Foundations Of Nursing 6th Edition by Barbara Lauritsen Christensen – Test Bank

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Foundations Of Nursing 6th Edition by Barbara Lauritsen Christensen – Test Bank

Christensen: Foundations of Nursing, 6th Edition

 

Chapter 02: Legal and Ethical Aspects of Nursing

 

Test Bank

 

MULTIPLE CHOICE

 

  1. When a nurse becomes involved in a legal action, the first step to occur is that a document is filed in an appropriate court. This document is called a(n):
a. deposition.
b. appeal.
c. complaint.
d. answer.

 

 

ANS:   C

A document called a complaint is filed in an appropriate court as the first step in litigation.

 

DIF:    Cognitive Level: Analysis       REF:    Page 23           OBJ:    1

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

 

  1. Assuming responsibility for a patient’s care forms a legally binding situation described as:
a. nurse-patient relationship.
b. accountability.
c. advocacy.
d. standard of care.

 

 

ANS:   A

When the nurse assumes responsibility for a patient’s care, the nurse-patient relationship is formed. This is a legally binding “contract” for which the nurse must take responsibility.

 

DIF:    Cognitive Level: Analysis       REF:    Page 24           OBJ:    2

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

 

  1. Universal guidelines that define appropriate measures for all nursing interventions that should be observed during the performance of those interventions are known as:
a. scope of practice.
b. advocacy.
c. standard of care.
d. prudent practice.

 

 

ANS:   C

Standards of care define actions that are permitted or prohibited in most nursing interventions. These standards are accepted as legal guidelines for appropriateness of performance.

 

DIF:    Cognitive Level: Analysis       REF:    Page 22           OBJ:    3

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

 

  1. The laws that formally define and limit the scope of nursing practice in that state are the:
a. standards of care.
b. regulation of practice.
c. American Nurses’ Association Code.
d. nurse practice act.

 

 

ANS:   D

It is the nurse’s responsibility to know the nurse practice act in his or her state.

 

DIF:    Cognitive Level: Application  REF:    Page 25           OBJ:    4

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

 

  1. A nurse who failed to irrigate a feeding tube as ordered resulting in harm to the patient could be found guilty of:
a. malpractice.
b. harm to the patient.
c. negligence.
d. failure to follow the Nurse Practice Act.

 

 

ANS:   A

The nurse can be held liable for malpractice for acts of omission. Failure to meet a legal duty, thus causing harm to another, is malpractice. The Nurse Practice Act has general guidelines that can support the charge of malpractice.

 

DIF:    Cognitive Level: Analysis       REF:    Page 26           OBJ:    5

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

 

  1. Patients have expectations regarding the health care services they receive. To protect these expectations, which has become law?
a. American Hospital Association’s Patient’s Bill of Rights
b. Self-Determination Act
c. American Hospital Association’s Standards of Care
d. JCAHO rights and responsibilities of patients

 

 

ANS:   A

The American Hospital Association developed the Patient’s Bill of Rights.

 

DIF:    Cognitive Level: Application  REF:    Page 26           OBJ:    7

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

 

  1. The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed?
a. Physical assessment
b. Interview
c. Informed consent
d. Surgical checklist

 

 

ANS:   C

The patient must consent to allow certain procedures to be performed after being fully informed of the benefits and risks.

 

DIF:    Cognitive Level: Application  REF:    Page 27           OBJ:    7

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

 

  1. By protecting the information in a patient’s record, the nurse fulfills the ethical responsibility of:
a. privacy.
b. disclosure.
c. confidentiality.
d. absolute secrecy.

 

 

ANS:   C

The nurse has an ethical and legal duty to protect information about a patient and preserve confidentiality. Some disclosures are legal and anticipated and may not be subject to the rules of confidentiality. None of the information in a chart is considered secret.

 

DIF:    Cognitive Level: Application  REF:    Page 26           OBJ:    7

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

MSC:   NCLEX: N/A

 

  1. An older adult is admitted to the hospital with numerous bodily bruises, and the nurse suspects elder abuse. The best nursing action is to:
a. cover the bruises with bandages.
b. take photographs of the bruises.
c. ask the patient if anyone has hit her.
d. report the bruises to the charge nurse.

 

 

ANS:   D

The nurse must be alert to signs of elder abuse and know procedures for reporting.

 

DIF:    Cognitive Level: Analysis       REF:    Page 29           OBJ:    7

TOP:    Elder abuse     KEY:   Nursing Process Step: N/A     MSC:   NCLEX: N/A

 

  1. The nurse concludes that the best way to avoid a lawsuit is to:
a. carry malpractice insurance.
b. spend time with the patient.
c. provide compassionate, competent care.
d. answer all call lights quickly.

 

 

ANS:   C

The best defense against a lawsuit is to provide compassionate and competent nursing care.

 

DIF:    Cognitive Level: Application  REF:    Page 29           OBJ:    6

TOP:    Avoiding a lawsuit                  KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. When seeking advice involving the patient’s right to refuse medication, the nurse should most appropriately consult:
a. a minister or priest.
b. the hospital ethics committee.
c. the nursing supervisor.
d. a more experienced nurse.

 

 

ANS:   B

The nurse should seek the advice of the hospital ethics committee.

 

DIF:    Cognitive Level: Analysis       REF:    Page 31           OBJ:    13

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

 

  1. Although the nurse may disagree with a do-not-resuscitate (DNR) order, legally he or she:
a. may question the doctor.
b. may seek advice from the family.
c. may discuss it with the patient.
d. must follow the order.

 

 

ANS:   D

When a DNR order is written in the chart, the nurse has a duty to follow the order.

 

DIF:    Cognitive Level: Application  REF:    Page 33           OBJ:    11

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

 

  1. The nurse has strong moral convictions that abortions are wrong. When assigned to assist with an abortion, the nurse has the right to:
a. ask for another assignment.
b. leave work.
c. transfer to another floor.
d. protest to the supervisor.

 

 

ANS:   A

The nurse should not abandon the patient, but ask for another assignment.

 

DIF:    Cognitive Level: Analysis       REF:    Page 33           OBJ:    14

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

 

  1. The new LPN/LVN is concerned regarding what should or should not be done for patients. Select the resource that will best provide this information.
a. Nurse Practice Act
b. Standards of care
c. Scope of nursing practice
d. Professional organizations

 

 

ANS:   B

Standards of care define what should or should not be done for patients.

 

DIF:    Cognitive Level: Analysis       REF:    Page 24           OBJ:    3

TOP:    Standards of care                    KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. The nurse who diligently works for the protection of patients’ interests is functioning in the role of:
a. caregiver.
b. health care administrator.
c. advocate.
d. health care evaluator.

 

 

ANS:   C

A nurse accepts the role of advocate when, in addition to general care, the nurse protects the patient’s interests.

 

DIF:    Cognitive Level: Application  REF:    Page 24           OBJ:    14

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

 

  1. When asked to perform a procedure that the nurse has never done before, what should the nurse do to legally protect himself or herself?
a. Go ahead and do it.
b. Refuse to perform it, citing lack of knowledge.
c. Discuss it with the charge nurse, asking for direction.
d. Ask another nurse who has performed the procedure.

 

 

ANS:   C

The nurse cannot use ignorance as an excuse for nonperformance. The nurse should ask for direction from the charge nurse, explaining she has never performed the procedure independently.

 

DIF:    Cognitive Level: Analysis       REF:    Page 25           OBJ:    6

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

 

  1. The nurse is assisting a patient to clarify values by encouraging the expression of feelings and thoughts related to the situation. The nurse recognizes it is necessary to:
a. compare her values with those of the patient.
b. make a judgment.
c. withhold an opinion.
d. give advice.

 

 

ANS:   C

The nurse can assist the patient in values clarification without giving an opinion.

 

DIF:    Cognitive Level: Analysis       REF:    Page 31           OBJ:    11

TOP:    Values clarification                 KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. When confronted with an ethical decision, the nurse must observe the first fundamental principle of:
a. autonomy.
b. beneficence.
c. respect for people.
d. nonmaleficence.

 

 

ANS:   C

The first fundamental principle is respect for people.

 

DIF:    Cognitive Level: Analysis       REF:    Page 32           OBJ:    14

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

 

  1. Since a nurse’s first duty is to the patient’s health, safety, and well-being, it is necessary to report:
a. unethical behavior of other staff members.
b. a worker who arrives late.
c. favoritism shown by nursing administration.
d. arguments among the staff.

 

 

ANS:   A

A member of the nursing profession must report behavior that does not meet established standards.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 32           OBJ:    13

TOP:    Unethical behavior                  KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. A nurse considering purchasing malpractice insurance should be aware that malpractice insurance provided by the hospital:
a. only offers protection while on duty.
b. is limited in the amount of coverage.
c. is difficult to renew.
d. can be terminated at any time.

 

 

ANS:   A

Most institutional insurance only provides liability coverage if the nurse is on duty at that facility.

 

DIF:    Cognitive Level: Application  REF:    Page 29           OBJ:    5

TOP:    Malpractice insurance             KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. Which is a nursing care error that violates the Health Insurance Portability and Accountability Act (HIPAA)?
a. Administering a stronger dose of drug than was ordered
b. Refusing to give a patient’s daughter information over the phone
c. Informing the patient’s medical power of attorney of a medication change
d. Leaving a copy of the patient’s history and physical in the photocopier

 

 

ANS:   D

Leaving the document in the photocopier could expose it to the public. Inappropriate drug administration is possible malpractice. Sharing information with the power of attorney is legal.

 

DIF:    Cognitive Level: Analysis       REF:    Page 27           OBJ:    15

TOP:    Health Insurance Portability and Accountability Act (HIPAA)

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

 

  1. A nurse could be cited for malpractice in the event of:
a. refusing to give 60 mg of morphine as ordered.
b. giving prochlorperazine (Compazine) to a patient allergic to phenothiazines.
c. dragging an injured motorist off the highway and causing further injury.
d. informing a visitor about a patient’s condition.

 

 

ANS:   B

Standards of care dictate that a nurse must be aware of all the properties of drugs administered. Prochlorperazine (Compazine) is a phenothiazine. Providing confidential information or refusing to give an excessively large narcotic dose is not considered malpractice. Good Samaritan laws generally protect a person giving aid to an injured motorist.

 

DIF:    Cognitive Level: Analysis       REF:    Page 26           OBJ:    5

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

 

  1. A lumbar puncture was performed on a patient without a signed informed consent form. This may be a situation in which a patient could sue for:
a. punitive damages.
b. civil battery.
c. assault.
d. nothing; no violation has occurred.

 

 

ANS:   B

Civil assault charges can be brought against someone performing an invasive procedure without the patient’s informed consent legally documented.

 

DIF:    Cognitive Level: Analysis       REF:    Page 27           OBJ:    7

TOP:    Informed consent                    KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. A physician instructs the nurse to bladder train a patient. The nurse clamps the patient’s indwelling urinary catheter but forgets to unclamp it. The patient develops a urinary tract infection. The nurse’s actions are an example of:
a. malpractice.
b. battery.
c. assault.
d. neglect of duty.

 

 

ANS:   A

A nurse is liable for acts of commission (doing an act) and omission (not doing an act) performed in the course of their professional duty. A charge of malpractice is likely when a duty exists, there is a breach of that duty, and harm has occurred to the patient.

 

DIF:    Cognitive Level: Analysis       REF:    Page 26           OBJ:    4

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

 

  1. What is true about nurse practice acts?
a. They informally define the scope of nursing practice.
b. They provide for unlimited scope of nursing practice.
c. Only some states have adopted a nurse practice act.
d. The nurse must know the nurse practice act within his or her state.

 

 

ANS:   D

The laws formally defining and limiting the scope of nursing practice are called nurse practice acts. All state, provincial, and territorial legislatures in the United States and Canada have adopted nurse practice acts, although the specifics they contain often vary. It is the nurse’s responsibility to know the nurse practice act that is in effect for her geographic region.

 

DIF:    Cognitive Level: Analysis       REF:    Page 25           OBJ:    4

TOP:    Nurse Practice Acts                KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. How can the medical record be used in litigation? (Select all that apply.)
a. Public record
b. Proof of adherence to standards
c. Evidence of omission of care
d. Documentation of time lapses
e. Evidence by only the plaintiff

 

 

ANS:   A, B, C, D

The information when used in court becomes a public record. The information can be used as proof of adherence to standards, omission of care, and documentation of time lapses. Both plaintiff and defendant can use the document.

 

DIF:    Cognitive Level: Analysis       REF:    Page 27           OBJ:    7

TOP:    Legal properties of medical record     KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. During a lunch break, an emergency department (ED) nurse truthfully tells another nurse about the condition of a patient who came to the ED last night. What is the ED nurse guilty of? (Select all that apply.)
a. HIPAA violation
b. Slander
c. Libel
d. Invasion of privacy
e. Defamation

 

 

ANS:   A, D

The disclosure is an invasion of privacy and a violation of HIPAA. Because the information is true and verbal, it cannot be considered slander or libel.

 

DIF:    Cognitive Level: Analysis       REF:    Pages 26-27     OBJ:    7

TOP:    Disclosure of information       KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. A nurse failed to monitor a patient’s respiratory status after medicating the patient with a narcotic analgesic. The patient’s respiratory status worsened, requiring intubation. The patient’s family claimed the nurse committed malpractice. For the nurse to be held liable ___________________ must be present? (Select all that apply.)
a. A nurse-patient relationship.
b. The nurse failed to perform in a reasonable manner.
c. There was harm to the patient.
d. The nurse was prudent in her performance.
e. The nurse did not cause the patient harm.
f. Duty does not exist.

 

 

ANS:   A, B, C

For the court to uphold the charge of malpractice, and to find the nurse liable, the following elements must be present: duty exists, there is a breach of duty, and harm must have occurred.

 

DIF:    Cognitive Level: Analysis       REF:    Page 26           OBJ:    5

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

 

  1. Personal beliefs about the worth of an object, idea, custom, or attitude that influence a person’s behavior in a given situation are referred to as ___________.

 

ANS:

values

Values are personal beliefs about the worth of an object, an idea, a custom, or an attitude. Values vary among people and cultures; they develop over time and undergo change in response to changing circumstances and necessity. Each of us adopts a value system that will govern what we feel is right or wrong (or good and bad) and will influence our behavior in a given situation.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 31           OBJ:    11

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

 

  1. Acts whose performance is required, permitted, or prohibited are defined by ___________ of ______________.

 

ANS:

standards, care

Standards of care define acts whose performance is required, permitted, or prohibited.

 

DIF:    Cognitive Level: Analysis       REF:    Page 24           OBJ:    3

TOP:    Standards of care                    KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

Christensen: Foundations of Nursing, 6th Edition

 

Chapter 14: Safety

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse manager clarifies that “safe hospital environment” implies that in the hospital setting people will be free from:
a. falls.
b. exposure to contaminates.
c. injury.
d. electrical hazard.

 

ANS:   C

A safe environment implies freedom from injury.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 343         OBJ:    5

TOP:    Safety             KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. To decrease the risk for injury to the patient, the nurse determines if the patient:
a. can read English.
b. is left-handed.
c. is able to eat unassisted.
d. can dress independently.

 

ANS:   B

A left-handed patient will twist to accommodate, which places them at risk for injury.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 354         OBJ:    1

TOP:    Safety             KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. To decrease the risk for falls, the nurse holds frequent in-services to ensure that staff has competent skills for:
a. bathing.
b. feeding.
c. transferring.
d. ambulating.

 

ANS:   C

The majority of patient falls occur during transfer.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 344         OBJ:    3

TOP:    Falls                KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. An important safety precaution the home health nurse teaches parents to prevent burns to small children is to:
a. never leave them unattended.
b. turn pot handles on stoves away from reach.
c. turn hot water on first when filling the bathtub.
d. keep side rails up on the crib.

 

ANS:   B

To protect infants and children from burns, turn the pot handles on stoves away from the child’s reach.

 

DIF:    Cognitive Level: Application             REF:    Page 346         OBJ:    4

TOP:    Safety             KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. Before applying a safety reminder device (SRD), the nurse must:
a. get permission from the family.
b. assess patient’s skin condition.
c. get a physician’s order.
d. explain the SRD to the patient.

 

ANS:   C

Initially, an order is necessary that specifies the type of SRD and the duration of its application.

 

DIF:    Cognitive Level: Analysis                  REF:    Pages 348-349, Skill 14-1

OBJ:    8                      TOP:    Safety reminder devices (SRDs)

KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. When offering a cup of hot coffee to a frail, older adult patient, the nurse must:
a. give the patient a straw.
b. dilute the coffee with cold water.
c. fill the cup half full.
d. offer a bib or an apron.

 

ANS:   C

Filling the cup half full promotes safety and does not change the flavor of the beverage, nor does it demean the patient as would making him or her wear a bib or apron.

 

DIF:    Cognitive Level: Application             REF:    Page 346         OBJ:    4

TOP:    Safety             KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

  1. When the oxygen concentrator machine malfunctions and causes an electrical fire, the nurse should use which type of fire extinguisher?
a. A
b. B
c. C
d. D

 

ANS:   C

Electrical fires require type C fire extinguishers.

 

DIF:    Cognitive Level: Application             REF:    Page 359         OBJ:    9

TOP:    Fires                KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. A disaster situation that involves an explosion in a hospital laundry would be classified as:
a. active.
b. external.
c. life-threatening.
d. internal.

 

ANS:   D

Internal disaster often threatens the safety of patients and staff.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 361         OBJ:    10

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

 

  1. The emergency department nurse can receive assistance in dealing with a victim of poisoning by calling the:
a. American Red Cross.
b. fire department paramedics.
c. poison control center.
d. civil defense office.

 

ANS:   C

The nurse can access the local poison control for assistance in caring for a victim of poisoning.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 360, Box 14-10

OBJ:    11                    TOP:    Poisoning        KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. A nurse instructs a nursing assistant about the proper use of a gait belt. The nurse should intervene after observing the nursing assistant:
a. walking on the patient’s strong side.
b. walking to the side of the patient.
c. securing the gait belt securely around the patient’s waist.
d. grasping the handles of the gait belt while the patient ambulates.

 

ANS:   A

A gait belt should be securely applied around the patient’s waist. It has handles attached for the nurse to grasp while the patient ambulates. The nurse should walk on the patient’s weaker side so that assistance may be given if the patient starts to fall.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 345         OBJ:    3

TOP:    Gait belt          KEY:   Nursing Process Step: N/A                MSC:   NCLEX: N/A

 

  1. A nurse who encounters a mercury spill should:
a. vacuum the spill.
b. open interior doors.
c. close all outside windows.
d. open any outside windows.

 

ANS:   D

In the event of a mercury spill, interior doors should be closed and outside windows should be opened. The spill should not be vacuumed.

 

DIF:    Cognitive Level: Application             REF:    Page 355, Box 14-6

OBJ:    10                    TOP:    Mercury spill

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

 

  1. When the nurse ambulates with a patient who has left-sided weakness, what actions should the nurse take? (Select all that apply.)
a. Walk on the patient’s right side.
b. Keep the patient away from heavy furniture.
c. Hold the patient’s arm securely.
d. Keep the leg nearest the patient behind the patient’s knee.
e. Use a gait belt.

 

ANS:   D, E

Ambulating with a person who has an identified weakness requires that the nurse walk on the same side as the weakness, slightly behind the patient, with the nurse’s near leg behind the patient’s knee. The nurse should use a gait belt and hold the patient at the waist and the gait belt. Furniture can be used as support.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 345         OBJ:    3

TOP:    Ambulating     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

 

  1. When reinforcing the PASS acronym for fire extinguisher use, the nurse reminds the staff that the final “S” stands for ______________.

 

ANS:

sweep

The acronym stands for: P = pull pin, A = aim, S = squeeze, S = sweep.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 358, Box 14-9

OBJ:    9                      TOP:    Fire extinguisher use

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. The nurse conducting a seminar on bioterrorism reviews several types of agents that may be used as weapons. An agent that does not seriously damage or kill the target population but only impairs it is classified as _____________.

 

ANS:

incapacitating

The agent that only impairs the target rather than killing or seriously damaging it is classified as an incapacitating agent.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 364         OBJ:    13

TOP:    Bioterrorism    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse explains that the measurement of radiation exposure is in multiples of Gy. The number of Gy an individual may absorb before becoming ill with radiation syndrome is _______.

 

ANS:

0.75

The amount of radiation absorbed is measured by the Gy. 1 Gy is equal to 100 rad. Absorption of 0.75 Gy will cause the individual to develop acute radiation syndrome.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 364         OBJ:    13

TOP:    Radiation syndrome                           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse assesses a patient in a Posey safety reminder device (SRD) for which problem(s) that may increase because of use of SRDs? (Select all that apply.)
a. Immobility
b. Restlessness
c. Risk for impaired circulation
d. Risk for skin impairment
e. Incontinence

ANS:   A, B, C, D, E

The use of SRDs increases a patient’s immobility, restlessness, risk for skin impairment, risk for impaired circulation, and incontinence.

 

DIF:    Cognitive Level: Application             REF:    Pages 346-347

OBJ:    8                      TOP:    Problems associated with SRDs

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

 

Christensen: Foundations of Nursing, 6th Edition

 

Chapter 28: Care of the High-Risk Mother, Newborn, and Family with Special Needs

 

Test Bank

 

MULTIPLE CHOICE

 

  1. A patient is admitted to the hospital with hyperemesis gravidarum. The patient is malnourished and severely dehydrated. The nurse alters the care plan to include interventions for:
a. hyperalimentation.
b. IV feedings and electrolyte replacement.
c. hormone replacement therapy.
d. vitamin supplements.

 

ANS:   B

Medical treatment is aimed at meeting nutritional needs and electrolyte replacement.

 

DIF:    Cognitive Level: Application             REF:    Pages 884-885

OBJ:    1                      TOP:    Hyperemesis gravidarum

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

 

  1. A patient with hyperemesis gravidarum asks the nurse what would have happened if she had not come to the hospital. The nurse explains that if untreated, this condition could result in:
a. a large for gestational age infant.
b. anorexia nervosa.
c. preterm delivery.
d. maternal or fetal death.

 

ANS:   D

If untreated, hyperemesis gravidarum can result in maternal or fetal death.

 

DIF:    Cognitive Level: Application             REF:    Page 885         OBJ:    1

TOP:    Hyperemesis gravidarum                    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse uses a picture to explain that twins who share a placenta, come from one fertilized ovum, and are identical are identified as:
a. dizygotic.
b. trizygotic
c. genetically different.
d. monozygotic.

ANS:   D

Monozygotic twins originate from one fertilized ovum and share a placenta.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 886         OBJ:    1

TOP:    Multifetal pregnancy                          KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. When assessing the woman who is pregnant with multiple fetuses, the nurse recognizes that the delivery will probably be:
a. complicated by an ectopic tendency.
b. difficult due to the fetal lie.
c. a vaginal delivery.
d. complicated by loss of uterine tone.

 

ANS:   D

Maternal and infant risks are increased when there are multiple fetuses because the delivery will probably be cesarean because labor will be complicated due to loss of uterine tone.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 886         OBJ:    1

TOP:    High-risk pregnancy                           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. A patient is admitted to the hospital with signs of an ectopic pregnancy. The nurse modifies the care plan to include:
a. long-term bed rest.
b. episodes of extreme hypertension.
c. surgery to remove the embryo/fetus.
d. risk for dehydration.

 

ANS:   C

An ectopic implantation occurs somewhere outside the uterus and either resolves itself in a spontaneous abortion or requires surgical intervention.

 

DIF:    Cognitive Level: Application             REF:    Page 888         OBJ:    1

TOP:    Ectopic pregnancy                              KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity

 

  1. A patient was admitted following a spontaneous abortion. When attempting to console the patient, the nurse tells her the percentage of first trimester pregnancies that abort is:
a. 5%.
b. 10%.
c. 15%.
d. 20%.

 

ANS:   C

It is estimated that 10% to 15% of first-trimester pregnancies end in spontaneous abortion.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 889         OBJ:    1

TOP:    Abortions        KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. During an antepartum visit, the nurse tells the mother that one sign that must be reported immediately, no matter what the stage of pregnancy, is:
a. backache.
b. urinary frequency.
c. vaginal bleeding.
d. uterine tightening.

 

ANS:   C

Women should be instructed to contact their physician if any bleeding occurs during pregnancy.

 

DIF:    Cognitive Level: Application             REF:    Page 890         OBJ:    1

TOP:    Vaginal bleeding                                KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. A patient in her second trimester of pregnancy arrives at the hospital complaining of bright red, painless vaginal bleeding. Based on this information, the nurse suspects a(n):
a. abruptio placentae.
b. hemorrhage.
c. placenta previa.
d. placentitis.

 

ANS:   C

Placenta previa consists of bright red painless vaginal bleeding occurring after 20 weeks of pregnancy.

 

DIF:    Cognitive Level: Application             REF:    Page 891         OBJ:    2

TOP:    Placenta previa                                   KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. A pregnant woman comes to the hospital 3 weeks before her estimated date of birth (EDB) complaining of severe pain and a rigid abdomen. The nurse recognizes these as signs and symptoms of:
a. placenta previa.
b. appendicitis.
c. ectopic pregnancy.
d. abruptio placentae.

 

ANS:   D

The major symptoms of abruptio placentae are severe pain and a rigid abdomen.

 

DIF:    Cognitive Level: Application             REF:    Page 892         OBJ:    2

TOP:    Abruptio placentae                             KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. A patient presents with symptoms of abruptio placentae. To facilitate uterine-placental perfusion, the nurse positions the patient in:
a. prone position.
b. Trendelenburg position.
c. supine position.
d. side-lying position.

 

ANS:   D

A side-lying position facilitates uterine-placental perfusion.

 

DIF:    Cognitive Level: Application             REF:    Page 893         OBJ:    2

TOP:    Abruptio placentae                             KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. A pregnant woman visits a clinic visit during her 21st week of pregnancy. The nurse identifies edema, hypertension, and proteinuria. The nurse recognizes these signs as indicative of a(n):
a. allergy.
b. protein deficiency.
c. circulatory problem.
d. gestational hypertension.

 

ANS:   D

Gestational hypertension (GH), formerly referred to as pregnancy-induced hypertension (PIH), is a disease encountered during pregnancy or early in the puerperium, characterized by increasing hypertension, proteinuria, and generalized edema. These signs generally appear after the 20th week of pregnancy.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 895         OBJ:    5

TOP:    Pregnancy-induced hypertension (PIH)

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

 

  1. A patient who has been diagnosed with gestational hypertension asks the nurse what caused it. The nurse explains that there are many theories, but the cause is:
a. too much salt.
b. a toxin.
c. unknown.
d. diabetes.

 

ANS:   C

The cause of gestational hypertension is unknown.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 896         OBJ:    5

TOP:    Pregnancy-induced hypertension (PIH)

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

 

  1. During prenatal visits, the nurse keeps a record of a patient’s blood pressure to identify:
a. ketoacidosis.
b. placenta previa.
c. gestational diabetes.
d. gestational hypertension.

 

ANS:   D

Blood pressure should be assessed routinely during pregnancy, because symptoms of gestational hypertension include hypertension.

 

DIF:    Cognitive Level: Application             REF:    Page 895         OBJ:    5

TOP:    Pregnancy-induced hypertension (PIH)

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. The nurse is assessing a “kick count” for a patient with gestational hypertension. A serious cause for concern is a count of fewer than:
a. three.
b. five.
c. seven.
d. nine.

 

ANS:   A

A kick count of fewer than three is considered serious.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 899         OBJ:    5

TOP:    Pregnancy-induced hypertension (PIH)

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

 

  1. When discussing toxoplasmosis infection during pregnancy, the nurse should caution the patient to avoid:
a. contact with an infected person.
b. emptying cat litterboxes bare-handed.
c. having unprotected sex.
d. eating excessive amounts of shellfish.

ANS:   B

A pregnant woman should wear gloves whenever having contact with cat feces as this is a possible source of infection.

 

DIF:    Cognitive Level: Application             REF:    Page 903, Box 28-5

OBJ:    8                      TOP:    Infections       KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. When a patient is diagnosed with gestational diabetes, the nurse cautions that a major complication is that during the early pregnancy the fetus suffers from:
a. lack of nutrition.
b. dehydration.
c. hypoglycemia.
d. hyperglycemia.

 

ANS:   D

A result of gestational diabetes is sustained fetal hyperglycemia during the early months of pregnancy.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 905         OBJ:    1

TOP:    Diabetes          KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. A pregnant patient who has type 2 diabetes (NIDDM) may require insulin. When the patient asks the nurse why this is necessary, the nurse responds that:
a. the growing baby will require more glucose.
b. oral hypoglycemic agents may be teratogenic.
c. increased hormone levels raise blood glucose.
d. oral hypoglycemics do not reach the fetus.

 

ANS:   B

Oral hypoglycemics are discontinued because of teratogenic effects.

 

DIF:    Cognitive Level: Application             REF:    Page 906         OBJ:    7

TOP:    Diabetes          KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. A major concern for the diabetic patient who is pregnant is the effect her blood glucose control has on the fetus. The fetus is totally dependent on the mother for this control because insulin:
a. requirements are higher.
b. is destroyed by the placenta.
c. does not cross the placenta.
d. is absorbed by the fetus.

 

ANS:   C

Insulin will not cross the placenta, but high glucose levels do.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 907         OBJ:    7

TOP:    Diabetes          KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. When assessing a newly admitted pregnant patient, the nurse identifies a history of rheumatic heart disease. To prevent further stress on the heart, the nurse anticipates a protocol of:
a. potassium.
b. calcium.
c. zinc.
d. iron.

 

ANS:   D

Iron intake must be adequate to prevent anemia, which will further stress the heart.

 

DIF:    Cognitive Level: Application             REF:    Page 908         OBJ:    14

TOP:    Cardiovascular defects                       KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. A 14-year-old pregnant adolescent arrives at the hospital in early labor. The nurse recognizes that because the adolescent is still growing, she is at greater risk for:
a. calcium deficit.
b. cephalopelvic disproportion.
c. bleeding tendency.
d. low hemoglobin levels.

 

ANS:   B

There are several physiological concerns for pregnant adolescents, including cephalopelvic disproportion.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 909         OBJ:    9

TOP:    Adolescent pregnancy                                    KEY:              Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. When an infant is delivered, it is important for the nurse to determine the gestational age of the baby within:
a. 5 to 10 minutes.
b. 1 to 2 hours.
c. 2 to 8 hours.
d. 12 to 24 hours.

 

ANS:   C

The gestational age tests are done within 2 to 8 hours of age.

 

DIF:    Cognitive Level: Application             REF:    Page 915         OBJ:    11

TOP:    Gestational age                                   KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. The newborn infant is determined to be preterm and has oxygenation problems and lack of subcutaneous fat. The nurse assesses the gestational age of the preterm infant as:
a. 0 to 37 complete weeks of pregnancy.
b. 38 to 41 complete weeks of pregnancy.
c. 14 to 36 complete weeks of pregnancy.
d. 42 or more complete weeks of pregnancy.

 

ANS:   A

The gestational age of the preterm is classified 0 to 37 complete weeks of pregnancy.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 916         OBJ:    11

TOP:    Preterm           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. The nurse explains that the mortality and morbidity rate for preterm infants is higher than that of an older infant of comparable weight by:
a. 1 to 2 times.
b. 2 to 3 times.
c. 3 to 4 times.
d. 4 to 5 times.

 

ANS:   C

The morbidity and mortality rate for preterm infants is higher by 3 to 4 times that of an older infant of similar weight.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 916         OBJ:    11

TOP:    Preterm           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. Respiratory distress syndrome is the greatest potential problem for the preterm infant, resulting from the immature respiratory system. The nurse explains this lack of oxygenation results because the lungs have not produced adequate:
a. mucus.
b. oxygen exchange.
c. surfactant.
d. carbon dioxide removal.

 

ANS:   C

For respiratory distress syndrome, the lungs are treated with artificial surfactant because of the lack of normal production.

 

DIF:    Cognitive Level: Application             REF:    Page 916         OBJ:    11

TOP:    Preterm           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The neonate is born with weak muscle tone, the extremities are froglike, and the ears fold easily. From these observations, the nurse places the gestational age at:
a. full term.
b. small for gestational age.
c. preterm.
d. post-term.

 

ANS:   C

Preterm infant posture is froglike and the ears are easily folded.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 917         OBJ:    11

TOP:    Preterm           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse closely monitors a baby born to a diabetic mother for the presence of:
a. hyperglycemia.
b. abnormal reflexes.
c. hypoglycemia.
d. brain damage.

 

ANS:   C

The infant of a diabetic mother will frequently exhibit hypoglycemia.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 918         OBJ:    1

TOP:    Diabetes          KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. A primigravida is Rh negative and her husband is Rh positive. She is concerned about the health of the fetus. The nurse explains that the only danger to the fetus is if it is Rh positive and the mother became sensitized during delivery. If this were the case, the mother would produce what in subsequent pregnancies?
a. Rh-negative blood cells
b. Rh-positive blood cells
c. Rh-negative antibodies
d. Rh-positive antibodies

 

ANS:   D

If the mother is exposed to the Rh antigen, Rh-positive antibodies will be produced after delivery of an Rh-positive baby. If the baby is Rh negative, no antibodies will be produced.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 918         OBJ:    7

TOP:    Hemolytic disease                              KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse assures a patient who has become sensitized to the Rh antigen that she can be protected for future pregnancies by receiving injections of:
a. iron.
b. vitamin B12.
c. RhoGAM.
d. type O blood.

 

ANS:   C

RhoGAM prevents the development of naturally occurring maternal antibodies.

 

DIF:    Cognitive Level: Application             REF:    Page 918         OBJ:    7

TOP:    Hemolytic disease                              KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. The nurse is assessing the newborn and discovers a yellowing of the skin. This jaundice appeared at birth and is considered:
a. within normal limits.
b. pathological.
c. a result of iron deficiency.
d. indicating possible hepatitis.

 

ANS:   B

Jaundice observed at birth is considered an indicator of a pathological condition, erythroblastosis fetalis.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 918         OBJ:    12

TOP:    Hemolytic disease                              KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. When teaching a class of primigravidas, the nurse explains that while the mother is pregnant, the physician may order a blood test to identify the maternal level of Rh antibodies. This test is called a(n):
a. indirect Coombs’ test.
b. hemolytic test.
c. Rh antibody test.
d. direct Coombs’ test.

ANS:   A

The indirect Coombs’ test measures the maternal level of antibodies.

 

DIF:    Cognitive Level: Application             REF:    Page 919         OBJ:    3

TOP:    Hemolytic disease                              KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. The nursery nurse is implementing phototherapy for the jaundiced infant. The nurse explains that the phototherapy:
a. is initiated when the bilirubin level reaches 5 mg/dL.
b. converts bilirubin to a water-soluble form to be excreted in the urine.
c. changes bilirubin to a bile salt to be excreted through the bowel.
d. requires eye patches to remain in place 24 hours a day.

 

ANS:   B

Phototherapy converts the bilirubin into a water-soluble form to be excreted by the kidneys. It is initiated when the bilirubin level reaches 12 to 15 mg/dL. The eye patches are worn during therapy, but removed for feeding, bathing, and socialization.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 920         OBJ:    12

TOP:    Hemolytic disease                              KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The home health nurse cautions a pregnant patient who ingests alcohol or illicit drugs that she places herself at risk and endangers her fetus, because alcohol and drugs:
a. are all absorbed into the bloodstream.
b. affect the mother.
c. cross the placental barrier.
d. increase the heart rate.

 

ANS:   C

Alcohol and illicit drugs cross the placental barrier and affect the fetus.

 

DIF:    Cognitive Level: Application             REF:    Page 921         OBJ:    10

TOP:    Fetal risk from drugs                          KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. The nurse uses a chart to demonstrate the cognitive impairment, facial abnormalities, and growth retardation in the fetus that are characteristic of:
a. fetal dependency.
b. fetal immaturity.
c. malnutrition dependency.
d. fetal alcohol syndrome.

ANS:   D

Use of alcohol may result in multiple anomalies called fetal alcohol syndrome.

 

DIF:    Cognitive Level: Application             REF:    Page 922, Table 28-4

OBJ:    10                    TOP:    Fetal risk         KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. When the gestational hypertensive patient is hospitalized, the nurse monitors the:
a. blood sugar.
b. temperature.
c. level of consciousness.
d. deep tendon reflexes.

 

ANS:   D

If the patient is hospitalized for gestational hypertension, deep tendon reflexes are monitored.

 

DIF:    Cognitive Level: Application             REF:    Page 896         OBJ:    6

TOP:    Eclampsia        KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse who administers magnesium sulfate to a patient with eclampsia recognizes the risk of toxic levels. The nurse ensures the availability of the antidote for magnesium sulfate toxicity, which is:
a. vitamin K.
b. calcium gluconate.
c. potassium sulfate.
d. calcium carbonate.

 

ANS:   B

The antidote for magnesium sulfate toxicity is calcium gluconate.

 

DIF:    Cognitive Level: Application             REF:    Page 899, Box 28-4

OBJ:    5                      TOP:    Maternal risk

KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. A patient who delivered her baby 4 weeks ago calls the home-health nurse because she is feeling very depressed. The nurse recognizes this call for help as a symptom of postpartum depression (PPD), and that one of the prominent features of this is:
a. failure to thrive.
b. rejection of the infant.
c. inability to care for the baby.
d. problems with the baby’s father.

 

ANS:   B

A prominent feature of PPD is rejection of the infant.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 921         OBJ:    1

TOP:    Postpartum depression (PPD)            KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Psychosocial Integrity

 

  1. For the mother suffering from postpartum depression (PPD), gradual improvement occurs over a 6-month period. When this does not occur, the usual treatment is:
a. improved nutrition.
b. vitamin therapy.
c. pharmacological interventions.
d. support group therapy.

 

ANS:   C

Support therapy is not enough for major PPD. Pharmacological interventions are needed in most instances.

 

DIF:    Cognitive Level: Application             REF:    Page 922         OBJ:    1

TOP:    Postpartum depression (PPD)            KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. Following an abruptio placentae, the patient suddenly becomes dyspneic, complains of chest pain, and begins to ooze blood from her IV insertion site. The nurse assesses these as indicators of _____________ ______________ _________________.

 

ANS:

disseminated intravascular coagulation

DIC

disseminated intravascular coagulation (DIC)

DIC is characterized by dyspnea, chest pain, and uncontrolled bleeding.

 

DIF:    Cognitive Level: Application             REF:    Pages 893-894

OBJ:    3                      TOP:    Disseminated intravascular coagulation (DIC)

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

 

  1. The nurse reports to the charge nurse that the 3-hour postpartum patient is bleeding excessively as she has saturated one peri-pad in less than ______ minutes.

 

ANS:

15

fifteen

The saturation of one peri-pad within 15 minutes is considered to be excessive bleeding.

 

DIF:    Cognitive Level: Application             REF:    Page 894         OBJ:    3

TOP:    Postpartum hemorrhage                     KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse explains that severe preeclampsia needs to be controlled because it can develop into another syndrome called _________________.

 

ANS:

HELLP

Hypertension, Elevated Liver enzymes, and Low Platelets

HELLP (Hypertension, Elevated Liver enzymes, and Low Platelets)

Progressive preeclampsia can develop into HELLP syndrome.

 

DIF:    Cognitive Level: Application             REF:    Page 900         OBJ:    4

TOP:    Hypertension, Elevated Liver enzymes, and Low Platelets (HELLP)

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. The patient who has taken the ovulation stimulant clomiphene (Clomid), and who has been determined to be pregnant, calls the clinic nurse to report that she is bleeding and has passed a small grape-like object. From this information the nurse suspects a _________ ____________.

 

ANS:

hydatidiform mole

Hydatidiform moles occur frequently in people who have taken Clomid. The physical changes are similar to a real pregnancy until bleeding occurs and some grape-like clusters are passed.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 887         OBJ:    3

TOP:    Hydatidiform mole                            KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. A woman who is 14 weeks pregnant calls the clinic nurse to report that after a brief bleeding episode a week ago, her uterus seems to have gotten smaller, but her periods have not begun. The nurse assesses the indicators for a _____________ abortion.

 

ANS:

missed

A missed abortion is initiated by a bleeding episode in which the fetus is not expelled. The uterus begins to shrink, but periods do not resume.

 

DIF:    Cognitive Level: Application             REF:    Page 889         OBJ:    3

TOP:    Missed abortion                                  KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

Christensen: Foundations of Nursing, 6th Edition

 

Chapter 40: Hospice Care

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The hospice nurse explains to the family that the overall objective of hospice service is to:
a. relieve symptoms of terminal disease.
b. educate the patient about the process of death.
c. keep the patient comfortable as death approaches.
d. relieve the family of the stress of death.

 

ANS:   C

Hospice is a philosophy of care that provides support and comfort to patients who are dying.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1222       OBJ:    1

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. In 1960, the hospice philosophy was launched by:
a. Cicely Saunders.
b. Lillian Wald.
c. Dorothea Dix.
d. Florence Nightingale.

 

ANS:   A

Dame Cicely Saunders renewed the idea of hospice in the 1960s.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 1223       OBJ:    1

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

 

  1. The hospice nurse clarifies that hospice service is initiated when what type of treatment is no longer effective?
a. Proactive
b. Palliative
c. Alternative
d. Curative

 

ANS:   D

Hospice care is appropriate when curative treatment is no longer effective. Hospice service is palliative, proactive, and an alternative to curative treatment.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 1224       OBJ:    2

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. The nurse differentiates for the family active and palliative care, in that active care is:
a. centered on symptom control.
b. focused on treatment for a cure.
c. not concerned with dying.
d. covered by health insurance.

 

ANS:   B

Active treatment is aggressive care that aims to cure disease and prolong life.

 

DIF:    Cognitive Level: Application             REF:    Page 1224       OBJ:    2

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. Because the family is confused about the meaning of palliative care, the hospice nurse explains it as treatment that is centered on a(n):
a. aggressive approach to prolong life.
b. protocol of pain relief.
c. form of organized care which relieves the family of responsibility.
d. integrated service of support for alleviation of symptoms.

 

ANS:   D

Palliative care is not curative but is an integrated plan designed to relieve pain and control symptoms.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1223       OBJ:    2

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. The hospice nurse explains that to qualify for admission to a hospice, the attending physician must certify that the patient has a life expectancy of fewer than:
a. 2 months.
b. 3 months.
c. 4 months.
d. 6 months.

 

ANS:   D

The patient must meet certain criteria to be admitted to hospice, such as a prognosis of 6 months or fewer to live.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 1224       OBJ:    3

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

  1. The hospice nurse requests that the patient designate a primary caregiver for himself. The primary caregiver:
a. must be a relative.
b. has complete control over the patient’s care.
c. acts as the patient’s spokesperson when necessary.
d. must have power of attorney.

 

ANS:   C

A primary caregiver is one who assumes responsibility for health maintenance and therapy.

 

DIF:    Cognitive Level: Application             REF:    Page 1224       OBJ:    3

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. The hospice nurse provides time to confer with the patient and family to:
a. show concern.
b. report changes in the plan of care designed by the team.
c. confirm the ongoing reimbursement.
d. plan for changes in the scope of care.

 

ANS:   D

The basic goals of hospice address controlling or alleviating patient’s symptoms, and allowing the patient and caregiver to be involved in planning care.

 

DIF:    Cognitive Level: Application             REF:    Page 1224       OBJ:    1

TOP:    Hospice           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Psychosocial Integrity

 

  1. The patient informs the hospice nurse, “I’m not sold on this hospice thing. I’m not looking for Jesus, I’m just dying.” The most therapeutic response by the nurse would be:
a. “Spiritualism is as you define it.”
b. “Rejecting the spiritual aspect of yourself may not be in your best interest.”
c. “Hospice service is about how to make your remaining time meaningful.”
d. “Based on what you say, hospice service may not answer your needs.”

 

ANS:   C

The holistic approach of hospice pertains to the total patient care including physical, emotional, social, economic, and spiritual needs of the patient with no particular emphasis on any one of those aspects.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1224       OBJ:    1

TOP:    Hospice           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Psychosocial Integrity

 

  1. The hospice nurse recognizes that the role of the medical director is to:
a. design and direct the plan of care.
b. evaluate the appropriateness of the care.
c. function as mediator between the team and the attending physician.
d. take the place of the patient’s attending physician.

 

ANS:   C

The medical director is a mediator between the interdisciplinary team and the attending physician.

 

DIF:    Cognitive Level: Application             REF:    Page 1225       OBJ:    4

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. The hospice nurse tells the family that the nurse coordinator, an RN, will visit them to:
a. collect initial fees for the hospice service.
b. officially admit the patient to the hospice service.
c. give the family a copy of the standardized plan of care.
d. distribute drugs prescribed for palliation.

 

ANS:   B

The nurse coordinator may do the initial assessment, admit the patient, and develop the plan of care with the interdisciplinary team.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1225       OBJ:    4

TOP:    Hospice           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Psychosocial Integrity

 

  1. The social worker evaluates and assesses the psychosocial needs of the patient. To work in a hospice, the social worker must have at least which degree?
a. Associate
b. Bachelor’s
c. Master’s
d. Doctorate

 

ANS:   B

The hospice social worker must have at least a bachelor’s degree.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 1226       OBJ:    4

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

 

  1. The hospice spiritual coordinator can be affiliated with any church, assists with the spiritual assessment of the patient, and develops the plan of care regarding spiritual matters. The spiritual coordinator must possess a(n):
a. bachelor’s degree.
b. master’s degree.
c. seminary degree.
d. associate degree.

 

ANS:   C

The hospice spiritual coordinator must have a seminary degree.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 1226       OBJ:    4

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

 

  1. The hospice nurse introduced the family to the volunteer coordinator who will assign a volunteer to the patient who will:
a. give the family respite.
b. give necessary medication in the absence of the nurse.
c. be at the family’s disposal 16 hours a week.
d. find appropriate recreational activities for the patient.

 

ANS:   A

The volunteer coordinator assigns volunteers to the family to give the family respite.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1226       OBJ:    4

TOP:    Hospice           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Psychosocial Integrity

 

  1. The hospice nurse instructs the family that they have access to a bereavement coordinator who follows the plan of care focused on the caregiver after the death of the patient for at least:
a. one week.
b. one month.
c. one year.
d. two years.

 

ANS:   C

The bereavement coordinator follows the plan of care for the caregiver for at least a year following the death of the patient.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 1226       OBJ:    4

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. The hospice nurse instructs the family that they have access to a hospice pharmacist, who is available for consultation on the drugs the hospice patient may be taking and who will:
a. provide all drugs necessary for pain alleviation.
b. evaluate drug interactions with food and other medications.
c. evaluate the safety of the drug storage in the patient’s home.
d. monitor drug effectiveness by frequent phone interviews with the family.

 

ANS:   B

The hospice pharmacist is available to consult about drug interactions with other drugs or food.

 

DIF:    Cognitive Level: Analysis                  REF:    Pages 1226-1227

OBJ:    4                      TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nutritional assessment is done at the time of admission by the:
a. physician.
b. hospice nurse.
c. caregiver.
d. nursing assistant.

 

ANS:   B

The hospice nurse does the nutritional assessment during admission.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1227       OBJ:    4

TOP:    Hospice           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. When a deficiency in nutritional status of a patient is assessed, the hospice nurse should:
a. make a comprehensive grocery list for the caregiver.
b. alert the licensed medical nutritionist.
c. seek culturally appropriate methods to increase nutrition.
d. instruct the caregiver to give the patient multivitamins.

 

ANS:   B

The hospice nurse can call on the nutritionist for assistance for the patient who is assessed as having a nutritional deficit.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1227       OBJ:    4

TOP:    Hospice           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse carefully assesses the symptom faced by the dying patient that often disrupts the quality and enjoyment of life and can be excruciating and terrifying. That symptom is:
a. fear.
b. anger.
c. grief.
d. pain.

ANS:   D

Pain disrupts the quality, activities, and enjoyment of life.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1227       OBJ:    5

TOP:    Hospice           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Psychosocial Integrity

 

  1. The nurse recognizes that pain can be managed what percentage of the time?
a. 50% to 55%
b. 60% to 65%
c. 70% to 80%
d. 95% to 97%

 

ANS:   D

It is believed that pain can be effectively managed 95% to 97% of the time.

 

DIF:    Cognitive Level: Comprehension       REF:    Pages 1227-1228

OBJ:    6                      TOP:    Hospice           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. During a pain assessment, the patient tells the nurse that the pain is aching, stabbing, and throbbing. The nurse recognizes this pain to be:
a. visceral.
b. neuropathic.
c. somatic.
d. psychogenic.

 

ANS:   C

Somatic pain arises from the musculoskeletal system and is aching, stabbing, or throbbing.

 

DIF:    Cognitive Level: Application             REF:    Page 1228       OBJ:    6

TOP:    Hospice           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse explains that because they can be delivered by all routes, give good pain control, and have no limit on the dose amount, the drugs of choice when caring for the hospice patient are:
a. nonsteroidal anti-inflammatory drugs.
b. anticholinergic drugs.
c. Duragesic patches.
d. opioid derivatives.

 

ANS:   D

Opioid derivatives are popular drugs of choice when dealing with the hospice patient because of the wide variety of modes of administration.

DIF:    Cognitive Level: Application             REF:    Page 1228       OBJ:    6

TOP:    Pain                 KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse must educate the patient and caregiver that large doses of narcotics are required to control pain. It is good to educate the patient and caregiver that the dose that works is the dose:
a. the physician ordered.
b. that provides pain relief.
c. that is not addictive.
d. agreed upon by the patient.

 

ANS:   B

The patient and caregiver should understand that pain can be controlled and that using large doses of opioids is common and necessary to achieve that control. It is good to educate the patient and caregiver that the dose that works is the dose that works.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1230       OBJ:    6

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse warns that nausea is a common side effect with opioid treatment, and rather than discontinuing the opioid, it is better to treat the nausea with:
a. antiemetics.
b. ice chips.
c. dry crackers.
d. ginger ale.

 

ANS:   A

Rather than discontinuing the opioid, the nausea should be treated with an antiemetic.

 

DIF:    Cognitive Level: Application             REF:    Page 1230       OBJ:    6

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. When educating a patient concerning ways to prevent nausea, the nurse suggests that eating slowly in a pleasant atmosphere will help, as well as taking an antiemetic how many minutes before meals?
a. 10
b. 20
c. 30
d. 60

 

ANS:   C

Taking an antiemetic 30 minutes before meals reduces nausea and increases appetite.

 

DIF:    Cognitive Level: Application             REF:    Page 1230       OBJ:    5

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse prepares the family for the most common problem of the terminally ill patient caused by narcotics, which is:
a. malnutrition.
b. constipation.
c. fluid retention.
d. dehydration.

 

ANS:   B

One of the most common opioid-induced problems of the terminally ill patient is constipation.

 

DIF:    Cognitive Level: Application             REF:    Page 1231       OBJ:    5

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The hospice nurse documents an assessment finding of cachexia in the patient record, which describes a state of:
a. deep sleep and unresponsiveness.
b. marked weakness and emaciation.
c. total addiction to opioids.
d. renewed energy.

 

ANS:   B

Malnutrition marked by weakness and emaciation is called cachexia.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 1231       OBJ:    5

TOP:    Hospice           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse reassures the patient and caregiver that part of the end-of-dying process is:
a. denial.
b. despair.
c. anorexia.
d. depression.

 

ANS:   C

The nurse often has to reassure the patient and caregiver that anorexia is part of the end-of-dying process.

 

DIF:    Cognitive Level: Application             REF:    Page 1231       OBJ:    5

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

  1. The nurse assures an anxious family that medication that will relax the patient’s respiratory effort and thus increase the efficiency of respiratory status is:
a. aminophylline.
b. theophylline.
c. epinephrine.
d. morphine.

 

ANS:   D

Respiratory distress may be relieved by morphine.

 

DIF:    Cognitive Level: Application             REF:    Page 1232       OBJ:    5

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The hospice nurse delays the use of oropharyngeal suctioning because it:
a. will decrease mucus production.
b. will be tiring to the patient.
c. is not necessary.
d. puts the patient at risk for infection.

 

ANS:   B

Suctioning should only occur if the patient is choking because it causes an increase in mucus production and is tiring to the patient.

 

DIF:    Cognitive Level: Application             REF:    Page 1232       OBJ:    5

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. During a visit by the hospice nurse, an older adult Hispanic male patient dies. To honor the cultural traditions, the nurse should:
a. have the body removed as quickly as possible.
b. call the priest immediately.
c. cover the face with a clean white cloth.
d. provide time for lengthy family visitation.

 

ANS:   D

Hispanic tradition involves lengthy visitation from the immediate and extended family before the body is removed.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1226       OBJ:    8

TOP:    Hospice           KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Psychosocial Integrity

 

 

 

 

  1. The hospice nurse recommends that the patient prepare the document that provides guidance to the family concerning the patient’s wishes regarding life-support measures and organ donation. This document is called a(n):
a. power of attorney.
b. living will.
c. advance directive.
d. conservatorship.

 

ANS:   C

An advance directive is a document prepared while the patient is alive and competent.

 

DIF:    Cognitive Level: Application             REF:    Page 1234       OBJ:    9

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. The hospice nurse instructs caregivers in repositioning the patient because the patient spends most of the time reclining, which can lead to:
a. contractures.
b. pressure ulcers.
c. bruising.
d. excoriation.

 

ANS:   B

Increased weakness is noted in the last stages of a terminal illness. With increased weakness, activity intolerance increases, and the patient spends most of the time reclining. This leads to risk for skin impairment and the formation of pressure ulcers.

 

DIF:    Cognitive Level: Application             REF:    Page 1232       OBJ:    5

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. When air hunger is assessed in the dying patient, the nurse can perform which intervention(s)? (Select all that apply.)
a. Circulate the air with a fan.
b. Use a tranquilizer to decrease anxiety.
c. Provide good oral hygiene.
d. Perform careful suctioning.
e. Raise the head of the bed 30 degrees.

 

ANS:   A, B, C, E

Suctioning will increase mucus production.

 

DIF:    Cognitive Level: Application             REF:    Page 1232       OBJ:    5

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The hospice nurse educates the patient and family about the members of the interdisciplinary team. Which caregivers are included? (Select all that apply.)
a. Medical director
b. Nurse coordinator
c. Social worker
d. Spiritual coordinator
e. Psychologist

 

ANS:   A, B, C, D

The interdisciplinary team does not include a psychologist.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 1224       OBJ:    4

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance

 

  1. When the dying patient becomes confused, the nurse should ____________ him or her.

 

ANS:

reorient

Reorientation regarding time, date, and location is the least distressing to the dying patient.

 

DIF:    Cognitive Level: Application             REF:    Page 1233, Table 40-4

OBJ:    7                      TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. Which are signs and symptoms of approaching death? (Select all that apply.)
a. Mottled extremities
b. Significant decrease in urine output
c. Increased restlessness and pulling at bed linens
d. Alteration in rhythmic respiration
e. Increased pulse rate

 

ANS:   A, B, C, D, E

All of the options are signals of approaching death.

 

DIF:    Cognitive Level: Application             REF:    Page 1233, Table 40-4

OBJ:    8                      TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. What are the goals of hospice service? (Select all that apply.)
a. Alleviating symptoms of approaching death
b. Educating and supporting primary caregivers
c. Using family input for designing a plan of care
d. Encouraging patients and caregivers to enjoy life
e. Focusing on patient desires in the plan of care

ANS:   A, B, C, D, E

All of the options listed are goals of hospice care.

 

DIF:    Cognitive Level: Application             REF:    Page 1224       OBJ:    1

TOP:    Hospice           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance

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