Fundamental Nursing Care, 2nd Edition by Roberta Pavy Ramont - Test Bank

Fundamental Nursing Care, 2nd Edition by Roberta Pavy Ramont – Test Bank

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ExamName___________________________________MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.1)A nurse is preparing to administer three medications to a client. The client was admitted two daysago with deep vein thrombophlebitis, is on bed rest, and has oxygen per nasal cannula. The nurseverifies the client’s identity and elevates the head of the bed. What is the most appropriate nextnursing action that promotes the client’s physiological safety?1)A)Remove the nasal cannula.B)Ask the client if he would like to take the medications one at a time or all together.C)Have the client take several sips of water.D)Assess the client’s gag reflex.Answer:CExplanation:A)Oxygen is drying to the mucous membranes. People receiving oxygen by nasalcannula tend to be mouth breathers and this increases the dryness. To facilitateswallowing medications (whether one by one or all at the same time), have theclient first moisten the mucous membranes of the mouth and pharynx. The nursecan ascertain the client’s preference for the order in which to take the medications,but it is more important to address the oral dryness to promote safety for the client.There is no indication that the gag reflex is absent or diminished. This is moreimportant with a new postoperative client or someone with swallowingdifficulties. An advantage of a nasal cannula is that it does not need to be removedfor the client to eat or take oral medications.PlanningPhysiological Integrity-Reduction of Risk PotentialAnalysisB)Oxygen is drying to the mucous membranes. People receiving oxygen by nasalcannula tend to be mouth breathers and this increases the dryness. To facilitateswallowing medications (whether one by one or all at the same time), have theclient first moisten the mucous membranes of the mouth and pharynx. The nursecan ascertain the client’s preference for the order in which to take the medications,but it is more important to address the oral dryness to promote safety for the client.There is no indication that the gag reflex is absent or diminished. This is moreimportant with a new postoperative client or someone with swallowingdifficulties. An advantage of a nasal cannula is that it does not need to be removedfor the client to eat or take oral medications.PlanningPhysiological Integrity-Reduction of Risk PotentialAnalysisC)Oxygen is drying to the mucous membranes. People receiving oxygen by nasalcannula tend to be mouth breathers and this increases the dryness. To facilitateswallowing medications (whether one by one or all at the same time), have theclient first moisten the mucous membranes of the mouth and pharynx. The nursecan ascertain the client’s preference for the order in which to take the medications,but it is more important to address the oral dryness to promote safety for the client.There is no indication that the gag reflex is absent or diminished. This is moreimportant with a new postoperative client or someone with swallowingdifficulties. An advantage of a nasal cannula is that it does not need to be removedfor the client to eat or take oral medications.PlanningPhysiological Integrity-Reduction of Risk PotentialAnalysis1
D)Oxygen is drying to the mucous membranes. People receiving oxygen by nasalcannula tend to be mouth breathers and this increases the dryness. To facilitateswallowing medications (whether one by one or all at the same time), have theclient first moisten the mucous membranes of the mouth and pharynx. The nursecan ascertain the client’s preference for the order in which to take the medications,but it is more important to address the oral dryness to promote safety for the client.There is no indication that the gag reflex is absent or diminished. This is moreimportant with a new postoperative client or someone with swallowingdifficulties. An advantage of a nasal cannula is that it does not need to be removedfor the client to eat or take oral medications.PlanningPhysiological Integrity-Reduction of Risk PotentialAnalysis2)A home care client with rheumatoid arthritis is seen by the home health nurse. The client is takingnaproxen (Naprosyn) 500 milligrams orally twice a day for pain control. As part of the nursingassessment for this client, it is essential that the nurse:2)A)Assess if the client has had any weight loss since the last nursing visit.B)Determine if the client is taking the medication 30 minutes before meals.C)Reinforce the necessity for range of motion exercises to all joints at least twice a day.D)Ask the client about the color of her stools.Answer:DExplanation:A)The client is taking a large dose of a nonsteroidal antiinflammatory medication thatcan cause gastrointestinal bleeding. The color of the stools can be an indicator ofbleeding. The medication should be taken with food, not on an empty stomach. Aclient with rheumatoid arthritis who is overweight is encouraged to lose weight;but this is not the focus of this question. Range of motion exercises need to betailored to the individual client and the status of the arthritis.AssessmentPhysiological Integrity — Pharmacological TherapiesApplicationB)The client is taking a large dose of a nonsteroidal antiinflammatory medication thatcan cause gastrointestinal bleeding. The color of the stools can be an indicator ofbleeding. The medication should be taken with food, not on an empty stomach. Aclient with rheumatoid arthritis who is overweight is encouraged to lose weight;but this is not the focus of this question. Range of motion exercises need to betailored to the individual client and the status of the arthritis.AssessmentPhysiological Integrity — Pharmacological TherapiesApplicationC)The client is taking a large dose of a nonsteroidal antiinflammatory medication thatcan cause gastrointestinal bleeding. The color of the stools can be an indicator ofbleeding. The medication should be taken with food, not on an empty stomach. Aclient with rheumatoid arthritis who is overweight is encouraged to lose weight;but this is not the focus of this question. Range of motion exercises need to betailored to the individual client and the status of the arthritis.AssessmentPhysiological Integrity — Pharmacological TherapiesApplication2
D)The client is taking a large dose of a nonsteroidal antiinflammatory medication thatcan cause gastrointestinal bleeding. The color of the stools can be an indicator ofbleeding. The medication should be taken with food, not on an empty stomach. Aclient with rheumatoid arthritis who is overweight is encouraged to lose weight;but this is not the focus of this question. Range of motion exercises need to betailored to the individual client and the status of the arthritis.AssessmentPhysiological Integrity — Pharmacological TherapiesApplication3)A nurse turns a client to the side, and notes that the client has several lightly reddened areas overthe back and hips. The skin is intact. What is an appropriate independent nursing action for thenurse to perform at this time?3)A)Massage the client’s back with lotion using circular motions around the reddened areas.B)Place small pillows under the shoulders and coccyx.C)Order an air mattress for the client.D)Document the observation and inform the nurse in charge.Answer:AExplanation:A)An independent decision and action that can be made by the nurse at this time is tostimulate circulation by providing a back massage. Reddened areas are not directlymassaged, because this may promote tissue damage in an already compromisedarea. It cannot be determined from the information in the scenario whether theclient is at risk for skin breakdown. There is none at this time. Although theobservation will be documented and the charge nurse will be informed, these twoactions are expected responses to observations, not independent nursing actions.Ordering an air mattress will require a collaborative (rather than independent)decision to identify the most appropriate nursing interventions for the client.Placing small pillows under the shoulder and coccyx is not correct and will lead tofurther pressure on these areas.ImplementationPhysiological Integrity-Basic Care and ComfortApplicationB)An independent decision and action that can be made by the nurse at this time is tostimulate circulation by providing a back massage. Reddened areas are not directlymassaged, because this may promote tissue damage in an already compromisedarea. It cannot be determined from the information in the scenario whether theclient is at risk for skin breakdown. There is none at this time. Although theobservation will be documented and the charge nurse will be informed, these twoactions are expected responses to observations, not independent nursing actions.Ordering an air mattress will require a collaborative (rather than independent)decision to identify the most appropriate nursing interventions for the client.Placing small pillows under the shoulder and coccyx is not correct and will lead tofurther pressure on these areas.ImplementationPhysiological Integrity-Basic Care and ComfortApplication3
C)An independent decision and action that can be made by the nurse at this time is tostimulate circulation by providing a back massage. Reddened areas are not directlymassaged, because this may promote tissue damage in an already compromisedarea. It cannot be determined from the information in the scenario whether theclient is at risk for skin breakdown. There is none at this time. Although theobservation will be documented and the charge nurse will be informed, these twoactions are expected responses to observations, not independent nursing actions.Ordering an air mattress will require a collaborative (rather than independent)decision to identify the most appropriate nursing interventions for the client.Placing small pillows under the shoulder and coccyx is not correct and will lead tofurther pressure on these areas.ImplementationPhysiological Integrity-Basic Care and ComfortApplicationD)An independent decision and action that can be made by the nurse at this time is tostimulate circulation by providing a back massage. Reddened areas are not directlymassaged, because this may promote tissue damage in an already compromisedarea. It cannot be determined from the information in the scenario whether theclient is at risk for skin breakdown. There is none at this time. Although theobservation will be documented and the charge nurse will be informed, these twoactions are expected responses to observations, not independent nursing actions.Ordering an air mattress will require a collaborative (rather than independent)decision to identify the most appropriate nursing interventions for the client.Placing small pillows under the shoulder and coccyx is not correct and will lead tofurther pressure on these areas.ImplementationPhysiological Integrity-Basic Care and ComfortApplication4)The desired outcome for a client is to have an oral temperature less than 100 degrees Fahrenheit(37.8 degrees Celsius) at 4:00 p.m. The client’s oral temperature at 4:00 p.m. is found to be 101degrees Fahrenheit (38.3 degrees Celsius). What should be the initial action by the nurse at thistime?4)A)Document the client’s temperature and note in narrative charting that the nursing goal wasnot met successfully.B)Wait at least five minutes and then re-check the client’s temperature.C)Revise the goal on the client’s nursing care plan.D)Determine possible reasons the goal has not been reached.Answer:DExplanation:A)When nursing goals are evaluated and it is found that they have not been reached,the next action is to identify reasons why the goal may have not been met. Thereasons can include improper technique in obtaining the temperature, ingestion ofhot beverages immediately prior to the measurement, a correct measurement of theclient’s body temperature, or broken equipment. Goals are not revised unless it isfound that they are not realistic for a client. The nurse may decide to re-check theclient’s temperature after identifying possible influencing factors. Documentationshould not be done as an initial action.EvaluationPhysiological Integrity-Reduction of Risk PotentialAnalysis4
B)When nursing goals are evaluated and it is found that they have not been reached,the next action is to identify reasons why the goal may have not been met. Thereasons can include improper technique in obtaining the temperature, ingestion ofhot beverages immediately prior to the measurement, a correct measurement of theclient’s body temperature, or broken equipment. Goals are not revised unless it isfound that they are not realistic for a client. The nurse may decide to re-check theclient’s temperature after identifying possible influencing factors. Documentationshould not be done as an initial action.EvaluationPhysiological Integrity-Reduction of Risk PotentialAnalysisC)When nursing goals are evaluated and it is found that they have not been reached,the next action is to identify reasons why the goal may have not been met. Thereasons can include improper technique in obtaining the temperature, ingestion ofhot beverages immediately prior to the measurement, a correct measurement of theclient’s body temperature, or broken equipment. Goals are not revised unless it isfound that they are not realistic for a client. The nurse may decide to re-check theclient’s temperature after identifying possible influencing factors. Documentationshould not be done as an initial action.EvaluationPhysiological Integrity-Reduction of Risk PotentialAnalysisD)When nursing goals are evaluated and it is found that they have not been reached,the next action is to identify reasons why the goal may have not been met. Thereasons can include improper technique in obtaining the temperature, ingestion ofhot beverages immediately prior to the measurement, a correct measurement of theclient’s body temperature, or broken equipment. Goals are not revised unless it isfound that they are not realistic for a client. The nurse may decide to re-check theclient’s temperature after identifying possible influencing factors. Documentationshould not be done as an initial action.EvaluationPhysiological Integrity-Reduction of Risk PotentialAnalysis5)A certified nursing assistant reports to the nurse that a client’s temperature is 39.1 degreesCentigrade (102.4 degrees Fahrenheit). The client has an order for acetaminophen (Tylenol) 650milligrams orally or rectally every 4 hours prn for temperature above 38.5 degrees C. (101.4 degreesF.). The nurse should first:5)A)Check the medication record to determine when the client last had the medication.B)Ask the client if he is nauseated or has diarrhea and then determine the route to use.C)Retake the temperature to determine if the nursing assistant’s measurement was accurate.D)Give the medication orally if there are no contraindications to using this route.Answer:AExplanation:A)Prior to giving any prn medication, the nurse must determine when the last dosagewas administered. There is no reason that the temperature needs to be reevaluated,because the certified nursing assistant should be qualified to obtain an accuratetemperature reading. After determining the time of the prior dose, the nurse canassess the client to determine which route to use for the medication.AssessmentPhysiological Integrity – Pharmacological TherapiesAnalysis5
B)Prior to giving any prn medication, the nurse must determine when the last dosagewas administered. There is no reason that the temperature needs to be reevaluated,because the certified nursing assistant should be qualified to obtain an accuratetemperature reading. After determining the time of the prior dose, the nurse canassess the client to determine which route to use for the medication.AssessmentPhysiological Integrity – Pharmacological TherapiesAnalysisC)Prior to giving any prn medication, the nurse must determine when the last dosagewas administered. There is no reason that the temperature needs to be reevaluated,because the certified nursing assistant should be qualified to obtain an accuratetemperature reading. After determining the time of the prior dose, the nurse canassess the client to determine which route to use for the medication.AssessmentPhysiological Integrity – Pharmacological TherapiesAnalysisD)Prior to giving any prn medication, the nurse must determine when the last dosagewas administered. There is no reason that the temperature needs to be reevaluated,because the certified nursing assistant should be qualified to obtain an accuratetemperature reading. After determining the time of the prior dose, the nurse canassess the client to determine which route to use for the medication.AssessmentPhysiological Integrity – Pharmacological TherapiesAnalysis6)A nursing diagnosis of Risk for Ineffective Airway Clearance related to shallow breathing pattern,pain, and fatigue has been established for a postoperative client. Nursing interventions have beenestablished. The nurse will determine that the diagnosis is no longer needed when the client:6)A)Consistently has a pulse oximetry above 95% when active and when at rest.B)Is able to deep-breathe and cough without discomfort.C)Has clear lung fields bilaterally.D)Correctly uses the incentive spirometer independently.Answer:AExplanation:A)A pulse oximetry reading over 95% is considered normal. Of the options provided,oxygen saturation is the most objective evaluation of the effectiveness of the client’srespiratory effort and efficiency. Consistently obtaining this value indicates that theairway is remaining clear. Correctly using the incentive spirometer and being ableto deep-breathe and cough without discomfort are nursing interventions to attainthe desired outcomes of effective airway clearance and prevent respiratorycomplications. Bilateral clear lung fields are an important assessment indetermining if nursing interventions have been successful.EvaluationPhysiological Integrity — Reduction of Risk PotentialAnalysis6
B)A pulse oximetry reading over 95% is considered normal. Of the options provided,oxygen saturation is the most objective evaluation of the effectiveness of the client’srespiratory effort and efficiency. Consistently obtaining this value indicates that theairway is remaining clear. Correctly using the incentive spirometer and being ableto deep-breathe and cough without discomfort are nursing interventions to attainthe desired outcomes of effective airway clearance and prevent respiratorycomplications. Bilateral clear lung fields are an important assessment indetermining if nursing interventions have been successful.EvaluationPhysiological Integrity — Reduction of Risk PotentialAnalysisC)A pulse oximetry reading over 95% is considered normal. Of the options provided,oxygen saturation is the most objective evaluation of the effectiveness of the client’srespiratory effort and efficiency. Consistently obtaining this value indicates that theairway is remaining clear. Correctly using the incentive spirometer and being ableto deep-breathe and cough without discomfort are nursing interventions to attainthe desired outcomes of effective airway clearance and prevent respiratorycomplications. Bilateral clear lung fields are an important assessment indetermining if nursing interventions have been successful.EvaluationPhysiological Integrity — Reduction of Risk PotentialAnalysisD)A pulse oximetry reading over 95% is considered normal. Of the options provided,oxygen saturation is the most objective evaluation of the effectiveness of the client’srespiratory effort and efficiency. Consistently obtaining this value indicates that theairway is remaining clear. Correctly using the incentive spirometer and being ableto deep-breathe and cough without discomfort are nursing interventions to attainthe desired outcomes of effective airway clearance and prevent respiratorycomplications. Bilateral clear lung fields are an important assessment indetermining if nursing interventions have been successful.EvaluationPhysiological Integrity — Reduction of Risk PotentialAnalysis7)A nurse is obtaining admission information from a client and his family. All of the followinginformation is obtained during the interview. The nurse should document what data as primaryobjective information? (Select all that apply.)7)A)The nurse observes that the client is pale and gets short of breath when talking.B)The client’s pulse rate is 94 and his blood pressure is 108/72.C)The client’s wife reports that the nurse at the doctor’s office told her that the client’s whiteblood cell count was 1800.D)The client says he sleeps 6-7 hours each night and has been taking short naps during theday more frequently.E)The client’s wife states that the client “has felt worse over the last week.”F)The client reports a pain level of 4 on a scale of 1 through 10.Answer:A, BExplanation:A)Primary objective data is observable, can be measured or tested against anaccepted standard, and is obtained directly from the client. It includes informationthat can be seen, felt, heard, or smelled.AssessmentHealth Promotion and MaintenanceApplication7
B)Primary objective data is observable, can be measured or tested against anaccepted standard, and is obtained directly from the client. It includes informationthat can be seen, felt, heard, or smelled.AssessmentHealth Promotion and MaintenanceApplicationC)Primary objective data is observable, can be measured or tested against anaccepted standard, and is obtained directly from the client. It includes informationthat can be seen, felt, heard, or smelled.AssessmentHealth Promotion and MaintenanceApplicationD)Primary objective data is observable, can be measured or tested against anaccepted standard, and is obtained directly from the client. It includes informationthat can be seen, felt, heard, or smelled.AssessmentHealth Promotion and MaintenanceApplicationE)Primary objective data is observable, can be measured or tested against anaccepted standard, and is obtained directly from the client. It includes informationthat can be seen, felt, heard, or smelled.AssessmentHealth Promotion and MaintenanceApplicationF)Primary objective data is observable, can be measured or tested against anaccepted standard, and is obtained directly from the client. It includes informationthat can be seen, felt, heard, or smelled.AssessmentHealth Promotion and MaintenanceApplication8)A nursing staff that consists of RNs and LPN/LVNs are discussing their difficulties with up-to-datenursing care plans when most of their clients are discharged after only a few days’ stay. Most ofthem feel that it is just more paperwork to do and interferes with the amount of time they haveavailable for the client. A helpful statement for these nurses to encourage them to continue usingthe nursing process in the care of their clients is that:8)A)Completed care plans are required to be done on all clients admitted to their unit.B)The focus of client care is quality rather than quantity.C)The incidence of nosocomial infections will decrease on their unit.D)They will make fewer errors in medication administration.Answer:BExplanation:A)The purpose of using the nursing process in client care is to provide a systematic,logical, holistic, and individualized framework to the practice of nursing and clientcare. The reduction of medication errors and nosocomial infections are part ofquality care and are more directly the result of how nurses carry out variousnursing procedures, rather than whether the nursing process is used.ImplementationSafe, Effective Care Environment-Coordinated CareApplication8
B)The purpose of using the nursing process in client care is to provide a systematic,logical, holistic, and individualized framework to the practice of nursing and clientcare. The reduction of medication errors and nosocomial infections are part ofquality care and are more directly the result of how nurses carry out variousnursing procedures, rather than whether the nursing process is used.ImplementationSafe, Effective Care Environment-Coordinated CareApplicationC)The purpose of using the nursing process in client care is to provide a systematic,logical, holistic, and individualized framework to the practice of nursing and clientcare. The reduction of medication errors and nosocomial infections are part ofquality care and are more directly the result of how nurses carry out variousnursing procedures, rather than whether the nursing process is used.ImplementationSafe, Effective Care Environment-Coordinated CareApplicationD)The purpose of using the nursing process in client care is to provide a systematic,logical, holistic, and individualized framework to the practice of nursing and clientcare. The reduction of medication errors and nosocomial infections are part ofquality care and are more directly the result of how nurses carry out variousnursing procedures, rather than whether the nursing process is used.ImplementationSafe, Effective Care Environment-Coordinated CareApplication9)A client is admitted to a skilled nursing facility after being discharged from an acute care hospital.The client is to be ambulated with assistance at least four times a day. To plan for the client’sambulation, the nurse should initially gather information about the client’s: (Select all that apply.)9)A)Self-identified needs for assistance when ambulating.B)Ambulation orders from the discharge information.C)Weight.D)Assistance requirements from the nurse’s notes from the acute care facility.E)Vital signs including pulse, respirations, and blood pressure.F)Height.Answer:A, C, E, FExplanation:A)To determine the amount and kind of assistance needed to safely ambulate theclient, the nurse should gather information about the client’s size, personalexperience with ambulation while in the acute care facility, and vital signs. Thenursing notes from the acute care facility are not transferred with the client. Theambulation order is to ambulate four times a day with assistance; it does not spellout the amount and kind of assistance needed.AssessmentSafe, Effective Care Environment — Safety and Infection ControlAnalysisB)To determine the amount and kind of assistance needed to safely ambulate theclient, the nurse should gather information about the client’s size, personalexperience with ambulation while in the acute care facility, and vital signs. Thenursing notes from the acute care facility are not transferred with the client. Theambulation order is to ambulate four times a day with assistance; it does not spellout the amount and kind of assistance needed.AssessmentSafe, Effective Care Environment — Safety and Infection ControlAnalysis9
C)To determine the amount and kind of assistance needed to safely ambulate theclient, the nurse should gather information about the client’s size, personalexperience with ambulation while in the acute care facility, and vital signs. Thenursing notes from the acute care facility are not transferred with the client. Theambulation order is to ambulate four times a day with assistance; it does not spellout the amount and kind of assistance needed.AssessmentSafe, Effective Care Environment — Safety and Infection ControlAnalysisD)To determine the amount and kind of assistance needed to safely ambulate theclient, the nurse should gather information about the client’s size, personalexperience with ambulation while in the acute care facility, and vital signs. Thenursing notes from the acute care facility are not transferred with the client. Theambulation order is to ambulate four times a day with assistance; it does not spellout the amount and kind of assistance needed.AssessmentSafe, Effective Care Environment — Safety and Infection ControlAnalysisE)To determine the amount and kind of assistance needed to safely ambulate theclient, the nurse should gather information about the client’s size, personalexperience with ambulation while in the acute care facility, and vital signs. Thenursing notes from the acute care facility are not transferred with the client. Theambulation order is to ambulate four times a day with assistance; it does not spellout the amount and kind of assistance needed.AssessmentSafe, Effective Care Environment — Safety and Infection ControlAnalysisF)To determine the amount and kind of assistance needed to safely ambulate theclient, the nurse should gather information about the client’s size, personalexperience with ambulation while in the acute care facility, and vital signs. Thenursing notes from the acute care facility are not transferred with the client. Theambulation order is to ambulate four times a day with assistance; it does not spellout the amount and kind of assistance needed.AssessmentSafe, Effective Care Environment — Safety and Infection ControlAnalysis10)Several staff nurses from an orthopedic unit are attending a workshop entitled “Nursing Diagnosesand Successful Client Care Planning.” An essential understanding for the nurses to take away fromthis conference is/are the:10)A)Correct methods to perform procedures that are required nursing activities on their unit.B)Requirement for client and family members to participate in the nursing process.C)Relationship of common nursing diagnoses and standardized care plans for orthopedicclients.D)Importance of being a critical thinker at all times.Answer:B10
Explanation:A)Client care, from assessment to evaluation, must have the input and cooperation ofthe client and family to be successful. Client care is individualized, notstandardized. Nursing diagnoses reflect this client focus. Critical thinking isrequired in many aspects of nursing practice; not “at all times.” The title of theconferences does not suggest it is about learning nursing procedures.PlanningSafe, Effective Care Environment-Coordinated CareAnalysisB)Client care, from assessment to evaluation, must have the input and cooperation ofthe client and family to be successful. Client care is individualized, notstandardized. Nursing diagnoses reflect this client focus. Critical thinking isrequired in many aspects of nursing practice; not “at all times.” The title of theconferences does not suggest it is about learning nursing procedures.PlanningSafe, Effective Care Environment-Coordinated CareAnalysisC)Client care, from assessment to evaluation, must have the input and cooperation ofthe client and family to be successful. Client care is individualized, notstandardized. Nursing diagnoses reflect this client focus. Critical thinking isrequired in many aspects of nursing practice; not “at all times.” The title of theconferences does not suggest it is about learning nursing procedures.PlanningSafe, Effective Care Environment-Coordinated CareAnalysisD)Client care, from assessment to evaluation, must have the input and cooperation ofthe client and family to be successful. Client care is individualized, notstandardized. Nursing diagnoses reflect this client focus. Critical thinking isrequired in many aspects of nursing practice; not “at all times.” The title of theconferences does not suggest it is about learning nursing procedures.PlanningSafe, Effective Care Environment-Coordinated CareAnalysis11)A mother brings her 3-week-old infant to the health center because of a large accumulation ofthick, yellow scales over the anterior fontanel. Before the infant is seen by the pediatrician, thenurse gathers information from the mother. Which of the following questions by the nurse willobtain the most helpful information?11)A)”How do you wash your baby’s scalp?”B)”Does this kind of skin disorder occur in other members of your family?”C)”Has the baby been exposed to anything recently?”D)”Have you changed the detergent you use for washing the baby’s clothing?”Answer:AExplanation:A)The case scenario suggests that the infant has seborrheic dermatitis, which iscommonly known as cradle cap. This is a non-genetic, noncommunicable skincondition that commonly occurs because the caregiver is uncomfortable washingthe baby’s scalp over the fontanel. Dermatitis related to detergents used to washthe baby’s clothes would not manifest only over the anterior fontanel.AssessmentHealth Promotion and MaintenanceAnalysis11
B)The case scenario suggests that the infant has seborrheic dermatitis, which iscommonly known as cradle cap. This is a non-genetic, noncommunicable skincondition that commonly occurs because the caregiver is uncomfortable washingthe baby’s scalp over the fontanel. Dermatitis related to detergents used to washthe baby’s clothes would not manifest only over the anterior fontanel.AssessmentHealth Promotion and MaintenanceAnalysisC)The case scenario suggests that the infant has seborrheic dermatitis, which iscommonly known as cradle cap. This is a non-genetic, noncommunicable skincondition that commonly occurs because the caregiver is uncomfortable washingthe baby’s scalp over the fontanel. Dermatitis related to detergents used to washthe baby’s clothes would not manifest only over the anterior fontanel.AssessmentHealth Promotion and MaintenanceAnalysisD)The case scenario suggests that the infant has seborrheic dermatitis, which iscommonly known as cradle cap. This is a non-genetic, noncommunicable skincondition that commonly occurs because the caregiver is uncomfortable washingthe baby’s scalp over the fontanel. Dermatitis related to detergents used to washthe baby’s clothes would not manifest only over the anterior fontanel.AssessmentHealth Promotion and MaintenanceAnalysis12)Final discharge teaching is to be done for a client who has had a total knee replacement. When thenurse begins to review the discharge instructions with the client, the client says that he does notknow if he will be able to follow the instructions because it makes him nervous to do anymovement with his operated knee. Which of the following options is the most appropriate nursingaction at this time?12)A)Identify ways in which the client’s concerns can be alleviated.B)Add the nursing diagnosis of Anxiety related to lack of self-confidence to the client’s nursingcare plan.C)Document that the client is anxious about his ability to do self care when he is discharged.D)Tell the client that he can call the surgeon’s office anytime he has questions or concerns.Answer:AExplanation:A)The nurse should plan to address the client’s nervousness first, in order todetermine whether there are interventions that can be done to facilitate the client’scompliance with the discharge instructions. Based on findings, the nurse shoulddetermine whether the client is able to correctly carry out the dischargeinstructions. The client may need to be referred to a home care agency.PlanningPsychosocial IntegrityAnalysisB)The nurse should plan to address the client’s nervousness first, in order todetermine whether there are interventions that can be done to facilitate the client’scompliance with the discharge instructions. Based on findings, the nurse shoulddetermine whether the client is able to correctly carry out the dischargeinstructions. The client may need to be referred to a home care agency.PlanningPsychosocial IntegrityAnalysis12
C)The nurse should plan to address the client’s nervousness first, in order todetermine whether there are interventions that can be done to facilitate the client’scompliance with the discharge instructions. Based on findings, the nurse shoulddetermine whether the client is able to correctly carry out the dischargeinstructions. The client may need to be referred to a home care agency.PlanningPsychosocial IntegrityAnalysisD)The nurse should plan to address the client’s nervousness first, in order todetermine whether there are interventions that can be done to facilitate the client’scompliance with the discharge instructions. Based on findings, the nurse shoulddetermine whether the client is able to correctly carry out the dischargeinstructions. The client may need to be referred to a home care agency.PlanningPsychosocial IntegrityAnalysis13)A resident of a long-term care facility has all of the following nursing diagnoses. Which nursingdiagnosis will have the lowest priority in planning nursing interventions?13)A)Risk for Falls related to antihypertensive medicationB)Risk for Impaired Skin Integrity (perineal area) related to severe arthritis of both handsC)Relocation Stress Syndrome related to isolation from family and friends.D)Feeding Self-Care Deficit related to severe arthritis of both handsAnswer:CExplanation:A)Nursing diagnoses related to psychosocial needs of a client will be lower inpriority than those for physiological and safety needs. Although the two nursingdiagnoses stating a risk for the client are potential rather than actual diagnoses,they are still concerned with physiological and safety needs and will have a higherpriority in planning interventions. Note that having a lower priority does not meanthat less attention is paid to the diagnosis or that nursing interventions are lessimportant.PlanningSafe, Effective Care Environment-Coordinated CareAnalysisB)Nursing diagnoses related to psychosocial needs of a client will be lower inpriority than those for physiological and safety needs. Although the two nursingdiagnoses stating a risk for the client are potential rather than actual diagnoses,they are still concerned with physiological and safety needs and will have a higherpriority in planning interventions. Note that having a lower priority does not meanthat less attention is paid to the diagnosis or that nursing interventions are lessimportant.PlanningSafe, Effective Care Environment-Coordinated CareAnalysis13
C)Nursing diagnoses related to psychosocial needs of a client will be lower inpriority than those for physiological and safety needs. Although the two nursingdiagnoses stating a risk for the client are potential rather than actual diagnoses,they are still concerned with physiological and safety needs and will have a higherpriority in planning interventions. Note that having a lower priority does not meanthat less attention is paid to the diagnosis or that nursing interventions are lessimportant.PlanningSafe, Effective Care Environment-Coordinated CareAnalysisD)Nursing diagnoses related to psychosocial needs of a client will be lower inpriority than those for physiological and safety needs. Although the two nursingdiagnoses stating a risk for the client are potential rather than actual diagnoses,they are still concerned with physiological and safety needs and will have a higherpriority in planning interventions. Note that having a lower priority does not meanthat less attention is paid to the diagnosis or that nursing interventions are lessimportant.PlanningSafe, Effective Care Environment-Coordinated CareAnalysis14
14)A client is receiving bumetanide (Bumex) 1 milligram orally once a day at 9:00 a.m. The nurse ischecking the most recent laboratory reports for the client. Which finding by the nurse is of mostconcern in relation to this medication?14)A)Potassium 4.1 mEq per literB)Hematocrit 35%C)Prothrombin time 12 secondsD)Hemoglobin 14.2 grams per deciliterAnswer:BExplanation:A)Bumetanide (Bumex) is a diuretic. Although it is a potassium-depleting diuretic,the potassium value in this client is within normal limits. The only laboratoryresult that is outside of normal range is the hematocrit value. Dehydration is ofconcern in any client receiving a diuretic.EvaluationPhysiological Integrity-Reduction of Risk PotentialAnalysisB)Bumetanide (Bumex) is a diuretic. Although it is a potassium-depleting diuretic,the potassium value in this client is within normal limits. The only laboratoryresult that is outside of normal range is the hematocrit value. Dehydration is ofconcern in any client receiving a diuretic.EvaluationPhysiological Integrity-Reduction of Risk PotentialAnalysisC)Bumetanide (Bumex) is a diuretic. Although it is a potassium-depleting diuretic,the potassium value in this client is within normal limits. The only laboratoryresult that is outside of normal range is the hematocrit value. Dehydration is ofconcern in any client receiving a diuretic.EvaluationPhysiological Integrity-Reduction of Risk PotentialAnalysisD)Bumetanide (Bumex) is a diuretic. Although it is a potassium-depleting diuretic,the potassium value in this client is within normal limits. The only laboratoryresult that is outside of normal range is the hematocrit value. Dehydration is ofconcern in any client receiving a diuretic.EvaluationPhysiological Integrity-Reduction of Risk PotentialAnalysis15)A 97-year-old client has had a right-sided cerebrovascular accident and now has very little use ofher left arm and leg. The client is to be transferred to a rehabilitation center later today. Prior to thedischarge, the nurse should give priority to which of the following nursing actions identified on theclient’s nursing care plan?15)A)Demonstrate how the client will learn to dress herself.B)Make sure that none of the client’s belongings are left in the room.C)Explain to the client where she is going and why.D)Teach the client to do passive range-of-motion exercises of her left arm and leg.Answer:CExplanation:A)In this scenario, priority shouldbe given to meeting the client’s psychosocial needsand ensuring that the client understands what is happening. Teaching the client todo passive range of motion exercises and how to dress herself will be done at therehabilitation center. Gathering and checking a client’s belongings before transferis one part of the discharge/transfer process. It is not a priority activity.ImplementationPsychosocial IntegrityAnalysis15
B)In this scenario, priority shouldbe given to meeting the client’s psychosocial needsand ensuring that the client understands what is happening. Teaching the client todo passive range of motion exercises and how to dress herself will be done at therehabilitation center. Gathering and checking a client’s belongings before transferis one part of the discharge/transfer process. It is not a priority activity.ImplementationPsychosocial IntegrityAnalysisC)In this scenario, priority shouldbe given to meeting the client’s psychosocial needsand ensuring that the client understands what is happening. Teaching the client todo passive range of motion exercises and how to dress herself will be done at therehabilitation center. Gathering and checking a client’s belongings before transferis one part of the discharge/transfer process. It is not a priority activity.ImplementationPsychosocial IntegrityAnalysisD)In this scenario, priority shouldbe given to meeting the client’s psychosocial needsand ensuring that the client understands what is happening. Teaching the client todo passive range of motion exercises and how to dress herself will be done at therehabilitation center. Gathering and checking a client’s belongings before transferis one part of the discharge/transfer process. It is not a priority activity.ImplementationPsychosocial IntegrityAnalysis16
Answer KeyTestname: C51)C2)D3)A4)D5)A6)A7)A, B8)B9)A, C, E, F10)B11)A12)A13)C14)B15)C17