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Test Bank for Medical-Surgical Nursing in Canada, 4th Edition

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Test Bank for Medical-Surgical Nursing in Canada, 4th Edition provides an extensive collection of questions to test your knowledge.

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    Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition MULTIPLE CHOICE 1. When caring for clients using evidence-informed practice, which of the following does the nurse use? a. Clinical judgement based on experience b. Evidence from a clinical research study c. The best available evidence to guide clinical expertise d. Evaluation of data showing that the client outcomes are met ANS: C Evidence-informed nursing practice is a continuous interactive process involving the explicit, conscientious, and judicious consideration of the best available evidence to provide care. Four primary elements are: (a) clinical state, setting, and circumstances; (b) client preferences and actions; (c) best research evidence; and (d) health care resources. Clinical judgement based on the nurse’s clinical experience is part of EIP, 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 client outcomes is important, but interventions should be based on research from randomized control studies with a large number of subjects. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning 2. Which of the following best explains the nurses’ primary use of the nursing process when providing care to clients? a. To explain nursing interventions to other health care professionals b. As a problem-solving tool to identify and treat clients’ health care needs c. As a scientific-based process of diagnosing the client’s health care problems d. To establish nursing theory that incorporates the biopsychosocial nature of humans ANS: B The nursing process is an assertive problem-solving approach to the identification and treatment of clients’ problems. Diagnosis is only one phase of the nursing process. The primary use of the nursing process is in client care, not to establish nursing theory or explain nursing interventions to other health care professionals. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation 3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-hour turning schedule to prevent skin breakdown. Which type of nursing function is demonstrated with this turning schedule? a. Dependent b. Cooperative c. Independent d. Collaborative ANS: D

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    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 client 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 TOP: Nursing Process: Implementation 4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells the nurse, “I do not feel right about leaving my children with my neighbour.” Which action should the nurse take next? a. Reassure the client that these feelings are common for parents. b. Have the client call the children to ensure that they are doing well. c. Call the neighbour to determine whether adequate childcare is being provided. d. Gather more data about the client’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 TOP: Nursing Process: Assessment 5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and assesses a pressure injury on the client’s left hip. Which of the following is the most appropriate nursing diagnosis for this client? a. Impaired physical mobility related to decrease in muscle control (left-sided paralysis) b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about protecting tissue integrity c. Impaired skin integrity related to pressure over bony prominence (impaired circulation) d. Ineffective tissue perfusion related to sedentary lifestyle ANS: C The client’s major problem is the impaired skin integrity as demonstrated by the presence of a pressure injury. The nurse is able to treat the cause of altered circulation and pressure by frequently repositioning the client. Although left-sided weakness is a problem for the client, the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this client, who already has impaired tissue integrity. The client does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health problem is. DIF: Cognitive Level: Application TOP: Nursing Process: Diagnosis 6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis. Which of the following is an appropriate client outcome? a. Client has a balanced intake and output.

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    b. Client’s bedding is changed when it becomes damp. c. Client understands the need for increased fluid intake. d. Client’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 TOP: Nursing Process: Planning 7. Which of the following represents a nursing activity that is carried out during the evaluation phase of the nursing process? a. Determining if interventions have been effective in meeting client outcomes b. Documenting the nursing care plan in the progress notes in the medical record c. Deciding whether the client’s health problems have been completely resolved d. Asking the client to evaluate whether the nursing care provided was satisfactory ANS: A Evaluation consists of determining whether the desired client outcomes have been met and whether the nursing interventions were appropriate. The other responses do not describe the evaluation phase. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Evaluation 8. Which of the following would the nurse perform during the assessment phase of the nursing process? a. Obtains data with which to diagnose client problems b. Uses client data to develop priority nursing diagnoses c. Teaches interventions to relieve client health problems d. Assists the client to identify realistic outcomes to health problems ANS: A During the assessment phase, the nurse gathers information about the client. The other responses are examples of the intervention, diagnosis, and planning phases of the nursing process. DIF: Cognitive Level: Knowledge TOP: Nursing Process: Assessment 9. Which of the following is an example of a correctly written nursing diagnosis statement? a. Altered tissue perfusion related to heart failure b. Risk for impaired tissue integrity related to sacral redness c. Ineffective coping related to insufficient sense of control. 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 client’s response to a health problem that can be treated by nursing. The use of a medical diagnosis (as in the responses beginning “Altered tissue perfusion” and “Altered urinary elimination”) is not appropriate. The response beginning “Risk for impaired tissue integrity” uses the defining characteristics as the etiology.

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    DIF: Cognitive Level: Comprehension TOP: Nursing Process: Diagnosis 10. Which of the following includes the components required for a complete nursing diagnosis statement? a. A problem and the suggested client goals or outcomes b. A problem, its cause, and objective data that support the problem 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 TOP: Nursing Process: Diagnosis 11. Which of the following refers to a situation that results in unintended harm to the client and is related to the care or services provided rather than the client’s medical condition? a. Negligence b. Adverse event c. Incident report d. Nonmaleficence ANS: B An adverse event is an event that results in unintended harm to the client and is related to the care or services provided to the client rather than to the client’s underlying medical condition. DIF: Cognitive Level: Knowledge TOP: Nursing Process: Evaluation 12. When using the Five Steps of the e vidence- i nformed p ractice (EIP) Process, which of the flowing elements is the final step when constructing a clinical question? a. Comparison of interest b. Population of interest c. Outcome of interest d. Timeframe of interest ANS: D The order of the nurse’s statements follows the PICOT format with the final step being the “T”, or timeframe of interest. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

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    Chapter 02: Cultural Competence and Health Equity in Nursing Care Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition MULTIPLE CHOICE 1. Which of the following terms refers to characteristics of a group whose members share a common social, cultural, linguistic, or religious heritage? a. Diversity b. Ethnicity c. Ethnocentrism d. Cultural imposition ANS: B Ethnicity is the common social, cultural, linguistic, or religious heritage of a group of people. Diversity is a presence of persons with differences from the majority or dominant group that is assumed to be the norm. Ethnocentrism is a tendency of individuals to believe that their way of viewing and responding to the world is the most correct, natural, and superior one. Cultural imposition is imposition of one person's own cultural beliefs and practices, intentionally or unintentionally, on another person or group of people. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning 2. The nurse is caring for Indigenous clients in a community clinic setting. Which of the following would the nurse include when developing strategies to decrease health care disparities? a. Improve public transportation. b. Obtain low-cost medications. c. Update equipment and supplies for the clinic. d. Educate staff about Indigenous 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 TOP: Nursing Process: Planning 3. A family member of an elderly Hispanic client admitted to the hospital tells the nurse that the client has traditional beliefs about health and illness. Which of the following actions is most appropriate for the nurse in this situation? a. Avoid asking any questions unless the client initiates conversation. b. Ask the client 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 client’s cultural beliefs from the daughter. ANS: B

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    Because the client has traditional health care beliefs, it is appropriate for the nurse to ask whether the client would like a visit from a cultural healer. Nurses ask key questions with regard to language, diet, religion, and acculturation and eliciting the client’s explanatory model of health and illness. There is no cultural reason for the nurse to avoid asking the client questions, and questions may be necessary to obtain necessary health information. The client (rather than the daughter) should be consulted about personal cultural beliefs. The hospital routines for meals, care, and visits should be adapted to the client’s preferences rather than expecting the client to adapt to the hospital schedule. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 4. When caring for an Indigenous client, which of the following actions is the best initial approach in relation to eye contact for the nurse to take? a. Avoid all eye contact with the client. b. Observe the client’s use of eye contact. c. Look directly at the client when interacting. d. Ask the family about the client’s cultural beliefs. ANS: B Eye contact varies greatly among and within cultures so the nurses’ initial action is to assess the client’s use of eye contact. Although nurses are often taught to maintain direct eye contact, clients who are Asian, Arab, or Indigenous may avoid direct eye contact and consider direct eye contact disrespectful or aggressive. Looking directly at the client or avoiding eye contact may be appropriate, depending on the client’s individual cultural beliefs. The nurse should assess the client, rather than asking family members about the client’s beliefs. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 5. A graduate nurse is assessing a newly admitted non–English-speaking Chinese client who complains of severe headaches. Which of the following actions by the graduate nurse would cause the charge nurse to intervene during this assessment interview? a. Sit down at the bedside. b. Palpate the client’s scalp. c. Call for a medical interpreter. d. Avoid eye contact with the client. ANS: B Many people of Asian ethnicity believe that touching a person’s head is disrespectful; the nurse should always ask permission before touching any client’s head. The other actions are appropriate. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 6. The nurse is caring for a client who speaks a language different from the nurse’s language and there is no interpreter available. Which of the following actions is the most appropriate for the nurse to implement? a. Use specific medical terms in the Latin form. b. Talk loudly and slowly so that each word is clearly heard. c. Repeat important words so that the client recognizes their importance. d. Use simple gestures to demonstrate meaning while talking to the client.

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    ANS: D The use of gestures will enable some information to be communicated to the client. The other actions will not improve communication with the client. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation 7. According to the ABC(DE)s of cultural competence, awareness of and sensitivity to cultural values is in which of the following domains? a. Skills domain b. Affective domain c. Knowledge domain d. Behavioural domain ANS: B The affective domain reflects an awareness of and sensitivity to cultural values, needs, and biases. The skills domain does not reflect an awareness of and sensitivity to cultural values, needs, and biases. There is no skills or knowledge domain; with ABC(DE) it is affective, behavioural, and cognitive domains as well as dynamics of difference and environment. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning 8. Which of the following actions represents the best example of culturally appropriate nursing care when caring for a newly admitted client? a. Have family members provide most of the client’s personal care. b. Maintain a personal space of at least 0.5 m when assessing the client. c. Ask permission before touching a client during the physical assessment. d. Consider the client’s ethnicity as the most important factor in planning care. ANS: C Many cultures consider it disrespectful to touch a client without asking permission, so asking a client for permission is always culturally appropriate. The other actions may be appropriate for some clients but are not appropriate across all cultural groups or for all individual clients. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation 9. While talking with the nursing supervisor, a staff nurse expresses frustration that an Indigenous client always has several family members at the bedside. Which of the following actions is the most appropriate action for the nursing supervisor in this situation? a. Remind the nurse that family support is important to this family and client. b. Have the nurse explain to the family that too many visitors will tire the client. c. Suggest that the nurse ask family members to leave the room during client care. d. Ask about the nurse’s personal beliefs about family support during hospitalization. ANS: D

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    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 client 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 client) are not culturally appropriate for this client. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 10. An elderly Asian Canadian client tells the nurse that she has lived in Canada for 50 years. The client speaks English but lives in a predominantly Asian neighbourhood. Which of the following actions is most appropriate for the nurse? a. Arrange to have a folk healer available when planning the client’s care. b. Ask the client about any special cultural beliefs or practices. c. Avoid making direct eye contact with the client during care. d. Involve the client’s oldest son in making health care decisions. ANS: B Further assessment of the client’s health care preferences is needed before making further plans for culturally appropriate care. The other responses indicate stereotyping of the client, based on ethnicity, and would not be appropriate initial actions. DIF: Cognitive Level: Application TOP: Nursing Process: Planning 11. Which of the following statements is true related to immigrants to Canada? a. Decreased risk of social exclusion related to Canada’s multicultural population. b. New immigrants tend to be in overall better health than the resident population. c. Health status of immigrants is not related to length of time in Canada. d. Unemployment is not associated with poorer health outcomes for immigrants. ANS: B The healthy immigrant effect indicates that new immigrants tend to be in better overall health than the general resident population. This finding is not surprising inasmuch as immigrants are screened before being granted admittance to Canada. Health status is related to length of time in Canada, the health of immigrants, 20 years after immigration, as determined by age-standardized mortality rates, is generally poorer than those of the Canadian-born population. Underemployment, unemployment, and workplace stress place immigrants at increased health risks as well as the risk for social exclusion. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning 12. Which of the following question formats is the most appropriate for the nurse to ask when communicating with a client that has limited English proficiency? a. Are you tired and in discomfort? b. You have taken your pills right? c. Are you alright? d. Are you in pain? ANS: D

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    When communicating with a client that has limited English proficiency, the best questions to ask are ones that are in simple language a couple of words, plain simple terms, such as “Are you in pain?” Asking about tiredness and discomfort in the same sentence should be avoided—ask one item at a time and use the term ‘pain’, not discomfort. Asking the client “are you alright” is vague and will elicit a yes or no answer. “You have taken your pills right?” is accusatory and should be avoided. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 13. An Indigenous client tells the nurse that he thinks his abdominal pain is caused by eating too much seal fat and that strong massage over the stomach will help it. Which of the following statements depicts what the client is describing to the nurse? a. Evidence-informed national guidelines b. Awareness and knowledge of his own culture c. The explanatory model of health and health practices d. Knowledge about the difference in modern and folk health practices ANS: C The explanatory model is a set of beliefs regarding what causes the disease or illness and the methods that would potentially treat the condition best. Different cultural groups have different beliefs about the causes of illness and the appropriateness of various treatments. The situation is not reflective of national guidelines. There is no comparison between modern and folk health practices. The client is explaining experiences and beliefs’ rather than awareness and knowledge. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment 14. Which of the following statements represents a health inequity currently experienced in Canada? a. Indigenous adults are less likely to smoke tobacco than other adults in Canada. b. Overall suicide rate among First Nation communities is about twice the rate of the general population. c. Individuals from lower income neighbourhoods undergo preventive health screening more that their higher income counterparts. d. Recent immigrants are more likely to have a primary care physician than Canadian-born individuals. ANS: B Suicide rates are five to seven times higher among Indigenous youth than among non-Indigenous youth. Suicide rates among Indigenous youth are among the highest in the world, at 11 times the national average. Smoking rates are more than two times higher among the three Indigenous groups than among the non-Indigenous population. Individuals from higher income neighbourhoods undergo preventive health screening more than those from lower income neighbourhoods. Recent immigrants are less likely to have a primary care physician than Canadian-born individuals. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment 15. When performing a cultural assessment with a client of a different culture, which of the following actions is the initial action to be taken by the nurse? a. Wait until a cultural healer is available to help with the assessment.

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    b. Obtain a list of any cultural remedies that the client currently uses. c. Ask the client about any affiliation with a particular cultural group. d. Tell the client what the nurse already knows about the client’s culture. ANS: C An early step in performing a cultural assessment is to determine the cultural group with which the client identifies. The other actions may be appropriate if the client does identify with a particular culture. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment 16. Equity in health care is concerned with creating equal opportunities for good health for everyone in which one of the following ways? a. Increase negative effect of social determinants of health. b. Increase awareness of acute care programs. c. Decrease non-modifiable risk factors. d. Reduce exclusion. ANS: D Health equity is concerned with creating equal opportunities for good health for everyone in two ways: (a) decreasing the negative effect of the social determinants of health and (b) by improving services to enhance access and reduce exclusion. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment

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    Chapter 03: Health History and Physical Examination Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition MULTIPLE CHOICE 1. An older-adult client who is having difficulty breathing is admitted to the hospital. Which of the following approaches is the best for the nurse to use to obtain a complete health history? a. Obtain subjective data about the client 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 client to gather subjective data. ANS: D In the case of an older-adult client with a low energy level, several short sessions may have to be scheduled. Allowing time for the client to volunteer information about particular areas of concern enables the nurse to work with the client to identify existing and potential health problems. 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 client will be able to give subjective information about the shortness of breath. Since the subjective data about the client’s respiratory status will be essential, obtaining the physical examination alone will not provide sufficient information. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment 2. Immediate surgery is planned for a client with acute abdominal pain. Which of the following questions will elicit the most complete information about the client’s coping-stress tolerance pattern? a. “Can you tell me how intense your pain is now?” b. “What do you think caused this abdominal pain?” 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 client. The health perception–health management pattern includes information about the client’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 TOP: Nursing Process: Assessment 3. During the health history interview, a client 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?”

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    d. “Do you have any other symptoms along with the spells?” ANS: B Information about the setting is obtained by asking where the client was and what the client 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 TOP: Nursing Process: Assessment 4. The nurse records the following general survey of a client: “The client is a 68-year-old male Asian accompanied 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.” Which of the following information should be added to this general survey documentation? a. Nutritional status b. Intake and output c. Reasons for contact with the health care system d. Comments of family members about his condition ANS: A The general survey also describes the client’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 client. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment 5. A nurse is performing a health history and physical examination for a client with right-sided rib fractures. Which of the following data is a pertinent negative finding? a. Client states that there have been no other health problems recently. b. Client denies having pain when the area over the fractures is palpated. c. Client has several bruised and swollen areas on the right anterior chest. d. Client refuses to take a deep breath because of the associated chest pain. ANS: B The nurse expects that a client 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 TOP: Nursing Process: Assessment 6. As the nurse assesses the client’s neck, the client says, “My neck is so stiff I can hardly move it.” This client statement indicates the nurse should perform which of the following assessments? a. Focused b. Screening c. Emergency d. Comprehensive ANS: A

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    The focused assessment is needed when a client 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 assessment is not recognized as one of the three main types of assessment. A comprehensive assessment is a detailed health history and physical examination. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment 7. The nurse is preparing to perform a focused abdominal assessment for a client 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 TOP: Nursing Process: Assessment 8. When the nurse is planning for the physical examination of an alert older-adult client, which of the following adaptations to the examination technique should be considered? a. Speaking slowly when directing the client 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 clients 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 clients. Less pressure should be used over the liver. Since the client is alert, there is no indication that there is any age-related difficulty in understanding directions from the nurse. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment 9. While the nurse is taking the health history, a client states, “My father and grandfather both had heart attacks and were unable to be very active afterwards.” This statement reflects which of the following functional health patterns? a. Activity—exercise b. Cognitive—perceptual c. Coping—stress tolerance d. Health perception—health management ANS: D The information in the client 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 TOP: Nursing Process: Assessment

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    10. A client is seen in the emergency department with chest pain and hypotension. Which type of assessment should the nurse do at this time? a. Focused b. Subjective c. Emergency d. Comprehensive ANS: C Since the client is hemodynamically unstable, an emergency assessment is needed. Comprehensive and focused assessments may be needed after the client is stabilized. Subjective information is needed, but objective data such as vital signs also are essential for the unstable client. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment 11. The nurse records the following general survey of a client: “The client is a 68-year-old Indigenous male accompanied 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.” Which of the following areas does the nurse need to assess to complete the general survey? a. Body movements b. Intake and output c. Reasons for contact with the health care system d. Comments of family members about his condition ANS: A To complete a general survey, the nurse needs to assess the client’s body movements. Intake and output, reasons for contact with the health care system, and comments of family members about the client’s condition are not part of the general survey. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment 12. When assessing the circulation to the lower leg of a client who has had knee surgery, which action should the nurse take first? a. Feel for the temperature of the foot. b. Visually inspect the colour of the foot. c. Check the client’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 TOP: Nursing Process: Assessment 13. When assessing a client’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.

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    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 TOP: Nursing Process: Assessment 14. When admitting a client who has just arrived on the medical unit with severe abdominal pain, what should the nurse do first? a. Complete only basic demographic data before addressing the client’s abdominal pain. b. Medicate the client for the abdominal pain before attending to the health history and examination. c. Inform the client that the abdominal pain will be treated as soon as the health history is completed. d. Take the initial vital signs and then deal with the abdominal pain before completing the health history. ANS: D The client priority in this situation will be to decrease the pain level because the client 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 pharmacological or nonpharmacological therapies for pain control. The vital signs may indicate hemodynamic instability that would need to be addressed immediately. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment 15. The nurse is completing a neurological assessment on an adult client. The nurse should implement which one of the following assessments when assessing the client’s motor status? a. Toe walk b. Finger to nose c. Romberg d. Heel to opposite shin ANS: A A neurological assessment is completed to observe motor status by assessing gait, toe and heel walk, and drift whereas when assessing coordination, the nurses observes finger to nose, Romberg sign and heel to opposite shin. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment

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    Chapter 04: Patient and Caregiver Teaching Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition MULTIPLE CHOICE 1. A client with newly diagnosed breast cancer has a nursing diagnosis of deficient knowledge related to insufficient information (about breast cancer). When the nurse is planning teaching for the client, which is the most important initial learning goal? a. The client will select the most appropriate breast cancer therapy. b. The client will state ways of preventing the recurrence of the tumour. c. The client will demonstrate coping skills needed to manage the disease. d. The client will choose methods to minimize adverse effects of treatment. ANS: A Adults learn best when given information that can be used immediately. The first action the client 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 TOP: Nursing Process: Planning 2. After the nurse implements diet instruction for a client with heart disease, the client can explain the information but fails to make the recommended dietary changes. Which of the following statements reflects the correct evaluation of the intervention? a. Learning did not occur because the client’s behaviour did not change. b. Choosing not to follow the diet is the behaviour that resulted from learning. c. The nursing responsibility for helping the client make dietary changes has been fulfilled. d. The teaching methods were ineffective in helping the client learn the dietary information. ANS: B Although the client behaviour has not changed, the client’s ability to explain the information indicates that learning has occurred and the client is choosing at this time to continue with the previous diet. The client 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 TOP: Nursing Process: Evaluation 3. The nurse is caring for an adult client who has been 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 client. c. Assure the client 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

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    diabetes management. ANS: B Principles of adult education indicate that readiness and motivation to learn are high when facing new tasks (such as wound care) and when demonstration and practice of skills are available. Although a home health referral may be needed for this client, 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 TOP: Nursing Process: Planning 4. A client admitted to the hospital with hyperglycemia and newly diagnosed diabetes mellitus is scheduled for discharge the second day after admission. When implementing client 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 client should know how to test blood glucose and administer medications to control glucose levels. The client 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 TOP: Nursing Process: Implementation 5. When using the Transtheoretical Model of Health Behaviour Change during client teaching, the nurse identifies that the client who states, “I told my wife that I was going to start exercising, and I think I will join a fitness club,” is in which of the following stages? a. Preparation b. Termination c. Maintenance d. Contemplation ANS: A The client’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.” Maintenance of a change occurs when the client practices the behaviour regularly. Termination would be indicated when the change is a permanent part of the lifestyle. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment 6. While admitting a client to the medical unit, the nurse learns that the client has difficulty reading. This information will guide the nurse in determining which of the following strategies would be the most appropriate when planning for client teaching? a. Assessing the degree of client motivation and readiness to learn b. Deciding what information the client will be able to understand

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    c. Ensuring that the family be included in the teaching process d. Choosing which instructional strategies should be used in teaching ANS: D The information that the client has poor health literacy skills indicates that the nurse should avoid the use of written materials in teaching and choose other strategies. The client does not indicate a lack of motivation or an inability to understand new information. The client’s lack of reading ability does not necessarily imply that the family must be included in the teaching process. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning 7. When assessing the learning needs for a client who has coronary heart disease, the nurse finds that the client has recently made dietary changes to decrease fat intake and has stopped smoking. Which of the following is the most appropriate initial statement by the nurse at this time? 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 client 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 TOP: Nursing Process: Implementation 8. When assessing a client’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 client 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 client at present. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment 9. The nurse is caring for a client with diabetes and develops a nursing diagnosis of ineffective health management related to insufficient knowledge of therapeutic regimen (resulting in low motivation). Which of the following client actions is the basis for this nursing diagnosis? a. Does not perform capillary blood glucose tests as directed b. Occasionally forgets to take the daily prescribed medication

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    c. Says that dietary intake does not seem t o impact fatigue level d. Cannot identify signs or symptoms of high and low blood glucose ANS: C The client’s motivation to follow a diabetic diet will be decreased if the client 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 TOP: Nursing Process: Diagnosis 10. A client 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 client will list three ways to protect the feet from injury by discharge. c. The nurse will instruct the client on appropriate foot care before discharge. d. The client will understand the rationale for proper foot care after instruction. ANS: B Learning goals should state clear, measurable outcomes of what is to be accomplished from the learning process. Demonstrating a proper technique or providing instruction are actions that the nurse will take, rather than behaviours that would indicate if client learning has occurred. Having the client understand the rational for proper foot care after instruction is an example of a learning outcome. DIF: Cognitive Level: Application TOP: Nursing Process: Planning 11. The nurse is planning a teaching session for a client who needs to improve skills in being more assertive. Which of the following is the most effective teaching strategy for this client? a. Role-playing b. Peer teaching c. Printed materials d. Lecture-discussion ANS: A Role playing allows the client to practice assertive behaviour and receive feedback about how the behaviour is perceived. This strategy is most often used when clients need to examine their attitudes and behaviours; understand the viewpoints and attitudes of others; or practise carrying out thoughts, ideas, or decisions. Lecture-discussion, peer teaching, and printed materials are more useful for other learning needs. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning 12. The client’s teaching plan includes this goal: “The client will select a 2-g 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 client’s menu choices over the next 3 days. b. Ask the client to identify which foods on the hospital menus are high in sodium. c. Have the client list favourite foods that are high in sodium and foods that could be substituted for these favourites. d. Compare the client’s sodium intake over the next 3 days with the sodium intake

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    before the teaching was implemented. ANS: A All of the answers address the client’s sodium intake, but the desired client behaviours in the learning objective are most clearly addressed by evaluation of the client’s menu choices. DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation 13. The nurse is preparing written handouts to be used as part of the standardized teaching plan for clients who have been recently diagnosed with diabetes and requires an awareness of literacy levels. Which of the following literacy levels is generally reflective of students who graduate from high school? a. 1 b. 2 c. 3 d. 4 ANS: C People with Level 3 literacy have the minimum skills necessary for everyday life in a complex society, such as graduation from high school. People with Level 1 literacy have very poor skills; for example, they were unable to determine the correct dose of medication from information on the package. People with Level 2 literacy require material to be simple and clearly laid out, and only tasks that are not too complex are to be included in learning material. People at this level could read but had poor test results. People with Levels 4 and 5 literacy had higher-order skills in information processing. DIF: Cognitive Level: Application TOP: Nursing Process: Planning 14. The nurse in the hospital has implemented a teaching plan to assist a client with rheumatoid arthritis in accomplishing daily activities independently. Which of the following actions is the best approach for the nurse to take in order to evaluate the client’s long-term response to the teaching? a. Make a referral to the home health nursing department for home visits. b. Assess the client’s ability to bathe without any assistance the next day. c. Have the client demonstrate the learned skills at the end of the teaching session. d. Arrange a physical therapy visit before the client is discharged from the hospital. ANS: A The client’s long-term response may need to be assessed after discharge; long-term evaluation necessitates follow-up by the nurse, outpatient clinic, or outside agency. In this case, a home health referral would allow this to occur. The other actions allow evaluation of the client’s short-term response to teaching. DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation 15. A young adult client tells the nurse, “I enjoy smoking and have no plans to quit.” Which stage of the Transtheoretical Model of Health Behaviour Change does this example portray? a. Contemplation b. Precontemplation

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    c. Preparation d. Maintenance ANS: B The precontemplation phase indicates that the client is not considering a change and is not ready to learn. In the contemplation phase, a change is being considered. The client starts gathering information for the change in the preparation stage. In the maintenance stage, the change has already occurred. DIF: Cognitive Level: Application TOP: Nursing Process: Diagnosis 16. An older-adult client is seen at the health clinic and diagnosed with protein malnutrition. Which of the following actions is priority to be included in the teaching plan? a. Suggest the use of liquid supplements as a way to increase protein intake. b. Encourage the client to increase the dietary intake of meat, cheese, and milk. c. Ask the client 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 client with health changes. The other answers may be appropriate for the client, but the nurse will not be able to determine this until the assessment of the client is complete. DIF: Cognitive Level: Application TOP: Nursing Process: Planning 17. The nurse is caring for a client who has been newly diagnosed with diabetes. The client tells the nurse, “I want to know how to give my own insulin.” Which initial action will the nurse take 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 client thinks is needed right now. All of the indicated information will need to be included when planning teaching for this client, but the teaching will be most effective if the nurse starts with the client’s stated priority topic. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 18. Which action should the nurse take first when teaching a client’s spouse how to manage the b lood p ressure (BP) for a client with newly diagnosed hypertension? a. Teach the caregiver how to take the client’s BP using a manual blood pressure cuff. b. Have the dietitian meet with the client and caregiver to discuss low sodium dietary choices. c. Ask the client and caregiver to select important information from a list of hypertension teaching topics. d. Provide written information about treatment and complications of hypertension for the client and caregiver.

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    ANS: C Since adults learn best when given information that they view as being needed immediately, asking the caregiver and client 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 client have, but the initial action should be to assess what the learners feel is important. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment 19. Which of the following determinants of learning is an evaluation of learning? a. Learner needs b. Demonstrated learner behaviour c. State of learner readiness d. Preferred learning style ANS: B Demonstrated learner behaviour is an evaluation of learning. The three determinants of learning that require learning assessments are learner needs, state of learner readiness, and the client’s preferred learning style. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment

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    Chapter 05: Chronic Illness Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition MULTIPLE CHOICE 1. The nurse is caring for a client with type 2 diabetes who has been hospitalized with severe hyperglycemia. Which of the following topics 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 c. Impact of the client’s family history on likelihood of developing diabetes d. Symptoms indicating that the client should contact the health care provider ANS: D One of the tasks for clients with chronic illnesses is to prevent and manage a crisis. The client 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 client teaching, but is not as essential in the client’s self-management of the illness. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 2. Which of the following diseases has the highest proportion of chronic illness deaths in Canada? a. Cancer b. Diabetes c. Cardiovascular disease d. Chronic respiratory disease ANS: C Cardiovascular diseases (37%) were responsible for the highest proportion of global deaths in 2012, followed by cancers (27%), chronic respiratory diseases (8%), and diabetes (4%). DIF: Cognitive Level: Knowledge TOP: Nursing Process: Assessment 3. Which of the following is an example of multimorbidity? a. Chronic obstructive pulmonary disease and a urinary tract infection b. Lung cancer and pneumonia c. Chronic kidney disease and appendicitis d. Diabetes and exacerbation of rheumatoid arthritis ANS: D Multimorbidity is the simultaneous occurrence of several chronic medical conditions, which may or may not be related to each other, in the same person. Pneumonia, urinary tract infection, and appendicitis are all acute conditions. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment 4. Which of the following factors has a major impact on the development of chronic illness? a. Poverty

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    b. Social stability c. Urban dwelling d. High school diploma ANS: A Poverty and socioeconomic disadvantage are recognized to have a major impact on the development of chronic illness. Social stability, urban living, and having a high school education are not factors contributing to the development of chronic illness. DIF: Cognitive Level: Knowledge TOP: Nursing Process: Assessment 5. Which of the following statements is true related to nonmodifiable risk factors for chronic illness? a. Cannot be changed b. Requires intervention in order to change c. Can be altered to benefit health outcomes d. Can be changed with client perseverance ANS: A Nonmodifiable risk factors cannot be changed. Requiring intervention in order to change, altering, and changed with perseverance all indicate that change is possible. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning 6. What is the average life expectancy in Canada? a. 60 years b. 70 years c. 80 years d. 90 years ANS: C The life expectancy in Canada is estimated to be 80 years, specifically in 2010, it was 78.5 years for males and 82.7 years for females. DIF: Cognitive Level: Knowledge TOP: Nursing Process: Planning 7. Which of the following types of cancers has a genetic predisposition to its occurrence? a. Lung b. Breast c. Cervix d. Testicles ANS: B Genetic testing can also show an inherited predisposition to several different types of cancer, including breast and ovarian cancer, melanoma, and colon cancer. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment 8. Which of the following models views disability as directly caused by disease or trauma? a. Social b. Nursing c. Medical

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    d. Collaborative ANS: C The medical model views disability as directly caused by disease, trauma, or another health condition. Disability, from the medical model perspective, necessitates medical care provided in the form of individual treatment by providers to “correct” the problem with the individual. The social model of disability, conversely, sees disability as a socially created problem and not an inherent attribute of an individual. DIF: Cognitive Level: Application TOP: Nursing Process: Planning 9. Which of the following client statements reflect an outcome expectancy statement? a. “I am not able to exercise.” b. “Exercise helps people lose weight.” c. “Exercise is too hard on my arthritis.” d. “Dietary restrictions work better than exercise to lose weight.” ANS: B An outcome expectancy is the individual’s belief that a specific behaviour will lead to certain outcomes. For example, the client who tells the nurse that exercising helps people to lose weight is voicing an outcome expectancy. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment 10. What is the most influential source of self-efficacy? a. Mastery b. Affective states c. Verbal persuasion d. Vicarious experience ANS: A Four primary influences shape an individual's self-efficacy beliefs: mastery; vicarious experience; verbal persuasion and other social influences; and physiological and affective states that help us judge our capability and our vulnerability to dysfunction. Mastery reflects a belief about whether or not “we have what it takes to succeed” and is considered the most influential source of self-efficacy. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment 11. Which of the following is a characteristic of health-related hardiness known as “challenge”? a. Confidence to appraise a health stressor b. Ability to modify responses to health stressors c. Viewing a health stressor as an opportunity for growth d. Optimal psychosocial adaptation to a health stressor ANS: C Challenge is the anticipation of change. The person with health-related hardiness, when confronted with a health stressor, possesses sufficient self-mastery and confidence to appraise and modify responses appropriately (control) and cognitively reappraises the health stressor so it is viewed as stimulating and beneficial or an opportunity for growth (challenge).

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    DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment 12. Which of the following characteristics is true related to chronic illness? a. Abrupt onset b. Usually single cause c. Short latency period d. Noninfectious origin ANS: D Chronic (or noncommunicable) illnesses are typically characterized as having an uncertain etiology, multiple risk factors, long latency, prolonged duration, and a noninfectious origin and can be associated with impairments or functional disability. Abrupt onset, usually a single cause and cure most likely, are characteristic of acute illness. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment 13. Clients with chronic illness want the health care system to provide them with which of the following? a. Less information b. Less travel time c. Ways to adjust to disease consequences d. Limited information on ways to cope with their symptoms ANS: C Clients with chronic illness want the health care system to provide them with ways to adjust to disease consequences such as uncertainty, fear and depression, anger, loneliness, sleep disorders, memory loss, exercise needs, nocturia, sexual dysfunction, and stress. They did not identify wanting less information, shorter travel times, or limited information on coping strategies but they do also want shorter wait times. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment 14. Which of the following models calls for a political response to disability? a. Social b. Medical c. Activist d. Collaborative ANS: A The social model of disability, conversely, sees disability as a socially created problem and not an inherent attribute of an individual (Barnes, 2012). The social model perspective calls for a political response, because the problem is created by an unaccommodating physical environment brought about by attitudes and other features of the social environment. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment 15. According to the World Health Organization’s ICF Bio-Psycho-Social Model, which of the following factors is an environmental contextual factor? a. Social background b. Behaviour pattern

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    c. Social attitudes d. Coping style ANS: C Contextual factors are composed of external environmental factors (e.g., social attitudes, architectural characteristics, and legal and social structures, as well as climate, terrain, and so forth). The other choices represent internal personal factors (e.g., gender, age, coping styles, social background, education, profession, past and current experience, overall behaviour pattern, character, and other factors that influence how disability is experienced by the individual). DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment 16. Which of these clients assigned to the nurse is most likely to need planning for long-term nursing management? a. 22-year-old with appendicitis who has had an emergency appendectomy b. 56-year-old with bilateral knee osteoarthritis who weighs 159 kg c. 34-year-old with cholecystitis who has had a laparoscopic cholecystectomy d. 62-year-old with acute sinusitis who will require antibiotic therapy for 5 days ANS: B The client’s osteoarthritis is a chronic problem that will require planning for long-term interventions such as physical therapy and nutrition counselling. The other clients have acute problems that are not likely to require long-term management. DIF: Cognitive Level: Application TOP: Nursing Process: Planning 17. “Set in motion and continue the trajectory projection and scheme” is a goal of management in which of the following trajectory phases? a. Pretrajectory b. Onset c. Comeback d. Downward ANS: C “Set in motion and continue the trajectory projection and scheme” is a goal of management in the trajectory phase of comeback. Pretrajectory goal is to prevent the onset of chronic illness. The onset goal of management is to form an appropriate trajectory projection and scheme. The goal of the downward phase is to adapt to increasing disability. DIF: Cognitive Level: Application TOP: Nursing Process: Planning 18. Which one of the following levels is part of the client response to health care recommendations based on a continuum of self-care? a. Self-esteem b. Adherence c. Denial d. Acceptance ANS: B

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    Compliance, adherence, and self-care makeup the three levels of client response to health care recommendations on a continuum of self-care. Adherence is now the term most widely accepted because it incorporates the notion of the client agreeing with the treatment plan presented by the health care provider. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment

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    Chapter 06: Community-Based Nursing and Home Care Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition MULTIPLE CHOICE 1. A family caregiver tells the home health nurse, “I feel like I can never get away to do anything for myself.” Which action is the most appropriate for the nurse to take? a. Assist the caregiver in finding respite services. b. Assure the caregiver that the work is appreciated. c. Teach the caregiver that family members provide excellent client care. d. Encourage the caregiver to discuss feelings openly with the nurse as-needed. ANS: A Respite services allow family caregivers to have free time. The other actions also may be helpful, but the caregiver’s statement clearly indicates the need for some free time. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 2. A client who was in an automobile accident is assigned a nurse as a case manager. Which of the following responsibilities is required of the nurse in this role? a. Care for the client during hospitalization for the injuries. b. Assist the client with home care activities during recovery. c. Coordinate the services that the client receives in the hospital and at home. d. Determine the types of medical care the client needs for optimal rehabilitation. ANS: C The role of the case manager is to coordinate the client’s care through multiple settings and levels of care to allow the maximal client benefit at the least cost. The case manager does not provide direct care in either the acute or home setting. The case manager coordinates and advocates for care but does not determine what types of medical care are needed, that is done by the health care provider or other provider. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation 3. The nurse is conducting a home visit and notes that the caregiver may be experiencing caregiver burnout. Which of the following assessments would support this finding? a. Anxiety b. Sleeplessness c. Weight gain d. Increased use of respite care ANS: B Assessment of the signs of caregiver burnout (e.g., sleeplessness, difficulty concentrating) is a critical role of the home care nurse. Weight gain is an indication that the caregivers’ nutritional intake exceeds requirements. An increased use of respite care could indicate an increased involvement of the caregiver in outside support and activity groups. This assessment finding would require further assessment before linking it to caregiver burnout. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment

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    4. An older-adult client who lives alone was hospitalized for a fractured hip and has recovered from the surgery but needs to continue to work to improve mobility. Which of the following settings would the nurse anticipate that the client be transferred to? a. Another acute care setting b. A transitional care setting c. A residential care facility d. Their own home with home health nursing ANS: D Home health nursing is appropriate for clients who need continued rehabilitation and can implement this in their own home. The client is no longer in need of the more continuous assessment and care given in acute care settings. There is no indication that the client will need the permanent and ongoing medical and nursing services available in intermediate care. The client is not yet independent enough to transfer to a residential care facility. DIF: Cognitive Level: Application TOP: Nursing Process: Planning 5. The nurse is describing home care services to a client that requires extended care. Which of the following statements is true related to home care services? a. Technologically complex therapies must be managed in the hospital. b. The client’s family will be included in planning and the client’s care. c. Home care services are limited to visits by registered nurses or home health aides. d. In order for insurance to cover the home care, the client must be confined to bed. ANS: B Family members who are providing care are included in planning the client’s care and treatments. Other disciplines, such as physical and occupational therapy, also provide appropriate home health services. The client must be homebound, but not bed bound, to receive reimbursement for home care services. High-tech services are increasingly accomplished in the home setting where the client is more comfortable and the risks for complications such as infection are less. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation 6. Which of the following statements represents a current trend in home health nursing? a. Increased numbers of registered nurses are being employed as home health nurses. b. Decreased numbers of licensed practical nurses are being employed as home health nurses. c. There are more employment opportunities for newly graduated nurses. d. That a minimum of two years of acute care experience is required before employment as a home health nurse. ANS: C

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