Medical Surgical Nursing Patient Centered Collaborative Care, 7th Edition by Donna D. Test Bank

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Medical Surgical Nursing Patient Centered Collaborative Care, 7th Edition by Donna D. Test Bank

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WITH ANSWERS

Medical Surgical Nursing Patient Centered Collaborative Care, 7th Edition by Donna D. Test Bank

Chapter 2: Introduction to Complementary and Alternative Therapies

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse wishes to learn more about the clients use of natural products and their effectiveness. The nurse consults the National Center for Complementary and Alternative Medicine because it is known that this center serves which function?
a. Educates health professionals about complementary therapies
b. Educates new mothers on the benefits of massage
c. Engages in fundraising to offset client expenses with medical care
d. Provides a scholarship for a student to study naturopathy

 

 

ANS:  A

The purposes of the National Center for Complementary and Alternative Medicine (NCCAM) are to fund studies examining the effectiveness of various complementary therapies, advance knowledge about complementary therapies of health professionals, and serve as a clearinghouse for information about these therapies. It does not fund scholarships, nor is it a nonprofit organization. It focuses on advancing knowledge for health professionals rather than the general public.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 9

TOP:   Client Needs Category: Physiological Integrity (Basic Care and ComfortNon-Pharmacological Comfort Interventions)

MSC:  Integrated Process: Teaching/Learning

 

  1. A client is anxious about having a dressing change. Which statement indicates that the nurse is promoting appropriate complementary therapy?
a. Ill call the doctor and ask for a larger dose of pain medication before the dressing change.
b. As we begin the next dressing change, I want you to think of a beautiful, calm place where you feel happy and peaceful.
c. Ill get another nurse to stay in the room with us during the dressing change so that you have a hand to hold during the procedure.
d. Are you familiar with acupuncture? Its a very effective technique.

 

 

ANS:  B

Because the clients primary problem is anxiety rather than pain at this point, the use of guided visual imagery should be the most effective intervention. Calling the physician for more pain medication and having another nurse present to help comfort the client will not address the main problem of the client. Acupuncture is used for relief of pain; an experienced practitioner is required to implement this technique.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Basic Care and ComfortNon-Pharmacological Comfort Interventions)

MSC:  Integrated Process: Nursing Process (Planning)

 

  1. The nurse has designed a treatment plan that includes the use of massage. Which intervention will the nurse implement first?
a. Assess the client to determine the most effective type of massage technique to use.
b. Inspect the skin over the tissue to be massaged to ensure that it is not infected or bruised.
c. Determine whether a licensed therapist will be needed to carry out the massage technique
d. Obtain permission from the client to implement this type of technique.

 

 

ANS:  D

Permission to use the procedure must be obtained from the client before any of the other interventions can be implemented.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Basic Care and ComfortNon-Pharmacological Comfort Interventions)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. A client who has been using which therapy requires the most immediate intervention by the nurse?
a. Aromatherapy to treat depression
b. Herbal preparations to treat hypertension
c. Therapeutic touch to decrease level of pain
d. Tai Chi to improve joint flexibility

 

 

ANS:  B

The client who has been using herbal preparations to treat hypertension may have endangered his or her life by inadvertently ingesting a substance that interacts poorly with another drug or that can be toxic. Aromatherapy may be used as a complementary therapy to treat depression. Therapeutic touch has been shown to decrease pain, and Tai Chi may assist in mobility. These therapies are appropriate and are not life threatening.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. A client scheduled for surgery has been taking garlic supplements. Which action is most important for the nurse to take?
a. No action is necessary because the herbal agent is harmless.
b. Notify the charge nurse that the client has been taking garlic.
c. Note the information on the clients record and place in the chart.
d. Notify the surgeon that the client has been taking garlic capsules.

 

 

ANS:  D

Because garlic acts as an antiplatelet agent and has the potential to decrease clotting, much in the same way as aspirin, the surgeon will have to decide whether the surgery will be postponed. The nurse should never assume that any herbal supplement is harmless because many can interact with medications and diet. The nurse will note the information on the clients chart, but the most important action is to notify the surgeon. Informing the charge nurse about the garlic is not necessary if the surgeon is notified.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems)                   MSC:  Integrated Process: Nursing Process (Planning)

 

  1. For which client does the nurse arrange animal-assisted therapy?
a. Middle-aged adult in a psychiatric facility with a history of schizophrenia
b. Older adult client with end-stage lung cancer in hospice care
c. Older adult client in a nursing home who is unresponsive
d. Adolescent in a drug treatment facility with a history of violent outbursts

 

 

ANS:  B

A client in hospice care may benefit from animal-assisted therapy because this type of therapy may decrease stress. A client in a psychiatric facility who has schizophrenia may not yet be stable enough to experience this type of therapy. A client who is unresponsive and is not interacting with the environment is not likely to benefit from this therapy. A client who is prone to violent outbursts would not be able to benefit from this type of therapy.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Psychosocial Integrity (Therapeutic Environment)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. Which statement indicates that the nurse understands the risks associated with herbal preparations?
a. Herbs are guaranteed to be safe and effective but are not necessarily natural.
b. Herbs require a different type of prescription than is required for standard prescribed medications.
c. Herbs are not classified as drugs and are regulated less strictly by the U.S. Food and Drug Administration (FDA).
d. Herbs are guaranteed to be all natural and of high quality but are not necessarily effective.

 

 

ANS:  C

Herbal preparations are regulated as food and nutritional supplements by the FDA. They do not require a prescription because they are not medications. Unfortunately, herbs are not under regulation by the government as drugs, and are not guaranteed to be natural, safe, or effective. This is one of the major disadvantages of herbal therapy.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 9

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)   MSC:  Integrated Process: Teaching/Learning

 

  1. A client asks the nurse to pray with him. The nurse is an atheist. Which statement by the nurse is the correct response?
a. Yes, lets pray together.
b. No, Im sorry, I cant do that.
c. No, I dont believe in prayer.
d. Ill hold your hand while you pray.

 

 

ANS:  D

By stating that he will hold the clients hand, the nurse offers support for the clients choice without compromising his beliefs. The nurse should not participate in any activity that goes against his or her beliefs. The nurse should not just state that he or she cant do this or tell the client personal views or preferences.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. The client has been diagnosed with cancer and is experiencing depression and insomnia as side effects of chemotherapy. The client tells the nurse that she has been supplementing her antidepressant medication with lavender oil and sandalwood but they arent working. Which statement by the nurse is the best response?
a. Tell me more about exactly what you are taking, how much you take, and when you take the antidepressants and use the oils.
b. Perhaps youre not using enough of the oil or are using it incorrectly.
c. Ill speak with your doctor to get you some medication that you can take while continuing the aromatherapy.
d. You dont want your doctor to put you on sleeping pills and antidepressants. Keep using them.

 

 

ANS:  A

The nurse should continue the assessment of the client to determine exactly what medications the client is taking and the specific type of complementary therapy the client is using, to determine whether the regimen is dangerous.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. The client is undergoing treatment for cancer and is experiencing a high level of anxiety. The client expresses interest in complementary therapies that might decrease the level of anxiety. Which action is the best choice for the nurse to implement with this client?
a. Direct the client to an imaginative peaceful setting using imagery.
b. Provide assistance in finding an acupuncturist.
c. Suggest Tai Chi during chemotherapy treatments.
d. Encourage the use of acupressure over tumor sites.

 

 

ANS:  A

Nurses traditionally have used a number of mind-body therapies such as prayer, imagery, meditation, music, and pet therapy to decrease anxiety in clients. Acupuncture and acupressure are pain relief therapies that usually require special education. Tai Chi is a body-based therapy that requires energy that may not be appropriate during chemotherapy sessions.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Basic Care and ComfortNon-Pharmacological Comfort Interventions)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. Which clients would benefit most from relaxation therapy?
a. Middle-age client who is undergoing chemotherapy treatments
b. Young client who is diagnosed with schizophrenia
c. Older client who is comatose and unresponsive
d. Young client who is diagnosed with major depression

 

 

ANS:  A

By reducing physical, mental, and emotional tension, relaxation is believed to result in changes opposite those of the fight-or-flight mechanism. Relaxation is helpful during painful procedures but may not be helpful with certain mental health problems or unresponsive clients because relaxation requires action from the client to relieve the tension.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Basic Care and ComfortNon-Pharmacological Comfort Interventions)

MSC:  Integrated Process: Nursing Process (Evaluation)

 

  1. A nurse is assisting a client in preparing for surgery by using progressive muscle relaxation. Which rationale best supports the use of this therapy at this time?
a. It rebalances or repatterns a persons energy field.
b. It improves flexibility and assists with positioning during surgery.
c. It applies pressure, releasing congestion and promoting energy flow.
d. It uses intentional tensing and releasing of successive muscle groups.

 

 

ANS:  D

Progressive muscle relaxation provides intentional tensing and releasing of successive muscle groups, thereby promoting relaxation and decreasing anxiety. Anxiety reduction would be the best rationale for a client preparing for surgery. The other statements are inaccurate descriptions of progressive muscle relaxation and its use.

 

DIF:    Cognitive Level: Knowledge/Remembering                               REF:    p. 11

TOP:   Client Needs Category: Physiological Integrity (Basic Care and ComfortNon-Pharmacological Comfort Interventions)

MSC:  Integrated Process: Caring; Nursing Process (Implementation)

 

  1. A client tells the nurse that he or she is considering using herbal supplements. What is the nurses best response?
a. Herbs are not classified as drugs in the United States, so there is no contraindication to using them.
b. Herbs have pharmacologic effects on the body and can interact with some prescription medications.
c. It is never permissible to use herbal supplements with prescription medications.
d. I will refer you to an herbalist, who can help you decide which medications you can take.

 

 

ANS:  B

Although herbs are not classified as drugs, they do possess pharmacologic properties. In caring for a client, the nurse should inquire whether the client takes herbal preparations and, if so, for what purpose. Many herbal preparations have not been adequately studied, and some can interact with prescription medications, causing toxic effects. The nurse should not refer the client to an herbalist. The client should be instructed that there are contraindications to herbal usage, but that herbs can be used with prescription medications, depending on the medication, the herbal substance, and the condition of the client.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 9

TOP:   Client Needs Category: Health Promotion and Maintenance (Health and Wellness)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. A client who is status post aortic valve replacement takes sodium warfarin (Coumadin) daily and has started taking Ginkgo biloba. What is the priority action for the nurse to take?
a. Encourage the use of Ginkgo biloba to enhance the clients systemic circulation.
b. Assess the client for any bruising or petechiae.
c. Explain that replacing Ginkgo biloba with garlic would be much safer.
d. Assess for any forgetfulness or inappropriate speech.

 

 

ANS:  B

Taking Ginkgo biloba with warfarin increases the clients risk of bleeding. Therefore, the client should be monitored first for bruising or bleeding associated with use of this combination. Ginkgo biloba is purported to reduce memory problems and dementia and has vasodilator properties, but these uses cannot be supported if the client is on an anticoagulant for the heart valve replacement. Garlic would not be a safer choice because it can act as an antiplatelet agent and would increase the risk of bleeding with warfarin (Coumadin).

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention)    MSC:           Integrated Process: Nursing Process (Planning)

 

  1. Which statement indicates that the client needs further teaching about complementary therapy?
a. Ive decided to use herb therapy for cancer treatment, so I can cancel my radiation treatments.
b. Im hoping that massage therapy will help reduce the amount of pain medication I use for my myalgia.
c. I think it helps me get better faster when I picture the drugs punching out the germs in my body.
d. I intend to pray about my cancer treatment several times a day. It makes me feel so much better.

 

 

ANS:  A

Complementary therapies are intended to be used with, rather than to replace, traditional forms of therapy to integrate mind, body, and spirit into the healing process. The client must have this information clarified, so that he will follow his recommended regimen for cancer treatment. The other statements appropriately indicate that the client understands the purpose of complementary therapy.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. Which teaching strategy is appropriate for a client who wishes to use mind-body complementary therapy to supplement traditional treatment for cancer?
a. Instruct the client to make a follow-up appointment with the health care provider after using mind-body treatments to assess the clients response to treatment.
b. Instruct the client never to use alternative or complementary treatments for serious illnesses.
c. Explain to the client that physicians and nurses are not prepared to recommend and monitor alternative treatments.
d. Explain to the client that physicians and nurses do not incorporate such treatments into their practice.

 

 

ANS:  A

Complementary or alternative treatments may be used in association with traditional therapy. The client who uses complementary or alternative therapy should be advised to make a follow-up visit to the health care provider to assess the clients response to therapy and to detect any adverse effects.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC:  Integrated Process: Teaching/Learning

 

  1. Which complementary or alternative therapy would the nurse recommend to a client with stiff joints to improve mobility?
a. Imagery
b. Animal-assisted therapy
c. Tai Chi
d. Aromatherapy

 

 

ANS:  C

Tai Chi is an active holistic therapy that integrates body movements, concentration, muscle relaxation, and breathing to improve body function, such as flexibility and posture. Imagery has been used successfully to reduce pain, nausea and vomiting, and anxiety. Animal-assisted therapy generally is used with clients who need to improve motor skills or the ability to concentrate. Aromatherapy uses essential oils to achieve relaxation, improve concentration, and ease depression.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Basic Care and ComfortNon-Pharmacological Comfort Interventions)

MSC:  Integrated Process: Teaching/Learning

 

  1. A client is experiencing nausea and vomiting from chemotherapy. Which alternative or complementary therapy would be best for the nurse to explore with the client?
a. Meditation
b. Imagery
c. Yoga
d. Music therapy

 

 

ANS:  B

Imagery has been used frequently to help clients reduce nausea and vomiting. Meditation, yoga, and music therapy are more useful for chronic pain, for hypertension, and in improving emotional health.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Basic Care and ComfortNon-Pharmacological Comfort Interventions)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. The nurse is working in the community and completes home visits with older adult clients. Which statement by a client demonstrates a need for further instruction about the use of complementary and alternative therapies?
a. My doctor monitors my kidney function since I started taking calcium.
b. I always talk to my doctor first before starting an herbal preparation.
c. I heard that St. Johns wort is good for any type of depression.
d. I may start a Tai Chi program to help with my mobility and lift my spirits.

 

 

ANS:  C

The client needs some education regarding the use of St. Johns wort for depression. It is advisable to seek the advice of a physician and to be evaluated for psychotherapy and/or drug therapy. Often older women consume too much calcium, and this can result in renal calculi. It is recommended that the older adult should have calcium levels monitored, as well as kidney function. All clients need to inform their health care team about any use of herbal preparations because of possible interactions with medications and possible side effects. Tai Chi is to be encouraged in the older adult to improve physical and mental health.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Health and Wellness)

MSC:  Integrated Process: Teaching/Learning

 

MULTIPLE RESPONSE

 

  1. During an initial health assessment interview, the nurse learns that the client is taking warfarin (Coumadin) for a history of deep vein thrombosis. Later, the client admits to taking several herbal preparations as well. Which herbal preparations would the nurse caution the client to avoid? (Select all that apply.)
a. Ginkgo biloba
b. Garlic
c. Ginseng
d. Zinc
e. St. Johns wort

 

 

ANS:  A, B, C

Ginkgo biloba may increase the anticoagulant effects of warfarin. Garlic and ginseng have been found to affect the international normalized ratio (INR).

 

DIF:    Cognitive Level: Knowledge/Remembering                               REF:    Table 2-2, p. 10

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. The nurse wishes to start music therapy with an older adult client who has high anxiety and hypertension. What essential elements should be considered when music is used with this client? (Select all that apply.)
a. Assess the clients preferences in choice of music.
b. Use fast tempo music to energize and motivate the client.
c. Consider rap music to provide diversion.
d. Consider live or recorded music such as music performed on a harp.
e. Consider generation-specific music.

 

 

ANS:  A, D, E

In music therapy, the nurse is encouraged to provide generation-appropriate music and to evaluate the clients preference. Live harp music may have a calming effect with anxious clients. Rap music is not generation-appropriate for older clients. Music with a fast tempo may escalate the clients anxiety and increase blood pressure.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Psychosocial Integrity (Stress Management)

MSC:  Integrated Process: Nursing Process (Planning)

Chapter 12: Concepts of Emergency and Disaster Preparedness

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse has been assigned the role of triage nurse after a weather-related disaster. What is the priority action of the nurse?
a. Call in additional staff to assist with care of the victims.
b. Splint fractures and clean and dress lacerations.
c. Perform a rapid assessment of clients to determine priority of care.
d. Provide psychological support to staff and family members.

 

 

ANS:  C

The triage nurse classifies victims of the explosion into priority of care based on illness or injury severity. Calling in additional staff more likely would be done by the hospital incident commander or designee. Physical care is provided to victims after triage occurs. Psychological support should be an ongoing part of the disaster plan but is not included in triage responsibilities; this ensures that the greatest good is provided to the greatest number of people.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at the nurse when dinner is served late. What is the nurses best response?
a. Do you need something for pain right now?
b. Please stop yelling. I brought dinner as soon as I could.
c. I suggest that you get control of yourself.
d. You seem upset. I have time to talk if you like.

 

 

ANS:  D

Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the clients options. Simply telling the client to gain control does nothing to promote therapeutic communication.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC:  Integrated Process: Communication and Documentation

 

  1. A client is receiving follow-up care after surviving a tornado. The client reports insomnia and the nurse notes that the client jumped as the nurse entered the room. Which action by the nurse is most appropriate?
a. Document findings on the clients chart and inform the physician.
b. Perform additional assessments for post-traumatic stress disorder.
c. Educate the client on nonpharmaceutical methods to promote sleep.
d. Plan to initiate a referral to a psychologist experienced in survivor issues.

 

 

ANS:  B

An individual may experience physical symptoms as a normal response to profound grief or loss, particularly after a traumatic incident. Manifestations such as insomnia, being startled easily, having flashbacks, or feelings of numbness may indicate post-traumatic stress disorder, and the nurse should first assess for this problem. The nurse should document assessment findings, but only after performing a more thorough assessment. A referral may be necessary, but the nurse does not have enough information yet to initiate it. If assessment reveals that methods to assist with sleep would be helpful, the nurse could provide that education.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Psychosocial Integrity (Coping Mechanisms)

MSC:  Integrated Process: Nursing Process (Assessment)

 

  1. An industrial accident has occurred near the hospital, and many victims are brought to the emergency department (ED) for treatment of their injuries. The nurse triages the victim with which injury with a red tag?
a. Dislocated right hip and an open fracture of the right lower leg
b. Large contusion to the forehead and a bloody nose
c. Closed fracture of the right clavicle and arm numbness
d. Multiple fractured ribs and shortness of breath

 

 

ANS:  D

Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the walking wounded and classified as nonurgent.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)           MSC:              Integrated Process: Nursing Process (Assessment)

 

  1. The nurse is working with a paramedic who just finished assisting at the scene of a school shooting where several students were killed. Which statement by the nurse is most therapeutic?
a. Would you like to talk about what happened?
b. Surely the department will give you the day off tomorrow.
c. At least the gunman was taken into custody.
d. Lets just sit here for a while quietly.

 

 

ANS:  A

Allowing staff members to ventilate their feelings about the incident can facilitate recovery and effective coping afterward. The other choices do not facilitate open communication because the nurse is not providing the opportunity for the paramedic to talk.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC:  Integrated Process: Caring

 

  1. A young man comes into the foyer of the hospital and says that he has a container of anthrax, which he opens and pours on the floor. Which is the priority action for the nurse who first comes upon the scene?
a. Don a protective gown, mask, and goggles.
b. Escort the man to the decontamination room.
c. Begin to evacuate the immediate area.
d. Notify the local health department of a biohazard situation.

 

 

ANS:  C

The highest priority is to remove people from immediate danger, so the nurse should evacuate the immediate area and prevent injury to those near the spill. Donning personal protective equipment would probably take the nurse away from the scene to obtain the equipment and would not help protect those in immediate danger. The man may need to be escorted to a decontamination area after people are removed from the scene. Reporting the incident to the health department should be done after the scene is secured and could be delegated to someone else.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlHandling Hazardous and Infectious Materials)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. Which is the priority action for the emergency department charge nurse in the event of a mass casualty situation?
a. Directing medical-surgical and case management nurses to assist emergency department (ED) staff with critically injured victims
b. Calling additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in
c. Informing the incident commander at the mass casualty scene about how many victims may be handled by the ED
d. Directing medical-surgical and critical care nurses to assist with clients who are already in the ED while the ED staff prepares to receive the mass casualty victims

 

 

ANS:  D

The ED charge nurse should direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive the mass casualty victims; however, they should not be assigned to the most critically ill or injured clients. The hospital incident commander is responsible for mobilizing resources and would have the responsibility for calling in staff. The medical command physician would be the person best able to communicate with on-scene personnel regarding the ability to take more clients.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of CareConcepts of Management)           MSC:              Integrated Process: Nursing Process (Planning)

 

  1. An accident has occurred near the hospital, and a victim is brought to the emergency department with severe chest pain, a pulse of 120 beats/min, blood pressure of 100/60 mm Hg, and a respiratory rate of 28 breaths/min. The nurse assesses shortness of breath and diaphoresis. Which color tag does the nurse use when triaging this client?
a. Red
b. Yellow
c. Green
d. Black

 

 

ANS:  A

The client in the emergent triage category has a condition that may post an immediate threat to life or limb and is given the highest priority. Clients who should be treated emergently receive a red tag. Yellow tags signify major but stable injuries that can wait 30 minutes to 2 hours for definitive care. Green tags designate walking wounded who can wait longer than 2 hours to receive care. Black tags are used to designate those who are dead or who are expected to die.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)           MSC:              Integrated Process: Nursing Process (Assessment)

 

  1. A nurse is working at the scene of a catastrophic natural event. Which person does the nurse attend to first?
a. Distraught mother looking for her children
b. Person walking about with a bleeding head wound
c. Supine person with pale, cool, clammy skin
d. Child with a deformed lower leg crying in pain

 

 

ANS:  C

The person with pale, cool, clammy skin is in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. The hospital is overwhelmed when caring for victims after an earthquake that occurred 48 hours ago. Which responsibility of the nursing supervisor is most important at this time?
a. Assuming leadership for implementation of the hospital emergency plan
b. Releasing updates of client conditions to the media
c. Converting the physical therapy clinic into a treatment area for the injured
d. Arranging relief and coordinating breaks so nursing staff can rest and eat

 

 

ANS:  D

The nursing supervisor should ensure that the staff is not becoming dangerously overtired by working long shifts without food or rest. Overall leadership for implementing the emergency plan and re-designating areas for client care would fall under the job of hospital incident commander. The community relations/public information officer would work with the media.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of CareConcepts of Management)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. The nurse is teaching nursing students about personal emergency preparedness. Which statement by a student indicates that further teaching is indicated?
a. I will get a prescription for antibiotics just in case I have to work in an area that has been infected with anthrax.
b. I should keep an extra uniform in my locker in case I get stuck at work.
c. I may be torn between caring for my young daughter and caring for victims at work.
d. I should make plans for my family to evacuate our house in case of tornado or earthquake.

 

 

ANS:  A

The student would have no reason to obtain a prescription for anthrax unless he or she demonstrates clinical evidence of anthrax infection or has been exposed to a substance that tests positive for anthrax. Statements about planning to keep an extra uniform at work, recognizing the moral dilemmas he or she might encounter when working in a disaster situation, and understanding personal preparation for disasters all indicate that the student comprehends information about disaster planning and emergency preparedness.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of CareEmergency Response Plan)   MSC:              Integrated Process: Teaching/Learning

 

  1. The hospital administration has arranged for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation?
a. You are free to express your feelings; whatever is said here stays here.
b. Lets determine what we can do better the next time we have this situation.
c. This session is only for nursing and medical staff, not for ancillary personnel.
d. Lets pass around the written policy compliance form for everyone.

 

 

ANS:  A

Strict confidentiality during stress debriefing is essential so that staff members can feel comfortable sharing their feelings, which should be accepted unconditionally. Brainstorming improvements and discussing policies would occur during an administrative review. Any employee present during a mass casualty situation is eligible for critical incident stress management services.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 162

TOP:   Client Needs Category: Psychosocial Integrity (Stress Management)

MSC:  Integrated Process: Communication and Documentation

 

  1. The nurse is caring for a client whose wife just died in an accident. The client says to the nurse, I cant believe that my wife is gone and I am left to raise my children all by myself. Which response by the nurse is most appropriate?
a. Please accept my sympathy for your loss.
b. I can call the hospital chaplain if you wish.
c. You sound anxious about being a single parent.
d. At least your children still have you in their lives.

 

 

ANS:  C

Therapeutic communication includes active listening and honesty. This statement demonstrates that the nurse recognizes the clients distress and has provided an opening for discussion. Extending sympathy and offering to call the chaplain do not give the client the opportunity to discuss feelings. Stating that the children still have one parent discounts the clients feelings and situation.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC:  Integrated Process: Communication and Documentation

 

  1. The emergency department nurse manager is explaining concepts of emergency and disaster preparedness to a group of students. Which statement by the nurse manager is most accurate?
a. An internal disaster is something that occurs inside the health care facility.
b. An external disaster occurs when someone not employed here disrupts our operations.
c. A multi-casualty event involves disasters at several different locations.
d. The Joint Commission requires that we participate in a disaster drill once a year.

 

 

ANS:  A

An internal disaster is something that occurs within the health care facility, such as a fire. External disasters, such as a tornado or a hurricane, occur outside the health care facility. A multi-casualty event can be managed with hospital resources. The Joint Commission requires hospitals to participate in two disaster drills a year.

 

DIF:    Cognitive Level: Knowledge/Remembering                               REF:    p. 155

TOP:   Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlEmergency Response Plan)         MSC:  Integrated Process: Teaching/Learning

 

  1. The emergency department (ED) is expecting a large number of casualties after a bridge collapse. Which is a priority consideration for the ED leadership when activating the disaster plan?
a. Responding paramedics and rescue personnel will notify the ED about exactly how many victims to expect.
b. Responding paramedics and rescue personnel will triage all victims at the bridge collapse site before bringing them to the ED.
c. The ED may receive many unexpected victims with minor injuries from the bridge collapse.
d. Victims who have been contaminated with gasoline will be decontaminated by rescue personnel before arriving at the ED.

 

 

ANS:  C

Paramedics may not note all the walking wounded to give the ED an accurate count of victims to expect because these people might evacuate themselves from the accident scene without being seen by paramedics or rescue personnel. They may then secure their own transportation to the hospital and could overwhelm an ED that is already handling many severely injured victims who have been brought in by emergency medical services (EMS).

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlEmergency Response Plan)         MSC:  Integrated Process: Nursing Process (Planning)

 

  1. A nursing administrator is evaluating the hospitals response to a recent internal disaster. The administrator assesses that goals for disaster planning have been met when which outcome is assessed?
a. The hospital was able to maintain client, staff, and visitor safety during the disaster.
b. Supplies were readily available and were transported rapidly where needed.
c. The hospital incident command officer successfully utilized ancillary areas for client care.
d. All employees followed the chain of command and established policies and procedures.

 

 

ANS:  A

The most important outcome of any internal disaster is maintenance of safety for the hospitals clients, staff, and visitors. Other outcomes listed would be part of a successful disaster response, but are all too narrow to meet this objective.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlEmergency Response Plan)         MSC:  Integrated Process: Nursing Process (Evaluation)

 

  1. A nursing administrator is reviewing a hospitals disaster planning. The administrator evaluates the plan that addresses which component as being the best?
a. Internal disasters such as fires or power outages
b. All possible catastrophes in the community
c. The Joint Commissions assessment of possible disasters
d. Responses to all types of weather-related emergencies

 

 

ANS:  B

When The Joint Commissionaccredited health care facilities are planning disaster preparedness programs, they need to take an all-hazards approach (versus planning by strict guidelines) and to plan for all credible threats to the community that could result in a disaster. This means planning for all events that could conceivably happen in that geographic area, including possible weather events. Planning only for internal disasters is too limited and does not account for weather- or terrorist-related threats. The Joint Commission does not assess what disasters are possible in the areas that accredited hospitals serve.

 

DIF:    Cognitive Level: Application/Applying or higher            REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlEmergency Response Plan)         MSC:  Integrated Process: Nursing Process (Planning)

 

  1. A nursing instructor is debriefing students who participated in a community-wide disaster drill. Several students are upset with the black-tagged triage category. Which statement by the nursing instructor is best?
a. To do the greatest good for the greatest number of people, it is necessary to sacrifice some.
b. Not everyone will survive a disaster, so it is best to identify those people early and move on.
c. In a disaster, extensive resources are not used for one person at the expense of many others.
d. With black tags, volunteers can identify those who are dying and can give them comfort care.

 

 

ANS:  C

In a disaster, military style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Clients are not sacrificed. Telling students to move on after identifying the expectant dead belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged to allow volunteers to give comfort care.

 

DIF:    Cognitive Level: Comprehension/Understanding            REF:   p. 157

TOP:   Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlEmergency Response Plan)         MSC:  Integrated Process: Teaching/Learning

 

  1. A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurses interests?
a. The Medical Reserve Corps
b. The National Guard
c. The Health Department
d. A Disaster Medical Assistance Team

 

 

ANS:  A

The Medical Reserve Corps (MRC) consists of volunteer medical and public health care professionals who support the community during times of need. They may help staff hospitals, establish first aid stations or special needs shelters, or set up acute care centers in the community. The National Guard often performs search and rescue operations and law enforcement. The Health Department focuses on communicable disease tracking, treatment, and prevention. A Disaster Medical Assistance Team is deployed to a disaster area for up to 72 hours, providing many types of relief services.

 

DIF:    Cognitive Level: Knowledge/Remembering                               REF:    p. 159

TOP:   Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlEmergency Response Plan)

MSC:  Integrated Process: Nursing Process (Implementation)

 

  1. A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. What statement by the nursing supervisor best addresses these concerns?
a.

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