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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 8th Edition

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    Lewis: Medical-Surgical Nursing, 8th Edition Chapter 1: Contemporary Nursing Practice Test Bank MULTIPLE CHOICE 1. The nurse has admitted a patient with a new diagnosis of pneumonia and explained to the patient that together they will plan the patient’s care and set goals for discharge. The patient says, “How is that different from what the doctor does?” Which response by the nurse is most appropriate? a. “ The role of the nurse is to administer medications and other treatments prescribed by your b. “ The nurse’s job is to help the doctor by collecting data and communicating when there are c. “ Nurses perform many of the procedures done by physicians, but nurses are here in the hos time than doctors.” d. “ In addition to caring for you while you are sick, the nurses will assist you to develop an in to maintain your health.” ANS: D This response is consistent with the American Nurses Association (ANA) definition of nursing, which describes the role of nurses in promoting health. The other responses describe some of the dependent and collaborative functions of the nursing role but do not accurately describe the nurse’s role in the health care system. DIF: Cognitive Level: Comprehension REF: 3 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. When providing patient care using evidence-based practice, the nurse uses a. clinical judgment based on experience. b. evidence from a clinical research study. c. evidence - based guidelines in addition to clinical expertise. d. evaluation of data showing that the patient outcomes are met. ANS: C Evidence-based practice (EBP) is the use of the best research-based evidence combined with clinician expertise. Clinical judgment based on the nurse’s clinical experience is part of EBP, but clinical decision making also should incorporate current research and research-based guidelines. Evidence from one clinical research study does not provide an adequate substantiation for interventions. Evaluation of

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    patient outcomes is important, but interventions should be based on research from randomized control studies with a large number of subjects. DIF: Cognitive Level: Comprehension REF: 6-8 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 3. The nurse primarily uses the nursing process in the care of patients a. to explain nursing interventions to other health care professionals b. as a problem - solving tool to identify and treat patients’ health care needs c. as a scientific - based process of diagnosing the patient’s health care problems d. to establish nursing theory that incorporates the biopsychosocial nature of humans ANS: B The nursing process is a problem-solving approach to the identification and treatment of patients’ problems. Diagnosis is only one phase of the nursing process. The primary use of the nursing process is in patient care, not to establish nursing theory or explain nursing interventions to other health care professionals. DIF: Cognitive Level: Comprehension REF: 10 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 4. The nurse plans an every 2-hour turning schedule to prevent skin breakdown for a critically ill patient in the intensive care unit. In this case, the nursing action is considered to be a. dependent. b. cooperative. c. independent. d. collaborative. ANS: D When implementing collaborative nursing actions, the nurse is responsible primarily for monitoring for complications of acute illness or providing care to prevent or treat complications. Independent nursing actions are focused on health promotion, illness prevention, and patient advocacy. A dependent action would require a physician order to implement. Cooperative nursing functions are not described as one of the formal nursing functions. DIF: Cognitive Level: Application REF: 10-11 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

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    5. A patient who has been admitted to the hospital for surgery tells the nurse, “I do not feel right about leaving my children with my neighbor.” Which action should the nurse take next? a. Rea ssure the patient that these feelings are common for parents. b. Have the patient call the children to ensure that they are doing well. c. Call the neighbor to determine whether adequate childcare is being provided. d. Gather more data about the patient’s feelings about the childcare arrangements. ANS: D Since a complete assessment is necessary in order to identify a problem and choose an appropriate intervention, the nurse’s first action should be to obtain more information. The other actions may be appropriate, but more assessment is needed before the best intervention can be chosen. DIF: Cognitive Level: Application REF: 11 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 6. A patient with a stroke is paralyzed on the left side of the body and has developed a pressure ulcer on the left hip. The best nursing diagnosis for this patient is a. impaired physical mobility related to left - sided paralysis. b. risk for impaired tissue integrity related to left - sided weakness. c. im paired skin integrity related to altered circulation and pressure. d. ineffective tissue perfusion related to inability to move independently. ANS: C The patient’s major problem is the impaired skin integrity as demonstrated by the presence of a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by frequently repositioning the patient. Although left-sided weakness is a problem for the patient, the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this patient, who already has impaired tissue integrity. The patient does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health problem is. DIF: Cognitive Level: Application REF: 11 TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

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    7. A patient with an infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis. An appropriate patient outcome identified by the nurse is that the a. patient has a balanced intake and output. b. patient’s bedding is changed when it becomes damp. c. patient understands the need for increased fluid intake. d. patient’s skin remains cool and dry throughout hospitalization. ANS: A This statement gives measurable data showing resolution of the problem of deficient fluid volume that was identified in the nursing diagnosis statement. The other statements would not indicate that the problem of deficient fluid volume was resolved. DIF: Cognitive Level: Application REF: 13 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 8. A nursing activity that is carried out during the evaluation phase of the nursing process is a. determining if interventions have been effective in meeting patient outcome s. b. documenting the nursing care plan in the progress notes in the medical record. c. deciding whether the patient’s health problems have been completely resolved. d. asking the patient to evaluate whether the nursing care provided was satisfactory. ANS: A Evaluation consists of determining whether the desired patient outcomes have been met and whether the nursing interventions were appropriate. The other responses do not describe the evaluation phase. DIF: Cognitive Level: Comprehension REF: 16 TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment 9. During the assessment phase of the nursing process, the nurse a. obtains data with which to diagnose patient problems. b. uses patient data to develop priority nursing diagnoses. c. teaches interventions to relieve patient health problems. d. helps the patient identify realistic outcomes to health problems. ANS: A

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    During the assessment phase, the nurse gathers information about the patient. The other responses are examples of the intervention, diagnosis, and planning phases of the nursing process. DIF: Cognitive Level: Knowledge REF: 11 TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 10. An example of a correctly written nursing diagnosis statement is a. altered tissue perfusion related to heart failure. b. risk for impaired tissue integrity related to sacral redness. c. ineffective coping related to response to biopsy test results. d. altered urinary elimination related to urinary tract infection. ANS: C This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a patient’s response to a health problem that can be treated by nursing. The use of a medical diagnosis (as in the responses beginning “Alt ered tissue perfusion” and “Altered urinary elimination”) is not appropriate. The response beginning “Risk for impaired tissue integrity” uses the defining characteristics as the etiology. DIF: Cognitive Level: Comprehension REF: 11-13 TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment 11. The nurse writes a complete nursing diagnosis statement by including a. a problem and the suggested patient goals or outcomes. b. a problem, its cause, and objective data that support the pro blem. c. a problem with all its possible causes and the planned interventions. d. a problem with its etiology and the signs and symptoms of the problem. ANS: D The PES format is used when writing nursing diagnoses. The subjective, as well as objective, data should be included in the defining characteristics. Interventions and outcomes are not included in the nursing diagnosis statement. DIF: Cognitive Level: Knowledge REF: 11-13 TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment 12. Using the Situation-Background-Assessment-Recommendation (SBAR) format, in which order should the nurse make these statements to communicate a change in patient status to a health care provider?

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    a. Mr. A was admitted 2 days ago with heart failure a nd has been receiving furosemide (Lasix but his urine output has been low. b. I think that he needs to be evaluated immediately and may need intubation and mechanical c. This is the nurse on the surgical unit. I am calling about Mr. A in room 3. After assessing h concerned about his shortness of breath. d. Today, he has crackles audible throughout the posterior chest and his O2 saturation is 89% very unstable. ANS: C A, D, B The order of the nurse’s statements follows the SBAR format. DIF: Cognitive Level: Application REF: 5-6 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 13. Which of these nursing actions for the patient with heart failure is appropriate for the nurse to delegate to experienced nursing assistive personnel (NAP)? a. Assess for shortness of breath or fatigue after ambulation. b. Instruct the patient about the need to alternate activity and rest. c. Obtain the patient’s blood pressure and pulse rate after ambulation. d. Determine whether the patient is ready to increase the activity level. ANS: C NAP education includes accurate vital sign measurement. Assessment and patient teaching require RN education and scope of practice and cannot be delegated. DIF: Cognitive Level: Application REF: 15-16 | eFig. 1-1 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 14. Which action by a newly graduated RN working on the postsurgical unit indicates that more education about delegation and assignment is needed? a. The nurse delegates measurement of patient oral intake and urine output to NAP. b. The nurse delegates assessment of a patient’s bowel sounds to experienced NAP. c. The nurse assigns an LPN/LVN to administer oral medications to several patients. d. The nurse assigns a “float” RN from pediatrics to care for a patient with diabetes. ANS: B Assessment requires RN education and scope of practice and cannot be delegated to NAP. The other actions by the new RN are appropriate.

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    DIF: Cognitive Level: Application REF: 15-16 | eFig. 1-1 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 15. Which of these tasks is appropriate for the registered nurse to delegate to a licensed practical/vocational nurse? a. Perform a sterile dressing change for an infected wound. b. Complete the initial admission assessment and plan of care. c. Teach a patient about the effects of prescribed medications. d. Document patient teaching about a routine surgical procedure. ANS: A The education and scope of practice of the LPN/LVN include activities such as sterile dressing changes. Patient teaching and the initial assessment and development of the plan of care are nursing actions that require RN-level education and scope of practice. DIF: Cognitive Level: Comprehension REF: 15 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment Chapter 2: Health Disparities and Culturally Competent Care Lewis: Medical-Surgical Nursing, 8th Edition Chapter 2: Health Disparities and Culturally Competent Care Test Bank MULTIPLE CHOICE 1. The nurse obtains information about all these areas during the health interview for a new patient. Which area will be the focus of patient teaching? a. Age and gender b. Hispanic/Latino ethnicity c. Family history of diabetes d. Refined carbohydrate intake ANS: D Behaviors are strongly linked to many health care problems. The patient’s carbohydrate intake is a behavior that the patient can change. The other information

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    will be useful as the nurse develops an individualized plan for improving the patient’s health, but will not be the focus of patient education. DIF: Cognitive Level: Application REF: 20-21 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 2. When developing strategies to decrease health care disparities, the nurse working in a clinic located in a neighborhood with many Vietnamese individuals will include a. improving public transportation. b. obtaining low - cost medications. c. updating equipment and supplies for the clinic. d. educating staff about Vietnamese health beliefs. ANS: D Health care disparities are due to stereotyping, biases, and prejudice of health care providers; the nurse can decrease these through staff education. The other strategies also may be addressed by the nurse but will not impact health disparities. DIF: Cognitive Level: Application REF: 21-23 | 32 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 3. Which information will the nurse need to collect when assessing the health status of a community? a. Average income of community members b. Morning traffic patterns in the community c. Median life expectancy for the community d. Occupations of individuals in the community ANS: C Health status is the aggregate of all health measures for individuals in a community and includes data such as life expectancy, birth and death rates, and mortality from various diseases. Although income, traffic patterns, and occupations are factors that impact a community’s health status, they are not health measures. DIF: Cognitive Level: Comprehension REF: 20-21 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 4. A family member of an elderly Hispanic patient admitted to the hospital tells the nurse that the patient has traditional beliefs about health and illness. The best action by the nurse is to

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    a. avoid asking any questions unless the patient initiates conversation. b. ask the patient whether it is important that cultural healers are contacted. c. explain the usual hospital routines for meal times, care, and family visits. d. obtain further information about the patient’s cultural beliefs from the daughter. ANS: B Because the patient has traditional health care beliefs, it is appropriate for the nurse to ask whether the patient would like a visit by a curandero(a) or other cultural healers. There is no cultural reason for the nurse to avoid asking the patient questions, and questions may be necessary to obtain necessary health information. The patient (rather than the daughter) should be consulted about personal cultural beliefs. The hospital routines for meals, care, and visits should be adapted to the patient’s preferences rather than expecting the patient to adapt to the hospital schedule. DIF: Cognitive Level: Application REF: 26 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 5. When caring for a patient who is Native American, the best initial action by the nurse is to a. avoid all eye contact with the patient. b. observe the patient’s use of eye contact. c. look directly at the patient when interacting. d. ask the family about the patient’s cultural beliefs. ANS: B Observation of the patient’s use of eye contact will be most useful in determining the best way to communicate effectively with the patient. Looking directly at the patient or avoiding eye contact may be appropriate, depending on the patient’s individual cultural beliefs. The nurse should assess the patient, rather than asking family members about the patient’s beliefs. DIF: Cognitive Level: Application REF: 24 | 27-28 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 6. A new RN graduate is assessing a newly admitted non – English-speaking Chinese patient who complains of severe headaches. The charge nurse should intervene if the new RN’s first action is to a. sit down at the bed side.

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    b. palpate the patient’s scalp. c. call for a medical interpreter. d. avoid eye contact with the patient. ANS: B Many people of Asian ethnicity believe that touching a person’s head is disrespectful; the RN should ask permission before touching the patient’s head. The other actions are appropriate. DIF: Cognitive Level: Application REF: 29 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 7. If an interpreter is not available when a patient speaks a language different from the nurse’s language, it is appropriate for the nurse to a. use specific medical terms in the Latin form. b. talk slowly so that each word is clearly heard. c. repeat important words so that the patient recognizes their importance. d. use simple gestures to demonstrate meaning while talking to the patient. ANS: D The use of gestures will enable some information to be communicated to the patient. The other actions will not improve communication with the patient. DIF: Cognitive Level: Comprehension REF: 34 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 8. When planning care for a hospitalized patient who uses culturally based treatments, the most appropriate action by the nurse is to a. coordinate the use of folk treatments with ordered medical therapies. b. discourage the use of culturally based treatments for Western diseases. c. teach the patient that folk remedies will interfere with Western treatments. d. ask the patient to discontinue the cultural treatments during hospitalization. ANS: A Many culturally based therapies can be accommodated along with the use of Western treatments and medications. The nurse should attempt to use both traditional folk treatments and the ordered Western therapies as much as possible. Some culturally based treatments can be effective in treating “Western” diseases. Not all folk remedies

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    interfere with Western therapies. It may be appropriate for the patient to continue some culturally based treatments while he or she is hospitalized. DIF: Cognitive Level: Comprehension REF: 30-31 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 9. The best example of culturally appropriate nursing care when caring for a newly admitted patient is a. having family members provide most of the patient’s personal care. b. maintaining a personal space of at least 2 feet when assessing the patient. c. asking permission before touching a patient during the physical assessment. d. considering the patient’s ethnicity as the most important facto r in planning care. ANS: C Many cultures consider it disrespectful to touch a patient without asking permission, so asking a patient for permission is always culturally appropriate. The other actions may be appropriate for some patients but are not appropriate across all cultural groups or for all individual patients. DIF: Cognitive Level: Comprehension REF: 29 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 10. While talking with the nursing supervisor, a staff nurse expresses frustration that a Native American patient always has several family members at the bedside. The most appropriate action by the nursing supervisor is to a. remind the nurse that family support is important to this family and patient. b. have the nurse explain to the family that too many visitors will tire the patient. c. suggest that the nurse ask family members to leave the room during patient care. d. ask about the nurse’s personal beliefs about family support during hospitalization. ANS: D The first step in providing culturally competent care is to understand one’s own beliefs and values related to health and health care. Asking the nurse about personal beliefs will help to achieve this step. Reminding the nurse that this cultural practice is important to the family and patient will not decrease the nurse’s frustration. The remaining responses (suggest that the nurse ask family members to leave the room, and have the nurse explain to family that too many visitors will tire the patient) are not culturally appropriate for this patient.

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    DIF: Cognitive Level: Application REF: 31 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 11. An 82-year-old Asian American patient tells the nurse that she has lived in the United States for 50 years. The patient speaks English but lives in a predominantly Asian neighborhood. The nurse will need to a. include a folk healer when planning the patient’s care. b. ask the patient about any special cultural beliefs or practices. c. avoid making direct eye contact with the patient during care. d. involve the patient’s oldest son in making health care decisions. ANS: B Further assessment of the patient’s health care preferences is needed before making further plans for culturally appropriate care. The other responses indicate stereotyping of the patient, based on ethnicity, and would not be appropriate initial actions. DIF: Cognitive Level: Application REF: 25 | 32 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 12. When planning health care for a community with a large number of recent immigrants from China, the most important intervention for the nurse to include is a. pregnancy testing. b. tuberculosis screening. c. contraceptive teaching. d. colonoscopy information. ANS: B Tuberculosis (TB) is endemic in many parts of Asia, and the incidence of TB is much higher in immigrants from China than in the general U.S. population. Teaching about contraceptive use, colonoscopy, and testing for pregnancy also may be appropriate for some patients but is not generally indicated for all members of this community. DIF: Cognitive Level: Application REF: 29-30 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 13. When doing an admission assessment for a patient, the nurse notices that the patient pauses before answering questions about the health history. The most appropriate action by the nurse is to a. stop doing the assessment and return later.

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    b. wait for the patient to answer the questions. c. ask the patient why the questions require so much time to answer. d. give the patient an assessment form listing the questions and a pen. ANS: B Patients from some cultures take time to consider a question carefully before answering. The nurse will show respect for the patient and help develop a trusting relationship by allowing the patient time to give a thoughtful answer. Asking the patient why the answers are taking so much time, stopping the assessment, and handing the patient a form indicate that the nurse does not have time for the patient. DIF: Cognitive Level: Application REF: 28 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 14. Which of these strategies should be a priority when the nurse is planning care for a hypertensive patient who is uninsured? a. Follow evidence - based national guidelines. b. Assist with dietary changes as the first action. c. Teach about the impact of exercise on hypertension. d. Obtain less expensive antihypertensive medications. ANS: A The use of standardized evidence-based guidelines will reduce the incidence of health care disparities among various socioeconomic groups. The other strategies also may be appropriate, but the priority concern should be that the patient receives care that meets the accepted standard. DIF: Cognitive Level: Application REF: 32 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 15. A Hispanic patient complains of abdominal cramping caused by empacho. The nurse’s first action should be to a. ask the patient what treatments are likely to help. b. give the patient medication to decrease the cramping. c. massage the patient’s abdomen until the pain is gone. d. offer to contact a curandero(a) to make a visit to the patient. ANS: A

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    Further assessment of the patient’s cultural beliefs is appropriate before implementing any interventions for a culture-bound syndrome such as empacho. Although medication, a visit by a curandero(a), or massage may be helpful, more information about the patient’s beliefs is needed to determine which intervention(s) will be most helpful. DIF: Cognitive Level: Application REF: 25 | 31-32 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 16. When performing a cultural assessment with a patient of a different culture, the nurse’s first action should be to a. wait until a cultural healer is available to help with the assessment. b. obtain a list of any cultural remedies that the patient currently uses. c. ask the patient about any affiliation with a particular cultural group. d. tell the patient what the nurse already knows about the patient’s culture. ANS: C An early step in performing a cultural assessment is to determine whether the patient feels an affiliation with any cultural group. The other actions may be appropriate if the patient does identify with a particular culture. DIF: Cognitive Level: Application REF: 32 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 17. The nurse working in a clinic in a primarily African American community notes a higher incidence of uncontrolled hypertension in clinic patients than the national average. To correct this health disparity, which action should the nurse take first? a. Initiate a regular home - visit program by nurses working at the clinic. b. Schedule teaching sessions about hypertension at community events. c. Assess the perceptions of community members about the care at the clinic. d. Obtain low - cost antihypertensive drugs using funding from government grants. ANS: C Before other actions are taken, additional assessment data are needed to determine the reason for the disparity. The other actions also may be appropriate, but additional assessment is needed before the next action is selected.

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    DIF: Cognitive Level: Application REF: 31-32 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance Chapter 3: Health History and Physical Examination Lewis: Medical-Surgical Nursing, 8th Edition Chapter 3: Health History and Physical Examination Test Bank MULTIPLE CHOICE 1. A patient who is having difficulty breathing is admitted to the hospital. The best approach for the nurse to use to obtain a complete health history is to a. obtain subjective data about the patient from family members. b. omit subjective data collection and obtain the physical examination. c. use the health care provider’s medical history to obtain subjective data. d. schedule several short sessions with the patient to gather subjective data. ANS: D In an emergency situation, the nurse may need to ask only the most pertinent questions for a specific problem and obtain more information later. A complete health history will include subjective information that is not available in the health care provider’s medical history. Family members may be able to provide some subjective data, but only the patient will be able to give subjective information about the shortness of breath. Since the subjective data about the patient’s respiratory status will be essential, obtaining the physical examination alone will not provide sufficient information. DIF: Cognitive Level: Application REF: 38 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 2. Immediate surgery is planned for a patient with acute abdominal pain. The question used by the nurse that will elicit the most complete information about the patient’s coping-stress tolerance pattern is a. “ Can you tell me how intense your pain is now?” b. “ What do you think caused this abdominal pain?”

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    c. “ How do you feel about yourself and your hospitalization?” d. “ Are there other major problems that are a concern right now?” ANS: D The coping-stress tolerance pattern includes information about other major stressors confronting the patient. The health perception – health management pattern includes information about the patient’s ideas about risk factors. Feelings about self and the hospitalization are assessed in the self-perception – self-concept pattern. Intensity of pain is part of the cognitive-perceptual pattern. DIF: Cognitive Level: Comprehension REF: 41-42 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 3. During the health history interview, a patient tells the nurse about periodic fainting spells. Which question by the nurse will be most helpful in determining the setting in which the fainting spells occur? a. “ How frequently do you have the fainting spells?” b. “ Where are you when you have the fainting spells?” c. “ Do the spells tend to occur at any special time of day?” d. “ Do you have any other symptoms along with the spells?” ANS: B Information about the setting is obtained by asking where the patient was and what the patient was doing when the symptom occurred. The other questions from the nurse are appropriate for obtaining information about chronology, frequency, and associated clinical manifestations. DIF: Cognitive Level: Comprehension REF: 39 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 4. The nurse records the following general survey of a patient: “The patient is a 68- year-old male Asian attended by his wife and two daughters. Alert and oriented. Does not make eye contact with the nurse and responds slowly, but appropriately, to questions. No apparent disabilities or distinguishing features.” Additional information that should be added to this general survey includes a. nutritional status. b. intake and output. c. reasons for contact with the health care system.

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    d. comments of family members about his condition. ANS: A The general survey also describes the patient’s general nutritional status. The other information will be obtained when doing the complete nursing history and examination but is not obtained through the initial scanning of a patient. DIF: Cognitive Level: Application REF: 44 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 5. A nurse is performing a health history and physical examination for a patient with right-sided rib fractures. The pertinent negative finding is that the patient a. states that there have been no other health problems recently. b. denies having pain when the area over the fractures is palpated. c. has several bruised and swollen areas on the right anterior chest. d. refuses to take a deep breath because of the associated chest pain. ANS: B The nurse expects that a patient with rib fractures will have pain over the fractured area. The first statement is neither a positive nor a negative finding with regard to the rib fractures. The bruising and swelling and pain with breathing are positive findings. DIF: Cognitive Level: Application REF: 42 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 6. As the nurse assesses the patient’s neck, the patient says, “My neck is so stiff I can hardly move it.” This finding indicates the nurse should perform a(n) a. focused assessment. b. screening assessment. c. emergency assessment. d. comprehensive assessment. ANS: A The focused assessment is needed when a patient has clinical manifestations that indicate a problem. An emergency assessment is done when the nurse needs to obtain information about life-threatening problems quickly while simultaneously taking action to maintain vital function. The screening examination or assessment is used to assess for possible problems such as colorectal cancer in patients who are age 50 or

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    older. A comprehensive assessment is a detailed health history and physical examination. DIF: Cognitive Level: Application REF: 45-46 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 7. The nurse is preparing to perform a focused abdominal assessment for a patient who has high-pitched bowel sounds. Which equipment will be needed? a. Flashlight b. Stethoscope c. Tongue blades d. Percussion hammer ANS: B A stethoscope is used to auscultate bowel sounds. The other equipment may be used for a comprehensive assessment, but will not be needed for a focused abdominal assessment. DIF: Cognitive Level: Comprehension REF: 43 | 45 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 8. When the nurse is planning for the physical examination of an alert 86-year-old patient, adaptations to the examination technique should include a. speaking slowly when directing the patient. b. avoiding the use of touch as much as possible. c. using slightly more pressure for palpation of the liver. d. organizing the sequence to minimize position changes. ANS: D Older patients may have age-related changes in mobility that make it more difficult to change position. There is no need to avoid the use of touch when examining older patients. Less pressure should be used over the liver. Since the patient is alert, there is no indication that there is any age-related difficulty in understanding directions from the nurse. DIF: Cognitive Level: Application REF: 45 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

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    9. While the nurse is taking the health history, a patient states, “My father and grandfather both had heart attacks and were unable to be very active afterwards.” This statement is related to the functional health pattern of a. activity - exercise. b. co gnitive - perceptual. c. coping - stress tolerance. d. health perception – health management. ANS: D The information in the patient statement relates to risk factors that may cause cardiovascular problems in the future. Identification of risk factors falls into the health perception – health maintenance pattern. DIF: Cognitive Level: Comprehension REF: 40-41 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 10. A patient is seen in the emergency department with chest pain and hypotension. Which type of assessment should the nurse do at this time? a. Focused assessment b. Subjective assessment c. Emergency assessment d. Comprehensive assessment ANS: C Since the patient is hemodynamically unstable, an emergency assessment is needed. Comprehensive and focused assessments may be needed after the patient is stabilized. Subjective information is needed, but objective data such as vital signs also are essential for the unstable patient. DIF: Cognitive Level: Comprehension REF: 46 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 11. When caring for a patient who was admitted a few hours previously with nausea and vomiting, which nursing action can the RN delegate to an LPN/LVN? a. Ask the patient about any current nausea. b. Finish documenting the admission assessment. c. Determine the patient’s priority nursing diagnoses. d. Obtain the health history from the patient’s caregiver.

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    ANS: A The RN may delegate parts of the focused assessment to an LPN/LVN. Obtaining the health history, documentation of the admission assessment, and determining nursing diagnoses require RN education and scope of practice. DIF: Cognitive Level: Application REF: 46 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 12. When assessing the circulation to the lower leg of a patient who has had knee surgery, which action should the nurse take first? a. Feel for the temperature of the foot. b. Visually ins pect the color of the foot. c. Check the patient’s pedal pulses using the fingertips. d. Compress the nail beds to determine capillary refill time. ANS: B Inspection is the first of the major techniques used in the physical examination. Palpation and auscultation are used later in the examination. DIF: Cognitive Level: Application REF: 43 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 13. When assessing a patient’s abdomen during the admission assessment, which of these actions should the nurse take first? a. Feel for any masses. b. Palpate the abdomen. c. Percuss the liver borders. d. Listen to the bowel sounds. ANS: D When assessing the abdomen, auscultation is done before palpation or percussion because palpation and percussion can cause changes in bowel sounds and alter the findings. All of the techniques are appropriate, but auscultation should be done first. DIF: Cognitive Level: Comprehension REF: 43 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

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    14. When admitting a patient who has just arrived on the medical unit with severe abdominal pain, what should the nurse do first? a. Complete only basic demog raphic data before addressing the patient’s abdominal pain. b. Medicate the patient for the abdominal pain before attending to the health history and exam c. Inform the patient that the abdominal pain will be treated as soon as the health history is co d. Take the initial vital signs and then deal with the abdominal pain before completing the hea ANS: D The patient priority in this situation will be to decrease the pain level because the patient will be unlikely to cooperate in providing demographic data or the health history until the nurse addresses the pain. However, obtaining information about vital signs is essential before using either pharmacologic or nonpharmacologic therapies for pain control. The vital signs may indicate hemodynamic instability that would need to be addressed immediately. DIF: Cognitive Level: Application REF: 39 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity Chapter 4: Patient and Caregiver Teaching Lewis: Medical-Surgical Nursing, 8th Edition Chapter 4: Patient and Caregiver Teaching Test Bank MULTIPLE CHOICE 1. A patient with newly diagnosed breast cancer has a nursing diagnosis of deficient knowledge about breast cancer. When the nurse is planning teaching for the patient, which is the most important initial learning goal? a. The patient will select the most appropriate breast cancer therapy. b. The patient will state ways of preventing the recurrence of the tumor. c. The patient will demonstrate coping skills needed to manage the disease. d. The patient will choose methods to minimize adverse effects of treatment. ANS: A

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    Adults learn best when given information that can be used immediately. The first action the patient will need to take after a cancer diagnosis is to choose a treatment option. The other goals may be appropriate as treatment progresses. DIF: Cognitive Level: Application REF: 50 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 2. After the nurse implements diet instruction for a patient with heart disease, the patient can explain the information but fails to make the recommended dietary changes. The nurse’s evaluation is that a. learning did not occur because the patient’s behavior did not chan ge. b. choosing not to follow the diet is the behavior that resulted from learning. c. the nursing responsibility for helping the patient make dietary changes has been fulfilled. d. the teaching methods were ineffective in helping the patient learn the dietary information. ANS: B Although the patient behavior has not changed, the patient’s ability to explain the information indicates that learning has occurred and the patient is choosing at this time to continue with the previous diet. The patient may be in the contemplation or preparation state in the Transtheoretical Model. The nurse should reinforce the need for change and continue to provide information and assistance with planning for change. DIF: Cognitive Level: Application REF: 50-51 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 3. A 43-year-old is diagnosed with type 2 diabetes mellitus after being admitted to the hospital with an infected foot wound. When applying principles of adult learning, which teaching strategy by the nurse is most likely to be effective? a. Discuss the importance of blood glucose control in maintenance of long - term health. b. Demonstrate the correct method for cleaning and redressing the wound to the patient. c. Assure the patient that the nurse is an expert on management of diabetes complications. d. Wait until after discharge and have a home health nurse teach about foot care and diabetes ANS: B Principles of adult education indicate that readiness and motivation to learn are high when facing new tasks (such wound care) and when demonstration and practice of skills are available. Although a home health referral may be needed for this patient,

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    teaching should not be postponed until discharge. Adult learners are independent; the nurse should act as a facilitator for learning, rather than as the expert. Adults learn best when the topic is of immediate usefulness; long-term goals may not be very motivating. DIF: Cognitive Level: Application REF: 50 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 4. A patient admitted to the hospital with hyperglycemia and newly diagnosed diabetes mellitus is scheduled for discharge the second day after admission. When implementing patient teaching, which is the best action for the nurse to take? a. Instruct about the increased risk for cardiovascular disease. b. Provide detailed information about dietary control of glucose. c. Teach glucose self - monitoring and medication administration. d. Give information about the effects of exercise on glucose control. ANS: C When time is limited, the nurse should focus on the priorities of teaching. In this situation, the patient should know how to test blood glucose and administer medications to control glucose levels. The patient will need further teaching about the role of diet, exercise, various medications, and the many potential complications of diabetes, but these topics can be addressed through planning for appropriate referrals. DIF: Cognitive Level: Application REF: 52 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 5. When using the Transtheoretical Model of Health Behavior Change during patient teaching, the nurse identifies that the patient who states, “I told my wife that I was going to start exercising, and I think I will join a fitness club,” is in the stage of a. preparation. b. termination. c. maintenance. d. contemplation. ANS: A The patient’s statement indicating that the plan for change is being shared with someone else indicates that the preparation stage has been achieved. Contemplation of a change would be indicated by a statement like “I know I should exercise.”

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    Maintenance of a change occurs when the patient practices the behavior regularly. Termination would be indicated when the change is a permanent part of the lifestyle. DIF: Cognitive Level: Comprehension REF: 50-51 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 6. While admitting a patient to the medical unit, the nurse learns that the patient does not read well. This information will guide the nurse in determining a. the degree of patient motivation and readiness to learn. b. what information the patient will be able to understand. c. that the family must be included in the teaching process. d. which instructional strategies should be used in teaching. ANS: D The information that the patient is illiterate indicates that the nurse should avoid the use of written materials in teaching and choose other strategies. The patient does not indicate a lack of motivation or an inability to understand new information. The patient’s lack of reading ability does not necessarily imply that the family must be included in the teaching process. DIF: Cognitive Level: Comprehension REF: 54 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 7. When assessing the learning needs for a patient who has coronary heart disease, the nurse finds that the patient has recently made dietary changes to decrease fat intake and has stopped smoking. The best initial statement by the nurse at this time is a. “ Although those are important, it is essential that you make other changes, too.” b. “ Are you having any difficulty in maintaining the changes you have already made?” c. “ You have already accomplished some changes that are important in heart health.” d. “ Which additional changes in your lifestyle would you like to implement at this time?” ANS: C Positive reinforcement of the learner’s achievements is critical in making lifestyle changes. This patient is in the action stage of the Transtheoretical Model, when reinforcement of the changes being made is an important nursing intervention. The other responses are also appropriate, but are not the best initial response. DIF: Cognitive Level: Application REF: 51 | 55 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

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    8. To assess a patient’s readiness to learn before planning teaching activities, which question should the nurse ask? a. “ What kind of work and leisure activities do you do?” b. “ What information do you think you need right now?” c. “ Do you have any religious beliefs that are inconsistent with the treatment?” d. “ Can you describe the types of activities that help you learn new information?” ANS: B Motivation and readiness to learn depend on what the patient values and perceives as important. The other questions are also important in developing the teaching plan, but do not address what information most interests the patient at present. DIF: Cognitive Level: Application REF: 55 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 9. The nurse develops a nursing diagnosis of ineffective health maintenance related to low motivation based on the finding that the diabetic patient a. does not perform capillary blood glucose tests as directed. b. occasionally forgets to take the daily prescribed medication. c. says that dietary intake does not seem to impact fatigue level. d. cannot identify signs or symptoms of high and low blood glucose. ANS: C The patient’s motivation to follow a diabetic diet will be decreased if the patient feels that dietary changes do not impact symptoms. The other responses do not indicate that the ineffective health maintenance is caused by lack of motivation. DIF: Cognitive Level: Application REF: 55 TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 10. A patient with poor circulation to the feet requires teaching about foot care. Which learning goal should the nurse include in the teaching plan? a. The nurse will demonstrate the proper technique for trimming toenails. b. The patient will list three ways to protect the feet from injury by discharge. c. The nurse will instruct the patient on appropriate foot care before discharge. d. The patient will understand the rationale for proper foot care after instruction. ANS: B

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    Learning goals should state clear, measurable outcomes of the learning process. Options a and c describe actions that the nurse will take, rather than behaviors that indicate that patient learning has occurred. Option d is too vague and nonspecific to measure whether learning has occurred. DIF: Cognitive Level: Application REF: 55-56 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 11. When the nurse is planning teaching for a patient who needs to improve skills in being more assertive, the most effective teaching strategy will be a. role playing. b. peer teaching. c. printed materials. d. lecture - discussion. ANS: A Role-playing allows the patient to practice assertive behavior and receive feedback about how the behavior is perceived. Lecture-discussion, peer-teaching, and printed materials are more useful for other learning needs. DIF: Cognitive Level: Comprehension REF: 57 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 12. The patient’s teaching plan includes this goal: “The patient will select a 2-gram sodium diet from the hospital menu for the next 3 days.” Which evaluation method will be best for the nurse to use when determining whether teaching was effective? a. Check the sodium content of the patient’s menu choices over the next 3 days b. Ask the patient to identify which foods on the hospital menus are high in sodium. c. Have the patient list favorite foods that are high in sodium and foods that could be substitu favorites. d. Compare the patient’s sodium intake over the next 3 days with the sodium intake before th implemented. ANS: A All of the answers address the patient’s sodium intake, but the desired patient behaviors in the learning objective are most clearly addressed by evaluation of the patient’s menu choices. DIF: Cognitive Level: Application REF: 58-59 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance

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    13. The nurse is preparing written handouts to be used as part of the standardized teaching plan for patients who have been recently diagnosed with diabetes. Which of the following statements would be appropriate to include in the handouts? a. Polyphagia, polydipsia, and polyuria are common symptoms of diabetes mellitus. b. The use of the right foods can help in keeping blood glucose at a near - normal level. c. Some diabetics control blood glucose with oral medications or nutritional interventions. d. Diabetes mellitus is characterized by chronic hyperglycemia and the associated symptoms. ANS: B Reading level for patient teaching materials should be at the 5th grade level. The other responses have words with three or more syllables, use many medical terms, and/or are too long. DIF: Cognitive Level: Application REF: 56 | 58 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 14. The nurse in the hospital has implemented a teaching plan to assist a patient with rheumatoid arthritis in accomplishing daily activities independently. To evaluate the patient’s long-term response to the teaching, the best action by the nurse will be to a. make a referral to the home health nursing departmen t for home visits. b. check the patient’s ability to bathe without any assistance the next day. c. have the patient demonstrate the learned skills at the end of the teaching session. d. arrange a physical therapy visit before the patient is discharged from the hospital. ANS: A The patient’s long-term response may need to be assessed after discharge; a home health referral would allow this to occur. The other actions allow evaluation of the patient’s short-term response to teaching. DIF: Cognitive Level: Application REF: 58-59 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 15. When assessing a 22-year-old male patient, the nurse learns that he smokes a pack of cigarettes daily. The patient tells the nurse, “I enjoy smoking and have no plans to quit.” Which nursing diagnosis is most appropriate? a. Health seeking behaviors related to cigarette use b. Ineffective health maintenance related to tobacco use c. Readiness for enhanced self - health management related to smoking

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    d. Deficient knowledge related to long - term effects of cigarette smoking ANS: B The patient’s statement indicates that he is not considering smoking cessation. Ineffective health maintenance is defined as the inability to identify, manage, and/or seek out help to maintain health. DIF: Cognitive Level: Application REF: 55 TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 16. A 73-year-old Hispanic/Latino patient is seen at the health clinic and diagnosed with protein malnutrition. The priority action in the nurse’s teaching plan will be to a. suggest the use of liquid supplements as a way to increase protein intake. b. encourage the patient to increase the dietary intake of meat, cheese, and milk. c. ask the patient to record the intake of all foods and beverages for a 3 - day period. d. focus on the use of combinations of beans and rice to improve daily protein intake. ANS: C Assessment is the first step in assisting a patient with health changes. The other answers may be appropriate for the patient, but the nurse will not be able to determine this until the assessment of the patient is complete. DIF: Cognitive Level: Application REF: 53 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 17. A newly diagnosed diabetic patient tells the nurse, “I want to know how to give my own insulin.” Which action will the nurse take first when implementing the standardized diabetic teaching plan? a. Demonstrate how to draw up and administer insulin. b. Discuss the use of exercise to decrease insulin needs. c. Teach about differences between the various types of insulin. d. Provide handouts about therapeutic and adverse effects of insulin. ANS: A Adult education is most effective when focused on information that the patient thinks is needed right now. All of the indicated information will need to be included when planning teaching for this patient, but the teaching will be most effective if the nurse starts with the patie nt’s stated priority topic.

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    DIF: Cognitive Level: Application REF: 50 | 55 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 18. Which action should the nurse take first when teaching a patient’s spouse how to manage the blood pressure (BP) for a patient with newly diagnosed high BP? a. Teach the caregiver how to take the patient’s BP using a manual blood pressure cuff. b. Have the dietician meet with the patient and caregiver to discus s low sodium dietary choice c. Ask the patient and caregiver to select important information from a list of hypertension te d. Provide written information about treatment and complications of hypertension for the pati caregiver. ANS: C Since adults learn best when given information that they view as being needed immediately, asking the caregiver and patient to prioritize learning needs is likely to be the most successful approach to home management of health problems. The other actions also may be appropriate, depending on what learning needs the caregiver and patient have, but the initial action should be to assess what the learners feel is important. DIF: Cognitive Level: Application REF: 50 | 53 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance Chapter 5: Chronic Illness and Older Adults Lewis: Medical-Surgical Nursing, 8th Edition Chapter 5: Chronic Illness and Older Adults Test Bank MULTIPLE CHOICE 1. When caring for a patient with type 2 diabetes who has been hospitalized with severe hyperglycemia, which topic will be most important to include in discharge teaching? a. Effect of endogenous insulin on transportation of glucose into cells b. Function of the liver in formation of glycogen and gluconeogenesis

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    c. Impact of the patient’s family history on likelihood of developing diabetes d. Symptoms indicating that the patient should contact the health care provider ANS: D One of the tasks for patients with chronic illnesses is to prevent and manage a crisis. The patient needs instruction on recognition of symptoms of hyperglycemia and appropriate actions to take if these symptoms occur. The other information also may be included in patient teaching, but is not as essential in the patient’s self-management of the illness. DIF: Cognitive Level: Application REF: 63 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. Which question will provide the most useful information when the nurse is performing a comprehensive geriatric assessment of an older adult who is being assessed for admission to an assisted-living facility? a. “ Have you had any recent infections?” b. “ How frequently do you see a doctor?” c. “ Do you have a history of heart disease?” d. “ Are you able to prepare your own meals?” ANS: D The patient’s functional abilities, rather than the presence of acute or chronic illness, are more useful in determining how well the patient might adapt to an assisted-living situation. The other questions also will provide helpful information but are not as useful in providing a basis for determining patient needs or for developing interventions for the older patient. DIF: Cognitive Level: Application REF: 73 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. The nurse is planning care for an alert and active 85-year-old patient who takes multiple medications for chronic cardiac and respiratory disease and lives with a daughter who works during the day. Which nursing diagnosis is most appropriate? a. Risk for injury related to drug - drug interactions b. Social isolation related to weakness and fatigue c. Compromised family coping related to the patient’s many care needs d. Caregiver role strain related to need to adjust family employment schedule

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