Ignatavicius: Medical-Surgical Nursing, 6th Edition

Chapter 1: Introduction to Medical-Surgical Nursing Test Bank M !TI"!E C#$ICE 1. Which action demonstrates that the nurse understands the purpose of the Rapid Response Team? a The nurse monitors the client for changes in postoperative status such as wound . infection. b The nurse documents all observed changes in the client and maintains a . postoperative flowsheet. c The nurse notifies the physician of the clients change in blood pressure from 140 . to 10 mm !g systolic. d The nurse notifies the physician of the clients increase in restlessness after . medication change. "#$% & The Rapid Response Team 'RRT( saves lives and decreases the ris) for harm by providing care to clients before a respiratory or cardiac arrest occurs. "lthough the RRT does not replace the &ode Team* who respond to client arrests* it intervenes rapidly for those who are beginning to decline clinically. +t would be appropriate for the RRT to intervene when the client has e,perienced a -./point drop in his blood pressure. 0onitoring the clients postoperative status* maintaining a postoperative flowsheet* and notifying the physician of a change in the clients status after a medication change would not be considered activities of the Rapid Response Team. 1+2% 567% T58% &are( 0$&% &ognitive 3evel% &omprehension R42% p. 3earning 5utcome &lient #eeds &ategory% $afe and 4ffective &are 4nvironment '0anagement of +ntegrated 8rocess% #ursing 8rocess '"ssessment(

. What is the nurses first action when beginning client education? a 6egins teaching sessions as soon as possible prior to discharge to ensure ade9uate . teaching time b 1etermines the clients interest in learning prior to initiation of teaching sessions . c "ssesses clients learning capabilities as well as those of his family members as a . group d +f client shows no interest in learning* documents attempt and notifies physician . "#$% 6
4lsevier items and derived items : 010* 00;* 00 by $aunders* an imprint of 4lsevier +nc.

Test 6an)

1/

The nurse should first assess the clients learning needs and barriers to learning when initiating education. The nurse should not ma)e assumptions and should assess each client individually. +f the client has no interest in learning* the nurse should wait for another time or setting before beginning health teaching. "lthough important* scheduling teaching sessions as early as possible prior to discharge* determining the learning capabilities of the client* and notifying the physician of the clients disinterest in learning would be less important. 1+2% &ognitive 3evel% &omprehension R42% p. 4 567% 3earning 5utcome < T58% &lient #eeds &ategory% !ealth 8romotion and 0aintenance '8rinciples of Teaching=3earning( 0$&% +ntegrated 8rocess% Teaching=3earning -. Which action shows an understanding of the principle of self/determination? a The nurse allows a postoperative client to decide to ta)e medication with fruit . >uice rather than water. b The nurse allows a teenager to decide not to tell her parents that her persistent . vaginal bleeding is related to an abortion. c The nurse allows a parent to decide not to proceed with a lifesaving operation for . a 1 /year/old client. d The nurse allows an older client with dementia to decide not to ta)e medication . throughout the shift. "#$% " Respect for people is one of three basic ethical principles that nurses and other health care professionals should use as a basis for clinical decision ma)ing. Respect implies that clients are treated as autonomous individuals capable of ma)ing informed decisions about their care. This client autonomy is referred to as self/determination* or self/management. This is best illustrated by allowing a client to decide to ta)e medication with fruit >uice rather than water. The other answer choices would not illustrate self/determination appropriately and might possibly endanger the clients life. 1+2% 567% T58% &are( 0$&% &ognitive 3evel% "pplication R42% #=" for "pplication and above 3earning 5utcome ; &lient #eeds &ategory% $afe and 4ffective &are 4nvironment '0anagement of +ntegrated 8rocess% #ursing 8rocess '"ssessment(

4. The nurse is initiating a series of teaching sessions with an older client. What is the nurses highest priority action prior to beginning the session? a 4nsure that the clients family are present and will participate. . b 0a)e certain that the client is wearing his glasses. . c !ave printed handouts ready to use during the session.

4lsevier items and derived items : 010* 00;* 00 by $aunders* an imprint of 4lsevier +nc.

Test 6an) . d $chedule the session for early evening after the clients meal and before his . medication.

1/-

"#$% 6 The most important action will be to ensure that the client is wearing his glasses. !is ability to see ade9uately will outweigh his need for the presence of his family* his use of printed handouts* and his hunger 'or lac) thereof(. 1+2% &ognitive 3evel% "pplication R42% #=" for "pplication and above 567% 3earning 5utcome . T58% &lient #eeds &ategory% !ealth 8romotion and 0aintenance '8rinciples of Teaching=3earning( 0$&% +ntegrated 8rocess% Teaching=3earning <. Which action demonstrates the nurse is using critical thin)ing when planning a menu for a ?ietnamese client who is newly diagnosed with diabetes? a "s)ing the client what food he would eat on a standard diabetic menu . b "s)ing family members to ma)e selections for the client from a diabetic menu . c &alling a ?ietnamese interpreter when teaching the client . d Researching the ?ietnamese culture prior to discussing diabetic meal planning . "#$% 1 &ritical thin)ing is best illustrated through the nurse researching ?ietnamese culture and native coo)ing prior to discussing meal planning. This shows that the nurse is interested and involved in the clients care. The nurse can then suggest foods from the standard diabetic menu to the client and his family. "n interpreter could be called* if necessary* but does not show the use of critical thought. 1+2% 567% T58% 0$&% &ognitive 3evel% "pplication R42% #=" for "pplication and above 3earning 5utcome @ &lient #eeds &ategory% 8hysiological +ntegrity '6asic &are and &omfort( +ntegrated 8rocess% Teaching=3earning

;. " middle/aged woman is referred for a mammogram. What level of illness prevention is being practiced in this situation? a 8rimary prevention . b $econdary prevention . c Tertiary prevention

4lsevier items and derived items : 010* 00;* 00 by $aunders* an imprint of 4lsevier +nc.

Test 6an) . d $elf/ prevention .

1/4

"#$% 6 $creening e,aminations are considered part of secondary prevention because some cases of disease will be uncovered with e,aminations that have normal results. +n primary prevention* interventions are delivered to avoid or delay disease onset. Tertiary prevention involves rehabilitation that occurs after a disease state stabiliAes. 1+2% 567% T58% 0$&% &ognitive 3evel% "pplication R42% #=" for "pplication and above 3earning 5utcome &lient #eeds &ategory% !ealth 8romotion and 0aintenance '1isease 8revention( +ntegrated 8rocess% #ursing 8rocess '+mplementation(

B. Which action by the nurse demonstrates the best practice for nursing documentation on a computeriAed record? a 1eleting all documentation errors on the computeriAed record . b Csing red color font to denote all significant events that have occurred . c Waiting until the end of the shift to record a summary of information . d #oting an error by putting one line through it and initialing . "#$% 1 The best practice for nursing documentation is to put one line through the error and initial it. The other practices listed are ineffective and are not recommended. 1+2% &ognitive 3evel% "pplication R42% #=" for "pplication and above 567% 3earning 5utcome 11 T58% &lient #eeds &ategory% $afe and 4ffective &are 4nvironment '$afety and +nfection &ontrol( 0$&% +ntegrated 8rocess% &ommunication and 1ocumentation .. " client is scheduled for a mastectomy. "s she is about to receive the preoperative medication* she tells the nurse that she does not want to have her breast removed but wants a lumpectomy. Which response indicates that the nurse is acting as a client advocate? a Telling the client that her surgeon is e,cellent and )nows what is best for her . condition b &alling the surgeon to come and e,plain all treatment options to the client . c !olding the clients hand and offering to pray with her for a good outcome to the

4lsevier items and derived items : 010* 00;* 00 by $aunders* an imprint of 4lsevier +nc.

Test 6an) . surgery d "rranging for a postoperative visit from a cancer survivor .

1/<

"#$% 6 &lients have the right to be fully informed about their treatment plans and to change their minds. " client e,pressing doubt* uncertainty* or a change of feeling about a treatment plan should be supported by the nurse* heard by the health care provider* and be an active participant in treatment planning. The nurse would be functioning best as a client advocate by notifying the surgeon that the client wants a different treatment option. The nurse would not be acting as a client advocate by providing vague reassurance* arranging for a cancer survivor to come meet with the client* or offering to pray with the client because none of these options would address the clients desire for a different treatment option. 1+2% 567% T58% &are( 0$&% &ognitive 3evel% "pplication R42% #=" for "pplication and above 3earning 5utcome B &lient #eeds &ategory% $afe and 4ffective &are 4nvironment '0anagement of +ntegrated 8rocess% &aring

@. What assessment data should be collected first from a client admitted to the emergency department with a lacerated artery? a +nformation regarding ne,t of )in to notify in case the client dies . b !istory about what medications the client is currently ta)ing . c 0easurement of blood pressure* pulse* and capillary refill time . d "ssessment of rate and depth of respiration to ensure that the airway is patent . "#$% 6 +n establishing an emergency database* assessment first focuses on the immediate problem* especially with a high probability for a life/threatening conse9uence. 1etermining the clients current medications is of higher priority than notifying ne,t of )in* determining capillary refill time* or measuring the rate and depth of respirations. 1+2% 567% T58% 0$&% &ognitive 3evel% "pplication R42% #=" for "pplication and above 3earning 5utcome @ &lient #eeds &ategory% 8hysiological +ntegrity '8hysiological "daptation( +ntegrated 8rocess% #ursing 8rocess '"ssessment(

4lsevier items and derived items : 010* 00;* 00 by $aunders* an imprint of 4lsevier +nc.

Test 6an)

1/;

10. The clients primary health care provider is an advanced practice nurse in an ambulatory care setting. Which intervention can the client e,pect to receive from a nurse in an ambulatory care setting? a 1rawing blood for preoperative testing . b Teaching the client how to change the dressing on an incisional biopsy site . c 5btaining the clients signature on the surgical consent form before surgery . d 8erforming a physical e,amination and ta)ing the health history of a new client . "#$% 6 &lient teaching is a primary role of the nurse. 5btaining a surgical consent is the responsibility of the person performing the surgery. 6lood drawing* ta)ing histories* and performing physicals may be done by the nurse but are not primary nursing responsibilities. 1+2% 567% T58% &are( 0$&% &ognitive 3evel% Dnowledge R42% p. 4 3earning 5utcome < &lient #eeds &ategory% $afe and 4ffective &are 4nvironment '0anagement of +ntegrated 8rocess% #ursing 8rocess '8lanning(

11. !ow does a community nurseErun clinic differ from a physicians office practice setting? a &lients at community nurseErun clinics are not eligible to receive care elsewhere. . b 8hysicians offices rarely use advanced practice nurses. . c The care provided is limited to interventions for nursing diagnoses. . d The primary health care providers are advanced practice nurses. . "#$% 1 The primary health care providers at community nursing centers are advanced practice nurses 'most often* certified nurse practitioners and certified nurse/midwives( who are authoriAed to intervene in specified medical diagnoses. +t is not accurate to say that clients receiving care at nursing community centers are not eligible to receive care elsewhere* that such centers have advanced practice nurses as providers* or that physicians offices are usually associated with large university medical centers. 1+2% &ognitive 3evel% "pplication 567% 3earning 5utcome < R42% #=" for "pplication and above

4lsevier items and derived items : 010* 00;* 00 by $aunders* an imprint of 4lsevier +nc.

Test 6an) T58% &lient #eeds &ategory% $afe and 4ffective &are 4nvironment '0anagement of &are( 0$&% +ntegrated 8rocess% #ursing 8rocess '8lanning(

1/B

1 . Which client is most li)ely to re9uire transitional subacute care before being discharged to the home setting? a The client with stable human immune deficiency virus '!+?( infection . b The client with a diagnosis of methicillin/resistant Staphyloccus aureus '0R$"( . coloniAation of the nares c The client re9uiring deep wound management . d The client who was hospitaliAed for 1 wee) . "#$% & "lthough disorders of clients re9uiring subacute care can encompass all these conditions* transitional care is considered as an alternative to a prolonged hospital stay before discharge home or to a long/term care facility. Transitional subacute care is provided to the client with a deep wound if it continued management before discharge. The stable client with !+? infection would receive medical and=or surgical subacute care* whereas the client who is ventilator dependent or who has a progressive neurologic disorder would re9uire chronic subacute care. 1+2% 567% T58% &are( 0$&% &ognitive 3evel% &omprehension R42% p. 4 3earning 5utcome < &lient #eeds &ategory% $afe and 4ffective &are 4nvironment '0anagement of +ntegrated 8rocess% #ursing 8rocess '8lanning(

1-. " client arrives at the health clinic and e,presses concern over being assessed by a nurse practitioner instead of a physician. The nurse develops a teaching plan for the client on the differences between a nurse practitioner and a physician. 5ther than educational preparation* what is the main difference between health care provided by a nurse practitioner and that provided by a physician? a 2ederal law permits only physicians to prescribe medications. . b #urse practitioners are limited to providing interventions centered on nursing . diagnoses. c #urse practitioners provide care from a wellness model* and physicians more . often focus on illness care. d There is no difference in scope and liability in the health care provided by nurse . practitioners and physicians.

4lsevier items and derived items : 010* 00;* 00 by $aunders* an imprint of 4lsevier +nc.

Test 6an)

1/.

"#$% & #urse practitioners '#8s( wor) from a wellness model focused on empowering clients to stay well and care for themselves. 1+2% 567% T58% &are( 0$&% &ognitive 3evel% "pplication R42% #=" for "pplication and above 3earning 5utcome B &lient #eeds &ategory% $afe and 4ffective &are 4nvironment '0anagement of +ntegrated 8rocess% #ursing 8rocess '8lanning(

14. Which statement best describes the process of nursing case management? a The coordination of care services to at/ris) populations . b " collaborative process to promote 9uality and cost/effective care . c The implementation of care to acutely ill* underserved populations . d " cost/effective model of care delivery that meets the needs of specially defined . groups "#$% 6 The process of case management involves collaboration to assess* plan* implement* coordinate* monitor* and evaluate services to meet health care needs in a manner that promotes 9uality and cost/effective outcomes. +t does not solely involve coordination of care services to at/ris) populations* implementation of care to acutely ill and underserved clientele* nor a cost/effective model of care delivery that will meet the needs of specially defined groups. 1+2% 567% T58% &are( 0$&% &ognitive 3evel% &omprehension R42% p. < 3earning 5utcome B &lient #eeds &ategory% $afe and 4ffective &are 4nvironment '0anagement of +ntegrated 8rocess% #ursing 8rocess '8lanning(

1<. Which client is best served by a case manager? a "n older woman with chronic cystitis . b " middle/aged man with moderate hypertension . c "n older woman with chronic congestive heart failure and diabetes mellitus . d " young adult with a fractured an)le from a sports in>ury and seasonal allergies .

4lsevier items and derived items : 010* 00;* 00 by $aunders* an imprint of 4lsevier +nc.

Test 6an)

1/@

"#$% & The case management process is reserved for clients who have comple, health problems 'high ris)( and incur a high cost to the health care system. &lients with chronic cystitis* moderate hypertension* and a fractured an)le would probably not incur high costs to the health care system. 1+2% 567% T58% &are( 0$&% &ognitive 3evel% &omprehension R42% p. < 3earning 5utcome B &lient #eeds &ategory% $afe and 4ffective &are 4nvironment '0anagement of +ntegrated 8rocess% #ursing 8rocess '8lanning(

1;. Which statement indicates that the health care professional re9uires teaching about clinical pathways? a F&linical pathways can be used in determining how effective specific treatment . plans are.G b F"lthough clinical pathways map out a specific plan of care* they are modifiable . for variances in client outcomes.G c FWithout implementation of clinical pathways* our agency could not be . accredited by T7&.G d F+nvolving multiple disciplines in developing clinical pathways allows for a . comprehensive plan to achieve the best outcomes.G "#$% & The 7oint &ommission does not re9uire the development or implementation of clinical pathways for accreditation. The other statements listed are accurate regarding clinical pathways. 1+2% 567% T58% &are( 0$&% &ognitive 3evel% &omprehension R42% p. 3earning 5utcome B &lient #eeds &ategory% $afe and 4ffective &are 4nvironment '0anagement of +ntegrated 8rocess% #ursing 8rocess '8lanning(

M !TI"!E %ES"$NSE 1. What health practices will improve and maintain health in adults? (Select all that apply.) a 0aintaining a body mass inde, '60+( that is appropriate for frame . b 4ngaging in aerobic e,ercises for at least 1 hour per wee) . c 3iberally using sunscreen when outdoors . d Hetting 4 to ; hours of sleep every 4 hours .

4lsevier items and derived items : 010* 00;* 00 by $aunders* an imprint of 4lsevier +nc.

Test 6an) e 0anaging stress using appropriate coping methods .

1/10

"#$% "* &* 4 Regardless of gender* age* or economic status* avoiding obesity* stress* and sun e,posure and getting regular sleep of about . hours a day have a positive correlation with health promotion in adults. The client will need to e,ercise for more than 1 hour wee)ly and needs more than 4 to ; hours of sleep for maintaining health. 1+2% 567% T58% 0$&% &ognitive 3evel% &omprehension R42% p. 3earning 5utcome 10 &lient #eeds &ategory% !ealth 8romotion and 0aintenance '$elf/&are( +ntegrated 8rocess% Teaching=3earning

. Which activity is considered to be within the role of the home care nurse? (Select all that apply.) a 8roviding direct nursing care to an ill client in the home . b "ssessing the community for environmental haAards and health ris)s . c &onsulting with an enterostomal nurse regarding a pressure ulcer . d Teaching family members how to monitor an intravenous infusion pump . e &onsulting a nutritionist regarding nutritional needs of a client with a wound . "#$% "* &* 1* 4 "lthough home care encompasses some aspects of public health nursing and community health nursing* the focus of home care is on the individual client and family* not the community. Therefore* rather than assessing the community* the nurse should be caring for the client* teaching family members* and consulting with a nutritionist. 1+2% 567% T58% &are( 0$&% &ognitive 3evel% &omprehension R42% p. 4 3earning 5utcome < &lient #eeds &ategory% $afe and 4ffective &are 4nvironment '0anagement of +ntegrated 8rocess% #ursing 8rocess '8lanning(

-. Which settings would re9uire ma,imum implementation of the nurse supervisor role? (Select all that apply.) a $ubacute care setting . b !ome care setting

4lsevier items and derived items : 010* 00;* 00 by $aunders* an imprint of 4lsevier +nc.

Test 6an) . c $)illed nursing facility . d "ssisted living facility .

1/11

"#$% "* 6* &* 1 +n s)illed nursing facilities* subacute care settings* assisted living facilities* and home care setting* there are numerous unlicensed assistive personnel who are delegated various tas)s. The registered nurse is responsible for overseeing the actions of such personnel and therefore would implement the supervisor role to its ma,imal e,tent. 1+2% 567% T58% &are( 0$&% &ognitive 3evel% &omprehension R42% p. 4 3earning 5utcome < &lient #eeds &ategory% $afe and 4ffective &are 4nvironment '0anagement of +ntegrated 8rocess% #ursing 8rocess '8lanning(

4. Which activities are within the role of the case manager? (Select all that apply.) a Hathering and organiAing data about a client from client records and interviews . b 8lanning care for a client with emphasis on client satisfaction . c &oordinating care among a variety of health care professionals and settings . d 8romoting the clientIs interests while negotiating necessary health care . e "dvocating for the client and family throughout the continuum of care . f Csing resources for appropriate client health care services . "#$% &* 1* 4* 2 The primary roles of the nursing case manager include wide/reaching assessment* planning for timely and cost/effective outcomes* facilitation* and advocacy. Roles of the nursing case manager do not include planning care for a client with emphasis on client satisfaction. 1+2% 567% T58% &are( 0$&% &ognitive 3evel% &omprehension R42% p. < 3earning 5utcome B &lient #eeds &ategory% $afe and 4ffective &are 4nvironment '0anagement of +ntegrated 8rocess% #ursing 8rocess '8lanning(

4lsevier items and derived items : 010* 00;* 00 by $aunders* an imprint of 4lsevier +nc.