Foundations Of Nursing 6th Edition by Barbara Lauritsen Christensen Test Bank

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Foundations Of Nursing 6th Edition by Barbara Lauritsen Christensen Test Bank

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WITH ANSWERS
Foundations Of Nursing 6th Edition by Barbara Lauritsen Christensen Test Bank

Christensen: Foundations of Nursing, 6th Edition

 

Chapter 02: Legal and Ethical Aspects of Nursing

 

Test Bank

 

MULTIPLE CHOICE

 

  1. When a nurse becomes involved in a legal action, the first step to occur is that a document is filed in an appropriate court. This document is called a(n):
a. deposition.
b. appeal.
c. complaint.
d. answer.

 

 

ANS:   C

A document called a complaint is filed in an appropriate court as the first step in litigation.

 

DIF:    Cognitive Level: Analysis       REF:    Page 23           OBJ:    1

TOP:    Legal   KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. Assuming responsibility for a patients care forms a legally binding situation described as:
a. nurse-patient relationship.
b. accountability.
c. advocacy.
d. standard of care.

 

 

ANS:   A

When the nurse assumes responsibility for a patients care, the nurse-patient relationship is formed. This is a legally binding contract for which the nurse must take responsibility.

 

DIF:    Cognitive Level: Analysis       REF:    Page 24           OBJ:    2

TOP:    Legal   KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. Universal guidelines that define appropriate measures for all nursing interventions that should be observed during the performance of those interventions are known as:
a. scope of practice.
b. advocacy.
c. standard of care.
d. prudent practice.

 

 

ANS:   C

Standards of care define actions that are permitted or prohibited in most nursing interventions. These standards are accepted as legal guidelines for appropriateness of performance.

 

DIF:    Cognitive Level: Analysis       REF:    Page 22           OBJ:    3

TOP:    Legal   KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. The laws that formally define and limit the scope of nursing practice in that state are the:
a. standards of care.
b. regulation of practice.
c. American Nurses Association Code.
d. nurse practice act.

 

 

ANS:   D

It is the nurses responsibility to know the nurse practice act in his or her state.

 

DIF:    Cognitive Level: Application  REF:    Page 25           OBJ:    4

TOP:    Legal   KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. A nurse who failed to irrigate a feeding tube as ordered resulting in harm to the patient could be found guilty of:
a. malpractice.
b. harm to the patient.
c. negligence.
d. failure to follow the Nurse Practice Act.

 

 

ANS:   A

The nurse can be held liable for malpractice for acts of omission. Failure to meet a legal duty, thus causing harm to another, is malpractice. The Nurse Practice Act has general guidelines that can support the charge of malpractice.

 

DIF:    Cognitive Level: Analysis       REF:    Page 26           OBJ:    5

TOP:    Legal   KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. Patients have expectations regarding the health care services they receive. To protect these expectations, which has become law?
a. American Hospital Associations Patients Bill of Rights
b. Self-Determination Act
c. American Hospital Associations Standards of Care
d. JCAHO rights and responsibilities of patients

 

 

ANS:   A

The American Hospital Association developed the Patients Bill of Rights.

 

DIF:    Cognitive Level: Application  REF:    Page 26           OBJ:    7

TOP:    Legal   KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed?
a. Physical assessment
b. Interview
c. Informed consent
d. Surgical checklist

 

 

ANS:   C

The patient must consent to allow certain procedures to be performed after being fully informed of the benefits and risks.

 

DIF:    Cognitive Level: Application  REF:    Page 27           OBJ:    7

TOP:    Legal   KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. By protecting the information in a patients record, the nurse fulfills the ethical responsibility of:
a. privacy.
b. disclosure.
c. confidentiality.
d. absolute secrecy.

 

 

ANS:   C

The nurse has an ethical and legal duty to protect information about a patient and preserve confidentiality. Some disclosures are legal and anticipated and may not be subject to the rules of confidentiality. None of the information in a chart is considered secret.

 

DIF:    Cognitive Level: Application  REF:    Page 26           OBJ:    7

TOP:    Confidentiality                        KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. An older adult is admitted to the hospital with numerous bodily bruises, and the nurse suspects elder abuse. The best nursing action is to:
a. cover the bruises with bandages.
b. take photographs of the bruises.
c. ask the patient if anyone has hit her.
d. report the bruises to the charge nurse.

 

 

ANS:   D

The nurse must be alert to signs of elder abuse and know procedures for reporting.

 

DIF:    Cognitive Level: Analysis       REF:    Page 29           OBJ:    7

TOP:    Elder abuse     KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. The nurse concludes that the best way to avoid a lawsuit is to:
a. carry malpractice insurance.
b. spend time with the patient.
c. provide compassionate, competent care.
d. answer all call lights quickly.

 

 

ANS:   C

The best defense against a lawsuit is to provide compassionate and competent nursing care.

 

DIF:    Cognitive Level: Application  REF:    Page 29           OBJ:    6

TOP:    Avoiding a lawsuit                  KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. When seeking advice involving the patients right to refuse medication, the nurse should most appropriately consult:
a. a minister or priest.
b. the hospital ethics committee.
c. the nursing supervisor.
d. a more experienced nurse.

 

 

ANS:   B

The nurse should seek the advice of the hospital ethics committee.

 

DIF:    Cognitive Level: Analysis       REF:    Page 31           OBJ:    13

TOP:    Ethics  KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. Although the nurse may disagree with a do-not-resuscitate (DNR) order, legally he or she:
a. may question the doctor.
b. may seek advice from the family.
c. may discuss it with the patient.
d. must follow the order.

 

 

ANS:   D

When a DNR order is written in the chart, the nurse has a duty to follow the order.

 

DIF:    Cognitive Level: Application  REF:    Page 33           OBJ:    11

TOP:    Legal   KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. The nurse has strong moral convictions that abortions are wrong. When assigned to assist with an abortion, the nurse has the right to:
a. ask for another assignment.
b. leave work.
c. transfer to another floor.
d. protest to the supervisor.

 

 

ANS:   A

The nurse should not abandon the patient, but ask for another assignment.

 

DIF:    Cognitive Level: Analysis       REF:    Page 33           OBJ:    14

TOP:    Ethics  KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. The new LPN/LVN is concerned regarding what should or should not be done for patients. Select the resource that will best provide this information.
a. Nurse Practice Act
b. Standards of care
c. Scope of nursing practice
d. Professional organizations

 

 

ANS:   B

Standards of care define what should or should not be done for patients.

 

DIF:    Cognitive Level: Analysis       REF:    Page 24           OBJ:    3

TOP:    Standards of care                    KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. The nurse who diligently works for the protection of patients interests is functioning in the role of:
a. caregiver.
b. health care administrator.
c. advocate.
d. health care evaluator.

 

 

ANS:   C

A nurse accepts the role of advocate when, in addition to general care, the nurse protects the patients interests.

 

DIF:    Cognitive Level: Application  REF:    Page 24           OBJ:    14

TOP:    Advocate        KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. When asked to perform a procedure that the nurse has never done before, what should the nurse do to legally protect himself or herself?
a. Go ahead and do it.
b. Refuse to perform it, citing lack of knowledge.
c. Discuss it with the charge nurse, asking for direction.
d. Ask another nurse who has performed the procedure.

 

 

ANS:   C

The nurse cannot use ignorance as an excuse for nonperformance. The nurse should ask for direction from the charge nurse, explaining she has never performed the procedure independently.

 

DIF:    Cognitive Level: Analysis       REF:    Page 25           OBJ:    6

TOP:    Legal   KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. The nurse is assisting a patient to clarify values by encouraging the expression of feelings and thoughts related to the situation. The nurse recognizes it is necessary to:
a. compare her values with those of the patient.
b. make a judgment.
c. withhold an opinion.
d. give advice.

 

 

ANS:   C

The nurse can assist the patient in values clarification without giving an opinion.

 

DIF:    Cognitive Level: Analysis       REF:    Page 31           OBJ:    11

TOP:    Values clarification                 KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. When confronted with an ethical decision, the nurse must observe the first fundamental principle of:
a. autonomy.
b. beneficence.
c. respect for people.
d. nonmaleficence.

 

 

ANS:   C

The first fundamental principle is respect for people.

 

DIF:    Cognitive Level: Analysis       REF:    Page 32           OBJ:    14

TOP:    Ethics  KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. Since a nurses first duty is to the patients health, safety, and well-being, it is necessary to report:
a. unethical behavior of other staff members.
b. a worker who arrives late.
c. favoritism shown by nursing administration.
d. arguments among the staff.

 

 

ANS:   A

A member of the nursing profession must report behavior that does not meet established standards.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 32           OBJ:    13

TOP:    Unethical behavior                  KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. A nurse considering purchasing malpractice insurance should be aware that malpractice insurance provided by the hospital:
a. only offers protection while on duty.
b. is limited in the amount of coverage.
c. is difficult to renew.
d. can be terminated at any time.

 

 

ANS:   A

Most institutional insurance only provides liability coverage if the nurse is on duty at that facility.

 

DIF:    Cognitive Level: Application  REF:    Page 29           OBJ:    5

TOP:    Malpractice insurance             KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. Which is a nursing care error that violates the Health Insurance Portability and Accountability Act (HIPAA)?
a. Administering a stronger dose of drug than was ordered
b. Refusing to give a patients daughter information over the phone
c. Informing the patients medical power of attorney of a medication change
d. Leaving a copy of the patients history and physical in the photocopier

 

 

ANS:   D

Leaving the document in the photocopier could expose it to the public. Inappropriate drug administration is possible malpractice. Sharing information with the power of attorney is legal.

 

DIF:    Cognitive Level: Analysis       REF:    Page 27           OBJ:    15

TOP:    Health Insurance Portability and Accountability Act (HIPAA)

KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. A nurse could be cited for malpractice in the event of:
a. refusing to give 60 mg of morphine as ordered.
b. giving prochlorperazine (Compazine) to a patient allergic to phenothiazines.
c. dragging an injured motorist off the highway and causing further injury.
d. informing a visitor about a patients condition.

 

 

ANS:   B

Standards of care dictate that a nurse must be aware of all the properties of drugs administered. Prochlorperazine (Compazine) is a phenothiazine. Providing confidential information or refusing to give an excessively large narcotic dose is not considered malpractice. Good Samaritan laws generally protect a person giving aid to an injured motorist.

 

DIF:    Cognitive Level: Analysis       REF:    Page 26           OBJ:    5

TOP:    Malpractice     KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. A lumbar puncture was performed on a patient without a signed informed consent form. This may be a situation in which a patient could sue for:
a. punitive damages.
b. civil battery.
c. assault.
d. nothing; no violation has occurred.

 

 

ANS:   B

Civil assault charges can be brought against someone performing an invasive procedure without the patients informed consent legally documented.

 

DIF:    Cognitive Level: Analysis       REF:    Page 27           OBJ:    7

TOP:    Informed consent                    KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. A physician instructs the nurse to bladder train a patient. The nurse clamps the patients indwelling urinary catheter but forgets to unclamp it. The patient develops a urinary tract infection. The nurses actions are an example of:
a. malpractice.
b. battery.
c. assault.
d. neglect of duty.

 

 

ANS:   A

A nurse is liable for acts of commission (doing an act) and omission (not doing an act) performed in the course of their professional duty. A charge of malpractice is likely when a duty exists, there is a breach of that duty, and harm has occurred to the patient.

 

DIF:    Cognitive Level: Analysis       REF:    Page 26           OBJ:    4

TOP:    Malpractice     KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. What is true about nurse practice acts?
a. They informally define the scope of nursing practice.
b. They provide for unlimited scope of nursing practice.
c. Only some states have adopted a nurse practice act.
d. The nurse must know the nurse practice act within his or her state.

 

 

ANS:   D

The laws formally defining and limiting the scope of nursing practice are called nurse practice acts. All state, provincial, and territorial legislatures in the United States and Canada have adopted nurse practice acts, although the specifics they contain often vary. It is the nurses responsibility to know the nurse practice act that is in effect for her geographic region.

 

DIF:    Cognitive Level: Analysis       REF:    Page 25           OBJ:    4

TOP:    Nurse Practice Acts                KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. How can the medical record be used in litigation? (Select all that apply.)
a. Public record
b. Proof of adherence to standards
c. Evidence of omission of care
d. Documentation of time lapses
e. Evidence by only the plaintiff

 

 

ANS:   A, B, C, D

The information when used in court becomes a public record. The information can be used as proof of adherence to standards, omission of care, and documentation of time lapses. Both plaintiff and defendant can use the document.

 

DIF:    Cognitive Level: Analysis       REF:    Page 27           OBJ:    7

TOP:    Legal properties of medical record     KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. During a lunch break, an emergency department (ED) nurse truthfully tells another nurse about the condition of a patient who came to the ED last night. What is the ED nurse guilty of? (Select all that apply.)
a. HIPAA violation
b. Slander
c. Libel
d. Invasion of privacy
e. Defamation

 

 

ANS:   A, D

The disclosure is an invasion of privacy and a violation of HIPAA. Because the information is true and verbal, it cannot be considered slander or libel.

 

DIF:    Cognitive Level: Analysis       REF:    Pages 26-27     OBJ:    7

TOP:    Disclosure of information       KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. A nurse failed to monitor a patients respiratory status after medicating the patient with a narcotic analgesic. The patients respiratory status worsened, requiring intubation. The patients family claimed the nurse committed malpractice. For the nurse to be held liable ___________________ must be present? (Select all that apply.)
a. A nurse-patient relationship.
b. The nurse failed to perform in a reasonable manner.
c. There was harm to the patient.
d. The nurse was prudent in her performance.
e. The nurse did not cause the patient harm.
f. Duty does not exist.

 

 

ANS:   A, B, C

For the court to uphold the charge of malpractice, and to find the nurse liable, the following elements must be present: duty exists, there is a breach of duty, and harm must have occurred.

 

DIF:    Cognitive Level: Analysis       REF:    Page 26           OBJ:    5

TOP:    Malpractice     KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. Personal beliefs about the worth of an object, idea, custom, or attitude that influence a persons behavior in a given situation are referred to as ___________.

 

ANS:

values

Values are personal beliefs about the worth of an object, an idea, a custom, or an attitude. Values vary among people and cultures; they develop over time and undergo change in response to changing circumstances and necessity. Each of us adopts a value system that will govern what we feel is right or wrong (or good and bad) and will influence our behavior in a given situation.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 31           OBJ:    11

TOP:    Values KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. Acts whose performance is required, permitted, or prohibited are defined by ___________ of ______________.

 

ANS:

standards, care

Standards of care define acts whose performance is required, permitted, or prohibited.

 

DIF:    Cognitive Level: Analysis       REF:    Page 24           OBJ:    3

TOP:    Standards of care                    KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

Christensen: Foundations of Nursing, 6th Edition

 

Chapter 14: Safety

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse manager clarifies that safe hospital environment implies that in the hospital setting people will be free from:
a. falls.
b. exposure to contaminates.
c. injury.
d. electrical hazard.

 

ANS:   C

A safe environment implies freedom from injury.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 343         OBJ:    5

TOP:    Safety             KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. To decrease the risk for injury to the patient, the nurse determines if the patient:
a. can read English.
b. is left-handed.
c. is able to eat unassisted.
d. can dress independently.

 

ANS:   B

A left-handed patient will twist to accommodate, which places them at risk for injury.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 354         OBJ:    1

TOP:    Safety             KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. To decrease the risk for falls, the nurse holds frequent in-services to ensure that staff has competent skills for:
a. bathing.
b. feeding.
c. transferring.
d. ambulating.

 

ANS:   C

The majority of patient falls occur during transfer.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 344         OBJ:    3

TOP:    Falls                KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. An important safety precaution the home health nurse teaches parents to prevent burns to small children is to:
a. never leave them unattended.
b. turn pot handles on stoves away from reach.
c. turn hot water on first when filling the bathtub.
d. keep side rails up on the crib.

 

ANS:   B

To protect infants and children from burns, turn the pot handles on stoves away from the childs reach.

 

DIF:    Cognitive Level: Application             REF:    Page 346         OBJ:    4

TOP:    Safety             KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. Before applying a safety reminder device (SRD), the nurse must:
a. get permission from the family.
b. assess patients skin condition.
c. get a physicians order.
d. explain the SRD to the patient.

 

ANS:   C

Initially, an order is necessary that specifies the type of SRD and the duration of its application.

 

DIF:    Cognitive Level: Analysis                  REF:    Pages 348-349, Skill 14-1

OBJ:    8                      TOP:    Safety reminder devices (SRDs)

KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. When offering a cup of hot coffee to a frail, older adult patient, the nurse must:
a. give the patient a straw.
b. dilute the coffee with cold water.
c. fill the cup half full.
d. offer a bib or an apron.

 

ANS:   C

Filling the cup half full promotes safety and does not change the flavor of the beverage, nor does it demean the patient as would making him or her wear a bib or apron.

 

DIF:    Cognitive Level: Application             REF:    Page 346         OBJ:    4

TOP:    Safety             KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

  1. When the oxygen concentrator machine malfunctions and causes an electrical fire, the nurse should use which type of fire extinguisher?
a. A
b. B
c. C
d. D

 

ANS:   C

Electrical fires require type C fire extinguishers.

 

DIF:    Cognitive Level: Application             REF:    Page 359         OBJ:    9

TOP:    Fires                KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. A disaster situation that involves an explosion in a hospital laundry would be classified as:
a. active.
b. external.
c. life-threatening.
d. internal.

 

ANS:   D

Internal disaster often threatens the safety of patients and staff.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 361         OBJ:    10

TOP:    Disaster           KEY:   Nursing Process Step: N/A                MSC:   NCLEX: N/A

 

  1. The emergency department nurse can receive assistance in dealing with a victim of poisoning by calling the:
a. American Red Cross.
b. fire department paramedics.
c. poison control center.
d. civil defense office.

 

ANS:   C

The nurse can access the local poison control for assistance in caring for a victim of poisoning.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 360, Box 14-10

OBJ:    11                    TOP:    Poisoning        KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. A nurse instructs a nursing assistant about the proper use of a gait belt. The nurse should intervene after observing the nursing assistant:
a. walking on the patients strong side.
b. walking to the side of the patient.
c. securing the gait belt securely around the patients waist.
d. grasping the handles of the gait belt while the patient ambulates.

 

ANS:   A

A gait belt should be securely applied around the patients waist. It has handles attached for the nurse to grasp while the patient ambulates. The nurse should walk on the patients weaker side so that assistance may be given if the patient starts to fall.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 345         OBJ:    3

TOP:    Gait belt          KEY:   Nursing Process Step: N/A                MSC:   NCLEX: N/A

 

  1. A nurse who encounters a mercury spill should:
a. vacuum the spill.
b. open interior doors.
c. close all outside windows.
d. open any outside windows.

 

ANS:   D

In the event of a mercury spill, interior doors should be closed and outside windows should be opened. The spill should not be vacuumed.

 

DIF:    Cognitive Level: Application             REF:    Page 355, Box 14-6

OBJ:    10                    TOP:    Mercury spill

KEY:   Nursing Process Step: N/A                MSC:   NCLEX: N/A

 

  1. When the nurse ambulates with a patient who has left-sided weakness, what actions should the nurse take? (Select all that apply.)
a. Walk on the patients right side.
b. Keep the patient away from heavy furniture.
c. Hold the patients arm securely.
d. Keep the leg nearest the patient behind the patients knee.
e. Use a gait belt.

 

ANS:   D, E

Ambulating with a person who has an identified weakness requires that the nurse walk on the same side as the weakness, slightly behind the patient, with the nurses near leg behind the patients knee. The nurse should use a gait belt and hold the patient at the waist and the gait belt. Furniture can be used as support.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 345         OBJ:    3

TOP:    Ambulating     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

 

  1. When reinforcing the PASS acronym for fire extinguisher use, the nurse reminds the staff that the final S stands for ______________.

 

ANS:

sweep

The acronym stands for: P = pull pin, A = aim, S = squeeze, S = sweep.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 358, Box 14-9

OBJ:    9                      TOP:    Fire extinguisher use

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. The nurse conducting a seminar on bioterrorism reviews several types of agents that may be used as weapons. An agent that does not seriously damage or kill the target population but only impairs it is classified as _____________.

 

ANS:

incapacitating

The agent that only impairs the target rather than killing or seriously damaging it is classified as an incapacitating agent.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 364         OBJ:    13

TOP:    Bioterrorism    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse explains that the measurement of radiation exposure is in multiples of Gy. The number of Gy an individual may absorb before becoming ill with radiation syndrome is _______.

 

ANS:

0.75

The amount of radiation absorbed is measured by the Gy. 1 Gy is equal to 100 rad. Absorption of 0.75 Gy will cause the individual to develop acute radiation syndrome.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 364         OBJ:    13

TOP:    Radiation syndrome                           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse assesses a patient in a Posey safety reminder device (SRD) for which problem(s) that may increase because of use of SRDs? (Select all that apply.)
a. Immobility
b. Restlessness
c. Risk for impaired circulation
d. Risk for skin impairment
e. Incontinence

ANS:   A, B, C, D, E

The use of SRDs increases a patients immobility, restlessness, risk for skin impairment, risk for impaired circulation, and incontinence.

 

DIF:    Cognitive Level: Application             REF:    Pages 346-347

OBJ:    8                      TOP:    Problems associated with SRDs

KEY:   Nursing Process Step: Assessment     MSC:   NCLEX: Physiological Integrity

 

 

Christensen: Foundations of Nursing, 6th Edition

 

Chapter 28: Care of the High-Risk Mother, Newborn, and Family with Special Needs

 

Test Bank

 

MULTIPLE CHOICE

 

  1. A patient is admitted to the hospital with hyperemesis gravidarum. The patient is malnourished and severely dehydrated. The nurse alters the care plan to include interventions for:
a. hyperalimentation.
b. IV feedings and electrolyte replacement.
c. hormone replacement therapy.
d. vitamin supplements.

 

ANS:   B

Medical treatment is aimed at meeting nutritional needs and electrolyte replacement.

 

DIF:    Cognitive Level: Application             REF:    Pages 884-885

OBJ:    1                      TOP:    Hyperemesis gravidarum

KEY:   Nursing Process Step: Planning         MSC:   NCLEX: Physiological Integrity

 

  1. A patient with hyperemesis gravidarum asks the nurse what would have happened if she had not come to the hospital. The nurse explains that if untreated, this condition could result in:
a. a large for gestational age infant.
b. anorexia nervosa.
c. preterm delivery.
d. maternal or fetal death.

 

ANS:   D

If untreated, hyperemesis gravidarum can result in maternal or fetal death.

 

DIF:    Cognitive Level: Application             REF:    Page 885         OBJ:    1

TOP:    Hyperemesis gravidarum                    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse uses a picture to explain that twins who share a placenta, come from one fertilized ovum, and are identical are identified as:
a. dizygotic.
b. trizygotic
c. genetically different.
d. monozygotic.

ANS:   D

Monozygotic twins originate from one fertilized ovum and share a placenta.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 886         OBJ:    1

TOP:    Multifetal pregnancy                          KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. When assessing the woman who is pregnant with multiple fetuses, the nurse recognizes that the delivery will probably be:
a. complicated by an ectopic tendency.
b. difficult due to the fetal lie.
c. a vaginal delivery.
d. complicated by loss of uterine tone.

 

ANS:   D

Maternal and infant risks are increased when there are multiple fetuses because the delivery will probably be cesarean because labor will be complicated due to loss of uterine tone.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 886         OBJ:    1

TOP:    High-risk pregnancy                           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. A patient is admitted to the hospital with signs of an ectopic pregnancy. The nurse modifies the care plan to include:
a. long-term bed rest.
b. episodes of extreme hypertension.
c. surgery to remove the embryo/fetus.
d. risk for dehydration.

 

ANS:   C

An ectopic implantation occurs somewhere outside the uterus and either resolves itself in a spontaneous abortion or requires surgical intervention.

 

DIF:    Cognitive Level: Application             REF:    Page 888         OBJ:    1

TOP:    Ectopic pregnancy                              KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity

 

  1. A patient was admitted following a spontaneous abortion. When attempting to console the patient, the nurse tells her the percentage of first trimester pregnancies that abort is:
a. 5%.
b. 10%.
c. 15%.
d. 20%.

 

ANS:   C

It is estimated that 10% to 15% of first-trimester pregnancies end in spontaneous abortion.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 889         OBJ:    1

TOP:    Abortions        KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. During an antepartum visit, the nurse tells the mother that one sign that must be reported immediately, no matter what the stage of pregnancy, is:
a. backache.
b. urinary frequency.
c. vaginal bleeding.
d. uterine tightening.

 

ANS:   C

Women should be instructed to contact their physician if any bleeding occurs during pregnancy.

 

DIF:    Cognitive Level: Application             REF:    Page 890         OBJ:    1

TOP:    Vaginal bleeding                                KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. A patient in her second trimester of pregnancy arrives at the hospital complaining of bright red, painless vaginal bleeding. Based on this information, the nurse suspects a(n):
a. abruptio placentae.
b. hemorrhage.
c. placenta previa.
d. placentitis.

 

ANS:   C

Placenta previa consists of bright red painless vaginal bleeding occurring after 20 weeks of pregnancy.

 

DIF:    Cognitive Level: Application             REF:    Page 891         OBJ:    2

TOP:    Placenta previa                                   KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. A pregnant woman comes to the hospital 3 weeks before her estimated date of birth (EDB) complaining of severe pain and a rigid abdomen. The nurse recognizes these as signs and symptoms of:
a. placenta previa.
b. appendicitis.
c. ectopic pregnancy.
d. abruptio placentae.

 

ANS:   D

The major symptoms of abruptio placentae are severe pain and a rigid abdomen.

 

DIF:    Cognitive Level: Application             REF:    Page 892         OBJ:    2

TOP:    Abruptio placentae                             KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. A patient presents with symptoms of abruptio placentae. To facilitate uterine-placental perfusion, the nurse positions the patient in:
a. prone position.
b. Trendelenburg position.
c. supine position.
d. side-lying position.

 

ANS:   D

A side-lying position facilitates uterine-placental perfusion.

 

DIF:    Cognitive Level: Application             REF:    Page 893         OBJ:    2

TOP:    Abruptio placentae                            

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