Introductory Medical Surgical Nursing 11th Edition by Barbara K. Timby, Nancy E. Smith test bank

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Introductory Medical Surgical Nursing 11th Edition by Barbara K. Timby, Nancy E. Smith test bank

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1. Which of the following nursing interventions will a nurse perform to transfer heat and improve circulation in a dying client?
A) Change the position frequently.
B) Gently massage the arms and legs.
C) Administer warm intravenous fluids.
D) Administer intramuscular injections.
Ans: B
Feedback:
A nurse should gently massage the clients arms and legs to transfer heat and improve circulation in a dying client. Changing the position frequently helps protect the clients skin from breakdown. Administering warm intravenous fluids and intramuscular injections will not help transfer heat and improve circulation in a dying client.

2. Which of the following should the nurse report so that the team can consider alternative nutritional and fluid administration routes for a dying client?
A) Altered gastrointestinal function
B) Drop in blood pressure and rapid heart rate
C) Weight loss and inadequate food intake
D) Irregular eating habits
Ans: C
Feedback:
The nurse should report weight loss and inadequate food intake so that the team can consider alternative nutritional and fluid administration routes for a dying client. The nurse need not report altered gastrointestinal function because it is a normal part of the dying process. A nurse should also not report a drop in blood pressure and rapid heart rate or irregular eating habits.

3. Which of the following nursing interventions should a nurse perform to promote the dignity and self-esteem of a dying client?
A) Communicate hopefulness.
B) Keep the client clean and well groomed.
C) Share emotional pain.
D) Help the client live according to his or her wishes.
Ans: B
Feedback:
A nurse should keep the client clean, well groomed, and free of unpleasant odors to promote his or her dignity and self-esteem. Although sharing emotional pain is an essential component of care for dying clients, it will not promote their dignity and self-esteem. Communicating hopefulness helps sustain hope in dying clients. Helping the client live according to his or her wishes is a feature of hospice care.

4. Which of the following interventions should the nurse perform to prevent drying of the oral mucous membranes and lips in a dying client?
A) Place the client in a cool temperature.
B) Provide water to the client at regular intervals.
C) Provide the client with absorbent pads.
D) Provide oral care, ice chips, and petroleum jelly.
Ans: D
Feedback:
The nurse provides oral care, ice chips, and petroleum jelly because mouth breathing makes the oral mucous membranes and lips dry. Placing the client in a cool temperature and providing water to the client at regular intervals will not help prevent drying of the oral mucous membranes. Providing the client with absorbent pads is useful only when the client has lost bladder control and does not prevent drying of the mucous membranes.

5. Which of the following nursing interventions should be implemented for the dying client who is incontinent of urine, with associated skin breakdown, and exhibits a decreased level of consciousness?
A) Insertion of an indwelling catheter
B) Use of absorbent pads
C) Offering a bedpan every 4 hours
D) Assisting the client to the commode every 2 hours
Ans: A
Feedback:
The client may need an indwelling or external catheter, particularly if skin breakdown is a problem. The other options would not be appropriate for the dying client.

6. Which of the following is an appropriate intervention for the client with pulmonary edema?
A) Administer the prescribed sedative to decrease anxiety.
B) Suction as needed to clear the lungs.
C) Position the client supine.
D) Use chest percussion.
Ans: A
Feedback:
Suctioning will not clear the lungs or ease breathing if the client has pulmonary edema. In this situation, the physician may prescribe a sedative to relieve the anxiety created by the feeling of suffocation.

7. What major complication is associated with oral intake in the client with a decreased level of consciousness?
A) Distended abdomen
B) Nausea
C) Aspiration
D) Pocketing of food
Ans: C
Feedback:
Difficulty in swallowing, gastric and intestinal distention, and vomiting create a potential for aspiration of fluids and a decrease in food intake.

8. Which of the following is a nursing intervention for promoting self-care in the dying client?
A) Apply glycerin to the lips.
B) Promote active range-of-motion exercises every hour.
C) Avoid oral hygiene to minimize risk of aspiration.
D) Assist with personal hygiene.
Ans: D
Feedback:
The nurse may need to assist with personal hygiene. Petroleum jelly helps keep the lips lubricated. Active range-of-motion exercises do not need to be done every hour. The nurse gives oral care and ice chips because mouth breathing makes the oral mucous membranes and lips dry.

9. Which of the following is an example of near-death awareness?
A) Feeling warm and peaceful
B) Floating above ones body
C) Premonition regarding date and time of death
D) Moving rapidly toward a bright light
Ans: C
Feedback:
Near-death awareness is a phenomenon characterized by a dying clients premonition of the approximate time and date of death. Near-death experiences include feeling warm and peaceful, floating above ones body, and moving rapidly toward a bright light.

10. Which of the following is an appropriate intervention to promote sleep in the dying client?
A) Cluster necessary activities.
B) Awaken client every three hours.
C) Allow a steady stream of visitors.
D) Provide maximal environmental stimulation to the client.
Ans: A
Feedback:
Nurses must cluster activities to avoid awakening the client and to protect the client from a steady stream of healthcare workers or visitors.

11. The nurse is caring for a pediatric client who is dying. The best way to provide care and comfort to dying clients and their families is to first do which of the following?
A) A workshop on caring for the dying client
B) Use evidence-based practice in daily care regimen.
C) Explore own feelings on mortality and death and dying.
D) Participate in a support group to learn clients feeling on care.
Ans: C
Feedback:
To care for others in the dying process, the nurse must explore his or her own feelings about mortality and death and dying. Understanding self provides a perspective to cope with and then support clients and families experiencing pain and grief. The other options are helpful in determining appropriate nursing care but not the first step.

12. A client has learned of a terminal illness and impending death. The client asks the nurse to explain the concepts and care that are provided under the definition of palliative care. Which of the following would the nurse include in the explanation for this client? Select all that apply.
A) Provides pain relief
B) Includes chemotherapy
C) Integrates spirituality
D) Hastens death
E) Offers a team approach to care
F) Enhances quality of life
Ans: A, C, E, F
Feedback:
The principles of palliative care include providing relief from pain and distressing symptoms. In the early course of disease, chemotherapy and radiation may be used to define care needed, but in the later stages, chemotherapy is typically not used. Psychological support including spirituality and bereavement counseling for family members is available. The care does not hasten nor postpone death but is aimed at enhancing a quality of the life that is remaining. A team approach meets the needs of the client and family.

13. When considering care for the dying, which awareness, by the nurse, provides the best rationale for general nursing care?
A) Comfort measures are essential during this period.
B) Death is the final stage of growth and development.
C) Care for grieving family members is important.
D) Technology extends death and dying.
Ans: B
Feedback:
When providing nursing care for the dying, it is important to recognize that death is natural, universal, and the final stage of growth and development. Comfort measures and care for grieving family members are specifics that guide nursing interventions. Technology does not always extend death and dying.

14. The nurse is caring for a client who just learned of his terminal diagnosis. After the physician leaves, the nurse remains to answer further questions so that the client can make an informed decision about further treatment. By providing all available information, the nurse is promoting which ethical principle?
A) The principle of justice
B) The principle of nonmaleficence
C) The principle of fidelity
D) The principle of autonomy
Ans: D
Feedback:
By promoting open discussion and informed decision making, the nurse is empowering the client to make his own decisions leading to autonomy. The principle of justice requires fairness and justice to all clients. The principle of nonmaleficence requires that nurse does not intentionally or unintentionally inflict harm on others. The principle of fidelity maintains that nurses are faithful to the care of the clients.

15. A nurse is caring for a terminally ill client who is receiving chemotherapy and radiation for an aggressive lung cancer. The treatment success is limited in shrinking the tumor, and the treatments are making the client very ill. The client states, I feel that I would like to stop treatments. I would like to enjoy the time that I have remaining with my family. Which emotional reaction does the nurse recognize that the client is experiencing?
A) Denial
B) Bargaining
C) Anger
D) Acceptance
Ans: D
Feedback:
In the final stage, dying clients accept their fate and makes peace spiritually and with those to whom they are close. Clients begin to detach themselves socially and wish to be with only a small group of close friends and family. The other options are stages that occur earlier in the process.

16. The nurse is caring for a client who has diminished lung function due to emphysema. The terminally ill client is short of breath on exertion and states he has difficulty sleeping in bed. The client states, I am so afraid of getting any worse. Which statement, by the nurse, assists the client in sustaining hope?
A) Do not worry, I will be here for you to help you with your needs.
B) I will talk with the physician to determine the next step in your care.
C) Your grandchild is almost here, and you will enjoy seeing it.
D) I hear you say that you are not sleeping well.
Ans: B
Feedback:
The client is assisted in hopefulness by believing that the healthcare team will make his remaining days meaningful. By conveying a sense that the nurse will discuss the clients condition with the physician, the client recognizes that the healthcare team will use whatever treatment and comfort measures are available. Telling a client not to worry is not therapeutic and is condescending. Waiting for a grandchild does not address the clients thought. Reflecting what the client said for clarification opens communication but does not instill hopefulness.

17. The nurse is caring for a 90-year-old male who has never completed an advanced directive. The man has a son but has not seen him in several years. A neighbor has assisted him with meals and housecleaning for many years. The neighbor states that the client expressed only wanting to have comfort measures. The estranged son wants his father to be treated aggressively. Which would be the nurses initial step?
A) Follow the sons directive.
B) Follow the neighbors directive.
C) Assess the clients ability to state wishes.
D) Notify the physician of the discrepancy.
Ans: C
Feedback:
It cannot be assumed that the client is unable to make his own decisions just because of his advanced age. Before any other person is asked about the clients wishes, the client needs to be asked first. The physician, who has a healthcare relationship with the client, may also have documented information about wishes.

18. A terminally ill client is admitted to a hospice facility. The client has an advanced directive indicating that no heroic measures be used to prolong life. What is the most appropriate nursing action when death appears imminent?
A) Sit quietly and stroke the clients hand.
B) Notify the clients clergy of the potential for death.
C) Call the funeral home to notify of imminent death.
D) Move the client to a private room.
Ans: A
Feedback:
The nurses greatest gift to give the client at the end of life is to spend time with the client. That time can be spent quietly. This helps the client to not feel abandoned and to die with dignity. It is premature to notify the clergy or funeral home. The nurse would not move the client to another room at this time.

19. The family of a terminally ill client is deciding between home care and a hospice facility. When comparing options, which factor of home care needs regular assessment?
A) Pain control
B) Caregiver strain
C) A comfortable environment
D) Transportation to appointments
Ans: B
Feedback:
A negative factor of home care is the burden it places on the primary caretaker. If prolonged, the role can be isolating and tiring. Regular assessment, by the nurse, is needed to ensure care for both client and family. Pain control is the same in home care or at a hospice facility. Although a comfortable environment is important and transportation to appointments may be needed, it is not as important.

20. The nurse is caring for a client at the end of life. The client is ordered a regular dosage of narcotics and short-acting narcotics for breakthrough pain. When administering the narcotics, the nurse is correct to realize which of the following?
A) Death is imminent.
B) Side effects must be treated.
C) Dosages are restricted.
D) Patient may become sedated.
Ans: B
Feedback:
The nurse who is administering narcotics at the end of life still must realize that there are side effects from the narcotics which must be addressed. Depending on the status of the client, death may be days or weeks away, not imminent. Pain medications are liberally given at the end of life to ensure that the client is comfortable. Typically, pain medications relax the client as the pain level is eased. The client is not sedated.

21. A nurse is caring for a terminally ill client inquiring about physician-assisted suicide. Which statement, made by the nurse, would correctly advocate for the practice?
A) The physician administers a lethal dose of medication via IV.
B) The physician provides the means for the clients to take their life.
C) The physician provides the means and waits to pronounce them dead.
D) The physician provides counseling and has a third party physician assist in the suicide.
Ans: B
Feedback:
Physician-assisted suicide is the practice of providing a means by which a client can end his or her life. Much controversy exists concerning the practice. Oregon, Washington, and Montana are the only states that permit physician-assisted suicide. The physician does not personally administer the dose, wait until the client is dead, or have a third party physician involved.

22. Which cardiovascular findings indicate to the nurse that the condition of the dying client is worsening?
A) Pulse 104 beats/minute in the morning, 62 beats/minute in the afternoon with mottled feet and ankles
B) Pulse 72 beats/minute, irregular; patient confused and agitated
C) Pulse 100 beats/minute, blood pressure 100/60 mm Hg, pale with poor skin turgor
D) Pulse 60 beats/minute, blood pressure 90/42 mm Hg, difficult to arouse
Ans: A
Feedback:
Earlier, a client with failing cardiac function exhibits a higher pulse as the body attempts to circulate oxygen. Next, cardiac output is decreased due to ineffective filling of the chambers, impairing circulation, and diminishing the hearts own oxygen supply. The heart rate and blood pressure then decrease. Peripheral circulation is impaired with the feet and ankles becoming pale and mottled.

23. The nurse is caring for a dying client in a hospice setting. The family is unsure whether to go home for rest or spend the night with the client. Which body system would the nurse assess to provide the first data on decline?
A) Central nervous system
B) Cardiovascular system
C) Respiratory system
D) Gastrointestinal system
Ans: B
Feedback:
The key word is first. Failing of cardiac functioning is one of the first signs that a condition is worsening. Symptoms within the other systems can also denote deterioration over time.

24. A nurse is caring for a dying patient. The family asks the nurse why there is a rattling in their loved ones chest. Which response is most appropriate?
A) The client picked up a virus and has respiratory symptoms.
B) The client has been lying in bed and secretions pool in the lung bases.
C) There is an accumulation of fluid in the pulmonary circulation and secretions throughout the respiratory tract.
D) Thick sputum accumulates as the client dehydrates from having little oral intake.
Ans: C
Feedback:
Failure of the hearts pumping function causes fluid to collect in the pulmonary circulation. Also, there is an accumulation of secretions in the respiratory tract. Both account for noisy respirations or what is called the death rattle. The client is typically not exposed to crowds where virus can be passed. Also, the symptoms the dying process would be different from that of a viral infection. It is true that secretions may pool in the lung bases; however, further symptoms cause the audible rattling in the upper bronchial tree. Although oral fluids may be limited, thick sputum is not common during the dying process.

25. As the moment of death approaches, which of the following does the nurse encourage the family to do?
A) Have the family sit in front of the client so they can be seen.
B) Rub the clients hand and arm to comfort the client.
C) Speak to the client in a calm and soothing voice.
D) Lie next to the client and hold the client.
Ans: C
Feedback:
Sight and touch diminish as the client approaches death; however, hearing tends to remain intact. Speaking to the client calmly is most appropriate.

26. Which of the following is the nurses primary concern when providing end-of-life care for a client and the family? Select all that apply.
A) Maintaining client comfort
B) Arranging plans for after death
C) Supporting family members
D) Providing personal care
E) Completing a head-to-toe assessment
F) Encouraging fluids
Ans: A, C, D
Feedback:
Nursing care of dying clients focuses on providing palliative care to the client and supporting family members. Arranging the plans after death is not a priority at this time. Completing a head-to-toe assessment may be completed for information but is not a priority at the end of life. There is no need to encourage fluids.

27. The family of a dying client being cared for at home is requesting information on how best to prepare food. Which suggestion by the nurse may stimulate appetite?
A) Eating alone so the client can eat at his own pace and not be hurried
B) Providing several choices on the plate so that the client has what may appeal to him
C) Offering high caloric foods to build fat and muscle
D) Preparing cool or cold foods that may be better tolerated
Ans: D
Feedback:
Preparing cool or cold foods may be tolerated better by the client and thus stimulate appetite. Hot foods may have an aroma that may cause nausea. Clients may enjoy a mealtime companion making the eating experience more pleasurable. Offering small portions is appropriate because large, multiple portions/choices may shut down the appetite. Although weight loss may be significant, clients should have the ability to pick and choose foods that interest them.

28. The nurse is caring for a client who is in the dying process. The nurse is reviewing orders to confirm that all is being done to meet client needs. Which additional nursing intervention may be helpful?
A) Lay client in the supine position.
B) Apply glycerin products for moisture.
C) Reposition client every 2 hours.
D) Remove extra blankets and covers.
Ans: C
Feedback:
A drop in blood pressure and heart failure lead to poor tissue and organ perfusion. Repositioning the client every 2 hours protects the skin from breakdown. Typically, the client is at a semi-Fowlers position to assist with respiratory function. Glycerin products pull moisture from the tissue and accentuate the drying process. Extra covers are typically needed to ensure comfort.

29. The nurse is caring for a client who is interested in learning about hospice care. Which of the eligibility criteria would the nurse stress?
A) Serious, progressive illness
B) Choice of palliative care over cure focused
C) Limited life expectancy
D) Physician-certified illness
Ans: B
Feedback:
An important focus of hospice care is that care is palliative in nature. No further aggressive treatment to find a cure for the illness is administered. The client must accept this philosophy of care. The other options are factual and agreed on.

30. The family of a dying client is noticing that their loved one is short of breath, restless in bed, and appears to be trying to tell them something. Which nursing intervention is appropriate at this time?
A) Offer the bedpan to urinate.
B) Call the physician to obtain an anxiolytic.
C) Get the client out of bed to the chair.
D) Offer the client sips to drink.
Ans: B
Feedback:
Clients may become restless and agitated when experiencing difficulty breathing. Obtaining an anxiolytic can reduce the clients anxiety and agitation. It is difficult for families to see the client agitated and trying to express something. It leaves the family feeling frustrated and with a lingering memory after death. Before death, the client loses muscle control of the bowel and bladder, needing a disposable undergarment. Sitting in the chair and offering sips to drink is not something necessary at the end of life.

31. The hospice nurse is visiting the client in the home. The client is comfortable with talking to the nurse. Which of the following statements, made by the client, demonstrates that the spiritual needs are being met?
A) I believe that there is a better place.
B) I am comfortable and feel no pain.
C) Family is the most important thing to me.
D) There have been many positives in my life, and I am grateful.
Ans: A
Feedback:
When the client states hopefulness in an afterlife, it is a positive statement that the spiritual needs are being met. Religious beliefs and customs influence attitudes about death. The other options are positive statements of living in the here and now. This does not address the spiritual needs.

32. All nurses care for clients who are grieving. It is important for the nurse to understand the grieving process for which reason?
A) Allows for the nurse to facilitate the grieving process
B) Allows for the nurse to take the client through in the appropriate order
C) Allows for the nurse to understand when the grieving process should be concluded
D) Allows the nurse to express his or her feelings
Ans: A
Feedback:
Grieving is a painful yet normal reaction that helps clients cope with loss and leads to emotional healing. The nurse is responsible for facilitating the grieving process and helping the client and family deal with their emotions.

33. Which action, following the death of a loved one, would the nurse witness the Chinese American family members doing?
A) Praying beside the body
B) Washing the body
C) Calling the spirits
D) Perfuming the body
Ans: B
Feedback:
Following the death of the Chinese American client, some family members prefer to wash their loved one themselves. By cleansing the body, it is a sign of respect. Many cultures offer prayers beside the body. Calling spirits and perfuming the body is not commonly completed.

34. Which statement, made by the nurse, can be most helpful when caring for a client in the third stage of Kbler-Rosss emotional reactions to dying?
A) Lets review the laboratory results and compare them with the diagnostic tests.
B) I understand that it would be wonderful to see your daughters graduation.
C) What makes you most angry about getting the disease?
D) I like your idea of living for today and enjoying those around you.
Ans: B
Feedback:
The third stage of Elisabeth Kbler-Rosss series of reactions is bargaining. Confirming the intention to live to a certain time is common in this stage. Reviewing laboratory and diagnostic tests occurs in the first stage, denial. Talking about anger occurs in the second stage, anger. Living for the day is an idea which occurs in the final stage, acceptance.

35. In which scenario would the nurse, caring for the palliative care client, encourage the treatment of chemotherapy?
A) When the chemotherapy can assist in managing distressing clinical symptoms
B) When the client and family requests to have more chemotherapy
C) When the client feels chemotherapy will cure the disease
D) When the chemotherapy helps the psychological state of the client
Ans: A
Feedback:
The use of chemotherapy for a palliative care client is encouraged when used to manage distressing symptoms. Palliative care clients have accepted that the focus of care is comfort not cure. The nurse would open communication to understand why the client and family are requesting chemotherapy. The nurse continuously assesses the psychological state of the client; however, chemotherapy at this stage, typically is not helpful.

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