TEST BANK for Physical Examination and Health Assessment 9th Edition by Jarvis Carolyn & Eckhardt An

Physical Examination and Health Assessment 9th Edition by Carolyn Jarvis & Ann L. Eckhardt ISBN-10 0323809847 ISBN-13 978-0323809849 Test Bank for Physical Examination and Health Assessment 9th Edition by Carolyn Jarvis & Ann L. Eckhardt

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Physical Examination and Health Assessment 9th Edition by Carolyn Jarvis & Ann L. Eckhardt

Chapter 1: Evolution of Nursing My Nursing Test Banks Chapter 1: Evolution of Nursing Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What is a nursing program considered when certified by a state agency? a. Accredited b. Approved c. Provisional d. Exemplified ANS: B Approved means certified by a state agency for having met minimum standards; accredited means certified by the NLN for having met more complex standards. Provisional and exemplified are not terms used in regard to nursing program certification. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 10 OBJ: 5 TOP: Nursing programs KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A 2. Which of the following must the nurse recognize regarding the health care delivery system? a. It includes all states. b. It affects the illness of patients. c. Insurance companies are not involved. d. The major goal is to achieve optimal levels of health care. ANS: D The nurse must recognize that in the health care delivery system, the major goal is to achieve optimal levels of health care. The health care system consists of a network of agencies, facilities, and providers involved with health care in a specified geographic area. Insurance companies do have involvement in the health care system. The illness of patients is not necessarily affected by the health care system. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 7 TOP: Health care systems KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 3. What is required by the health care team to identify the needs of a patient and to design care to meet those needs? a. The Kardex b. The physicians order sheet c. An individualized care plan d. The nurses notes ANS: C An individualized care plan involves all health care workers and outlines care to meet the needs of the individual patient. The Kardex, physicians order sheet, and nurses notes do not identify the needs of the patient nor are they designed to assist all members of the health care team to meet those needs. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 13, 16 OBJ: 8 | 9 TOP: Care plan KEY: Nursing Process Step: Planning MSC:NCLEX: N/A 4. Patient care emphasis on wellness, rather than illness, begins as a result of: a. increased education concerning causes of illness.

b. improved insurance payments. c. decentralized care centers. d. increased number of health care givers. ANS: A The acute awareness of preventive medicine has resulted in todays emphasis on education about issues such as smoking, heart disease, drug and alcohol abuse, weight control, and mental health and wellness promotion activities. This preventive education has resulted in an emphasis on wellness, rather than illness. Improved insurance payments, decentralized care centers, and increased numbers of health care givers did not influence an emphasis on wellness. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 4 | 8 TOP: Wellness KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 5. What is the most effective process to ensure that the care plan is meeting the needs of the patient? a. Documentation b. Communication c. Evaluation d. Planning ANS: B Communication is the primary essential component among the health care team to evaluate and modify the care plan. Documentation, evaluation, and planning are not primary essential components to ensure the care plan is meeting the needs of the patient. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 16 OBJ: 8 TOP: Communication KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 6. How does an interdisciplinary approach to patient treatment enhance care? a. By improving efficiency of care b. By reducing the number of caregivers c. By preventing the fragmentation of patient care d. By shortening hospital stay

ANS: C An interdisciplinary approach prevents fragmentation of care. An interdisciplinary approach does not improve the efficiency of care, reduce the number of caregivers, or shorten hospital stay. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 16 OBJ: 8 | 9 TOP: Interdisciplinary approach KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 7. How may a newly licensed LPN/LVN practice? a. Independently in a hospital setting b. With an experienced LPN/LVN c. Under the supervision of a physician or RN d. As a sole practitioner in a clinic setting ANS: C An LPN/LVN practices under the supervision of a physician, dentist, OD, or RN. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 13, 19 OBJ: 11 TOP: Vocational nursing KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 8. Whose influence on nursing practice in the 19th century was related to improvement of patient environment as a method of health promotion? a. Clara Barton b. Linda Richards c. Dorothea Dix d. Florence Nightingale ANS: D The influence of Florence Nightingale was highly significant in the 19th century as she fought for sanitary conditions, fresh air, and general improvement in the patient environment. Clara Barton developed the American Red Cross in 1881. Linda Richards is known as the first trained nurse in America, was responsible for the development of the first nursing and hospital records, and is credited with the development of our present-day documentation system. Dorothea Dix was the pioneer crusader for elevation of standards of care for the mentally ill and superintendent of female nurses

of the Union Army. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 2, 17 Table 1-2 OBJ: 2 | 4 TOP: Nursing leaders KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 9. What document identifies the roles and responsibilities of the LPN/LVN? a. NLN Accreditation Standards b. Nurse Practice Act c. NAPNE Code d. American Nurses Association Code ANS: B The LPN/LVN functions under the Nurse Practice Act. NLN Accreditation Standards, the NAPNE Code, and the American Nurses Association Code do not identify the roles and responsibilities of the LPN/LVN. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 13 OBJ: 11 TOP: Roles and Responsibilities KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 10. What is a cost-effective delivery of care used by many hospitals that allows the LPN/LVN to work with the RN to meet the needs of patients? a. Focused nursing b. Team nursing c. Case management d. Primary nursing ANS: C Case management is a cost-effective method of care. Focused nursing, team nursing, and primary nursing are not cost-effective methods of delivering care that allow the LPN/LVN to work with the RN to meet patient needs. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 14 OBJ: 7 | 9 TOP: Patient care delivery systems KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 11. What is the title of the American Hospital Associations 1972 document that outlines the patients expectations to be treated with dignity and compassion?

a. Code of Ethics b. Patients Bill of Rights c. OBRA d. Advance directives ANS: B Patient expectations are outlined by the Patients Bill of Rights. Patient expectations are not outlined in the Code of Ethics, OBRA, or advance directives. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 15 OBJ: 4 | 8 TOP: Patients rights KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 12. The relationships among nursing, patients, health, and the environment are the basis for: a. care plans. b. nursing models. c. physicians orders. d. evaluation of patient care. ANS: B Nursing models are theories based on the relationship between nursing, patients, health, and environment. Care plans, physicians orders, and evaluation of patient care are not based on the relationships among nursing, patients, health, and environment. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 17 OBJ: 1 TOP: Nursing models KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 13. What system reduces the number of employees but still provides quality care for patients? a. Team nursing b. Cross-training c. Use of critical pathways d. Case management ANS: B Cross-training reduces the number of employees but does not alter the quality

of patient care. Team nursing, use of critical pathways, and case management do not reduce the number of employees while continuing to provide quality care for patients. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 14-15 OBJ: 8 TOP: Patient care KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 14. What is the purpose of licensing laws for LPN/LVNs? a. To limit the number of LPN/LVNs. b. Prevention of malpractice c. Protection of the public from unqualified people d. To increase revenue for the state board of nursing ANS: C The purpose of licensing laws for LPN/LVNs is to protect the public from unqualified practitioners. Licensing laws purpose is not to limit the number of LPNs/LVNs, prevent malpractice, or increase revenue for the state board of nursing. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 4-5 OBJ: 4 | 9 | 10 TOP: Licensure KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 15. What premise is Maslows hierarchy of needs based on? a. All needs are equally important. b. Basic needs must be met before the next level of needs can be met. c. Self-actualization is a primary need. d. Individuals prioritize needs the same way. ANS: B Maslows hierarchy of needs is based on the premise that basic needs must be met first. It is not based on all needs being equally important or that individuals prioritize needs the same way. Self-actualization is not a primary need according to Maslow. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 8 TOP: Maslows hierarchy of needs KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 16. What must the nurse realize when assessing physical and social

environmental factors affecting health and illness? a. They affect one another. b. They cause illness. c. They cause patients to react similarly. d. They can be separated. ANS: A Physical and social factors affect each other, cannot be separated, and cause each patient to react in a unique manner. They do not necessarily cause illness or cause patients to react similarly, and they cannot be separated. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 12 OBJ:4 | 8TOP:Environmental factors KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 17. What organization, established during World War II, provided nursing education and training? a. Nightingale school b. Cadet Nurse Corps c. Public health department d. Frontier Nursing Service ANS: B The Cadet Nurse Corps was established during World War II to provide nursing education and training. The Nightingale school, public health department, and Frontier Nursing Service are not organizations established during World War II to provide nursing education and training. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 5 OBJ: 1 | 4 TOP: Nursing education KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 18. What is a modern educational advancement program for the LPN/LVN to enter RN education? a. Repetition b. Exclusion c. Articulation d. Coexistence

ANS: C Most states have some type of articulation program in which the LPN/LVN can achieve advanced standing in an RN program without having to enroll in the entire curriculum. Repetition, exclusion, and coexistence do not refer to educational advancement. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 10 OBJ: 1 | 9 TOP: Nursing education KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 19. Where did Florence Nightingales original nursing education take place? a. Saint Thomas b. Kings College Hospital c. Crimean Hospital d. Kaiserswerth School ANS: D Florence Nightingale trained at Kaiserswerth School. Florence Nightingales original training was not at Saint Thomas, Kings College Hospital, or Crimean Hospital. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2 OBJ: 2 TOP: Nursing programs KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 20. What system of comprehensive patient care considers the physical, emotional, and social environment and spiritual needs of a person? a. Interdependent care b. Holistic health care c. Illness prevention care d. Health promotion care ANS: B Holistic health care encompasses the physical, emotional, social, and spiritual aspects of the patient. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 13 OBJ: 8 TOP: Health care KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 21. What official agency exists exclusively for LPN/LVN membership and

promotes standards for the LPN/LVN? a. NFLPN b. ANA c. NLN d. NAPNES ANS: A The NFLPN exists solely for the LPN/LVN. The other options have membership that includes RNs and the lay public. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 9 OBJ: 5 | 6 | 9 TOP: Nursing organizations KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 22. What score does the graduate practical nurse require to be issued a license upon completion of the computerized examination? a. 70% or better b. This is defined and set by each state c. Designated as pass d. Within the 75th percentile ANS: C Currently graduates of an approved vocational school are eligible to take the licensing examination and be awarded a license with a score of pass that is recognized by all states. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 11 OBJ: 3 TOP: Licensure examination KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 23. What document, published in 1965 by the ANA, clearly defined two levels of nursing practice? a. Licensing standards b. Position paper c. Smith-Hughes Act d. Nurse practice act ANS: B The ANAs position paper of 1965 defined two levels of nursing: registered nurse and technical nurse. Licensing standards, the Smith-Hughes Act, and

the nurse practice act were not documents defining two levels of nursing practice published in 1965. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 11 OBJ: 3 | 4 | 9 TOP: Position paper KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 24. What is the wellness/illness continuum defined as? a. A concept that never changes b. The range of a persons total health c. A continuum influenced only by ones physical condition d. An idea that focuses strictly on an individuals social well-being ANS: B The wellness/illness continuum is defined as the range of a persons total health. This continuum is ever-changing, and it is influenced by the individuals physical condition, mental condition, and social well-being. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 8 TOP: Wellness/Illness continuum KEY: Nursing Process Step: N/A MSC:NCLEX: N/A MULTIPLE RESPONSE 25. Florence Nightingale established a nursing school at Saint Thomas Hospital in London. What was it characterized by? (Select all that apply.) a. Allowing all applicants who applied to be enrolled b. Offering formal and practical educational experiences c. Keeping records of students progress d. Focusing on sanitation and hygiene e. Retaining a registry of all graduates ANS: B, C, D, E The nursing school established by Florence Nightingale rigorously screened its applicants. The curriculum, which included both formal education and practical experiences, was focused on hygiene and sanitation. The school kept records of the students progress during their school years, and also kept a registry of the graduates. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 3 OBJ:1 | 2TOP:School established by Florence Nightingale

KEY:Nursing Process Step: N/AMSC:NCLEX: N/A COMPLETION 26. Primitive medical interventions were based on the belief that illness was caused by the presence of . ANS: evil spirits Illness was thought to be caused by the inhabitation of the body by evil spirits. Medical interventions were designed to drive out the evil spirits by introducing good spirits. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1 OBJ: 1 TOP: Primitive health care KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 27. During early civilization performed witchcraft and rituals to induce the bad spirits to leave the body of the ailing person. ANS: medicine men Medicine men performed witchcraft and rituals to induce the bad spirits to leave the body of the ailing person during early civilization. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2 OBJ: 1 TOP: Primitive health care KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 28. The National Council of State Boards of Nursing (NCSBN) performs a job analysis every years to determine the scope of practice of LPN/LVNs. ANS: 3 three The National Council of State Boards of Nursing performs a job analysis every 3 years to measure the scope of practice for LPN/LVNs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 18 OBJ: 6 | 9 TOP: National Council analysis KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 29. Graduates of the first school for training the practical nurse were referred to as nurses.

ANS: attendant The first school for training the practical nurse started in Brooklyn, New York in 1892 and was conducted under the auspices of the Young Womens Christian Association (YWCA). The Ballard School, as it was known, was approximately 3 months in duration and trained its students to care for the chronically ill, invalids, children, and the elderly. The main emphasis was on home care and included cooking, nutrition, basic science, and basic procedures. Graduates of this program were referred to as attendant nurses. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 9 OBJ: 1 TOP: Attendant nurses KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 30. In 1949, the National Federation of Licensed Practical Nurses (NFLPN) was founded by . ANS: Lillian Kuster In 1949 the National Federation of Licensed Practical Nurses (NFLPN) was founded by Lillian Kuster. This association is the official membership organization for licensed practical nurses/licensed vocational nurses (LPN/LVNs), and membership is limited to LPNs and LVNs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 9 OBJ: 2 TOP: National Federation of Licensed Practical Nurses KEY:Nursing Process Step: N/AMSC:NCLEX: N/A OTHER 31. What is the order of Maslows hierarchy of needs beginning with the most basic? a. Safety and security b. Love/belongingness c. Physiological d. Self-actualization e. Esteem ANS: C, A, B, E, D Abraham Maslow believed that an individuals behavior is formed by the

individuals attempts to meet essential human needs, which he identified as physiological, safety and security, love and belongingness, and esteem and self-actualization. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 8 TOP: Maslows Hierarchy of Needs KEY: Nursing Process Step: N/A MSC:NCLEX: N/A Chapter 2: Legal and Ethical Aspects of Nursing My Nursing Test Banks Chapter 2: Legal and Ethical Aspects of Nursing Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. When a nurse becomes involved in a legal action, the first step to occur is that a document is filed in an appropriate court. What is this document called? a. Deposition b. Appeal c. Complaint d. Summons ANS: C A document called a complaint is filed in an appropriate court as the first step in litigation. A deposition is when witnesses are required to undergo questioning by the attorneys. An appeal is a request for a review of a decision by a higher court. A summons is a court order that notifies the defendant of the legal action. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 23 OBJ: 1 TOP: Legal KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 2. The nurse caring for a patient in the acute care setting assumes responsibility for a patients care. What is this legally binding situation? a. Nurse-patient relationship b. Accountability c. Advocacy d. Standard of care ANS: A

When the nurse assumes responsibility for a patients care, the nurse-patient relationship is formed. This is a legally binding contract for which the nurse must take responsibility. Accountability is being responsible for ones own actions. An advocate is one who defends or pleads a cause or issue on behalf of another. Standards of care define acts whose performance is required, permitted, or prohibited. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 24 OBJ: 3 TOP: Legal KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 3. What are the universal guidelines that define appropriate measures for all nursing interventions? a. Scope of practice b. Advocacy c. Standard of care d. Prudent practice ANS: C Standards of care define actions that are permitted or prohibited in most nursing interventions. These standards are accepted as legal guidelines for appropriateness of performance. The laws that formally define and limit the scope of nursing practice are called nurse practice acts. An advocate is one who defends or pleads a cause or issue on behalf of another. Prudent is a term that refers to careful and/or wise practice. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 25 OBJ: 4 TOP: Legal KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 4. An LPN/LVN is asked by the RN to administer an IV chemotherapeutic agent to a patient in the acute care setting. What law should this nurse refer to before initiating this intervention? a. Standards of care b. Regulation of practice c. American Nurses Association Code d. Nurse practice act ANS: D

It is the nurses responsibility to know the nurse practice act in his or her state. Standards of care, regulation of practice, and the American Nurses code are not laws that the nurse should refer to before initiating this treatment. PTS: 1 DIF: Cognitive Level: Application REF: Page 25 OBJ: 5 TOP: Legal KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 5.A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the patient. This nurse could be found guilty of: a. malpractice. b. harm to the patient. c. negligence. d. failure to follow the nurse practice act. ANS: A The nurse can be held liable for malpractice for acts of omission. Failure to meet a legal duty, thus causing harm to another, is malpractice. The nurse practice act has general guidelines that can support the charge of malpractice. PTS: 1 DIF: Cognitive Level: Application REF: Pages 22-23 OBJ: 2 TOP: Legal KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 6. Patients have expectations regarding the health care services they receive. To protect these expectations, which of the following has become law? a. American Hospital Associations Patients Bill of Rights b. Self-determination act c. American Hospital Associations Standards of Care d. The Joint Commissions rights and responsibilities of patients ANS: A Patients have expectations regarding the health care services they receive. In 1972, the American Hospital Association (AHA) developed the Patients Bill of Rights. The Self-determination act, American Hospital Associations Standards of Care, and The Joint Commissions rights and responsibilities do not address patients expectations regarding health care. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 26 OBJ: 3 | 4 TOP: Legal KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A 7. The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed? a. Physical assessment b. Interview c. Informed consent d. Surgical checklist ANS: C The doctrine of informed consent refers to full disclosure of the facts the patient needs to make an intelligent (informed) decision before any invasive treatment or procedure is performed. A physical assessment, interview, and surgical checklist are not required before this procedure. PTS: 1 DIF: Cognitive Level: Application REF: Pages 26-27 OBJ: 8 TOP: Legal KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 8. When a nurse protects the information in a patients record what ethical responsibility is the nurse fulfilling? a. Privacy b. Disclosure c. Confidentiality d. Absolute secrecy ANS: C The nurse has an ethical and legal duty to protect information about a patient and preserve confidentiality. Some disclosures are legal and anticipated, and may not be subject to the rules of confidentiality. None of the information in a chart is considered secret. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 28 OBJ: 9 TOP: Confidentiality KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 9. An older adult is admitted to the hospital with numerous bodily bruises, and the nurse suspects elder abuse. What is the best nursing action? a. Cover the bruises with bandages. b. Take photographs of the bruises.

c. Ask the patient if anyone has hit her. d. Report the bruises to the charge nurse. ANS: D The law stipulates that the health care professional is required to report certain information to the appropriate authorities. The report should be given to a supervisor or directly to the police, according to agency policy. When acting in good faith to report mandated information (e.g., certain communicable diseases or gunshot wounds), the health care professional is protected from liability. PTS: 1 DIF: Cognitive Level: Application REF: Page 29 OBJ: 9 TOP: Elder abuse KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 10. What is the best way for a nurse to avoid a lawsuit? a. Carry malpractice insurance b. Spend time with the patient c. Provide compassionate, competent care d. Answer all call lights quickly ANS: C The best defense against a lawsuit is to provide compassionate and competent nursing care. Carrying malpractice insurance is prudent, but it will not avoid a lawsuit. Spending time with patients and answering call lights quickly will not necessarily help avoid a lawsuit. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 29-30 OBJ: 8 TOP: Avoiding a lawsuit KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 11. The nurse is caring for a patient with a do-not-resuscitate (DNR) order. Although the nurse may disagree with this order, what is his or her legal obligation? a. To question the doctor b. To seek advice from the family c. To discuss it with the patient d. To follow the order ANS: D

When a DNR order is written in the chart, the nurse has a duty to follow the order. Questioning the doctor, seeking advice from the family, and discussing it with the patient are not legal obligations of the nurse. PTS: 1 DIF: Cognitive Level: Application REF: Page 35 OBJ: 10 | 14 TOP: Legal KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 12. The nurse has strong moral convictions that abortions are wrong. When assigned to assist with an abortion, what is the most appropriate action for the nurse to take? a. Ask for another assignment b. Leave work c. Transfer to another floor d. Protest to the supervisor ANS: A The nurse should not abandon the patient, but ask for another assignment. PTS: 1 DIF: Cognitive Level: Application REF: Page 35 OBJ: 9 | 16 TOP: Ethics KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 13. The new LPN/LVN is concerned regarding what should or should not be done for patients. What resource will best provide this information? a. Nurse practice act b. Standards of care c. Scope of nursing practice d. Professional organizations ANS: B Standards of care define what should or should not be done for patients. The nurse practice act, scope of nursing practice, and professional organizations do not provide the best information as to what should or should not be done for patients. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 25 OBJ: 5 TOP: Standards of care KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 14. What role is the nurse who diligently works for the protection of patients

interests playing? a. Caregiver b. Health care administrator c. Advocate d. Health care evaluator ANS: C A nurse accepts the role of advocate when, in addition to general care, the nurse protects the patients interests. Caregiver, health care administrator, and health care evaluator are not terms for the nurse who diligently works for the protection of patients. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 24 OBJ: 9 | 12 TOP: Advocate KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 15. When asked to perform a procedure that the nurse has never done before, what should the nurse do to legally protect himself or herself? a. Go ahead and do it b. Refuse to perform it, citing lack of knowledge c. Discuss it with the charge nurse, asking for direction d. Ask another nurse who has performed the procedure ANS: C The nurse cannot use ignorance as an excuse for nonperformance. The nurse should ask for direction from the charge nurse, explaining she has never performed the procedure independently. PTS: 1 DIF: Cognitive Level: Application REF: Page 25 OBJ: 8 TOP: Legal KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 16. The nurse is assisting a patient to clarify values by encouraging the expression of feelings and thoughts related to the situation. What is the most appropriate action for the nurse? a. Compare values with those of the patient b. Make a judgment c. Withhold an opinion d. Give advice

ANS: C The nurse can assist the patient in values clarification without giving an opinion. PTS: 1 DIF: Cognitive Level: Application REF: Pages 33-34 OBJ: 3 | 8 TOP: Values clarification KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 17. What fundamental principle must the nurse first observe when confronted with an ethical decision? a. Autonomy b. Beneficence c. Respect for people d. Nonmaleficence ANS: C The first fundamental principle is respect for people. Autonomy, beneficence, and nonmaleficence are not the first fundamental principles to observe when confronted with an ethical decision. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 34 OBJ: 13 | 15 TOP: Ethics KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 18.A nurse working on an acute care medical surgical unit is aware that his or her first duty is to the patients health, safety, and well-being. Given this knowledge, which of the following is most necessary for the nurse to report? a. Unethical behavior of other staff members b. A worker who arrives late c. Favoritism shown by nursing administration d. Arguments among the staff ANS: A A member of the nursing profession must report behavior that does not meet established standards. Unethical behavior involves failing to perform the duties of a competent caring nurse. PTS: 1 DIF: Cognitive Level: Application REF: Page 35 OBJ: 13 TOP: Unethical behavior KEY: Nursing Process Step: N/A MSC:NCLEX: N/A

19.A nurse is considering purchasing malpractice insurance. What should the nurse be aware of regarding malpractice insurance provided by the hospital? a. Only offers protection while on duty b. Is limited in the amount of coverage c. Is difficult to renew d. Can be terminated at any time ANS: A Most institutional insurance only provides liability coverage if the nurse is on duty at that facility. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 30 OBJ: 2 TOP: Malpractice insurance KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 20. Which is a nursing care error that violates the Health Insurance Portability and Accountability Act (HIPAA)? a. Administering a stronger dose of drug than was ordered b. Refusing to give a patients daughter information over the phone c. Informing the patients medical power of attorney of a medication cha d. Leaving a copy of the patients history and physical in the photocopie ANS: D Leaving the document in the photocopier could expose it to the public. Inappropriate drug administration is possible malpractice. Sharing information with the power of attorney is legal. Refusing to give a patients daughter information over the phone is appropriate practice. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 26, 28 OBJ: 7 TOP: Health Insurance Portability and Accountability Act (HIPAA) KEY:Nursing Process Step: N/AMSC:NCLEX: N/A 21. Which of the following could cause a nurse to be cited for malpractice? a. Refusing to give 60 mg of morphine as ordered b. Giving prochlorperazine (Compazine) to a patient allergic to phenoth c. Dragging an injured motorist off the highway and causing further inj d. Informing a visitor about a patients condition ANS: B Standards of care dictate that a nurse must be aware of all the properties of

drugs administered. Prochlorperazine (Compazine) is a phenothiazine. Providing confidential information or refusing to give an excessively large narcotic dose is not considered malpractice. Good Samaritan laws generally protect a person giving aid to an injured motorist. PTS: 1 DIF: Cognitive Level: Application REF: Pages 22-23 OBJ: 2 TOP: Malpractice KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 22.A lumbar puncture was performed on a patient without a signed informed consent form. This patient might sue for: a. punitive damages. b. civil battery. c. assault. d. nothing; no violation has occurred. ANS: B Civil battery charges can be brought against someone performing an invasive procedure without the patients informed consent legally documented. This patient could not sue for punitive damages or an assault. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 28 OBJ: 6 | 8 TOP: Informed consent KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 23.A physician instructs the nurse to bladder train a patient. The nurse clamps the patients indwelling urinary catheter but forgets to unclamp it. The patient develops a urinary tract infection. What do the nurses actions exemplify? a. Malpractice b. Battery c. Assault d. Neglect of duty ANS: A A nurse is liable for acts of commission (doing an act) and omission (not doing an act) performed in the course of their professional duty. A charge of malpractice is likely when a duty exists, there is a breach of that duty, and harm has occurred to the patient. PTS: 1 DIF: Cognitive Level: Application REF: Pages 22-23

OBJ: 2 TOP: Malpractice KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 24. What is true about nurse practice acts? a. They informally define the scope of nursing practice. b. They provide for unlimited scope of nursing practice. c. Only some states have adopted a nurse practice act. d. The nurse must know the nurse practice act within his or her state. ANS: D The laws formally defining and limiting the scope of nursing practice are called nurse practice acts. All state, provincial, and territorial legislatures in the United States and Canada have adopted nurse practice acts, although the specifics they contain often vary. It is the nurses responsibility to know the nurse practice act that is in effect for her geographic region. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 25 OBJ: 1 TOP: Nurse practice acts KEY: Nursing Process Step: N/A MSC:NCLEX: N/A MULTIPLE RESPONSE 25. How can the medical record be used in litigation? (Select all that apply.) a. Public record b. Proof of adherence to standards c. Evidence of omission of care d. Documentation of time lapses e. Evidence by only the plaintiff ANS: A, B, C, D The information when used in court becomes a public record. The information can be used as proof of adherence to standards, omission of care, and documentation of time lapses. Both plaintiff and defendant can use the document. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 28 OBJ: 4 TOP: Legal properties of medical record KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 26. During a lunch break, an emergency department (ED) nurse truthfully tells

another nurse about the condition of a patient who came to the ED last night. What is the ED nurse guilty of? (Select all that apply.) a. HIPAA violation b. Slander c. Libel d. Invasion of privacy e. Defamation ANS: A, D The disclosure is an invasion of privacy and a violation of HIPAA. Because the information is true and verbal, it cannot be considered slander or libel. PTS: 1 DIF: Cognitive Level: Application REF: Pages 26, 28 OBJ: 7 TOP: Disclosure of information KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 27.A nurse failed to monitor a patients respiratory status after medicating the patient with a narcotic analgesic. The patients respiratory status worsened, requiring intubation. The patients family claimed the nurse committed malpractice. What must be present for the nurse to be held liable? (Select all that apply.) a. A nurse-patient relationship exists. b. The nurse failed to perform in a reasonable manner. c. There was harm to the patient. d. The nurse was prudent in her performance. e. The nurse did not cause the patient harm. f. Duty does not exist. ANS: A, B, C For the court to uphold the charge of malpractice, and to find the nurse liable, the following elements must be present: duty exists, there is a breach of duty, and harm must have occurred. PTS: 1 DIF: Cognitive Level: Application REF: Page 24 OBJ: 2 TOP: Malpractice KEY: Nursing Process Step: N/A MSC:NCLEX: N/A COMPLETION 28. Personal beliefs about the worth of an object, idea, custom, or attitude that

influence a persons behavior in a given situation are referred to as . ANS: values Values are personal beliefs about the worth of an object, an idea, a custom, or an attitude. Values vary among people and cultures; they develop over time and undergo change in response to changing circumstances and necessity. Each of us adopts a value system that will govern what we feel is right or wrong (or good and bad) and will influence our behavior in a given situation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 33 OBJ: 11 | 12 TOP: Values KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 29. Acts whose performance is required, permitted, or prohibited are defined by of . ANS: standards, care Standards of care define acts whose performance is required, permitted, or prohibited. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 25 OBJ: 4 TOP: Standards of care KEY: Nursing Process Step: N/A MSC:NCLEX: N/A Chapter 3: Documentation My Nursing Test Banks Chapter 3: Documentation Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What does documentation of type of care, time of care, and signature of the person prove? a. The person who signed the documentation did all the work noted. b. No litigation can be brought against the person who signed. c. Interventions were implemented to meet the patients needs. d. The patients response to the intervention was positive. ANS: C Documenting type of care, time of care, and signature of the person results in

recording the interventions that are implemented to meet the patients needs. Many charting entries include doctors visits, presence of family, or interventions by other departments. Patient response to some interventions is not always positive. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 38 OBJ:1TOPocumentation KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 2.Why is documentation especially significant in managed care? a. The hospital needs to show that employees care for patients. b. Institutions are reimbursed only for patient care that is documented. c. Patients might bring lawsuits if care was not given. d. Documents may become part of a lawsuit. ANS: B Cost reimbursement rates by government plans (Medicare, Medicaid) are based on the prospective payment system of diagnosis-related groups (DRGs); a system that classifies patients by age, diagnosis, surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 40 OBJ: 1 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 3. The nurse charts only additional treatments done, changes in patient condition, and new concerns. What is this system of documentation? a. SOAP b. Block c. CBE d. Focus ANS: C Charting additional treatments done, changes in a patients condition, and new concerns during the shift is charting by exception (CBE). PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 46 OBJ: 1 | 5 | 7 TOP: Documentation KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A 4. What form explains the lapse when events are not consistent with facility or national standards of expected care? a. Subjective data b. Focus chart c. Incident report d. Nursing assessment ANS: C An incident report is completed when patient care was not consistent with facility or national standards. The form explains the event, time, extent of injury, and who was notified. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 47 OBJ: 1 | 7 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 5. The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type. This is known as a: a. nursing order. b. Kardex. c. nursing care plan. d. critical pathway. ANS: D Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay for patients of a specific case type. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 51 OBJ:8TOPocumentation KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 6.What makes home health care documentation unique? a. Some charting is retained at the hospital. b. The physicians office needs separate charting. c. Different health care providers need access. d. The physician is the pivotal person in the charting. ANS: C

Home health care documentation has unique problems because of the need for different health care workers to access the medical record. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 53 OBJ: 9 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 7. What regulates standards for long-term care documentation? a. OBRA b. Title XXII c. Nursing diagnoses d. The care plan ANS: A OBRA (Omnibus Budget Reconciliation Act) was a significant Medicare and Medicaid legislation for long-term health care documentation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 53 OBJ: 10 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 8. What is the nurse required to do to adhere to the concept of confidentiality for the patients medical record? a. Provide information only to another nurse b. Provide information only to an attorney c. Share information only with the family d. Have a clinical reason for reading the record ANS: D The nurse should not read the patients medical record unless there is a clinical reason for doing so. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 54 OBJ: 4 TOP: Confidentiality KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 9. Documentation is necessary for the evaluation of patient care. Of which phase of the nursing process is this an integral part? a. Assessment b. Planning c.

Implementation

d. Evaluation ANS: C Documentation is part of the implementation phase of the nursing process. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 38 OBJ: 1 | 4 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 10. What does the nurse use as a basis for documentation in focus charting? a. Problem list b. Nursing orders c. Nursing diagnoses d. Evaluation ANS: C In focus charting, instead of using the problem list, modified nursing diagnoses are used as an index for nursing documentation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 45 OBJ: 7 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 11. What is the purpose of QA (quality assurance)? a. To screen employment applications b. To evaluate care results against accepted standards c. To conduct in-services for quality documentation d. To report deviation from standards to the state health department ANS: B QA is an in-house department that evaluates care services and results against accepted standards. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 39 OBJ: 1 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 12. What is the process used to appraise the practice of an individual nurse known as? a. Quality assurance b. Incident reporting c.

OBRA

d. Peer review ANS: D Peer review is an in-house department study that may appraise the nursing practice of individual nurses. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 39 OBJ: 4 TOP: Peer review KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 13. What is the documentation format that uses the acronym SOAPE? a. Problem-oriented b. Focused c. Traditional d. Crisis ANS: A The problem-oriented medical record uses the acronym SOAPE to format and for focus charting on a list of patient problems/nursing diagnoses. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 45 OBJ:7TOProblem-oriented medical record (POMR) KEY:Nursing Process Step: N/AMSC:NCLEX: N/A 14.Who is the legal owner of the patients medical record? a. Patient b. Physician c. Institution d. State ANS: C Ownership of a medical record belongs to the institution in the case of a hospitalized patient, or the physician in the case of private office visits. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 53 OBJ:4TOP:Legal ownership KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 15. When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered?

a. Charting in code b. Logging off c. Charting in privacy d. Signing on with a password ANS: B Logging off closes the computer file that was opened with the nurses password. Any other data entry will require that person to sign on with their password. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 54, 55 Box 3-5 OBJ: 2 TOP: Computer documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 16. What is the system that classifies patients by age, diagnosis, and surgical procedure and produces 300 different categories used for predicting the use of hospital resources? a. Quality assurance b. Resource assessment c. Quality improvement d. Diagnosis-related groups ANS: D Cost reimbursement rates under government plans are based on diagnosisrelated groups (DRGs), which is a system that classifies patients by age, diagnosis, and surgical procedure, producing 300 different categories used in predicting the use of hospital resources, including length of stay. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 39 OBJ: 5 TOP: Diagnostic-related groups KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 17.A nurse is using the data, action, response, education (DARE) system of charting, and is completing the data portion. What data are the nurses focus? a. Planning b. Assessment c. Implementation d. Patient teaching ANS: B

DARE is the acronym for four different aspects of charting using the focus format. Data (D) is both subjective and objective and is equivalent to the assessment step of the nursing process. Action (A) is a combination of planning and implementation. Response (R) of the patient is the same as evaluation of effectiveness. Some facilities include education/patient teaching (E). PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 45 OBJ: 7 TOP: Charting KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 18.A new patient is being admitted to a long-term care facility. Who has primary responsibility for each patients initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified? a. Physician b. Registered nurse c. Nursing assistant d. Licensed practical nurse/licensed vocational nurse ANS: B The registered nurse (RN) has primary responsibility for each patients initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 41 OBJ: 4 | 10 TOP: Scope of practice KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 19. What will the nurse implement when an error is made when documenting in a patients chart? a. Scratch out the error b. Apply correction fluid c. Erase the error completely d. Draw a single line through the error ANS: D A nurse should not erase, apply correction fluid, or scratch out errors made while recording in a patients chart. Instead, the nurse should draw a single

line through the error, write the word error above it, and sign her name or initials. PTS: 1 DIF: Cognitive Level: Application REF: Pages 42, 43 Table 3-2 OBJ: 6 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 20. What should the nurse be sure to do when documenting in a patients chart? a. Include speculation b. Chart consecutively c. Leave blank spaces d. Include retaliatory comments ANS: B A nurse should not write retaliatory or critical comments about a patient or care by other health care professionals. The nurse should not leave blank spaces in the nurses notes. The nurse should be certain the entry is factual and not speculate or guess. The nurse should chart consecutively, line by line. PTS: 1 DIF: Cognitive Level: Application REF: Pages 42, 43 Table 3-2 OBJ: 6 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A MULTIPLE RESPONSE 21. What are categories of inadequate documentation that may lead to a malpractice claim? (Select all that apply.) a. Incorrectly recording the time of an event b. Failing to record verbal orders c. Charting events in advance d. Documenting an incorrect date e. Marking out and initialing charting errors ANS: A, B, C, D Marking out with a single line and initialing is an acceptable method to indicate a charting error. PTS: 1 DIF: Cognitive Level: Application REF: Pages 42, 43 Table 3-2 OBJ: 4 TOP: Inadequate documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A

22. When documenting an incident in the nurses notes, what should the nurse

include? (Select all that apply.) a. Description of injury, including diagrams of injury placement b. Date, time, and location of incident c. Name of physician and family members notified d. Chronologic order of events of the incident e. Confirmation that an incident report was initiated ANS: A, B, C, D The documentation of the initiation of an incident report should not be included in the nurses notes. Nurses notes are part of the legal medical record; the incident report is not. To note that an incident report was initiated is a red flag that a problem has occurred. PTS: 1 DIF: Cognitive Level: Application REF: Pages 42, 47 OBJ: 4 | 6 TOP: Documenting incident reports KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 23. What are some problems associated with electronic (or computerized) charting? (Select all that apply.) a. Security b. Expense of training staff c. Legibility d. Easy retrieval e. New terminology ANS: A, B, E Security, expensive staff training, and learning new terminology are all problems of electronic charting. Legibility and easy retrieval are advantages. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 40, 41, 54 OBJ: 1 TOP: Computer charting KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 24. What are the basic purposes of written patient records? (Select all that apply.) a. Teaching b. Legal record of care

c. Written communication d. Research and data collection e. Permanent record for accountability f. Temporary record of hospitalization ANS: A, B, C, D, E There are five basic purposes for written patient records: (1) written communication, (2) permanent record for accountability, (3) legal record of care, (4) teaching, and (5) research and data collection. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 39 OBJ: 1 TOP: Medical record KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 25. What should a medical record provide for all health care providers? (Select all that apply.) a. Care given to the patient b. Care planned for the patient c. A patients nursing problems d. A patients medical problems e. Details about any incident reports f. The patients response to treatment ANS: A, B, C, D, F A medical record should furnish all health care providers with a concise, accurate, written picture of a patients medical and nursing problems, care planned and given, and the patients response to treatments. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 39 OBJ: 1 TOP: Medical record KEY: Nursing Process Step: N/A MSC:NCLEX: N/A COMPLETION 26. The best defense against malpractice claims associated with nursing care is accurate . ANS: documentation Accurate documentation can guard against malpractice claims because it should describe when, what, and how events occurred.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 42 OBJ: 4 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 27. Twenty-fourhour charting is designed to establish levels to help determine staffing needs. ANS: acuity Patient acuity, which is reflected in 24-hour charting compilation, can dictate staffing needs. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 47 OBJ: 7 TOP: 24-hour charting KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 28. Documentation using the DARE format (Data, Action, Response, Education) includes elements of the charting system. ANS: focused Focused charting uses the acronym DARE to direct and formalize charting. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 45 OBJ: 7 TOP: Focused charting KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 29.A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as . ANS: quality assurance quality assessment quality improvement Quality assurance/assessment/improvement is an audit in health care that evaluates services provided and the results achieved compared with accepted standards. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 39 OBJ:1TOP:Quality assurance/assessment/improvement KEY:Nursing Process Step: N/AMSC:NCLEX: N/A OTHER

30.A nurse is receiving a telephone order from a physician. The nurse uses a safety measure of preventing errors that is recognized by The Joint Commission as one method of meeting National Patient Safety Goals. What is the correct order of this method? a. Read back b. Background c. Recommendation d. Situation e. Assessment ANS: D, B, E, C, A SBAR (Situation, Background, Assessment, and Recommendation) is a method of communication among health care workers and a part of documentation (Kaiser Permanente, 2007). SBAR is considered a safety measure in preventing errors from poor communication during hand-off or handover interactions, the communication that occurs from one shift to the next or when a nurse phones a health care provider with information about a patient. An additional R is added. The additional R (SBARR) represents read back when the nurse reads back the order for clarification. PTS: 1 DIF: Cognitive Level: Application REF: Page 41 Box 3-1 OBJ: 3 TOP: SBARR KEY: Nursing Process Step: N/A MSC:NCLEX: N/A Chapter 4: Communication My Nursing Test Banks Chapter 4: Communication Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. Although the patient denies pain, the nurse observes the patient breathing rapidly with clenched fists and facial grimacing. What is the nurses best response to these observations? a. I am glad you are feeling better and have no discomfort. b. Where do you hurt? c. What you are saying and what I am observing dont seem to match. d. It makes me uncomfortable when you are not honest with me.

ANS: C The nonverbal communication should be clarified to prevent miscommunication. PTS: 1 DIF: Cognitive Level: Application REF: Pages 59-61 OBJ:2 | 3TOP:Communication KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse considers the feelings and needs of a patient by stating, I know you are concerned about your surgery tomorrow. How can I help you? What type of communication is this? a. Intrusive b. Aggressive c. Closed d. Assertive ANS: D Assertive communication takes a patients feelings and needs into account, yet honors the patients rights as an individual. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 61 OBJ:4TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 3. If the nurse aggressively says to a patient, Why couldnt you have asked me to give you your pain medication when I was in here earlier? what feeling is the patient most likely to demonstrate? a. Anger b. Satisfaction that his needs are met c. Humiliation and worthlessness d. Confidence that his request will be granted ANS: C Aggressive communication is highly destructive. Although anger may eventually come, the patient most likely feels humiliated first. PTS: 1 DIF: Cognitive Level: Application REF: Page 62 OBJ:7TOP:Communication

KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 4. What does therapeutic communication accomplish? a. Facilitates the formation of a positive nurse-patient relationship b. Manipulates the patient c. Assigns the patient a passive role d. Requires the patient to accept what the nurse says ANS: A A positive nurse-patient relationship is facilitated by therapeutic communication. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 62 OBJ: 10 TOP: Communication KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 5. The nurse is sitting in a chair near the patients bed, leaning forward to hear what the patient is saying, and does not interrupt. What is the nurse demonstrating? a. Support b. Caring c. Active listening d. Interest ANS: C When demonstrating active listening, the nurse must give his or her full attention and make an effort to understand both the verbal and nonverbal message. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 63 OBJ:5TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 6. What therapeutic communication technique requires a great deal of skill and is not used as frequently as other communication techniques? a. Touch b. Silence c. Listening

d. Summarizing ANS: B Silence is an extremely effective therapeutic communication skill that is frequently underused because the nurse feels uncomfortable applying it. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 63 OBJ: 5 TOP: Communication KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 7.A patient does not speak English; therefore, the nurse cannot use words to provide comfort during a painful procedure. What is another intervention that may provide comfort to this patient? a. Silence b. Listening c. Touch d. Restating ANS: C Holding the hand of a nonEnglish-speaking patient is effective and comforting. PTS: 1 DIF: Cognitive Level: Application REF: Page 63 OBJ:9TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 8.A patient states, I do cocaine when I feel things are out of my control. The nurse responds by asking, What else does cocaine do for you? What communication skill does this exemplify? a. Summarization b. Restating c. Showing acceptance d. Stating observations ANS: C Acceptance is the willingness to listen and respond to what the patient is saying without passing judgment. PTS: 1 DIF: Cognitive Level: Application REF: Page 64-65 OBJ:5TOP:Communication

KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 9.A patient states, Im really strung out about this pregnancy. The nurse responds by asking, What about this pregnancy worries you? What communication technique is this? a. Closed inquiry b. Restating c. Open-ended question d. Minimal encouraging ANS: C Open-ended questions convey interest and do not require a specific response. PTS: 1 DIF: Cognitive Level: Application REF: Pages 65 OBJ:5TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 10.A grieving young widow cries out, Why was my husband killed? Why wasnt it me? What is the nurses best response? a. Stating You need to be strong for your children. b. Silently placing her hand on the widows arm. c. Asking if there is anyone the widow needs to have notified. d. Stating You are feeling overwhelmed about your husbands death. ANS: B The ability to listen and assist those who are newly grieving through the use of silence and a quiet presence is very effective. Stating You need to be strong for your children is a clich. Asking if there is anyone the widow needs to have notified and stating You are feeling overwhelmed about your husbands death are not therapeutic in this immediate grieving time. PTS: 1 DIF: Cognitive Level: Application REF: Pages 63-64 OBJ:5TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 11.A nurse is assessing a patient with a nursing diagnosis of impaired verbal communication. What is the lowest number of defining characteristics for this

diagnosis? a. One b. Two c. Three d. Four ANS: A If one or more of the defining characteristics is present, a nursing diagnosis of impaired verbal communication can be determined. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 72 OBJ:9TOP:Communication KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 12. What communication technique should the nurse use when communicating with an unresponsive patient? a. Avoid speaking directly to the patient b. Assume verbal stimuli are heard c. Speak in a loud voice d. Use simple words ANS: B A person interacting with an unresponsive patient should assume all sounds and verbal stimuli have the potential of being heard by the patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 75 OBJ:10TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 13. If in response to the patient statement, I am upset about all this lab work the nurse responds, Youre upset? What is this is an example of? a. An open-ended question b. Reflecting c. Restating d. Paraphrasing ANS: C Restating is one of the most effective methods of therapeutic communication

to encourage the patient to offer more information. PTS: 1 DIF: Cognitive Level: Application REF: Pages 65-66 Table 4-3 OBJ:5TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 14. What is one of the main characteristics of therapeutic communication? a. It allows the patient a passive role. b. It uses only verbal communication. c. It involves the patient as a person. d. It is directive. ANS: C Therapeutic communication actively involves the patient in all areas of the nursing process. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 64-65 OBJ: 1 TOP: Communication KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 15.A nurse is standing at the bedside with the patient lying in bed. What can the nurse be construed as demonstrating? a. Interest b. Power c. Caring d. Support ANS: B Standing at the bedside with the patient in bed may imply that the nurse has power. PTS: 1 DIF: Cognitive Level: Application REF: Page 68 OBJ:6 | 7TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 16.A nurse actively avoids the use of one-way communication. What is the major problem with one-way communication? a. The receiver is in control. b. Feedback is provided to the sender.

c. Participation is not equal. d. The communication is unstructured. ANS: C One-way communication is seldom effective because the sender is in control and gets very little feedback from the receiver. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 59 OBJ:7TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 17.A nurse must violate the personal space of a patient to perform an invasive procedure. How can the nurse reduce the discomfort of the patient? a. By approaching the interaction in a professional manner b. By distracting the patient with jokes and humor c. By asking another nurse to be present at the bedside d. By assuring the patient that all people dislike invasion of personal sp ANS: A The intimate zone can cause uneasiness for both patient and nurse; therefore, approach the interaction in a professional manner. PTS: 1 DIF: Cognitive Level: Application REF: Page 69 OBJ:6TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 18. What would be the best method for a literate, English-speaking patient on a ventilator to communicate his or her needs? a. Eye blinking for yes and no b. Magic slate or paper and pencil c. Computer d. Message board or cards ANS: B Writing devices are preferred as they do not limit the patients messages compared to a message board or cards. Eye blinks are tiring and timeconsuming. Computers require space and the ability to type. PTS: 1 DIF: Cognitive Level: Application REF: Page 74

OBJ:10TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 19.A patient roughly asks the nurse to bring him some ice cream. What would be considered an assertive response by the nurse? a. You are hungry and want a snack. b. I can do that in 10 minutes when I finish my rounds. c. Maybe I can get one of the aides to bring you something in a while. d. Call the nursing station and ask them to have the kitchen bring whate ANS: B Assertiveness is the most effective style of communication to be responsive to the patient and set limits. PTS: 1 DIF: Cognitive Level: Application REF: Pages 61 OBJ:4TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 20.A nurse tells a patient, This PM you are going for an abdominal A&P, an H&H, as well as an IV pyelogram. Please sign these consent forms. What may this use of medical jargon cause? a. Understanding b. Speed in communication c. Misinterpretation d. Clarity in the message ANS: C Jargon is terminology unique to people in a special type of work and is not understood by everyone. Although jargon does speed communication and is clear to those who know it, it may be misinterpreted and not understood by all people. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 59 OBJ:7TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 21. During a complete assessment, which type of questioning is not usually

conducive to fostering communication? a. Open-ended b. Focused c. Closed d. Clarifying ANS: C Closed questions are types of questions that the nurse may choose to use that are not usually conducive to fostering communication. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 65 OBJ:7TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 22.A patient states, My husband has told me how he feels about my having a mastectomy. The nurse nods and says, Go on. This is an example of: a. clarifying. b. restating. c. focusing. d. minimal encouraging. ANS: D The nurse uses minimal encouragement to lead the patient to provide more information. PTS: 1 DIF: Cognitive Level: Application REF: Page 65 OBJ:5TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 23.A nurse is communicating with an older adult. How might the nurse enhance communication? a. Speak in a rapid manner to accommodate the patients short attention b. Speak in a lower voice tone to accommodate hearing loss. c. Speak in a simple manner as if speaking to a child. d. Speak in a loud voice directly at ear level. ANS: B Older adults lose their ability to hear higher frequency sound. Speaking in a

lower tone enhances communication. Speaking overly loud and as if to a child may be irritating and demeaning. Rapid speech may be difficult for older adults to understand. PTS: 1 DIF: Cognitive Level: Application REF: Page 70 OBJ: 6 TOP: Physiologic factors affecting communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 24. What does maintaining eye contact for 2 to 6 seconds during communication with a patient do? a. Keeps the nurses attention on the conversation b. Counteracts shyness in the patient c. Indicates continuous focused attention d. Assesses if the patient is involved in the conversation ANS: C Maintaining eye contact for 2 to 6 seconds involves the person in what is being said, is indicative of continued interest, and conveys to the patient an accepting attitude. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 59 OBJ:2TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 25. The nurse recognizes that a patient experiencing stress feels vulnerable. What would be the most appropriate way for the nurse to intervene? a. Use technical language b. Direct the conversation c. Modify communication methods d. Offer all the information ANS: C When the patient is experiencing stress, the nurse should modify communication methods. PTS: 1 DIF: Cognitive Level: Application REF: Pages 61-63 OBJ:6TOP:Communication KEY:Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity 26.A nurse communicates with a patient by maintaining eye contact and through the use of touch. What type of communication technique is the nurse demonstrating? a. Verbal b. Persuasive c. Directive d. Nonverbal ANS: D Messages transmitted without the use of words (either oral or written) constitute nonverbal communication. Nonverbal cues include tone and rate of voice, volume of speech, eye contact, physical appearance, and use of touch. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 59 OBJ:5TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 27.A nurse frequently looks at her watch when giving a patient a bed bath. What message is most likely conveyed to the patient from the nurse? a. She desires to spend more time with the patient. b. She is anxious to listen to the patients concerns. c. She is feeling hurried. d. She likes her watch. ANS: C Frequently looking at ones watch while interacting with a patient conveys to the patient that the nurse is in a hurry and really has no desire to spend time with him or her. PTS: 1 DIF: Cognitive Level: Application REF: Page 60 OBJ: 8 TOP: Gestures KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 28. When listening to a patient, what action by the nurse demonstrates disinterest and coldness? a. Tightly crossing her arms b. Uncrossing her arms

c. Uncrossing her legs d. Facing the patient ANS: A The way that an individual sits, stands, and moves is called posture. Posture has the potential to convey warmth and acceptance, or distance and disinterest. An open posture is demonstrated with a relaxed stance with uncrossed arms and legs while facing the other individual. A slight shift in body position toward an individual, a smile, and direct eye contact are all consistent with open posturing and convey warmth and caring. Closed posture is a more formal, distant stance, generally with the arms, and possibly the legs, tightly crossed. A person will often interpret closed posture as disinterest, coldness, and even nonacceptance. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 60 OBJ: 1 | 7 | 8 TOP: Posture KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 29. How can the nurse demonstrate warmth and acceptance when listening to a patient? a. Tightly crossing her arms b. Uncrossing her arms c. Tightly crossing her legs d. Facing away from the patient ANS: B The way that an individual sits, stands, and moves is called posture. Posture has the potential to convey warmth and acceptance, or distance and disinterest. An open posture is demonstrated with a relaxed stance with uncrossed arms and legs while facing the other individual. A slight shift in body position toward an individual, a smile, and direct eye contact are all consistent with open posturing and convey warmth and caring. Closed posture is a more formal, distant stance, generally with the arms, and possibly the legs, tightly crossed. A person will often interpret closed posture as disinterest, coldness, and even nonacceptance. PTS: 1 DIF: Cognitive Level: Application REF: Page 60 OBJ: 1 | 5 | 8 TOP: Posture KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity

30. How may a nurse caring for a pediatric patient best be perceived as

nonthreatening? a. Tightly crossing her arms b. Maintaining an open posture c. Maintaining a tense posture d. Standing at the bedside ANS: B Standing at the bedside looking down at the patient in the bed places the nurse in a position of authority and control. The patient is likely to experience this as intimidating and condescending. Whenever possible, the nurse should be level with the patient; this is especially important with pediatric patients. Sitting at the bedside in a relaxed and open posture is one example. PTS: 1 DIF: Cognitive Level: Application REF: Page 60 OBJ: 1 | 5 TOP: Posture KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 31.A nurse is caring for a patient who is experiencing excruciating pain and requires frequent administration of analgesics. What statement would be anexample of the nurse demonstrating aggressive communication? a. Please let me know when you start to have pain. b. Lets practice some guided imagery. c. Lets try repositioning you. d. I will only medicate you every 4 hours. ANS: D Aggressive communication is when a person interacts with another in an overpowering and forceful manner to meet his or her own personal needs at the expense of the other. By only medicating a patient every 4 hours for excruciating pain, the nurse meets his or her own needs at the expense of the patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 62 OBJ:7TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 32.A nurse is caring for a newly admitted diabetic patient and is performing

the initial assessment. What statement made by the nurse demonstrates use of a closed question? a. What time do you take your insulin? b. How do you feel about taking insulin? c. Tell me about your support system. d. How do you feel about having diabetes? ANS: A Much of the information gathered from a patient comes from questioning them directly. A closed question is focused and seeks a particular answer. For example, when interviewing a newly admitted patient with diabetes, the nurse asks, What time do you take your insulin? A specific question with a specific answer is a typical closed question, which generally requires only one or two words in response. PTS: 1 DIF: Cognitive Level: Application REF: Page 65 OBJ:7TOP:Closed questioning KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 33.A nurse is caring for a patient experiencing respiratory distress. The physician places an endotracheal tube. What is the most appropriate nursing diagnosis for this patient? a. Ineffective coping b. Risk for infection c. Altered nutrition: less than body requirements d. Impaired verbal communication ANS: D Because of the placement of an endotracheal tube, the patient is unable to speak. The nursing diagnosis of impaired verbal communication is most appropriate. PTS: 1 DIF: Cognitive Level: Application REF: Page 72 OBJ:9TOP:Nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 34.A nurse examines whether patient interventions have been appropriate and

expected outcomes have been met. The nurse is demonstrating which step in the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation ANS: D A nurse evaluates the effectiveness of interventions based on the patients ability to meet established goals and outcomes. PTS: 1 DIF: Cognitive Level: Application REF: Page 72 OBJ:9TOP:Nursing process KEY:Nursing Process Step: EvaluationMSC:NCLEX: Evaluation 35.Which question below is open-ended? a. Are you going to Europe this fall? b. Are you sailing to Europe? c. What are you most looking forward to in Europe? d. Have you been to Europe before? e. Where in Europe are you going? ANS: C Only the question What are you most looking forward to in Europe? allows an unlimited answer. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 65 OBJ: 5 TOP: Open-ended communication KEY: Nursing Process Step: N/A MSC:NCLEX: N/A MULTIPLE RESPONSE 36. Which are true regarding communicating while using eye contact? (Select all that apply.) a. Eye contact is responsible for much communication. b. Eye contact is responsible for much miscommunication. c. Making eye contact generally indicates an intention to interact. d. Eye contact always results in a positive outcome. e. Extended eye contact can imply aggression. f. Extended eye contact can lead to heightened anxiety.

ANS: A, B, C, E, F Eye contact is responsible for much communication and much miscommunication. Generally, making eye contact communicates an intention to interact. However, the nature of the interaction and the results of eye contact are not necessarily always positive. Extended eye contact sometimes implies aggression and arouses anxiety. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 59 OBJ: 3 TOP: Eye contact KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 37. Which are examples of passive listening? (Select all that apply.) a. The nurse nods frequently while the patient speaks. b. The nurse maintains eye contact while listening to the patient. c. The nurse occasionally interjects, I see, when listening to the patient. d. The nurse gives verbal feedback to the patient. e. The nurse verbally interprets the meaning of what the patient has sai ANS: A, B, C, D Listening is sometimes active and sometimes passive. Active listening requires full attention to what the patient is saying. The message is heard, its meaning is interpreted, and the patient is given feedback, indicating understanding of the message. Verbally interpreting the meaning of what the patient has said is an example of active listening. In passive listening, the nurse indicates that they are listening to what the patient is saying either nonverbally, through eye contact and nodding, or verbally through encouraging phrases such as Uh-huh and I see. All of the other options are examples of passive listening. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 63 OBJ: 5 TOP: Listening KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 38. What is true about the use of touch in therapeutic communication? (Select all that apply.) a. Touch is a form of nonverbal communication. b. Touch is a form of verbal communication. c. Touch should be used with indiscretion.

d. Touch can convey warmth and caring. e. Touch can convey support and understanding. f. Touch should be used sincerely and genuinely. ANS: A, D, E, F Touch is a form of nonverbal communication that is inherent in the practice of nursing. Nearly every nursing intervention for the purpose of providing physical care calls for touch. Touch is frequently highly personal or of an intimate nature (e.g., giving a bed bath, assisting a patient on or off a bedpan, inserting a urinary catheter). Because of the intimate nature of touch in the nursing context, it is necessary to use it with great discretion to fit into sociocultural norms and guidelines. Some nurses are uncomfortable with touch because of a fear of it seeming inappropriate or being misinterpreted. When a nurse feels comfortable with physical contact with a patient, touch has great potential for conveying warmth, caring, support, and understanding. For the nurse to convey warmth, it is absolutely necessary for the nature of their touch to be sincere and genuine. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 62 OBJ: 5 TOP: Touch KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 39. When speaking to a person of a different culture, how should the nurse consider modifying his or her communication style? (Select all that apply.) a. Speak slowly and with increased volume b. Use of touch c. Use of eye contact d. Reference of address e. Meaning of gestures ANS: B, C, D, E Use of touch, eye contact, reference of address, and meaning of gestures all may have cultural significance and connotation. Slow, loud speech would not assist with speaking to a person of a different culture. PTS: 1 DIF: Cognitive Level: Application REF: Pages 70 OBJ: 7 TOP: Culture KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity

40. Which defining characteristics support the nursing diagnosis of impaired

verbal communication? (Select all that apply.) a. Aphasia b. Geriatric patients c. Profoundly deaf d. Legally blind e. Severe COPD ANS: A, C, D, E Difficulty speaking, attending, disorientation, dyspnea, and sensory deficits are all defining characteristics that warrant a diagnosis of impaired verbal communication. Being a geriatric patient does not necessarily support the nursing diagnosis of impaired verbal communication. PTS: 1 DIF: Cognitive Level: Application REF: Page 72 OBJ:9TOP:Impaired communication KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 41. What is true about the use of silence in therapeutic communication? (Select all that apply.) a. Maintaining silence is an effective therapeutic communication techni b. Maintaining silence is generally overused in therapeutic communicat c. The sender often becomes uncomfortable when using silence. d. The ability to use silence effectively requires skill and timing. e. Prolonged periods of misunderstood silence can cause tension. f. Purposeful use of silence often conveys lack of respect. ANS: A, C, D, E Maintaining silence is an extremely effective therapeutic communication technique, and yet tends to be quite underused. Because silence often feels awkward in American society, people tend to feel the need to fill it. This impulse does not always allow the people involved in an interaction time to organize their thoughts sufficiently to communicate what they would like. It is common for a person to need several seconds after hearing a verbal message to interpret what has been stated and to formulate the most appropriate response. Unfortunately, the receiver often does not get this

amount of time before a response is necessary. In many cases, the sender becomes uncomfortable with the silence and begins speaking again before the receiver has had an opportunity to formulate a response and is really ready to deliver it. The ability to use silence effectively requires skill and timing. It is easy for prolonged periods of misunderstood silence to cause uneasiness and tension. However, in many cases, purposeful use of silence conveys respect, understanding, caring, and support, and it is often used in conjunction with therapeutic touch. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 63 OBJ: 5 TOP: Silence KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity COMPLETION 42. The nurse explains to a patient that based on the description of personal space, the area within 18 inches of the patient is designated as the zone. ANS: intimate Personal space zones: 0 to 18 inches = intimate, 18 inches to 4 feet = personal zone, 4 to 12 feet = social zone, more than 12 feet = public zone. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 69 OBJ:8TOP:Space and territoriality KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 43.A patient with aphasia who cannot understand a spoken or written message is said to have aphasia. ANS: receptive Aphasic patients who do not understand verbal exchanges are classified as receptive aphasics. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 75 OBJ: 7 TOP: Aphasia KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 44. The term that describes an individuals perception or understanding of a particular word or phrase is .

ANS: connotation Connotation is the meaning an individual applies to a word or phrase. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 59 OBJ: 2 TOP: Connotation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 45. When a nurse lectures to a large group, the method of communication is usually in the form of communication. ANS: one-way One-way communication allows the sender to be in control with little expectation of or desire for feedback. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 59 OBJ: 5 TOP: Communication KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 46. As the nurse listens to a supervisor, the nurse has a smile on her face but has crossed her arms in front of her chest and has crossed her legs. This is an example of a posture. ANS: closed A posture with crossed limbs frequently is indicative of nonacceptance. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 60 OBJ: 6 | 7 TOP: Posture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 47. is the reciprocal process in which messages are sent and received between people. ANS: communication Communication is essential to the delivery of nursing care. It is the reciprocal process in which messages are sent and received between people. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 58 OBJ: 1 TOP: Communication KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 48. The is the person conveying the message, whereas the

is the individual or individuals to whom the message is conveyed. ANS: sender, receiver For communication to occur, a sender and a receiver of a message are both necessary. The sender is the person conveying the message, whereas the receiver is the individual or individuals to whom the message is conveyed. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 58 OBJ: 1 TOP: Communication KEY: Nursing Process Step: N/A MSC:NCLEX: N/A Chapter 5: Nursing Process and Critical Thinking My Nursing Test Banks Chapter 5: Nursing Process and Critical Thinking Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What best defines the nursing process? a. A method to ensure that the physicians orders are implemented corre b. A series of assessments that isolate a patients health problem.

c. A framework for the organization of individualized nursing care. d. A preset formula for the design of nursing care. ANS: C The nursing process is a framework by which to organize individualized nursing care. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 78 OBJ: 1 TOP: Nursing process KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 2. All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment? a. 53-year-old admitted with a perforated ulcer b. 5-year-old admitted for the implant of grommets in the middle ear c. 76-year-old admitted for a knee replacement d. 40-year-old admitted for possible bowel obstruction ANS: A A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient should receive a focused assessment. The remaining options are not considered critical illnesses. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ: 2 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. What subjective data does the nurse record following a head-to-toe examination? a. Rash on back b. Prolonged nausea c. Blood pressure of 190/100 d. White blood cell count of 19,000 ANS: B Another term for subjective data is symptoms, which cannot be observed or measured. This data must come from the patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ:3TOP:Subjective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological

Integrity 4. What objective data should the nurse include after a patient assessment? a. Headache of 3 days duration b. Severe stomach cramps c. Flatulence d. Anxiety ANS: C Objective data are observable and measurable by people other than the patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ:3TOP:Objective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. What is classified as information provided by the family when a patient is unable to provide data during assessment? a. Primary b. Secondary c. Unreliable d. Biased ANS: B Secondary sources include family members. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 79-80 OBJ: 3 TOP: Assessment KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 6. What are the two primary methods used to collect data? a. Written report by patient and family b. Review of the chart and the nurses notes c. Interview and physical examination d. Review of the physicians orders and the Kardex ANS: C The two primary methods of collecting data are interviewing and physical examination. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 79-80

OBJ: 3 TOP: Assessment KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 7. The nurse writes two nursing diagnoses: (1) inadequate nutritional intake related to vomiting as manifested by a 3-lb weight loss and (2) risk for impaired skin integrity related to inadequate nutrition. What is the major difference between these diagnoses? a. The second diagnosis needs no defined nursing interventions. b. The second diagnosis needs medical intervention. c. The second diagnosis will not need to be evaluated. d. The second diagnosis reflects a problem that does not yet exist. ANS: D The actual nursing diagnosis represents a condition that is currently present. Risk for diagnoses are those that the patient is susceptible to, but not yet troubled by. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83 OBJ:4TOP:Nursing diagnosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. What framework does the establishment of priorities of care during the planning phase of the nursing process often use? a. Eriksons developmental tasks b. Piagets cognitive table c. Maslows hierarchy of needs d. Freuds classifications ANS: C A useful framework to guide prioritization is Maslows hierarchy of needs. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 85 OBJ:9TOPriorities of care KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 9.What is an appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway clearance related to thick secretions? a. The patient will increase intake to 1000 mL daily to liquefy secretion b. The patient will cough more frequently within 3 days.

c. The patient will breathe better within 3 days. d. The patient will perform deep-breathing exercises four times daily. ANS: A The patient goal would be to improve airway clearance. Coughing more frequently within 3 days and performing deep-breathing exercises four times daily do not directly relate to the problem of thick secretions. Breathing better within 3 days is too vague. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 84 OBJ:6TOP:Nursing diagnosis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 10.What is the primary purpose of nursing orders? a. To support physicians orders b. To provide direction for all caregivers c. To provide broad, general statements d. To clarify nursing principles ANS: B Nursing orders are necessary to provide instructions for all caregivers. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 85-86 OBJ:7TOP:Nursing orders KEY:Nursing Process Step: PlanningMSC:NCLEX: N/A 11.What documentation reflects implementation? a. Patient selected low-sugar snacks independently. b. Patient was medicated with Tylenol 500 mg PO for pain. c. Patient was ambulated for 15 minutes after lunch. d. Patient participated in group therapy session without reminder. ANS: C Implementation is the nurse carrying out nursing orders to promote outcome achievement. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 87-88 OBJ:2TOP:Implementation KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 12.Which nursing order is complete and correct? a. May 10: Nursing assistants will ambulate patient. A. Nurse

b. Day nurse will cleanse wound and change dressings every day. May 1 c. Nursing assistants will serve 8 oz glass of juice at each meal, 5/10. d. P.M. nurse will ensure that heel protectors are in place before bedtime ANS: B Nursing orders must be signed, dated, and have specific designation as to who will perform intervention and specifics about time or frequency of the intervention. PTS: 1 DIF: Cognitive Level: Application REF: Pages 85-86 OBJ:7TOP:Nursing orders KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13.A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date, it is determined that what has occurred? a. Omission b. Variance c. Failure d. Error ANS: B A variance occurs when a projected outcome is not met. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 90 OBJ:8 | 11TOP:Critical pathways KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 14. During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a nursing diagnosis plan. What does this data represent? a. Symptoms b. Data clustering c. Signs of fluid overload d. Urinary retention ANS: B

The nurse organizes data, and those that are related are referred to as clustering. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 80 OBJ: 3 | 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. What type of assessment is performed continuously throughout nursepatient contact? a. Complete b. Body systems c. Focused d. Subjective ANS: C Focused assessments are performed continuously throughout nurse-patient contact based on the nursing care plan. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 79 OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 16. What assists the nurse in the identification of nursing diagnoses? a. Objective data b. Subjective data c. Data clustering d. Validated data ANS: C Data clustering assists the nurse in determining nursing diagnoses. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83 OBJ:4TOP:Nursing diagnosis KEY:Nursing Process Step: AssessmentMSC:NCLEX: N/A 17.What organized approach might the nurse use when performing a complete physical examination? a. Maslows hierarchy of needs b. A head-to-toe assessment c. Subjective data collection d.

Objective data collection

ANS: B A head-to-toe format provides a systematic approach. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ: 3 TOP: Assessment KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 18. Who is the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis? a. Physician b. LPN/LVN c. RN d. Technician ANS: C The RN is responsible for analyzing and interpreting data. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 80 OBJ: 4 TOP: Role responsibility KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 19. What is the basis for designing and selecting nursing interventions to meet patient needs? a. Nursing diagnosis b. Care plan c. Physicians orders d. Nurses notes ANS: A The nursing diagnosis is the basis for developing nursing interventions. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 80 OBJ:4TOP:Nursing diagnosis KEY:Nursing Process Step: PlanningMSC:NCLEX: N/A 20. The patient is confined to bed rest, which contributes to immobility. What is bed rest considered in this situation? a. Contributing to the patients recovery b. A risk factor c. Difficult to maintain d.

A nursing responsibility

ANS: B Risk factors are those that increase the susceptibility of a patient to a problem. PTS: 1 DIF: Cognitive Level: Application REF: Page 82 OBJ: 5 TOP: Risk factors KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 21. What is a nursing diagnosis considered when a problem is suspected but data to support it are lacking? a. A syndrome nursing diagnosis b. An actual nursing diagnosis c. A risk for diagnosis d. A possible nursing diagnosis ANS: D A possible nursing diagnosis requires additional data to confirm a problem or to complete a data cluster so that it can be related to a NANDA-I label. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83 OBJ:4 | 10TOP:Nursing diagnosis KEY:Nursing Process Step: AssessmentMSC:NCLEX: N/A 22. When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in which phase of the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation ANS: B During the planning phase, the nurse connects nursing interventions to nursing orders. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 85 OBJ:2TOP:Nursing process KEY:Nursing Process Step: PlanningMSC:NCLEX: N/A 23. What is an important consideration when developing the care plan? a. Ensure the number of interventions is limited b. Ensure the patient is involved in the process

c. Ensure interventions will be easy to implement d. Ensure evaluation of the nursing diagnoses is possible ANS: B Plans are more effective when the patient is involved in the process. The care plan is not limited in terms of the number of interventions, nor do they have to be easy. The nursing diagnoses are not evaluated; the patients progress toward the outcome is. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 85 OBJ: 6 | 9 TOP: Care plan KEY: Nursing Process Step: Planning MSC:NCLEX: N/A 24. From where are the risk for nursing diagnoses identified? a. The care plan b. The interventions c. The assessment d. The evaluation ANS: C Nursing diagnoses should be identified from the assessment. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 82-83 OBJ:2TOP:Nursing process KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. What expected outcome exemplifies accepted criteria? a. Nurse will assess vital signs every day b. Resident will observe safety guidelines while smoking c. Resident will take part in one activity daily for the next 90 days d. Nurse will monitor O2 saturation to maintain at gr ANS: C Expected outcomes must be patient-centered, measurable, and refer to a time frame. PTS: 1 DIF: Cognitive Level: Application REF: Page 84 OBJ:6TOP:Nursing process KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 26.During an admission assessment, the nurse collects objective and

subjective data. What is an example of subjective data? a. The patient complains of nausea. b. The patient is vomiting. c. The patient experiences tachycardia. d. The patent is pacing the halls. ANS: A Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of nausea is an example of subjective data. All other options are examples of objective data. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ:1 | 3TOP:Subjective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 27. During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data? a. The patient is asleep. b. The patient is tearful. c. The patient has facial grimacing. d. The patient states, I hurt all over. ANS: D Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Stating I hurt all over is an example of subjective data. All other options are examples of objective data. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ:1 | 3TOP:Nursing process KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 28.During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data? a. The patient is coughing. b. The patient has cyanosis of the lips. c. The patient experiences tachypnea.

d. The patient complains of generalized discomfort. ANS: D Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of generalized discomfort is an example of subjective data. All other options are examples of objective data. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ:1 | 3TOP:Subjective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data? a. The patient complains of chest pain. b. The patient states, I feel nauseous. c. The patient complains of feeling faint. d. The patient is short of breath on exertion. ANS: D Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Shortness of breath on exertion is an example of objective data. All other options are examples of subjective data. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ:1 | 3TOP:Objective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data? a. The patient is jaundiced. b. The patient states, I am nervous. c. The patient complains of palpitations. d.

The patient denies dizziness when ambulating.

ANS: A Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. The patient is jaundiced is an example of objective data. All other options are examples of subjective data. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ:1 | 3TOP:Objective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 31. During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data? a. The patient complains of feeling depressed. b. The patient states, I hear voices in my head. c. The patient complains of auditory hallucinations. d. The patient is pacing back and forth while chanting. ANS: D Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Pacing back and forth while chanting is an example of objective data. All other options are examples of subjective data. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ:1 | 3TOP:Objective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 32. What is an example of an appropriate nursing diagnosis? a. Impaired skin integrity b. Skin breakdown noted c. Turn patient every 2 hours d.

The patient has scabies on his back

ANS: A Impaired skin integrity is an example of a nursing diagnosis. Skin breakdown noted is an example of a charting entry, turn patient every 2 hours is a nursing intervention, and scabies is a medical diagnosis. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83 OBJ:4TOP:Nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 33. What is an example of an appropriate nursing diagnosis? a. Constipation b. Patient complains of constipation c. Need for laxatives d. Patient has a duodenal ulcer ANS: A Constipation is an example of a nursing diagnosis, a patient complaining of constipation is an example of a charting entry, a need for laxatives is an example of a patient need, and a patient has a duodenal ulcer is an example of a medical diagnosis. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83 OBJ:4TOP:Nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 34.A nurse is formulating a nursing diagnosis. What is an example of an appropriately written nursing diagnosis? a. Risk for impaired skin integrity related to physical immobilization b. Physical immobilization secondary to risk for impaired skin integrity c. Risk for impaired skin integrity related to diagnosis of decubitus ulce d. Physical immobilization secondary to decreased cognitive ability ANS: A Risk for impaired skin integrity related to physical immobilization is the only appropriately written nursing diagnosis. All other options are not listed as NANDA-I approved nursing diagnoses. PTS: 1 DIF: Cognitive Level: Application REF: Pages 81-83

OBJ:4TOP:Nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 35. Which is an example of a nursing diagnosis? a. Pneumonia b. Diabetes mellitus c. Impaired skin integrity d. Congestive heart failure ANS: C Impaired skin integrity is the only example of a nursing diagnosis; all other options are examples of medical diagnoses. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83 OBJ:4TOP:Nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 36. Which is an example of a medical diagnosis? a. Constipation b. Diabetes mellitus c. Impaired skin integrity d. Altered nutrition: less than body requirements ANS: B Diabetes mellitus is the only example of a medical diagnosis; all other options are examples of nursing diagnoses. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 83 OBJ:4TOP:Medical diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 37. Which is an example of a medical diagnosis? a. Pain b. Anxiety c. Pneumonia d. Impaired skin integrity ANS: C

Pneumonia is the only example of a medical diagnosis; all other options are examples of nursing diagnoses. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 83 OBJ:4TOP:Medical diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 38. Which are acceptable secondary sources for data? (Select all that apply.) a. Patient b. Family members c. Other health professionals d. Diagnostic reports e. Textbooks ANS: B, C, D, E A patient is not a secondary source. The patient is the primary data source. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 79-80 OBJ: 3 TOP: Data sources KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 39. Which are official categories of nursing diagnoses? (Select all that apply.) a. Actual b. Risk c. Wellness d. Syndrome e. Potential ANS: A, B, C, D Actual, risk, wellness, and syndrome are the four categories of nursing diagnoses. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83 OBJ: 4 TOP: Nursing diagnosis KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 40. Which are considered phases of the nursing process? (Select all that apply.) a. Diagnosis

b. Prediction c. Assessment d. Evaluation e. Implementation f. Outcome identification ANS: A, C, D, E, F The nursing process consists of six dynamic and interrelated phases: diagnosis, assessment, outcome identification, planning, implementation, and evaluation. Prediction is not a phase of the nursing process. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 78 OBJ: 2 TOP: Nursing process KEY: Nursing Process Step: All MSC:NCLEX: N/A COMPLETION 41. NANDA International meets to reorganize diagnosis labels and language every years. ANS: 2 NANDA meets every 2 years to revise language, form, and diagnosis labels. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 81 OBJ: 10 TOP: NANDA KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 42. The standards that name and measure patient outcomes are referred to as . ANS: NOC (Nursing Outcome Classification) NOC Nursing Outcome Classification NOC sets up outcome criteria based on a patient problem. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 88-89 OBJ: 10 TOP: NOC KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 43. The document that outlines a multidisciplinary plan for care interventions over a specified time frame is a . ANS:

clinical pathway critical path A clinical pathway is an organized multidisciplinary plan over a specified time frame, which outlines aspects of patient care. They are also called critical paths, action plans, and care maps. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 90 OBJ: 11 TOP: Clinical pathways KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 44.A systematic method by which nurses plan and provide care for patients is known as the . ANS: nursing process The nursing process serves as the organizational framework for the practice of nursing. It is a systematic method by which nurses plan and provide care for patients. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 78 OBJ: 2 TOP: Nursing process KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 45.A systemic, dynamic process by which the nurse, through interaction with the patient, significant others, and health care providers, collects and analyzes data about the patient is known as . ANS: assessment The American Nurses Association (ANA) defines assessment as a systemic, dynamic process by which the nurse, through interaction with the client, significant others, and health care providers, collects and analyzes data about the client. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 78 OBJ:2TOP:Nursing process KEY:Nursing Process Step: AssessmentMSC:NCLEX: N/A 46.Any health care condition that requires diagnostic, therapeutic, or educational actions is known as a . ANS: problem

A problem is any health care condition that requires diagnostic, therapeutic, or educational actions. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 81 OBJ: 2 TOP: A problem KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 47.A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes is known as a . ANS: nursing diagnosis A nursing diagnosis is a type of health problem that can be identified. It is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 81 OBJ:4TOP:Nursing diagnosis KEY:Nursing Process Step: DiagnosisMSC:NCLEX: N/A 48. The human responses to health conditions/life processes that exist in an individual, family, or community are known as a(n) . ANS: actual nursing diagnosis An actual nursing diagnosis is described as the human responses to health conditions/life processes that exist in an individual, family, or community. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 81-83 OBJ:4TOP:Actual nursing diagnosis KEY:Nursing Process Step: DiagnosisMSC:NCLEX: N/A 49. Human responses to health conditions and life processes that may develop in a vulnerable individual, family, or community are known as a(n) . ANS: risk nursing diagnosis A risk nursing diagnosis is defined as the human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 81-83 OBJ:4TOP:Risk nursing diagnosis KEY:Nursing Process Step: DiagnosisMSC:NCLEX: N/A 50.Human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement are known as a . ANS: wellness nursing diagnosis A wellness nursing diagnosis is defined as human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 83 OBJ:4TOP:Wellness nursing diagnosis KEY:Nursing Process Step: DiagnosisMSC:NCLEX: N/A 51.The identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures is known as a . ANS: medical diagnosis A medical diagnosis is the identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 83 OBJ: 4 TOP: Medical diagnosis KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 52.A health care system that provides control over health care services for a specific group of individuals in an attempt to control cost is known as . ANS: managed care Managed care is a health care system that provides control over health care services for a specific group of individuals in attempts to control cost. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 90 OBJ: 6 | 11 TOP: Risk Managed care KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A 53.A multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases is known as a . ANS: critical pathway A critical pathway is a multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 90 OBJ: 11 TOP: Clinical pathways KEY: Nursing Process Step: N/A MSC:NCLEX: N/A Chapter 6: Cultural and Ethnic Considerations My Nursing Test Banks Chapter 6: Cultural and Ethnic Considerations Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. Culture varies from patient to patient. Why is it important that the nurse understand and accept each person as an individual? a. To develop a plan of care b. To provide holistic care c. To identify differences d. To support each patient ANS: B Accepting each person as an individual is the first step in providing holistic care. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 95 OBJ: 2 TOP: Culture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 2. What is a fixed concept of how all members of an ethnic group act or think? a. Variations within a cultural group b. Identical practices c. Holistic nursing

d. Ethnic stereotypes ANS: D Ethnic stereotypes are fixed concepts of how all members of an ethnic group act or think. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 95 OBJ: 4 TOP: Culture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 3. All nurses should work to provide culturally appropriate nursing care. What is the integration of cultural knowledge into all aspects of care? a. Cultural competence b. Transcultural nursing c. Nursing process d. Team nursing ANS: B All nurses should provide transcultural nursing, which is the integration of cultural knowledge into all aspects of care. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 95-96 OBJ: 1 | 2 TOP: Culture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 4. What is the term for when members of a particular ethnic group believe that their beliefs and practices are the best? a. Prejudice b. Separatism c. Ethnocentrism d. Bias ANS: C When members of a particular ethnic group believe that their practices and beliefs are the best, it is referred to as ethnocentrism. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 95 OBJ: 4 TOP: Culture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 5. What is the term used to describe cultures in which women make decisions about health care and provide the care and discipline to the children?

a. Biologic b. Matriarchal c. Cultural d. Patriarchal ANS: B In a matriarchal society, women make the decisions about health care. In patriarchal society, the men make decisions about health care. There is no such thing as biologic or cultural cultures. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 100 OBJ: 4 TOP: Culture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 6. What basic philosophy in the United States is relevant to health care? a. Folk remedies b. Biomedical therapy c. Holistic therapy d. Spiritual intervention ANS: B Most people in the United States believe biomedical therapy is the best way to treat disease. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 106 Table 6-2 OBJ: 4 TOP: Culture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 7. What is a set of learned values, beliefs, customs, and practices shared by a group? a. Race b. Ethnicity c. Culture d. Religion ANS: C Culture is a set of learned values, beliefs, customs, and practices shared by a group. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 94 OBJ: 4 TOP: Culture KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A 8.A nurse is American-born and works in a large hospital with patients from many cultures. What must this nurse develop to provide the best care? a. Another language b. Assessment skills c. Cultural competence d. Care planning ability ANS: C To provide care to patients from different cultures, the nurse must develop cultural competence. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 95 OBJ: 3 TOP: Culture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 9. The nurse from New York City is caring for a patient from Atlanta, Georgia. What difference between the nurse and patient may cause them to experience difficulty in communicating? a. Race b. Subculture c. Ethnic group d. Culture ANS: B Subcultures have characteristic patterns that distinguish them from the rest of the culture. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 94 OBJ: 2 TOP: Subculture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 10. The father of an American Indian has just died. What should the nurse do immediately after death? a. Provide privacy so that the family may touch and kiss the deceased g b. Ask about providing help with the death ceremony c. Carefully wrap the deceaseds clothing for the family to take home d. Mention the deceased by name frequently ANS: B

In the American Indian culture it is taboo to touch the deceased or any of the belongings of the deceased. After death, the name of the deceased is not spoken. PTS: 1 DIF: Cognitive Level: Application REF: Page 112 Table 6-4 OBJ:1 | 4 | 6TOP:American Indian KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 11. What is the term for a generalization about a form of behavior, an individual, or a group? a. Dialect b. Religion c. Ethnicity d. Stereotype ANS: D A stereotype is a generalization about a form of behavior, an individual, or a group. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 95 OBJ: 4 TOP: Stereotype KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 12. What is the term for a group of people who share biologic physical characteristics? a. Race b. Culture c. Religion d. Social organization ANS: A A race is a group of people who share biologic physical characteristics. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 96 OBJ: 4 TOP: Race KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 13. What is the term for a group of people who share a common social and cultural heritage based on shared traditions, national origin, and physical and biologic characteristics?

a. Race b. Culture c. Religion d. Ethnicity ANS: D Ethnicity refers to a group of people who share a common social and cultural heritage based on shared traditions, national origin, and physical and biologic characteristics. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 96 OBJ: 4 TOP: Ethnicity KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 14.A nurse is caring for a neonate born to observant Orthodox Jewish parents. Who can the nurse anticipate will name the neonate? a. Father b. Mother c. Grandfather d. Grandmother ANS: A For observant Jews, babies are named by the father. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 103 Box 6-4 OBJ: 2 | 3 TOP: Religious practices KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 15.A nurse is caring for a male neonate born to observant Orthodox Jewish parents. Who will the nurse anticipate will circumcise the neonate? a. A bishop b. A mohel c. His father d. His physician ANS: B Male children are named 8 days after birth, when ritual circumcision is done. A mohel performs the circumcision. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 103 Box 6-4 OBJ: 2 | 4 TOP: Religious practices KEY: Nursing Process Step: N/A

MSC: NCLEX: Psychosocial Integrity 16.A nurse is caring for a female neonate born to observant Orthodox Jewish parents. What book does the nurse know will be used when naming this neonate? a. Bible b. Koran c. Holy Torah d. Book of Mormon ANS: C For observant Jews, female babies are usually named during a reading of the Holy Torah. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 103 Box 6-4 OBJ: 2 | 4 TOP: Religious practices KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 17.A nurse is caring for an Orthodox Jewish woman immediately after she has given birth. What can the nurse expect regarding the spouses participation in his wifes care? a. He will share a bed with the patient. b. He will ask to bathe with the patient. c. He will touch the patient frequently. d. He will avoid physical contact with the patient. ANS: D For observant Jews, a woman is considered to be in a ritual state of impurity whenever blood is coming from her uterus, such as during menstrual periods and after the birth of a child. During this time, her husband will not have physical contact with her. When this time is completed, she will bathe herself in a pool called a mikvah. Nurses need to be aware of this practice and be sensitive to the husband and wife because the husband will not touch his wife. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 103 Box 6-4 OBJ: 4 | 5 TOP: Religious practices KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 18.A nurse is caring for an Orthodox Jewish patient. What is the most

appropriate dietary requirement for the nurse to implement? a. Mixing of milk and meat at a meal b. Use of separate cooking utensils for meat and milk products c. Use of one set of cooking utensils for meat and milk products d. Consumption of food not slaughtered in accordance with Jewish law ANS: B For observant Jews, Kosher dietary laws include the following: no mixing of milk and meat at a meal; no consumption of food or any derivative thereof from animals not slaughtered in accordance with Jewish law; use of separate cooking utensils for meat and milk products; if a patient requires milk and meat products for a meal, the dairy foods should be served first, followed later by the meat. PTS: 1 DIF: Cognitive Level: Application REF: Page 103 Box 6-4 OBJ: 4 TOP: Religious practices KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 19. The nurse is preparing an Orthodox Jewish patients tray during Passover. What intervention is appropriate for this patient? a. Avoid fish dishes b. Encourage time for prayer c. Offer the patient leavened products d. Encourage the use of loud music in celebration ANS: B Orthodox Jews say prayers over the bread and wine before meals. Time and a quiet environment should be provided for this. During Passover, no leavened products are eaten. PTS: 1 DIF: Cognitive Level: Application REF: Page 103 Box 6-4 OBJ: 4 TOP: Religious practices KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 20.A nurse is preparing to discuss birth control options for a Roman Catholic patient. What is the most appropriate method for the nurse to discuss with this patient? a. Abstinence b. Vasectomy

c. Tubal ligation d. Oral contraceptives ANS: A Birth control for Roman Catholics is prohibited except for abstinence or natural family planning. Referral to a priest for questions about this can be of great help. Nurses can teach the techniques of natural family planning if they are familiar with them; otherwise, this should be referred to the physician or to a support group of the Church that instructs couples in this method of birth control. Sterilization is prohibited unless there is an overriding medical reason. PTS: 1 DIF: Cognitive Level: Application REF: Page 104 Box 6-4 OBJ: 3 | 5 | 7 TOP: Religious practices KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 21.A nurse is preparing a meal tray for a patient who is a Latter-Day Saint. What beverage should the nurse prepare? a. Tea with all meals b. Coffee each morning c. Cola beverages d. Fruit juice ANS: D For observant Latter-Day Saints, beverages with caffeine such as cola, coffee, and tea; alcohol; and other substances are considered injurious. PTS: 1 DIF: Cognitive Level: Application REF: Pages 101-102 Box 6-4 OBJ: 4 | 7 TOP: Religious practices KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 22.A nurse is caring for a patient who is a Latter-Day Saint. The nurse is aware members of this faith may wear sacred undergarments. What intervention is appropriate for the nurse caring for this patient? a. Instruct the patient to remove the undergarments b. Allow the patient to wear the undergarments only at night c. Allow the patient to wear the undergarments only during the day d. Remove the undergarments in emergency situations only ANS: D

For observant Latter-Day Saints, a sacred undergarment may be worn at all times and should be removed only in emergency situations. PTS: 1 DIF: Cognitive Level: Application REF: Page 101 Box 6-4 OBJ: 4 | 5 TOP: Religious practices KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 23. Which statement about the biomedical health belief system is true? a. Life processes can be manipulated by human beings by mechanical in b. Life processes cannot be manipulated by human beings by mechanica c. Disease has a nonspecific cause, onset, course, and treatment. d. Disease is only caused by failure of body parts and chemical imbalanc ANS: A Characteristic of the biomedical health belief system include the beliefs that life is regulated by biomedical and physical processes. Life processes can be manipulated by human beings by mechanical interventions. Health is the absence of disease or signs and symptoms of disease. Disease is an alteration of the structure and function of the body. Disease has a specific cause, onset, course, and treatment. It is caused by trauma, pathogens, chemical imbalances, or failure of body parts. Treatment focuses on the use of physical and chemical treatments. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 106 Table 6-2 OBJ: 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 24. Which health belief system is commonly referred to as third-world beliefs and practices? a. Folk health belief system b. Holistic health belief system c. Biomedical health belief system d. Alternative/complementary belief system ANS: A The folk health belief system is commonly referred to as third-world beliefs and practices. It is often called strange or weird by nurses and other health professionals who are unfamiliar with folk medicine beliefs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 106 Table 6-2

OBJ: 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 25. Which health belief system includes a belief of a supernatural force exerting influence to cause health or illness? a. Folk b. Holistic c. Biomedical d. Alternative/complementary ANS: A The folk health belief system is commonly referred to as third-world beliefs and practices. It is often called strange by nurses and other health professionals who are unfamiliar with folk medicine beliefs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 106 Table 6-2 OBJ: 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 26. Which health belief system focuses on restoring balance with physical, social, and metaphysical worlds? a. Folk health belief system b. Holistic health belief system c. Biomedical health belief system d. Alternative/complementary belief system ANS: B The treatment based on the holistic health belief system is designed to restore balance with physical, social, and metaphysical worlds. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 106 Table 6-2 OBJ: 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 27. The nurse is caring for a patient who fasts during daylight hours during Ramadan. The nurse recognizes that the patient is adhering to the cultural beliefs of which culture? a. Muslims b. African Americans c. Chinese Americans

d. Mexican Americans ANS: A Muslims practice fasting during daylight hours during Ramadan. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 101-102 Box 6-4 OBJ: 4 | 5 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 28. The nurse is caring for a Muslim patient. What dietary selection should the nurse serve to this patient? a. Bacon, eggs, and toast b. Pork fried rice c. Ham and cheese sandwich d. Chicken and rice ANS: D Muslims practice avoidance of foods that include pork products. Bacon, pork, and ham are all pork products. Only the chicken and rice meal does not include a pork product. PTS: 1 DIF: Cognitive Level: Application REF: Pages 101-102 Box 6-4 OBJ: 1 | 2 | 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 29.A patient requests a consultation between the physician and a religious leader known as an Imam. What is this patients cultural belief? a. Muslim b. African American c. Chinese American d. Mexican American ANS: A Muslims may wish to have their doctor consult with an Imam, a religious leader. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 112 Table 6-4 OBJ: 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 30. The nurse is delivering a meal tray to a female Muslim patient. What intervention is most appropriate for this patient?

a. Offering her a ham and cheese sandwich b. Providing her with a male nurse c. Providing her with a female nurse d. Offering her bacon and eggs ANS: C When caring for Muslims, same-sex health care providers should be used if at all possible. Ham and bacon are not appropriate items to offer a Muslim patient, since they do not consume pork products. PTS: 1 DIF: Cognitive Level: Application REF: Page 112 Table 6-4 OBJ: 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 31. The nurse is caring for a Chinese American patient. How should this nurse demonstrate cultural awareness? a. Maintain eye contact with the patient b. Hold the patients hand while conversing c. Touch the patients arm when speaking to the patient d. Sit side-to-side when speaking with the patient ANS: D Chinese Americans view maintaining eye contact as ill-mannered and disrespectful. They are uncomfortable when face-to-face, and prefer to sit side-to-side or at a right angle to carry on conversation. Touching is not usual during conversation; it is regarded as disrespectful or impolite. PTS: 1 DIF: Cognitive Level: Application REF: Page 111 Table 6-4 OBJ: 4 | 5 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 32. The nurse is caring for a Mexican American patient. What nursing intervention would best demonstrate cultural sensitivity? a. Encouraging consultation of male members of the family regarding he b. Discouraging consultation of male members of the family regarding h c. Insisting on providing all personal care required by the patient d. Asking only female family members about health care decisions ANS: A When caring for Mexican Americans, families may expect to help care for

the patient. Male family members usually are consulted before health care decisions are made. PTS: 1 DIF: Cognitive Level: Application REF: Page 112 Table 6-4 OBJ: 4 | 5 | 7 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 33. The nurse is caring for an African American patient. Who would the nurse expect to be the primary decision maker in the patients family? a. Men b. Women c. Clergy d. Grandparents ANS: B When caring for African Americans, women are primarily the decision makers in the family and are frequently the head of the household. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 112 Table 6-4 OBJ: 1 | 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 34. The nurse is caring for a Mexican American patient who is in labor. How can this nurse best demonstrate cultural sensitivity? a. Encouraging female family members to be present for the delivery b. Encouraging the patients spouse to be present for the delivery c. Asking the patients spouse to see his baby before cutting the umbilic d. Asking the patients spouse to hold the neonate before bathing the neo ANS: A When caring for Mexican Americans, it is considered inappropriate for the husband to be present during birth. The father is not expected to see his wife or baby until both are cleaned and dressed. PTS: 1 DIF: Cognitive Level: Application REF: Page 112 Table 6-4 OBJ: 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 35. The nurse is caring for a postpartum patient who requests to dry and bury the umbilical cord near an object or in a place that symbolizes what the parents want for the childs future. Which cultural beliefs does the nurse

recognize this patient adhering to? a. American Indian b. African American c. Chinese American d. Mexican American ANS: A After delivery, American Indians practice taking the umbilical cord from the newborn, drying and burying it near an object or place that symbolizes what the parents want for the childs future. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 112 Table 6-4 OBJ: 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 36. What are some characteristics that cultures have in common? (Select all that apply.) a. Economic practices b. Survival modes c. Transportation systems d. Language e. Family systems ANS: A, B, C, E Language may differ within cultures; the rest are shared characteristics. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 95 Box 6-1 OBJ: 1 | 4 TOP: Common traits KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 37. What should the culturally sensitive nurse do for a Muslim woman being treated in the hospital? (Select all that apply.) a. Assign only female staff to care for her. b. Keep her head and extremities covered as much as possible. c. Arrange for family to bring specially prepared pork dishes. d. Let her make decisions relative to her care. e. Allow privacy for prayer. ANS: A, B, E

Muslim women are not accustomed to making decisions, leaving it to the head of the house or the family as a whole. Muslims do not eat pork. PTS: 1 DIF: Cognitive Level: Application REF: Page 102 Box 6-4 OBJ: 4 | 5 TOP: Muslims KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 38.A nurse working in a long-term care facility is admitting an 85-year-old resident of Hispanic descent diagnosed with Alzheimer disease. What should this nurse take into consideration when caring for the resident? (Select all that apply.) a. Cultural background has an important role in determining the residen b. The resident will be culturally sensitive to caregivers c. Home remedies may have value even if harmful d. The resident will have a strong sense of trust for health care workers e. Communication should involve gesturing whenever possible ANS: A, C Cultural background has an impact on family dynamics and plays an important role in determining the role and the status of the older person. Some older adults are less tolerant of other cultures as a result of influences or experiences early in their lives, which raises the possibility of misunderstandings and distrust when the caregiver is of a cultural group different than that of the older person. Communication should suit the individual needs of the resident and does not necessarily involve gesturing. PTS: 1 DIF: Cognitive Level: Application REF: Page 96 OBJ: 6 TOP: Older Adult KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity COMPLETION 39. The nurse should not maintain eye contact with a Korean patient because many Asians believe prolonged eye contact is . ANS: impolite rude Many Asians avoid eye contact, believing it to be impolite or rude. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 111 Table 6-4 OBJ: 2 | 4 TOP: Asians KEY: Nursing Process Step: Implementation

MSC:NCLEX: N/A 40. The cultural characteristic of unwillingness to leave a current activitywhich may result in late or missed appointmentsis called . ANS: elasticity Elasticity is the ethnic characteristic of being late or missing an appointment altogether because of involvement in a current activity. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 100 OBJ: 4 TOP: Elasticity KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 41. Following the death of a Presbyterian infant, the nurse should help arrange for . ANS: baptism Presbyterians believe in infant baptism. PTS: 1 DIF: Cognitive Level: Application REF: Page 104 Box 6-4 OBJ:4TOP:Infant baptism KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 42. While caring for a Mexican American family in the home, the home health nurse recognizes that the family may also consult the for health advice. ANS: curandero, folk healer curandero folk healer The curandero or folk healer is an important figure in the health care of MexicanAmericans. PTS: 1 DIF: Cognitive Level: Application REF: Page 107 Figure 6-2 OBJ:4TOP:Mexican Americans KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 43.A nation, community, or broad group of people who establish particular

aims, beliefs, or standards of living and conduct is known as a . ANS: society A society is a nation, community, or broad group of people who establish particular aims, beliefs, or standards of living and conduct. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 94 OBJ: 4 TOP: Society KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 44.A set of learned values, beliefs, customs, and practices that are shared by a group and are passed from one generation to another is known as . ANS: culture Culture is a set of learned values, beliefs, customs, and practices that are shared by a group and are passed from one generation to another. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 94 OBJ: 4 TOP: Culture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 45.A generalization about a form of behavior, an individual, or a group is known as a . ANS: stereotype A stereotype is a generalization about a form of behavior, an individual, or a group. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 95 OBJ: 4 TOP: Stereotype KEY: Nursing Process Step: N/A MSC:NCLEX: N/A Chapter 7: Asepsis and Infection Control My Nursing Test Banks Chapter 7: Asepsis and Infection Control Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What is true regarding surgical asepsis?

a. It inhibits growth of pathogenic organisms. b. It is known as a cleaning technique. c. It includes hand hygiene. d. It is known as a sterile technique. ANS: D Surgical asepsis is known as a sterile technique. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 117 OBJ: 1 TOP: Infection KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 2. What action exemplifies a nurse practicing medical asepsis in performing daily care? a. Lifting a sterile swab from a sterile field b. Using disposable sterile gowns c. Washing hands for 5 minutes between patients d. Keeping bed linens off the floor ANS: D Keeping the bed linens off the floor is an example of medical asepsis; all other options are examples of surgical asepsis. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 117 OBJ: 1 | 2 TOP: Infection KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 3. What bacteria can lie dormant when conditions for growth are not favorable? a. Residue b. Capsules c. Spores d. Flagella ANS: C Spore formation occurs when conditions are unfavorable, causing the bacteria to take a dormant form. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 118 OBJ: 2 | 4 TOP: Bacteria KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment

4.A patient with a respiratory infection reports that he is not yet on an antibiotic. The nurse explains that the physician is waiting on the results of the culture and sensitivity. What does this test determine? a. What media the bacteria requires to grow b. How fast the bacteria grow c. Which antibiotics stop bacterial growth d. When the bacteria colonize ANS: C Sensitivity tests are done to determine which antibiotics will stop growth. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 118 OBJ:6TOP:Laboratory tests KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. What bacterium is responsible for more diseases than any other organism? a. Staphylococcus b. Pseudomonas aeruginosa c. Haemophilus influenzae d. Streptococcus ANS: D The Streptococcus bacterium is responsible for more diseases than any other organism. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 118 OBJ: 3 TOP: Bacteria KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 6. What additional complication does a disease caused by a virus have compared to a disease caused by bacteria? a. Multiplies rapidly b. Returns frequently c. Is not killed by antibiotics d. Is unable to be cultured ANS: C Antibiotics do not alter the course of a disease caused by a virus. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 119

OBJ: 3 TOP: Virus KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 7.A patient with ringworm asks the nurse if she has worms. What does the nurse inform the patient about the cause of ringworm? a. Bacteria b. Protozoa c. Virus d. Fungi ANS: D Ringworm is caused by fungi. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 121 OBJ: 3 TOP: Infection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. What should the nurse be diligent in to provide a safe environment for the patient? a. Keeping a light on at night to prevent falls b. Hand hygiene between patient contacts c. Regulating the temperature to avoid drafts d. Changing the bed linen to diminish microorganisms ANS: B One of the most important actions is hand hygiene before caring for another patient. PTS: 1 DIF: Cognitive Level: Application REF: Pages 126 OBJ:5 | 8 | 9TOP:Safe environment KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 9. What does the nurse describe when giving an example of a fomite vehicle? a. Rabid dog b. Person with AIDS c. Contaminated stethoscope d. Infected wound ANS: C If a vehicle is an inanimate (nonliving) object, it is called a fomite.

PTS: 1 DIF: Cognitive Level: Application REF: Page 122 OBJ: 2 TOP: Infection KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 10. The nurse observes a patient demonstrating wound cleaning. What action indicates the need for further instruction? a. Using sterile gloves to perform the cleaning b. Applying an antiseptic to the area c. Cleaning the area from the outside in d. Washing hands with soap ANS: C Cleaning away from the wound prevents entrance of microorganisms. PTS: 1 DIF: Cognitive Level: Application REF: Pages 123-125, 141 OBJ: 13 TOP: Wounds KEY: Nursing Process Step: Evaluation MSC:NCLEX: Safe, Effective Care Environment 11. The nurse is concerned when a patient admitted with a diagnosis of pneumonia suddenly develops a urinary tract infection (UTI). What type of infection is this UTI considered? a. Viral infection b. Bacterial infection c. Health careassociated infection d. Spore infection ANS: C More than 40 million people are admitted to hospitals each year and as many as 10% of them acquire a health careassociated infection while there. Criteria for health careassociated infections require that the infection manifest at least 48 hours after hospitalization or contact with another health agency. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 124 OBJ:2TOP:Health careassociated infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. The nurse prioritizes the care of four patients. Which patient has a systemic infection? a. 14-year-old with acute appendicitis

b. 80-year-old with a urinary tract infection c. 40-year-old with AIDS d. 50-year-old with arthritis ANS: C AIDS is a systemic viral infection. Acute appendicitis and urinary tract infections are local infections. Arthritis is not an infection. PTS: 1 DIF: Cognitive Level: Application REF: Pages 119-120; 126 OBJ:6TOP:Systemic infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. What assessment does the nurse recognize as an inflammatory response in a surgical wound on the leg of a patient? a. A foul drainage is coming from the wound b. The affected leg is cooler than the other leg c. There are raised, red, pruritic welts on the leg d. Rubor and edema appear around the wound ANS: D Rubor and edema are two of the cardinal signs of an inflammatory response. Foul drainage suggests infection, the affected leg being cooler than the other leg suggests circulatory disorder, and raised, red, pruritic welts on the leg suggest allergy. PTS: 1 DIF: Cognitive Level: Application REF: Page 124 OBJ:7TOP:Inflammatory response KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. The infection control practitioner plans an in-service on control of health care-associated infections. What should be the focus of this program? a. Observing nurses caring for patients b. Screening patients who are admitted to the hospital c. Educating hospital personnel about aseptic practices d. Discharging infectious patients from the hospital ANS: C Duties of the infection control practitioner include staff education on

infection control. PTS: 1 DIF: Cognitive Level: Application REF: Page 124 OBJ: 5 | 13 TOP: Infection KEY: Nursing Process Step: Planning MSC:NCLEX: Safe, Effective Care Environment 15.A health care worker is stuck by a needle left on the patients bedside table. The staff member appropriately reports the needlestick. What will the indicated treatment be combatting? a. Hepatitis B b. Streptococcal infections c. Staphylococcal infections d. Influenza ANS: A Workers who have had a needlestick need to complete an injury report and seek treatment in the event of exposure to hepatitis B. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 126 OBJ: 3 | 5 TOP: Needlesticks KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 16. What technique should the nurse use when disposing of linens contaminated with feces? a. Don gown, gloves, and mask b. Wash hands for 5 minutes after disposal c. Don gloves only d. Double-bag the sheets ANS: C All health care workers should follow Standard Precautions to prevent infection from pathogens. Standard Precautions for the disposal of ordinary feces require only that the nurse don gloves. PTS: 1 DIF: Cognitive Level: Application REF: Page 135 OBJ:13TOP:Standard Precautions KEY: Nursing Process Step: Analysis MSC: NCLEX: Safe, Effective Care Environment 17. The nurse is instructing a patient about the most important preventive technique for breaking the chain of infection. What technique is the patient

learning about? a. Sterilization b. Standard Precautions c. Hand hygiene d. Medical asepsis ANS: C Hand hygiene is the most important preventive measure for interrupting the infection process. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 126 OBJ: 2 | 9 TOP: Infection KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 18. How long should the nurse perform hand hygiene before beginning care of a patient? a. 5 minutes b. 2 minutes c. 1 minute d. 30 seconds ANS: D The nurse should wash hands after using the bathroom, after contact with any secretions, before eating, and before and after patient care. The nurse should use warm water, soap, and friction for 15 to 30 seconds, and dry hands thoroughly. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 126 OBJ: 9 TOP: Infection KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 19.A nurse is observing isolation precautions by wearing a mask while performing complex patient care. How often should the nurse change masks? a. 5-10 minutes b. 10-20 minutes c. 20-30 minutes d. 30-40 minutes ANS: C The mask should be changed every 20 to 30 minutes.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 134 OBJ: 8 TOP: Mask KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 20.A major threat to health care workers is blood-contaminated sharps. What should the nurse use to discard the used syringe? a. Wastebasket b. Sink c. Puncture-proof container d. Disinfecting soap ANS: C All patient care areas where sharps are used require puncture-proof containers. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 135 OBJ: 8 TOP: Sharps KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 21. The nurse is transporting a patient in respiratory isolation to the radiology department. What intervention should the nurse implement? a. Cover the patient with a sheet b. Take the patient down the service elevator c. Apply a mask to the patient d. Call x-ray to come and get the patient ANS: C If a patient requiring respiratory isolation must be transported to another area, the patient must don a mask. PTS: 1 DIF: Cognitive Level: Application REF: Pages 135-136 OBJ: 5 | 8 TOP: Isolation KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 22. The patient in isolation may experience psychological or emotional deprivation. What should the nurse do to help minimize these feelings? a. Be cheerful b. Spend extra time with the patient c. Protect the patient from additional infection d. Answer the call light quickly

ANS: B To minimize feelings of psychological or emotional deprivation, the nurse should spend extra time with the patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 137 OBJ: 13 TOP: Isolation KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 23. The infection control officer is observing hospital staff for appropriate use of aseptic technique. What observation demonstrates the need for more instruction on surgical asepsis? a. Facing the sterile field b. Placing a sterile dressing on a sterile field c. Touching the edges of the sterile field with sterile gloves d. Keeping gloved hands above the waist ANS: C The edges of a sterile field are not considered sterile. PTS: 1 DIF: Cognitive Level: Application REF: Pages 139-141 OBJ:1TOP:Sterile technique KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment 24. The nurse is pouring a sterile solution from a bottle. What direction should the label on the bottle be in for appropriate technique? a. Facing outward b. Covered c. Facing downward d. In the palm of the hand ANS: D The bottle should be held with the label in the palm of the hand. PTS: 1 DIF: Cognitive Level: Application REF: Page 146 OBJ:11 | 12TOP:Sterile technique KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 25. What is a method used to kill all microorganisms, including spores? a. Disinfecting

b. Using an antiseptic c. Using chlorine bleach d. Sterilizing ANS: D Sterilization refers to methods used to kill all microorganisms and spores. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 152 OBJ: 12 TOP: Pathogens KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 26. The nurse accidently spills blood from a specimen container. The first action the nurse takes is to don gloves. What should the nurse then spray the fluid with? a. Liquid detergent b. 20% bleach solution c. 10% bleach solution d. Warm soapy water ANS: C Any accidental body fluid spill should be cleaned up as soon as possible. The person cleaning the spill should wear gloves. One cup of bleach diluted with 10 cups of water should be used as a disinfectant to spray over the spill and clean up with paper towels. The paper towels should then be placed in the plastic-lined waste container. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 153 OBJ: 12 TOP: Body fluids KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 27. When assessing a patient for signs of an infection, the nurse recognizes which laboratory result as indicative of an infection? a. Lowered red blood cell count b. Increased white blood cell count c. Lowered white blood cell count d. Increased red blood cell count ANS: B Increased white blood cell count may indicate an infection. PTS: 1 DIF: Cognitive Level: Application REF: Page 124

OBJ: 3 | 4 TOP: Lab results KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28. What can result from the nurse consistently performing hand hygiene and using sterile supplies when caring for patients in the hospital setting? a. Hospital stay is shortened b. Sense of self-worth is improved c. Risk of infection is reduced d. Nursing care needed is reduced ANS: C Hand hygiene is the most important measure for interrupting the infectious process. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 125 OBJ: 5 TOP: Infection KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 29. Recognizing the stages of an infection assists the nurse in identifying the progression of an infection. What is the nonspecific to specific symptom stage of an infection? a. Convalescent b. Illness c. Prodromal d. Incubation ANS: C The prodromal stage progresses from onset of nonspecific signs and symptoms to more specific signs and symptoms. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 124 Box 7-3 OBJ: 4 | 6 TOP: Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. What is the most dependable and practical method to use when sterilizing instruments for the operating room? a. Chemical solution b. Boiling water c. Steam under pressure d. Dry heat

ANS: C Steam under pressure is the most practical and dependable method for destruction of all microorganisms. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 152 box 7-3 OBJ: 12 TOP: Sterilization KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 31. What contribution did Joseph Lister introduce to medical practice? a. Isolation of infected patients b. Iodine and alcohol use as disinfectants c. The autoclave d. Aseptic technique ANS: D Joseph Lister contributed to medical practice through the introduction of the aseptic technique. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 116 OBJ: 1 TOP: Joseph Lister KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 32. The nurse is providing instruction to an anxious mother of a child with Rocky Mountain spotted fever. When discussing this diagnosis what information will the nurse relay about this disease? a. It is extremely contagious among humans. b. It is contracted from handling unvaccinated animals. c. It is a hemolytic B Streptococcus infection spread by droplet transmi d. It is a serious disease contracted from the bite of a tick. ANS: D Rocky Mountain spotted fever is contracted through the bite of a tick vector. It is not contagious among humans. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 119 OBJ:2 | 3TOP:Vector transmission KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. The emergency department nurse is assessing a puncture wound of the foot. What is the most likely type of infection in this wound?

a. Aerobic bacterial infection b. Anaerobic bacterial infection c. Viral infection d. Fungal infection ANS: B An anaerobic bacterial infection is one that grows in an oxygenated environment. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 118 OBJ:6TOP:Anaerobic infections KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 34. The nurse is instructing a bioterrorism class regarding anthrax. How can anthrax be transmitted? a. From person to person b. Through microscopic skin punctures c. Through inhalation of the spores d. By exposure to animals that have anthrax ANS: C Anthrax is contracted by inhaling the spores. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 119 OBJ: 3 TOP: Anthrax KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 35. The nurse is providing teaching to elementary students regarding vectors. What example will the nurse provide as an example of a vector? a. Child with measles giving it to his sister b. Tick whose bite causes Lyme disease c. Woman with syphilis infecting her partner d. Dog whose bite causes rabies ANS: B A vector is a person or animal not sick with the disease harboring an organism that is contagious. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 121 OBJ: 3 TOP: Vector KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity 36.What type of organism causes malaria? a. Bacterium b. Virus c. Protozoan d. Fungus ANS: C Malaria is caused by the introduction of protozoa from the bite of a mosquito. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 121 OBJ:4TOProtozoan infections KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 37.A nurse is performing an admission assessment on a patient with suspected tuberculosis. What assessment findings by the nurse are consistent with tuberculosis? a. Hemoptysis b. Weight gain c. Night terrors d. Hypothermia ANS: A Suspicious symptoms consistent with tuberculosis include fatigue, unexplained weight loss, dyspnea, fever, night sweats, and hemoptysis (a cough that can be productive of blood). PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 137-138 OBJ:6TOP:Tuberculosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 38.A nurse is performing an admission assessment on a patient with suspected tuberculosis. What is the greatest risk of exposure to tuberculosis? a. After a diagnosis is made b. Before a diagnosis is made c. After the patient has begun medication therapy d. After implementation of isolation precautions

ANS: B The risk of exposure to tuberculosis is greatest before a diagnosis is made and isolation precautions are implemented. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 137-138 OBJ:8TOP:Tuberculosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 39. Which numbered portion of the illustration below depicts the bacterial class bacilli? a.1 b.2 c.3 d.4 e.5 ANS: E Bacilli are elongated microorganisms. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 119, Figure 7-3 OBJ: 3 TOP: Microorganisms KEY: Nursing Process Step: N/A MSC:NCLEX: N/A MULTIPLE RESPONSE 40.A person can spread a bacterial infection by which actions? (Select all that apply.) a. Kissing others b. Sneezing at work c. Donating blood d. Coming in contact with blood products e. Leaving used tissue on the lavatory ANS: A, B, E Bacteria can be spread by direct, indirect, or airborne transmission. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 118 OBJ:14TOP:Bacterial transmission KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance

41. What are some characteristics of microorganisms? (Select all that apply.)

a. Involved in a life process of their own b. Pathogens that cause disease c. Nonpathologic organisms that cause disease d. May be infectious e. Can enter the body via skin, air, or blood ANS: A, B, D, E Microorganisms are involved in a life process of their own, pathogens cause disease, may be infectious, and can enter the body via skin, air, or blood. Nonpathologic organisms do not cause disease. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 116-117 OBJ:3TOP:Characteristics of microorganisms KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment COMPLETION 42.A patient is distressed that an antibiotic has not been effective for the control of the infection. The nurse explains that some bacteria are capable of defending against antibiotics by the formation of a . ANS: capsule Some bacteria can protect themselves by the formation of a capsule of sticky protein that prevents antibiotics from entering the cell. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 118 OBJ:4TOP:Bacterial capsules KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 43.The nurse reminds a group of nursing students that the type of asepsis that destroys all microorganisms and their spores is asepsis. ANS: surgical Surgical asepsis destroys all microorganisms and their spores. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 117 OBJ:1TOP:Surgical asepsis KEY:Nursing Process Step: Implementation

MSC:NCLEX: Safe, Effective Care Environment Chapter 8: Body Mechanics and Patient Mobility My Nursing Test Banks Chapter 8: Body Mechanics and Patient Mobility Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse instructs a nursing assistant to use large muscle groups when lifting. What is the rationale for this instruction? a. Workers compensation claims will be prevented b. Big muscles work more effectively c. It guarantees no muscle strain d. It distributes workload more evenly ANS: D Proper body mechanics provide for even distribution of workload. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 161 OBJ:1 | 2TOP:Body mechanics KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 2. What should the nurse do to reduce the effort of moving a heavy object? a. Bring the feet close together and flex the knees b. Keep the back straight and bend at the waist c. Widen the base of support in the direction of movement d. Broaden the base of support and twist toward the direction of movem ANS: C The base of support should be broadened in the direction of movement. PTS: 1 DIF: Cognitive Level: Application REF: Page 161 OBJ:1 | 2TOP:Body mechanics KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 3. What should the nurse do to protect his or her back when lifting or moving a patient? a. Lowering the height of the bed b. Holding the back straight with locked knees

c. Bending knees and hips d. Getting the patient to the side of the bed ANS: C The nurses back can be well protected when he or she bends knees and hips. PTS: 1 DIF: Cognitive Level: Application REF: Page 161 OBJ:11TOP:Body mechanics KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 4. Where should the nurse place the load when carrying heavy objects? a. In a low position b. To the side of the body c. Close to the body midline d. With anothers assistance ANS: C The nurse should carry objects close to the midline of the body. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 162 OBJ:11TOP:Body mechanics KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 5. The nurse is educating a patient on ways to regain the ability to perform ADLs and maintain normal physiological activities. What will the nurse relay as a requirement? a. Strength b. Wellness c. Alertness d. Mobility ANS: D The purpose of mobility is completing ADLs and maintaining physiological activities. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 166 OBJ: 4 TOP: Mobility KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse counsels the immobilized patient in regard to prevention of

muscle atrophy and contractures. What will the nurse be sure to include when counseling this patient? a. The need for additional calcium b. The need for additional protein c. The need for some type of exercise d. The need for a special protective bed ANS: C The immobilized patient must receive some type of exercise to prevent atrophy and contractures. PTS: 1 DIF: Cognitive Level: Application REF: Page 169 OBJ: 6 TOP: Immobility KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. What is the term for range of motion (ROM) when it is performed by the patient? a. Assisted b. Passive c. Active d. Coordinated ANS: C ROM performed actively by the patient is designated as active ROM.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 169 OBJ:9TOP:Range of motion (ROM) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse is performing passive range of motion (ROM) for the patient. How will the nurse move the joint through ROM? a. The fullest extent b. Place the joint in normal position c. The point of pain d. Relax the patient ANS: C The joints are moved to the point of resistance or pain. PTS: 1 DIF: Cognitive Level: Application REF: Pages 173 OBJ:9TOP:Range of motion (ROM) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. How should the nurse assist the patient with moving when pain is anticipated? a. Be supportive b. Apply heat before moving them c. Administer medication before ambulation d. Obtain assistance if the patient is heavy ANS: C The nurse may want to administer medication before an activity that may be painful. PTS: 1 DIF: Cognitive Level: Application REF: Page 174 Skill 8-3 OBJ:6TOP:Body mechanics KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The 125-pound nurse assesses the weight of a patient. What weight is the heaviest the nurse may safely lift by herself? a. 158.75 lb b. 168.75 lb

c. 178.75 lb d. 188.75 lb ANS: B Nurses should never attempt to lift more than 35% above their own body weight. 125 0.35 = 43.75 125 + 43.75 = 168.75 PTS: 1 DIF: Cognitive Level: Analysis REF: Page 182 OBJ:11TOP:Body mechanics KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 11. What is the site of the most common strain injury acquired by the nurse when working? a. Trapezius muscle group b. Thoracic muscle group c. Lumbar muscle group d. Thigh muscle group ANS: C The most common back injury is strain of the lumbar muscle group. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 159 OBJ: 2 TOP: Body mechanics KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 12. What implementation might the nurse use to improve safety during a transfer? a. Weighing the patient first b. Using a transfer belt c. Putting shoes on the patient d. Supporting a flaccid arm ANS: B As a general rule, the nurse should use a transfer belt. PTS: 1 DIF: Cognitive Level: Application REF: Page 182 OBJ:5TOP:Body mechanics KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment

13. What is considered to be the minimum number of hours of daily activity

necessary to prevent the negative consequences of immobility? a. 2 hours b. 4 hours c. 6 hours d. 8 hours ANS: A The amount of exercise required to prevent physical disuse syndrome is 2 hours in 24 hours. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 167 Box 8-2 OBJ: 6 TOP: Immobility KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse is performing passive range-of-motion exercises on a patient following a traumatic injury. What is the number of times the nurse should move each joint when performing passive range-of-motion (ROM) exercises? a. Three b. Four c. Five d. Six ANS: C Each movement should be repeated five times. PTS: 1 DIF: Cognitive Level: Application REF: Page 173 Skill 8-2 OBJ:6TOP:Range of motion (ROM) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. What profession has the highest workers compensation claim rates of any occupation or industry? a. Firefighters b. Truck drivers c. Law enforcement d. Nursing personnel ANS: D Studies of workers compensation claims show that nursing personnel have

the highest claim rates of any occupation or industry. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 159 OBJ: 2 TOP: Workers compensation KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 16.A nurse instructs a nursing assistant about moving older adult patients in bed. When should the nurse intervene when observing the nursing assistant perform a return demonstration? a. The nursing assistant is using simple language. b. The nursing assistant is avoiding jerky movements. c. The nursing assistant is avoiding sudden movements. d. The nursing assistant is pulling the patient across bed linens. ANS: D The skin of older adults is more fragile and susceptible to injury. When moving or transferring older adults, it is essential to avoid pulling them across bed linens because this may cause shearing or tearing of the skin. The nurse should explain each step in simple language and avoid jerky, sudden movements. PTS: 1 DIF: Cognitive Level: Application REF: Page 174 Skill 8-3 OBJ:10 | 11TOP:Moving patients KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The LPN/LVN assists a patient into the semi-Fowler position per physician order. What would indicate that this patient is in the correct position? a. Patient is leaning over the bedside table b. Head of bed is at a 30-degree angle c. Knee is drawn toward the chest d. Arms are flexed toward the head ANS: B The semi-Fowler position is when the head of the bed is raised approximately 30 degrees. Orthopneic position is when the patient is leaning over the bedside table. Sims position is when the knee is drawn toward the chest. Arms are not flexed toward the head in the semi-Fowler position.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 164 Skill 8-1 OBJ:7TOPositioning patients KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 18.A newly hired group of graduate practical/vocational nurses are attending orientation at a long-term care facility. What information will be included regarding considerations of mobility and the older adult? (Select all that apply.) a. The skin of older adults is more fragile and susceptible to injury. b. Always support older adults under the soft tissue when moving them i Weakness and hypertension are common signs and symptoms noted in c. bed rest. d. Aging tends to result in loss of flexibility and joint mobility. e. Older adults sometimes become fearful when hydraulic lifts are used f ANS: A, D, E The skin of older adults is more fragile and susceptible to injury. Aging tends to result in the loss of flexibility and joint mobility and older adults sometimes do become fearful with use of hydraulic lifts. Older adults should be supported under the joints when moving in bed. Weakness and hypotension are common signs and symptoms noted in an older adult on bed rest. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 160 OBJ: 3 TOP: Older adult KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 19. The nurse receives a patient from the recovery room following total hip replacement surgery. What will the nurse include when assessing neurovascular status on this patient? (Select all that apply.) a. Pupils b. Pain c. Sensation d. Color e. Skin temperature

ANS: B, C, D, E One of the responsibilities of the nurse is to frequently monitor the patients neurovascular function, or circulation, movement, and sensation (CMS) assessment. The LPN/LVN checks for skin color, temperature, movement, sensation, pulses, capillary refill, and pain. Pupil assessment is part of a neurologic assessment. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 166 OBJ:8 | 13TOP:Neurovascular function KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION 20. The most common cause of musculoskeletal disorders in nurses involves a movement that requires the nurse to and at the same time. ANS: twist, lift lift, twist The motion of twisting and lifting at the same time frequently strains the muscles of the lower back. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 162 OBJ: 1 | 2 TOP: Muscle strain KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 21. To maintain a wide base of support, the nurse should stand with the feet separated by the distance of times the length of the nurses shoe. ANS: 1.5 one and one half A wide base of support of 1.5 times the length of the nurses shoe is recommended. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 161 OBJ:1TOP:Base of support KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 22. When a fall occurs, the nurse should document the incident and initiate

a(n) report. ANS: incident The nurse must initiate an incident report describing the events of a patients fall. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 167 Box 8-2 OBJ:6TOP:Incident report KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 23. machines flex and extend joints to mobilize them passively without the strain of active exercises. ANS: Continuous passive motion (CPM) Continuous passive motion CPM Continuous passive motion (CPM) machines flex and extend joints to mobilize them passively without the strain of active exercises. It is imperative that the CPM machine be set according to the health care providers orders for the degree and the speed of flexion and extension for each individual patient to prevent damage to the joint or surgical site. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 172 OBJ:12TOP:Continuous passive motion machines KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. The nurse points to the X in the illustration below and describes this point as the of . ANS: center, gravity The center of gravity is the centermost point from the base of support. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 161 OBJ:2TOP:Center of gravity KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity OTHER

25. Place the nursing activities in priority order for the preparation of a patient

to ambulate. Put a comma and space between each answer choice (A, B, C, D, etc.). a. Dangle the patient at the side of the bed b. Apply a gait belt c. Assist the patient to stand d. Inform the patient of activity e. Roll up the head of the bed ANS: D, E, A, B, C The order that is most organized is inform, roll up head of bed, dangle, apply belt, and assist to stand. PTS: 1 DIF: Cognitive Level: Application REF: Page 167 box 8-2 OBJ:6TOPreparation to ambulate KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment Chapter 9: Hygiene and Care of the Patients Environment My Nursing Test Banks Chapter 9: Hygiene and Care of the Patients Environment Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is preparing to bathe a patient. What should the room temperature be set at? a. No warmer than 67 F b. No cooler than 68 F c. No cooler than 70 F d. 75 F or warmer ANS: B The recommended room temperature is 68 to 74 F. PTS: 1 DIF: Cognitive Level: Application REF: Page 186 OBJ:1 | 2 | 4TOPatients environment KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

2. The nurse explains that the purpose of a sitz bath is to reduce inflammation

in the perineal and anal area. What is the least amount of time the nurse will instruct for a sitz bath? a. 10 to 15 minutes b. 20 to 30 minutes c. 30 to 40 minutes d. 1 hour ANS: B The sitz bath should last 20 to 30 minutes. PTS: 1 DIF: Cognitive Level: Application REF: Page 191 OBJ:2 | 3TOP:Therapeutic baths KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3.A patient is recovering from a hemorrhoidectomy and experiences dizziness within 5 minutes when taking a sitz bath. What action should the nurse implement? a. Cover the patient to prevent chilling b. Stay with the patient until the full time for the bath has elapsed c. Remove the patient from the sitz bath and return to bed d. Assess vital signs every 5 minutes during the remainder of the sitz ba ANS: C The patient may become dizzy during a sitz bath due to dilation of the large vessels in the abdomen. If this occurs, the patient should be removed from the sitz bath and returned to bed. Vital signs should be assessed until they return to normal. PTS: 1 DIF: Cognitive Level: Application REF: Page 191 OBJ: 3 TOP: Sitz bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. What should the water temperature be when preparing a tepid bath for a patient? a. 98.6 F b. 100.2 F c. 104.8 F

d. 110.4 F ANS: A The tepid bath is taken in water that is 98.6 F. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 191 OBJ: 4 TOP: Tepid bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is assessing a patients skin for signs of impaired skin integrity. Which finding by the nurse is considered a major manifestation? a. Burn b. Laceration c. Pressure ulcer d. Infection ANS: C A major manifestation of impaired skin integrity is a pressure ulcer. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 200 OBJ:5TOPressure ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6.A nurse assesses an area of sustained redness on the coccyx area of a resident in long-term care. What is the most likely cause of this pressure area? a. Heat from pressure b. Collapse of blood vessels c. Friction from pressure d. Collapse of skin tissue ANS: B A pressure ulcer occurs when there is sufficient pressure to collapse the blood vessels. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 200 OBJ:5TOPressure ulcers KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 7. The nurse is caring for an unconscious patient with a risk for skin

impairment. How often will the nurse plan to change the position of this patient? a. Every 30 minutes b. Every 60 minutes c. Every 120 minutes d. Every 180 minutes ANS: C The bedfast patient should have a position change every 2 hours (120 minutes) because skin compromise can occur if there is unrelieved pressure during that amount of time. PTS: 1 DIF: Cognitive Level: Application REF: Page 202 Box 9-5 OBJ:5TOPressure ulcers KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse assesses a red blister over the right superior iliac area of a patient. What stage is this decubitus ulcer? a.I b.II c.III d.IV ANS: B A pressure ulcer demonstrating blisters is a stage II decubitus ulcer. PTS: 1 DIF: Cognitive Level: Application REF: Page 202 OBJ:5TOPressure ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. The nursing assessment of a pressure ulcer includes size, depth, pain, odor, and color of tissue. What does this evaluate? a. Treatment needed b. Effectiveness of implementation c. Whether improvement is occurring d. Need for additional interventions ANS: C

Ongoing assessment of a pressure ulcer will evaluate whether improvement is occurring. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 201 OBJ:5TOPressure ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. The nurse attempts to avoid a pressure ulcer for a bedridden patient by turning the patient frequently. What is the most favorable position for the nurse to move this patient into? a. Back-lying b. Full lateral c. 30-degree lateral d. Full prone ANS: C It is preferable to use the 30-degree lateral incline position. PTS: 1 DIF: Cognitive Level: Application REF: Page 202 Box 9-5 OBJ:5TOPressure ulcers KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. One reason the nurse focuses on oral hygiene is to maintain a healthy state of the oral cavity. What is another reason to promote oral hygiene? a. To improve self-esteem b. To stimulate appetite c. To restore tooth destruction d. To assist with periodontitis ANS: B A sense of well-being can stimulate appetite. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 204 OBJ:6TOP:Oral hygiene KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. How will the nurse correctly replace a patients dentures after cleaning? a. Inserting the lower denture first

b. Asking the patient to insert them c. Inserting both dentures together d. Inserting the upper denture first ANS: D When reinserting dentures, replace the upper dentures first. PTS: 1 DIF: Cognitive Level: Application REF: Page 206 Skill 9-2 OBJ:6TOP:Oral hygiene KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. Proper hair care is important for the patients self-image. What is the proper water temperature when shampooing a patients hair? a. 101 F b. 105 F c. 110 F d. 120 F ANS: C Water at 110 F should be used to shampoo a patients hair. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 208 Skill 9-3 OBJ: 6 TOP: Hair care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. When must the nurse remember to use an electric razor when shaving a patient? a. When a bleeding tendency is present b. When there is a risk for suicide c. When the facial hair is fine d. When speed is essential ANS: A A patient with a bleeding disorder should use an electric razor. PTS: 1 DIF: Cognitive Level: Application REF: Page 207 OBJ: 6 TOP: Shaving KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is bathing a patient with a deep vein thrombosis in the left leg. What modification will the nurse make when attending to the left leg?

a. Washing the leg with long, firm strokes and drying with a towel b. Omitting washing the leg at all c. Gently washing the leg and patting dry with a towel d. Applying lotion in long, smooth strokes ANS: C The lower extremities of people with circulatory disorders are gently washed and patted dry, omitting any stroking or massaging. PTS: 1 DIF: Cognitive Level: Application REF: Page 194 Skill 9-1 OBJ: 3 TOP: Bathing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is providing hand and foot care to a patient and notices the patient has extremely hard nails. Who is the person best prepared to provide nail care for patients with extremely hard nails? a. Physician b. RN c. CNA d. Podiatrist ANS: D If the patients nails are extremely hard, a podiatrist should provide care. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 207, 210 Skill 9-3 OBJ: 6 TOP: Foot care KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 17. How often should the nurse cleanse the meatal-catheter junction of a patient with an indwelling catheter? a. At least once a day b. At least twice a day c. At bedtime d. Each shift ANS: B Catheter care should be performed at least two times daily. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 207 OBJ:8TOP:Catheter care KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity 18. The nurse is preparing to perform perineal care for the female patient. What is the best method for using a bath blanket to drape the patient? a. Square position b. Long position c. Diamond position d. Rectangular position ANS: C Drape the patient with a bath blanket in the diamond position. PTS: 1 DIF: Cognitive Level: Application REF: Page 211 Skill 9-4 OBJ:8TOPerineal care KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. Clear water is used to cleanse the eyes. It is important to use proper technique when cleansing the eyes to prevent infection. What direction will the water flow when cleansing a patients eyes? a. Upward toward the forehead b. Downward toward the chin c. From the outer toward the inner canthus d. From the inner toward the outer canthus ANS: D The eye is cleansed from the inner to outer canthus. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 213 OBJ: 6 TOP: Eye care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. How frequently should the nurse clean the nares of patients who have a nasogastric tube or are receiving oxygen by nasal cannula? a. At least every 2 hours b. At least every 6 hours c. At least every 8 hours d. At least every 10 hours ANS: C When receiving oxygen by a nasal cannula or when a nasogastric tube is in

place, the nurse should cleanse the nares every 8 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 214 OBJ: 6 TOP: Nasal care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse must follow the principles of medical asepsis while making a patients bed, including procedures for handling linens. How should the nurse handle soiled linens? a. Place on the floor b. Fan in the air c. Hold away from the uniform d. Place at the end of the bed ANS: C Soiled linen should not come into contact with a uniform. PTS: 1 DIF: Cognitive Level: Application REF: Page 215 Skill 9-5 OBJ: 10 TOP: Bed making KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 22. How should the nurse cleanse the meatal opening when performing male perineal care? a. From the meatus outward b. With an alcohol swab c. In a circular motion d. With a cotton-tipped applicator ANS: A The nurse should cleanse the meatal opening from the meatus outward. PTS: 1 DIF: Cognitive Level: Application REF: Page 212 Skill 9-4 OBJ:8TOPerineal care KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. The nurse lowers the bed to place the patient on the bedpan. The angle of the head of the bed should be raised to: a. 20 degrees. b. 45 degrees. c. 90 degrees.

d. 30 degrees. ANS: D Elimination is facilitated with the head of the bed elevated 30 degrees. PTS: 1 DIF: Cognitive Level: Application REF: Page 221 Skill 9-6 OBJ: 12 TOP: Elimination KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. What does the nurse recognize is important to consider when using the nursing process to plan hygiene care of the patient? a. Nurses orders b. Physicians orders c. Patients preferences d. Outcome goals ANS: C Individual patients will have individual desires and choices. PTS: 1 DIF: Cognitive Level: Application REF: Page 222 OBJ: 2 TOP: Hygiene KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 25. The nurse is providing personal hygiene for a Hindu patient from India. What intervention should the nurse implement? a. Not serve meat b. Shampoo the patients hair weekly c. Give a daily bath d. Cut nails monthly ANS: C A daily bath is part of the religious duty of Indian Hindus. PTS:1DIF:Cognitive Level: Application REF: Page 186, Cultural Considerations OBJ: 2 TOP: Hygiene KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. The nurse is assisting a patient to perform personal hygiene. What is the most important focus of the nurse when assisting this patient? a. Nursing care b. Independence

c. Repetition d. Performance ANS: B The nurse should encourage the patients independence as much as possible. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 185 OBJ: 2 TOP: Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. The nurse discovers a reddened area over a patients hip. What should be the nurses first intervention? a. Cover the area with an occlusive dressing b. Apply mild ointment with a cotton-tipped applicator c. Press the area gently to assess for blanching d. Rub gently to increase circulation ANS: C If the area is a stage I decubitus ulcer, the area will not blanch. PTS: 1 DIF: Cognitive Level: Application REF: Page 201 OBJ:5TOPressure ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28. The nurse is educating a patient regarding a tub bath. What is the maximum length of time the nurse should instruct the patient to remain in the water? a. 5 to 10 minutes b. 10 to 20 minutes c. 20 to 30 minutes d. 30 to 40 minutes ANS: B A patient should not stay in the water for more than 20 minutes. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 195 Skill 9-1 OBJ: 3 TOP: Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. Where should a nurse performing a backrub begin? a. Shoulder

b. Base of the neck c. Sacral area d. Lumbar area ANS: C The nurse should begin a massage in the sacral area. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 199 Skill 9-1 OBJ: 7 TOP: Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. The nurse is caring for a patient experiencing presbycusis. What intervention should the nursing personnel be instructed to implement? a. Speak quickly to the patient b. Speak in loud tones to the patient c. Speak slowly and clearly to the patient d. Tell the patient they must purchase a hearing aid ANS: C Age-related hearing loss, presbycusis, is a common finding in older adults. It is important to speak slowly and clearly to the patient with presbycusis. Not all patients with this type of hearing loss require a hearing aid. PTS: 1 DIF: Cognitive Level: Application REF: Page 214 OBJ: 6 TOP: Hearing loss KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 31.A physician orders a patient to be placed in the Trendelenburg position. How will the nurse position the bed? a. On the floor b. Parallel with the floor c. Tilted with the head of the bed down d. Tilted with the foot of the bed down ANS: C The entire bed is tilted downward with the head of the bed down when placing a patient in the Trendelenburg position. PTS: 1 DIF: Cognitive Level: Application REF: Page 189 Table 9-1 OBJ: 1 TOP: Positioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

32. The physician orders a patient to be placed in the reverse Trendelenburg

position. How should the nurse place the bed? a. On the floor b. Parallel with the floor c. Tilted with the head of the bed down d. Tilted with the foot of the bed down ANS: D The entire bed is tilted downward with the foot of the bed down when placing a patient in the reverse Trendelenburg position. PTS: 1 DIF: Cognitive Level: Application REF: Page 189 Table 9-1 OBJ: 1 TOP: Positioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. Which guideline should be followed when giving a backrub? a. Observing the skin for abnormalities b. Massaging for at least 10 minutes c. Following massage with a brisk alcohol rub d. Conversing with patient continually throughout the backrub e. Using alcohol-based lotion for disinfection ANS: A The backrub should last for about 3 to 5 minutes, giving the nurse an opportunity to observe for skin abnormalities. Conversation should be kept to a minimum to enhance relaxation. Alcohol either as a rub or used as disinfectant is drying to the skin. PTS: 1 DIF: Cognitive Level: Application REF: Page 199 Skill 9-1 OBJ: 7 TOP: Backrub KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 34. The nurse is preparing to make an occupied bed. What procedure will the nurse follow to correctly complete this task? (Select all that apply.) a. Remove spread and blanket separately b. Place soiled sheet at end of bed c. Place bath blanket over patient on top sheet d. Slide mattress to bottom of bed

e. Position patient to far side of bed ANS: A, C, E When making an occupied bed the nurse will remove the spread and blanket separately. The bath blanket is placed over the patient on the top sheet and the patient is positioned to the far side of the bed. Soiled linen is placed in the laundry bin, not at the end of the bed. The mattress is slid to the top of the bed. PTS: 1 DIF: Cognitive Level: Application REF: Pages 215-216 Skill 9-5 OBJ:11TOP:Making occupied bed KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment COMPLETION 35. The nurse avoids dragging the patient across the bed linen to decrease the potential risk of skin injury by . ANS: friction Dragging the patient across bed linen rather than lifting can cause skin damage from friction. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 201-202 OBJ: 5 | 9 TOP: Friction KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 36. Because of its effect on epithelization, the LPN/LVN should confirm the order to use or on a stage III pressure ulcer. ANS: peroxide, alcohol alcohol, peroxide Peroxide and alcohol have a negative effect on epithelization of a pressure ulcer. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 202 Box 9-5 OBJ:5TOPressure ulcers KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 37. To prevent skin breakdown in a wheelchair-bound patient, the nurse teaches the patient to shift the patients weight every minutes.

ANS: 15 fifteen People who are wheelchair-bound should shift their weight by pushing on the arms of their chair every 15 minutes to prevent skin breakdown. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 202 Box 9-5 OBJ:5TOP:Skin breakdown KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 38. As a safety precaution against breakage of dentures, the nurse should place in the emesis basin before cleaning the dentures. ANS: water Water in the basin will break the fall of the dentures if they are dropped. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 206 Skill 9-2 OBJ:6TOP:Oral hygiene KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment Chapter 10: Safety My Nursing Test Banks Chapter 10: Safety Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse manager is providing an in-service regarding a safe hospital environment. What will this education mainly focus on preventing? a. Falls b. Exposure to contaminants c. Injury d. Electrical hazard ANS: C A safe environment implies freedom from injury. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 228 OBJ: 6 TOP: Safety KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment

2. What is important for the nurse to determine in order to decrease the risk

for injury to a patient? a. If patient can read English b. If patient is left-handed c. If patient is able to eat unassisted d. If patient can dress independently ANS: B A left-handed patient will twist to accommodate, which places them at risk for injury. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 229-230 OBJ: 1 TOP: Safety KEY: Nursing Process Step: Assessment MSC:NCLEX: Safe, Effective Care Environment 3. What skills should health care workers frequently attend in-services about to ensure that staff has competent skills and risk for falls can be decreased? a. Bathing b. Feeding c. Transferring d. Ambulating ANS: C The majority of patient falls occur during transfer. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 229-230 OBJ: 3 TOP: Falls KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 4. What important safety precaution should the home health nurse teach parents in order to prevent burns to small children? a. Never leave them unattended b. Turn pot handles on stoves away from reach c. Turn hot water on first when filling the bathtub d. Keep side rails up on the crib ANS: B To protect infants and children from burns, turn the pot handles on stoves away from the childs reach. PTS: 1 DIF: Cognitive Level: Application REF: Page 230

OBJ: 2 TOP: Safety KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 5. What must the nurse do before applying a safety reminder device (SRD)? a. Get permission from the family b. Assess patients skin condition c. Get a physicians order d. Explain the SRD to the patient ANS: C Initially, an order is necessary that specifies the type of SRD and the duration of its application. PTS: 1 DIF: Cognitive Level: Application REF: Page 232, Box 10-4 OBJ:4TOP:Safety reminder devices (SRDs) KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 6. What should the nurse do when offering a cup of hot coffee to a frail, older adult patient? a. Give the patient a straw b. Dilute the coffee with cold water c. Fill the cup half full d. Offer a bib or an apron ANS: C Filling the cup half full promotes safety and does not change the flavor of the beverage, nor does it demean the patient as would making him or her wear a bib or apron. PTS: 1 DIF: Cognitive Level: Application REF: Page 230-231 OBJ: 2 TOP: Safety KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 7. What type of fire extinguisher should the nurse use when the oxygen concentrator machine malfunctions and causes an electrical fire? a. Type A b. Type B c. Type C d. Type D

ANS: C Electrical fires require type C fire extinguishers. PTS: 1 DIF: Cognitive Level: Application REF: Page 241 OBJ: 7 TOP: Fires KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 8.A disaster situation occurs and involves an explosion in a hospital laundry. What would this be classified as ? a. Active b. External c. Life-threatening d. Internal ANS: D Internal disaster often threatens the safety of patients and staff. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 244 OBJ: 9 TOP: Disaster KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 9. The emergency department nurse admits a victim of poisoning. Who should the nurse call to receive the best assistance for dealing with this victim? a. American Red Cross b. Fire department paramedics c. Poison control center d. Civil defense office ANS: C The nurse can access the local poison control center for assistance in caring for a victim of poisoning. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 244 OBJ: 8 TOP: Poisoning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10.A nurse instructs a nursing assistant about the proper use of a gait belt and is observing a return demonstration. What action by the nursing assistant should cause the nurse to intervene? a. Nursing assistant is walking on the patients strong side b. Nursing assistant is walking to the side of the patient

c. Nursing assistant is securing the gait belt securely around the patients d. Nursing assistant is grasping the handles of the gait belt while the pati ANS: A A gait belt should be securely applied around the patients waist. It has handles attached for the nurse to grasp while the patient ambulates. The nurse should walk on the patients weaker side so that assistance may be given if the patient starts to fall. PTS:1DIF:Cognitive Level: Application REF: Pages 230, 234-235 Skill 10-1 OBJ: 4 TOP: Gait belt KEY:Nursing Process Step: N/AMSC:NCLEX: N/A 11. What should a nurse do when encountering a mercury spill? a. Vacuum the spill b. Open interior doors c. Close all outside windows d. Open any outside windows ANS: D In the event of a mercury spill, interior doors should be closed and outside windows should be opened. The spill should not be vacuumed. PTS: 1 DIF: Cognitive Level: Application REF: Pages 238-239 Box 10-6 OBJ: 9 TOP: Mercury spill KEY: Nursing Process Step: N/A MSC:NCLEX: N/A MULTIPLE RESPONSE 12. When the nurse ambulates with a patient who has left-sided weakness, what actions should the nurse take? (Select all that apply.) a. Walk on the patients right side b. Keep the patient away from heavy furniture c. Hold the patients arm securely d. Keep the leg nearest the patient behind the patients knee e. Use a gait belt ANS: D, E Ambulating with a person who has an identified weakness requires that the nurse walk on the same side as the weakness, slightly behind the patient, with the nurses near leg behind the patients knee. The nurse should use a gait belt

and hold the patient at the waist and the gait belt. Furniture can be used as support. PTS: 1 DIF: Cognitive Level: Application REF: Page 230 OBJ: 3 TOP: Ambulating KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 13. The nurse assesses a patient in a Posey safety reminder device (SRD) for which problem(s) that may increase because of the use of SRDs? (Select all that apply.) a. Immobility b. Lethargy c. Risk for impaired circulation d. Risk for skin impairment e. Incontinence ANS: A, C, D, E The use of SRDs increases a patients immobility, risk for skin impairment, risk for impaired circulation, and incontinence. A SRD would not increase lethargy. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 231 OBJ:4TOProblems associated with SRDs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14.A long-term care facility is committing to a restraint-free environment. What will the health care workers implement to encourage this environment? (Select all that apply.) a. Frequent orientation to surroundings b. Explain all procedures and treatments c. Discourage visitors d. Maintain toileting routines e. Minimize exercise and ambulation ANS: A, B, D To encourage a restraint-free environment health care workers should provide frequent orientation to surroundings, thoroughly explain all procedures and treatments, and maintain toileting routines. Visitors should be

encouraged so they may sit with the residents, and frequent exercise and ambulation also should be encouraged. PTS: 1 DIF: Cognitive Level: Application REF: Page 232 Box 10-3 OBJ:5TOP:Restraint-free environment KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe: Effective Care Environment COMPLETION 15. is a violent or dangerous act used to intimidate or coerce a person or government to further a political or social agenda. ANS: Terrorism Terrorism is a violent or dangerous act used to intimidate or coerce a person or government to further a political or social agenda. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 245 OBJ: 9 TOP: Terrorism KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 16. When reinforcing the PASS acronym for fire extinguisher use, the nurse reminds the staff that the final S stands for . ANS: sweep The acronym stands for: P = pull pin, A = aim, S = squeeze, S = sweep. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 241, 243 Box 10-10 OBJ:7TOP:Fire extinguisher use KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 17. The nurse conducting a seminar on bioterrorism reviews several types of agents that may be used as weapons. An agent that does not seriously damage or kill the target population but only impairs it is classified as . ANS: incapacitating The agent that only impairs the target rather than killing or seriously damaging it is classified as an incapacitating agent. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 246-249

OBJ: 11 TOP: Bioterrorism KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse explains that the measurement of radiation exposure is in multiples of Gy. The number of Gy an individual may absorb before becoming ill with radiation syndrome is . ANS: 0.75 The amount of radiation absorbed is measured by the Gy. 1 Gy is equal to 100 rad. Absorption of 0.75 Gy will cause the individual to develop acute radiation syndrome. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 248 OBJ:11TOP:Radiation syndrome KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity Chapter 11: Vital Signs My Nursing Test Banks Chapter 11: Vital Signs Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What part of the body maintains a balance between heat production and heat loss, regulating body temperature? a. Thymus b. Thyroid c. Hypothalamus d. Adrenal glands ANS: C Body temperature is regulated by the hypothalamus. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 257 OBJ: 9 | 13 TOP: Vital signs KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 2. What type of body temperature remains relatively constant? a. Surface b. Rectal c. Oral

d. Core ANS: D The core body temperature remains relatively constant. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 257 OBJ: 2 TOP: Vital signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse uses cooling techniques to keep the body temperature below 105 F. What can result from an elevated temperature? a. Excessive thirst b. Excessive perspiration c. Damage to body cells d. Increased heart rate ANS: C If the temperature exceeds 105 F, normal body cells may be damaged. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 258 OBJ: 8 TOP: Vital signs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The emergency department nurse quickly assesses the temperature of an unconscious patient who has been outside all night in below-freezing temperatures. What temperature is the nurse aware of that can lead to death? a. 95.2 F b. 93.0 F c. 93.2 F d. 90.8 F ANS: C Death can occur if the temperature falls below 93.2 F. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 258 OBJ: 9 TOP: Vital signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. What is the term for a fever that rises and falls but does not return to normal until the patient is well? a. Constant b. Intermittent

c. Remittent d. Elevated ANS: C A remittent fever does not return to normal until the patient becomes well. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 258 OBJ:9TOP:Remittent fever KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. How should the nurse position the ear pinna when using the tympanic thermometer on a child? a. Upward and back b. Parallel c. Downward and back d. Upward and forward ANS: C Using the tympanic thermometer for a child, the nurse will tug the ear pinna down and back. PTS: 1 DIF: Cognitive Level: Application REF: Page 262, Skill 11-1 OBJ:3 | 9TOP:Tympanic thermometer for a child KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. How should the nurse position the earpieces on a stethoscope to ensure optimum reception? a. Backward b. Parallel to the ears c. Toward the face d. Downward ANS: C To ensure the best reception of sound, place earpieces pointing toward the face. PTS: 1 DIF: Cognitive Level: Application REF: Page 264 OBJ: 9 | 12 TOP: Vital signs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

8. What does the nurse use the diaphragm of the stethoscope to best assess?

a. Carotid sounds b. Lung sounds c. Vascular sounds d. Low-pitched sounds ANS: B Lung sounds are auscultated by using the diaphragm of the stethoscope. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 265 OBJ:6 | 9TOP:Stethoscope use KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. What is the pulsethe expansion and contraction of an artery produced by? a. Contraction of the right atrium b. Contraction of the right ventricle c. Contraction of the left atrium d. Contraction of the left ventricle ANS: D Expansion and contraction of an artery is caused by the ejection of blood from the left ventricle. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 265 OBJ: 4 TOP: Vital signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. When assessing vital signs on a 40-year-old male, the nurse identifies a pulse rate of 120. What is this pulse interpreted as by the nurse? a. Normal b. Bradycardic c. Arrhythmic d. Tachycardic ANS: D If the pulse is faster than 100 bpm on an adult patient, it is considered to be tachycardic. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 265 OBJ: 5 TOP: Tachycardia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity 11. The patients pulse is below 60. The nurse is aware that the patient is not receiving digoxin. What does the nurse suspect is causing the bradycardia? a. Low exercise tolerance b. Unrelieved severe pain c. Excessive bed rest d. A prone position ANS: B Bradycardia can result from unrelieved severe pain. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 265 OBJ: 5 TOP: Bradycardia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. What site should be selected if a peripheral pulse needs to be assessed quickly? a. Radial pulse b. Brachial pulse c. Carotid pulse d. Pedal pulse ANS: C The carotid site is the best for finding a pulse quickly. PTS: 1 DIF: Cognitive Level: Application REF: Page 266 OBJ: 5 TOP: Carotid KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. What is the term for the exchange of carbon dioxide and oxygen that takes place at the alveolar level? a. Tachypnea b. Internal respiration c. External respiration d. Bradypnea ANS: B Internal respiration is the exchange of gas at the alveolar level. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 269 OBJ:6TOP:Internal respiration

KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14.A patient is suspected of having a cardiac arrhythmia. The nurse is concerned with the findings of an apical rate of 88 and a radial rate of 80. What is the term for the difference between these two rates? a. Pulse pressure b. Unequal pulses c. Pulse deficit d. Tachycardia ANS: C The difference between radial and apical pulses is called a pulse deficit. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 268-269 Box 11-10 OBJ: 5 TOP: Pulse deficit KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. The nurse is alarmed when a patient with a severe head injury of the occipital lobe has a respiratory rate of 10 breaths per minute. Where might this finding indicate that there is an injury? a. Cerebellum b. Medulla oblongata c. Cortex d. Cerebrum ANS: B Rate of respiration is controlled by the medulla oblongata. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 270 OBJ:6TOP:Respiratory rate KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. The nurse assesses respirations of a patient demonstrating pursed-lip breathing, flared nostrils, and retractions. How will the nurse describe these respirations? a. Tachypnea b. Stertorous c. Dyspnea

d. Cheyne-Stokes ANS: C The patient who is using ancillary muscles to breathe is exhibiting dyspnea. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 271 OBJ: 6 TOP: Dyspnea KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17.A nurse assesses a neonates temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonates temperature is 96 F? a. Record the findings b. Notify the physician c. Check the axillary temperature d. Check the tympanic temperature ANS: A The neonates temperature normally ranges from 96 to 99.5 F (35.5 to 37.5 C). Temperature regulation is labile (unstable) during infancy because of immature physiological mechanisms. Axillary measurement is considered the least accurate method and is used less frequently since the advent of the tympanic membrane thermometer. Tympanic thermometer readings are suitable for patients of all ages, except infants. PTS: 1 DIF: Cognitive Level: Application REF: Page 258, Box 11-4 OBJ: 8 TOP: Vital signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18.A nurse assesses a neonates temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonates temperature is 99.5 F? a. Record the findings b. Notify the physician c. Check the axillary temperature d. Check the tympanic temperature ANS: A The neonates temperature normally ranges from 96 to 99.5 F (35.5 to 37.5 C). Temperature regulation is labile (unstable) during infancy because of

immature physiological mechanisms. Axillary measurement is considered the least accurate method and is used less frequently since the advent of the tympanic membrane thermometer. Tympanic thermometer readings are suitable for patients of all ages, except infants. PTS: 1 DIF: Cognitive Level: Application REF: Page 258, Box 11-4 OBJ: 8 TOP: Vital signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19.A nurse assesses a patients dorsalis pedis pulse. The pulse is difficult to feel and not palpable when only slight pressure is applied. How should the nurse document this finding? a. Weak pulse b. Normal pulse c. Thready pulse d. Bounding pulse ANS: C A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied. A bounding pulse feels full and springlike even under moderate pressure. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 266, Table 11-3 OBJ: 4 | 15 TOP: Pulses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20.A nurse assesses a patients dorsalis pedis pulse. The pulse is not palpable when light pressure is applied. How should the nurse document this finding? a. Weak pulse b. Normal pulse c. Thready pulse d. Bounding pulse ANS: A A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt

but not palpable when moderate pressure is applied. A bounding pulse feels full and springlike even under moderate pressure. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 266, Table 11-3 OBJ: 4 | 15 TOP: Pulses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21.A nurse assesses a patients dorsalis pedis pulse. The pulse is easily felt but not palpable when moderate pressure is applied. How should the nurse document this finding? a. Weak pulse b. Normal pulse c. Thready pulse d. Bounding pulse ANS: B A normal pulse is easily felt but not palpable when moderate pressure is applied. A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A bounding pulse feels full and springlike even under moderate pressure. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 266, Table 11-3 OBJ: 4 | 15 TOP: Pulses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22.A nurse assesses a patients dorsalis pedis pulse. The pulse feels full and springlike even under moderate pressure. How should the nurse document this finding? a. Weak pulse b. Normal pulse c. Thready pulse d. Bounding pulse ANS: D A bounding pulse feels full and springlike even under moderate pressure. A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not

palpable when moderate pressure is applied. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 266, Table 11-3 OBJ: 4 | 15 TOP: Pulses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 23. When instructing a primary caregiver about keeping a daily log of blood pressure readings, what instructions should the nurse include? (Select all that apply.) a. Take the reading at different times during the day. b. Apply the cuff approximately 2 inches above the antecubital fossa. c. If unable to get a reading the first time, immediately reinflate the cuf d. Assess pulse with the bell of the stethoscope. e. Apply the cuff snugly. ANS: B, E Readings for a blood pressure log should be taken at the same time every day on the same arm. The cuff should be applied 2 inches above the antecubital fossa and snugly secured. The pulse should be assessed with the diaphragm of the stethoscope. If unable to get a reading the first time, the cuff should be deflated completely and reinflated after several minutes. PTS: 1 DIF: Cognitive Level: Application REF: Pages 276-278, Skill 11-5 OBJ:7TOP:Blood pressure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24. When assessing factors that may influence the patients pulse rate, what should the nurse take into consideration? (Select all that apply.) a. Age b. Sex c. Emotion d. Temperature e. Religion ANS: A, B, C, D All the options listed can affect the pulse rate except religion. PTS: 1 DIF: Cognitive Level: Application REF: Page 265

OBJ:5TOP:Influences on pulse rate KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25.A patient is admitted to a medical surgical unit. What factors will determine how frequently vital signs will be assessed? (Select all that apply.) a. Desire of the patient b. Judgment of need by the nurse c. Discretion of the family d. Orders of the health care provider e. Patients condition ANS: B, D, E Whether and how frequently vital signs are measured depends on the nurses judgment of need, orders of the health care provider, and patients condition. Desire of the patient and family members cannot override these factors, but can be taken into consideration within reason of these factors. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 254-255, Box 112 OBJ:11TOP:Frequency of vital signs measurement KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. The home health nurse is preparing to educate a patient regarding electronic self-blood pressure measurement. What information should the nurse provide regarding this procedure? (Select all that apply.) a. Expect precise values b. Proper measurement techniques are necessary c. Cuff fits over clothing d. Stethoscope is not required e. Recalibration is not necessary ANS: B, C, D Self-blood pressure monitoring requires proper measurement techniques, cuff is made to fit over clothing, and stethoscopes are not required. Values may be inaccurate and recalibration is necessary at least once a year. PTS: 1 DIF: Cognitive Level: Application REF: Pages 278-279

OBJ:14TOP:Self-Blood Pressure Measurement KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. The physician orders daily weights on a patient residing in a long-term care setting. What actions should the nurse implement to assess weight accurately? (Select all that apply.) a. Weigh patient at the same time each day b. Schedule weighing immediately after breakfast c. Encourage patient to void before being weighed d. Ensure same amount of clothing is worn by patient e. Calibrate by setting scale at zero after each weight ANS: A, C, D Accurate assessment of weight should occur at the same time each day, preferably at 6 AM before breakfast. The patient should be encouraged to void before being weighed and the same amount of clothing should be worn each day. The scale should be calibrated to zero before (not after) each weight is taken. PTS: 1 DIF: Cognitive Level: Application REF: Page 281-282, Skill 11-6 OBJ:10TOP:Weight measurement KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 28. The nurse assesses for the fifth vital sign, which is . ANS: pain Pain is considered the fifth vital sign. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 253 OBJ:1TOPain as a vital sign KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. If a patient has an axillary temperature of 96.2 F, the nurse understands that the true temperature is . ANS: 97.2 F

Axillary temperatures are considered to be 1 F below core temperature. PTS:1DIF:Cognitive Level: Comprehension REF: Page 257-259, 261 Skill 11-1 OBJ: 3 TOP: Axillary temperature KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. The nurse assesses the blood pressure as 192/86, noting that the patient has a pulse pressure of . ANS: 106 one hundred six The pulse pressure is the difference between the diastolic and systolic readings. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 273 OBJ:7TOPulse pressure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity Chapter 12: Physical Assessment My Nursing Test Banks Chapter 12: Physical Assessment Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is collecting data during an initial assessment. What can be seen, heard, measured, or felt and is objective? a. Symptom b. Observation c. Sign d. Assessment ANS: C A sign can be seen, heard, measured, or felt. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 286 OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 2. As part of an assessment, the nurse asks the patient for subjective information related to the present illness. What are the subjective findings

perceived by the patient? a. Assessments b. Symptoms c. Signs d. Observations ANS: B Symptoms are subjective indications of illness that are perceived by the patient. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 287 OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 3. Any disturbance of a structure or function of the body is a pathologic condition. What is the term for this condition? a. Injury b. Condition c. Disease d. Pathology ANS: C A disease is any disturbance of a structure or function of the body. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 287 OBJ: 2 TOP: Disease KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 4. The nurse is assessing a patient for collection of subjective and objective data. What will this data provide the basis for making? a. Care plan b. Medical diagnosis c. Nursing assessment d. Nursing diagnosis ANS: D Nurses rely on assessment of signs and symptoms to formulate a nursing diagnosis. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 287 OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC:NCLEX: N/A 5. The nurse is discussing the origin of diabetes with a diabetic patient. What will the nurse discuss as the most appropriate explanation for the cause of this disease? a. Pituitary b. Adrenals c. Pancreas d. Thyroid ANS: C Diabetes mellitus results from dysfunction of the pancreas. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 287 OBJ: 2 TOP: Disease KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 6. There are four categories of factors that increase an individuals vulnerability to develop a disease: genetic, physiological, age, and lifestyle. What is the term for these factors? a. Risk factors b. Causative factors c. Etiologic factors d. Hazardous factors ANS: A Risk factors are placed into four categories. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 288 OBJ: 3 TOP: Disease KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 7. When discussing diabetes with a patient, the nurse describes this disease as falling into which group in terms of duration? a. Acute b. Organic c. Chronic d. Functional ANS: C Diabetes mellitus is an example of a chronic disease.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 288 OBJ: 4 TOP: Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. What is the term used to describe a disease where there has been a partial or complete disappearance of clinical and subjective characteristics of the disease? a. Acute b. Functional c. Chronic d. Remission ANS: D Remission means there has been partial or complete disappearance of the clinical and subjective characteristics. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 288 OBJ: 4 TOP: Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. What type of disease results in a structural change in an organ that interferes with its functioning? a. Functional disease b. Organic disease c. Acute disease d. Chronic disease ANS: B An organic disease results in a structural change in an organ. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 288 OBJ: 2 TOP: Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. The signs and symptoms of both infection and inflammation include erythema, edema, and pain. What is considered the major difference between infection and inflammation? a. Inflammation is a result of bacteria. b. Inflammation is a protective response. c. Inflammation is a disease process.