TEST BANK for Timby's Fundamental Nursing Skills and Concepts 12th Edition

Chapter 1 1. A client reports to the emergency department with ankle pain due to a minor road accident. By asking the client to describe the accident, which type of nursing skill is the nurse using? A. assessment skills B. comforting skills C. counseling skills D. caring skills Answer: A Rationale: By asking the client to describe the accident, the nurse is using assessment skills to collect more information about the client's condition. The nurse is interviewing the client to collect related data. The nurse is not using comforting skills, as the nurse is not providing any emotional support. The counseling skills of the nurse are also not used, as no health education is provided. Caring skills include assistance provided with the activities of daily living, which is not applicable in this scenario. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 15 2. One of the nursing achievements in the Crimean War was that the death rate of soldiers dropped from 60% to 1%. What is the most appropriate reason for the fall in the death rate? A. increased motivation among the soldiers B. decreased rate of infection and gangrene C. increased funds courtesy of donations from families D. college-based education and training of nurses Answer: B Rationale: During the Crimean War, the death rate of British soldiers was 60%, which dropped to 1% due to the nursing care provided. The nurses improved the ventilation, nutritional, and sanitary conditions of the soldiers, leading to decreased rates of infection and gangrene. As a result, the death rate dropped. The families and the soldiers donated funds after the war, not during the war, through which an organized education and training facility for nurses was started. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 3

3. A nurse at a health care facility provides information, assistance, and encouragement to clients during the various phases of nursing care. In which activity does the nurse use counseling skills? A. educating a group of young girls about AIDS B. telling a client to localize the pain in his abdomen C. encouraging a client to walk without support D. assisting a lactating mother in feeding her child Answer: A Rationale: The activity of educating a group of young girls about AIDS is based on the nurse using counseling skills. Telling a client to localize his pain is an assessment skill. Encouraging a client to walk without support can be both a comforting skill and a caring skill. Assisting a lactating mother in feeding her baby is an example of a caring skill. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Understand Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 15 4. A nurse is conducting an interview of a 40-year-old client who is admitted with chest pain. Which action by the nurse indicates active listening? A. listening to the client silently B. interrupting after each sentence C. asking for clarifications and repetitions D. talking about the nurse's own experience Answer: C Rationale: Active listening is an important component of counseling skills. It encourages the client to open up and express their concerns. The nurse may ask the client to repeat and clarify statements. Interrupting after every sentence may annoy the client. When the nurse listens to the client silently, the client may feel that the nurse is not interested. On the other hand, if the nurse talks about the nurse's own experience, the focus of the session shifts to the nurse rather than to the client. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 15 5. A student wants to attend a nursing program that prepares its graduates for both staff and managerial positions. Which type of nursing program should the nurse suggest for this student? A. hospital-based diploma

B. baccalaureate nursing program C. associate degree program D. continuing nursing program Answer: B Rationale: Baccalaureate-prepared nurses have the greatest potential for qualifying for nursing positions at both staff and managerial levels. Hospital-based diploma programs are 3year courses and provide maximum exposure to clinical nursing. Students becoming nurses through the associate degree program would not be expected to work in a management position. Continuing nursing programs are on-the-job educational programs. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Remember Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 11 6. A client is brought to the emergency department with a head injury following an all-terrain vehicle (ATV) accident. The nurse asks the family members to describe how the accident occurred. The nurse is implementing which type of skill? A. assessment skills B. caring skills C. counseling skills D. comforting skills Answer: A Rationale: The immediate requirement when a client is brought to the emergency department with a head injury is to assess the injury and the system affected, as well as a description of how the accident occurred. This requires implementation of assessment skills. Subsequently, the nurse can implement caring skills, counseling skills, and comforting skills; however, assessment should be the priority. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 15 7. Training schools for nurses were established in the United States after the Civil War. The standards of U.S. schools deviated from those of the Nightingale paradigm. Which statement is true about U.S. training schools? A. Training schools were affiliated with a few select hospitals. B. Training of nurses provided no financial advantages to the hospital. C. Training was formal, based on nursing care. D. Training schools eliminated the need to pay employees. Answer: D

Rationale: Training schools in the United States profited by eliminating the need to pay employees because students worked without pay in return for training, which usually consisted of chores. U.S. training schools were established by any hospital; there was no formal training. Training was an outcome of work, which eliminated the need to pay employees. Nightingale training schools were affiliated with a few select hospitals, training of nurses provided no financial advantages to the hospital, and the training was formal, based on nursing care. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Remember Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 5 8. In a nursing unit, the RN delegates nursing tasks to the LPN. Keeping in mind the delegation guidelines, which statement denotes the right task for the LPN? A. Make beds with the help of unlicensed assistive personnel. B. Assist clients with nasogastric tube feeds. C. Take orders from an in-house physician. D. Assess the client's needs and start an intravenous line. Answer: B Rationale: Assisting clients with nasogastric tube feeding is an appropriate task for an LPN, as it does not require independent decisions and sophisticated techniques. According to the delegation guidelines, "right task" means that the task should be assigned according to the competency of the caregiver. LPNs may not be authorized to make independent decisions, like starting an IV line, for the client. Bed making is a very basic task and may not be appropriate for an LPN if the UAP is already present. When the RN and LPN are present, the RN takes the physician's orders. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 8 9. A 50-year-old client reports to a primary care unit with an open wound due to a fall in the bathroom. Which nursing actions represent caring skills? A. The nurse cleans the wound and applies a dressing to it. B. The nurse inspects and examines the wound for swelling. C. The nurse tells the client to take care while on slippery surfaces. D. The nurse informs the client that the wound is small and will heal easily. Answer: A Rationale: The nursing action of cleaning the wound and applying a dressing indicates caring skills. Caring skills involve nursing interventions that restore or maintain a person's health.

The nurse implements assessment skills while inspecting and examining the wound. The nurse counsels the client to take care when walking on slippery surfaces. By informing the client about the wound's condition, the nurse uses comforting skills. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Caring Reference: p. 15 10. The scope and character of nursing practice underwent significant changes in the years following the Civil War. Which activity exemplifies nursing practice in the early years of the 20th century? A. providing basic health care to recent immigrants to the United States B. contributing to the scientific knowledge base of nursing by conducting research C. participating in collaborative practice with physicians D. establishing school nursing as a recognized specialty in urban settings Answer: A Rationale: In the early 20th century, some nurses moved into communities and established "settlement houses" where they lived and worked among poor immigrants. This period of history was not characterized by collaboration between physicians and nurses due to the subservient view of nursing that prevailed. Research and school nursing were not major focuses at this time. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 4 11. A nursing student has begun a clinical placement at a large hospital that serves a diverse population. The student has consequently acquired a new appreciation for the fact that nursing combines art with science. What is the clearest manifestation of the scientific basis for nursing? A. mentoring students and junior nurses B. providing evidence-based nursing care C. maintaining an attitude of curiosity D. participating in continuing educational activities Answer: B Rationale: By developing an accumulating body of unique scientific knowledge, it is now possible to predict which nursing interventions are most likely to produce desired outcomes, a process referred to as evidence-based practice (EBP). EBP is possible because of the scientific basis that underlies nursing. Mentoring, maintaining curiosity, and participating in continuing education are beneficial, but these are not direct manifestations of the scientific basis for nursing. Question format: Multiple Choice

Chapter 1: Nursing Foundations Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 6 12. Beginning with Florence Nightingale, many definitions of nursing have been put forth by individual nurses and by nursing organizations. Which statement best describes an aspect of the changes in these definitions over time? A. drawing a clear distinction between the art of nursing and science of nursing B. definitions of nursing that have become narrower in scope over time C. characterization of nursing as a discipline that is a distinct alternative to medical treatment D. definition of an independent health care practice that is not solely dependent on physicians Answer: D Rationale: The most recent definitions of nursing specify that nursing has an independent area of practice in addition to traditional dependent and interdependent functions involving physicians. This does not mean, however, that nursing is an alternative to medical treatment. Definitions have become broader over time and address the fact that nursing combines art with science. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 6 13. A team of nurses who provide care in a community hospital have been encouraged to participate in continuing educational activities. Why is continuing education needed in nursing? A. Continuing education helps to delineate the distinctions between nurses and physicians. B. Continuing education increases the public visibility of individual nurses and the nursing profession. C. Continuing education has the potential to partially alleviate the nursing shortage. D. Continuing education allows for safer division of labor on hospital units and more effective delegation of tasks. Answer: C Rationale: Health care officials hope that enrollment in all nursing programs and continuing education will reduce the current and projected critical shortage of nurses. Continuing education is not driven by a desire to increase the visibility of nursing, to draw distinctions between nursing and medicine, or to facilitate the division of labor. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 11

14. A nurse has completed a hospital-based educational program that has allowed the nurse to become cross-trained. A nurse who is cross-trained is able to: A. perform certain nonnursing duties in addition to traditional nursing duties. B. adopt a work schedule that deviates from the normal shift rotation at the hospital. C. orientate new graduates and nursing students to the hospital. D. retire with full benefits at an earlier date than a nurse who is not cross-trained. Answer: A Rationale: A nurse who is cross-trained is able to assume nonnursing jobs, depending on the census or levels of client acuity on any given day. This does not necessarily guarantee changes to work scheduling or earlier retirement. Cross-training does not address the orientation of new employees or students. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 12 15. A medical-surgical unit manager intends to have licensed practical nurses (LPNs) in the unit administer intravenous push (IVP) medications. What source would the manager contact to include this procedure in the LPNs' practice? A. American Nurses Association (ANA) B. state nurse practice act (NPA) C. facility policies and procedures committee D. National League of Nursing (NLN) Answer: B Rationale: Each state has its own NPA, which determines what the nurse is allowed to do in each particular state, providing constraints within which nurses practice. The NPA delineates scope of practice. Therefore, the manager would contact the NPA in this scenario. The other sources are not appropriate given the context of the scenario. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Reference: p. 8 16. The nurse is caring for a client who cannot meet health needs independently. Which action made by the nurse depicts concern and attachment? A. telling the client, "I will be back in 15 minutes to change your dressing." B. asking the client, "How are you today? I am really worried about you." C. talking about diabetes and teaching the client how to do foot care D. organizing the work for the day and evaluating how the day went Answer: B

Rationale: Concern and attachment are the result of a close relationship of one human being with another. Thus, asking the client how the client is feeling and expressing concern exemplifies caring. Stability and security, communication and teaching, and organization and evaluation are physical care themes that are part of nursing care. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 15 17. A registered nurse (RN) is caring for four clients on a medical-surgical unit. Which task is most appropriate for the nurse to delegate to the licensed practical nurse (LPN)? A. administering bedside blood glucose testing B. administering blood products C. administering intravenous push medication D. administering chemotherapy Answer: A Rationale: The LPN, under the nurse practice act (NPA), is permitted to administer testing for bedside blood glucose. The nurse must recognize the scope of practice of the delegate, and remember that client needs and activities delegated must be matched to skill level. The RN would not delegate administration of blood products, intravenous push medication, or chemotherapy to the LPN, as these tasks are not covered under the LPN's NPA. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 8 18. A middle-aged nurse is concerned about a potential shortage of nurses when the baby boomer generation retires. What proactive intervention can the nurse take to address this anticipated deficit of nurses? A. develop a community program related to healthy nutrition and exercise B. recruit more nurses to the acute care facility C. encourage parents to immunize their children D. lobby to increase the retirement age Answer: A Rationale: The promotion of wellness is important not only in community, but also in nationwide health. Promotion of healthy habits and nutrition/exercise will be able to decrease some of the risk factors leading to acute and chronic illnesses and will lead to a decrease in hospital admissions. If effective, it would contribute to the management of issues that require an increase in the number of nurses required. Nurses fill roles other than in acute care facilities and the recruitment of more nurses to those facilities does not address the issue of the shortage in other areas of nursing. Immunization of children does not affect the nursing shortage directly because there is not a relationship between the lack of immunization

increasing the risk of illness to the present nurses employed in the field . Increasing the retirement age can have a detrimental affect on those nurses being required to work with agerelated changes affecting health. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 8 19. The nurse is caring for a client at the end stage of life. The client is crying and states to the nurse, "I just cannot believe I am going to be leaving my children without a parent. I am not ready to go." What response by the nurse demonstrates the expression of empathy to the client? A. "This is so sad and I feel so bad that you are in this situation." B. "It sounds as though you are most concerned about how your children will feel." C. "I am so sorry that I am crying with you when you need my support the most." D. "This just is not fair at all and I do not understand why this is happening to you." Answer: B Rationale: The nurse is demonstrating empathy when reiterating what the client is saying. This helps the nurse become effective at providing for the client's emotional needs while maintaining detachment. The other responses indicate that the nurse is feeling sympathy for the client, which includes feeling as emotionally distraught as the client. While this may be an unavoidable response, it may not help the client move through the grieving process as effectively. Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 15 20. The nurse is delegating tasks to the unlicensed assistive personnel (UAP) prior to beginning the shift on the acute care unit. Which task would be appropriate to delegate to the UAP? A. starting an IV for a client with dehydration B. inserting a nasogastric tube for a client with a small bowel obstruction C. assisting an older adult client with using the bedside commode D. performing an assessment on a newly-admitted client Answer: C Rationale: When delegating tasks to UAPs, the nurse should perform the rights of delegation prior to delegating. Assisting the client with activities of daily living such as transfers, assisting with toileting, and feeding are some of the tasks that are able to be performed by the UAP. Inserting a nasogastric tube, starting an IV, and performing an assessment for a newlyadmitted client are tasks that the nurse must perform and are outside of the scope of practice for the UAP.

Question format: Multiple Choice Chapter 1: Nursing Foundations Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 15

Chapter 2 1. A client with HIV has been admitted to a health care facility. Which nursing diagnosis should be the priority, keeping in mind the client's condition? A. Risk for Activity Intolerance B. Risk for Ineffective Coping C. Risk for Infection D. Risk for Imbalanced Nutrition Answer: C Rationale: Clients with HIV have decreased immunity and are prone to infections. Infection in a client with HIV is life-threatening, because it makes the client vulnerable to other infections, and also impairs their already weakened immune functions. Clients with HIV may not have problems with other activities and food. They may often feel depressed, but this is not the highest priority. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 25 2. A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which data collected can be classified as subjective data? A. Blood pressure B. Nausea C. Heart rate D. Respiratory rate Answer: B Rationale: Subjective data are those that only the client can experience and describe. Nausea is subjective data, as it can only be described and not measured. Blood pressure, heart rate, and respiratory rate are measurable factors and are therefore objective data. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 20 3. A client who has to undergo a parathyroidectomy is worried about possibly having to wear a scarf around the neck after surgery. What nursing diagnosis should the nurse document in the care plan? A. Risk for Impaired Physical Mobility due to surgery

B. Ineffective Denial related to poor coping mechanisms C. Disturbed Body Image related to the incision scar D. Risk of Injury related to surgical outcomes Answer: C Rationale: The client is concerned about the surgery scar on the neck, which would disturb the client's body image; therefore, the appropriate diagnosis should be Disturbed Body Image related to the incision scar. Risk for Impaired Physical Mobility may be present after surgery, but is not related to the concerns expressed by the client. Likewise, Ineffective Denial related to poor coping mechanisms and Injury related to surgical outcomes are also not related to the client's concern. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 25 4. A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client? A. The client will ambulate with assistance by the nurse to a bedside chair. B. The client will return to performing activities of daily living. C. The client will walk 1 mile briskly five times per week. D. The client will not undergo repeat surgery. Answer: A Rationale: The short-term goal in this case is to help the client ambulate to the bedside chair. The other goals, like helping the client return to activities of daily living, to maintain a healthy and active lifestyle, and to prevent repeat surgery are long-term goals and may take weeks or months to achieve. On the other hand, short-term goals can be achieved in a day or a week. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 25 5. A nurse, who is caring for a client admitted to the patient care unit with acute abdominal pain, formulates the care plan for the client. Which nursing diagnosis is the priority for this client? A. Impaired Comfort B. Disturbed Body Image C. Disturbed Sleep Pattern D. Activity Intolerance Answer: A

Rationale: Acute pain in the abdomen disturbs all the systems of the body. Relieving the pain should be the nurse's first priority. According to Maslow, physiologic needs are the highest priority. The client may have Disturbed Body Image, Disturbed Sleep Pattern, or Activity Intolerance, but all these are secondary to pain. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 25 6. A nurse is interviewing an asthmatic client who has a high respiratory rate and is having difficulty breathing. The client is consequently restless and can only speak a few words before pausing to catch a breath. What appropriate nursing diagnosis should the nurse document? A. Impaired Gas Exchange related to the disease condition B. Impaired Verbal Communication related to the breathing problem C. Inability to Speak due to ineffective airway clearance D. Impaired Physical Mobility related to tachypnea Answer: B Rationale: The client has a high respiratory rate and difficulty breathing; the client therefore has trouble communicating. Impaired Verbal Communication related to the breathing problem is the appropriate diagnosis. Although Impaired Gas Exchange may occur in an asthma attack, it does not relate to the concern regarding the client's ability to communicate nor would it be of primary concern in this case. There is no evidence that the client is experiencing Impaired Physical Mobility due to the condition. Inability to Speak due to ineffective airway clearance is not a properly structured nursing diagnosis (it should include "related to" rather than "due to") and is not accurate, in that the client is able to speak, although the speech is impaired. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 25 7. A client is brought to the emergency department in an unconscious condition. The client's spouse hands over the previous medical files and points out that the client suddenly fell unconscious after trying to get out of bed. Which is a primary source of information in this case? A. The client's spouse B. The client's medical documents C. The client's test results D. The client's assessment data Answer: A

Rationale: In this case, the primary source of information is the client's spouse, as the client, who is normally the primary source of information, is unconscious. The spouse can provide a detailed description of the incident as well as provide the medical history of the client. The client's medical files, test results, and assessment data are secondary sources of information. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 20 8. A nurse is caring for a client with Parkinson's disease. Which nursing diagnosis identified by the nurse should be the priority? A. Impaired Physical Mobility B. Risk for Memory Loss C. Ineffective Role Performance D. Potential for Injury Answer: D Rationale: Clients with Parkinson's disease are at higher risk of injury due to their physical limitations and cognitive deficiencies. Therefore, it becomes important for the nurse to ensure that the environment is safe. The client may also have Impaired Physical Mobility, Risk for Memory Loss, and Ineffective Role Performance, but the highest priority is to prevent injury, as it may lead to other grave conditions. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 25 9. Which action is a priority role of the nurse when caring for a client with collaborative problems? A. Assessing the client's understanding of risk factors B. Resolving health issues through independent nursing measures C. Reporting trends that suggest the development of complications D. Managing an emerging problem with the help of another registered nurse Answer: C Rationale: For a client with collaborative problems, the nurse should report trends that suggest the development of complications to bring to notice the need for collaborative intervention for the client. Collaborative problems are physiologic complications that require both nurse- and physician-prescribed interventions. Actions that exclude members of other disciplines are not characteristic of collaborative problem management. The development of complications is a priority over assessment of the client's knowledge of risk factors, even though the nurse must assess these. Question format: Multiple Choice

Chapter 2: Nursing Process Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 24 10. A nurse is evaluating and revising a plan of care for a client with cardiac catheterization. Which action should the nurse perform before revising a plan of care? A. Discuss any lack of progress with the client. B. Collect information on abnormal functions. C. Identify the client's health-related problems. D. Select appropriate nursing interventions. Answer: A Rationale: The nurse should discuss any lack of progress with the client so that both the client and the nurse can speculate on what activities need to be discontinued, added, or changed. Collecting information on abnormal functions and risk factors is done during the assessment. Identification of the client's health-related problems is done during diagnosis. Nurses select appropriate nursing interventions and document the plan of care in the planning stage of the nursing process, not during evaluation. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 28 11. Which action would the nurse perform in the assessment phase of the nursing process? A. Developing a plan to manage the client's health problems B. Coming up with a nursing diagnosis based on a potential health risk C. Asking the client whether the client has cultural preferences D. Determining whether the client's goals for wellness have been met Answer: C Rationale: Assessing the client involves gathering information about the client's physical and emotional health; cognition; spiritual, cultural, or religious preferences; and sociodemographics. Developing a plan to manage the client's health problems falls within the planning phase of the nursing process. Coming up with the nursing diagnosis falls within the diagnosing phase of the nursing process. Determining whether the client's goals for wellness have been met occurs in the evaluation phase of the nursing process. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 20

12. The novice nurse demonstrates proper understanding of collaborative problems by making which statement? A. "A medical diagnosis of heart failure with the possible consequence of fluid in the lungs could lead to the collaborative problem of pulmonary edema." B. "The collaborative problem is the combination of the nursing diagnosis and the medical diagnosis, once it is approved by the physician." C. "A physiologic human need could possibly result in a collaborative nursing diagnosis of Impaired Swallowing." D. "The client has reached the goals, because treatment was implemented consistently, so nursing orders can be discontinued on the basis of collaborative problems." Answer: A Rationale: Physicians and nurses work together on collaborative problems. Understanding collaborative problems involves piecing together the medical diagnosis or medical treatment with the possible consequence. The combination of the nursing diagnosis and medical diagnosis does not equate to a collaborative problem. When discussing physiologic needs, this relates to the nursing diagnosis process. Describing client goals pertains to outcomes from evaluation. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 24 13. A client is administered an anxiolytic. Which nursing action demonstrates the nurse evaluating the client? A. Asking whether the client feels less anxious 30 minutes after administering the medicine B. Assigning the client a new nursing diagnosis based on the client's controlled anxiety C. Devising a plan for the client to practice anti-anxiety exercises at home D. Collecting data about the client's history with anxiety Answer: A Rationale: Evaluation allows the nurse to determine whether the client has met the goal. By analyzing the client's response to the anxiolytic, the nurse determines the effectiveness of the nursing care. The other actions demonstrate other parts of the nursing process: assessment (collecting data about the client's history with anxiety), diagnosis (assigning the client a new nursing diagnosis based on the client's controlled anxiety), and planning (devising a plan for the client to practice anti-anxiety exercises at home). Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 28 14. Which is an example of a subjective finding that the nurse would likely obtain when performing a review of systems (ROS)?

A. A blood glucose level of 108 mg/dL B. A client report of shooting pain up the left leg C. Grip weakness in the right hand D. Crackles in bilateral lung bases Answer: B Rationale: Subjective data consists of information that the client can describe, also known as symptoms. Therefore, a client report of pain in the leg is an example of a subjective finding that the nurse would likely obtain when performing an ROS. A blood glucose level of 108 mg/dL, an observation of weakness in the right hand, and auscultation of crackles in bilateral lung bases are examples of objective data that the nurse or health care provider can observe and measure. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 20 15. The nurse is caring for a client who is suspected of having a kidney infection. Which scenario involves the use of subjective data from the primary source? A. The nurse tells the client to attempt to void. B. The client tells the nurse that there is a burning sensation when voiding. C. The physician prescribes medication to help the client void. D. The client's spouse reports the client experienced incontinence a few days ago. Answer: B Rationale: Subjective data consist of information that only the client can describe, such as feelings, sensations, or experiences. An example of subjective data is a client's report of pain or fatigue. Objective data are those that can be measured and observed by others, a fever or a broken bone. The primary source is the client. Secondary sources include family members, reports, test results, and other health care providers. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 20 16. Which scenario represents a nurse demonstrating the critical thinking process? A. assessing whether physician help is needed B. assessing why a physician encounter form is missing from the record C. collaborating with the respiratory therapist and physical therapist to address a complication D. using power for more control and freedom over the daily tasks Answer: A

Rationale: Critical thinking involves consistency, relevancy, and logical thinking. It enables the nurse to make decisions. Therefore, assessing whether physician help is needed is an example of the critical thinking process. The other actions support other nursing soft skills. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 19 17. Which statement made by the nurse indicates data that would be documented as part of an objective assessment? A. "The client's sister reports that the client has unrelieved pain." B. "The client's right leg is cold to the touch, from the knee to the foot." C. "The client reports nausea following eating." D. "The client reports having heartburn after breakfast." Answer: B Rationale: Objective data are information that is observable and measurable, such as observing that the client's right leg is cold to the touch. Subjective data relate to phenomena that only the client can experience, such as unrelieved pain, nausea, or heartburn. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 20 18. The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment in this case? A. Obtaining data regarding the amount and frequency of drinking B. Interviewing friends to ascertain the client's exercise habits C. Asking the client to discuss social functioning D. Performing an abdominal assessment Answer: A Rationale: A focused assessment is information that provides more details about specific problems and expands the original database. Obtaining data regarding the amount and frequency of drinking qualifies as a focused assessment. The other actions do not relate to the client's drinking habits or potential for alcohol overuse and thus would not be included in a focussed assessment of these issues. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 20

19. A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage? A. Risk of self-harm B. Lack of support C. Low self-esteem D. Feelings of not belonging Answer: A Rationale: Safety and security are the priority for the client, so the risk of self-harm is what the nurse must address first. Lack of support, low self-esteem, and feelings of not belonging, although still important to address, are not as critical as safety and security. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 25 20. A client is admitted to a psychiatric treatment unit with psychosis. What is the priority diagnosis for this client? A. Self-Care Deficit B. Disturbed Thought Processes C. Risk for Self-Harm D. Risk for Imbalanced Nutrition: Less Than Body Requirements Answer: B Rationale: A client with psychosis is unable to recognize reality, their communication is impaired, and they cannot identify people. The client may also experience hallucinations and delusions. Therefore, Disturbed Thought Process is the most appropriate nursing diagnosis for such a client. The client may be at risk for suicidal thoughts, have difficulty in dressing and grooming, and may not eat properly; however, the priority is the thought process because it is the main reason for all other symptoms. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 25 21. The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse? A. involving the client with all the steps of the process in care development B. ensuring the client is informed after decisions are made with care delivery C. requiring the client to evaluate the plan of care after implementation D. implementing the standard plan of care for all clients with diabetes mellitus Answer: A

Rationale: Because the plan of care should be client-centered, the client should be directly involved with all phases of the creation of the care plan. This will involve assessing the learning needs of the client as well as goal setting, implementation, and evaluation. The client should be involved and not just informed of decisions regarding care during the evaluation phase. The client may be involved with the evaluation but the nurse will assess to determine if the plan of care is effective and if the client's goals are being met. Standard plans of care do not address the needs of the individual and should be tailored to the individual client. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 19 22. The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing? A. comprehensive assessment B. database assessment C. focused assessment D. functional assessment Answer: D Rationale: The nurse is performing a functional assessment that focuses on areas that relate to the physical performance of activities, such as how the client is able to meet activities of daily living, demonstration of cognitive abilities, and social functioning. A comprehensive assessment encompasses all of the assessment data for the client. The focused assessment relies on one area of funcitoning such as the respiratory system if a client is having an asthma attack. The database assessment is performed during the initial history and physical portion of the client's illness and represents a comprehensive and all inclusive initial collection of data. Question format: Multiple Choice Chapter 2: Nursing Process Cognitive Level: Understand Client Needs Pn: Health Promotion and Maintenance Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 20

Chapter 3 1. A client who has undergone resection of the intestine is NPO with a nasogastric (NG) tube in place. A food tray with regular food comes to the room, and the client insists that the health care provider be called. The nurse insists that it is okay and encourages the client eat the food. The client complies and later develops complications that require another operation. Which action constitutes the primary breach of duty in this situation? A. The nurse did not call the health care provider when requested. B. The nurse did not realize the importance and purpose of the NG tube. C. The dietary department sent the wrong diet for the client. D. The nurse encouraged the client to eat. Answer: B Rationale: Negligence is defined as harm that occurs because the person did not act reasonably. Establishing liability for negligence requires four elements: duty, breach of duty, causation, and damages. In this case, the primary breach of duty is that the nurse did not realize that the client was on an NG tube and should consequently have been on liquid feeds after intestinal surgery; as a result, the client at the food and developed complications. The acts of not calling the physician and insisting the client have food are not the primary breach of duty, as they are logical based on the assumption that the client could take food by mouth. The dietary department sending the wrong food is unrelated to the nurse. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 38 2. A client who is scheduled for hernioplasty needs clarification regarding the procedure. The nurse calls the physician at the client's insistence. The physician, who is in a bad mood, is overheard telling the client that the nurse does not know anything. Which legal tort has the physician committed? A. Libel B. Battery C. Assault D. Slander Answer: D Rationale: The physician has committed slander by defaming the nurse orally. Slander is a character attack uttered orally in the presence of others. Libel refers to damaging statements written and read by others. Assault is an act in which bodily harm is threatened or attempted. Battery is unauthorized physical contact, not applicable in this situation. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care

Integrated Process: Communication and Documentation Reference: p. 38 3. A nurse enters a client's room and finds that the client is lying on the floor. The nurse makes the client comfortable on the bed and completes an examination. She informs the physician and the nursing supervisor about this incident and also completes an incident report. Which action by the nurse indicates correct knowledge of handling an incident report? A. The nurse documents a complete description of the happenings in the client's records. B. The nurse makes a copy of the incident report and places it in the client's records. C. The nurse makes a copy of the incident report to give to the physician. D. The nurse mentions in the client's report that an incident report was completed. Answer: A Rationale: An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. It is kept separate from the medical record. The incident report is a legal document and making a copy of it is not advisable. It should not be placed in the client's records; however, the nurse can mention the incident in the client's records without mentioning the incident report. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Communication and Documentation Reference: p. 40 4. A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is coming to prepare a living will and requests the nurse to sign as witness. Which action should the nurse take? A. State that the physician will be a witness. B. Arrange for other colleagues to sign as a witness. C. Note that the nurse caring for the client cannot be a witness. D. Inform the physician about the living will. Answer: C Rationale: A living will is an instructive form of an advance directive. It is a written document that identifies a person's preferences regarding medical interventions to use in a terminal condition, irreversible coma, or persistent vegetative state with no hope of recovery. Employees of the health care facility cannot sign as witnesses; therefore, the nurse cannot sign as witness. Refusing a client may not be a good communication method; instead, the nurse could politely indicate her reason. Calling for a physician or asking another colleague to sign is an inappropriate action. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 44

5. An HIV-positive client discovers that the client's name is published in a research report on HIV care prepared by the client's nurse. The client is hurt and files a lawsuit against the nurse. Which offense has the nurse committed? A. Unintentional tort B. Invasion of privacy C. Defamation of character D. Negligence of duty Answer: B Rationale: The nurse has committed the tort of invasion of privacy. Personal names and identities should be concealed or obliterated in case studies or research work. Invasion of privacy is a type of intentional tort. Defamation is an act in which untrue information harms a person's reputation and is therefore not applicable here. Negligence is the harm that results because a person did not act reasonably. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 38 6. A nurse warns a client that he may fall off his bed during a seizure attack if he does not put on the side rails of the bed. Before leaving the client's room, the nurse puts on the side rails, but after the nurse has left, the client lowers them again. Later, the client has a fall from the bed and holds the nurse responsible for it. Which legal provision protects the nurse in this case? A. Good Samaritan law B. statute of limitations C. common law D. assumption of risk Answer: D Rationale: The nurse is protected by the provision of assumption of risk. If a client is forewarned of a potential safety hazard and chooses to ignore the warning, the court may hold the client responsible. It is essential that the nurse documents warning the client and that the client disregarded the warning. Good Samaritan laws provide legal immunity to passersby who provide emergency first aid to accident victims. The statute of limitations is the designated time within which a person can file a lawsuit. Common laws are decisions based on prior similar cases. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Reference: p. 40

7. A client informs the nurse that the client wants to discontinue treatment and go home. Later, the nurse finds the client dressed to leave. Which action should the nurse take in this situation? A. Let the client go after signing a document stating that the client is going against medical advice. B. Restrain the client until medical treatment is over. C. Call the physician and get the discharge paper signed. D. Warn the client that the client may not be able to access health care again. Answer: A Rationale: If a client wishes to go before the client's medical treatment is finished, the nurse should have the client sign a document indicating personal responsibility for leaving against medical advice. The nurse should not restrain the client, as it would make the nurse liable for legal action. The nurse may call the physician and get the discharge paper signed, but this is not appropriate. The nurse should not warn the client that the client will be denied health care in the future, because it is the client's right to access the health care facility whenever needed. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 37 8. A client is admitted with symptoms of psychosis. The nurse hurries to the client's room on hearing the client calling for help. The nurse finds the client lying on the ground. The nurse assists the client back to the bed and performs a thorough assessment. The nurse informs the physician and completes the incident report. Which statement should the nurse document in the incident report? A. The client was trying to lower the side rails. B. The client was found lying on the floor. C. The client was trying to get out of the bed. D. The client was not aware that the client had fallen. Answer: B Rationale: An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. All of the details given in the incident report should be accurate and not assumed. Accurate and detailed documentation helps to prove that the nurse acted reasonably or appropriately in the circumstance. The nurse should document that the client was found lying on the floor. The other statements are assumptions and should not be included in the incident report. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Communication and Documentation Reference: p. 40

9. A nurse assesses a client with psychotic symptoms and determines that the client needs vest restraints. However, the client asks the nurse not to put on vest restraints. What would be the best nursing action? A. Contact the physician and obtain necessary orders. B. Restrain the client with vest restraints. C. Apply restraints after giving a sedative. D. Apply wrist restraints instead of vest restraints. Answer: A Rationale: If a nurse feels that a client needs to be restrained, the nurse should inform the physician and obtain necessary orders. The nurse should also discuss this with the client's family members and ask their opinion. The nurse should not sedate the client and then restrain him, as the nurse could be charged with battery if there is restraint without orders. Applying a wrist restraint instead of a vest restraint is like compromising with the client, which is unethical. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs Pn: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Communication and Documentation Reference: p. 37 10. A nurse is caring for a client who has undergone coronary angioplasty. The cardiac monitor is showing abnormal electrocardiogram waves, indicating atrial fibrillation. The nurse does not recognize the importance of the sign; as a result, the client's condition deteriorates and the client has to be taken up for an emergency procedure. Which describes the nurse's legal liability? A. Felony B. Defamation C. Tort D. Slander Answer: C Rationale: A tort is a cause of action in which one person asserts that a physical, emotional, or financial injury was a consequence of another person's actions or failure to act. A tort implies that one breached one's duty to another person. In this case, the nurse had a duty that was breached. A felony is a serious criminal offense, such as murder. Defamation is an act in which untrue information harms a person's reputation. Slander is a character attack uttered orally in the presence of others. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 38

11. A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist, and learns that the nurse wrongfully attributed the disease to the client's contact with sex workers. With what legal action could the nurse be charged? A. libel B. slander C. malpractice D. tort Answer: B Rationale: The nurse can be charged with slander, which is a character attack uttered orally in the presence of others. Libel includes damaging statements written and read by others. The description is also not appropriate for tort or malpractice. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 38 12. A nurse is caring for a very weak client with multiple pregnancies. Which view would a teleologist have in such a situation? A. Support the procedure of selective abortion. B. Argue that destroying any fetus is wrong. C. Avoid telling the truth to the client. D. Avoid analyzing ethical dilemmas of a case. Answer: A Rationale: A teleologist would argue that selective abortion is ethical because it will ensure the full-term birth of those who remain. Teleologists analyze ethical dilemmas on a case-bycase basis. A deontologist would argue that destroying any fetus is wrong on moral grounds. Deontologists believe that lying is never acceptable because it violates the duty to tell the truth to those entitled to honest information. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 42 13. A nurse is applying for professional liability insurance. The nurse knows that professional liability insurance is important for which reason? A. to obtain sound compensation B. to be familiar with legal mechanisms C. to upgrade professional knowledge D. to obtain free medication for family

Answer: B Rationale: The number of lawsuits involving nurses is increasing. It is to every nurse's advantage to obtain liability insurance and to become familiar with legal mechanisms, such as Good Samaritan laws and statutes of limitations that may prevent or relieve culpability and provide a sound legal defense. Professional liability insurance does not focus on enhancing the nurse's professional knowledge, does not offer free medication for family, or obtain sound compensation to a nurse. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Remember Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 39 14. A home care nurse is caring for a paralyzed client who needs regular position changes and back massages. A man identifying himself as a family friend inquires if he can be of any help to the family. What should be the nurse's response? A. The nurse should ask the man to talk to the family directly. B. The nurse should invite the man to learn the caring techniques. C. The nurse should state that the family does not need any help. D. The nurse should refer the man to the local social worker. Answer: A Rationale: The nurse should ask the man to talk to the family directly. Revealing information about the client's care is a violation of the client's privacy. The nurse should not invite the man for a learning session because it would be a breach of the client's right to privacy. Referring him to a social worker is not an appropriate choice. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 38 15. A nurse finds that a colleague is intoxicated while on duty. What appropriate action should the nurse take? A. Inform the nursing supervisor. B. Tell the colleague to take a 30-minute break. C. Inform the physician. D. Watch the colleague closely during the shift. Answer: A Rationale: When a colleague is intoxicated while on duty, the nurse should immediately inform the nursing supervisor, who may take necessary action. It would be an irresponsible action if the nurse tells the colleague to take a rest. Likewise, informing a physician is not the

appropriate response. The nurse should not ignore the incident and simply observe the colleague because client care may be affected. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Communication and Documentation Reference: p. 46 16. A client with a bone infection had a central venous catheter ordered for the long-term administration of antibiotics. The intravenous line was inserted at the bedside by a qualified nurse, but the nurse was observed to make a serious lapse in aseptic technique and the client developed sepsis. What type of law most directly addresses this situation? A. criminal law B. civil law C. common law D. statutory law Answer: B Rationale: This nurse has committed a breach of duty, which is an offense under civil law. It is unlikely that this constitutes a criminal offense. Statutory law and common law do not address such events that involve an act between two individuals. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 35 17. After several years of providing bedside care in an inpatient setting, a nurse has taken a position with the state board of nursing. In this role, the nurse may contribute to which activities of a state board of nursing? A. issuing and transferring nursing licenses within the state B. providing consultation on ethically challenging clinical situations C. promoting the visibility of the nursing profession within the state D. allocating financial resources within clinics and hospitals in the state Answer: A Rationale: State boards of nursing perform multiple roles, including issuing and transferring licenses of nurses in the state. Consultations on ethics, allocation of resources, and promotion of the nursing profession are not typical activities of state boards of nursing. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 34

18. A group of nursing students is reviewing the ANA's current code of ethics. A code of ethics is important in the nursing profession because: A. nurses are highly vulnerable to criminal and civil prosecution in the course of their work. B. nurses interact with clients and families from diverse cultural and religious backgrounds. C. nursing practice involves numerous interactions between laws and individual values. D. nurses are responsible for carrying out actions that have been ordered by other individuals. Answer: C Rationale: A code of ethics is necessary to guide nurses' conduct, especially with regard to the interaction between laws and individual values. Diversity and legal liability do not provide the main justification for a code of ethics, though each is often a relevant consideration. The fact that nurses often carry out the orders of others is not the justification for a code of ethics. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 42 19. A group of nurses who work at a large, long-term care facility have become embroiled in controversy over a large number of residents who are refusing a seasonal influenza vaccination. Specifically, there is controversy around the appropriate amount of influence that nurses can exercise when encouraging residents to become immunized. A teleological perspective on this issue would prioritize what consideration? A. the "rightness" or "wrongness" of coercion B. the legal rights of the individual C. the greatest good for the greatest number D. historical precedents Answer: C Rationale: Teleology is ethical theory based on final outcomes. It is also known as utilitarianism because the ultimate ethical test for any decision is based on what is best for the most people. Deontology focuses on the morality of an act. Teleology does not prioritize historical precedent or the legal rights of the individual. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 42 20. An illegal immigrant with no health insurance sustained life-threatening injuries in an automobile accident. Which action in this case demonstrates the ethical principle of justice? A. Airlifting the client to a local trauma center for emergency surgery B. Avoiding treating the client so as to not do any additional harm C. Filing the paperwork for the client to receive retroactive health insurance D. Telling the client honest information about the client's medical condition and prognosis

Answer: A Rationale: The ethical principle of justice mandates that clients be treated impartially without discrimination according to age, gender, race, religion, socioeconomic status, weight, marital status, or sexual orientation. An immediate airlift to the local trauma center demonstrates that this client is begin treated impartially. Avoiding causing the client additional harm would demonstrate nonmaleficence. Attempting to help the client obtain health insurance would demonstrate beneficence and advocacy. Telling the client the truth about the client's medical condition and prognosis would demonstrate integrity and honesty (veracity). Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 43 21. A nurse who is infected with human immunodeficiency virus (HIV) accidentally gets a cut while debriding a wound, exposing the client to possible HIV infection. Failure of the nurse to report this incident violates which ethical principles? Select all that apply. A. Justice B. Autonomy C. Nonmaleficence D. Veracity E. Fidelity Answer: C, D, E Rationale: Nonmaleficence means "doing no harm" or avoiding an action that deliberately harms a person. By not reporting this incident, the nurse is deliberately harming the client. Veracity means the duty to be honest and avoid deceiving or misleading a client. Fidelity means being faithful to work-related commitments and obligations, such as reporting the incident. Justice and autonomy do not apply in this scenario. Question format: Multiple Select Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Communication and Documentation Reference: p. 42 22. A nurse completing admission paperwork asks the client about having an advanced directive. The client states, "I do not know, what is an advanced directive?" What is the nurse's best response? A. "It is a written document that identifies a person's preferences regarding which medical interventions to use in the event of a terminal condition." B. "It is an agreement that authorizes the hospital to make decisions on your behalf, if you become incapacitated." C. "I will contact the hospital social worker to come and discuss the development of an advance directive with you."

D. "It is a document created by you and your attorney naming a beneficiary to handle your estate if you become terminally ill." Answer: A Rationale: An advance directive is a written statement identifying a competent person's preferences regarding which medical interventions to use in the event that the client cannot make a decision for themselves concerning terminal care. The other responses are not correct. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 44 23. During a nursing shift, which events warrant completion of an incident report? Select all that apply. A. A nurse reports that a client is crying and distraught over a diagnosis of metastatic cancer. B. An intravenous antibiotic was administered 2 hours late because the IV site infiltrated. C. A visitor slipped and fell in the hallway, but was not injured. D. A client falls while being transferred from the bed to the chair. E. A nurse asks an unlicensed assistive personnel (UAP) to feed a client. Answer: B, C, D Rationale: An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. Late administration of medication is considered a medication error and is potentially injurious to the client. A visitor fall and a client fall are both reportable situations. A client crying following a diagnosis of cancer could be expected, and a nurse delegating appropriate care to a UAP is not reportable. Therefore, these actions do not require an incident report to be filed. Question format: Multiple Select Chapter 3: Laws and Ethics Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Communication and Documentation Reference: p. 40 24. An oncology nurse is caring for a client suffering from metabolic encephalopathy and end-stage kidney disease. The client has no known family and no advance directives. Upon entering the room, the nurse observes the client is pale and has no spontaneous respiration. What is the priority action the nurse should take? A. Contact the physician. B. Call the coroner. C. Notify the charge nurse. D. Begin CPR. Answer: D

Rationale: A code status refers to how health care providers are required to manage care in the case of cardiac or respiratory arrest. A full code means that all measures to resuscitate the client are used. The nurse should immediately begin CPR. Although it is necessary to notify the physician and charge nurse, this is not the priority. It is not appropriate to contact the coroner at this time. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 45-46 25. A nurse is caring for a client with hypertension whose blood pressure has increased from 154/78 mmHg to 196/98 mmHg with a heart rate of 110 beats per minute during the past hour. The nurse goes to lunch without reporting the change to the health care provider, and the client experiences a cardiac arrest. What tort has the nurse likely committed? A. Negligence B. Battery C. Invasion of privacy D. False imprisonment Answer: A Rationale: Negligence, such as not reporting a change in a client condition, is harm that results because a person did not act reasonably. Based on the definition of negligence, harm resulted due to the nurse's lack of action (omission). Battery, invasion of privacy, and false imprisonment did not occur in this scenario. Battery includes willful, angry, and violent or negligent touching of another person's body or clothes or anything attached to or held by that other person. Invasion of privacy is a breach in confidentiality in which one's personal information is given to another without the person's consent. False imprisonment is unjustified retention or prevention of the movement of another person without proper consent. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 38 26. A nurse is called to a deposition for a malpractice charge that has resulted in the death of a client. As the chart is reviewed, the prosecuting attorney questions the nurse about several defaming comments written in the medical record about the client. What charges can be filed against the nurse due to these comments? A. Malpractice B. Slander C. Libel D. Negligence Answer: C

Rationale: Libel is damaging statements written and read by others. Because defaming comments were written in the chart, libel charges could be appropriate. Malpractice is negligence in performing or failing to perform expected duties of one's profession. Slander is oral defamation of character. Negligence is performing an action a reasonable person would not perform or failing to perform an action that a reasonable person would perform, resulting in harm to another. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 38 27. A nurse is caring for a hospitalized client. Which nursing actions demonstrate a caring and compassionate attitude? Select all that apply. A. Leaving the room promptly once care is completed B. Notifying the client before leaving for lunch C. Offering snacks and beverages to visiting family D. Explaining all nursing procedures clearly E. Listening to the client tell stories about past experiences Answer: B, C, D, E Rationale: One of the best methods for avoiding lawsuits is to administer compassionate care. Notifying the client before leaving for lunch, offering snacks and beverages to visiting family, explaining all nursing procedures clearly, and listening to the client tell stories are examples of a caring and compassionate attitude. Leaving the room promptly once care is completed does not demonstrate care or compassion. Question format: Multiple Select Chapter 3: Laws and Ethics Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 39 28. A nurse who works on a palliative care unit has participated in several clinical scenarios that have required the application of ethics. Ethics is best defined as: A. the relationship between law and culture. B. moral values that are considered to be universal. C. the principles that determine whether an act is right or wrong. D. the laws that govern acceptable and unacceptable behavior. Answer: C Rationale: Ethics involves moral or philosophical principles that direct actions as being either right or wrong. Laws are often rooted in ethics, but the two terms are not synonymous. Similarly, morals and values are closely associated with ethics, but these do not constitute the definition of ethics. Ethics are not universally agreed upon, as many different applications exist. Question format: Multiple Choice

Chapter 3: Laws and Ethics Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 41 29. A nurse witnesses a traffic accident in which a child is badly hurt. The nurse dresses the open wounds sustained by the child. The family tries to give monetary compensation, which the nurse refuses. Later, in the hospital, the child develops complications due to infection in the wound. The family holds the nurse responsible for the complications and wants to file a lawsuit. Which of the following statements is true regarding the Good Samaritan law? A. The Good Samaritan law will provide legal immunity to the nurse. B. The Good Samaritan law will not protect the nurse, as she did not accept the compensation. C. The Good Samaritan law is not applicable to health care workers. D. The Good Samaritan law provides absolute exemption from prosecution. Answer: A Rationale: Good Samaritan laws provide legal immunity to passersby who provide emergency first aid to victims of accidents. Therefore, the law is applicable to the nurse as well; moreover, the nurse did not accept any compensation for the service provided. The law is equally applicable to everyone, but does not provide absolute exemption from prosecution in cases of negligence. Paramedics, ambulance personnel, physicians, and nurses who stop to provide assistance are still held to a higher standard of care because they have training above and beyond that of the average layperson. In cases of gross negligence, health care workers may be charged with a criminal offense. Question format: Multiple Choice Chapter 3: Laws and Ethics Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 40

Chapter 4 1. A nurse is caring for a child with Huntington's chorea, a hereditary condition. Which statement is true of hereditary conditions? A. The symptoms are manifested immediately after birth. B. The condition is due to maternal exposure to toxins. C. The condition is acquired from genes of one or both parents. D. The course is associated with exacerbations and remissions. Answer: C Rationale: Hereditary conditions are acquired from genes of one or both parents. The symptoms may or may not be manifested immediately after birth. Some hereditary diseases, including Huntington's chorea, remain asymptomatic and undiagnosed until adulthood. Hereditary conditions are not due to abnormalities in embryonic development. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 51 2. A nurse is caring for a client who is confined to bed due to paralysis. The client has a medical history of stroke, hypertension, and diabetes mellitus for the past five years, besides having asthma since childhood. Which is a secondary illness seen in the client? A. diabetes mellitus B. asthma C. hypertension D. stroke Answer: D Rationale: Stroke is a secondary illness caused by high blood pressure. Secondary illness is a disorder that develops from a preexisting condition. In this case, the client had a history of hypertension, which is a primary illness that caused a stroke. Diabetes mellitus and asthma represent primary illnesses in the client, as there are no preexisting conditions predisposing the client to asthma and diabetes mellitus. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 51 3. A client with Crohn's disease in remission is admitted to the nursing unit for follow-up care. The remission state is characterized by: A. permanent relief from the signs and symptoms. B. disappearance of signs and symptoms associated with the disease.

C. periodic occurrence in clients with long-standing diseases. D. reactivation of the disease and presence of symptoms. Answer: B Rationale: Remission is a temporary state of disappearance of the signs and symptoms related to a particular disease. It is of short duration, but the duration is unpredictable. It is a condition opposite to exacerbation, which is characterized by reactivation of symptoms. Remission is not permanent, but is rather a temporary relief from signs and symptoms. Exacerbation is the periodic occurrence of disease in clients with chronic diseases. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 51 4. A client admitted for hernioplasty is discharged two days later than the calculated time due to postoperative complications. The client is insured through a capitation scheme. In the event of late discharge of the client, who is at loss? A. the client B. the hospital C. the insurers D. the doctors Answer: B Rationale: The hospital is at loss if the client is discharged late from the hospital. The client is insured through a capitation scheme, which provides a pre-set fee per member to the health care provider, regardless of whether the member requires services. If a client is discharged earlier, the hospital keeps the difference; if the client is discharged late, the hospital is at loss. The client is not at loss because he pays a fixed amount to the provider whether he utilizes the care or not. The doctors and the health care workers are not affected. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 54 5. A nurse is caring for a client who has undergone total hip replacement and is advised to undergo physiotherapy after discharge. Which level of care is the physiotherapy center? A. continuity of care B. extended care C. secondary care D. tertiary care Answer: B

Rationale: Physiotherapy is an example of extended care. It does not involve acute care and is not compulsorily done on hospital premises. The hospital providing surgical facilities is a tertiary care center. The client, after being discharged from tertiary care, joins a physiotherapy unit for extended care. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 52 6. A client arrives at a health care facility complaining of pain in the abdomen and diarrhea. The physician diagnoses the client with colitis, an acute illness. Why is colitis considered an acute illness? A. The onset is sudden. B. It lasts for a long time. C. It is difficult to treat. D. It is not curable. Answer: A Rationale: Colitis, in this case, is an acute illness because the onset is sudden. Acute illnesses affect a person for a short duration and are cured in a short time. Acute illnesses are not difficult to treat and are curable. On the other hand, chronic illnesses have a gradual onset and require a longer period to be cured. In some cases, the illness may remain lifelong. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Physiological Adaptation Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 50 7. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse explains to the client that COPD is a chronic disease. Why is COPD considered a chronic disease? A. It persists for a long time. B. It is a sequela of acute illness. C. It takes a long time to cure. D. It has a gradual onset and lasts for a long time. Answer: D Rationale: Chronic illness has a gradual onset and lasts for a long time. It is usually seen in old age. It may or may not be due to acute illness. Chronic diseases are a major cause of morbidity in the population. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Remember Client Needs Pn: Physiological Integrity: Physiological Adaptation

Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 50 8. A client who suffered a stroke is discharged from a health care unit and the nurse is assigned to provide nursing care to the client at home. This is an example of which kind of care? A. extended care B. secondary care C. tertiary care D. primary care Answer: A Rationale: Extended care represents services that meet the health needs of clients who no longer require acute hospital care. It includes skilled nursing care in a person's home or a nursing home and hospice care for dying clients. Primary care is provided by the family physician, the nurse, or any health care facility that is the first contact for the client. Secondary care and tertiary care are provided at specialized health care units. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 52 9. Consultation and diagnostic tests are included in which level of health care? A. Primary care B. Secondary care C. Tertiary care D. Extended care Answer: B Rationale: Consultation and diagnostic tests are included in the secondary level of health care. The first contact with a general physician is the primary care, and the reference to a highly specialized facility for desensitization is the tertiary care level. The secondary and tertiary care facilities are equipped to provide highly specialized care. Extended care is care provided to clients who no longer require acute hospital care. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Remember Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 51

10. A client arrives at a health care facility reporting diarrhea and abdominal pain for the past 24 hours. The helath care provider diagnoses the client with gastritis, an acute illness. Why is gastritis considered an acute illness? A. The onset is sudden. B. It lasts for a long time. C. It is difficult to treat. D. It is not curable. Answer: A Rationale: Gastritis in this case is an acute illness because the onset is sudden. Acute illnesses affect clients for a short duration and are cured in a short time. Acute illnesses are not necessarily difficult to treat and are often curable. Whereas, chronic illnesses have a gradual onset and require a longer period to be cured. In some cases, the illness may remain for a lifetime. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 50 11. A middle-aged client is distraught at receiving a diagnosis of type 2 diabetes in spite of being conscientious about her health for the majority of her adult life. The client tells the nurse, "I can't believe I no longer have my health." The nurse should be aware that the World Health Organization defines health as: A. the absence of acute and chronic health issues that affect the client's quality of life. B. a level of function that is equal to or superior to individuals of similar age. C. the ability to contribute unimpeded to the quality of life on oneself and others. D. a state of physical, mental, and social well-being. Answer: D Rationale: The WHO defines health as "a state of complete physical, mental, and social wellbeing, not merely the absence of disease or infirmity." This definition does not preclude the other listed aspects of health, but none of these is considered definitive by the WHO. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Communication and Documentation Reference: p. 48 12. A nurse has become involved in political efforts to ensure that a greater percentage of Americans have access to affordable health care, regardless of their individual circumstances. This view of health is reflective of what belief? A. Health is a limited resource. B. Health is a right.

C. Health is inevitable. D. Health is personal responsibility. Answer: B Rationale: Efforts to eradicate health disparities are often rooted in the belief that health care is a right. The belief that health care is a limited resource underlies views of the preciousness of preserving health. Personal responsibility is foundational to the view of individual ownership of one's health status. It is unrealistic to believe that health is inevitable. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Communication and Documentation Reference: p. 48 13. After experiencing an ST-wave elevation myocardial infarction, a 64-year-old man has been admitted to the cardiac unit of the hospital for care. The nurse has completed a comprehensive assessment and is creating a plan of care that is holistic in its focus. How can the nurse best integrate the principles of holism into the client's care? A. by creating a plan of care that utilizes the knowledge and skills of disciplines other than nursing B. by continually evaluating the efficacy of nursing interventions and by making changes as needed C. by prioritizing the client's spiritual and psychosocial needs over his physical needs D. by integrating each of the various dimensions of the client's identity into his care Answer: D Rationale: Holism is considered to be the sum of physical, emotional, social, and spiritual health. Care that reflects this multidimensional nature of individuals can be considered to be holistic. Interdisciplinary care and continual evaluation are congruent with holistic care, but they are not definitive. It is not appropriate to prioritize nonphysical needs in every client; prioritization of needs should be determined on an individual basis. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Health Promotion and Maintenance Integrated Process: Culture and Spirituality Reference: p. 49 14. A nurse has learned that more than 8% of the population are currently living with diabetes mellitus. This statistic represents what epidemiological concept? A. morbidity B. mortality C. distribution D. onset

Answer: A Rationale: Morbidity is the incidence of a specific disease, disorder, or injury and refers to the rate or numbers of people affected. Mortality denotes the number of people who died from a particular disease or condition. Onset and distribution are not concepts that are central to epidemiology. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 50 15. Which client growth needs are included in the love and belonging level of Maslow's hierarchy? (Select all that apply.) A. Family B. Self-respect C. Intimacy D. Status E. Friendships Answer: A, C, E Rationale: Love and belonging includes the need for affection, belonging, and meaningful relations with others (family, intimacy, friendships). Self-esteem includes self-respect and status. Question format: Multiple Select Chapter 4: Health and Illness Cognitive Level: Remember Client Needs: Psychosocial Integrity Client Needs Pn: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 50 16. A nurse is explaining A1C diagnostic testing to a client with diabetes. What level of health care delivery does this test suggest? A. Quanternary B. Secondary C. Tertiary D. Primary Answer: D Rationale: Primary care delivery is provided by the first healthcare provider or agency a person contacts and includes teaching and basic care. Quaternary care is an extension of tertiary care and includes experimental medicine and procedures and highly uncommon, specialized surgeries. Secondary care delivery is when primary caregivers refer clients for consultation and additional testing. Tertiary care is health services provided at hospitals or medical centers that have complex technology and specialists.

Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs Pn: Health Promotion and Maintenance Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 51 17. Which nursing activity reflects care given on the tertiary level of healthcare delivery? A. Educating the client about safe habits B. Recommending regular exams C. Assisting with transplant surgery D. Teaching the client about exercise programs Answer: C Rationale: Tertiary care is health services provided at hospitals or medical centers that have complex technology and specialists. Educating the client about safe habits, recommending regular exams, and teaching the client about exercise programs are examples of primary care. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Apply Client Needs Pn: Health Promotion and Maintenance Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 51 18. The nurse is working in an acute care setting and performs primary, secondary, and tertiary prevention. Which activity performed by the nurse is classified as tertiary prevention? A. Promoting safety in the home B. Instructing a client on how to use crutches C. Counseling a client about a low-sodium diet D. Assessing a client's blood glucose level Answer: B Rationale: Tertiary prevention is used after an injury or sickness to help rehabilitate the client or to decrease potential risk and further damage, such as instructing the client on how to use crutches. Promoting safety in the home and counseling a client about a low-sodium diet are examples of primary prevention (preventing a disease from occurring in the first place). Assessing blood glucose level is an example of secondary prevention (screening to detect a disease early). Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Client Needs Pn: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 51

19. A pregnant client at 10 weeks' gestation is receiving education by the nurse about the importance of abstaining from alcohol while pregnant. What statement made by the client demonstrates an understanding of the education provided? A. "If I drink alcohol while pregnant, my child will have a hereditary disorder." B. "Abstaining from alcohol will prevent any type of congenital disorder." C. "I should abstain from alcohol to prevent the development of a fetal alcohol specturm disorder." D. "Alcohol use while pregnant will predispose my child to idiopathic illness." Answer: C Rationale: Congenital disorders such as fetal alcohol spectrum disorders may be prevented by the client abstaining from alcohol while pregnant. Fetal alcohol spectrum disorders are congenital disorders caused by an undetermined amount of alcohol ingested by the mother which affects the fetus in the developmental stages of growth. Abstaining from alcohol will not prevent all types of congenital disorders, but clients should be educated about a variety of preventative measures in order to prevent interruption of the growth and development of the fetus. An idiopathic illness is one in which the cause is undetermined. A hereditary disorder is genetic and not altered by substance intake during pregnancy. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Client Needs Pn: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 53-54 20. A client is seeking health care at a local rural clinic for frequent and debilitating headaches. The nurse is making a referral to a university teaching facility 60 miles away from the clinic for evaluation of the headaches. Which form of care will this client be receiving? A. primary care B. secondary care C. tertiary care D. extended care Answer: C Rationale: The client will be referred to a tertiary care facility where complex care, testing, and evaluation can be performed to evaluate the client's condition. Primary care can be provided at the rural health care clinic. Secondary care is provided at a lower level for additional testing and consultation. Extended care would be received in a long-term care facility or a rehabilitation center. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Client Needs Pn: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 51

21. The nurse is working in a clinic in a rural setting that has a diverse population of clients. Which client will the nurse refer to the case manager to determine eligibility for Medicaid? A. a 65-year-old client retiring from a job with the school system B. a client who is changing jobs and will be without medical coverage for 60 days C. a client who is disabled from a work-related accident D. a client with four children who works part-time in a fast food restaurant making minimum wage Answer: D Rationale: The client in the low income category of a part-time job with four children would most likely qualify for the Medicaid program. Medicaid is a federally funded, stateadministered health care program that provides for those in the low-income category. The 65year-old client qualifies for Medicare benefits. The Consolidated Omnibus Budget Reconciliation Act (COBRA) protects clients who are transferring jobs. Thus, a client who is transferring jobs will be given the option of coverage from the previous insurance until the new insurance becomes active. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 52 22. The nurse is caring for a client who has recovered from injuries incurred from a motor vehicle accident where two other family members did not survive. The client informs the nurse that he or she will grieve without demonstrating ineffective coping mechanisms. Which type of health behaviors does the nurse identify the client is exhibiting? A. physical health B. emotional health C. spiritual health D. social health Answer: B Rationale: The client is exhibiting the holistic concept of emotional health since the client is demonstrating an ability to cope with a stressor effectively. Physical health is an optimal state of physical functioning when body organs function normally. Social health is an outcome of feeling accepted and useful. Spiritual health is the feeling that one's life has a purpose and function. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Caring Reference: p. 49

23. A client with chronic obstructive pulmonary disease (COPD) is admitted to the hospital for the second time in 2 months with wheezing, dyspnea, and use of accessory muscles when breathing. Which type of situation does the nurse identify is occurring with this client? A. The client is experiencing the effects of a terminal illness. B. The client is having an exacerbation of the COPD. C. This is the effect of a secondary illness. D. The client is experiencing remission of the COPD. Answer: B Rationale: COPD is a chronic illness that has periods when the client goes from a chronic state to an acute state such as an acute onset of symptoms. The client will experience periods of exacerbation according to certain precipitating circumstances. Remission occurs in illnesses such as cancer when the symptoms or clinical manifestations disappear. A secondary illness is caused by complications from a primary illness. Clients with a terminal illness have no hope of recovery. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Analyze Client Needs Pn: Physiological Integrity: Reduction of Risk Potential Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 51 24. The nurse manager of the acute care unit has decided to implement a team nursing approach for client care. One of the staff members asks, "Will we each take care of our own clients?" What is the appropriate response by the manager? A. "Each registered nurse (RN) will be assigned a client and be responsible for planning and evaluating care." B. "I will plan the care based on the client's diagnosis or type of case." C. "The care will be divided and the registered nurse (RN) will have a licensed practical/vocational nurse (LPN/LVN) and unlicensed assistive personnel (UAP) to provide care together." D. "One person will provide skilled care, one will give medications, and one will help with hygienic needs." Answer: C Rationale: The team nursing approach is organized and directed by a team leader who assigns and supervises the care of the team and may also contribute to the care. Functional nursing is when each nurse is assigned specific tasks to perform, such as medication administration or wound care. This is more of a task-oriented role. A case-based approach is used when the nurse manager assigns tasks based on the client's diagnosis. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Apply Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 55

25. The client experienced a stroke with left-sided weakness. The case manager determines that the client no longer requires acute care but currently is unable to return to the home environment. Which health care environment will be the appropriate referral option for this client? A. primary care B. secondary care C. tertiary care D. extended care Answer: D Rationale: The client who is unable to return to the home environment but no longer requires acute care will be referred to an extended care facility to meet the rehabilitation needs after a stroke. Primary care is delivered in an office or clinic setting with a health care provider. Secondary care is a referral made from the primary care provider for specialty consultation or additional testing. Tertiary care is the environment from which the client is being released that provides acute care. Question format: Multiple Choice Chapter 4: Health and Illness Cognitive Level: Understand Client Needs Pn: Safe, Effective Care Environment: Coordinated Care Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 52

Chapter 5 1. The nurse is caring for a client who is a doctor in a general hospital. He complains about the stressful condition of his job. Lately, he has become increasingly susceptible to colds, headaches, muscular tension, excessive tiredness, and many other symptoms. At what stage of stress is the client? A. alarm stage B. exhaustion stage C. resistance stage D. secondary stage Answer: B Rationale: The client is in the exhaustion stage, when one or more adaptive/resistive mechanisms can no longer protect the person experiencing a stressor; this results in exhaustion. The effects of stress-related neurohormones suppress the immune system, and the body is open to various ailments. In the alarm stage, the person is prepared for a fight-orflight response. In the resistance stage, the client's body is returned to the homeostasis state. Consequently, one or more organs or physiologic processes may eventually lead to increased vulnerability to stress-related disorders, or progression to the stage of exhaustion. The secondary stage is not a stage related to stress. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Reference: p. 66 2. A client visits a health care facility after his spouse's death. The client is quite depressed and feels very lonely. The nurse asks him to confront the reality and be emotionally strong. What type of strategy is the nurse following in this case? A. nontherapeutic coping strategy B. therapeutic coping strategy C. negative coping strategy D. sensory manipulation strategy Answer: B Rationale: Therapeutic coping strategies usually help the person acquire insight, gain confidence to confront reality, and develop emotional maturity. People use nontherapeutic coping strategies such as mind- and mood-altering substances, hostility and aggression, excessive sleep, avoidance of conflict, and abandonment of social activities. Sensory manipulation involves altering moods, feelings, and physiologic responses by stimulating pleasure centers in the brain, using sensory stimuli. Negative coping strategies may provide immediate temporary relief from a stressor, but they eventually cause problems. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply

Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 66 3. A nurse is trying to calm an upset client who has been involved in an accident. The client escaped with minor bruises from the accident. What should the nurse do in order to calm the client? A. prescribe sedatives to calm the nerves B. ask family members to take the client for a vacation C. explain that things could have been worse D. advise the client to file a claim on their accident insurance Answer: C Rationale: The nurse, using alternative thinking techniques, should explain to the client that the situation could have been worse. Alternative thinking techniques are those that facilitate a change in a person's perceptions from negative to positive. Sedatives have a temporary effect in calming a person, but reframing the mind is a better way of coping with the stress. The client may need to file an insurance claim, but that is not the nurse's priority intervention. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Caring Reference: p. 69 4. A client visits a health care facility reporting work-related stress that alters his mood when he comes home. The nurse suggests that the client make changes to his home décor to include vibrant colors and bright lighting, and listen to soothing music when he returns home. Which stress-reducing technique is the nurse following in this case? A. sensory manipulation technique B. alternative thinking technique C. nontherapeutic technique D. alternative behavior technique Answer: A Rationale: The nurse is using a sensory manipulation technique. Sensory manipulation involves altering moods, feelings, and physiologic responses by stimulating pleasure centers in the brain, using sensory stimuli. For example, certain colors, full-spectrum lighting in the home and workplace, music, and food help change a person's mood. Alternative thinking techniques are those that facilitate a change in a person's perceptions from negative to positive. A behavioral technique for modifying stress is to take control rather than become immobilized by stress. Nontherapeutic techniques would involve using mind- and moodaltering substances, which are not appropriate in this case. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand

Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Caring Reference: p. 69 5. A 7-year-old child is admitted to a health care facility. His parents explain that the child is not able to interpret what they say and so is not able to speak clearly. The child is also not able to remember anything he is taught in school. What should the nurse conclude about the part of the brain that is affected in this case? A. The cortex is affected. B. The subcortex is affected. C. The mid-brain is affected. D. The brainstem is affected. Answer: A Rationale: The cortex is considered the higher-functioning portion of the brain. It enables people to think abstractly, use and understand language, accumulate and store memories, and make decisions about information received. Therefore, the nurse can conclude that the client's cortex is affected. The subcortex consists of the structures in the mid-brain and brainstem. The subcortical structures are primarily responsible for regulating and maintaining physiologic activities that promote survival. They regulate breathing, heart contraction, blood pressure, body temperature, sleep, appetite, and stimulation and inhibition of hormone production. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs: Psychosocial Integrity Client Needs Pn: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 61 6. A client visits the medical unit with the client's father for a scheduled checkup. The client's father has been recently diagnosed with hypertension. The nurse suggests that the client get his blood pressure regularly checked to avoid possible problems. What level of prevention is the nurse following in this case? A. primary level B. secondary level C. general guidance level D. tertiary level Answer: B Rationale: The nurse is following secondary prevention, which includes screening for risk factors and providing a means for early diagnosis of disease. An example is regularly measuring the blood pressure of a client with a family history of hypertension. Primary prevention involves eliminating the potential for illness before it occurs. Tertiary prevention minimizes the consequences of a disorder through aggressive rehabilitation or appropriate management of the disease. Note that there is no general guidance level of prevention. Question format: Multiple Choice

Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Client Needs Pn: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 67 7. When discussing his problem, a client tells the nurse that he is always doing small, petty jobs for everyone and he is not happy about it. Because of this, he is feeling stressed and has been getting into fights with his wife. What should the nurse suggest to help the client overcome this problem? A. change jobs B. avoid people who dump tasks on him C. take control of the situation D. avoid doing petty jobs Answer: C Rationale: A behavioral technique for modifying stress is to take control rather than become immobilized. This is also known as alternative behavior. Another behavioral approach to reduce stress is to sometimes say "no" in order to avoid becoming overwhelmed and more stressed. Changing jobs, avoiding the person, or avoiding the petty jobs would not help. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 69 8. When discussing his concerns with the nurse, the client discloses that when he comes home from work, he plays with his pet dog and this makes him feel relaxed. His friends make fun of him because of this, however. The nurse explains that this is perfectly normal and is not a cause of worry. In this case, how is the client relieving stress? A. by adopting an alternative lifestyle B. by adopting alternative behaviors C. by adopting alternative thinking D. by adopting alternative hobbies Answer: A Rationale: In alternative lifestyles, people with pets find it soothing and relaxing to stroke and touch an animal that responds affectionately, regardless of a person's age, physical characteristics, or accomplishments. Pets seem to improve a person's feelings of self-worth in a way that extends to human relationships as well. Alternative thinking techniques are those that facilitate a change in a person's perceptions, from negative to positive. Alternative behaviors are behavioral techniques for modifying stress, which encourage one to take control rather than become immobilized. Making choices and pursuing actions promote selfconfidence over feeling victimized. Question format: Multiple Choice

Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 70 9. A client who is a drug addict visits a health care facility for treatment. During counseling, he discloses that he took to drugs because it helped him deal with stressful situations. The nurse explains that he is not using the correct coping strategy to overcome his stress-related problems. What kind of strategy has the client used in this case? A. nontherapeutic coping strategy B. therapeutic coping strategy C. stress-reduction strategy D. antidepressant strategy Answer: A Rationale: The client has used nontherapeutic coping strategies such as mind- and moodaltering substances to cope with stress. Negative coping strategies may provide immediate temporary relief from a stressor, but they eventually cause problems. Therapeutic coping strategies usually help the person to acquire insight, gain confidence to confront reality, and develop emotional maturity. Also, the client has not used an antidepressant strategy. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 66 10. A client who tends to volunteer to complete major assignments but forgets to complete his own work is stressed because of this. The nurse suggests that the client prioritize the work, complete the difficult part of the work first, and delegate the rest of the work to colleagues. In this case, what technique is the nurse asking the client to follow? A. alternative lifestyle B. alternative behaviors C. alternative coping D. negative technique Answer: B Rationale: Alternative behaviors means behavioral approaches that help to reduce stress, including prioritizing what needs to be accomplished and initially attending to that which is most important or difficult. Less important activities may be postponed or delegated to others. A negative technique may provide immediate temporary relief from a stressor, but it will eventually cause problems. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand

Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 69 11. A client, while driving, hits a small child crossing the road. The child survives with some minor bruises and cuts. The client feels very stressed and is depressed when thinking of the child's injury. Which technique should the nurse implement in this case? A. alternative thinking B. alternative behaviors C. alternative lifestyles D. adaptive activities Answer: A Rationale: Alternative thinking techniques are those that facilitate a change in a person's perceptions from negative to positive. Reframing helps a person analyze a stressful situation from various perspectives and ultimately conclude that the situation is not as bad as it once seemed. Alternative behavior is a technique for modifying stress by taking control rather than becoming immobilized. Making choices and pursuing actions promotes self-confidence over feeling victimized. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 69 12. A nurse is assisting a neurologist, who is assessing the norepinephrine (noradrenaline) level of a client who is reporting stress. Which function does norepinephrine (noradrenaline) perform? A. stabilizes mood and regulates temperature B. promotes coordinated movement C. heightens arousal and increases energy D. transmits sensation of pain Answer: C Rationale: Norepinephrine (noradrenaline) heightens arousal and increases energy. Acetylcholine and dopamine promote coordinated movement. Serotonin stabilizes mood, induces sleep, and regulates the temperature of a person. Substance P transmits the sensation of pain, whereas endorphins and enkephalins interrupt the transmission of substance P and promote a sense of well-being. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Physiological Adaptation Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process

Reference: p. 60-61 13. A nurse is assessing a client with stress-related problems. Which factor influences responses to stressors? A. eating habits B. social support C. economic status D. personal hygiene Answer: B Rationale: A person's response to stressors depends on social support, intensity of the stressor, number of stressors, duration of the stressor, physical health status, life experiences, coping strategies, personal beliefs, attitudes, and values. A person's response to stressors is independent of education, eating habits, economic status, or personal hygiene. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 63-64 14. A nurse is caring for a client who is an investment banker. The client is stressed because of the sudden fall of share prices in the stock exchange. Which stress-reduction technique should the nurse use with this client? A. advocate on behalf of the client to others B. discourage family from interacting with the client C. avoid referring the client to other organizations D. avoid discussing the client's condition with client's family Answer: A Rationale: The nurse should advocate on behalf of the client to others. If need be, the nurse should refer the client and his family to organizations or people who provide post-discharge assistance. The nurse should keep the client and the client's family informed about the client's condition and encourage the family members to interact with the client. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 67 15. A nurse is assessing an obese teenager who is unhappy and stressed out because she has not lost weight despite working out at the gym. The physician asks the nurse to try the modeling intervention for stress management for the client. Which action should the nurse perform when adhering to the modeling intervention? A. ask the client to change her exercise regimen

B. introduce the client to someone with a positive attitude C. ask the client to cut down on her food intake D. ask the client to undergo liposuction surgery Answer: B Rationale: The nurse should introduce the client to a person who demonstrates a positive attitude or behavior, as this promotes the ability to learn an adaptive response. The nurse should not ask the client to change her exercise regimen, cut down on her food intake, or undergo liposuction surgery as that could lead to further medical complications. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 69 16. A client had an argument at work about his salary. The client has been consuming a lot of caffeine. The client suffers from insomnia and gets angry quickly. Which technique should the nurse promote to help the client? A. Nontherapeutic coping strategy B. Negative coping strategy C. Therapeutic coping strategy D. Sensory manipulation strategy Answer: C Rationale: Therapeutic coping strategies usually help the person to acquire insight, gain confidence to confront reality, and develop emotional maturity. Maladaptation results when people use nontherapeutic coping strategies such as mind- and mood-altering substances, hostility and aggression, excessive sleep, avoidance of conflict, and abandonment of social activities. Sensory manipulation involves altering moods, feelings, and physiologic responses by stimulating pleasure centers in the brain using sensory stimuli. Negative coping strategies may provide immediate temporary relief from a stressor, but they eventually cause problems. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs Pn: Psychosocial Integrity Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 66 17. A client who is an intravenous drug user visits a health care facility for treatment. During counseling, the client discloses that he initially took drugs because it helped him deal with stressful situations. The nurse recognizes that he is not using an effective coping strategy to overcome his stress-related problems. What kind of strategy has the client used in this case? A. nontherapeutic coping strategy B. therapeutic coping strategy C. stress-reduction strategy

D. antidepressant strategy Answer: A Rationale: The client has used nontherapeutic coping strategies such as mind- and moodaltering substances to cope with stress. Negative coping strategies may provide immediate temporary relief from a stressor, but they eventually cause problems. Therapeutic coping strategies usually help the person to acquire insight, gain confidence to confront reality, and develop emotional maturity. Also, the client has not used an antidepressant strategy. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Analyze Client Needs: Psychosocial Integrity Client Needs Pn: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 66 18. A nurse is working with a client whose quality of life is impacted by the presence of numerous comorbid health problems. The nurse is aware that the client's body is attempting to maintain homeostasis, a process that primarily involves: A. minimizing the body's exposure to external influences. B. maximizing the serum levels of hormones. C. ensuring a stable level of blood glucose. D. responding appropriately to internal and external influences. Answer: D Rationale: Homeostasis is dependent on the body maintaining constancy by adjusting and readjusting in response to changes in the internal and external environment that foster disequilibrium. This does not always involve a stable blood glucose level or high levels of hormones. As well, homeostasis is not dependent on minimizing exposure to external influences, though this may often be necessary. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs Pn: Health Promotion and Maintenance Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 59 19. A nurse is planning the care of a client who will soon begin radiotherapy for the treatment of breast cancer. The nurse has been identifying interventions that are rooted in the notion of holism, which states that: A. interactions between the mind and the body can profoundly influence health. B. an individual's medical diagnosis has local, but not systemic, effects. C. most physical illnesses do not require pharmacologic interventions or surgery. D. a client's illness affects friends and family in the same way that the client is affected. Answer: A

Rationale: Holism is the foundation of two commonly held beliefs: (1) both the mind and the body directly influence humans, and (2) the relationship between the mind and the body can potentially sustain health as well as cause illness. This does not necessarily mean that the medical interventions are unnecessary or that others are affected in the same way as the client. Holism does not preclude the presence of systemic effects of disease. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Remember Client Needs Pn: Health Promotion and Maintenance Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Culture and Spirituality Reference: p. 59 20. A client is receiving treatment in the intensive care unit for sepsis, a systemic infection that poses a grave threat to the body's homeostasis. The body is adapting to numerous threats, a process that primarily involves the integration of what body systems? Select all that apply. A. central nervous system B. autonomic nervous system C. endocrine system D. cerebellar system E. integumentary system Answer: A, B, C Rationale: Neurotransmitters mediate homeostatic adaptive responses by coordinating functions of the central nervous system, autonomic nervous system, and endocrine system. The cerebellum controls balance, which is only peripherally involved in adaptation. The integumentary system (skin and associated structures) is not a major contributor to adaptation. Question format: Multiple Select Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 60 21. A client who has been dealing with numerous physical, interpersonal, and financial stressors appears to be experiencing the final stage of Selye's general adaptation syndrome (GAS). Individuals in the final stage of the GAS are likely to experience: A. resumption of normal life roles. B. resumption of normal hormone levels. C. increased susceptibility to illness. D. increased stamina. Answer: C Rationale: The stage of exhaustion is the last phase in the GAS. It occurs when one or more adaptive or resistive mechanisms are no longer able to protect the person experiencing a stressor. Consequently, the person is vulnerable to illness. This stage of the GAS is not

associated with the adoption of normal life roles or increased stamina. Hormone levels are abnormal in the exhaustion stage. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 64 22. A client has been admitted to the emergency department following a motorcycle accident and is experiencing major physiological and psychological stressors during this period. What sign or symptom may be attributable to the parasympathetic effects of stress? A. increased muscle tone B. increased perspiration C. increased bronchoconstriction D. increased heart rate Answer: C Rationale: Contraction of the bronchial muscles is associated with the parasympathetic stress response. Increased heart rate, muscle tone, and perspiration are characteristics of sympathetic stress effects. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Physiological Adaptation Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 62 23. A nurse is providing care for client who experienced a stroke. Which nursing intervention reflects the tertiary level of prevention? A. provide care transition at discharge for speech therapy B. assess blood pressure every 4 hours C. conduct mental status assessment every 2 hours D. discuss family history of hypertension Answer: A Rationale: Tertiary prevention minimizes the consequences of a disorder through aggressive rehabilitation or appropriate management of the disease. An example is speech therapy to help restore ability. Blood pressure and mental status exams are examples of secondary prevention associated with the acute stroke. Discussing family history is also secondary prevention in terms of assessing for further risk factors. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 67

24. A client with persistent nausea is diagnosed with somatization. What is the appropriate nursing action when the client reports nausea? A. Immediately administer an antiemetic. B. contact the primary care provider C. sit with the client and ask them about their feelings D. explain that the physical symptoms are all in their head Answer: C Rationale: Somatization is manifesting an emotional stress through a physical disorder. Treating the nausea with an antiemetic will not get at the root cause of the emotional issue. Contacting the primary care provider is not appropriate, as the diagnosis of somatization is present. Explaining that the physical symptoms are all in the client's head is not therapeutic. Sitting with the client to explore what is really going on is most appropriate nursing response. Question format: Multiple Choice Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 66 25. A client experienced a fight-or-flight response immediately following a car accident. What clinical symptoms would the nurse expect to assess? Select all that apply. A. increased heart rate B. decreased digestion C. heightened awareness D. pallor E. pupil constriction F. relaxed muscle tone Answer: A, B, C, D Rationale: When a situation occurs that the mind perceives as dangerous, the sympathetic nervous system prepares the body for a fight-or-flight response. Increased heart rate, decreased digestion, heightened awareness, and pallor are all clinical presentations of the sympathetic nervous system. Pupil constriction and relaxed muscle tone are associated with the parasympathetic nervous system, which restores equilibrium when danger is no longer present. Question format: Multiple Select Chapter 5: Homeostasis, Adaptation, and Stress Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 62 26. A client is experiencing a stress response each time the family visits the room. What nursing intervention is most appropriate? A. tell the family they are causing too much stress B. limit the family visits to once daily