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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Document preview page 1

Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 1

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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition

Master difficult topics with Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition, offering targeted practice for your exams.

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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 1 preview imageChapter 1: Professional Nursing PracticeChapter 1: Professional Nursing PracticeTest BankMULTIPLE CHOICE1.The nurse completes an admission database and explains that the plan of care anddischarge goals will be developed with thepatient’sinput. The patient states,“Howisthis different from what the doctordoes?”Which response would be most appropriatefor the nurse to make?a.“Theroleofthenurseistoadministermedicationsandothertreatmentsprescribedbyyourb.“Thenurse’sjobistohelpthedoctorbycollectinginformationandcommunicatinganyprooccur.”c.“Nursesperformmanyofthesameproceduresasthedoctor,butnursesarewiththepatientimethanthedoctor.”d.“Inadditiontocaringforyouwhileyouaresick,thenurseswillassistyoutodevelopanintomaintainyourhealth.”ANS: DThis response is consistent with the American Nurses Association (ANA) definitionof nursing, which describes the role of nurses in promoting health. The otherresponses describe some of the dependent and collaborative functions of the nursingrole but do not accurately describe thenurse’srole in the health care system.DIF: Cognitive Level: Understand (comprehension) REF: 3TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment2.The nurse describes to a student nurse how to use evidence-based practiceguidelines when caring for patients. Which statement, if made by the nurse, would bethe most accurate?a.“Inferencesfromclinicalresearchstudiesareusedasaguide.”b.“Patientcareisbasedonclinicaljudgment,experience,andtraditions.”c.“Dataareevaluatedtoshowthatthepatientoutcomesareconsistentlymet.”d.“Recommendationsarebasedonresearch,clinicalexpertise,andpatientpreferences.”ANS: DEvidence-based practice (EBP) is the use of the best research-based evidencecombined with clinician expertise. Clinical judgment based on thenurse’sclinicalexperience is part of EBP, but clinical decision making should also incorporate
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 2 preview image
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 3 preview imagecurrent research and research-based guidelines. Evaluation of patient outcomes isimportant, but interventions should be based on research from randomized controlstudies with a large number of subjects.DIF: Cognitive Level: Remember (knowledge) REF: 11TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment3.The nurse teaches a student nurse about how to apply the nursing process whenproviding patient care. Which statement, if made by the student nurse, indicates thatteaching was successful?a.“Thenursingprocessisascientific-basedmethodofdiagnosingthepatient’shealthcareprb.“Thenursingprocessisaproblem-solvingtoolusedtoidentifyandtreatpatients’healthcac.“Thenursingprocessisbasedonnursingtheorythatincorporatesthebiopsychosocialnatud.“ThenursingprocessisusedprimarilytoexplainnursinginterventionstootherhealthcareANS: BThe nursing process is a problem-solving approach to the identification and treatmentofpatients’problems. Diagnosis is only one phase of the nursing process. Theprimary use of the nursing process is in patient care, not to establish nursing theory orexplain nursing interventions to other health care professionals.DIF: Cognitive Level: Understand (comprehension) REF: 7TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment4.A patient has been admitted to the hospital for surgery and tells the nurse,“Ido notfeel comfortable leaving my children with myparents.”Which action should the nursetake next?a.Reassurethepatientthatthesefeelingsarecommonforparents.b.Havethepatientcallthechildrentoensurethattheyaredoingwell.c.Gathermoredataaboutthepatient’sfeelingsaboutthechild-carearrangements.d.Callthepatient’sparentstodeterminewhetheradequatechildcareisbeingprovided.ANS: CSince a complete assessment is necessary in order to identify a problem and choose anappropriate intervention, thenurse’sfirst action should be to obtain more information.The other actions may be appropriate, but more assessment is needed before the bestintervention can be chosen.DIF: Cognitive Level: Apply (application) REF: 6-7
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 4 preview imageOBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity5.A patient who is paralyzed on the left side of the body after a stroke develops apressure ulcer on the left hip. Which nursing diagnosis is most appropriate?a.Impairedphysicalmobilityrelatedtoleft-sidedparalysisb.Riskforimpairedtissueintegrityrelatedtoleft-sidedweaknessc.Impairedskinintegrityrelatedtoalteredcirculationandpressured.IneffectivetissueperfusionrelatedtoinabilitytomoveindependentlyANS: CThepatient’smajor problem is the impaired skin integrity as demonstrated by thepresence of a pressure ulcer. The nurse is able to treat the cause of altered circulationand pressure by frequently repositioning the patient. Although left-sided weakness is aproblem for the patient, the nurse cannot treat the weakness. The“riskfor”diagnosisis not appropriate for this patient, who already has impaired tissue integrity. Thepatient does have ineffective tissue perfusion, but the impaired skin integrity diagnosisindicates more clearly what the health problem is.DIF: Cognitive Level: Apply (application) REF: 7-9TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity6.A patient with a bacterial infection has a nursing diagnosis of deficient fluid volumerelated to excessive diaphoresis. Which outcome would the nurse recognize asmostappropriate for this patient?a.Patienthasabalancedintakeandoutput.b.Patient’sbeddingischangedwhenitbecomesdamp.c.Patientunderstandstheneedforincreasedfluidintake.d.Patient’sskinremainscoolanddrythroughouthospitalization.ANS: AThis statement gives measurable data showing resolution of the problem of deficientfluid volume that was identified in the nursing diagnosis statement. The otherstatements would not indicate that the problem of deficient fluid volume was resolved.DIF: Cognitive Level: Apply (application) REF: 7-9TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 5 preview image7.A nurse asks the patient if pain was relieved after receiving medication. What is thepurpose of the evaluation phase of the nursing process?a.Todetermineifinterventionshavebeeneffectiveinmeetingpatientoutcomesb.Todocumentthenursingcareplanintheprogressnotesofthemedicalrecordc.Todecidewhetherthepatient’shealthproblemshavebeencompletelyresolvedd.ToestablishifthepatientagreesthatthenursingcareprovidedwassatisfactoryANS: AEvaluation consists of determining whether the desired patient outcomes have beenmet and whether the nursing interventions were appropriate. The other responses donot describe the evaluation phase.DIF: Cognitive Level: Understand (comprehension) REF: 7-9TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment8.The nurse interviews a patient while completing the health history and physicalexamination. What is the purpose of the assessment phase of the nursing process?a.Toteachinterventionsthatrelievehealthproblemsb.Tousepatientdatatoevaluatepatientcareoutcomesc.Toobtaindatawithwhichtodiagnosepatientproblemsd.TohelpthepatientidentifyrealisticoutcomesforhealthproblemsANS: CDuring the assessment phase, the nurse gathers information about the patient todiagnose patient problems. The other responses are examples of the planning,intervention, and evaluation phases of the nursing process.DIF: Cognitive Level: Understand (comprehension) REF: 7-9TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment9.Which nursing diagnosis statement is written correctly?a.Alteredtissueperfusionrelatedtoheartfailureb.Riskforimpairedtissueintegrityrelatedtosacralrednessc.Ineffectivecopingrelatedtoresponsetobiopsytestresultsd.AlteredurinaryeliminationrelatedtourinarytractinfectionANS: CThis diagnosis statement includes a NANDA nursing diagnosis and an etiology thatdescribes apatient’sresponse to a health problem that can be treated by nursing. The
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 6 preview imageuse of a medical diagnosis as an etiology (as in the responses beginning“Alteredtissueperfusion”and“Alteredurinary elimination”)is not appropriate. The responsebeginning“Riskfor impaired tissueintegrity”uses the defining characteristic as theetiology.DIF: Cognitive Level: Understand (comprehension) REF: 7TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment10.The nurse admits a patient to the hospital and develops a plan of care. Whatcomponents should the nurse include in the nursing diagnosis statement?a.Theproblemandthesuggestedpatientgoalsoroutcomesb.Theproblemwithpossiblecausesandtheplannedinterventionsc.Theproblem,itscause,andobjectivedatathatsupporttheproblemd.TheproblemwithanetiologyandthesignsandsymptomsoftheproblemANS: DWhen writing nursing diagnoses, this format should be used: problem, etiology, andsigns and symptoms. The subjective, as well as objective, data should be included inthe defining characteristics. Interventions and outcomes are not included in thenursing diagnosis statement.DIF: Cognitive Level: Remember (knowledge) REF: 8-9TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment11.A nurse is caring for a patient with heart failure. Which task is appropriate for thenurse to delegate to experienced unlicensed assistive personnel (UAP)?a.Monitorforshortnessofbreathorfatigueafterambulation.b.Instructthepatientabouttheneedtoalternateactivityandrest.c.Obtainthepatient’sbloodpressureandpulserateafterambulation.d.Determinewhetherthepatientisreadytoincreasetheactivitylevel.ANS: CUAP education includes accurate vital sign measurement. Assessment and patientteaching require registered nurse education and scope of practice and cannot bedelegated.DIF: Cognitive Level: Apply (application) REF: 15OBJ: Special Questions: Delegation TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 7 preview image12.A nurse is caring for a group of patients on the medical-surgical unit with the helpof one float registered nurse (RN), one unlicensed assistive personnel (UAP), and onelicensed practical/vocational nurse (LPN/LVN). Which assignment, if delegated bythe nurse, would be inappropriate?a.Measurementofapatient’surineoutputbyUAPb.AdministrationoforalmedicationsbyLPN/LVNc.CheckforthepresenceofbowelsoundsandflatulencebyUAPd.CareofapatientwithdiabetesbyRNwhousuallyworksonthepediatricunitANS: CAssessment requires RN education and scope of practice and cannot be delegated toan LPN/LVN or UAP. The other assignments made by the RN are appropriate.DIF: Cognitive Level: Apply (application) REF: 15-16OBJ: Special Questions: Delegation TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment13.Which task is appropriate for the nurse to delegate to a licensedpractical/vocational nurse (LPN/LVN)?a.Completetheinitialadmissionassessmentandplanofcare.b.Documentteachingcompletedbeforeadiagnosticprocedure.c.Instructapatientaboutlow-fat,reducedsodiumdietaryrestrictions.d.Obtainbedsidebloodglucoseonapatientbeforeinsulinadministration.ANS: DThe education and scope of practice of the LPN/LVN include activities such asobtaining glucose testing using a finger stick. Patient teaching and the initialassessment and development of the plan of care are nursing actions that requireregistered nurse education and scope of practice.DIF: Cognitive Level: Apply (application) REF: 15-16OBJ: Special Questions: Delegation TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment14.A nurse is assigned as a case manager for a hospitalized patient with a spinal cordinjury. The patient can expect the nurse functioning in this role to perform whichactivity?a.Careforthepatientduringhospitalizationfortheinjuries.
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 8 preview imageb.Assistthepatientwithhomecareactivitiesduringrecovery.c.Determinewhatmedicalcarethepatientneedsforoptimalrehabilitation.d.Coordinatetheservicesthatthepatientreceivesinthehospitalandathome.ANS: DThe role of the case manager is to coordinate thepatient’scare through multiplesettings and levels of care to allow the maximal patient benefit at the least cost. Thecase manager does not provide direct care in either the acute or home setting. The casemanager coordinates and advocates for care but does not determine what medical careis needed; that would be completed by the health care provider or other provider.DIF: Cognitive Level: Apply (application) REF: 15TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment15.The nurse is caring for an older adult patient who had surgery to repair a fracturedhip. The patient needs continued nursing care and physical therapy to improvemobility before returning home. The nurse will help to arrange for transfer of thispatient to which facility?a.Askilledcarefacilityb.Aresidentialcarefacilityc.Atransitionalcarefacilityd.AnintermediatecarefacilityANS: CTransitional care settings are appropriate for patients who need continuedrehabilitation before discharge to home or to long-term care settings. The patient is nolonger in need of the more continuous assessment and care given in acute caresettings. There is no indication that the patient will need the permanent and ongoingmedical and nursing services available in intermediate or skilled care. The patient isnot yet independent enough to transfer to a residential care facility.DIF: Cognitive Level: Apply (application)REF: eTable 1-1 | eTable 1-2 | eTable 1-3 TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment16.A home care nurse is planning care for a patient who has just been diagnosed withtype 2 diabetes mellitus. Which task is appropriate for the nurse to delegate to thehome health aide?
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 9 preview imagea.Assistthepatienttochooseappropriatefoods.b.Helpthepatientwithadailybathandoralcare.c.Checkthepatient’sfeetforsignsofbreakdown.d.Teachthepatienthowtomonitorbloodglucose.ANS: BAssisting with patient hygiene is included in home health-aide education and scope ofpractice. Assessment of the patient and instructing the patient in new skills, such asdiet and blood glucose monitoring, are complex skills that are included in registerednurse education and scope of practice.DIF: Cognitive Level: Apply (application) REF: 14OBJ: Special Questions: Delegation TOP: Nursing Process: ImplementationMSC: NCLEX: Safe and Effective Care Environment17.The nurse is providing education to nursing staff on quality care initiatives. Whichstatement would be themostaccurate description of the impact of health carefinancing on quality care?a.“Hospitalsarereimbursedforallcostsincurredifcareisdocumentedelectronically.”b.“Paymentforpatientcareisprimarilybasedonclinicaloutcomesandpatientsatisfaction.”c.“Ifapatientdevelopsacatheter-relatedinfection,thehospitalreceivesadditionalfunding.”d.“Becausehospitalsareaccountableforoverallcare,itisnotnursing’sresponsibilitytomondeliveredbyothers.”ANS: BPayment for health care services programs reimburses hospitals for their performanceon overall quality-of-care measures. These measures include clinical outcomes andpatient satisfaction. Nurses are responsible for coordinating complex aspects ofpatient care, including the care delivered by others, and identifying issues that areassociated with poor quality care. Payment for care can be withheld if somethinghappens to the patient that is considered preventable (e.g., acquiring a catheter-relatedurinary tract infection).DIF: Cognitive Level: Apply (application) REF: 4-5TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment18.The nurse documenting thepatient’sprogress in the care plan in the electronichealth record before an interdisciplinary discharge conference is demonstratingcompetency in which QSEN category?
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 10 preview imagea.Patient-centeredcareb.Qualityimprovementc.Evidence-basedpracticed.InformaticsandtechnologyANS: DThe nurse is displaying competency in the QSEN area of informatics and technology.Using a computerized information system to document patient needs and progress andcommunicate vital information regarding the patient with health care team membersprovides evidence that nursing practice standards related to the nursing process havebeen maintained during the care of the patient.DIF: Cognitive Level: Apply (application) REF: 5 | 10-11TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care EnvironmentMULTIPLE RESPONSE1.Which information will the nurse consider when deciding what nursing actions todelegate to a licensed practical/vocational nurse (LPN/LVN) who is working on amedical-surgical unit (select all that apply)?a.Institutionalpoliciesb.Stabilityofthepatientc.Statenursepracticeactd.LPN/LVNteachingabilitiese.ExperienceoftheLPN/LVNANS: A, B, C, EThe nurse should assess the experience of LPN/LVNs when delegating. In addition,state nurse practice acts and institutional policies must be considered. In general,LPN/LVN scope of practice includes caring for patients who are stable, whileregistered nurses should provide most of the care for unstable patients. SinceLPN/LVN scope of practice does not include patient education, this will not be part ofthe delegation process.DIF: Cognitive Level: Apply (application) REF: 14OBJ: Special Questions: Delegation TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 11 preview image2.The nurse is administering medications to a patient. Which actions by the nurseduring this process are consistent with promoting safe delivery of care (select all thatapply)?a.Throwsawayamedicationthatisnotlabeledb.Usesahandsanitizerbeforepreparingamedicationc.Identifiesthepatientbytheroomnumberonthedoord.Checkslabtestresultsbeforeadministeringadiuretice.GivesthepatientalistofcurrentmedicationsupondischargeANS: A, B, D, ENational Patient Safety Goals have been established to promote safe delivery of care.The nurse should use at least two reliable ways to identify the patient such as askingthepatient’sfull name and date of birth before medication administration. Otheractions that improve patient safety include performing hand hygiene, disposing ofunlabeled medications, completing appropriate assessments before administeringmedications, and giving a list of the current medicines to the patient and caregiverbefore discharge.DIF: Cognitive Level: Apply (application) REF: 15-16TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care EnvironmentOTHER1.The nurse uses the Situation-Background-Assessment-Recommendation (SBAR)format to communicate a change in patient status to a health care provider. In whichorder should the nurse make the following statements?(Put a comma and a spacebetween each answer choice [A, B, C, D].)a.“Thepatient needs to be evaluated immediately and may need intubation andmechanicalventilation.”b.“Thepatient was admitted yesterday with heart failure and has been receivingfurosemide (Lasix) for diuresis, but urine output has beenlow.”c.“Thepatient has crackles audible throughout the posterior chest and the most recentoxygen saturation is 89%. Her condition is veryunstable.”d.“Thisis the nurse on the surgical unit. After assessing the patient, I am veryconcerned about increased shortness of breath over the pasthour.”ANS:D, B, C, A
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 12 preview imageThe order of thenurse’sstatements follows the SBAR format.DIF: Cognitive Level: Apply (application) REF: 15OBJ: Special Questions: Prioritization TOP: Nursing Process: ImplementationMSC: NCLEX: Safe and Effective Care Environment
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 13 preview imageChapter 2: Health Disparities and CulturallyCompetent CareChapter 2: Health Disparities and Culturally Competent CareTest BankMULTIPLE CHOICE1.The nurse is obtaining a health history from a new patient. Which data will be thefocus of patient teaching?a.Ageandgenderb.Saturatedfatintakec.Hispanic/Latinoethnicityd.FamilyhistoryofdiabetesANS: BBehaviors are strongly linked to many health care problems. Thepatient’ssaturatedfat intake is a behavior that the patient can change. The other information will beuseful as the nurse develops an individualized plan for improving thepatient’shealth,but will not be the focus of patient teaching.DIF: Cognitive Level: Apply (application) REF: 31TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance2.The nurse works in a clinic located in a community with many Hispanics. Whichstrategy, if implemented by the nurse, would decrease health care disparities for theHispanic patients?a.Improvepublictransportationtotheclinic.b.Updateequipmentandsuppliesattheclinic.c.Obtainlow-costmedicationsforclinicpatients.d.TeachclinicstaffaboutHispanichealthbeliefs.ANS: DHealth care disparities are due to stereotyping, biases, and prejudice of health careproviders. The nurse can decrease these through staff education. The other strategiesalso may be addressed by the nurse but will not directly impact health disparities.DIF: Cognitive Level: Apply (application) REF: 24-25TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 14 preview image3.What information should the nurse collect when assessing the health status of acommunity?a.Airpollutionlevelsb.Numberofhealthfoodstoresc.Mostcommoncausesofdeathd.EducationleveloftheindividualsANS: CHealth status measures of a community include birth and death rates, life expectancy,access to care, and morbidity and mortality rates related to disease and injury.Although air pollution, access to health food stores, and education level are factorsthat affect acommunity’shealth status, they are not health measures.DIF: Cognitive Level: Understand (comprehension) REF: 19TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance4.The nurse is caring for a Native American patient who has traditional beliefs abouthealth and illness. Which action by nurse ismostappropriate?a.Avoidaskingquestionsunlessthepatientinitiatestheconversation.b.Askthepatientwhetheritisimportantthatculturalhealersarecontacted.c.Explaintheusualhospitalroutinesformealtimes,care,andfamilyvisits.d.Obtainfurtherinformationaboutthepatient’sculturalbeliefsfromafamilymember.ANS: BBecause the patient has traditional health care beliefs, it is appropriate for the nurse toask whether the patient would like a visit by ashamanor other cultural healer. There isno cultural reason for the nurse to avoid asking the patient questions because they arenecessary to obtain health information. The patient (rather than the family) should beconsulted about personal cultural beliefs. The hospital routines for meals, care, andvisits should be adapted to thepatient’spreferences rather than expecting the patientto adapt to the hospital schedule.DIF: Cognitive Level: Apply (application) REF: 26TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity5.The nurse is caring for an Asian patient who is being admitted to the hospital.Which action would bemostappropriate for the nurse to take when interviewing thispatient?
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 15 preview imagea.Avoideyecontactwiththepatient.b.Observethepatient’suseofeyecontact.c.Lookdirectlyatthepatientwheninteracting.d.Askafamilymemberaboutthepatient’sculturalbeliefs.ANS: BObservation of thepatient’suse of eye contact will be most useful in determining thebest way to communicate effectively with the patient. Looking directly at the patientor avoiding eye contact may be appropriate, depending on thepatient’sindividualcultural beliefs. The nurse should assess the patient, rather than asking familymembers about thepatient’sbeliefs.DIF: Cognitive Level: Apply (application) REF: 28 | 31TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity6.A female staff nurse is assessing a male patient of Arab descent who is admittedwith complaints of severe headaches. It is most important for the charge nurse tointervene if the nurse takes which action?a.Thenurseexplainsthe0to10intensitypainscale.b.Thenurseasksthepatientwhentheheadachesstarted.c.Thenursesitsdownatthebedsideandclosestheprivacycurtain.d.Thenursecallsforamalenursetobringahospitalgowntotheroom.ANS: CMany males of Arab ethnicity do not believe it is appropriate to be alone with anyfemale except for their spouse. The other actions are appropriate.DIF: Cognitive Level: Apply (application) REF: 28TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity7.The nurse cares for a patient who speaks a different language. If an interpreter is notavailable, which action by the nurse ismostappropriate?a.Talkslowlysothateachwordisclearlyheard.b.Speakloudlyincloseproximitytothepatient’sears.c.Repeatimportantwordssothatthepatientrecognizestheirsignificance.d.Usesimplegesturestodemonstratemeaningwhiletalkingtothepatient.ANS: D
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 16 preview imageThe 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: Understand (comprehension) REF: 32TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity8.The nurse plans care for a hospitalized patient who uses culturally based treatments.Which action by the nurse isbest?a.Encouragetheuseofdiagnosticprocedures.b.Coordinatetheuseoffolktreatmentswithorderedmedicaltherapies.c.Askthepatienttodiscontinuetheculturaltreatmentsduringhospitalization.d.Teachthepatientthatfolkremedieswillinterferewithordersbythehealthcareprovider.ANS: BMany culturally based therapies can be accommodated along with the use of Westerntreatments and medications. The nurse should attempt to use both traditional folktreatments and the ordered Western therapies as much as possible. Some culturallybased treatments can be effective in treating“Western”diseases. Not all folk remediesinterfere with Western therapies. It may be appropriate for the patient to continuesome culturally based treatments while he or she is hospitalized.DIF: Cognitive Level: Apply (application) REF: 26TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity9.The nurse is caring for a newly admitted patient. Which intervention isthebestexample of a culturally appropriate nursing intervention?a.Insistfamilymembersprovidemostofthepatient’spersonalcare.b.Maintainapersonalspaceofatleast2feetwhenassessingthepatient.c.Askpermissionbeforetouchingapatientduringthephysicalassessment.d.Considerthepatient’sethnicityasthemostimportantfactorinplanningcare.ANS: CMany cultures consider it disrespectful to touch a patient without asking permission,so asking a patient for permission is always culturally appropriate. The other actionsmay be appropriate for some patients but are not appropriate across all cultural groupsor for all individual patients. Ethnicity may not be the most important factor inplanning care, especially if the patient has urgent physiologic problems.DIF: Cognitive Level: Understand (comprehension) REF: 28
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 17 preview imageTOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity10.A staff nurse expresses frustration that a Native American patient always hasseveral family members at the bedside. Which action by the charge nurseismostappropriate?a.Remindthenursethatfamilysupportisimportanttothisfamilyandpatient.b.Havethenurseexplaintothefamilythattoomanyvisitorswilltirethepatient.c.Suggestthatthenurseaskfamilymemberstoleavetheroomduringpatientcare.d.Askaboutthenurse’spersonalbeliefsaboutfamilysupportduringhospitalization.ANS: DThe first step in providing culturally competent care is to understandone’sownbeliefs and values related to health and health care. Asking the nurse about personalbeliefs will help achieve this step. Reminding the nurse that this cultural practice isimportant to the family and patient will not decrease thenurse’sfrustration. Theremaining 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 notculturally appropriate for this patient.DIF: Cognitive Level: Apply (application) REF: 30-31TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity11.An older Asian American patient tells the nurse that she has lived in the UnitedStates for 50 years. The patient speaks English and lives in a predominantly Asianneighborhood. Which action by the nurse ismostappropriate?a.Includeashamanwhenplanningthepatient’scare.b.Avoiddirecteyecontactwiththepatientduringcare.c.Askthepatientaboutanyspecialculturalbeliefsorpractices.d.Involvethepatient’soldestsontoassistwithhealthcaredecisions.ANS: CFurther assessment of thepatient’shealth care preferences is needed before makingfurther plans for culturally appropriate care. The other responses indicate stereotypingof the patient based on ethnicity and would not be appropriate initial actions.DIF: Cognitive Level: Apply (application) REF: 31TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 18 preview image12.The nurse plans health care for a community with a large number of recentimmigrants from Vietnam. Which intervention is themostimportant for the nurse toimplement?a.Hepatitistestingb.Tuberculosisscreeningc.Contraceptiveteachingd.ColonoscopyinformationANS: BTuberculosis (TB) is endemic in many parts of Asia, and the incidence of TB is muchhigher in immigrants from Vietnam than in the general U.S. population. Teachingabout contraceptive use, colonoscopy, and testing for hepatitis may also beappropriate for some patients but is not generally indicated for all members of thiscommunity.DIF: Cognitive Level: Apply (application) REF: 29TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity13.When doing an admission assessment for a patient, the nurse notices that thepatient pauses before answering questions about the health history. Which action bythe nurse ismostappropriate?a.Interviewafamilymemberinstead.b.Waitforthepatienttoanswerthequestions.c.Remindthepatientthatyouhaveotherpatientswhoneedcare.d.Givethepatientanassessmentformlistingthequestionsandapen.ANS: BPatients from some cultures take time to consider a question carefully beforeanswering. The nurse will show respect for the patient and help develop a trustingrelationship by allowing the patient time to give a thoughtful answer. Asking thepatient why the answers are taking so much time, stopping the assessment, andhanding the patient a form indicate that the nurse does not have time for the patient.DIF: Cognitive Level: Apply (application) REF: 28TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity14.Which strategy should be aprioritywhen the nurse is planning care for a diabeticpatient who is uninsured?
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 19 preview imagea.Obtainlessexpensivemedications.b.Followevidence-basedpracticeguidelines.c.Assistwithdietarychangesasthefirstaction.d.Teachabouttheimpactofexerciseondiabetes.ANS: BThe use of standardized evidence-based guidelines will reduce the incidence of healthcare disparities among various socioeconomic groups. The other strategies may alsobe appropriate, but the priority concern should be that the patient receives care thatmeets the accepted standard.DIF: Cognitive Level: Apply (application) REF: 23 | 31OBJ: Special Questions: Prioritization TOP: Nursing Process: PlanningMSC: NCLEX: Health Promotion and Maintenance15.A Hispanic patient complains of abdominal cramping caused byempacho.Whichaction should the nurse takefirst?a.Askthepatientwhattreatmentsarelikelytohelp.b.Massagethepatient’sabdomenuntilthepainisgone.c.Administerprescribedmedicationstodecreasethecramping.d.Offertocontactacurandero(a)tomakeavisittothepatient.ANS: AFurther assessment of thepatient’scultural beliefs is appropriate before implementingany interventions for a culture-bound syndrome such asempacho.Althoughmedication, a visit by acurandero(a),or massage may be helpful, more informationabout thepatient’sbeliefs is needed to determine which intervention(s) will be mosthelpful.DIF: Cognitive Level: Apply (application) REF: 26 | 30OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity16.The nurse performs a cultural assessment with a patient from a different culture.Which action by the nurse should be takenfirst?a.Requestaninterpreterbeforeinterviewingthepatient.b.Waituntilafamilymemberisavailabletohelpwiththeassessment.c.Askthepatientaboutanyaffiliationwithaparticularculturalgroup.
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 20 preview imaged.Tellthepatientwhatthenursealreadyknowsaboutthepatient’sculture.ANS: CAn early step in performing a cultural assessment is to determine whether the patientfeels an affiliation with any cultural group. The other actions may be appropriate if thepatient does identify with a particular culture.DIF: Cognitive Level: Apply (application) REF: 30-31OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity17.The nurse working in a clinic in a primarily African American community notes ahigher incidence of uncontrolled hypertension in the patients. To correct this healthdisparity, which action should the nurse takefirst?a.Initiatearegularhome-visitprogrambynursesworkingattheclinic.b.Scheduleteachingsessionsaboutlow-saltdietsatcommunityevents.c.Assesstheperceptionsofcommunitymembersaboutthecareattheclinic.d.Obtainlow-costantihypertensivedrugsusingfundingfromgovernmentgrants.ANS: CBefore other actions are taken, additional assessment data are needed to determine thereason for the disparity. The other actions also may be appropriate, but additionalassessment is needed before the next action is selected.DIF: Cognitive Level: Apply (application) REF: 30-31OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Health Promotion and MaintenanceMULTIPLE RESPONSE1.The nurse is performing an admission assessment for a non-English speakingpatient who is from China. Which actions could the nurse take to enhancecommunication (select all that apply)?a.Useanelectronictranslationapplication.b.Useatelephone-basedmedicalinterpreter.c.Waituntilanagencyinterpreterisavailable.d.Askthepatient’steenagedaughtertointerpret.e.Useexaggeratedgesturestoconveyinformation.ANS: A, B, C
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 21 preview imageElectronic translation applications, telephone-based interpreters, and agencyinterpreters are all appropriate to use to communicate with non–English-speakingpatients. When no interpreter is available, family members may be considered, butsome information that will be needed in an admission assessment may bemisunderstood or not shared if a child is used as the interpreter. Gestures areappropriate to use, but exaggeration of the gestures is not needed.DIF: Cognitive Level: Apply (application) REF: 32-33TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 22 preview imageChapter 3: Health History and PhysicalExaminationChapter 3: Health History and Physical ExaminationTest BankMULTIPLE CHOICE1.A patient who is actively bleeding is admitted to the emergency department. Whichapproach isbestfor the nurse to use to obtain a health history?a.Brieflyinterviewthepatientwhileobtainingvitalsigns.b.Obtainsubjectivedataaboutthepatientfromfamilymembers.c.Omitsubjectivedatacollectionandobtainthephysicalexamination.d.Usethehealthcareprovider’smedicalhistorytoobtainsubjectivedata.ANS: AIn an emergency situation the nurse may need to ask only the most pertinent questionsfor a specific problem and obtain more information later. A complete health historywill include subjective information that is not available in the health careprovider’smedical history. Family members may be able to provide some subjective data, butonly the patient will be able to give subjective information about the bleeding.Because the subjective data about the cause of thepatient’sbleeding will be essential,obtaining the physical examination alone will not provide sufficient information.DIF: Cognitive Level: Apply (application) REF: 45TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance2.Immediate surgery is planned for a patient with acute abdominal pain. Whichquestion by the nurse will elicit themostcomplete information about thepatient’scoping-stress tolerance pattern?a.“Canyourateyourpainona0to10scale?”b.“Whatdoyouthinkcausedthisabdominalpain?”c.“Howdoyoufeelaboutyourselfandyourhospitalization?”d.“Arethereothermajorproblemsthatareaconcernrightnow?”ANS: DThe coping-stress tolerance pattern includes information about other major stressorsconfronting the patient. The health perception–health management pattern includesinformation about thepatient’sideas about risk factors. Feelings about self and the
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 23 preview imagehospitalization are assessed in the self-perception–self-concept pattern. Intensity ofpain is part of the cognitive-perceptual pattern.DIF: Cognitive Level: Apply (application) REF: 41TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity3.During the health history interview, a patient tells the nurse about periodic faintingspells. Which question by the nurse willbestelicit any associated clinicalmanifestations?a.“Howfrequentlydoyouhavethefaintingspells?”b.“Whereareyouwhenyouhavethefaintingspells?”c.“Dothespellstendtooccuratanyspecialtimeofday?”d.“Doyouhaveanyothersymptomsalongwiththespells?”ANS: DAsking about other associated symptoms will provide the nurse more informationabout all the clinical manifestations related to the fainting spells. Information aboutthe setting is obtained by asking where the patient was and what the patient was doingwhen the symptom occurred. The other questions from the nurse are appropriate forobtaining information about chronology and frequency.DIF: Cognitive Level: Apply (application) REF: 42TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance4.The nurse records the following general survey of a patient:“Thepatient is a 50-year-old Asian female attended by her husband and two daughters. Alert and oriented.Does not make eye contact with the nurse and responds slowly, but appropriately, toquestions. No apparent disabilities or distinguishingfeatures.”What additionalinformation should the nurse add to this general survey?a.Nutritionalstatusb.Intakeandoutputc.Reasonsforcontactwiththehealthcaresystemd.CommentsoffamilymembersabouthisconditionANS: AThe general survey also describes thepatient’sgeneral nutritional status. The otherinformation will be obtained when doing the complete nursing history andexamination but is not obtained through the initial scanning of a patient.
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 24 preview imageDIF: Cognitive Level: Understand (comprehension) REF: 39-41TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance5.A nurse performs a health history and physical examination with a patient who hasa right leg fracture. Which assessment would be a pertinent negative finding?a.Patienthasseveralbruisedandswollenareasontherightleg.b.Patientstatesthattherehavebeennootherrecenthealthproblems.c.Patientrefusestobendtherightkneebecauseoftheassociatedpain.d.Patientdenieshavingpainwhentheareaoverthefractureispalpated.ANS: DThe nurse expects that a patient with a leg fracture will have pain over the fracturedarea. The bruising and swelling and pain with bending are positive findings. No otherrecent health problems is neither a positive nor a negative finding with regard to a legfracture.DIF: Cognitive Level: Apply (application) REF: 41TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance6.The nurse who is assessing an older adult with rectal bleeding asks,“Haveyou everhad acolonoscopy?”The nurse is performing what type of assessment?a.Focusedassessmentb.Emergencyassessmentc.Detailedhealthassessmentd.ComprehensiveassessmentANS: AA focused assessment is an abbreviated assessment used to evaluate the status ofpreviously identified problems and monitor for signs of new problems. It can be donewhen a specific problem is identified. An emergency assessment is done when thenurse needs to obtain information about life-threatening problems quickly whilesimultaneously taking action to maintain vital function. A comprehensive assessmentincludes a detailed health history and physical examination of one body system ormany body systems. It is typically done on admission to the hospital or onset of carein a primary care setting.DIF: Cognitive Level: Understand (comprehension) REF: 42TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 25 preview image7.The nurse is preparing to perform a focused assessment for a patient complaining ofshortness of breath. Which equipment will be needed?a.Flashlightb.Stethoscopec.Tonguebladesd.PercussionhammerANS: BA stethoscope is used to auscultate breath sounds. The other equipment may be usedfor a comprehensive assessment but will not be needed for a focused respiratoryassessment.DIF: Cognitive Level: Understand (comprehension) REF: 42TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance8.The nurse plans to complete a physical examination of an alert, older patient. Whichadaptations to the examination technique should the nurse include?a.Avoidtheuseoftouchasmuchaspossible.b.Useslightlymorepressureforpalpationoftheliver.c.Speaksoftlyandslowlywhentalkingwiththepatient.d.Organizethesequencetominimizethepositionchanges.ANS: DOlder patients may have age-related changes in mobility that make it more difficult tochange position. There is no need to avoid the use of touch when examining olderpatients. Less pressure should be used over the liver. Because the patient is alert, thereis no indication that there is any age-related difficulty in understanding directionsfrom the nurse.DIF: Cognitive Level: Apply (application) REF: 42TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance9.While the nurse is taking the health history, a patient states,“Mymother and sisterboth had double mastectomies and were unable to be very active forweeks.”Whichfunctional health pattern is represented by thispatient’sstatement?a.Activity-exerciseb.Cognitive-perceptualc.Coping-stresstolerance
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 26 preview imaged.Healthperception–healthmanagementANS: DThe information in the patient statement relates to risk factors and importantinformation about the family history. Identification of risk factors falls into the healthperception–health maintenance pattern.DIF: Cognitive Level: Understand (comprehension) REF: 39-40TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance10.A patient is seen in the emergency department with severe abdominal pain andhypotension. Which type of assessment should the nurse do at this time?a.Focusedassessmentb.Subjectiveassessmentc.Emergencyassessmentd.ComprehensiveassessmentANS: CBecause the patient is hemodynamically unstable, an emergency assessment isneeded. Comprehensive and focused assessments may be needed after the patient isstabilized. Subjective information is needed, but objective data such as vital signs areessential for the unstable patient.DIF: Cognitive Level: Understand (comprehension) REF: 42 | 45TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance11.The registered nurse (RN) cares for a patient who was admitted a few hourspreviously with back pain after falling. Which action can the RN delegate tounlicensed assistive personnel (UAP)?a.Finishdocumentingtheadmissionassessment.b.Determinethepatient’sprioritynursingdiagnoses.c.Obtainthehealthhistoryfromthepatient’scaregiver.d.Takethepatient’stemperature,pulse,andbloodpressure.ANS: DThe RN may delegate vital signs to the UAP. Obtaining the health history,documentation of the admission assessment, and determining nursing diagnosesrequire the education and scope of practice of the RN.DIF: Cognitive Level: Apply (application) REF: 38
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 27 preview imageOBJ: Special Questions: Delegation TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment12.When assessing for formation of a possible blood clot in the lower leg of a patient,which action should the nurse takefirst?a.Visuallyinspecttheleg.b.Feelforthetemperatureoftheleg.c.Checkthepatient’spedalpulsesusingthefingertips.d.Compressthenailbedstodeterminecapillaryrefilltime.ANS: AInspection is the first of the major techniques used in the physical examination.Palpation and auscultation are then used later in the examination.DIF: Cognitive Level: Apply (application) REF: 41OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Health Promotion and Maintenance13.When assessing apatient’sabdomen during the admission assessment, whichaction should the nurse takefirst?a.Feelforanymasses.b.Palpatetheabdomen.c.Listenforbowelsounds.d.Percusstheliverborders.ANS: CWhen assessing the abdomen, auscultation is done before palpation or percussionbecause palpation and percussion can cause changes in bowel sounds and alter thefindings. All of the techniques are appropriate, but auscultation should be done first.DIF: Cognitive Level: Understand (comprehension) REF: 41OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Health Promotion and Maintenance14.When admitting a patient who has just arrived on the unit with a severe headache,what should the nurse dofirst?a.Completeonlybasicdemographicdatabeforeaddressingthepatient’spain.b.Medicatethepatientfortheheadachebeforedoingthehealthhistoryandexamination.c.Taketheinitialvitalsignsandthenaddresstheheadachebeforecompletingthehealthhisto
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 28 preview imaged.InformthepatientthattheheadachewillbetreatedassoonasthehealthhistoryiscompletANS: CThe patient priority in this situation will be to decrease the pain level because thepatient will be unlikely to cooperate in providing demographic data or the healthhistory until the nurse addresses the pain. However, obtaining information about vitalsigns is essential before using either pharmacologic or nonpharmacologic therapies forpain control. The vital signs may indicate hemodynamic instability that would need tobe addressed immediately.DIF: Cognitive Level: Apply (application) REF: 37OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Physiological IntegrityOTHER1.In what order will the nurse perform these actions when doing a physicalassessment for a patient admitted with abdominal pain?(Put a comma and a spacebetween each answer choice [A, B, C, D].)a. Percuss the abdomen to locate any areas of dullness.b. Palpate the abdomen to check for tenderness or masses.c. Inspect the abdomen for distention or other abnormalities.d. Auscultate the abdomen for the presence of bowel sounds.ANS:C, D, A, BWhen assessing the abdomen, the initial action is to inspect the abdomen.Auscultation is done next because percussion and palpation can alter bowel soundsand produce misleading findings.DIF: Cognitive Level: Understand (comprehension) REF: 41TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 29 preview imageChapter 4: Patient and Caregiver TeachingChapter 4: Patient and Caregiver TeachingTest BankMULTIPLE CHOICE1.A patient with newly diagnosed colon cancer has a nursing diagnosis of deficientknowledge about colon cancer. The nurse should initially focus on which learninggoal for this patient?a.Thepatientwillselectthemostappropriatecoloncancertherapy.b.Thepatientwillstatewaysofpreventingtherecurrenceofthecancer.c.Thepatientwilldemonstratecopingskillsneededtomanagethedisease.d.Thepatientwillchoosemethodstominimizeadverseeffectsoftreatment.ANS: AAdults learn best when given information that can be used immediately. The firstaction the patient will need to take after a cancer diagnosis is to choose a treatmentoption. The other goals may be appropriate as treatment progresses.DIF: Cognitive Level: Apply (application) REF: 48TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance2.After the nurse provides dietary instructions for a patient with diabetes, the patientcan explain the information but fails to make the recommended dietary changes. Howwould the nurse evaluate thepatient’ssituation?a.Learningdidnotoccurbecausethepatient’sbehaviordidnotchange.b.Choosingnottofollowthedietisthebehaviorthatresultedfromlearning.c.Thenursingresponsibilityforhelpingthepatientmakedietarychangeshasbeenfulfilled.d.Theteachingmethodswereineffectiveinhelpingthepatientlearnthedietaryinstructions.ANS: BAlthough the patient behavior has not changed, thepatient’sability to explain theinformation indicates that learning has occurred and the patient is choosing at thistime not to change the diet. The patient may be in the contemplation or preparationstage in the Transtheoretical Model. The nurse should reinforce the need for changeand continue to provide information and assistance with planning for change.DIF: Cognitive Level: Apply (application) REF: 49TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 30 preview image3.A patient is diagnosed with heart failure after being admitted to the hospital forshortness of breath and fatigue. Which teaching strategy, if implemented by the nurse,ismostlikely to be effective?a.Assurethepatientthatthenurseisanexpertonmanagementofheartfailure.b.Teachthepatientateachmealabouttheamountsofsodiuminvariousfoods.c.Discusstheimportanceofmedicationcontrolinmaintenanceoflong-termhealth.d.Referthepatienttoahomehealthnurseforinstructionsondietandfluidrestrictions.ANS: BPrinciples of adult education indicate that readiness and motivation to learn are highwhen facing new tasks (such as learning about the sodium amounts in various fooditems) and when demonstration and practice of skills are available. Although a homehealth referral may be needed for this patient, teaching should not be postponed untildischarge. Adult learners are independent. The nurse should act as a facilitator forlearning, rather than as the expert. Adults learn best when the topic is of immediateusefulness. Long-term goals may not be very motivating.DIF: Cognitive Level: Apply (application) REF: 48TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance4.A patient who was admitted to the hospital with hyperglycemia and newlydiagnosed diabetes mellitus is scheduled for discharge the second day after admission.When implementing patient teaching, what is thepriorityaction forthe nurse?a.Instructabouttheincreasedriskforcardiovasculardisease.b.Providedetailedinformationaboutdietarycontrolofglucose.c.Teachglucoseself-monitoringandmedicationadministration.d.Giveinformationabouttheeffectsofexerciseonglucosecontrol.ANS: CWhen time is limited, the nurse should focus on the priorities of teaching. In thissituation, the patient should know how to test blood glucose and administermedications to control glucose levels. The patient will need further teaching about therole of diet, exercise, various medications, and the many potential complications ofdiabetes, but these topics can be addressed through planning for appropriate referrals.DIF: Cognitive Level: Apply (application) REF: 50TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
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Test Bank For Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition - Page 31 preview image5.A patient states,“Itold my husband Iwouldn’tbuy as much prepared food snacks,so I will go the grocery store to buy fresh fruit, vegetables, and wholegrains.”Whenusing the Transtheoretical Model of Health Behavior Change, the nurse identifies thatthis patient is in which stage of change?a.Preparationb.Terminationc.Maintenanced.ContemplationANS: AThepatient’sstatement indicating that the plan for change is being shared withsomeone else indicates that the preparation stage has been achieved. Contemplation ofa change would be indicated by a statement like“Iknow I shouldexercise.”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: Understand (comprehension) REF: 49TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance6.While admitting a patient to the medical unit, the nurse determines that the patientis hard of hearing. How should the nurse use this information to plan teaching andlearning strategies?a.Motivationandreadinesstolearnwillbeaffected.b.Thefamilymustbeincludedintheteachingprocess.c.Thepatientwillhaveproblemsunderstandinginformation.d.Writtenmaterialsshouldbeprovidedwithverbalinstructions.ANS: DThe information that the patient is hard of hearing indicates that the nurse should usewritten and verbal materials in teaching along with other strategies. The patient doesnot indicate a lack of motivation or an inability to understand new information. Thepatient’sdecreased hearing does not necessarily imply that the family must beincluded in the teaching process.DIF: Cognitive Level: Understand (comprehension) REF: 52TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
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Medical-Surgical Nursing: Assessmen...

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