asmaturation.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance4.Themostappropriate response of the nurse when a mother asks what the Denver II does isthat ita.candiagnosedevelopmental disabilities.b.identifiesaneedforphysical therapy.c.isadevelopmental screeningtool.d.providesaframeworkforhealthteaching.ANS:CThe Denver II is the most commonly used measure of developmental status used byhealthcare professionals; it is a screening tool. Screening tools do not provide a diagnosis.Diagnosisrequiresathorough neurodevelopment historyand physicalexamination.Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. Theneed for any therapy would be identified with a comprehensive evaluation, not a screeningtool. Some providers use the Denver II as a framework for teaching about expecteddevelopment, but thisisnot theprimary purpose of thetool.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance5.To planearly interventionanNdcareforan infantwithDownsyndrome, thenurseconsidersknowledgeof other physical development exemplars such asa.cerebralpalsy.b.autism.c.attention-deficit/hyperactivitydisorder(ADHD).d.failuretothrive.ANS:DFailure to thrive is also a physical development exemplar. Cerebralpalsy is an exemplar ofmotor/developmental delay. Autism is an exemplar of social/emotional developmentaldelay.ADHD isan exemplarof a cognitive disorder.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance6.To plan early intervention and care for a child with a developmental delay, the nurse wouldconsiderknowledgeoftheconceptsmost significantlyimpactedbydevelopment, includinga.culture.b.environment.c.functionalstatus.d.nutrition.ANS:C

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Function is one of the concepts most significantly impacted by development. Others includesensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of theseconcepts can help the nurse anticipate areas that need to be addressed. Culture is a conceptthat is considered to significantly affect development; the difference is the concepts thataffect development are those that represent major influencing factors (causes); hencedetermination of development would be the focus of preventiveinterventions. Environmentis considered to significantly affect development. Nutrition is considered to significantlyaffectdevelopment.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance7.A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talksto her toys and makes up stories. The mother wants her child to have a psychologicalevaluation.Thenurse’sbestinitialresponseis toa.referthechildto apsychologistimmediately.b.explainthatplayingmakebelieveisnormalatthisage.c.completeadevelopmental screening usingavalidatedtool.d.separatethechildfromthemothertogetmoreinformation.ANS:BBy the end of the fourth year, it is expected that a child will engage in fantasy, so this isnormal at this age. A referral to a psychologist would be premature based only on thecomplaint of the mother. Completing a developmental screening would be veryappropriatebut not the initial response. The nurse would certainly want to get more information, butseparatingthechild fromthemotheris not necessaryat this time.OBJ:NCLEXClientNeedsNCategory:HealthPromotionandMaintenance8.A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she isso needy and acting like a child. Thebestresponse of the nurse is that in the hospital,adolescentsa.haveseparation anxiety.b.rebelagainstrules.c.regressbecauseofstress.d.wanttoknoweverything.ANS:CRegression to an earlier stage of development is a common response to stress. Separationanxiety is most common in infants and toddlers. Rebellion against hospital rules is usuallynot an issue if the adolescentunderstands the rules and would not create childlike behaviors.An adolescent may want to “know everything” with their logical thinking and deductivereasoning,but that wouldnot explain whythey would act likeachild.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance

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Concept02:FunctionalAbilityGiddens:ConceptsforNursingPractice,3rdEditionMULTIPLECHOICE1.The nurse is assessing a patient’s functional ability. Which patientbestdemonstrates thedefinitionoffunctional ability?a.Considersselfasahealthy individual; usescaneforstabilityb.Collegeeducated;travelsfrequently;canbalance acheckbookc.Worksout daily,readswell,cooks,andcleanshouseontheweekendsd.Healthy individual, volunteers at church, works part time, takes care of family andhouseANS:DFunctional ability refers to the individual’s ability to perform the normal daily activitiesrequired to meet basic needs; fulfill usual roles in the family, workplace, and community;and maintain health and well-being. The other options are good; however,healthyindividual, church volunteer, part time worker, and the patient who takes care of the familyandhousefully meets the criteriafor functionalability.OBJ:NCLEXClientNeedsCategory:PhysiologicalIntegrity:BasicCareandComfort2.Thenurseisassessingapatient’sfunctionalperformance.Whatassessmentparameterswillbemostimportantinthisassessment?a.Continenceassessment,gaitassessment,feedingassessment,dressingassessment,transferassessmentb.Height,weight,bodymassindex(BMI),vitalsignsassessmentc.Sleep assessment, energy assessment, memory assessment, concentrationassessmentd.Health and well-being, amount of community volunteer time, working outside thehome,and ability to careforfamily and houseANS:AFunctional impairment, disability, or handicap refers to varying degrees of an individual’sinability to perform the tasks required to complete normal life activities without assistance.Height, weight, BMI, and vital signs are part of a physical assessment. Sleep, energy,memory, and concentration are part of a depression screening. Healthy, volunteering,working,andcaring for family and housearefunctionalabilities,not performance.OBJ:NCLEXClient NeedsCategory:Physiological Integrity:ReductionofRiskPotential3.The nurse is assessing a patient with a mobility dysfunction and wants to gain insight intothepatient’s functionalability.Whatquestionwouldbethemostappropriate?a.“Areyouabletoshopforyourself?”b.“Doyouuseacane, walker,orwheelchairtoambulate?”c.“Doyouknowwhattoday’sdateis?”d.“Were you sad or depressed more than once in the last 3 days?”ANS:B

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“Do you use a cane, walker, or wheelchair to ambulate?” will assist the nurse in determiningthe patient’s ability to perform self-care activities. A nutritional health risk assessment is notthe functional assessment. Knowing the date is part of a mental status exam. Assessingsadnessis aquestion to ask in thedepression screening.OBJ:NCLEXClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation4.The nurse is developing an interdisciplinary plan of care using the Roper-Logan-TierneyModel of Nursing for a patient who is currently unconscious. Which interventions would bemostcritical to developing a plan ofcareforthispatient?a.Eatinganddrinking,personalcleansinganddressing,working andplayingb.Toileting,transferring,dressing,andbathingactivitiesc.Sleeping,expressingsexuality,socializingwithpeersd.Maintainingasafeenvironment,breathing,maintaining temperatureANS:DThe most critical aspects of care for an unconscious patient are safe environment, breathing,and temperature. Eating and drinking are contraindicated in unconscious patients. Toileting,transferring, dressing, and bathing activities are BADLs. Sleeping, expressing sexuality, andsocializing with peers are a part of the Roper-Logan-Tierney Model of Nursing; however,thesearenotthemostcritical fordevelopingthe planof carein an unconsciouspatient.OBJ:NCLEXClientNeedsCategory: PhysiologicalIntegrity:PhysiologicalAdaptation5.The home care nurse is trying to determine the necessary services for a 65-year-old patientwho was admitted to the home care service after left knee replacement. Which tool is thebestforthe nurseto utilize?a.MinimumDataSet(MDS)b.FunctionalStatusScale(FSS)c.24-HourFunctionalAbilityQuestionnaire(24hFAQ)d.TheEdmontonFunctionalAssessmentToolANS:CThe 24hFAQ assesses the postoperative patient in the home setting. The MDS is for nursinghomepatients. The FSSis forchildren.TheEdmonton isforcancerpatients.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance6.The nurse is assessing a patient’s functional abilities and asks the patient, “How would yourate your ability to prepare a balanced meal?” “How would you rate your ability to balance acheckbook?” “How would you rate your ability to keep track of your appointments?” Whichtoolwouldbeindicated forthebestresults ofthispatient’sperception oftheir abilities?a.FunctionalActivitiesQuestionnaire(FAQ)b.MiniMentalStatusExam(MMSE)c.24hFAQd.Performance-based functional measurementANS:A

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The FAQ is an example of a self-report tool which provides information about the patient’sperception of functional ability. The MMSE assesses cognitive impairment. The 24hFAQ isused to assess functional ability in postoperative patients. Performance-based tools involveactual observation of a standardized task, completion of which is judged by objectivecriteria.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenanceMULTIPLERESPONSE1.A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse isassessing the patient’s risk for falls so that falls prevention can be implemented if necessary.Select all the risk factors that apply from this patient's history and physical. (Select all thatapply.)a.Beingawomanb.Taking morethansixmedicationsc.Havinghypertensiond.Havingcataractse.Musclestrength3/5bilaterallyf.IncontinenceANS:B,D,E, FAdverse effects of medications can contribute to falls. Cataracts impair vision, which is arisk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine orstool increases risk for falls. Men have a higher risk for falls. Hypertension itself does notcontributetofalls.TakingmeNdicationstotreathypertensionthatmayleadtohypotensionanddizzinessisafall risk. Dizzinessdoescontributetofalls.OBJ:NCLEXClient NeedsCategory:Physiological Integrity:ReductionofRiskPotential

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Concept03:FamilyDynamicsGiddens:ConceptsforNursingPractice,3rdEditionMULTIPLECHOICE1.Themostappropriate initial nursing intervention when the nurse notes dysfunctionalinteractions and lack offamily supportfor apatient wouldbetoa.enforcehospitalvisitingpolicies.b.monitorthedysfunctionalinteractions.c.notifytheprimarycareprovider.d.rolemodel appropriatesupport.ANS:DNurses can, at times, role model more appropriate interactions or provide suggestions forimprovingcommunicationandinteractionsamongfamilymembers. Ifthenursedeterminesthat the number of visitors has a negative impact on the patient, hospital policy may be tolimit visitors, but that would not be the initial action. Monitoring the dysfunctionalinteractions would not be an adequate response. The primary care provider should certainlybenotified, but that wouldnot bethe initial response.OBJ:NCLEXClientNeedsCategory:Psychosocial Integrity2.The nurse caring for a patient would identify a need for additional interventions related tofamilydynamics whena.extendedfamily offerstohelp.b.familymembersexpressconcern.c.theillmemberdemandsattention.d.memoriesareshared.ANS:CIt is not uncommon for the ill family member to become demanding and indicate that theydeserve special treatment and care, and the supportive family may need assistance inunderstanding the dynamics of the illness in order to continue to be supportive. Offers fromextended family to help can be indicative of positive dynamics. Concern expressed byfamily members can be indicative of positive dynamics. Sharing of family memories can beindicativeof positive dynamics.OBJ:NCLEXClientNeedsCategory:Psychosocial Integrity3.Two women have an established long-term relationship and are attending parenting classesin anticipation of finalizing adoption of a baby. The nurse identifies them as which type offamily?a.Cohabitingb.Nuclearc.Same-sexd.Single parentANS:C

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This family would be considered a same-sex family.Cohabitingrefers to a couple who livetogether with no legal bond.Nuclearrefers to the traditional male and female core familywith one or more children.Single parentrefers to a family with one adultand one or morechildren.OBJ:NCLEXClientNeedsCategory:Psychosocial Integrity4.The nurse identifies the family with a child graduating from college as having which effectonthe family lifecycle?a.Minimalimpactb.Considered tobeanegativeimpact on thefamilyunitc.Leadstoroleconfusiond.Expectation ofrolechangeANS:DThe family life cycle developmental theory focuses on the growth and development ofchanges in role relationships during transitional periods. A child graduating from college isan example of a transition which requires a role change. As this is a transition, one wouldexpect to see a change so minimal impact would not be expected. Graduation does not implythatit will beanegativechangeon thefamilylifecycleorlead toroleconfusion.OBJ:NCLEXClientNeedsCategory:PsychosocialIntegrity5.When reviewing the purposes of a family assessment, the nurse educator would identify aneed for further teaching if the student responded that family assessment is used to gain anunderstanding of whichaspect of the family?a.Developmentb.Functionc.Politicalviewsd.StructureANS:CAn understanding of the political views of family members is not a primary purpose of afamily assessment. A family assessment provides the nurse with information and anunderstanding of family dynamics. This is important to nurses for the provision of qualityhealth care. A family assessment provides an understanding of family development,function,and structure.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance6.Anurseis planningtoassessthestructureofafamily.Whichquestionshould thenurseask?a.“Wholiveswithyou inthishome?”b.“Whodoesthegroceryshopping?”c.“Whoprovidessupportinyourfamily?”d.“How old are the members of your family?”ANS:A

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The structure of the family includes who is in the family and what their relationship is.“Who does the shopping?” would provide information about family functioning. “Whoprovides support?” would provide information about family functioning. “How old are themembers?” would provideinformation aboutfamily development.OBJ:NCLEXClientNeedsCategory:Psychosocial Integrity7.Whichfactorswhichwouldalertthenursetonegative/dysfunctional familydynamics?a.Agingoffamilymembersb.Chronicillnessofafamily memberc.Disabilityofafamilymemberd.IntimatepartnerviolenceANS:DIntimate partner violence is an exemplar of negative/dysfunctional family dynamics. Agingof family members is an exemplar of changes to family dynamics. Chronic illness of afamily member is an exemplar of changes to family dynamics. Disability of a familymemberis an exemplar of changestofamily dynamics.OBJ:NCLEXClientNeedsCategory:Psychosocial Integrity

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Concept04:CultureGiddens:ConceptsforNursingPractice,3rdEditionMULTIPLECHOICE1.ThenurseiscaringforanolderChineseadult malewhoisgrimacingandappearsrestlessafterabdominalsurgery.Whatisthenurse’sbestaction?a.Askthepatientifheis anxious about hishospital stay.b.Askatranslatortoconduct aFACES painscaleassessment.c.Askthepatientaboutpain andassessvitalsigns.d.Askthepatientaboutanyhistoryofdepressionor anxiety.ANS:CIn the Chinese culture, elderly Chinese people believe that they must be stoic about pain andthere is a stigma about talking about any mental health problems. The nurse should ask thepatient aboutpainandalsoassessvitalsignsforphysiologicalsignsofpain,sincethepatient may not admit to any pain. Assuming the patient is depressed or anxious is not thebest action when considering individual cultural differences and the risk of pain after majorsurgery.Theregisterednurseshouldneverdelegateassessmenttoanyunlicensedmemberof the healthcare team such as a translator. The translator may assist with communication,butthe nurseis responsibleforthepainassessment.OBJ:NCLEX Client Needs Category: Psychosocial Integrity | NCLEX Client NeedsCategory:Physiological Integrity: BasicCareandComfort2.Understanding cultural differncesinhealthcareisimportantbecauseitwillhelp thenursetounderstandthemannerinwhichpeopledecide onobtaining treatmentsandmedicalcare.Inindependent culturesanindividualwilla.puthimselffirst.b.consultfamilymembers foradvice.c.askforasecond opinion.d.travelgreatdistancestoreceivethebestcare.ANS:AIn independent cultures, an individual will put himself first in the case of a life-threateningillness, whereas even in dire circumstances, members of collectivist cultures may stillconsult other family members for the best course of action. In independent cultures, anindividual will not consult with other family members, ask for a second opinion, or travelgreatdistancesto receivethe best care.OBJ:NCLEXClientNeedsCategory:Psychosocial Integrity3.When teaching an Asian patient with newly diagnosed diabetes, the nurse notes the patientnodding yes to everything that is being said. With a better understanding of culturalinterdependencein self-concept, a nurseshouldimmediatelya.writeeverythingdownforthepatient torefertolater.b.promptfurthertoelicit additionalquestionsorconcerns.c.calltherecognizedelderforthispatient.d.call theoldestmalerelativeforhelp withdecisionmaking.e

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ANS:BWhen a nurse provides nutritional education to a patient who is from a culture that valuesgreater power distance, it might appear that the patient is willing to accept all that the nursesuggests, when further prompting would elicit additional questions or concerns. The patientfromacollectivistculturewill usuallyconsultfamilymembersforabestcourseofaction.Itis not acceptable for nurses to take it upon themselves to call the recognized elder or oldestmale relative for help with decision making. While writing everything down may be OK forsome cultures, with Asian patients it may be best to prompt further to elicit additionalquestionsor concerns.OBJ:NCLEXClientNeedsCategory:Psychosocial Integrity4.Women who are given the job of caretaker for aging relatives are subject to caregiver strainduetoa.feminineattributes.b.unequalgender.c.fixedgenderroles.d.femaleinequality.ANS:CIn cultures with more fixed gender roles, women are usually given the role of caretaker foraging relatives and may suffer the stresses of caregiver strain. Feminine attributes refers toharmonious relationships, modesty, and taking care of others. Unequal gender refers to rolesof males and females being unevenly distributed. Female inequality refers to female genderandroles being lessthanor unequalto maleroles.OBJ:NCLEXClientNeedsCategory:Psychosocial Integrity5.A 60-year-old Italian immigrant presents for an annual physical. He is counseled aboutdiagnostic testing including laboratory testing, colonoscopy, influenza vaccination, andpneumococcal vaccination. His reply is “If it ain’t broke, don’t try to fix it.” Whendeveloping a plan of care, the nurse should consider which cultural orientation for thispatient?a.Shorttermb.Longtermc.Leisurelytermd.NoncommittalANS:AShort-term cultural orientation focuses on the present or past and emphasizes quick results.Long-term cultural orientationfocusesthe futureand long-termrewards.Long-term-oriented cultures favor thrift, perseverance, and adopting to changingcircumstances.Leisurely termandnoncommittalareundefinedinculturalorientation.OBJ:NCLEXClientNeedsCategory:Psychosocial Integrity6.Theemphasis onunderstandingculturalinfluence onhealthcareisimportantbecauseofa.disabilityentitlements.b.HIPAArequirements.

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c.increasingglobaldiversity.d.litigioussociety.ANS:CCulture is an essential aspect of health care because of increasing diversity. Disabilityentitlements refer to defined benefits for eligible mental or physically disabled beneficiariesin relation to housing, employment, and health care. HIPAA requirements refers to theHIPAA Privacy Rule, which protects the privacy of individually identifiable healthinformation; the HIPAA Security Rule, which sets national standards for the security ofelectronic protected health information; and the confidentiality provisions of the PatientSafety Rule, which protect identifiable information being used to analyze patient safetyevents and improve patient safety. Litigious society refers to excessively ready to go to laworinitiate alawsuit.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance7.Whatinterrelatedconstructsfacilitateanursetobecomeculturally competent?a.Culturaldiversity,self-awareness,culturalskill,andculturalknowledgeb.Culturaldesire,self-awareness,culturalknowledge,andculturalidentityc.Culturaldesire,self-awareness,culturalknowledge,andculturaldiversityd.Culturaldesire,self-awareness,culturalknowledge,andculturalskillANS:DTheprocessofcultural competenceconsistsoffourinterrelatedconstructs: culturaldesire,self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context ofhealthcarereferstoachievingthehighestlevelofhealthcareforallpeople byaddressingsocietal inequalitiesandhistorical andcontemporary injustices. Cultural identity isthenorms,values,beliefs,ofaculturelearnedthroughfamiliesand groupmembers.OBJ:NCLEXClientNeedsCategory:Psychosocial Integrityand behaviors

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Concept05:SpiritualityGiddens:ConceptsforNursingPractice,3rdEditionMULTIPLECHOICE1.Thenurseisassessinga patient'sspirituality andobservesthepatientmeditatingbeforeanytreatments.What isthenurse’sbestaction?a.Documentthatthepatientisnot religious.b.Offerthepatient acopy oftheBibletoread.c.Arrangeforquiettimeforthepatient as needed.d.Limitthetimepatientcanmeditatebeforeprocedures.ANS:CThenursecanbestpromotethepatient’sspirituality practicesbyarrangingforthepatienttobe left alone when possible to meditate. Meditation is an exemplar of spirituality, notnecessarily of the Christian faith. The Bible is most often read by believers in the Christianfaith. Meditationdoes not imply that the patient is not religious. Time for meditation shouldnotbelimited, wheneverpossible.OBJ:NCLEX Client Needs Category: Safe and Effective Care Environment: HealthPromotion and Maintenance2.When conducting a spiritual assessment of a hospitalized patient, the nurse should remainawareof which potentialbarriertoeffectivecommunication?a.Clarifying themeaningofapatient’sstatement.b.Multi-taskingwhiletalkinpatient.c.Listeningtopatients’complete statements.d.Discussingpatient’sfeelingswhilehospitalized.ANS:BSeveral barriers may result in the nurse’s inability to be totally present and communicateeffectively with the patient. First, the nurse may be distracted by other things and may notpay attention to the patient. Multi-tasking while trying to listen to a patient may be a barrierto effective communication. Second, the nurse may miss the meaningof the patient’smessage because of failure to clarify the meaning of a word, a phrase, or a facial expression.Third, the nurse may interject personal feelings and reactions into the patient’s situationrather than allow the patient to explore and discuss his own feelings and reactions. The lastbarrieroccurswhenthenurseisbusyformulatinga responsewhilethepatientisstilltalking.In thisinstance, thenursenever hears thepatient’s message.OBJ:NCLEX Client Needs Category: Safe and EffectiveCare Environment: PsychosocialIntegrity3.A patient uses rosary beads and attends mass once a week. This expression of spirituality isbestdescribedwith which term?a.Religiosityb.Faithc.Beliefd.Authenticityg to the

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ANS:AThere are a few similar and related terms to spirituality worth mentioning to providedistinction and clarification. Faith, as defined by Dyess, refers to an “evolving pattern ofbelieving, that grounds and guides authentic living and gives meaning in thepresentmoment of inter-relating.” Religiosity, another similar term, is an external expression(public or private), in the form of practicing a belief or faith, whereas spirituality is aninternalized spiritual identity (or experiential). Specifically, religiosity is defined as “theadherence to religious dogma or creed, the expression of moral beliefs, and/or theparticipation in organizedorindividual worship,orsacredpractices.”OBJ:NCLEX Client Needs Category: Safe and Effective Care Environment:PsychosocialIntegrity4.When developing a plan of care, the nurse should consider which attribute of the concept ofspirituality?a.Spiritualityisnotawell-knownuniversalconcept.b.Chronicversusacuteillnessesaffectspirituality.c.Convincingpatientstoprayisapriorityintervention.d.Referralsmaybeneededtospiritualcounselors.ANS:DThe attributes of the concept of spirituality in the context of nursing care are describedbelow.•Spirituality is universal. All individuals, even those who profess no religious belief,aredriven to derivemeaning and purpose from life.•Illnessimpactsspiritulity in a variety ofways.Some patientsandfamilieswill drawclosertoGodorhowever they conceivethat higherPowerto beinan effort to seeksupport, healing, and comfort. Others may blame and feel anger toward that HigherPower for any illness and misfortune that may have befallen a loved one or theirentirefamily. Stillotherswillbeneutral in theirspiritual reactions.•There has to be willingness on the part of patient and/or family to share and/or act onspiritual beliefsand practices.•The nurse needs to be aware that specific spiritual beliefs and practices are impactedbyfamily and culture.•The nurse needs to be willing to assess the concept of spirituality in patients andfamilies and based on this ongoing assessment to integrate the spiritual beliefs ofpatients and families intocare.•The nurse needs to be willing to refer the patient or family to a Spiritual Expert i.e., aMinister, Priest,Rabbi, an Imam.•Community-based religious organizations can provide supportive care to familiesandpatients and nursesneed to beawareof these resources.OBJ:NCLEX Client Needs Category: Safe and Effective Care Environment: PsychosocialIntegrityMULTIPLERESPONSEa

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1.When completing the FICA tool for spiritual assessment, which questions should the nurseaskthepatient? (Select all that apply.)a.Whatthings doyoubelieveinthatgivemeaning tolife?b.Areyouconnectedwith afaithcenterinyourcommunity?c.Howhasyourillnessaffectedyourpersonalbeliefs?d.Whenwasthelasttimeyouhavebeentochurch?e.WhatcanIdoforyou?ANS:A,B,C,EThe FICA tool for spiritual assessment stands forFaith or beliefs, Importance and influence,Community, andAddress. “When was the last time you have been to church?” is not aquestion included in the FICA assessment. The patient may attend community activities,besideschurch, that foster his/herspiritual well-being.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance2.Which are true statements about the definition of spirituality in nursing? (Select all thatapply.)a.Patient’squalityoflife,health,andsenseofwholenessareaffectedbyspirituality.b.Anexact definitionwasdevelopedandadoptedinthelate 1980s.c.Encompassesprinciple,anexperience,attitudes,andbeliefregardingGodd.Headknowledgeaffects spiritualitymorethanheartknowledge.e.Mind,body, spirit,love,andcaring areinterconnected.ANS:A,C, EThe concept of Spirituality is an elusive concept to define. Authors who write aboutspirituality in nursingadvocaposition that apatient’s quality of life,health,andsenseofwholenessareaffected byspirituality, yetstilltheprofession ofnursingstrugglestodefine it. Why? There are a number of explanations for this. One explanation is thatspirituality represents “heart” not “head” knowledge and “heart” knowledge is difficult toencapsulate into words. A second explanation is that spirituality is unique to each person soa precise definition is somewhat elusive. The definitions of spirituality encompass thefollowing:aprinciple,anexperience,attitudesandbeliefregardingGod,asenseofGod,theinner person. Most descriptions of spirituality include not only transcendence but also theconnection of mind, body, and spirit, plus love, caring, and compassion and a relationshipwiththeDivine.OBJ:NCLEX Client Needs Category: Safe and Effective Care Environment: HealthPromotion and Maintenance3.Which life events should the nurse recognize as being spiritually life changing? (Select allthat apply.)a.Birthsb.Weddingsc.Medicaldiagnosesd.Careerdayto dayjobdutiese.Loss of independenceANS:A,B, C, Ete the

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The meaning and significance of the event might only be experienced by one individual;others who might be participants in the event might be left virtually untouched andunchanged. These life changing spiritual events include just aboutany occurrence that hasintense and personal relevance to those involved in the event. Examples of spiritually lifechanging events include births, deaths, weddings, divorces, illnesses, diagnoses, and loss ofabilities, loss of independence, death and so many more. These events, having the power tochange individuals and families, also have the power to draw people toward thetranscendent—for many people that transcendent is known as God but this is not universal.Day-to-dayactivitiesare notthebestexamplesof spiritually lifechanging events.OBJ:NCLEX Client Needs Category: Safe and Effective Care Environment: PsychosocialIntegrity

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Concept06:AdherenceGiddens:ConceptsforNursingPractice,3rdEditionMULTIPLECHOICE1.A patient has been newly diagnosed with hypertension. The nurse assesses the need todevelop a collaborative plan of care that includes a goal of adhering to the prescribedregimen. When the nurse is planning teaching for the patient, which is the most importantinitial learning goal?a.Thepatient willselectthetypeoflearningmaterialstheyprefer.b.The patient will verbalize an understanding of the importance of followingtheregimen.c.Thepatient willdemonstratecopingskillsneededtomanagehypertension.d.Thepatient willverbalizethesideeffects oftreatment.ANS:AAdults learn best when given information they can understand that is tailored to theirlearning styles and needs. Verbalizing an understanding is important; however, the nursewill first need to teach the patient.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance2.After the nurse implements a teaching plan for a newly diagnosed patient with hypertension,the patient can explain the information but fails to take the medications as prescribed. Whatisthenurse’snextaction?a.Reeducate thepatient, becuselearning did not occurbecausethepatient’sbehaviordid not change.b.Assessthepatient’sperceptionandattitudetowardtherisksassociatedwithnottakingtheiranti-hypertensives.c.Takefullresponsibilityforhelpingthepatientmakedietarychanges.d.Ask the provider to prescribe a different medication, because the patient does notwantto takethis medication.ANS:BAlthough the patient behavior has not changed, the patient’s ability to explain theinformation indicates that learning has occurred. The nurse would need to ask what thepatient’s perceptions are of taking the medications to determine if the patient understandstheramifications ofnottaking themedication.Thepatientmaybeinthecontemplationorpreparation state (see Health Belief Model). The nurse should reinforce the need for changeandcontinue to provideinformation andassistancewithplanning for change.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance3.A diabetic patient presents to the diabetes clinic withA1clevels of 7.5%. The nurse has metthis patient for the first time. When applying principles of Theory of Planned Behavior(TPB),which teaching strategyby thenurseismostlikelytobeeffective?a.Provide information on the importance of blood glucose control in maintenance oflong-term health and evaluate how the patient has been following the prescribedregime.a

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b.Establish a rapport with the patient by complimenting them on what they didcorrectly, and ask whatstrategies they havetriedthus far.c.Refer the patient to a certified diabetic educator, because the educator is an expertonmanagement ofdiabetes complications.d.Have the patient explain what medications they are on and what diet they shouldbefollowing.ANS:BPrinciples of a TPB indicate that the patient will need to establish a good rapport with thenurse in order to talk about nonadherence. If the patient finds it difficult to discuss theirdiabetes self-management and adherence with the nurse, the patient may not open up to thenurse. Although a referral to an educator is a good idea, it would be better to use thisresource as a follow-up for this visit. Having the patient verbalize medications and diet isnotpart ofthe TPB method.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance4.The nurse is assessing a newly diagnosed diabetic, and the patient’s readiness to learn aboutglucose monitoring. Before planning teaching activities, which approach would bemosteffective?a.Assistthepatientwithlong-termgoalsandplanteachingaccordingtothese goals.b.Provide the patient with all the latest research from the Internet on glucosemonitoring.c.Refer the patient to the diabetic specialist who can assist the patient with theglucometer.d.Assistthepatientindevelopingrealisticshort-termgoals.ANS:DConcordance reflects development of an alliance with patients based on realisticexpectations. Providing the patient with the research will not help with the practical skill ofusing the glucometer. Long-term goals are useful; however, the goals need to beimmediatewith a newly diagnosed patient learning a new skill. Referring the patient would be useful ifthepatient has notbeenable to grasp theconcept afterseveral attempts.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance5.The nurse is developing a care plan for a patient who has low motivation and nonadherencewith blood glucose monitoring. Which statement by the patient would indicate to the nursethatthe patient isnot motivated andwillmostlikely notcomply?a.“Ido notliketo testmy sugar,butIdoit becausemy wifenagsme.”b.“Iforgettocheckmysugaronceinawhile.”c.“Idon’t seeorfeel any differentwhenIdo keepmy bloodsugars undercontrol.”d.“Ihavenoideawhatthe signsof lowblood sugarare.”ANS:CIf patients do not perceive any benefit from changing their behavior, sustaining the changebecomes very difficult. Having someone remind the patient is more likely to reinforcecompliance. Forgetting to check glucose occasionally may indicate the patientneedsmemory cues or joggers. The patient who does not know the signs of low glucose will needfurtherteaching.

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OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance6.The nurse is preparing a discharge teaching plan for a patient who has peripheral vasculardisease and has poor circulation to the feet. Which learning goal should the nurse include intheteaching plan?a.Thenursewilldemonstratethepropertechniquefortrimming toenails.b.Thepatient will understandtherationaleforproperfootcareafterinstruction.c.Thenursewill instruct thepatient onappropriatefoot carebeforedischarge.d.The patient will post reminder stickers on the calendar to check feet every day andrecordscheduledappointments with podiatrist.ANS:DTo improve the patient adherence to treatment, it will be important to help them developreminder strategies that fit into their lifestyle. Options A and C describe actions that thenurse will take, rather than behaviors that indicate that patient learning has occurred. OptionBis toovagueand nonspecificto measurewhetherlearning has occurred.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance7.Apatientwith hypertensionisprescribedalow-sodiumdiet.Thepatient’steaching planincludes this goal: “The patient will select a 2-gram sodium diet from the hospital menu forthe next 3 days.” Which intervention would be most effective at increasing the patient’scompliancewith thediet?a.Checkthesodiumcontentof thepatient’smenuchoices overthenext3days.b.Askthepatient toidentifywhichfoodson thehospital menusarehigh insodium.c.Havethe patient listfavoNritefoodsthatarehigh insodiumandfoods that could besubstitutedforthesefavorites.d.Comparethepatient’ssodium intakeoverthenext 3dayswiththesodiumintakebeforetheteaching was implemented.ANS:CIncluding a patient’s favorite foods will most likely increase compliance, because the patientis not being deprived. Checking the sodium will be useful for teaching strategies but will notbethe most effective means of increasingadherence.OBJ:NCLEXClient NeedsCategory:HealthPromotionandMaintenance8.The nurse is evaluating the need to refer a patient with osteoarthritis for a home care visit tobe sure the patient can function in accomplishing daily activities independently. What is thenurse’sfirstpriority?a.Determine if the patient has had home visits before and if the experience waspositive.b.Checkthepatient’sabilitytobathewithout anyassistancethenextday.c.Havethepatientdemonstratethelearnedskillsattheend oftheteachingsession.d.Arrange a physical therapy visit before the patient is discharged from the hospital.ANS:A

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To begin the assessment of adherence, it is first important to clarify with the patient (a) theirbeliefs and perceptions about their health risk status, (b) their existing knowledge aboutcardiovascular disease risk reduction, (c) anyprior experience with healthcare professionals,and (d) their degree of confidence with controlling the disease. The other actions allowevaluationofthepatient’sshort-termresponsetoteaching.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance9.A 73-year-old male patient is seen in the home setting for a routine physical. The nursenotes which behavior as themostreassuring sign that the patient has been following thetreatmentplanforthediagnoses ofhypertension,diabetes, and hyperlipidemia?a.Thepatienthas alistofglucosereadingsforthepast10days.b.Thepatient has alistof medications alongwithnewlyrefilledmeds.c.Thepatienthasalist ofall foodsandbeveragesfor a3-dayperiod.d.Thepatient verbalizesthesideeffects ofallhismedications.ANS:BConfirminghowoftenapatientrenewsorrefillshis/herprescriptionsisameasurementofthe patient’s persistence with continuation of the treatment. Having a list of glucose readingsorverbalizing side effects does not necessarily mean that the patient is compliant unless thereadings wereallnormal,which isnot indicated.Listingfoods maynotindicatethe patientisfollowing thetreatment plan.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance

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Concept07:Self-ManagementGiddens:ConceptsforNursingPractice,3rdEditionMULTIPLECHOICE1.The nurse is developing a plan of care for a newly diagnosed hypertensive patient who isbeing discharged on medications and given the Dietary Approaches to Stop Hypertension(DASH) diet to follow. What statement by the patient signals to the nurse that the patient ismotivatedto learn?a.“Iamsurethemedicationswillhelptobringdownmybloodpressure.”b.“Ican’twait totrythenewrecipes,andI’mhopefulIwill loseweight.”c.“Do Ireallyneedtofollowthediet andtakemedications?”d.“Ihavemyparentstoblameforthis.Theybothhavehighbloodpressure.”ANS:BA patient who is motivated will see what the benefits of following the teaching will do forthem and will most likely be able to manage their own care. The patient who believesmedications aretheonly solutionmay notbemotivated tofollow theprescribeddiet.Blaming the parents for their condition does not show accountability or motivation forchange.OBJ:NCLEX Client Needs Category: Physiological Integrity | NCLEX Client NeedsCategory:Physiological Integrity: Physiological Adaptation2.The nurse is assessing a patient’s readiness to be discharged and ability to manage care athome.What isthemostapproNpriatequestionforthenursetoaskto determinethepatient’slearningneeds before planning teaching activities?a.“Whatareyourhobbiesandoccupation?”b.“Whatdoyouneed toknowbeforeyougohome fromthehospital?”c.“Do you have any cultural or religious beliefs that you would like incorporatedintoyourplan ofcare?”d.“Whatwereyourgradesandlearningstylewhenyouwereinschool?”ANS:BMotivation and readiness to learn depend on what the patient values. The other questions arealso important but do not address what information interests the patient most at presentandwill assistthe patient inmanaging hisown care.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance3.Which acute medical event should the nurse identify as requiring self-management whenplanningcare forapatient?a.Prenatalcareb.Depressionc.Diabetesd.Femur fractureANS:D

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A femur fracture is considered an acute medical event. Pregnancy is an expected and normallifeevent/condition.Depressionand diabetesareconsidered diseasestates.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance4.An8-year-oldchildisnewlydiagnosedwithasthma.Whichnursinginterventionbestpromotesself-efficacyfortheparents tohelpthechildfollowtheprescribedtreatments?a.Askparentstolistallpossibletriggersforasthma.b.Requestaspacerforthemetereddoseinhaler.c.Suggesttheparentsenforceastrictexerciseregimen.d.Recommendreplacingcarpetinginthehomewith woodflooring.ANS:BThe most realistic and helpful interventions will promote self-management. A spacer ishelpful for children learning to use inhaled medication. Listing all the triggers for asthmamay be overwhelming. The parents should focus on the individual triggers forthe child.Enforcing a strict exercise regimen is restrictive and will not promote self-management.Environmental changes must be feasible and cost-effective. Replacing carpeting is optimalbutmay not beaffordable.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance5.When developing a plan of care to promote self-management, which patient isleastlikely tobeaffected by depression?a.A55-year-oldemployedfemaleb.A35-year-oldHispanic malec.A40 year oldwith 5th grNadeeducationd.A42 year old with privateinsuranceANS:DIndividuals most affected by depression are midlife adults ages 45–64, women, minorities,individuals withoutahigh schooleducation,andindividualswithouthealthinsurance.Treatment for depression includes theuse of medication and psychological therapy.Additionally, patients must learn to manage moods including suicidal thoughts, recognizetriggersand relapse,andsetgoals forbehavioralmanagementoftheirdisease.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance6.The nurse is assisting an older adult patient, diagnosed with type 2 diabetes, withself-injection of insulin. What is themostappropriate intervention for this patient atdischarge?a.Arrangedailyhomevisitsforinjections.b.Requestaninsulinpenprescription.c.Recommendupperarminjectionsites.d.Supply patient with 100 unit insulin syringes.ANS:B

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An insulin pen will be the most effective method for injection for an older adult secondaryto reduced eyesight and dexterity compared to using syringes. A 100 unit syringe has verysmall calibration marks and numbers, making it more difficult for older adults to see theappropriate doses. Daily home visits are not usually paid for by insurance.Most patientsmust learn to administer medications themselves. The upper arm subcutaneous site is toodifficultforself-administration andmaynot befeasibleforan olderadult.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenanceMULTIPLERESPONSE1.The nurse is developing a teaching plan for a patient diagnosed with congestive heartfailure. Which are themostappropriate teaching points to include that will assist inself-management of the disease? (Select all that apply.)a.Side effects of medicationsb.Activity restrictionsc.Daily weightsd.Increased sodium intakee.Blood pressure monitoringANS: A, B, C, ECongestive heart failure (CHF) is one of the most common complications of coronary arterydisease in which the heart fails to pump efficiently enough to meet the metabolic demandsof the body. Fluid overload is a common complication. As with most chronic conditions,patients with CHF benefit from education about their disease and self-managing diet,physical activity, weight, and medication adherence. Fluid retention occurs with increasedsodium intake; therefore sodium is usually restricted in a congestive heart failure diet.OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance

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Concept08:FluidandElectrolytesGiddens:ConceptsforNursingPractice,3rdEditionMULTIPLECHOICE1.The nurse is admitting an older adult with decompensated congestive heart failure. Thenursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. Whichphysicianorder should thenursequestion?a.Intravenous (IV)500mLof 0.9%NaCl at125mL/hrb.Furosemide(Lasix)20mg POnowc.Oxygenviafacemaskat8L/mind.KCl20mEqPOtwotimesperdayANS:AA patient with decompensated heart failure has extracellular fluid volume (ECV) excess.The IV of 0.9% NaCl is normal saline, which should be questioned because it would expandECV and place an additional load on the failing heart. Diuretics such as furosemide areappropriate to decrease the ECV during heart failure. Increasing the potassiumintake withKCl is appropriate, because furosemide increases potassium excretion. OxygenadministrationisappropriateinthissituationofnearpulmonaryedemafromECVexcess.OBJ:NCLEX Client Needs Category: Physiological Integrity: Pharmacological andParenteral Therapies2.The nurse assessed four patients at the beginning of the shift. Which finding should thenurse reportimmediatelyto the physician?a.Swollen ankles in patient with compensated heart failureb.Positive Chvostek sign in patient with acute pancreatitisc.Dry mucous membranes in patient taking a new diureticd.Constipation in patient who has advanced breast cancerANS: BPositive Chvostek sign indicates increased neuromuscular excitability, which can progressto dangerous laryngospasm or seizures and thus needs to be reported first. The otherassessment findings are less urgent and need further assessment. Bilateral ankle edema is asign of ECV excess, and follow-up is needed, but the situation is not immediatelylife-threatening. Dry mucous membranes in a patient taking a diuretic may be associatedwith ECV deficit; however, additional assessments of ECV deficit are required beforereporting to the physician. Constipation has many causes, including hypercalcemia andopioid analgesics, and it needs action, but not as urgently as a positive Chvostek sign.OBJ:NCLEXClientNeedsCategory:PhysiologicalIntegrity:ReductionofRiskPotential3.The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it.Which assessment finding should cause the nurse to hold the IV solutionand contact thephysician?a.Weightgainof2poundssincelastweekb.Drymucousmembranesandskin tentingc.Urineoutput8mL/hr

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d.Bloodpressure98/58ANS:CAdministering IV potassium to a patient who has oliguria is not safe, because potassiumintake faster than potassium output can cause hyperkalemia with dangerous cardiacdysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 areconsistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does notnecessarily indicate fluid overload, because it can be from increased nutritional intake. Anovernightweight gain indicates a fluid gain.OBJ:NCLEX Client Needs Category: Physiological Integrity: Pharmacological andParenteral Therapies4.At change-of-shift report, the nurse learns the medical diagnoses for four patients. Whichpatientshould thenurseassessmostcarefullyfordevelopment of hyponatremia?a.Vomitingall dayandnotreplacing anyfluidb.Tumorthatsecretesexcessiveantidiuretichormone(ADH)c.Tumorthatsecretesexcessivealdosteroned.Tumorthatdestroyed theposteriorpituitaryglandANS:BADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thuscauses hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia.The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia. Vomitingwithout fluid replacementcausesECV deficitandhypernatremia.OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential5.The patient is receiving tube feedings due to a jaw surgery. What change in assessmentfindings should prompt the nurse to request an order for serum sodium concentration?a.Development of ankle or sacral edemab.Increased skin tenting and dry mouthc.Postural hypotension and tachycardiad.Decreased level of consciousnessANS: DTube feedings pose a risk for hypernatremia unless adequate water is administered betweentube feedings. Hypernatremia causes the level of consciousness to decrease. The serumsodium concentration is a laboratory measure for osmolality imbalances, not ECVimbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth,postural hypotension, and tachycardia all can be signs of ECV deficit.OBJ:NCLEXClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation6.The patient with which diagnosis should have thehighestpriority for teaching regardingfoodsthat arehigh in magnesium?a.Severehemorrhageb.Diabetesinsipidusc.Oliguricrenaldiseased.Adrenalinsufficiency

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ANS:CWhen renal excretion is decreased, magnesium intake must be decreased also, to preventhypermagnesemia. The other conditions are not likely to require adjustment of magnesiumintake.OBJ:NCLEXClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation7.The patient’s laboratory report today indicates severe hypokalemia, and the nurse hasnotified the physician. Nursing assessment indicates that heart rhythm is regular. What is theprioritynursing intervention?a.Raise bed side rails due to potential decreased level of consciousness andconfusion.b.Examinesacralareaandpatient’sheelsforskinbreakdownduetopotentialedema.c.Establish seizure precautions due to potential muscle twitching, cramps, andseizures.d.Institute fall precautions due to potential postural hypotension and weak legmuscles.ANS:DHypokalemia can cause postural hypotension and bilateral muscle weakness, especially inthe lower extremities. Both of these increase the risk of falls. Hypokalemia does not causeedema,decreased level of consciousness,orseizures.OBJ:NCLEXClient NeedsCategory:Physiological Integrity:ReductionofRiskPotentialMULTIPLE RESPONSE1.The home health nurse is caring for a patient with a diagnosis of acute immunodeficiencysyndrome (AIDS) who has chronic diarrhea. Which assessments should the nurse use todetect the fluid and electrolyte imbalances for which the patient hashighestrisk? (Select allthat apply.)a.Bilateral ankle edemab.Weaker leg muscles than usualc.Postural blood pressure and heart rated.Positive Trousseau signe.Flat neck veins when uprightf.Decreased patellar reflexesANS: B, C, DChronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, andhypomagnesemia because it increases fecal excretion of sodium-containing fluid, potassium,calcium, and magnesium. Appropriate assessments include postural blood pressure and heartrate for ECV deficit; weaker leg muscles than usual for hypokalemia; and positiveTrousseau sign for hypocalcemia and hypomagnesemia. Bilateral ankle edema is a sign ofECV excess, which is not likely with chronic diarrhea. Flat neck veins when upright is anormal finding. Decreased patellar reflexes is associated with hypermagnesemia, which isnot likely with chronic diarrhea.OBJ:NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

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2.The patient has recent bilateral, above-the-knee amputations and has developedC. difficilediarrhea. What assessments should the nurse use to detect ECV deficit in this patient?(Selectall that apply.)a.Testforskintenting.b.Measurerateandcharacterofpulse.c.Measureposturalbloodpressureandheartrate.d.CheckTrousseausign.e.Observeforflatnessofneckveins whenupright.f.Observeforflatnessofneckveins whensupine.ANS:A,B, FECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins whensupine, which can be assessed in this patient. Although ECV deficit also causes posturalblood pressure drop with tachycardia, this assessment is not appropriate for a patient withrecent bilateral, above-the-knee amputations. Trousseau sign is a test for increasedneuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins whenuprightis anormal finding.OBJ:NCLEXClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation

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Concept09:Acid–BaseBalanceGiddens:ConceptsforNursingPractice,3rdEditionMULTIPLECHOICE1.Thepatient haddiarrhea for5daysanddevelopedanacid-baseimbalance. Whichstatementwouldindicatethatthenurse’steachingaboutthe acid-baseimbalancehasbeeneffective?a.“Toprevent anotherproblem,Ishouldeatlesssodium duringdiarrhea.”b.“Myblood becametooacidbecauseIlostsomebasein thediarrheafluid.”c.“Diarrhearemovesfluidfromthebody,soIshould drinkmoreicewater.”d.“Ishouldtrytoslowmybreathingsomyacidsand baseswillbebalanced.”ANS:BDiarrhea causes metabolic acidosis through loss of bicarbonate, which is a base. Eating lesssodium during diarrhea increases the risk of ECV deficit. Although diarrhea does removefluidfromthebody,it alsoremovessodiumand bicarbonatewhichneedtobereplaced.Rapid deep respirations are the compensatory mechanism for metabolic acidosis and shouldbeencouragedratherthan stopped.OBJ:NCLEXClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation2.The patient has type B chronic obstructive pulmonary disease (COPD) exacerbated by anacute upper respiratory infection. Which blood gas values should the nurse expect to see?a.pH high, PaCO2high, HCO3–highb.pH low, PaCO2low, HCO3–lowc.pH low, PaCO2high, HCO3–highd.pH low, PaCO2high, HCO3–normalANS: CType B COPD is a chronic disease that causes impaired excretion of carbonic acid, thuscausing respiratory acidosis, with PaCO2high and pH low. This chronic disease exists longenough for some renal compensation to occur, manifested by high HCO3–. Answers thatinclude low or normal bicarbonate are not correct, because the renal compensation forrespiratory acidosis involves excretion of more hydrogen ions than usual, with retention ofbicarbonate in the blood. High pH occurs with alkalosis, not acidosis.OBJ:NCLEXClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation3.The patient has severe hyperthyroidism and will have surgery tomorrow. What assessmentismostimportant for the nurse to perform in order to detect development of thehighestriskacid-baseimbalance?a.Urineoutput andcolorb.Levelofconsciousnessc.Heartrateandbloodpressured.Lung sounds in lung basesANS:B

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