Basic Nursing Concepts, Skills & Reasoning 1st Edition by Treas , Leslie S Test Bank

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Basic Nursing Concepts, Skills & Reasoning 1st Edition by Treas , Leslie S Test Bank

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WITH ANSWERS
Basic Nursing Concepts, Skills & Reasoning 1st Edition by Treas , Leslie S Test Bank

 

Chapter 2. Critical Thinking & the Nursing Process

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.         Which of the following characteristics do the various definitions of critical thinking have in common? Critical thinking

1)

Requires reasoned thought

2)

Asks the questions why? or how?

3)

Is a hierarchical process

4)

Demands specialized thinking skills

 

ANS:   1

The definitions listed in the text as well as definitions in Box 2-1 state that critical thinking requires reasoning or reasoned thinking. Critical thinking is neither linear nor hierarchical. That means that the steps involved in critical thinking are not necessarily sequential, where mastery of one step is necessary to proceed to the next. Critical thinking is a purposeful, dynamic, analytic process that contributes to reasoned decisions and sound contextual judgments.

 

PTS:    1          DIF:    Moderate         REF:    p. 25; high-level question, answer not stated verbatim

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Analysis

 

 

 

____    2.         A few nurses on a unit have proposed to the nurse manager that the process for documenting care on the unit be changed. They have described a completely new system. Why is it important for the nurse manager to have a critical attitude? It will help the manager to

1)

Consider all the possible advantages and disadvantages

2)

Maintain an open mind about the proposed change

3)

Apply the nursing process to the situation

4)

Make a decision based on past experience with documentation

 

ANS:   2

A critical attitude enables the person to think fairly and keep an open mind.

 

PTS:    1          DIF:    Moderate         REF:    pp. 26

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension

 

 

 

____    3.         The nurse has just been assigned to the clinical care of a newly admitted patient. To know how to best care for the patient, the nurse uses the nursing process. Which step would the nurse probably do first?

1)

Assessment

2)

Diagnosis

3)

Plan outcomes

4)

Plan interventions

 

ANS:   1

Assessment is the first step of the nursing process. The nursing diagnosis is derived from the data gathered during assessment, outcomes from the diagnosis, and interventions from the outcomes.

 

PTS:    1          DIF:    Easy    REF:    p. 30-31

KEY:   Nursing process: Assessment | Client need: SECE | Cognitive level: Application

 

 

 

____    4.         Which of the following is an example of theoretical knowledge?

1)

A nurse uses sterile technique to catheterize a patient.

2)

Room air has an oxygen concentration of 21%.

3)

Glucose monitoring machines should be calibrated daily.

4)

An irregular apical heart rate should be compared with the radial pulse.

 

ANS:   2

Theoretical knowledge consists of research findings, facts, principles, and theories. The oxygen concentration of room air is a scientific fact. The others are examples of practical knowledgewhat to do and how to do it.

 

PTS:    1          DIF:    Moderate         REF:    p. 30; high-level question, answer not stated verbatim

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Application

 

 

 

____    5.         Which of the following is an example of practical knowledge? (Assume all are true.)

1)

The tricuspid valve is between the right atrium and ventricle of the heart.

2)

The pancreas does not produce enough insulin in type 1 diabetes.

3)

When assessing the abdomen, you should auscultate before palpating.

4)

Research shows pain medication given intravenously acts faster than by other routes.

 

ANS:   3

Practical knowledge is knowing what to do and how to do it, such as how to do an assessment. The others are examples of theoretical knowledge, anatomy (tricuspid valve), fact (type 1 diabetes), and research (IV pain medication).

 

PTS:    1          DIF:    Moderate         REF:    p. 30; high-level question, answer not stated verbatim

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Application

 

 

 

____    6.         Which of the following is an example of self-knowledge? The nurse thinks, I know that I

1)

Should take the clients apical pulse for 1 minute before giving digoxin

2)

Should follow the clients wishes even though it is not what I would want

3)

Have religious beliefs that may make it difficult to take care of some clients

4)

Need to honor the clients request not to discuss his health concern with the family

 

ANS:   3

Self-knowledge is being aware of your religious and cultural beliefs and values. Taking the pulse is an example of practical knowledge. Following client wishes and honoring client requests are examples of ethical knowledge.

 

PTS:    1          DIF:    Difficult          REF:    p. 30; high-level question, answer not stated verbatim | V1, p. 32; high-level question, answer not stated verbatim

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Application

 

 

 

____    7.         Which of the following is the most important reason for nurses to be critical thinkers?

1)

Nurses need to follow policies and procedures.

2)

Nurses work with other healthcare team members.

3)

Nurses care for clients who have multiple health problems.

4)

Nurses have to be flexible and work variable schedules.

 

ANS:   3

Critical thinking is essential for client care, particularly when the care is complex, involving numerous health issues. Following policies and procedures does not necessarily require critical thinking, and working with others or being flexible and working different schedules do not necessarily require critical thinking.

 

PTS:    1          DIF:    Moderate         REF:    p. 26-27; high-level question, answer not stated verbatim

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Application

 

 

 

____    8.         The nurse administering pain medication every 4 hours is an example of which aspect of patient care?

1)

Assessment data

2)

Nursing diagnosis

3)

Patient outcome

4)

Nursing intervention

 

ANS:   4

Interventions are activities that will help the patient achieve a goal, such as administering pain-relieving medication. An example of assessment data might be, Patient reports pain is a 5 on a 1 to 10 scale. The nursing diagnosis would be Pain. The nurse might define the patient outcome in this scenario as, The patient will state the level of pain is less than 4.

 

PTS:    1          DIF:    Moderate         REF:    p. 31; high-level question, answer not stated verbatim

KEY:   Nursing process: Interventions | Client need: SECE | Cognitive level: Application

 

 

 

____    9.         How does nursing diagnosis differ from a medical diagnosis? A nursing diagnosis is

1)

Terminology for the clients disease or injury

2)

A part of the clients medical diagnosis

3)

The clients presenting signs and symptoms

4)

A clients response to a health problem

 

ANS:   4

A nursing diagnosis is the clients response to actual or potential health problems.

 

PTS:    1          DIF:    Moderate         REF:    p. 31

KEY:   Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall

 

 

 

____    10.       Which statement about the nursing process is correct?

1)

It was developed from the ANA Standards of Care.

2)

It is a problem-solving method to guide nursing activities.

3)

It is a linear process with separate, distinct steps.

4)

It involves care that only the nurse will give.

 

ANS:   2

The nursing process is a problem-solving process that guides nursing actions. The ANA organizes its Standards of Care around the nursing process, but the process was not developed from the standards. The nursing process is cyclical and involves care the nurses give or delegate to other members of the healthcare team.

 

PTS:    1          DIF:    Easy    REF:    p. 31

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Recall

 

 

 

____    11.       What do critical thinking and the nursing process have in common?

1)

They are both linear processes used to guide ones thinking.

2)

They are both thinking methods used to solve a problem.

3)

They both use specific steps to solve a problem.

4)

They both use similar steps to solve a problem.

 

ANS:   2

Critical thinking and the nursing process are ways of thinking that can be used in problem solving (although critical thinking can be used beyond problem-solving applications). Neither method of thinking is linear. The nursing process has specific steps; critical thinking does not.

 

PTS:    1          DIF:    Difficult          REF:    p. 31

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Analysis

 

 

 

____    12.       A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. To develop a nursing diagnosis, the nurse must now

1)

Analyze the assessment data

2)

Consult standards of care

3)

Decide which interventions are appropriate

4)

Ask the clients perceptions of her health problem

 

ANS:   1

The basis of the nursing diagnosis is the assessment data. Standards of care are referred to when establishing nursing interventions. Customizing interventions personalizes nursing care. Asking the patient about her perceptions is a method to validate whether the nurse has chosen the correct nursing diagnosis and would probably have been done during the comprehensive assessment.

 

PTS:    1          DIF:    Moderate         REF:    p. 31

KEY:   Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application

 

 

 

____    13.       The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. She has made sure that nursing assistive personnel change the patients position every 2 hours. In the evaluation phase of the nursing process, which of the following would the nurse do first?

1)

Determine whether she has gathered enough assessment data.

2)

Judge whether the interventions achieved the stated outcomes.

3)

Follow up to verify that care for the nursing diagnosis was given.

4)

Decide whether the nursing diagnosis was accurate for the patients condition.

 

ANS:   2

The evaluation phase judges whether the interventions were effective in achieving the desired outcomes and helped to alleviate the nursing diagnosis. This must be done before examining the nursing process steps and revising the care plan.

 

PTS:    1          DIF:    Moderate         REF:    p. 31

KEY:   Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis

 

 

 

____    14.       In caring for a patient with comorbidities, the nurse draws upon her knowledge of diabetes and skin integrity. In a spirit of inquiry, she looks up the latest guidelines for providing skin care and includes them in the plan of care. The nurse provides skin care according to the procedural guidelines and begins regular monitoring to evaluate the effectiveness of the interventions. These activities are best described as

1)

Full-spectrum nursing

2)

Critical thinking

3)

Nursing process

4)

Nursing knowledge

 

ANS:   1

Full-spectrum nursing (1) involves the use of critical thinking, nursing knowledge, nursing process, and patient situation. Although the other answers are important for planning and delivering nursing care, they do not reflect all the nurse has demonstrated.

 

PTS:    1          DIF:    Difficult          REF:    pp. 32-33; high-level question, answer not stated verbatim

KEY:   Nursing process: N/A | Client need: PHSI | Cognitive level: Analysis

 

 

 

____    15.       The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient is obese. The nurse has been overweight at one time and works very hard now to maintain a healthy weight. She immediately thinks, I know I tend to feel negatively about obese people; I figure if I can stop eating, they should be able to. I must remember how very difficult that is and be very careful not to be judgmental of this patient. This best illustrates

1)

Theoretical knowledge

2)

Self-knowledge

3)

Using reliable resources

4)

Use of the nursing process

 

ANS:   2

Self-knowledge is self-understandingawareness of ones beliefs, values, biases, and so on. That best describes the nurses awareness that her bias can affect her patient care. Theoretical knowledge consists of information, facts, principles, and theories in nursing and related disciplines; it consists of research findings and rationally constructed explanations of phenomena. Using reliable resources is a critical thinking skill. The nursing process is a problem-solving process consisting of the steps of assessing, diagnosing, planning outcomes, planning interventions, implementing, and evaluating. The nurse has not yet met this patient, so she could not have begun the nursing process.

 

PTS:    1          DIF:    Difficult          REF:    pp. 30; high-level question, answer not stated verbatim

KEY:   Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension

 

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____    1.         Which aspects of healthcare are affected by a clients culture? Select all that apply.

1)

How the clients views healthcare

2)

How the client views illness

3)

How the client will pay for healthcare services

4)

The types of treatments the client will accept

5)

When the client will seek healthcare services

6)

The environment where the healthcare services are provided

7)

The ease of accessibility of healthcare services

 

ANS:   1, 2, 4, 5

Culture affects clients view of health and healthcare. It influences how they will define illness, when they will seek healthcare, and what treatments are acceptable in their culture. How services are paid for is related to economic status. Regardless of culture, anyone can be affected by previous healthcare experiences, the environment in which healthcare is provided, and accessibility of services.

 

PTS:    1          DIF:    Moderate         REF:    p. 27

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Recall

 

 

 

Matching

 

Match the critical thinking attitude on the left with the appropriate example on the right.

 

1) Reading the instruction manual of a new glucose monitoring machine

2) Asking for help with a procedure because you have not done it before

3) Obtaining the latest research about a new diagnostic procedure even though the articles are difficult to find

4) Questioning the reason for a new staffing policy

5) Realizing your feelings about alternative medicine may interfere with the care you give a patient

6) Asking a patients feelings about his cancer diagnosis

7) Questioning your feelings when a patients family requests withholding nutrition for a terminally ill client

 

____    1.         Independent thinking

 

____    2.         Intellectual curiosity

 

____    3.         Intellectual humility

 

____    4.         Intellectual empathy

 

____    5.         Intellectual courage

 

____    6.         Intellectual perseverance

 

  1. ANS: 4          PTS:    1          DIF:    Difficult          REF:    p. 26

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Application

 

  1. ANS: 1          PTS:    1          DIF:    Difficult          REF:    p. 26

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Application

 

  1. ANS: 2          PTS:    1          DIF:    Difficult          REF:    p. 26

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Application

 

  1. ANS: 6          PTS:    1          DIF:    Difficult          REF:    p. 26

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Application

 

  1. ANS: 7          PTS:    1          DIF:    Difficult          REF:    p. 26

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Application

 

  1. ANS: 3          PTS:    1          DIF:    Difficult          REF:    p. 26

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Application

 

 

 

Match the terms from the critical thinking model in your text with the correct example.

 

1) I wonder if my values about quality of life have affected my thinking.

2) What should I have done differently?

3) I need to talk with the client to make sure the family gave me the correct information.

4) I have been through a situation like this before.

5) There are several interventions that would work in this situation.

6) I need to follow the steps in the procedure manual.

 

____    7.         Contextual awareness

 

____    8.         Inquiry

 

____    9.         Considering alternatives

 

____    10.       Analyzing assumptions

 

____    11.       Reflecting skeptically

 

  1. ANS: 4          PTS:    1          DIF:    Difficult

REF:    p. 28-29; High-level question, answer not stated verbatim

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Analysis

 

  1. ANS: 3          PTS:    1          DIF:    Difficult

REF:    p. 28-29; High-level question, answer not stated verbatim

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Analysis

 

  1. ANS: 5          PTS:    1          DIF:    Difficult

REF:    p. 28-29; High-level question, answer not stated verbatim

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Analysis

 

  1. ANS: 1          PTS:    1          DIF:    Difficult

REF:    p. 28-29; High-level question, answer not stated verbatim

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Analysis

 

  1. ANS: 2          PTS:    1          DIF:    Difficult

REF:    p. 28-29; High-level question, answer not stated verbatim

KEY:   Nursing process: N/A | Client need: SECE | Cognitive level: Analysis

 

 

 

 

Chapter 16. Spirituality

 

True/False

Indicate whether the statement is true or false.

 

____    1.         Religion provides people with instruction and guidance about what to believe and what values are essential.

 

ANS:   T

Religion provides instruction and guidance on beliefs, values, and codes of conduct. In contrast, spirituality is a journey that integrates life experiences and understanding.

 

PTS:    1          DIF:    Easy    REF:    p. 339

KEY:   Nursing process: N/A | Client need: PSI | Cognitive level: Recall

 

 

 

____    2.         Spirituality occurs over time and involves the accumulation of life experiences and understanding.

 

ANS:   T

Spirituality is like a journey; it occurs over time and involves the accumulation of experiences and understanding, whereas religion provides general instruction and guidance on beliefs, values, and codes of conduct.

 

PTS:    1          DIF:    Easy    REF:    pp. 339-340

KEY:   Nursing process: N/A | Client need: PSI | Cognitive level: Recall

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.         Which statement best describes theology?

1)

Discussions and theories related to God and His relation to the world

2)

Doctrines about the human soul and its relation to eternal life

3)

A life-long journey involving accumulation of experience and understanding

4)

Codes of conduct that integrate beliefs and values

 

ANS:   1

Theology is best described as discussions and theories related to God and His relation to the world. Eschatology includes doctrines about the human soul and its relation to death, judgment, and eternal life. Spirituality is considered a lifelong journey. Religion provides codes of conduct that integrate beliefs and values.

 

PTS:    1          DIF:    Moderate         REF:    p. 339

KEY:   Nursing process: N/A | Client need: PSI | Cognitive level: Recall

 

 

 

____    2.         Which of the following is considered a religious denomination within the tradition of Christianity?

1)

Buddhism

2)

Jehovahs Witnesses

3)

Sikhism

4)

Islam

 

ANS:   2

Jehovahs Witnesses is a religious denomination within Christianity. Buddhism, Sikhism, and Islam are all religious traditions outside of Christianity.

 

PTS:    1          DIF:    Easy                REF:    pp. 342-343; ESG, Chapter 16, Supplemental Materials, Major Religions: What Should I Know?

KEY:   Nursing process: N/A | Client need: PSI | Cognitive level: Recall

 

 

____    3.         Which factor is held in common by many of the world religions?

1)

Strict health code, including dietary laws

2)

Belief that one must submit to a god or gods

3)

Rules prohibiting alcohol consumption

4)

Sacred writings that reveal the nature of the Supreme Being

 

ANS:    4

Many of the world religions have sacred writings that are authoritative and reveal the nature of the Supreme Being. Mormons follow a strict health code, which advises healthful living. Islam means submission; therefore people of Islamic faith submit to Allah. Some religions, such as Mormon, Christian Science, Bahai, and Sikhism, prohibit alcohol consumption, but many other religions permit it.

 

PTS:     1          DIF:     Easy     REF:    p. 339

KEY:   Nursing process: N/A | Client need: HPM | Cognitive level: Recall

 

 

 

____    4.         A female patient tells the charge nurse that she does not want a male nurse caring for her. Which intervention by the charge nurse is best?

1)

Explain that hospital policy does not allow nursing assignments based on the gender of the nurse.

2)

Explore with the patient her beliefs and determine which might have caused her to make this statement.

3)

Assure the patient that each nurse is capable of providing professional nursing care, regardless of their gender.

4)

Comply with the patients request and assign a female nurse to care for the patient.

 

ANS:    2

The charge nurse can best serve the patient and her staff by exploring the patients beliefs that might prevent her from being cared for by a male. There are many reasons the woman may prefer a female nurse: she may be very modest, or she may be prejudiced against male nurses, for example. Hospital policy might state that, to prevent discrimination issues, nursing assignments should not be made based on the gender of the patient or nurse. However, even if this is so, before explaining this to the patient, the charge nurse should explore the patients beliefs and make special arrangements with hospital administration to uphold the patients beliefs, if possible. Telling the patient that each nurse is capable of providing care is not sensitive to the patient and her beliefs. Simply complying with the patients wishes without further investigation may alienate the nursing staff.

 

PTS:     1          DIF:     Moderate         REF:    pp. 341-343, pp. 351-352

KEY:   Nursing process: Interventions | Client need: PSI | Cognitive level: Application

 

 

 

____    5.         A patient of Orthodox Jewish faith is admitted to the hospital with heart failure on Yom Kippur. The physician prescribes digoxin 0.25 mg to be given orally for this patient. Based on the patients religious affiliation, which of the following actions should the nurse take?

1)

Administer the medication as prescribed.

2)

Hold the medication until after Yom Kippur.

3)

Explain the importance of taking the medication despite the holiday.

4)

Ask the physician to change the route of administration.

 

ANS:    4

Orthodox Jews require an alternative to the oral route of drug administration on Yom Kippur to comply with their religious beliefs. Therefore, the nurse should ask the physician to change the route of administration. Administering the medication as prescribed breaks the patients religious tradition on the holiest day of the Jewish calendar. Holding the medication until after Yom Kippur delays treatment and may cause harm to the patient; furthermore, it is not within the scope of nursing practice to hold medications that have been prescribed by a physician. The nurse should explain the importance of the medication in any case; but the nurse should not try to convince the patient to break away from his religious tradition when an alternative route of administration is available.

 

PTS:     1          DIF:     Moderate         REF:    p. 341

KEY:   Nursing process: Interventions | Client need: PSI | Cognitive level: Application

 

 

 

____    6.         The nurse is admitting a Roman Catholic adult patient who is critically ill. Based on her knowledge of the patients religion, for which religious rite should she expect to notify the hospital chaplain?

1)

Anointing of the Sick

2)

Baptism

3)

Eucharist

4)

Sacrament of Reconciliation

 

ANS:    1

In Catholicism, those who are seriously ill might want to receive the sacrament of Anointing the Sick. The Sacrament of Reconciliation, which is performed by a priest, is used to gain forgiveness for past sins. The Eucharist, or communion, can be prepared and administered to a hospitalized patient, but it is not typically administered to someone who is critically ill. Baptism may be offered when infants or children of Christian parents are critically ill.

 

PTS:     1          DIF:     Easy     REF:    p. 342

KEY:   Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension

 

 

 

____    7.         Because of religious beliefs, which of the following patients will most likely refuse a blood transfusion? One who is affiliated with

1)

Islam

2)

Bahai

3)

Hinduism

4)

Jehovahs Witness

 

ANS:    4

Those of Jehovahs Witness faith believe that taking blood into ones body is morally wrong. Therefore, they will not consent to transfusions of whole blood or its components. Those of Islam, Bahai, and Hindu faith will, as a rule, consent to blood transfusion.

 

PTS:     1          DIF:     Easy     REF:    p. 342

KEY:   Nursing process: N/A | Client need: PSI | Cognitive level: Recall

 

 

 

____    8.         Which special consideration may the nurse need to make when caring for a female Rastafarian patient?

1)

Allow the patient to wear her own clothing.

2)

Provide a diet that is caffeine-free.

3)

Allow the patient to wear jewelry with religious symbols.

4)

Provide free-flowing water for bathing.

 

ANS:   1

Wearing secondhand clothes is taboo in the Rastafarian faith; therefore, the nurse should allow the patient to wear her own bedclothes instead of a hospital gown. Rastafarians typically consume tea, but some do not drink milk or coffee. Muslim women may wear a locket containing religious writing around the neck in a small leather bag. These are worn for protection and strength and should not be removed. Hindus prefer washing with free-flowing water for bathing, which should be provided when possible.

 

PTS:    1          DIF:   Moderate        REF:   ESG, Chapter 16, Supplemental Materials, Major Religions: What Should I Know?

KEY:   Nursing process: Interventions | Client need: PSI | Cognitive level: Application

 

 

 

 

____    9.         What is the most effective action by the nurse when delivering spiritual care to a patient of the same religion as the nurse?

1)

Understanding that the patient shares the same beliefs

2)

Striving to meet the patients spiritual needs independently

3)

Explaining her own religious beliefs to the patient

4)

Developing a greater awareness of her own spirituality

 

ANS:   4

The nurse can best deliver spiritual care by developing a greater awareness of her own spirituality. This allows the nurse to be a better listener and provide better care for the patient. The nurse should avoid assuming that a patient who shares the same religious affiliation has the same beliefs. Moreover, the nurse should avoid trying to meet the patients spiritual needs independently. A team approach to spirituality provides more comprehensive care. Also, unless asked, the nurse should avoid explaining her own religious beliefs, which might offend the patient.

 

PTS:    1          DIF:    Moderate         REF:    p. 345

KEY:   Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension

 

 

 

____    10.       A Muslim client has asked the nurse to pray with her. Which item should the nurse anticipate that the patient may request before praying?

1)

Bathing water

2)

Rosary beads

3)

Mala beads

4)

Prayer cloth

 

ANS:   1

Muslims may want water to wash the mouth, nostrils, and hands before praying. Roman Catholics may want to hold their rosary beads while praying. Some Buddhists and Hindus meditate with a set of beads, called a mala. Others may use a prayer cloth or other religious items.

 

PTS:    1          DIF:    Moderate         REF:    pp. 342-343, 350-351; ESG, Chapter 16, Supplemental Materials, Major Religions: What Should I Know?

KEY:   Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension

 

 

 

____    11.       When performing a spiritual assessment, who is the preferred source of information?

1)

Durable power of attorney

2)

Next of kin

3)

Patient

4)

Patients clergyman

 

ANS:   3

The patient is the preferred source of information. In the event of an emergency admission or when a patient cannot give information, the nurse can consult the next of kin or the durable power of attorney for information about the patients spirituality. Contacting the clergyman without the patients permission is a breach of patient confidentiality.

 

PTS:    1          DIF:    Moderate         REF:    pp. 346-347; high-level question, not answered verbatim in text.

KEY:   Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis

 

 

 

____    12.       Which type of medicine do those of Hindu faith typically practice?

1)

Ayurvedic medicine

2)

Western medicine

3)

Chiropractic medicine

4)

Qigong

 

ANS:   1

Those of Hindu faith typically practice Ayurvedic medicine, which encompasses all aspects of life, including diet, sleep, elimination, and hygiene. Some believe in the medicinal properties of hot and cold foods, which have nothing to do with temperature or degree of spiciness. People who practice Hinduism do not typically practice Western medicine, chiropractic medicine, or Qigong. Qigong, a form of Chinese martial arts, is used to achieve healing through focus on the bodys energy centers.

 

PTS:    1          DIF:    Moderate         REF:    p. 343

KEY:   Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension

 

 

 

____    13.       A patient tells the nurse, I feel that God has abandoned me. I am so angry that I cant even pray. The patient refuses to see his clergyman when he calls. Which is the most appropriate nursing diagnosis for this patient?

1)

Spiritual Distress

2)

Risk for Spiritual Distress

3)

Impaired Religiosity

4)

Moral Distress

 

ANS:   1

This patient exhibits three defining characteristics for Spiritual Distress (feeling abandoned by God, inability to pray, refusing to see a religious leader). Therefore, the actual problem of Spiritual Distress exists, not the potential problem of Risk for Spiritual Distress. Impaired Religiosity is difficulty in exercising or impaired ability to exercise reliance on beliefs or to participate in rituals of a faith tradition (e.g., going to church). This patient is not unable to see the clergyman but chooses not to. Moral Distress occurs when a person makes a moral decision but is prevented from carrying out the chosen action.

 

PTS:    1          DIF:    Moderate         REF:    p. 348

KEY:   Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis

 

 

 

____    14.       The nurse is asking the patient reflective, clarifying questions to help the patient make a list of what is important and not important in life and the time commitment for each. Which standardized (NIC) nursing intervention does this action implement?

1)

Spiritual Support

2)

Self-Esteem Enhancement

3)

Values Clarification

4)

Hope Inspiration

 

ANS:   3

One of the steps of most values-clarification processes is to list values (what is important and not important in ones life) and the time commitment for each. The nurse facilitates this by asking reflective, clarifying questions of the patient. Values clarification does not necessarily directly enhance self-esteem, inspire hope, or provide spiritual support, although it can indirectly contribute to development of spiritual identity.

 

PTS:    1         DIF:    Moderate        REF:    ESG, Chapter 16, Standardized Language, Table   Standardized Language: Using Selected NIC Interventions and Activities to Support Spirituality

KEY:    Nursing process: Interventions | Client need: PSI | Cognitive level: Application

 

 

 

 

____    15.       The nurse is a Christian. She is caring for a Jewish patient who has asked her to offer a prayer at the bedside. The nurse feels comfortable doing so. Which of the following actions by the nurse is appropriate?

1)

Offer a prayer for healing using the nurses usual words and format.

2)

Begin the prayer with Jehovah God as she always does while avoiding the name of Jesus.

3)

Avoid saying any name for the Supreme Being while praying and quote an Old Testament Bible scripture as the prayer.

4)

Say, What name would you like for me to use to address the Supreme Being when I am praying for you?

 

ANS:   4

Ask how the patient prefers to address the Divine. Some people prefer the use of parental language in their prayers; for example, Father God or Divine Mother. Some use the names Jehovah, Yahweh, or Allah. Hindus may address one or more of multiple gods, each of whom has several names. So seek direction from the patient in these matters: Most people are honored to be able to explain their beliefs and practices to someone who is open to the experience. The nurse should not assume that using the names Jesus and Jehovah God would be supportive to the patient, although they might not offend in any way. The nurse does not need to avoid addressing God by a name, but the most supportive way to do so is to find out the name the patient wishes to use. Furthermore, the nurse should not assume that the patient would find a New Testament Bible verse to be helpful spiritually.

 

PTS:    1          DIF:    Moderate         REF:    p. 350

KEY:   Nursing process: Implementation | Client need: PSI | Cognitive level: Application

 

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____    1.         A patient has a nursing diagnosis of Noncompliance with medication regimen related to a belief that God will heal her and that it would show a lack of faith to take the medications. The nurse and a clergyman have spent some time discussing spiritual and treatment issues with the patient. Which of the following would indicate that progress is being made toward achieving compliance with healthcare therapy? (Choose all that apply.) The patient says

1)

I will try to pray more often for stronger faith that God will heal me.

2)

Let me think about it until tomorrow; I may see my way to taking those pills then.

3)

You know, Ive known some very holy people who were not cured by God.

4)

There is no confusion in my mind as to the right thing for me to do.

 

ANS:   2, 3

Agreeing to consider treatment (think about it) and recognizing that sometimes faithful people are not cured both suggest that the patient is at least considering that it is all right for her to question her beliefs. Praying for stronger faith in Gods healing suggests that she is holding strong in her belief that she will be healed if she only has enough faith. Having no confusion about the right thing to do would be evidence of problem resolution, provided the right thing to do is to take the medication. However, you need more information to know if that is what the patient means. It could just as easily mean that she is more sure than ever that she should not take the medication.

 

PTS:    1          DIF:    Difficult          REF:    pp. 346-349; answer not stated in text; student must infer answer from question content

KEY:   Nursing process: Evaluation | Client need: PSI | Cognitive level: Application

 

Chapter 32. Pain

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____       1.   A patient suddenly develops right lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patients pain?

1)

Acute

2)

Chronic

3)

Intractable

4)

Neuropathic

 

 

ANS:       1

Acute pain typically has a short duration and a rapid onset. Chronic pain lasts longer than 6 months and interferes with daily activities. Intractable pain is chronic and highly resistant to relief. Neuropathic pain is a type of chronic pain that occurs from injury to one or more nerves.

 

PTS:    1                      DIF:    Easy                REF:    p. 1092

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

 

 

 

____       2.   How should the nurse classify pain that a patient with lung cancer is experiencing?

1)

Radiating

2)

Deep somatic

3)

Visceral

4)

Referred

 

 

ANS:       3

Visceral pain is commonly experienced in the abdominal cavity, cranium, or thorax. Lung cancer produces visceral pain. Radiating pain starts at the source and extends to other locations. Deep somatic pain is typically caused by fracture, sprain, arthritis, and bone cancer. Referred pain occurs in an area distant from the original site.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1091

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

 

 

 

____       3.   A patient who underwent a left above-the-knee amputation complains of pain in his left foot. The nurse should document this finding as what type of pain?

1)

Psychogenic

2)

Phantom

3)

Referred

4)

Radiating

 

 

ANS:       2

The nurse should document this finding as phantom pain. Phantom pain is pain that is perceived to originate in an area that has been amputated. Psychogenic pain refers to pain experienced by a person which does not match the symptoms or the apparent source of pain. It is thought to arise from psychological factors and is disproportional to the painful stimuli. Referred pain occurs in an area distant from the original site. Radiating pain starts at the source but extends to other locations.

 

PTS:    1                      DIF:    Easy                REF:    p. 1091

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

 

 

 

____       4.   A patient who sustained a leg laceration in an industrial accident is brought to the emergency department. The area around the laceration is red, swollen, and tender. Which substance is responsible for causing this response?

1)

Histamine

2)

Prostaglandin

3)

Bradykinin

4)

Serotonin

 

 

ANS:       3

Tissue damage causes the release of the substances histamine, bradykinin, and prostaglandin. Bradykinin triggers the release of inflammatory chemicals that cause the injured area to become red, swollen, and tender. Serotonin is a neurotransmitter and is not involved in the inflammatory response.

 

PTS:    1                      DIF:    Difficult          REF:    p. 1092

KEY:   Nursing process: NA | Client need: PHSI | Cognitive level: Application

 

 

 

____       5.   In which process do peripheral nerves carry the pain message to the dorsal horn of the spinal cord?

1)

Transduction

2)

Transmission

3)

Perception

4)

Modulation

 

 

ANS:       2

Peripheral nerves carry the pain message to the dorsal horn of the spinal cord during a process known as transmission. In a process called transduction, specialized nociceptors convert potentially damaging mechanical, thermal, and chemical stimuli into electrical activity that leads to the experience of pain. Perception involves the recognition of pain by the frontal cortex of the brain. During modulation, pain signals can be facilitated or inhibited, and the perception of pain can be changed.

 

PTS:    1                      DIF:    Difficult          REF:    p. 1092

KEY:   Nursing process: NA | Client need: PHSI | Cognitive level: Recall

 

 

 

____       6.   A patient reports that he uses music therapy to help control his chronic pain. Music therapy works by prompting the release of endogenous opioids during which stage of the pain process?

1)

Perception

2)

Transduction

3)

Transmission

4)

Modulation

 

 

ANS:       4

Music therapy can prompt the release of endogenous opioids during the modulation stage, which is the stage of the pain process where the perception of pain changes. It is not during the perception (recognizing the pain sensation), transmission (relaying the pain message), or transduction (converting potentially damaging stimuli into electrical activity leading to pain sensation).

 

PTS:    1                      DIF:    Moderate        REF:    pp. 1093, 1100; synthesis of information required

KEY:   Nursing process: Planning | Client need: PHSI | Cognitive level: Recall

 

 

 

____       7.   The nurse is assessing an intubated patient who returned from coronary artery bypass surgery 3 hours ago. Which assessment finding might indicate that this patient is experiencing pain?

1)

Blood pressure 160/82 mm Hg

2)

Temperature 100.6F

3)

Heart rate 80 beats/min

4)

Oxygen saturation 95%

 

 

ANS:       1

This patient has an elevation in blood pressure which is a physiological finding associated with pain. The patient has a mild temperature elevation, which is a common response to surgery. Heart rate and oxygen saturation are within normal limits.

 

PTS:    1                      DIF:    Moderate        REF:    pp. 1095-1096

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

 

 

 

____       8.   A patient who sustained rib fractures in a motor vehicle accident is complaining that his pain medication is ineffective. Inadequate pain control places this patient at risk for which complication?

1)

Metabolic alkalosis

2)

Pneumothorax

3)

Pneumonia

4)

Hemothorax

 

 

ANS:       3

Pain associated with rib fractures causes splinting. Splinting often causes the patient to breathe shallowly and avoid deep coughing to expel sputum, which can lead to pneumonia. Rib fractures can also lead to complications such as pneumothorax and hemothorax; however, they do not result from inadequate pain control. Respiratory acidosis, not metabolic alkalosis, may result from the shallow breaths caused by pain and restricted chest wall movement with splinting.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1096

KEY:   Nursing process: Planning | Client need: PHSI | Cognitive level: Application

 

 

 

____       9.   When should the nurse assess pain?

1)

Whenever a full set of vital signs is taken

2)

During the admission interview

3)

Every 4 hours for the first 2 days after surgery

4)

Only when the patient complains of pain

 

 

ANS:       1

The nurse should assess pain whenever a full set of vital signs is checked. Moreover, the nurse should assess pain on admission of a patient to the facility, even when pain is not the chief complaint. Patients may have chronic pain that has no association with their reason for seeking care. Pain should be assessed more frequently than every 4 hours in the immediate postoperative period. Pain should be reassessed after any treatment is given to evaluate effectiveness of the treatment. Some patients may not complain of pain unless they are specifically asked whether they are in pain. Pain rating scales help to quantify the intensity of pain for the nurse providing analgesia.

 

PTS:    1                      DIF:    Moderate        REF:    pp. 1096-1098

KEY:   Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

 

 

 

____     10.   Which nursing diagnosis is most appropriate for the patient who returns from the postanesthesia care unit after undergoing right hemicolectomy surgery for colon cancer?

1)

Acute pain secondary to surgery

2)

Acute pain (abdominal) secondary to surgery for colon cancer

3)

Chronic pain secondary to cancer diagnosis

4)

Chronic pain (abdominal) secondary to abdominal surgery

 

 

ANS:       2

The nurse should identify a diagnosis by specifying the location of the pain and any precipitating or etiological factors. This patient is experiencing acute abdominal pain that is related to his surgery for colon cancer; therefore, a nursing diagnosis that specifies the surgery is the most appropriate diagnosis for this patient. In addition, options listing chronic pain are incorrect because the pain is acute, not chronic.

 

PTS:    1                      DIF:    Moderate        REF:    p. 1100

KEY:   Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application

 

 

 

____     11.   Which drug might the primary care provider prescribe to help facilitate pain management in a client with chronic pain?

1)

Selective serotonin reuptake inhibitor

2)

Selective norepinephrine reuptake inhibitor

3)

Narcotic analgesic

4)

Anti-emetic

 

 

ANS:       1

The control of depression greatly facilitates pain management, especially for patients experiencing chronic pain. Therefore, the physician may prescribe a selective serotonin uptake inhib

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