Foundations of Nursing 7th Edition By  Kim Cooper- Kelly Gosnell – Test Bank

$20.00

Description

INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS

 

Foundations of Nursing 7th EditionBy  Kim Cooper- Kelly Gosnell – Test Bank

 

Sample  Questions

 

Chapter 5: Nursing Process and Critical Thinking

Cooper and Gosnell: Foundations of Nursing, 7th Edition

 

MULTIPLE CHOICE

 

  1. What best defines the nursing process?
a. A method to ensure that the physician’s orders are implemented correctly.
b. A series of assessments that isolate a patient’s health problem.
c. A framework for the organization of individualized nursing care.
d. A preset formula for the design of nursing care.

 

 

ANS:  C

The nursing process is a framework by which to organize individualized nursing care.

 

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

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

MSC:  NCLEX: N/A

 

  1. All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment?
a. 53-year-old admitted with a perforated ulcer
b. 5-year-old admitted for the implant of grommets in the middle ear
c. 76-year-old admitted for a knee replacement
d. 40-year-old admitted for possible bowel obstruction

 

 

ANS:  A

A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient should receive a focused assessment. The remaining options are not considered critical illnesses.

 

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

TOP:   Assessment    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What subjective data does the nurse record following a head-to-toe examination?
a. Rash on back
b. Prolonged nausea
c. Blood pressure of 190/100
d. White blood cell count of 19,000

 

 

ANS:  B

Another term for subjective data is symptoms, which cannot be observed or measured. This data must come from the patient.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   3

TOP:   Subjective data                               KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What objective data should the nurse include after a patient assessment?
a. Headache of 3 days duration
b. Severe stomach cramps
c. Flatulence
d. Anxiety

 

 

ANS:  C

Objective data are observable and measurable by people other than the patient.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   3

TOP:   Objective data                                           KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is classified as information provided by the family when a patient is unable to provide data during assessment?
a. Primary
b. Secondary
c. Unreliable
d. Biased

 

 

ANS:  B

Secondary sources include family members.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   3

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

 

  1. What are the two primary methods used to collect data?
a. Written report by patient and family
b. Review of the chart and the nurse’s notes
c. Interview and physical examination
d. Review of the physician’s orders and the Kardex

 

 

ANS:  C

The two primary methods of collecting data are interviewing and physical examination.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   3

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

 

  1. The nurse writes two nursing diagnoses: (1) inadequate nutritional intake related to vomiting as manifested by a 3-lb weight loss and (2) risk for impaired skin integrity related to inadequate nutrition. What is the major difference between these diagnoses?
a. The second diagnosis needs no defined nursing interventions.
b. The second diagnosis needs medical intervention.
c. The second diagnosis will not need to be evaluated.
d. The second diagnosis reflects a problem that does not yet exist.

 

 

ANS:  D

The actual nursing diagnosis represents a condition that is currently present. “Risk for” diagnoses are those that the patient is susceptible to, but not yet troubled by.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   4

TOP:   Nursing diagnosis                           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What framework does the establishment of priorities of care during the planning phase of the nursing process often use?
a. Erikson’s developmental tasks
b. Piaget’s cognitive table
c. Maslow’s hierarchy of needs
d. Freud’s classifications

 

 

ANS:  C

A useful framework to guide prioritization is Maslow’s hierarchy of needs.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   9

TOP:   Priorities of care                             KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. What is an appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway clearance related to thick secretions?
a. The patient will increase intake to 1000 mL daily to liquefy secretions.
b. The patient will cough more frequently within 3 days.
c. The patient will breathe better within 3 days.
d. The patient will perform deep-breathing exercises four times daily.

 

 

ANS:  A

The patient goal would be to improve airway clearance. Coughing more frequently within 3 days and performing deep-breathing exercises four times daily do not directly relate to the problem of thick secretions. Breathing better within 3 days is too vague.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   6

TOP:   Nursing diagnosis                           KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. What is the primary purpose of nursing orders?
a. To support physician’s orders
b. To provide direction for all caregivers
c. To provide broad, general statements
d. To clarify nursing principles

 

 

ANS:  B

Nursing orders are necessary to provide instructions for all caregivers.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   7

TOP:   Nursing orders                                          KEY:              Nursing Process Step: Planning

MSC:  NCLEX: N/A

 

  1. What documentation reflects implementation?
a. “Patient selected low-sugar snacks independently.”
b. “Patient was medicated with Tylenol 500 mg PO for pain.”
c. “Patient was ambulated for 15 minutes after lunch.”
d. “Patient participated in group therapy session without reminder.”

 

 

ANS:  C

Implementation is the nurse carrying out nursing orders to promote outcome achievement.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   2

TOP:   Implementation                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: N/A

 

  1. Which nursing order is complete and correct?
a. “May 10: Nursing assistants will ambulate patient. A. Nurse”
b. “Day nurse will cleanse wound and change dressings every day. May 10, A. Nurse”
c. “Nursing assistants will serve 8 oz glass of juice at each meal, 5/10.”
d. “P.M. nurse will ensure that heel protectors are in place before bedtime.”

 

 

ANS:  B

Nursing orders must be signed, dated, and have specific designation as to who will perform intervention and specifics about time or frequency of the intervention.

 

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

TOP:   Nursing orders                                          KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date, it is determined that what has occurred?
a. Omission
b. Variance
c. Failure
d. Error

 

 

ANS:  B

A variance occurs when a projected outcome is not met.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   8| 11

TOP:   Critical pathways                            KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a nursing diagnosis plan. What does this data represent?
a. Symptoms
b. Data clustering
c. Signs of fluid overload
d. Urinary retention

 

 

ANS:  B

The nurse organizes data, and those that are related are referred to as clustering.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   3| 12

TOP:   Assessment    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What type of assessment is performed continuously throughout nurse-patient contact?
a. Complete
b. Body systems
c. Focused
d. Subjective

 

 

ANS:  C

Focused assessments are performed continuously throughout nurse-patient contact based on the nursing care plan.

 

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

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

 

  1. What assists the nurse in the identification of nursing diagnoses?
a. Objective data
b. Subjective data
c. Data clustering
d. Validated data

 

 

ANS:  C

Data clustering assists the nurse in determining nursing diagnoses.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   4

TOP:   Nursing diagnosis                           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: N/A

 

  1. What organized approach might the nurse use when performing a complete physical examination?
a. Maslow’s hierarchy of needs
b. A head-to-toe assessment
c. Subjective data collection
d. Objective data collection

 

 

ANS:  B

A head-to-toe format provides a systematic approach.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   3

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

 

  1. Who is the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis?
a. Physician
b. LPN/LVN
c. RN
d. Technician

 

 

ANS:  C

The RN is responsible for analyzing and interpreting data.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 123        OBJ:   4

TOP:   Role responsibility                          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What is the basis for designing and selecting nursing interventions to meet patient needs?
a. Nursing diagnosis
b. Care plan
c. Physician’s orders
d. Nurse’s notes

 

 

ANS:  A

The nursing diagnosis is the basis for developing nursing interventions.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   4

TOP:   Nursing diagnosis                           KEY:  Nursing Process Step: Planning

MSC:  NCLEX: N/A

 

  1. The patient is confined to bed rest, which contributes to immobility. What is bed rest considered in this situation?
a. Contributing to the patient’s recovery
b. A risk factor
c. Difficult to maintain
d. A nursing responsibility

 

 

ANS:  B

Risk factors are those that increase the susceptibility of a patient to a problem.

 

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

TOP:   Risk factors    KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. What is a nursing diagnosis considered when a problem is suspected but data to support it are lacking?
a. A syndrome nursing diagnosis
b. An actual nursing diagnosis
c. A “risk for” diagnosis
d. A possible nursing diagnosis

 

 

ANS:  D

A possible nursing diagnosis requires additional data to confirm a problem or to complete a data cluster so that it can be related to a NANDA-I label.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   4| 10

TOP:   Nursing diagnosis                           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: N/A

 

  1. When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in which phase of the nursing process?
a. Assessment
b. Planning
c. Implementation
d. Evaluation

 

 

ANS:  B

During the planning phase, the nurse connects nursing interventions to nursing orders.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   2

TOP:   Nursing process                              KEY:  Nursing Process Step: Planning

MSC:  NCLEX: N/A

 

  1. What is an important consideration when developing the care plan?
a. Ensure the number of interventions is limited
b. Ensure the patient is involved in the process
c. Ensure interventions will be easy to implement
d. Ensure evaluation of the nursing diagnoses is possible

 

 

ANS:  B

Plans are more effective when the patient is involved in the process. The care plan is not limited in terms of the number of interventions, nor do they have to be easy. The nursing diagnoses are not evaluated; the patient’s progress toward the outcome is.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   6| 9

TOP:   Care plan       KEY:  Nursing Process Step: Planning       MSC:  NCLEX: N/A

 

  1. From where are the “risk for” nursing diagnoses identified?
a. The care plan
b. The interventions
c. The assessment
d. The evaluation

 

 

ANS:  C

Nursing diagnoses should be identified from the assessment.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   2

TOP:   Nursing process                              KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What expected outcome exemplifies accepted criteria?
a. Nurse will assess vital signs every day
b. Resident will observe safety guidelines while smoking
c. Resident will take part in one activity daily for the next 90 days
d. Nurse will monitor O2 saturation to maintain at greater than 90%

 

 

ANS:  C

Expected outcomes must be patient-centered, measurable, and refer to a time frame.

 

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

TOP:   Nursing process                              KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?
a. The patient complains of nausea.
b. The patient is vomiting.
c. The patient experiences tachycardia.
d. The patent is pacing the halls.

 

 

ANS:  A

Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of nausea is an example of subjective data. All other options are examples of objective data.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   1| 3

TOP:   Subjective data                               KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?
a. The patient is asleep.
b. The patient is tearful.
c. The patient has facial grimacing.
d. The patient states, “I hurt all over.”

 

 

ANS:  D

Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Stating “I hurt all over” is an example of subjective data. All other options are examples of objective data.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   1| 3

TOP:   Nursing process                              KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?
a. The patient is coughing.
b. The patient has cyanosis of the lips.
c. The patient experiences tachypnea.
d. The patient complains of generalized discomfort.

 

 

ANS:  D

Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of generalized discomfort is an example of subjective data. All other options are examples of objective data.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   1| 3

TOP:   Subjective data                               KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?
a. The patient complains of chest pain.
b. The patient states, “I feel nauseous.”
c. The patient complains of feeling faint.
d. The patient is short of breath on exertion.

 

 

ANS:  D

Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Shortness of breath on exertion is an example of objective data. All other options are examples of subjective data.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   1| 3

TOP:   Objective data                                           KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?
a. The patient is jaundiced.
b. The patient states, “I am nervous.”
c. The patient complains of palpitations.
d. The patient denies dizziness when ambulating.

 

 

ANS:  A

Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. The patient is jaundiced is an example of objective data. All other options are examples of subjective data.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   1| 3

TOP:   Objective data                                           KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?
a. The patient complains of feeling depressed.
b. The patient states, “I hear voices in my head.”
c. The patient complains of auditory hallucinations.
d. The patient is pacing back and forth while chanting.

 

 

ANS:  D

Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Pacing back and forth while chanting is an example of objective data. All other options are examples of subjective data.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   1| 3

TOP:   Objective data                                           KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is an example of an appropriate nursing diagnosis?
a. Impaired skin integrity
b. Skin breakdown noted
c. Turn patient every 2 hours
d. The patient has scabies on his back

 

 

ANS:  A

“Impaired skin integrity” is an example of a nursing diagnosis. “Skin breakdown noted” is an example of a charting entry, “turn patient every 2 hours” is a nursing intervention, and “scabies” is a medical diagnosis.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages              OBJ:   4

TOP:   Nursing diagnosis                           KEY:  Nursing Process Step: Diagnosis

MSC:  NCLEX: Physiological Integrity

 

  1. What is an example of an appropriate nursing diagnosis?
a. Constipation
b. Patient complains of constipation
c. Need for laxatives
d. Patient has a duodenal ulcer

 

 

ANS:  A

Constipation is an example of a nursing diagnosis, a patient complaining of constipation is an example of a charting entry, a need for laxatives is an example of a patient need, and a patient has a duodenal ulcer is an example of a medical diagnosis.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages              OBJ:   4

TOP:   Nursing diagnosis                           KEY:  Nursing Process Step: Diagnosis

MSC:  NCLEX: Physiological Integrity

 

  1. A nurse is formulating a nursing diagnosis. What is an example of an appropriately written nursing diagnosis?
a. Risk for impaired skin integrity related to physical immobilization
b. Physical immobilization secondary to risk for impaired skin integrity
c. Risk for impaired skin integrity related to diagnosis of decubitus ulcers
d. Physical immobilization secondary to decreased cognitive ability

 

 

ANS:  A

Risk for impaired skin integrity related to physical immobilization is the only appropriately written nursing diagnosis. All other options are not listed as NANDA-I approved nursing diagnoses.

 

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

TOP:   Nursing diagnosis                           KEY:  Nursing Process Step: Diagnosis

MSC:  NCLEX: Physiological Integrity

 

  1. Which is an example of a nursing diagnosis?
a. Pneumonia
b. Diabetes mellitus
c. Impaired skin integrity
d. Congestive heart failure

 

 

ANS:  C

Impaired skin integrity is the only example of a nursing diagnosis; all other options are examples of medical diagnoses.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   4

TOP:   Nursing diagnosis                           KEY:  Nursing Process Step: Diagnosis

MSC:  NCLEX: Physiological Integrity

 

  1. Which is an example of a medical diagnosis?
a. Constipation
b. Diabetes mellitus
c. Impaired skin integrity
d. Altered nutrition: less than body requirements

 

 

ANS:  B

Diabetes mellitus is the only example of a medical diagnosis; all other options are examples of nursing diagnoses.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages 126, 127

OBJ:   4                    TOP:   Medical diagnosis

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

 

  1. Which is an example of a medical diagnosis?
a. Pain
b. Anxiety
c. Pneumonia
d. Impaired skin integrity

 

 

ANS:  C

Pneumonia is the only example of a medical diagnosis; all other options are examples of nursing diagnoses.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages 126, 127

OBJ:   4                    TOP:   Medical diagnosis

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

 

MULTIPLE RESPONSE

 

  1. Which are acceptable secondary sources for data? (Select all that apply.)
a. Patient
b. Family members
c. Other health professionals
d. Diagnostic reports
e. Textbooks

 

 

ANS:  B, C, D, E

A patient is not a secondary source. The patient is the primary data source.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   3

TOP:   Data sources  KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. Which are official categories of nursing diagnoses? (Select all that apply.)
a. Actual
b. Risk
c. Wellness
d. Syndrome
e. Potential

 

 

ANS:  A, B, C, D

Actual, risk, wellness, and syndrome are the four categories of nursing diagnoses.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   4

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

MSC:  NCLEX: N/A

 

  1. Which are considered phases of the nursing process? (Select all that apply.)
a. Diagnosis
b. Prediction
c. Assessment
d. Evaluation
e. Implementation
f. Outcome identification

 

 

ANS:  A, C, D, E, F

The nursing process consists of six dynamic and interrelated phases: diagnosis, assessment, outcome identification, planning, implementation, and evaluation. Prediction is not a phase of the nursing process.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   2

TOP:   Nursing process                              KEY:  Nursing Process Step: All

MSC:  NCLEX: N/A

 

COMPLETION

 

  1. NANDA International meets to reorganize diagnosis labels and language every ______ years.

 

ANS:

2

 

NANDA meets every 2 years to revise language, form, and diagnosis labels.

 

DIF:    Cognitive Level: Knowledge          REF:   Pages              OBJ:   10

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

 

  1. The standards that name and measure patient outcomes are referred to as ___________.

 

ANS:

NOC (Nursing Outcome Classification)

NOC, Nursing Outcome Classification

NOC

Nursing Outcome Classification

NOC sets up outcome criteria based on a patient problem.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   10

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

 

  1. The document that outlines a multidisciplinary plan for care interventions over a specified time frame is a _______ ________.

 

ANS:

clinical pathway

critical path

 

A clinical pathway is an organized multidisciplinary plan over a specified time frame, which outlines aspects of patient care. They are also called critical paths, action plans, and care maps.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   11

TOP:   Clinical pathways                           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A systematic method by which nurses plan and provide care for patients is known as the _________ ____________.

 

ANS:

nursing process

 

The nursing process serves as the organizational framework for the practice of nursing. It is a systematic method by which nurses plan and provide care for patients.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   2

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

MSC:  NCLEX: N/A

 

  1. A systemic, dynamic process by which the nurse, through interaction with the patient, significant others, and health care providers, collects and analyzes data about the patient is known as ______________________.

 

ANS:

assessment

 

The American Nurses Association (ANA) defines assessment as “a systemic, dynamic process by which the nurse, through interaction with the client, significant others, and health care providers, collects and analyzes data about the client.”

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   2

TOP:   Nursing process                              KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: N/A

 

  1. Any health care condition that requires diagnostic, therapeutic, or educational actions is known as a ______________.

 

ANS:

problem

 

A problem is any health care condition that requires diagnostic, therapeutic, or educational actions.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   2

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

 

  1. A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes is known as a _____________ ___________.

 

ANS:

nursing diagnosis

 

A nursing diagnosis is a type of health problem that can be identified. It is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   4

TOP:   Nursing diagnosis                           KEY:  Nursing Process Step: Diagnosis

MSC:  NCLEX: N/A

 

  1. The human responses to health conditions/life processes that exist in an individual, family, or community are known as a(n) _________ _______________ _____________.

 

ANS:

actual nursing diagnosis

 

An actual nursing diagnosis is described as the human responses to health conditions/life processes that exist in an individual, family, or community.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   4

TOP:   Actual nursing diagnosis                 KEY:  Nursing Process Step: Diagnosis

MSC:  NCLEX: N/A

 

  1. Human responses to health conditions and life processes that may develop in a vulnerable individual, family, or community are known as a(n) __________ __________ ____________.

 

ANS:

risk nursing diagnosis

 

A risk nursing diagnosis is defined as the human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   4

TOP:   Risk nursing diagnosis                    KEY:  Nursing Process Step: Diagnosis

MSC:  NCLEX: N/A

 

  1. Human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement are known as a _____________ ____________ ____________.

 

ANS:

wellness nursing diagnosis

 

A wellness nursing diagnosis is defined as human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   4

TOP:   Wellness nursing diagnosis             KEY:  Nursing Process Step: Diagnosis

MSC:  NCLEX: N/A

 

  1. The identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures is known as a _________ _______.

 

ANS:

medical diagnosis

 

A medical diagnosis is the identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   4

TOP:   Medical diagnosis                           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A health care system that provides control over health care services for a specific group of individuals in an attempt to control cost is known as ___________ ______________.

 

ANS:

managed care

 

Managed care is a health care system that provides control over health care services for a specific group of individuals in attempts to control cost.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   6| 11

TOP:   Risk Managed care                         KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases is known as a ___________ ____________.

 

ANS:

critical pathway

 

A critical pathway is a multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   11

TOP:   Clinical pathways                           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

Chapter 7: Asepsis and Infection Control

Cooper and Gosnell: Foundations of Nursing, 7th Edition

 

MULTIPLE CHOICE

 

  1. What is true regarding surgical asepsis?
a. It inhibits growth of pathogenic organisms.
b. It is known as a cleaning technique.
c. It includes hand hygiene.
d. It is known as a sterile technique.

 

 

ANS:  D

Surgical asepsis is known as a sterile technique.

 

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

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

 

  1. What action exemplifies a nurse practicing medical asepsis in performing daily care?
a. Lifting a sterile swab from a sterile field
b. Using disposable sterile gowns
c. Washing hands for 5 minutes between patients
d. Keeping bed linens off the floor

 

 

ANS:  D

Keeping the bed linens off the floor is an example of medical asepsis; all other options are examples of surgical asepsis.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   1| 2

TOP:   Infection        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. What bacteria can lie dormant when conditions for growth are not favorable?
a. Residue
b. Capsules
c. Spores
d. Flagella

 

 

ANS:  C

Spore formation occurs when conditions are unfavorable, causing the bacteria to take a dormant form.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   2| 4

TOP:   Bacteria          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A patient with a respiratory infection reports that he is not yet on an antibiotic. The nurse explains that the physician is waiting on the results of the culture and sensitivity. What does this test determine?
a. What media the bacteria requires to grow
b. How fast the bacteria grow
c. Which antibiotics stop bacterial growth
d. When the bacteria colonize

 

 

ANS:  C

Sensitivity tests are done to determine which antibiotics will stop growth.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages              OBJ:   6

TOP:   Laboratory tests                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What bacterium is responsible for more diseases than any other organism?
a. Staphylococcus
b. Pseudomonas aeruginosa
c. Haemophilus influenzae
d. Streptococcus

 

 

ANS:  D

The Streptococcus bacterium is responsible for more diseases than any other organism.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   3

TOP:   Bacteria          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. What additional complication does a disease caused by a virus have compared to a disease caused by bacteria?
a. Multiplies rapidly
b. Returns frequently
c. Is not killed by antibiotics
d. Is unable to be cultured

 

 

ANS:  C

Antibiotics do not alter the course of a disease caused by a virus.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   3

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

MSC:  NCLEX: Physiological Integrity

 

  1. A patient with ringworm asks the nurse if she has worms. What does the nurse inform the patient about the cause of ringworm?
a. Bacteria
b. Protozoa
c. Virus
d. Fungi

 

 

ANS:  D

Ringworm is caused by fungi.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   3

TOP:   Infection        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What should the nurse be diligent in to provide a safe environment for the patient?
a. Keeping a light on at night to prevent falls
b. Hand hygiene between patient contacts
c. Regulating the temperature to avoid drafts
d. Changing the bed linen to diminish microorganisms

 

 

ANS:  B

One of the most important actions is hand hygiene before caring for another patient.

 

DIF:    Cognitive Level: Application          REF:   Pages              OBJ:   5| 8| 9

TOP:   Safe environment                           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. What does the nurse describe when giving an example of a fomite vehicle?
a. Rabid dog
b. Person with AIDS
c. Contaminated stethoscope
d. Infected wound

 

 

ANS:  C

If a vehicle is an inanimate (nonliving) object, it is called a fomite.

 

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

TOP:   Infection        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The nurse observes a patient demonstrating wound cleaning. What action indicates the need for further instruction?
a. Using sterile gloves to perform the cleaning
b. Applying an antiseptic to the area
c. Cleaning the area from the outside in
d. Washing hands with soap

 

 

ANS:  C

Cleaning away from the wound prevents entrance of microorganisms.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   13

TOP:   Wounds         KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The nurse is concerned when a patient admitted with a diagnosis of pneumonia suddenly develops a urinary tract infection (UTI). What type of infection is this UTI considered?
a. Viral infection
b. Bacterial infection
c. Health care–associated infection
d. Spore infection

 

 

ANS:  C

More than 40 million people are admitted to hospitals each year and as many as 10% of them acquire a health care–associated infection while there. Criteria for health care–associated infections require that the infection manifest at least 48 hours after hospitalization or contact with another health agency.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages              OBJ:   2

TOP:   Health care–associated infection    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse prioritizes the care of four patients. Which patient has a systemic infection?
a. 14-year-old with acute appendicitis
b. 80-year-old with a urinary tract infection
c. 40-year-old with AIDS
d. 50-year-old with arthritis

 

 

ANS:  C

AIDS is a systemic viral infection. Acute appendicitis and urinary tract infections are local infections. Arthritis is not an infection.

 

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

TOP:   Systemic infection                          KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What assessment does the nurse recognize as an inflammatory response in a surgical wound on the leg of a patient?
a. A foul drainage is coming from the wound
b. The affected leg is cooler than the other leg
c. There are raised, red, pruritic welts on the leg
d. Rubor and edema appear around the wound

 

 

ANS:  D

Rubor and edema are two of the cardinal signs of an inflammatory response. Foul drainage suggests infection, the affected leg being cooler than the other leg suggests circulatory disorder, and raised, red, pruritic welts on the leg suggest allergy.

 

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

TOP:   Inflammatory response                   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The infection control practitioner plans an in-service on control of health care-associated infections. What should be the focus of this program?
a. Observing nurses caring for patients
b. Screening patients who are admitted to the hospital
c. Educating hospital personnel about aseptic practices
d. Discharging infectious patients from the hospital

 

 

ANS:  C

Duties of the infection control practitioner include staff education on infection control.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   5| 13

TOP:   Infection        KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A health care worker is stuck by a needle left on the patient’s bedside table. The staff member appropriately reports the needlestick. What will the indicated treatment be combatting?
a. Hepatitis B
b. Streptococcal infections
c. Staphylococcal infections
d. Influenza

 

 

ANS:  A

Workers who have had a needlestick need to complete an injury report and seek treatment in the event of exposure to hepatitis B.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages              OBJ:   3| 5

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

 

  1. What technique should the nurse use when disposing of linens contaminated with feces?
a. Don gown, gloves, and mask
b. Wash hands for 5 minutes after disposal
c. Don gloves only
d. Double-bag the sheets

 

 

ANS:  C

All health care workers should follow Standard Precautions to prevent infection from pathogens. Standard Precautions for the disposal of ordinary feces require only that the nurse don gloves.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   13

TOP:   Standard Precautions                                 KEY:              Nursing Process Step: Analysis

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The nurse is instructing a patient about the most important preventive technique for breaking the chain of infection. What technique is the patient learning about?
a. Sterilization
b. Standard Precautions
c. Hand hygiene
d. Medical asepsis

 

 

ANS:  C

Hand hygiene is the most important preventive measure for interrupting the infection process.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   2| 9

TOP:   Infection        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. How long should the nurse perform hand hygiene before beginning care of a patient?
a. 5 minutes
b. 2 minutes
c. 1 minute
d. 30 seconds

 

 

ANS:  D

The nurse should wash hands after using the bathroom, after contact with any secretions, before eating, and before and after patient care. The nurse should use warm water, soap, and friction for 15 to 30 seconds, and dry hands thoroughly.

 

DIF:    Cognitive Level: Knowledge          REF:   Page , Health Promotion

OBJ:   9                    TOP:   Infection        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A nurse is observing isolation precautions by wearing a mask while performing complex patient care. How often should the nurse change masks?
a. 5-10 minutes
b. 10-20 minutes
c. 20-30 minutes
d. 30-40 minutes

 

 

ANS:  C

The mask should be changed every 20 to 30 minutes.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 284        OBJ:   8

TOP:   Mask              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A major threat to health care workers is blood-contaminated sharps. What should the nurse use to discard the used syringe?
a. Wastebasket
b. Sink
c. Puncture-proof container
d. Disinfecting soap

 

 

ANS:  C

All patient care areas where sharps are used require puncture-proof containers.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   8

TOP:   Sharps            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The nurse is transporting a patient in respiratory isolation to the radiology department. What intervention should the nurse implement?
a. Cover the patient with a sheet
b. Take the patient down the service elevator
c. Apply a mask to the patient
d. Call x-ray to come and get the patient

 

 

ANS:  C

If a patient requiring respiratory isolation must be transported to another area, the patient must don a mask.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   5| 8

TOP:   Isolation         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The patient in isolation may experience psychological or emotional deprivation. What should the nurse do to help minimize these feelings?
a. Be cheerful
b. Spend extra time with the patient
c. Protect the patient from additional infection
d. Answer the call light quickly

 

 

ANS:  B

To minimize feelings of psychological or emotional deprivation, the nurse should spend extra time with the patient.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   13

TOP:   Isolation         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The infection control officer is observing hospital staff for appropriate use of aseptic technique. What observation demonstrates the need for more instruction on surgical asepsis?
a. Facing the sterile field
b. Placing a sterile dressing on a sterile field
c. Touching the edges of the sterile field with sterile gloves
d. Keeping gloved hands above the waist

 

 

ANS:  C

The edges of a sterile field are not considered sterile.

 

DIF:    Cognitive Level: Application          REF:   Page 11          OBJ:   1

TOP:   Sterile technique                             KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The nurse is pouring a sterile solution from a bottle. What direction should the label on the bottle be in for appropriate technique?
a. Facing outward
b. Covered
c. Facing downward
d. In the palm of the hand

 

 

ANS:  D

The bottle should be held with the label in the palm of the hand.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   11| 12

TOP:   Sterile technique                             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. What is a method used to kill all microorganisms, including spores?
a. Disinfecting
b. Using an antiseptic
c. Using chlorine bleach
d. Sterilizing

 

 

ANS:  D

Sterilization refers to methods used to kill all microorganisms and spores.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   12

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

 

  1. The nurse accidently spills blood from a specimen container. The first action the nurse takes is to don gloves. What should the nurse then spray the fluid with?
a. Liquid detergent
b. 20% bleach solution
c. 10% bleach solution
d. Warm soapy water

 

 

ANS:  C

Any accidental body fluid spill should be cleaned up as soon as possible. The person cleaning the spill should wear gloves. One cup of bleach diluted with 10 cups of water should be used as a disinfectant to spray over the spill and clean up with paper towels. The paper towels should then be placed in the plastic-lined waste container.

 

DIF:    Cognitive Level: Knowledge          REF:   Page , Health Promotion

OBJ:   12                  TOP:   Body fluids    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. When assessing a patient for signs of an infection, the nurse recognizes which laboratory result as indicative of an infection?
a. Lowered red blood cell count
b. Increased white blood cell count
c. Lowered white blood cell count
d. Increased red blood cell count

 

 

ANS:  B

Increased white blood cell count may indicate an infection.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   3| 4

TOP:   Lab results     KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What can result from the nurse consistently performing hand hygiene and using sterile supplies when caring for patients in the hospital setting?
a. Hospital stay is shortened
b. Sense of self-worth is improved
c. Risk of infection is reduced
d. Nursing care needed is reduced

 

 

ANS:  C

Hand hygiene is the most important measure for interrupting the infectious process.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   5

TOP:   Infection        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Recognizing the stages of an infection assists the nurse in identifying the progression of an infection. What is the nonspecific to specific symptom stage of an infection?
a. Convalescent
b. Illness
c. Prodromal
d. Incubation

 

 

ANS:  C

The prodromal stage progresses from onset of nonspecific signs and symptoms to more specific signs and symptoms.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   4| 6

TOP:   Infection        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is the most dependable and practical method to use when sterilizing instruments for the operating room?
a. Chemical solution
b. Boiling water
c. Steam under pressure
d. Dry heat

 

 

ANS:  C

Steam under pressure is the most practical and dependable method for destruction of all microorganisms.

 

DIF:    Cognitive Level: Comprehension   REF:   Page , Box 12-13

OBJ:   12                  TOP:   Sterilization    KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What contribution did Joseph Lister introduce to medical practice?
a. Isolation of infected patients
b. Iodine and alcohol use as disinfectants
c. The autoclave
d. Aseptic technique

 

 

ANS:  D

Joseph Lister contributed to medical practice through the introduction of the aseptic technique.

 

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

TOP:   Joseph Lister                                  KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The nurse is providing instruction to an anxious mother of a child with Rocky Mountain spotted fever. When discussing this diagnosis what information will the nurse relay about this disease?
a. It is extremely contagious among humans.
b. It is contracted from handling unvaccinated animals.
c. It is a hemolytic B Streptococcus infection spread by droplet transmission.
d. It is a serious disease contracted from the bite of a tick.

 

 

ANS:  D

Rocky Mountain spotted fever is contracted through the bite of a tick vector. It is not contagious among humans.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 269        OBJ:   2| 3

TOP:   Vector transmission                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The emergency department nurse is assessing a puncture wound of the foot. What is the most likely type of infection in this wound?
a. Aerobic bacterial infection
b. Anaerobic bacterial infection
c. Viral infection
d. Fungal infection

 

 

ANS:  B

An anaerobic bacterial infection is one that grows in an oxygenated environment.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   6

TOP:   Anaerobic infections                                 KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is instructing a bioterrorism class regarding anthrax. How can anthrax be transmitted?
a. From person to person
b. Through microscopic skin punctures
c. Through inhalation of the spores
d. By exposure to animals that have anthrax

 

 

ANS:  C

Anthrax is contracted by inhaling the spores.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages              OBJ:   3

TOP:   Anthrax          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is providing teaching to elementary students regarding vectors. What example will the nurse provide as an example of a vector?
a. Child with measles giving it to his sister
b. Tick whose bite causes Lyme disease
c. Woman with syphilis infecting her partner
d. Dog whose bite causes rabies

 

 

ANS:  B

A vector is a person or animal not sick with the disease harboring an organism that is contagious.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 271        OBJ:   3

TOP:   Vector            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What type of organism causes malaria?
a. Bacterium
b. Virus
c. Protozoan
d. Fungus

 

 

ANS:  C

Malaria is caused by the introduction of protozoa from the bite of a mosquito.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 271        OBJ:   4

TOP:   Protozoan infections                       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A nurse is performing an admission assessment on a patient with suspected tuberculosis. What assessment findings by the nurse are consistent with tuberculosis?
a. Hemoptysis
b. Weight gain
c. Night terrors
d. Hypothermia

 

 

ANS:  A

Suspicious symptoms consistent with tuberculosis include fatigue, unexplained weight loss, dyspnea, fever, night sweats, and hemoptysis (a cough that can be productive of blood).

 

DIF:    Cognitive Level: Comprehension   REF:   Pages              OBJ:   6

TOP:   Tuberculosis                                   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A nurse is performing an admission assessment on a patient with suspected tuberculosis. What is the greatest risk of exposure to tuberculosis?
a. After a diagnosis is made
b. Before a diagnosis is made
c. After the patient has begun medication therapy
d. After implementation of isolation precautions

 

 

ANS:  B

The risk of exposure to tuberculosis is greatest before a diagnosis is made and isolation precautions are implemented.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   8

TOP:   Tuberculosis                                   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Which numbered portion of the illustration below depicts the bacterial class bacilli?

 

a. 1
b. 2
c. 3
d. 4
e. 5

 

 

ANS:  E

Bacilli are elongated microorganisms.

 

DIF:    Cognitive Level: Comprehension   REF:   Page , Figure 12-3

OBJ:   3                    TOP:   Microorganisms                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

MULTIPLE RESPONSE

 

  1. A person can spread a bacterial infection by which actions? (Select all that apply.)
a. Kissing others
b. Sneezing at work
c. Donating blood
d. Coming in contact with blood products
e. Leaving used tissue on the lavatory

 

 

ANS:  A, B, E

Bacteria can be spread by direct, indirect, or airborne transmission.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 269        OBJ:   14

TOP:   Bacterial transmission                     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. What are some characteristics of microorganisms? (Select all that apply.)
a. Involved in a life process of their own
b. Pathogens that cause disease
c. Nonpathologic organisms that cause disease
d. May be infectious
e. Can enter the body via skin, air, or blood

 

 

ANS:  A, B, D, E

Microorganisms are involved in a life process of their own, pathogens cause disease, may be infectious, and can enter the body via skin, air, or blood. Nonpathologic organisms do not cause disease.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages 7-272, 7-273

OBJ:   3                    TOP:   Characteristics of microorganisms

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

COMPLETION

 

  1. A patient is distressed that an antibiotic has not been effective for the control of the infection. The nurse explains that some bacteria are capable of defending against antibiotics by the formation of a _______.

 

ANS:

capsule

 

Some bacteria can protect themselves by the formation of a capsule of sticky protein that prevents antibiotics from entering the cell.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 268        OBJ:   4

TOP:   Bacterial capsules                           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse reminds a group of nursing students that the type of asepsis that destroys all microorganisms and their spores is _______ asepsis.

 

ANS:

surgical

 

Surgical asepsis destroys all microorganisms and their spores.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 267        OBJ:   1

TOP:   Surgical asepsis                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

Chapter 13: Admission, Transfer, and Discharge

Cooper and Gosnell: Foundations of Nursing, 7th Edition

 

MULTIPLE CHOICE

 

  1. When admitting a patient to the hospital, the nurse observes that the patient is distracted and tense. What does this behavior suggest as a common reaction to hospitalization?
a. Relief about being cared for
b. Fear of the unknown
c. Feeling of powerlessness
d. Concern about cost

 

 

ANS:  B

Fear of the unknown may be the most common reaction to hospitalization.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 248        OBJ:   3| 5

TOP:   Admission      KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse is admitting a patient to an acute care facility. During the admission procedure, what nursing intervention would best help reduce patient anxiety?
a. Transport the patient by wheelchair.
b. Inform the physician that the patient is admitted.
c. Greet the patient by name.
d. Collect financial information during the interview.

 

 

ANS:  C

Greeting the patient by name is one of the most important aspects of admission.

 

DIF:    Cognitive Level: Application          REF:   Page 251        OBJ:   1| 4| 5

TOP:   Admission      KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. What essential part of the admission procedure is performed by the RN?
a. Securing the patient’s valuables
b. Confirming the type of insurance coverage
c. Obtaining a health history
d. Familiarizing the patient with the room

 

 

ANS:  C

Admission assessment is performed by the RN.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 253        OBJ:   5| 6

TOP:   Admission      KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. When should discharge planning begin?
a. The day before discharge
b. On the first day postoperatively
c. Shortly after admission
d. When the doctor orders it

 

 

ANS:  C

Discharge planning begins shortly after admission.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 260        OBJ:   5| 8

TOP:   Discharge       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Where can a nurse refer the family of a patient to find a source of financial aid to meet medical expenses?
a. A local bank
b. A clinical nurse specialist
c. The hospital administration
d. Social services

 

 

ANS:  D

Often a patient will require services of various disciplines within the hospital. Social services can assist with meeting medical financial obligations.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 262, Health Promotion

OBJ:   8                    TOP:   Social services

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. When a patient demands to be discharged without a physician’s order and is leaving the unit with his belongings, what should the nurse ask the patient to sign?
a. A form exercising the patient’s rights
b. A discharge against medical advice form
c. An informed consent
d. An advanced directive

 

 

ANS:  B

If a doctor cannot convince the patient to stay, the patient should sign an against medical advice form.

 

DIF:    Cognitive Level: Application          REF:   Page 263, Box 11-6

OBJ:   10                  TOP:   Discharge       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The nurse must be sensitive to an older adult patient experiencing separation anxiety when admitted to the hospital. When a child experiences separation anxiety they will usually cry. What will an older adult often demonstrate when experiencing separation anxiety?
a. Withdrawal
b. Anger
c. Depression
d. Regression

 

 

ANS:  C

The older adult may demonstrate depression as a result of separation anxiety entering the hospital.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 249        OBJ:   3

TOP:   Admission      KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. Upon admission, the nurse notes that a patient without family members present has a billfold filled with cash. Where can the nurse suggest the money be placed?
a. In a sealed envelope in the bedside table
b. In the care of hospital security
c. Locked in the narcotic cupboard
d. In the hospital safe

 

 

ANS:  D

Valuables should be locked in the hospital safe.

 

DIF:    Cognitive Level: Application          REF:   Page 252        OBJ:   6

TOP:   Care of valuables                           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. If a patient has an order for an interagency transfer where does the nurse explain that the patient will be moved?
a. A double room to a private room
b. One unit of the hospital to another
c. One room of the unit to another
d. One facility to another

 

 

ANS:  D

The interagency transfer moves a patient from one health care agency to another.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 257        OBJ:   7

TOP:   Transfer         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. Before the actual discharge occurs, what must the nurse ensure ?
a. The patient is well enough to go home.
b. The patient has not been overly medicated.
c. The patient understands the discharge instructions.
d. The patient has adequate transportation.

 

 

ANS:  C

It is essential that the patient be fully aware of the discharge instructions before being discharged.

 

DIF:    Cognitive Level: Application          REF:   Pages 260, 262, Skill 11-3

OBJ:   5| 9                 TOP:   Discharge       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A patient who is alert and oriented is threatening to leave the hospital against medical advice (AMA). What action should the nurse take?
a. Forcibly detain and restrain the patient.
b. Administer a sedative hypnotic medication.
c. Prevent patient from leaving until an AMA form is signed.
d. Notify the physician that the patient is threatening to leave AMA.

 

 

ANS:  D

When a patient threatens to leave AMA, the physician should be notified immediately. If the physician fails to convince the patient to remain in the facility, the physician will ask the patient to sign an AMA form releasing the facility from legal responsibility for any medical problems the patient may experience after discharge. If the physician is not available, the nurse should discuss the discharge form with the patient and obtain the patient’s signature. If the patient refuses to sign the AMA form, the patient should not be detained. This violates the patient’s legal rights. After the patient leaves, the nurse should document the incident thoroughly in the nurse’s notes and notify the physician. A rational adult patient who will not sign the AMA form cannot be forcibly detained.

 

DIF:    Cognitive Level: Application          REF:   Page 263, Box 11-6

OBJ:   10                  TOP:   Against medical advice

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. How can the nurse demonstrate cultural sensitivity to a Haitian American patient?
a. By providing a well-lit  room 24 hours a day
b. By writing out all instructions given to the patient
c. By allowing the patient to keep leaves in her room
d. By asking the physician to provide all directions to the patient

 

 

ANS:  C

Many Haitians believe that leaves have a special significance in healing. Leaves may be found in the clothes and on various parts of the body. Leaves are thought to have mystical power related to regaining or keeping health.

 

DIF:    Cognitive Level: Application          REF:   Page 250, Cultural Considerations

OBJ:   4                    TOP:   Cultural awareness

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychological Integrity

 

  1. A nurse is caring for a Haitian American patient. How might the nurse demonstrate cultural sensitivity?
a. Discarding any leaves the patient may have brought with them
b. Assigning the patient to a room with any Haitian American patient
c. Instructing the patient to ride in a wheelchair when discharged
d. Allowing the patient to walk out of the hospital when discharged

 

 

ANS:  D

Some Haitian Americans associate wheelchairs with being sick. Therefore, on discharge, the patient who is allowed to walk out of the hospital will be more likely to feel that care has been effective. A poor patient with a Haitian background and a wealthy patient with a Haitian background, although from the same country, may find the same room assignment together in the hospital very distasteful.

 

DIF:    Cognitive Level: Application          REF:   Page 250, Cultural Considerations

OBJ:   4                    TOP:   Cultural awareness

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychological Integrity

 

MULTIPLE RESPONSE

 

  1. How can the nurse help reduce the stress of a hospital admission? (Select all that apply.)
a. Show the patient how bedside equipment works.
b. Explain the need to establish a clear source of reimbursement.
c. Give simple explanation of policies.
d. Involve the patient in the plan of care.
e. Keep family interventions to a minimum.

 

 

ANS:  A, C, D

An empathic reception reduces anxiety of admission; for instance, demonstrating how bedside equipment works, explaining hospital policies, and involving the patient in the plan of care from the start all help to reduce the stress of a hospital admission. Securing financial information is not a role of the nurse, and family interventions are frequently helpful in reducing stress.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 249        OBJ:   4| 5

TOP:   Stress reduction                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse adheres to the discharge standards set by The Joint Commission (TJC), which include that patients will receive instruction regarding which aspect(s) of care? (Select all that apply.)
a. Medications
b. Rehabilitation techniques
c. Referral to community agencies
d. Medical equipment to be used
e. Obtaining health insurance

 

 

ANS:  A, B, C, D

The Joint Commission (TJC) standards require that a patient have information pertinent to medication, rehabilitation instructions, referral to community agencies, instruction in using any medical equipment, family care responsibility, diet, and how to obtain further treatment if necessary.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 260        OBJ:   9

TOP:   TJC standards for discharge           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

COMPLETION

 

  1. The nurse completes thorough documentation before, during, and after a transfer to ensure _______ of _______.

 

ANS:

continuity, care

 

Clear documentation before, during, and after a transfer ensures that the patient’s condition is being monitored and maintains the continuity of care.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 257        OBJ:   5| 7

TOP:   Documentation                               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Some _____________________patients consider sundown Friday to sundown Saturday to be the Sabbath, which is a time of rest.

 

ANS:

Orthodox Jewish

 

Some Orthodox Jewish patients consider sundown Friday to sundown Saturday to be the Sabbath, which is a time of rest. These patients may avoid the use of any electronic equipment, so the nurse should find alternatives to the use of this equipment if possible.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 250, Cultural Considerations

OBJ:   3                    TOP:   Orthodox Jewish culture

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. Because of the stress caused by hospitalization, the nurse assesses a newly admitted older adult patient for ________________.

 

ANS:

disorientation

 

In a normally alert and oriented older adult, medical conditions that necessitate hospitalization often result in some level of disorientation.

 

DIF:    Cognitive Level: Application          REF:   Page 249, Life Span Considerations

OBJ:   3| 5                 TOP:   Disorientation in older adults

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