Fundamentals Nursing Vol 1 3rd Edition By Wilkinson Treas Test Bank

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Fundamentals Nursing Vol 1 3rd Edition By Wilkinson Treas Test Bank

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WITH ANSWERS
Fundamentals Nursing Vol 1 3rd Edition By Wilkinson Treas Test Bank

Chapter 2. Critical Thinking & Nursing Process

 

MULTIPLE CHOICE

 

  1. Which of the following characteristics do the various definitions of critical thinking have in common? Critical thinking:
a) Requires reasoned thought
b) Asks the questions why or how
c) Is a hierarchical process
d) Demands specialized thinking skills

 

 

ANS:  A

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

 

(High-level question, answer not stated verbatim)

Nursing Process: Not applicable

Client Need: Safe and Effective Care

Cognitive Level: Analysis

Difficulty: Moderate

 

PTS:   1

 

  1. 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:
a) Consider all the possible advantages and disadvantages
b) Maintain an open mind about the proposed change
c) Apply the Nursing Process to the situation
d) Make a decision based on past experience with documentation

 

 

ANS:  B

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

 

Nursing Process: Not applicable

Client Need: Safe and Effective Care

Cognitive Level: Comprehension

Difficulty: Moderate

 

PTS:   1

 

  1. The nurse has just been assigned to the clinical care of a newly admitted patient. To know how best to care for the patient, the nurse uses the Nursing Process. Which step would the nurse probably undertake first?
a) Make an assessment
b) Make a diagnosis
c) Plan outcomes
d) Plan interventions

 

 

ANS:  A

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.

 

Nursing Process: Assessment

Client Need: Safe and Effective Care

Cognitive Level: Application

Difficulty: Easy

 

PTS:   1

 

  1. Which of the following is an example of practical knowledge? Assume all are true.
a) The tricuspid valve is located between the right atrium and ventricle of the heart.
b) The pancreas does not produce enough insulin in type 1 diabetes.
c) When assessing the abdomen, you should auscultate before palpating.
d) Research shows pain medication given intravenously acts faster than medication given by other routes.

 

 

ANS:  C

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

 

(High-level question, answer not stated verbatim)

Nursing Process: Not applicable

Client Need: Safe and Effective Care

Cognitive Level: Application

Difficulty: Moderate

 

PTS:   1

 

  1. Which of the following is an example of self-knowledge? The nurse thinks, I know that I:
a) Should take the clients apical pulse for 1 full minute before giving digoxin
b) Should follow the clients wishes even though it is not what I would want
c) Have religious beliefs that may make it difficult to take care of some clients
d) Need to honor the clients request not to discuss his health concern with the family

 

 

ANS:  C

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.

 

(High-level question, answer not stated verbatim)

Nursing Process: Not applicable

Client Need: Safe and Effective Care

Cognitive Level: Application

Difficulty: Difficult

 

PTS:   1

 

  1. Which of the following is the most important reason for nurses to be critical thinkers?
a) Nurses need to follow policies and procedures.
b) Nurses work with other healthcare team members.
c) Nurses care for clients who have multiple health problems.
d) Nurses have to be flexible and work variable schedules.

 

 

ANS:  C

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; working with others or being flexible and working different schedules do not necessarily require critical thinking.

 

(High level question, answer not stated verbatim)

Nursing Process: Not applicable

Client Need: Safe and Effective Care

Cognitive Level: Application

Difficulty: Moderate

 

PTS:   1

 

  1. The nurse administering pain medication every 4 hours is an example of which aspect of patient care?
a) Assessment data
b) Nursing diagnosis
c) Patient outcome
d) Nursing intervention

 

 

ANS:  D

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.

 

(High-level question, answer not stated verbatim)

Nursing Process: Interventions

Client Need: Safe and Effective Care

Cognitive Level: Application

Difficulty: Moderate

 

PTS:   1

 

  1. How does a nursing diagnosis differ from a medical diagnosis? A nursing diagnosis is:
a) Terminology for the clients disease or injury
b) A part of the clients medical diagnosis
c) The clients presenting signs and symptoms
d) A clients response to a health problem

 

 

ANS:  D

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

 

Nursing Process: Diagnosis

Client Need: Safe and Effective Care

Cognitive Level: Knowledge

Difficulty: Easy

 

PTS:   1

 

  1. What do critical thinking and the Nursing Process have in common?
a) They are both linear processes used to guide ones thinking.
b) They are both thinking methods used to solve a problem.
c) They both use specific steps to solve a problem.
d) They both use similar steps to solve a problem.

 

 

ANS:  B

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

 

Nursing Process: Not applicable

Client Need: Safe and Effective Care

Cognitive Level: Analysis

Difficulty: Difficult

 

PTS:   1

 

  1. 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:
a) Analyze the assessment data
b) Consult standards of care
c) Decide which interventions are appropriate
d) Ask for the clients perceptions of her health problem

 

 

ANS:  A

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.

 

Nursing Process: Diagnosis

Client Need: Safe and Effective Care

Cognitive Level: Application

Difficulty: Moderate

 

PTS:   1

 

  1. 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?
a) Determine whether she has gathered enough assessment data
b) Judge whether the interventions achieved the stated outcomes
c) Follow up to verify that care for the nursing diagnosis was given
d) Decide whether the nursing diagnosis was accurate for the patients condition

 

 

ANS:  B

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.

 

Nursing Process: Evaluation

Client Need: Safe and Effective Care

Cognitive Level: Analysis

Difficulty: Moderate

 

PTS:   1

 

  1. In caring for a patient with both diabetes and Impaired Skin Integrity (comorbidity), the nurse draws on 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. The nurse has demonstrated:
a) Full-spectrum nursing
b) Critical thinking
c) Nursing Process
d) Nursing knowledge

 

 

ANS:  A

Full-spectrum nursing 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.

 

(High level question, answers not stated verbatim)

Nursing Process: Not applicable

Client Need: PHSI

Cognitive Level: Analysis

Difficulty: Difficult

 

PTS:   1

 

  1. It is important for nurses to be critical thinkers because:
a) All clients are unique and have individual needs and differences
b) All nursing actions are based on theoretical knowledge
c) Nurses choose their actions primarily by following professional guidelines
d) Nurses provide care based on individual client preferences

 

 

ANS:  A

All clients are unique and have individual differences. Nursing actions are not solely based on theoretical knowledge. Actions are based on theoretical knowledge, practical knowledge, and self-knowledge. Following guidelines does not usually require critical thinking, and guidelines often do not offer adequate help in managing complex situations. Client preferences are certainly included in the plan of care but they do not cover the broad spectrum of being a critical thinkerit does not require critical thinking merely to do what the client prefers.

 

Nursing Process: Not applicable

Client Need: Safe and Effective Care

Cognitive Level: Comprehension

Difficulty: Moderate

 

PTS:   1

 

  1. A full-spectrum nurse uses a critical-thinking model to organize her thinking when caring for a patient. The nurse realizes she lacks some facts about the patients pathophysiology, so she makes sure to use a credible source for the information. She considers the alternatives for action, then again looks up some information. Before deciding what to do, she thinks about the patients family situation. What aspect of a critical-thinking model does this best illustrate? The nurse is:
a) Following model guidelines for specific interventions
b) Using linear processes to think critically
c) Moving back and forth between steps, and not thinking sequentially
d) Using self-knowledge in the decision-making process

 

 

ANS:  C

Critical thinking is not sequential, and critical-thinking models are not applied sequentially. Critical-thinking models do not proceed from top to bottom, nor are they linear. Nurses may jump back and forth between the various steps. Critical-thinking models do not prescribe guidelines for specific interventions. Although self-knowledge may be used as part of a decision-making process, this is not the best answer to complete the statement. The only way self-knowledge is involved in this scenario is that the nurse recognizes that she is lacking some information/knowledge.

 

Nursing Process: Not applicable

Client Need: Safe and Effective Care

Cognitive Level: Application

Difficulty: Difficult

 

PTS:   1

 

  1. Which is the best example of a critical-thinking attitude? The nurse:
a) Has extensive knowledge of principles and theories
b) Has a lively curiosity and enjoys discovering new ways of doing things
c) Applies the problem-solving process he was taught in nursing school
d) Responds to patients mainly on the basis of what is socially approved

 

 

ANS:  B

Attitudes are more akin to feelings and traits than to intellectual skills. Therefore, extensive knowledge is not a good example of an attitude. Attitudes are addressed in nursing school but it is unlikely that one can teach attitudes. A problem-solving process does necessarily require critical thinking; moreover, applying a process simply because one learns it in school would mean the person is not demonstrating an attitude of intellectual independence. Society and culture do help to form attitudes, but that is not the same as basing actions on what is socially approved. Again, that would not demonstrate independent thinking or any of the other critical-thinking attitudes.

 

Nursing Process: Not applicable

Client Need: Safe and Effective Care

Cognitive Level: Application

Difficulty: Difficult

 

PTS:   1

 

  1. What is the best description of the Nursing Process? The Nursing Process is:
a) A way to create nursing knowledge for use in practice
b) A systematic view of a specific phenomenon in nursing
c) A linear process for providing nursing care
d) A systematic process for the delivery of nursing care

 

 

ANS:  D

The Nursing Process is central to nursing care. It is a systematic problem-solving process that guides all nursing actions. The process does not create knowledge. Knowledge is created through theoretical and practical research. The Nursing Process is not a view of a specific phenomenon. Finally, the Nursing Process is not linear; the steps are reflexive and overlapping.

 

Nursing Process: Not applicable

Client Need: Safe and Effective Care

Cognitive Level: Comprehension

Difficulty: Easy

 

PTS:   1

 

  1. The nurse is caring for a client with heart failure. She begins to obtain the clients history and vital signs and then listens to breath sounds. The nurse is practicing which aspect of the Nursing Process?
a) Assessment
b) Planning interventions
c) Planning outcomes
d) Evaluation

 

 

ANS:  A

Obtaining the history, auscultating breath sounds, and obtaining vital signs are part of the assessment process. In the assessment step, the nurse gathers patient data and information. In the planning interventions step, the nurse chooses nursing activities aimed at meeting patient goals (and thus relieving the patients problem). In the planning outcomes phase, the nurse and patient identify goals for the patients healthexpected or desired outcomes of the care. After performing nursing activities, in the evaluation stage the nurse reassesses the patient to determine whether goals have been met.

 

Nursing Process: Assessment

Client Need: Safe and Effective Care

Cognitive Level: Application

Difficulty: Moderate

 

PTS:   1

 

  1. The nurse is caring for a client with skin breakdown of the coccyx area. The physician has ordered a medication to be applied to the area. In applying the medication, the nurse is practicing which aspect of the Nursing Process?
a) Assessment
b) Planning interventions
c) Implementation
d) Evaluation

 

 

ANS:  C

Application of a medication to the coccyx area is an action. The nurse both plans and carries out the intervention. The nurse carries out (and records) interventions in the implementation phase. Evaluation is done after the plan (or nursing action) is implemented.

 

Nursing Process: Implementation

Client Need: Safe and Effective Care

Cognitive Level: Application

Difficulty: Moderate

 

PTS:   1

 

  1. The nurse documents in the client plan of care that the wound treatment to the clients left foot has resulted in wound healing. She removed the Skin Integrity diagnosis from the plan of care. The nurse is using which aspect of the Nursing Process?
a) Assessment
b) Evaluation
c) Planning outcomes
d) Planning interventions

 

 

ANS:  B

Documenting nursing interventions and a patients immediate responses (e.g., expressed pain, became restless) is done in the implementation stage. However, in this scenario the nurse also documented that the wound was healing and she removed the nursing diagnosis from the care plan. This demonstrates evaluation.

 

Nursing Process: Evaluation

Client Need: Safe and Effective Care

Cognitive Level: Analysis

Difficulty: Difficult

 

PTS:   1

 

  1. The nurse enters a room to find the client sitting up in the chair, crying. The nurse best displays a critical-thinking attitude, as well as a caring attitude, by:
a) Telling the client that shell be back to chat after she sees her other clients
b) Calling the family to come and sit with the client
c) Trying to determine the reasons for the clients crying
d) Placing a do not disturb sign on the door to protect the clients privacy

 

 

ANS:  C

The nurse should try to find out why the client is crying so that she may intervene appropriately and correctly. Postponing talking with the client does not assist the client nor does it enable the nurse to make an appropriate intervention. Telling the client shell be back may cause the client to feel that her needs are less important. Calling the family may be helpful to the client once the nurse identifies why the client is crying. However, depending on the reason, the family may not be at all helpful. A do not disturb sign, without obtaining more information, may isolate the client. Upon further exploration, the nurse may discover that the client is already feeling alone and that she does not want or need privacy right now.

 

Nursing Process: Implementation

Client Need: PSI

Cognitive Level: Application

Difficulty: Moderate

 

PTS:   1

 

  1. Select the answer that best completes the following statement: The primary purpose of employing the full-spectrum nursing model is to:
a) Assist nurses in testing psychomotor skills
b) Have a positive effect on a clients health outcomes
c) Adequately use all aspects of the Nursing Process
d) Assist nurses in completing their work on time

 

 

ANS:  B

The question is asking for the best answer to complete the statement. The best answer is to have a positive effect on a clients health outcomes, which is also a goal of nursing in general. The full-spectrum model may assist nurses in performing psychomotor skills and even in completing their work on timeespecially when something unexpected occurs. However, that is not the focus of the model. Full-spectrum nursing would likely improve the nurses problem-solving ability (as in the Nursing Process); however, that is not the end purpose of full-spectrum nursing. It is merely a means to achieving the purpose of positively affecting health outcomes.

 

Nursing Process: Not applicable

Client Need: Safe and Effective Care

Cognitive Level: Comprehension

Difficulty: Moderate

 

PTS:   1

 

  1. The nurse has gathered her assessment data and notes several significant changes in the clients health status. The clients weight has increased by 5 lb over the past 24 hours, he is short of breath, and crackles are auscultated at both lung bases. To which step of the Nursing Process should the nurse proceed after organizing these data?
a) Diagnosis
b) Planning
c) Implementation
d) Evaluation

 

 

ANS:  A

After gathering and analyzing the assessment data, the nurse should next formulate a nursing diagnosis. The other options are not done until after the problem has been diagnosed. The problem is used to plan goals, which are then used to plan interventions. After implementing the intervention(s), evaluation is done to identify change in health status and determine whether goals have been met.

 

Nursing Process: Diagnosis

Client Need: Safe and Effective Care

Cognitive Level: Application

Difficulty: Moderate

 

PTS:   1

 

MULTIPLE RESPONSE

 

  1. Which aspects of healthcare are affected by a clients culture? Select all that apply.
a) How the client views healthcare
b) How the client views illness
c) Whether insurance will pay for healthcare services
d) The types of treatments the client will accept
e) When the client will seek healthcare services
f) The environment in which the healthcare services are provided
g) The ease of accessibility of healthcare services

 

 

ANS:  A, B, D, E

Culture impacts clients views 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 social environment and economic status. Regardless of culture, anyone can be affected by previous healthcare experiences, the environment in which healthcare is provided, and accessibility of services.

 

Nursing Process: Not applicable

Client Need: Safe and Effective Care

Cognitive Level: Knowledge

Difficulty: Moderate

 

PTS:   1

 

  1. Caring is a central concept in nursing that involves which of the following? Select all that apply.
a) Treating all clients with a similar disease in exactly the same way
b) Responding compassionately to client needs
c) Acting in ways to preserve human dignity
d) Connecting with others to give and receive help
e) Using active listening

 

 

ANS:  B, C, D, E

Treating all clients in exactly the same way just because they share similar disease processes does not consider their uniqueness nor honor their personhoodand thus does not reflect caring. The other options are all aspects of caring.

 

Nursing Process: Not applicable

Client Need: PSI

Cognitive Level: Analysis

Difficulty: Moderate

 

PTS:   1

 

Chapter 16. Spirituality

 

MULTIPLE CHOICE

 

  1. Which statement made by the student nurse to a Jehovahs Witness patient indicates a need for further learning?
a) I documented in your medical records that you do not want blood transfusions or blood products.
b) I will decorate your room with holiday ornaments.
c) Happy Birthday. I will have the dietary department send up a cake for you.
d) The organ procurement (donation) center was notified that you did not want to donate an organ.

 

 

ANS:  C

Jehovahs Witnesses do not celebrate birthdays or holidays, with the exception of the anniversary of Christs death. Thus, asking the dietary department to send up a birthday cake for celebration indicates that the nurse does not understand the Jehovahs Witnesses beliefs and practices. The nurse is correct in noting that Jehovahs Witnesses do not accept blood transfusions or products or donate their organs. Decorating the patients room for Christmas shows the nurse does not understand the patients religion.

 

Difficulty: Moderate

Client Need: PSI

Cognitive Level: Analysis

 

PTS:   1

 

  1. A student nurse is preparing a Mormon female for surgery. Which statement made or question asked by the nurse indicates an understanding of the patients religious practices or beliefs?
a) This is a new gown. No one else has worn it.
b) How would you like me to handle your undergarments?
c) I will let your surgical team know that only females can touch you.
d) Would you like me to pray with you?

 

 

ANS:  B

Both male and female Mormons wear special sacred undergarments that are removed only for hygiene, intimacy, and bathroom use. Nurses may also remove it before surgery, but it must be considered intensely private and be treated with respect. Rastafarian females will not wear second-hand clothes and require a gown that has not been worn by others. Muslim women prefer to be treated by female staff. Inquiring about prayer is inappropriate because the patient should initiate the request; further, prayer is not specific to this religion.

 

Difficulty: Moderate

Client Need: PSI

Cognitive Level: Application

 

PTS:   1

 

  1. Which question is most important to ask of a newly admitted patient to effectively incorporate spiritual care in the nursing care plan?
a) What is your familys religious background?
b) With what organized religion are you affiliated?
c) Do you go to church, and if so, how often?
d) What are your personal spiritual beliefs?

 

 

ANS:  D

Identifying the patients personal spiritual belief will provide you with more information to incorporate into the plan of care. These beliefs may be associated with or independent of religious affiliations. Not all people of a religious group adhere to its norms, rituals, and/or practices; therefore, questions should extend beyond focusing only on the patients or his familys religion.

 

Difficulty: Moderate

Nursing Process: Assessment

Client Need: PSI

Cognitive Level: Comprehension

 

PTS:   1

 

  1. 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?
a) Explain that hospital policy does not allow nursing assignments based on the gender of the nurse.
b) Explore with the patient her beliefs and determine which might have caused her to make this statement.
c) Assure the patient that each nurse is capable of providing professional nursing care, regardless of gender.
d) Comply with the patients request and assign a female nurse to care for the patient.

 

 

ANS:  B

The nurse should explore reason behind the patients request, which may have implications for additional nursing needs. If the reason is religious or spiritual, this provides an optimal time to engage in spiritual care. Explaining hospital policy or reassuring the patient of the nurses competence does not help the nurse understand the primary reason for the request, nor promote patient trust. The same is true of simply complying with the patients request.

 

Difficulty: Moderate

Client Need: PSI

Cognitive Level: Application

 

PTS:   1

 

  1. 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?
a) Administer the medication as prescribed.
b) Hold the medication until after Yom Kippur.
c) Explain the importance of taking the medication despite the holiday.
d) Ask the physician to change the route of administration.

 

 

ANS:  D

Yom Kippur is one of the holiest of the Jewish holidays. Self-denial includes abstaining from eating, drinking, bathing, and other rituals. Digoxin is not a non-kosher medication, so the most spiritually appropriate nursing intervention is to ask the provider to change the route of administration. The patient is in heart failure and needs the medication; thus, withholding the medication is not an option. Although the patient may understand the importance of the medication, it is not appropriate to create internal conflict between adhering to religious practices and complying with the medical regimen, when changing the route would address both concerns.

 

Difficulty: Moderate

Nursing Process: Interventions

Client Need: PSI

Cognitive Level: Comprehension

 

PTS:   1

 

  1. Which special consideration may the nurse need to make when caring for a female Rastafarian patient?
a) Allow the patient to wear her own clothing.
b) Provide a diet that is caffeine free.
c) Allow the patient to wear jewelry with religious symbols.
d) Provide free-flowing water for bathing.

 

 

ANS:  A

Wearing second-hand 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; however, 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.

 

Difficulty: Moderate

Nursing Process: Interventions

Client Need: PSI

Cognitive Level: Application

 

PTS:   1

 

  1. What is the most effective action for the nurse to take when delivering spiritual care to a patient of the same religion as the nurse?
a) Understanding that the patient shares the same beliefs
b) Striving to meet the patients spiritual needs independently
c) Explaining her own religious beliefs to the patient
d) Developing a greater awareness of her own spirituality

 

 

ANS:  D

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.

 

Difficulty: Moderate

Nursing Process: Interventions

Client Need: PSI

Cognitive Level: Comprehension

 

PTS:   1

 

  1. Which type of medicine do those of the Hindu faith typically practice?
a) Ayurvedic medicine
b) Western medicine
c) Chiropractic medicine
d) Tribal medicine

 

 

ANS:  A

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 tribal medicine. Native Americans practice tribal medicine or remedies that incorporates natural remedies.

 

Difficulty: Moderate

Nursing Process: Assessment

Client Need: PSI

Cognitive Level: Comprehension

 

PTS:   1

 

  1. 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 minister when he calls. Which is the most appropriate nursing diagnosis for this patient?
a) Spiritual Distress
b) Risk for Spiritual Distress
c) Impaired Religiosity
d) Moral Distress

 

 

ANS:  A

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, 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 minister, but chooses not to. Moral Distress occurs when a person makes a moral decision but is prevented from carrying out the chosen action.

 

Difficulty: Moderate

Nursing Process: Diagnosis

Client Need: PSI

Cognitive Level: Analysis

 

PTS:   1

 

  1. The nurse is asking the patient reflective, clarifying questions to help the patient make a list of what is important and unimportant in life and the time commitment for each. Which standardized (NIC) nursing intervention does this action implement?
a) Spiritual support
b) Self-Esteem Enhancement
c) Values Clarification
d) Hope Inspiration

 

 

ANS:  C

One of the steps of most valued clarification processes is to list values (what is important and not important in 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 the process can indirectly contribute to development of spiritual identity.

 

Difficulty: Moderate

Nursing Process: Interventions

Client Need: PSI

Cognitive Level: Application

 

PTS:   1

 

  1. 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?
a) Offer a prayer for healing using the nurses usual words and format.
b) Begin the prayer with Jehovah God, as she always does, while avoiding the name of Jesus.
c) Avoid saying any name for the Supreme Being while praying, and quote an Old Testament Bible scripture as the prayer.
d) Say, What name would you like for me to use to address the Supreme Being when I am praying for you?

 

 

ANS:  D

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 Jehovah, Yahweh, or Allah. Hindus may address one or more multiple gods, each of whom has several names. 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.

 

Difficulty: Moderate

Nursing Process: Implementation

Client Need: PSI

Cognitive Level: Application

 

PTS:   1

 

  1. Over the past few centuries, nurses have placed less attention on spiritual care primarily because:
a) Nurses providing care are less religious and spiritual now
b) Spirituality and religion are unproven with regard to influencing health
c) Greater emphasis has been placed on science and scientific evidence
d) Nurses are uncomfortable when discussing spiritual aspects of care

 

 

ANS:  C

By the mid-20th century, nursing in the United States began to see spiritual care as less important. As science has continued to develop and expand, and as more nurses studied in university settings, nursing joined ranks with scientific disciplines: Its spiritual underpinnings were replaced by what could be seen and tested by the scientific method. Only recently has nursing reclaimed the spiritual dimension as a vital part of its identity and recognized its power to influence health.

 

Difficulty: Moderate

Nursing Process: NA

Client Need: PSI

Cognitive Level: Analysis

 

PTS:   1

 

  1. The nurse is caring for a patient recently diagnosed with cancer. The patient states, I really never believed in a god or followed any religion. Should I do something now? What is the most appropriate response by the nurse?
a) Religion and spirituality are not for everyone. If youve not had it in your life to this point, you may not need it.
b) I am a Catholic and it works for me. Would you like me to tell you about my religion?
c) It is important to have some religion or spirituality in your life as it can help you get through difficult times.
d) It is up to you. If you would like, I can arrange for one of our nondenominational chaplains to come and speak with you.

 

 

ANS:  D

There are times when a nurse may not know the answer to a patient question regarding spirituality or religion. Clearly, there are times when the nurse should then refer to others with more knowledge and experience and with the patients permission. Referring the patient to a facility chaplain is the best response by the nurse. A person may not have any religion or spirituality in his life; however, this does not mean that with changes in health status, aging, and developmental levels, a person should not reach out to ask for help or seek guidance. It is also important to understand the point at which a patient is in his thinking and not impose or convert others to ones own beliefs.

 

Difficulty: Moderate

Nursing Process: Assessment

Client Need: PSI

Cognitive Level: Application

 

PTS:   1

 

  1. The nurse is speaking with a 40-year-old woman at a fund-raiser. The woman states, I have never had a mammogram. I am a Buddhist and I believe if I get cancer, then that is what my fate will be. What is the most appropriate response by the nurse?
a) You are 40 years old and really should start thinking about having a mammogram.
b) Breast cancer can be cured if caught and treated early enough. You are not giving yourself an opportunity think about your own health.
c) I dont know of any religion that just allows people to die. You may need to rethink this.
d) This is certainly your choice; however, there is research that shows screening is helpful and effective.

 

 

ANS:  D

The focus of this item is to demonstrate that certain religions, spirituality, and ways of thinking can and do have an effect on patients willingness to seek out healthcare, most specifically, preventive screening. Researchers have investigated the effect of religious beliefs on health disparities. Fatalism, which is rooted in Buddhism, views fatal diseases as destined by nature and acceptance as a sign of wisdom and maturity. This group is known to have a highly pessimistic perception that preventive screening would lower their risk of getting cancer. The patient in this item is less likely to obtain a mammogram as a screening tool. The most appropriate response by the nurse is to first acknowledge and accept the patients belief in her religion or way of life; however, the nurse should also provide a nonthreatening and educated response by giving the facts in support of what research has demonstrated and what prevention can do. Nurses cannot tell patients what they should and should not do, nor should they be critical of a persons religion.

 

Difficulty: Moderate

Nursing Process: Intervention

Client Need: PSI

Cognitive Level: Application

 

PTS:   1

 

  1. The nursing student is completing her clinical rotation in the intensive care unit. While caring for a patient, she says to the primary nurse, This family is bringing in all kinds of beads and medals and putting them on the patient and bed. This is intensive care! What should I do? What is the most appropriate response by the nurse?
a) Remove the medals from the patient so they dont get in the way of your work.
b) Remove the beads from the bed so they dont get in the way of your work.
c) Explain to the family that these objects cannot be brought into intensive care as our work is too intricate and these things can get in the way.
d) This is not uncommon in intensive care. Try to work around this as best you can, as these objects are important to the family and patient.

 

 

ANS:  D

Nurses must respect a patients dress and other requirements or symbols as determined by his religion. It is not uncommon for religious groups such as Hindus and Roman Catholics to wear medals or beads as symbolic icons of their religion. The most appropriate response by the nurse is to inform the student that this practice is common in all units of care and must be respected. If the nurse needs to remove any items, she should first obtain permission from the patient or significant other.

 

Difficulty: Moderate

Nursing Process: Intervention

Client Need: PSI

Cognitive Level: Application

 

PTS:   1

 

  1. The nurse is caring for a patient in the hospital. The patient states, No matter what happens to me, I believe my path is already predetermined. Nothing is going to change my destiny. This patient is most likely exhibiting:
a) Fatalism
b) Hopelessness
c) Lack of faith
d) Self-pity

 

 

ANS:  A

The patient is exhibiting fatalism. Fatalism, which is rooted in Buddhism, views fatal diseases as destined by nature and acceptance as a sign of wisdom and maturity. In this view, diseases are predetermined with a predictable outcome. Faith is an evolving pattern of believing that grounds and guides us, helps us make sense of the world, and helps us confront the challenges we face. It allows us to trust and to maintain an optimistic perspective on life events and to find purpose in life. Hope is a dynamic process that reflects a positive orientation towards future outcomes. There is no evidence in this item that this patient is exhibiting self-pity or hopelessness.

 

Difficulty: Moderate

Nursing Process: Evaluation

Client Need: PSI

Cognitive Level: Analysis

 

PTS:   1

 

  1. The nurse is working in a pediatric intensive care unit. A young couple has just been informed that their 6-year-old son has died after being in the unit for 1 month. The couple is grief stricken and says to the nurse, We cant believe this has happened. He was too young. God is watching over him. Do you believe in God? What is the most appropriate response by the nurse?
a) It was his time. He is in a better place.
b) He suffered enough. He is in peace now.
c) I believe he is with angels, but what you think is most important.
d) It doesnt matter what I think. It is only important what you think.

 

 

ANS:  C

The death of a child is one of the most difficult life events for a family as well as for the nurse who may witness it. In this item, a seemingly harmless statement such as He is in a better place or He has suffered enough may be hurtful and even offensive for the family. It is better not to offer opinions or judgments. If a family asks what you, the nurse, think, you can briefly share your beliefs and answer their question, but reflect their questions back to them. The most appropriate response by the nurse is to briefly answer the question and refer back to the family. The answer, It doesnt matter what I think . . . sounds abrupt and opinionated.

 

Difficulty: Moderate

Nursing Process: Interventions

Client Need: PSI

Cognitive Level: Application

 

PTS:   1

 

MULTIPLE RESPONSE

 

  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 statements made by the patient would indicate that progress is being made toward achieving compliance with healthcare therapy? Select all that apply.
a) I will try to pray more often for stronger faith that God will heal me.
b) Let me think about it until tomorrow; I may see my way to taking those pills then.
c) You know, Ive known some very holy people who were not cured by God.
d) There is no confusion in my mind as to the right thing for me to do.

 

 

ANS:  B, C

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 whether 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.

 

Difficulty: Difficult

(Answer not stated in text; student must infer answer from question content.)

Nursing Process: Evaluation

Client Need: PSI

Cognitive Level: Application

 

PTS:   1

 

  1. What are some possible barrier(s) for nurses in providing spiritual care? Select all that apply.
a) Spiritual care is related to end-of-life care and many nurses do not work in this area.
b) Greater emphasis in nursing is placed on meeting patients physical needs.
c) Many nurses experience time constraints and inadequate staffing.
d) Many nurses lack an understanding of their own spiritual belief systems.

 

 

ANS:  B, C, D

Although most nurses would acknowledge that patients have a spiritual dimension, few actually identify spiritual problems or provide spiritual interventions. This may be a result of economic constraints, poor staffing, and high-tech care, which force nurses to focus only on physical needs. Other barriers include a general lack of awareness of spirituality and a lack of awareness of ones own spirituality. Spiritual interventions and care, although prevalent in critical care areas and at end-of-life events, can take place in any area and at any time in the patients life journey.

 

Difficulty: Moderate

Nursing Process: Evaluation

Client Need: PSI

Cognitive Level: Comprehension

 

PTS:   1

 

  1. What is meant by the nurses being present with a patient? Select all that apply.
a) Being open to patients beliefs and concerns
b) Setting the agenda and leading discussions
c) Allowing the patient to tell stories about his illness
d) Using active listening skills

 

 

ANS:  A, C, D

Being present means to be with the patient and family in meaningful ways. This requires not only a nurses actual presence at the bedside, but also for him to be open to issues and concerns of the patient. Presence is allowing the patient to lead discussions, set the agenda, and control the conversation. It involves sincere communication and being fully available to the patient, and might include listening to the patients stories about his illness. Active and focused listening is also a quality of being present with the patient.

 

Difficulty: Moderate

Nursing Process: NA

Client Need: PSI

Cognitive Level: Comprehension

 

PTS:   1

 

  1. What are some activities nurses can do to gain a broader view of spirituality? Select all that apply.
a) Develop critical and reflective thinking abilities
b) Participate in religious and spiritual practices regularly
c) Increase knowledge base of religion and spirituality
d) Recognize that all spirituality is deeply ingrained in religion

 

 

ANS:  A, C

There are many activities nurses can engage in to gain a broader view and understanding of spirituality. You can increase your knowledge about spirituality, develop your critical and reflective thinking abilities, explore your own spirituality, reflect on thoughts and feelings about end-of-life issues, and reflect on your personal experiences with grief and loss. Spirituality is understood in different ways by patients, families, and nurses. Spirituality may be deeply ingrained in or totally separate from formal religion. There is nothing that supports that nurses need to participate in religious and spiritual practices on a regular basis.

 

Difficulty: Difficult

Nursing Process: NA

Client Need: PSI

Cognitive Level: Analysis

 

PTS:   1

 

Chapter 32. Physical Activity & Mobility

 

MULTIPLE CHOICE

 

  1. A 15-year-old patient complains of left ankle pain after being tackled while playing football. He asks the nurse what tests he needs to have to determine whether he has a strain or a fracture. How should the nurse reply?
a) You dont need an x-ray; I can tell by the way your ankle looks and feels whether you have a strain or fracture.
b) Sprains, strains, and fractures have similar symptoms at first; you will need an x-ray of the joint to be certain.
c)

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