Medica Surgical Nursing Preparation For Practice 2nd Ed By Osborn – Test Bank

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Medica Surgical Nursing Preparation For Practice 2nd Ed By Osborn – Test Bank

Osborn, Medical-Surgical Nursing, 2e
Chapter 02

Question 1

Type: MCSA

The nurse is a member of a committee that is studying the frequency of medication errors. Other committee members include a health care provider, pharmacist, pharmacy technician, and nurse manager. The nurse is most likely participating in which specific type of quality process?

  1. Total quality management
  2. Continuous quality improvement
  3. Quality improvement
  4. Quality assurance

Correct Answer: 2

Rationale 1: Total quality management is a way to ensure customer satisfaction by involving all employees in the improvement of the quality of every product or service.

Rationale 2: Continuous quality improvement is the process of improving a system by using multidisciplinary teams to analyze the system, collect measurements, and propose changes.

Rationale 3: Quality improvement programs are large programs that focus on accountability to the payer and consumer.

Rationale 4: Quality assurance refers to an organization’s efforts to provide services that follow professional standards and guarantee or ensure quality of care.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-1

 

Question 2

Type: MCSA

At the end of a scheduled work shift, the nurse asks each of his patients if there was anything he could have done to make their day more comfortable. The nurse is most likely participating in which process?

  1. Quality improvement
  2. Self-assessment
  3. Continuous quality improvement study
  4. Departmental assessment

Correct Answer: 1

Rationale 1: At the level of the individual nurse and patient, the quality improvement process is an appraisal of how the nurse performed in taking care of the patients.

Rationale 2: Self-assessment is not the best description of this activity.

Rationale 3: A continuous quality improvement study is conducted by a multidisciplinary team to analyze a system, collect data, and propose changes.

Rationale 4: There is no evidence to suggest a departmental assessment.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-1

 

Question 3

Type: MCSA

The hospital benefits manager describes a health care program in which the nurse employee will pay a certain amount of money each month for comprehensive health services. The nurse will have a primary physician who will direct care within a specific network of providers. The nurse’s heath care must be provided by these in-network physicians. The nurse will have which type of health care?

  1. Health maintenance organization (HMO)
  2. Traditional insurance service plan
  3. Independent practice association (IPA) coverage
  4. Preferred provider organization (PPO)

Correct Answer: 1

Rationale 1: An HMO is a group health agency that provides basic and supplemental health treatment with a fee being set without regard to the amount or kind of service provided.

Rationale 2: Traditional insurance service plans contract with providers to accept payment based on a fee schedule. The insured may have some restrictions on providers, and the provider is paid directly by the plan.

Rationale 3: An IPA is a group of health care providers who join together to offer services to managed care organizations; the fees are collected and distributed according to fee-for-service arrangements. The physicians remain independent contractors.

Rationale 4: In a PPO, a network of physicians provide care. For a higher deductible, the insured can contract to be able to see providers outside the network.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-2

 

Question 4

Type: MCSA

A patient tells the nurse that her primary care provider wants her to see a specialist, but the specialist is out of the network and her deductible will be higher. The nurse realizes the patient is a member of which type of health care organization?

  1. Medicare
  2. Health maintenance organization (HMO)
  3. Independent practice association (IPA)
  4. Preferred provider organization (PPO)

Correct Answer: 4

Rationale 1: Medicare is the national health insurance program that covers people 65 years of age or older, some people under 65 with disabilities, and people with end-stage renal disease.

Rationale 2: HMOs deliver comprehensive care for fixed prepaid fees or capitation; they typically restrict access to a specific network of providers.

Rationale 3: An IPA is a type of health care provider business structure in which physicians contract with an HMO to provide services but remain independent contractors with separate practices. This business model does not match the described scenario.

Rationale 4: PPOs provide reimbursement for covered care to non-network providers but at a different rate, and the patient may have to pay a higher deductible.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-2

 

Question 5

Type: MCSA

A 46-year-old patient, unemployed and diagnosed with kidney disease, tells the nurse that he is having difficulty with his medical bills. What should the nurse do to help this patient?

  1. Work with the pharmacist to determine which medications the patient can discontinue and still maintain an acceptable level of health.
  2. Suggest the patient take prescribed medications every other day to make the prescription last longer.
  3. Ask social services to discuss Medicare as a health care coverage option.
  4. Assure the patient that the nurse will ask the health care provider if the patient can be quickly discharged to home.

Correct Answer: 3

Rationale 1: Encouraging the patient to discontinue medications is not an acceptable nursing practice.

Rationale 2: The nurse should not suggest that the patient skip doses. This practice would not constitute good care.

Rationale 3: The nurse should find out from social services whether the patient is eligible for Medicare coverage. Medicare is the national health insurance program that covers people 65 years or older, some people under age 65 with disabilities, and people with end-stage renal disease.

Rationale 4: The patient should remain hospitalized as long as necessary to receive essential care.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-2

 

Question 6

Type: MCMA

A patient brought into the emergency department tells the nurse that she does not need anything because she cannot pay for any health services. The nurse’s assessment is that the patient is very ill and needs care. What nursing actions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Provide paperwork for the patient to sign out of the hospital against medical advice.
  2. Explain that all care will be covered by the Emergency Medical Treatment and Labor Act (EMTALA).
  3. Ask the health care provider for medication because the patient is confused.
  4. Encourage the patient to stay until care is provided.
  5. Agree that services cannot be delivered without pay and refer the patient to the local free clinic.

Correct Answer: 1,4

Rationale 1: If the patient cannot be persuaded to receive services, the nurse should be certain paperwork is signed to indicate the patient is aware of the risks associated with leaving against medical advice.

Rationale 2: EMTALA does not reimburse the hospital for care provided.

Rationale 3: There is no indication that this patient is confused.

Rationale 4: The nurse should encourage the patient to receive care. Contact with social services may be suggested.

Rationale 5: The hospital cannot turn away a patient who requires emergency care services.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-1

 

Question 7

Type: MCSA

The state board of nursing has notified a hospital about the changes in mandatory continuing education requirements for the nurses. The administration realizes these changes would impact which activity?

  1. Regulations
  2. Accreditation
  3. Licensure
  4. Life safety

Correct Answer: 3

Rationale 1: Regulations are rules or laws that govern delivery of care or maintenance of the facility or work environment.

Rationale 2: Accreditation is the process of evaluating actual care delivered to patients, the hospital’s performance as an organization, and the outcomes of treatment for patients.

Rationale 3: Licensing regulations differ from state to state and impact the delivery of care, including the credentials and competency of employees.

Rationale 4: Life safety standards and regulations vary from state to state and include having the facility checked for building code compliance and safety standards.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2-4

 

Question 8

Type: MCSA

A patient tells the nurse that he had made some decisions about his care when he thought he was going to die, but now that he knows he isn’t, he wants all possible medical treatment. Which nursing action is indicated?

  1. Tell the patient that he cannot change is mind or treatment plan.
  2. Change the patient’s classification in the medical record.
  3. Contact social services to discuss the change in plans.
  4. Contact the health care provider for the patient to discuss the patient’s decision.

Correct Answer: 4

Rationale 1: Advance directives can be changed as the individual’s needs and goals change.

Rationale 2: Simply changing this classification will not result in wide dissemination of the decision.

Rationale 3: There is no reason to contact social services.

Rationale 4: The patient should discuss this change with the health care provider.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-7

 

Question 9

Type: MCSA

A patient tells the nurse that if he does not wake up after surgery, his friend should be contacted because the friend knows what should be done concerning his health care needs. After referring to the patient’s medical record, the nurse realizes that the friend has which relationship with the patient?

  1. The patient’s best friend
  2. The patient’s health care power of attorney
  3. The patient’s next-door neighbor
  4. The patient’s brother

Correct Answer: 2

Rationale 1: There is not enough information to determine if this person is the patient’s best friend.

Rationale 2: The health care power of attorney is a legal document that establishes a surrogate decision maker to make medical decisions for the patient should he become incapacitated. The nurse reviewed the patient’s medical record to ensure that information about the friend was documented.

Rationale 3: There is not enough information to determine if the friend is the patient’s next-door neighbor.

Rationale 4: There is not enough information to determine if the friend is the patient’s brother.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-7

 

Question 10

Type: MCSA

A patient cries quietly while undergoing a painful treatment. The nurse realizes that although the treatment is painful, it is necessary for the patient’s healing and recovery. Which ethical principle does this situation exemplify?

  1. Paternalism
  2. Nonmaleficence
  3. Veracity
  4. Respect for others

Correct Answer: 2

Rationale 1: Paternalism allows one to make decisions for another.

Rationale 2: Even though the principle of nonmaleficence states that a person should do no harm, the focus of the projected treatment or procedure is on the consequences of the benefits to the patient, not on the harm that occurs at the time of the intervention.

Rationale 3: Veracity is the concept that individuals should always tell the truth.

Rationale 4: Respect for others acknowledges the right of individuals to make decisions and to live by those decisions.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-5

 

Question 11

Type: MCSA

The health care team is confronted with an ethical dilemma surrounding the types of care available for a particular patient. The team decides to apply ethical principles to determine the best course of action for this patient. This is an example of which ethical theory?

  1. Deontological theories
  2. Principlism
  3. Utilitarianism
  4. Teleological

Correct Answer: 2

Rationale 1: Deontological theories derive norms and rules from the duties human beings owe to one another by virtue of commitments made and roles assumed.

Rationale 2: Principlism incorporates existing ethical principles and attempts to resolve conflicts by applying one or more of the principles.

Rationale 3: Utilitarianism is another term for teleological theories and can be divided into “rule” and “act” utilitarianism.

Rationale 4: Teleological theories derive norms or rules for conduct from the consequences of actions.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-5

 

Question 12

Type: MCMA

A patient asks the nurse to promise that nothing bad will happen while the patient is under anesthesia for a surgical procedure. The patient is creating a conflict in which of the nurse’s ethical principles?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Fidelity
  2. Respect for others
  3. Paternalism
  4. Veracity
  5. Autonomy

Correct Answer: 1,4

Rationale 1: Fidelity means keeping one’s promises or commitments. The patient is putting the nurse “in the middle” of a potentially conflicting situation. The nurse cannot promise that nothing bad will happen to the patient under anesthesia.

Rationale 2: Respect for others acknowledges the right of individuals to make decisions and to live by these decisions.

Rationale 3: Paternalism allows one person to make decisions for another.

Rationale 4: Veracity is the concept that one should always tell the truth. The nurse cannot truthfully make the statement that nothing “bad” will happen to the patient.

Rationale 5: Autonomy addresses personal freedom and the right of an individual to choose what will happen to herself. The nurse’s personal autonomy is not at risk in this situation as the nurse is expected to provide safe and effective care.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-5

 

Question 13

Type: MCSA

A health care provider is reviewing the steps taken to address an ethical issue with a patient. Within which step of the MORAL model is this health care provider working?

  1. Massage the dilemma.
  2. Look back and evaluate.
  3. Outline the options.
  4. Act by applying the chosen option.

Correct Answer: 2

Rationale 1: Massaging the dilemma means identifying the issues.

Rationale 2: The health care provider is looking back and evaluating. This is the process of reviewing and reexamining whether desired outcomes were attained and whether new options need to be implemented.

Rationale 3: Outlining the options means fully examining the options, including those that are less realistic.

Rationale 4: Acting by applying the chosen option means implementing the chosen option to resolve the dilemma.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-5

 

Question 14

Type: MCSA

A patient is telling the nurse manager that she believes a wrongful act occurred when she was given the wrong medication. Which type of law would the nurse expect to address this issue?

  1. Criminal law
  2. Common law
  3. Civil law
  4. Tort law

Correct Answer: 4

Rationale 1: Criminal law is public law that involves the prosecution by the government of a person for an act that has been classified as a crime.

Rationale 2: Common law is derived from principles rather than rules and regulations. It is based on precedent rather than statutory laws.

Rationale 3: Civil law is based on normative principles that are codified in codes and statutes.

Rationale 4: A tort is a wrongful act committed against another person or the person’s property and resulting in injury or harm, thereby constituting the basis for a claim by the injured party. Although some torts are crimes punishable by imprisonment, the primary aim of tort law is to provide relief for the damages incurred and to deter others from committing the same harms. The injured person may sue for an injunction to prevent the continuation of the tortuous conduct or for monetary damages.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-6

 

Question 15

Type: MCSA

A patient tells the nurse that he had money in the top drawer of his bedside table that is now missing. He is phoning his attorney and plans to press charges. The nurse realizes this patient is planning to implement which type of law?

  1. Contract law
  2. Tort law
  3. Common law
  4. Criminal law

Correct Answer: 4

Rationale 1: Contract law is a way to govern promises or agreements made between two parties.

Rationale 2: A tort is a wrongful act committed against another person or the person’s property. The primary aim of tort law is to provide relief for damages.

Rationale 3: Common law is a system of law based on precedent rather than statutory laws.

Rationale 4: Criminal law involves the prosecution by the government of a person for an act that has been classified as a crime. The patient is claiming that money was stolen, which is a crime.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-6

 

Question 16

Type: MCSA

The nursing staff at a local hospital are unable to get to work because of deteriorating weather conditions. The administration realizes the lack of staff to provide care will impact which quality standard?

  1. Improvement
  2. Structure
  3. Outcome
  4. Process

Correct Answer: 2

Rationale 1: Quality improvement is an overall umbrella term that measures and evaluates all three quality standards.

Rationale 2: Structure standards focus on the internal characteristics of the organization and the personnel.

Rationale 3: Outcome standards measure the effectiveness, quality, and time allocated for care.

Rationale 4: Process standards focus on whether the activities within an organization are being conducted appropriately.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-3

 

Question 17

Type: MCMA

The nurse is reviewing activities to assess the quality of care provided for a group of patients. Which situation would be used to measure a process standard?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. The patient is able to ambulate without assistance.
  2. Every nurse scheduled to work has current cardiopulmonary resuscitation certification.
  3. A patient’s output is 2400 cc after receiving one dose of a diuretic.
  4. Nurses turn and reposition patients on bed rest every 2 hours and as needed.
  5. Morning assessments will be completed and documented by 0800.

Correct Answer: 4,5

Rationale 1: A patient’s ability to ambulate would be considered an outcome standard.

Rationale 2: Evidence of current CPR certification would be considered a structure standard.

Rationale 3: A patient’s urine output after a medication is administered would be considered an outcome standard.

Rationale 4: Process standards focus on nursing activities, interventions, and the sequence of caregiving events.

Rationale 5: Process standards focus on activities, interventions, and the sequence of caregiving events.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2-3

 

Question 18

Type: MCMA

The nurse has been asked to join a group reviewing patient-focused functions in the hospital. Which situations would the nurse anticipate reviewing?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Number of cases reviewed by the ethics committee over the last year
  2. How information is managed in the hospital
  3. Processes used to identify patients at risk for infection after surgery
  4. The hospital’s hiring practices
  5. Implementation of a new drug distribution system

Correct Answer: 1,3,5

Rationale 1: Ethics, rights, and responsibilities are patient-focused functions.

Rationale 2: Management of information is an organization function.

Rationale 3: Surveillance, prevention, and control of infection are patient-focused functions.

Rationale 4: Human resources manages hiring practices. Management of human resources is an organization function.

Rationale 5: Medication management is a patient-focused function.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2-4

 

Question 19

Type: MCMA

A patient tells the nurse manager that he is going to charge a nurse with battery for actions that occurred in the emergency department. Which characteristics of battery should the manager consider when formulating a response?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. For battery to occur, actual contact must be made.
  2. Battery could not have occurred unless the patient specifically told the nurse not to touch him just before the contact occurred.
  3. Battery can occur even if the patient is not touched.
  4. For the patient to prove battery, an injury must have occurred.
  5. It will be difficult for the patient to prove battery occurred because he gave consent for treatment.

Correct Answer: 1,3,5

Rationale 1: Battery is actual contact with another person or the person’s property.

Rationale 2: The patient does not have to be awake or alert for battery to occur.

Rationale 3: Battery has occurred if someone touches the patient, something the patient is holding, or the patient’s belongings.

Rationale 4: The patient does not need to experience any harm, injury, or pain to claim that battery has occurred.

Rationale 5: For battery to occur, there must be an absence of legal consent on the part of the patient.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2-6

 

Question 20

Type: MCMA

A patient in the emergency department required resuscitation, including administration of medications, blood products, and intravenous fluids. The next day, the patient threatens legal action because blood was administered without consent. What questions should the nurse manager ask when investigating this situation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Was the patient conscious when admitted?
  2. Did the patient say he did not want blood products?
  3. Would the patient have died if the blood product had not been administered?
  4. Was another form of treatment other than administration of blood possible?
  5. What is the experience level of the providers caring for this patient?

Correct Answer: 1,2

Rationale 1: If the patient was conscious and participated in treatment, the doctrine of implied consent may apply.

Rationale 2: The manager should determine if the patient refused blood and then was given blood after becoming unconscious.

Rationale 3: If the patient is of age and competent and refuses any treatment, the treatment cannot be administered no matter the urgency.

Rationale 4: The possibility of another form of treatment is not significant in this case.

Rationale 5: The experience level of the providers is not a factor in this case.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-6

Osborn, Medical-Surgical Nursing, 2e
Chapter 12

Question 1

Type: MCSA

Which statement explains why the nurse should assess each patient’s pain response individually in every situation?

  1. Everyone has a unique tolerance to pain.
  2. Everyone has the same pain threshold.
  3. Everyone perceives painful stimuli at the same intensity.
  4. Most people have the same pain response to surgery.

Correct Answer: 1

Rationale 1: Each person’s pain tolerance is different and should be assessed on an individual basis.

Rationale 2: Everyone does not have the same pain threshold.

Rationale 3: Everyone perceives pain at a different intensity.

Rationale 4: Different people have a different pain response, even to the same surgery.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-1

 

Question 2

Type: MCSA

A patient is being treated for chronic pain. The nurse realizes that which characteristic is typical of chronic pain?

  1. The pain rating may be inconsistent with the underlying pathology.
  2. Chronic pain usually has a clear, physiologic cause.
  3. Chronic pain typically lasts 2 months or less.
  4. The pain reported is usually less severe than acute pain.

Correct Answer: 1

Rationale 1: The patient might not exhibit signs of pain such as elevations in vital signs, grimacing, writhing, or moaning.

Rationale 2: There may not be an identified physiologic cause for chronic pain.

Rationale 3: Chronic pain is typically persistent beyond 3 to 6 months.

Rationale 4: There is no indication that chronic pain is less severe than acute pain, although in some instances it may be more diffuse.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-3

 

Question 3

Type: MCMA

The nurse is managing care for a group of patients with pain. The nurse plans care for acute pain for which patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. A patient who had a cholecystectomy this morning
  2. A patient with phantom limb pain
  3. A patient with a compound femur fracture that occurred 5 days ago
  4. A patient with degenerative joint disease
  5. A patient being treated for a burn that occurred 8 months ago

Correct Answer: 1,3,5

Rationale 1: Pain associated with surgery, such as gallbladder removal, is of relatively short duration and is considered acute pain.

Rationale 2: The neuropathic pain associated with amputation, phantom limb pain, may not begin immediately and may become a chronic problem lasting more than 6 months.

Rationale 3: A patient with a compound femur fracture will experience acute pain. The pain will still be considered acute 5 days after injury.

Rationale 4: Degenerative joint disease is associated with chronic rather than acute pain.

Rationale 5: The treatment is current, so pain is acute.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-3

 

Question 4

Type: MCSA

The nurse is planning care for a patient with chronic pain. What would be the most appropriate pain control goal for this patient?

  1. The patient will reduce the focus on pain.
  2. The patient will require minimal analgesic medications.
  3. The patient will be completely pain free.
  4. The patient will report that the pain is bearable.

Correct Answer: 1

Rationale 1: Pain management goals for the patient with chronic pain include reducing the focus on pain; optimizing comfort; increasing participation in activities of daily living, work, and relationships; and restoring a sense of joy and purpose.

Rationale 2: The goal should not be to use minimal analgesics; the patient should be provided with the amount required to control pain.

Rationale 3: Being completely pain free might be an unattainable goal for a patient with chronic pain.

Rationale 4: The goal is to make the patient comfortable, not to reduce pain simply to bearable levels.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12-7

 

Question 5

Type: MCSA

The nurse, caring for a patient recovering from surgery, knows that which intervention will provide the most pain relief for the patient?

  1. Offer pain relief before the patient complains of pain.
  2. Wait until the patient can describe the pain specifically.
  3. Assess the pain level every 4 hours around the clock.
  4. Allow the patient to “sleep off” the anesthesia, and then offer pain medication.

Correct Answer: 1

Rationale 1: Anticipating a patient’s pain will ensure a more manageable pain experience than will waiting until the patient complains of pain.

Rationale 2: Pain management needs to be implemented before the patient can describe specific postoperative pain, or “sleeping off” anesthesia.

Rationale 3: The patient should not be awakened every 4 hours to assess pain unless there are other significant nonverbal signs during sleep that indicate the patient is in pain. These can include grimacing, moaning, thrashing, or guarding of a surgical site.

Rationale 4: Pain management should be implemented prior to the patient “sleeping off” anesthesia.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12-7

 

Question 6

Type: MCMA

A patient is receiving an opioid for severe acute pain. What information should the nurse provide regarding this medication?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Increase fluid intake.
  2. Take a vitamin D supplement.
  3. Eat more protein.
  4. Increase intake of complex carbohydrates.
  5. Take a stool softener daily.

Correct Answer: 1,5

Rationale 1: Patients receiving opioids are at risk for constipation. Increasing fluid intake helps to reduce this effect.

Rationale 2: Increasing vitamin D intake is not a recommendation specifically related to the effects of an opioid medication.

Rationale 3: Increasing protein intake is not a recommendation specifically related to the effects of opioid medication.

Rationale 4: Increasing carbohydrate intake is not a recommendation specifically related to the effects of an opioid medication.

Rationale 5: Opioids are constipating, so a stool softener is necessary.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-7

 

Question 7

Type: MCSA

The nurse is planning to administer a pain medication to a patient who has just returned to the unit following bowel resection surgery. The patient has four standing orders for pain medication. Which order should the nurse select?

  1. The one to be administered intravenously by patient demand and under patient control
  2. The one to be given intramuscularly to work quickly
  3. The one ordered on a prn basis
  4. The one to be administered orally

Correct Answer: 1

Rationale 1: Patient-controlled analgesia allows self-management of pain and is a common postoperative method of administering pain medication. The advantages to this method are dose precision, timeliness, and convenience.

Rationale 2: The medication that is administered intramuscularly is not typically recommended for moderate to severe pain that will require more than one dose.

Rationale 3: Administering a prn medication this soon after a major surgery would not be the most effective strategy.

Rationale 4: Administering an oral medication this soon after a major surgery would not be the most effective strategy.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-4

 

Question 8

Type: MCMA

A patient recovering from abdominal surgery is refusing hydromorphone (Dilaudid) because she has heard that people may become addicted. She is crying and rates her pain 10 of 10. Which information should the nurse include as part of the patient’s education?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Because the patient will take the medication on a prn basis, addiction cannot occur.
  2. Untreated pain can result in poor wound healing.
  3. Patients with uncontrolled pain have a higher risk of blood clots.
  4. Dehydration can result from poorly managed pain.
  5. Family members do not want to visit patients with visible signs of pain.

Correct Answer: 2,3

Rationale 1: Pain medications should be dosed on a continuous basis after surgery. The use of prn dosing schedules does not guarantee that the patient will not become addicted if the medication is misused.

Rationale 2: Pain has physiological consequences, including poor wound healing.

Rationale 3: Pain has physiological consequences, including coagulation leading to DVT or PE.

Rationale 4: There is no evidence that poor pain relief causes dehydration.

Rationale 5: There is no evidence that poor pain relief causes family members to refuse to visit.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-4

 

Question 9

Type: MCSA

A patient with a history of chronic pain tells the nurse, “I do a variety of things to make my body produce its own pain reliever.” How should the nurse evaluate this statement?

  1. This is a common denial technique.
  2. The patient is trying to appear to be a pain expert.
  3. This statement offers the nurse a reason to reduce the amount of pain medication prescribed.
  4. The patient is taking advantage of the body’s ability to make endorphins.

Correct Answer: 4

Rationale 1: The patient did not deny the pain.

Rationale 2: The patient is an expert on his or her own pain. There is no evidence that this is the stimulus for this statement.

Rationale 3: There was no discussion of pain medication amounts.

Rationale 4: There is a pain inhibitory center within the dorsal horns of the spinal cord. The exact nature of this inhibitory mechanism is unknown. However, the most clearly defined chemical inhibitory mechanism is fueled by endorphins, which are naturally occurring opioid peptides in neurons in the brain, spinal cord, and gastrointestinal tract. Endorphins work by binding with opiate receptors on the neurons to inhibit pain impulse transmission.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-2

 

Question 10

Type: MCSA

A patient has periodic severe nerve pain that is not well controlled with the current pain medication regimen. The nurse anticipates adding a medication from which category?

  1. Nonsteroidal anti-inflammatory drugs (NSAID)
  2. Opioids
  3. Antidepressants
  4. Local anesthetics

Correct Answer: 3

Rationale 1: The NSAID group can have serious side effects, including bleeding tendencies, and would not be appropriate in a long-term situation.

Rationale 2: Other medications are prescribed before introducing opioids.

Rationale 3: Antidepressants within the tricyclic and related chemical groups act on the production and retention of serotonin in the CNS, thus inhibiting pain sensation. They also promote normal sleeping patterns, which further alleviates the suffering of the patient in pain. They are useful with neuropathic pain.

Rationale 4: A local anesthetic would not be appropriate for long-term pain management.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12-4

 

Question 11

Type: MCSA

A patient who is receiving pain medication around the clock complains of an acute exacerbation of pain. What should the nurse do to help this patient?

  1. Provide the medication ordered for breakthrough pain.
  2. Talk the patient through the pain.
  3. Encourage the patient to ignore the pain.
  4. Give the patient a nonsteroidal anti-inflammatory drug (NSAID).

Correct Answer: 1

Rationale 1: Breakthrough pain (BTP) occurs in patients who are receiving long-acting analgesics for chronic pain. It is a transitory experience of moderate to severe pain that is often precipitated by coughing or movement but may occur spontaneously. A short-acting opioid for this type of pain should be administered as needed in addition to the around-the-clock (ATC) dose for chronic, persistent pain.

Rationale 2: The pain must be addressed; it is not appropriate to talk the patient through it.

Rationale 3: The pain must be addressed; it is not appropriate to encourage the patient to ignore it.

Rationale 4: NSAIDs can only be given with the physician’s order.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-7

 

Question 12

Type: MCMA

A patient with chronic pain is being started on a “patch.” What should the nurse include when instructing the patient about this pain-relieving delivery system?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. It will not work as well as oral pain medications.
  2. Do not apply heat over the area where the patch is placed.
  3. The patient will never experience breakthrough pain.
  4. The patient will never overdose with this delivery method.
  5. Do not massage the area where the patch is placed.

Correct Answer: 2,5

Rationale 1: The continuous dosage of the transdermal or “patch” form of medication is an advantage over oral medications.

Rationale 2: Application of heat or massaging the skin increases blood flow to the area, resulting in rapid absorption and potential overdose.

Rationale 3: Additional short-acting medication is often needed for breakthrough pain.

Rationale 4: Overdose can occur with this route.

Rationale 5: Massaging the area where the patch is placed can increase blood flow to the area, resulting in rapid absorption and potential overdose.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-4

 

Question 13

Type: MCSA

A patient is seen talking and laughing in the clinic’s waiting room, yet complains of excruciating pain. The nurse realizes this patient is most likely demonstrating which behavior?

  1. Opioid drug-seeking
  2. Denial
  3. Fake pain
  4. Inconsistent behavioral response to pain

Correct Answer: 4

Rationale 1: There is no mention of the patient requesting opioids.

Rationale 2: The patient does not deny pain.

Rationale 3: The nurse cannot determine if the patient’s pain is real.

Rationale 4: Behavioral responses to pain may or may not coincide with the patient’s report of pain and are not very reliable cues to the pain experience. The nurse needs to manage the pain if the patient verbalizes that it is present, even if the nonverbal signs are not congruent.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-2

 

Question 14

Type: MCSA

Which patient’s (or patients’) physiologic assessment findings are consistent with the classic signs of acute pain?

  1. Patients A and C
  2. Patient A only
  3. Patients B and D
  4. Patient C only

Correct Answer: 3

Rationale 1: Slight expiratory wheezes and lower-extremity edema are not changes caused by pain.

Rationale 2: Slight expiratory wheezes are not changes caused by pain.

Rationale 3: Predictable physiologic changes occur in the presence of acute pain. These may include muscle tension; tachycardia; rapid, shallow respirations; increased blood pressure; dilated pupils; sweating; and pallor.

Rationale 4: Lower-extremity edema is not a change caused by pain.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-2

 

Question 15

Type: MCSA

Which patient (or patients) is reporting symptoms that are most likely to be related to side effects of an opioid pain medication regimen?

  1. Patients A and C
  2. Patient C only
  3. Patients B and D
  4. Patient D only

Correct Answer: 1

Rationale 1: Nausea and vomiting are common adverse effects of opioid analgesics, as is constipation.

Rationale 2: Another patient is also experiencing the effects of opioid analgesics.

Rationale 3: Opioids may cause stomach upset, but bruising is not a common side effect of opioid administration.

Rationale 4: Bruising is not a common side effect of opioid administration.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 12-4

 

Question 16

Type: MCSA

While caring for a nonverbal patient, which action ensures appropriate and timely pain management?

  1. Have the family medicate the patient, based on their knowledge of the patient’s response to pain.
  2. Use the McGill pain questionnaire to determine the optimal pain management plan.
  3. Administer opioids around the clock, adding NSAIDS when necessary.
  4. Medicate the patient based on the pathologic condition, nonverbal cues, and pain procedures.

Correct Answer: 4

Rationale 1: The family members are not likely to have the understanding of pharmacology and physiologic parameters to make pain management decisions, and in fact, out of concern, may “overread” the presence of pain.

Rationale 2: The McGill questionnaire requires the client’s input regarding pain and impact on ADLs and therefore is not an appropriate screening tool for this patient.

Rationale 3: The appropriate analgesic should be used for the situation. There is no indication that an opioid is necessary.

Rationale 4: Use of a behavioral pain assessment in addition to administering analgesics based on what would be considered a painful condition or procedure to others is the standard of practice.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12-3

 

Question 17

Type: MCSA

A nurse in the emergency department is caring for a patient with a fractured tibia and fibula who admits to regular heroin use. Which factor should be used to determine the presence of pain and need for pain medication?

  1. The patient has taken an opiate already today.
  2. The shift report indicates the patient has been sleeping on and off.
  3. The patient is angry about being in the hospital.
  4. The patient reports pain in the leg of an intensity of 10 out of 10 on the numeric rating scale.

Correct Answer: 4

Rationale 1: A chronic opiate user/abuser will experience withdrawal symptoms if the usual or base dose of opiate is not given. The patient may require additional medication for pain.

Rationale 2: A patient in pain may appear asleep or have closed eyes, but the quality of sleep may be poor.

Rationale 3: Anger at the nursing staff does not reflect the presence or absence of pain.

Rationale 4: The nurse should accept all pain reports as valid but negotiate treatment goals early in care. The patient’s own report of pain is the best means of assessing pain intensity.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-6

 

Question 18

Type: MCSA

The nurse is assessing a patient with chronic pain and learns the patient is not able to sleep through the night. The nurse realizes this patient is demonstrating which problem?

  1. The inability to cope with pain
  2. A side effect of chronic pain medication use
  3. Sleep deprivation because of poor pain control
  4. Lying as a way to be prescribed more pain medication without an identified need

Correct Answer: 3

Rationale 1: There is no evidence that this patient does not have the ability to cope with pain.

Rationale 2: There is no evidence that this patient is experiencing a side effect of pain medication use.

Rationale 3: Pain has been associated with agitation, decreased mobility, and sleep deprivation.

Rationale 4: The nurse should be nonjudgmental and not assume the patient is attempting to obtain more pain medication without an identified need.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-1

 

Question 19

Type: MCSA

The nurse is administering analgesic medication to a group of patients. Which statement should guide the nurse in this work?

  1. Pain should be managed to improve the patient’s quality of life.
  2. Opiates are not recommended for patients with addiction issues.
  3. The nurse should be certain pain is present prior to administering opiates.
  4. Patients with psychiatric diseases should avoid opiates for malignant pain.

Correct Answer: 1

Rationale 1: The purpose of effective pain management is to relieve or reduce pain to improve quality of life.

Rationale 2: Opiates may be needed by patients with addiction issues if the pain is severe; the dosage is adjusted to include the daily intake, plus additional medicine to control pain.

Rationale 3: If the nurse follows the definition of pain as what the patient describes, then the nurse’s role is to respond to the patient’s report of pain.

Rationale 4: Patients with psychiatric disorders still experience pain and are entitled to pain relief equivalent to that given to patients without psychiatric disorders.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-6

 

Question 20

Type: MCSA

A patient says that she has pain every day but never asks her health care provider for medication because she doesn’t want to “become addicted.” What is the nurse’s best response to this patient?

  1. “Pain isn’t always a bad thing to experience.”
  2. “It’s better to experience the pain than to cover it up.”
  3. “There are many medications your doctor can prescribe that are not addicting.”
  4. “I wouldn’t want to become addicted either.”

Correct Answer: 3

Rationale 1: The nurse should not minimize the impact of the patient’s pain on her ability to function or experience the pain.

Rationale 2: The nurse should not recommend that it is better to allow pain to continue without treatment.

Rationale 3: This patient’s fear of becoming addicted to pain medication is evidence of inaccurate consumer education and consumer fears. The nurse should suggest that the patient talk with her health care provider regarding pain medication options.

Rationale 4: The nurse should not support the patient’s fears regarding addiction.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-6

 

Question 21

Type: MCSA

The nurse, completing a pain assessment, would attribute which data to the affective dimension of pain?

  1. The patient is pale and moaning.
  2. The patient rates the pain as 9 on a scale of 1 to 10.
  3. The patient states, “The pain comes in waves in my abdomen.”
  4. The patient states that the pain is “punishment for my misdeeds.”

Correct Answer: 4

Rationale 1: Pallor and moaning are objective findings.

Rationale 2: Pain scales are tools to determine the severity of the pain.

Rationale 3: The quality of the pain is a subjective report of the sensory component of pain.

Rationale 4: The affective domain is the emotions or feelings associated with the pain.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-1

 

Question 22

Type: MCSA

A patient is seen resting quietly; however, when the nurse enters the room, the patient grimaces and asks for more pain medication. What should the nurse do?

  1. Tell the patient that medication cannot be provided at this time and leave the room.
  2. Assess the level of pain and provide the requested pain medication.
  3. Confront the patient and ask about the sudden demonstration of pain.
  4. Refuse the medication and document that the patient appears to be faking the need for pain medication.

Correct Answer: 2

Rationale 1: The nurse should not deny the patient pain medication.

Rationale 2: The behavioral dimension of pain states that responses to pain can be situational, developmental, or learned. Failure to respond to a patient’s complaint of pain may lead to learned pain behaviors. The patient may have learned that without an open demonstration of pain, the complaint might be ignored. The nurse should assess the level of pain and provide the medication.

Rationale 3: There is no need to confront the patient about this behavior.

Rationale 4: The nurse should not document that the patient is faking pain.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-7

 

Question 23

Type: MCMA

The nurse is performing a multidimensional pain assessment. Which questions should be included in this type of assessment?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. “Can you rate the pain’s severity?”
  2. “Is there a history of similar pain in your family?”
  3. “How are you managing your daily activities?”
  4. “How does the pain make you feel?”
  5. “Can you point to the area of pain?”

Correct Answer: 1,3,4,5

Rationale 1: A multidimensional pain assessment tool assesses more than one dimension of pain, including pain intensity.

Rationale 2: The patient is the focus of the pain assessment, not the family.

Rationale 3: A multidimensional pain assessment tool assesses more than one dimension of pain, including quality of life and ability to participate in ADLs.

Rationale 4: A multidimensional pain assessment tool assesses more than one dimension of pain, including the quality and characteristics of pain.

Rationale 5: A multidimensional pain assessment tool assesses more than one dimension of pain, including the area of pain.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-2

 

Question 24

Type: MCSA

The nurse is assessing a patient who is unable to supply a self-report of pain. What should the nurse do to assess the patient’s pain?

  1. Use a surrogate pain rating from the family or caregiver.
  2. Document that the client cannot scale the pain.
  3. Document the client’s pain using a numeric rating scale.
  4. Use the McGill pain questionnaire to assess the pain.

Correct Answer: 1

Rationale 1: Using a surrogate pain rating from caregivers and family is an acceptable assessment strategy for at-risk patients.

Rationale 2: Documenting that the patient cannot scale pain is not an assessment tool.

Rationale 3: The patient who cannot report pain will be unable to use the numeric rating scale.

Rationale 4: The patient must be aware and able to answer questions regarding pain and quality of life to use the McGill pain questionnaire.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-6

 

Question 25

Type: MCSA

The nurse is caring for a patient with prostate cancer with metastasis to S-1 and the adjacent nerve root. The patient complains of unrelenting pain. When collaborating with the provider, the nurse would advocate for which example of balanced analgesia?

  1. Use escalating doses of an opioid analgesic per the third step of the World Health Organization (WHO) analgesic ladder.
  2. Use an opioid around the clock rather than on an as-needed (prn) basis.
  3. Begin with the first step of the analgesic ladder as described by the World Health Organization (WHO), and then evaluate the client’s response.
  4. Use an opioid for background pain and gabapentin (Neurontin) for the neuropathic pain.

Correct Answer: 4

Rationale 1: Using escalating doses of an opioid does not address balanced analgesia.

Rationale 2: The use of around-the-clock medication over prn is appropriate; however, it does not address balanced analgesia.

Rationale 3: The step approach, in which the provider begins at the lowest step and moves through each step to reach the top, is not necessary, nor does it address balanced analgesia.

Rationale 4: Balanced analgesia or multimodal analgesia facilitates improved analgesia that is not possible with a single medication; various medications and adjunctive therapies are used to target specific types of pain and provide optimal relief in a safe manner.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-4

 

Question 26

Type: MCMA

The nurse is evaluating a patient receiving hydromorphone (Dilaudid). Which findings are adverse effects of this medication?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Pruritus
  2. Polyuria
  3. Nausea
  4. Decreased respiratory rate
  5. Tachypnea

Correct Answer: 1,3,4

Rationale 1: Side effects of narcotic or opioid analgesics include itching (pruritus).

Rationale 2: Polyuria, or excessive urine output, does not occur with opiates.

Rationale 3: Side effects of narcotic or opioid analgesics include nausea and vomiting.

Rationale 4: Side effects of narcotic or opioid analgesics include respiratory depression.

Rationale 5: Tachypnea, or rapid breathing, is not an adverse effect associated with opioid analgesics.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 12-4

 

Question 27

Type: MCSA

A patient is prescribed ibuprofen for back pain. The nurse preparing to educate this patient about the drug would consider which information?

  1. The drug should be used with caution in patients who consume more than three alcoholic beverages per day.
  2. The drug can be taken safely up to the day of a surgical procedure.
  3. The drug should be taken at a higher dose if administered with an opioid.
  4. The drug is a step 1 analgesic in the World Health Organization’s three-step approach to pain management.

Correct Answer: 4

Rationale 1: Acetaminophen should be used with caution in patients who consume more than three alcoholic beverages per day.

Rationale 2: Nonsteroidal anti-inflammatory drugs should be discontinued 1 to 2 weeks prior to a surgical procedure to reduce the risk of bleeding.

Rationale 3: If a nonsteroidal anti-inflammatory drug is administered with an opioid, the opioid dose can be reduced. The NSAID dose does not need to be adjusted.

Rationale 4: Acetaminophen and nonsteroidal anti-inflammatory drugs such as ibuprofen are analgesics used in the first step in the World Health Organization’s three-step approach to pain management.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-4

 

Question 28

Type: MCSA

A patient tells the nurse that putting a small pillow under the knee and rubbing the thigh helps reduce hip pain. How would the nurse interpret this statement?

  1. As a way to deny the presence of the hip pain
  2. As demonstrating fear of taking pain medication
  3. As a way to hide a previous pain medication addiction
  4. As a nonpharmacologic method to reduce the hip pain

Correct Answer: 4

Rationale 1: The patient is not denying the presence of pain.

Rationale 2: The nurse should not assume that the patient is fearful of taking pain medication.

Rationale 3: The nurse should not assume that the patient has a history of pain medication addiction.

Rationale 4: Although largely unsupported by scientific evidence, complementary therapies are often used in conjunction with medications, or alone, to control chronic pain.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-5

 

Question 29

Type: MCSA

When carrying out the order for morphine 2 mg IV every 3 hours prn, the nurse recognizes that which intervention is most appropriate?

  1. The nurse should wait until the previous dose of morphine has worn off before administering more.
  2. For best results, the patient should receive the morphine every 3 hours.
  3. The nurse should assess pain every hour and routinely offer the drug.
  4. The nurse should wait until the patient requests the morphine to administer the drug.

Correct Answer: 3

Rationale 1: Waiting for a previous dose of medication to wear off will reduce the blood level of analgesic; the patient may then need more than the ordered amount to regain control over pain.

Rationale 2: Administering the medication every 3 hours around the clock circumvents the nurse’s responsibility to assess the pain and administer medication when the patient needs it.

Rationale 3: While around-the-clock dosing has been proven more effective than as-needed (prn) dosing, the nurse should educate the patient about the medication, assess pain frequently, and offer the drug every 3 hours. If the patient is experiencing breakthrough pain, the nurse should contact the prescriber.

Rationale 4: Waiting for the patient to request the drug may allow too much time to elapse, resulting in severe pain that will require more than the ordered amount to relieve.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-4

 

Question 30

Type: FIB

A patient who had abdominal surgery this morning is receiving opioid pain medication on a routine basis. The nurse would hold the medication if the patient’s respirations fall below _____ per minute.

Standard Text:

Correct Answer: 12

Rationale : Opioid medications cause respiratory depression. If the respiratory rate falls below 12 per minute, the nurse should hold the medication. Frequent reassessment is necessary.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-6

Osborn, Medical-Surgical Nursing, 2e
Chapter 24

Question 1

Type: MCSA

The nurse would prioritize which nursing diagnosis when caring for a patient diagnosed with a spinal cord injury?

  1. Fluid Volume Deficit
  2. Impaired Physical Mobility
  3. Ineffective Breathing Pattern
  4. Altered Tissue Perfusion

Correct Answer: 3

Rationale 1: Fluid Volume Deficit is the nurse’s second priority, as it deals with circulation.

Rationale 2: Impaired Physical Mobility is an appropriate nursing diagnosis but is not the priority.

Rationale 3: The priority nursing diagnosis is Ineffective Breathing Pattern. Spinal cord injury can result in interruption of the nerves controlling breathing muscles.

Rationale 4: Altered Tissue Perfusion is a high-priority nursing diagnosis for this patient but does not hold the highest priority.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 24-4

 

Question 2

Type: MCSA

A patient with a spinal cord injury at the T1 level complains of a severe headache and an “anxious feeling.” Which is the most appropriate initial reaction by the nurse?

  1. Try to calm the patient and make the environment soothing.
  2. Assess for a full bladder.
  3. Notify the health care provider.
  4. Prepare the patient for diagnostic radiography.

Correct Answer: 2

Rationale 1: A calm, soothing environment is fine, but not what the patient needs in this case.

Rationale 2: Autonomic dysreflexia occurs in patients with injury at level T6 or higher. It is a life-threatening condition that requires immediate intervention. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea.

Rationale 3: The nurse must perform an assessment first, then communicate the findings to the health care provider.

Rationale 4: This would not be an initial response for this patient.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-5

 

Question 3

Type: MCSA

The school nurse is called after a student falls down a flight of stairs. The student is breathing but unconscious. After calling the ambulance, which is the most appropriate action by the nurse?

  1. Tilt the child’s head back to help maintain an airway.
  2. Place the child on the side to prevent aspiration.
  3. Immobilize the neck, securing the head.
  4. Try to rouse the child by gently shaking the shoulders.

Correct Answer: 3

Rationale 1: Guidelines for emergency care are avoiding flexing, extending, or rotating the neck. The child is breathing, so the nurse should monitor the airway but should not move the child’s head.

Rationale 2: If the child vomits, the nurse should utilize the log-roll technique to turn the child while keeping the head, neck, and spine in alignment.

Rationale 3: Guidelines for emergency care are avoiding flexing, extending, or rotating the neck; immobilizing of the neck; securing the head; maintaining the patient in the supine position; and transferring from the stretcher with a backboard in place to the hospital bed. This patient is unconscious, and the nurse must protect the neck from any (or any further) damage.

Rationale 4: Rousing the child by shaking could cause damage to the spinal cord.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-1

 

Question 4

Type: FIB

The health care provider orders 2.5 mg IV of morphine sulfate (Morphine) to be administered to a patient with a ruptured intervertebral disc. The nurse has a 1 milliliter (mL) vial containing 10 mg of morphine sulfate. The nurse needs to withdraw ______ mL of morphine sulfate from the vial.

Standard Text:

Correct Answer: 0.25

Rationale : 10 mg/1 mL = 25 mg/x mL
x = 0.25 mL

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-4

 

Question 5

Type: FIB

The health care provider orders 15 mg IV of ketorolac (Toradol) for a patient who has recently undergone a spinal fusion. The nurse has a 5 milliliter (mL) ampule containing 60 mg of ketorolac. The nurse withdraws ______ mL of ketorolac from the ampule.

Standard Text:

Correct Answer: 1.25

Rationale : 60 mg/ 5 mL = 15 mg / x mL
x = 1.25 mL

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-4

 

Question 6

Type: MCSA

A hospitalized patient with a C7 cord injury asks, “Why can’t I feel my legs anymore?” Which is the most appropriate action by the nurse?

  1. Remind the patient of her injury and try to comfort her.
  2. Call the health care provider and get an order for radiologic evaluation.
  3. Prepare the patient for surgery, as her condition is worsening.
  4. Explain to the patient that this could be a common, temporary problem.

Correct Answer: 4

Rationale 1: This action will be necessary but is not the most complete strategy.

Rationale 2: There is no indication that a radiologic evaluation is necessary.

Rationale 3: Surgery is not indicated at this point, as loss of sensation below the injury may occur.

Rationale 4: Spinal shock is a condition that affects almost half the people with acute spinal injury. It is characterized by a temporary loss of reflex function below the level of injury and includes the following symptomatology: flaccid paralysis of skeletal muscles, loss of sensation below the injury, and possibly bowel and bladder dysfunction and loss of ability to perspire below the injury level.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-3

 

Question 7

Type: SEQ

The nurse witnesses a motor vehicle accident (MVA) while off duty. Upon approaching the scene, the nurse observes a victim lying on the ground after being ejected from the vehicle. Beginning with the action the nurse must first take, place the actions in the correct order. All options must be used.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Check the victim’s breathing.

Choice 2. Check the victim’s pulse.

Choice 3. Check the victim’s airway.

Choice 4. Immobilize the victim’s spine.

Choice 5. Check for responsiveness.

Correct Answer: 5,4,3,1,2

Rationale 1: After immobilization, the nurse assesses the patient’s ABCs: airway, breathing, and circulation (pulse).

Rationale 2: After immobilization, the nurse assesses the patient’s ABCs: airway, breathing, and circulation (pulse).

Rationale 3: After immobilization, the nurse assesses the patient’s ABCs: airway, breathing, and circulation (pulse).

Rationale 4: The nurse immobilizes the spine using the jaw-thrust technique to prevent further injury to the spine.

Rationale 5: In an emergency situation, the nurse first assesses the patient’s level of consciousness during the primary survey of CPR.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-4

 

Question 8

Type: MCSA

The nurse is educating a patient and the family about different types of stabilization devices. Which statement by the patient indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-Wells tongs?

  1. “I will have less pain if I use the halo device.”
  2. “The halo device will allow me to get out of bed.”
  3. “I am less likely to get an infection with the halo device.”
  4. “The halo device does not have to stay in place as long.”

Correct Answer: 2

Rationale 1: The patient’s pain level is not affected by the type of stabilization device used.

Rationale 2: A halo device does not require weights as the tongs do, thereby allowing the patient to be mobile.

Rationale 3: The patient does not have a greater risk of infection with the Gardner-Wells tongs; both devices require pins inserted into the skull.

Rationale 4: The time required for stabilization is not dependent on the type of stabilization device used.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 24-4

 

Question 9

Type: MCSA

A patient with a spinal cord injury was given IV Decadron (dexamethasone) after arriving in the emergency department. The patient also has a history of hypoglycemia. During the hospital stay, the nurse would expect to see which response to this medication?

  1. Increased episodes of hypoglycemia
  2. Possible episodes of hyperglycemia
  3. No change in the patient’s glycemic parameters
  4. Both hyper- and hypoglycemic episodes

Correct Answer: 2

Rationale 1: Another side effect is more common than hypoglycemia.

Rationale 2: A common side effect of corticosteroids is hyperglycemia. Stress as well as the medication could cause periods of elevated blood sugars.

Rationale 3: Corticosteroids commonly have an effect on serum glucose.

Rationale 4: Corticosteroids do not both increase and decrease serum glucose.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 24-4

 

Question 10

Type: MCSA

Which nursing action is appropriate for turning a patient who sustained a spinal cord injury?

  1. This patient should not be turned.
  2. Place pillows under the patient’s side for support turning the turn.
  3. Have the patient grasp the side rail to turn.
  4. Logroll the patient.

Correct Answer: 4

Rationale 1: The patient must be turned in order to avoid skin breakdown.

Rationale 2: Pillows are soft and will not provide the needed support to prevent twisting the spine.

Rationale 3: Grasping the side rail will twist the spine, which must be avoided.

Rationale 4: Logrolling is part of standard spinal precautions.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-4

 

Question 11

Type: MCSA

Which patient is at highest risk for a spinal cord injury?

  1. 18-year-old male with a prior arrest for driving while intoxicated (DWI)
  2. 20-year-old female with a history of substance abuse
  3. 50-year-old female with osteoporosis
  4. 35-year-old male who coaches a soccer team

Correct Answer: 1

Rationale 1: The three major risk factors for spinal cord injuries (SCI) are age (young adults), gender (higher incidence in males), and alcohol or drug abuse.

Rationale 2: Females tend to engage in less risk-taking behavior than young men.

Rationale 3: This woman does not have a higher risk of spinal cord injury.

Rationale 4: This man is not at increased risk of spinal cord injury.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-1

 

Question 12

Type: MCSA

How should the nurse explain to a patient with a spinal cord injury why the extent of injury cannot be determined for several days to a week?

  1. “Tissue repair does not begin for 72 hours.”
  2. “We have to wait until spinal shock resolves.”
  3. “Neurons need time to regenerate, so it is hard to predict how you will progress.”
  4. “The most serious changes after an injury take days to develop.”

Correct Answer: 2

Rationale 1: The inability to determine the extent of injury is not related to delayed tissue repair.

Rationale 2: Spinal shock is a state of areflexia that occurs as a result of primary injury. It is not possible to determine the extent of injury until this condition abates.

Rationale 3: Neurons do not regenerate.

Rationale 4: Within 24 hours of the injury, necrosis of both gray and white matter begins if ischemia has been prolonged and the function of nerves passing through the injured area is lost.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-2

 

Question 13

Type: MCSA

A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly?

  1. Autonomic dysreflexia
  2. Autonomic crisis
  3. Autonomic shutdown
  4. Autonomic failure

Correct Answer: 1

Rationale 1: The nurse caring for spinal cord injury (SCI) patients should be attuned to the prevention of a distended bladder to prevent the chain of events that leads to autonomic dysreflexia.

Rationale 2: Autonomic crisis is not the term used to describe common complications of spinal injury associated with bladder distension.

Rationale 3: Autonomic shutdown is not the term used to describe common complications of spinal injury associated with bladder distension.

Rationale 4: Autonomic failure is not the term used to describe common complications of spinal injury associated with bladder distension.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-5

 

Question 14

Type: MCSA

The nurse suspects that a patient with spinal cord injury (SCI) is experiencing autonomic dysreflexia. The nurse elevates the head of the bed and removes the patient’s compression stockings while searching for the cause of this response. Performing these interventions helps to avoid which very dangerous complication of autonomic dysreflexia?

  1. Hypoxia
  2. Bradycardia
  3. Elevated blood pressure
  4. Tachycardia

Correct Answer: 3

Rationale 1: Hypoxia is not the most dangerous complication of autonomic dysreflexia.

Rationale 2: Bradycardia may occur but is not the most immediately dangerous complication.

Rationale 3: Autonomic dysreflexia is an emergency that requires immediate assessment and intervention to prevent complications of extremely high blood pressure. Additional nursing assistance will be needed and a colleague needs to reach the physician stat.

Rationale 4: Tachycardia is not the most common complication.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-5

 

Question 15

Type: MCSA

A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and the lower part of the body. The nurse should use which medical term to correctly describe this in documentation?

  1. Hemiplegia
  2. Paresthesia
  3. Paraplegia
  4. Tetraplegia

Correct Answer: 4

Rationale 1: Hemiplegia describes paralysis on one side of the body.

Rationale 2: Paresthesia does not involve paralysis.

Rationale 3: Paraplegia is paralysis of the lower body.

Rationale 4: Tetraplegia describes complete paralysis of the upper extremities and complete paralysis of the lower part of the body.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-1

 

Question 16

Type: MCSA

The patient is admitted with injuries that were sustained in a fall. During the nurse’s first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right side, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are most consistent with which condition?

  1. Paraplegia
  2. Neurogenic shock
  3. High cervical injury
  4. Temporary hypovolemia

Correct Answer: 2

Rationale 1: Paraplegia is paralysis of both lower extremities. This patient has paralysis on the right.

Rationale 2: Findings associated with neurogenic shock include hypotension, bradycardia, peripheral vasodilation, and decreased cardiac output.

Rationale 3: There is no mention of the lack of respiratory effort generally associated with high cervical injury.

Rationale 4: Because the patient is bradycardic, the cause of these findings is more likely to be neurogenic shock than hypovolemic shock.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-5

 

Question 17

Type: MCMA

A patient with a T5 spinal cord injury has manifestations of autonomic dysreflexia. Which assessments would indicate a possible cause for this condition?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Presence of a pressure ulcer
  2. Kinked urinary catheter tubing
  3. Respiratory congestion
  4. Diarrhea
  5. Fecal impaction

Correct Answer: 1,2,5

Rationale 1: The presence of noxious stimuli below the level of the SCI may result in autonomic dysreflexia. A pressure ulcer may cause this complication.

Rationale 2: Autonomic dysreflexia can be caused by kinked catheter tubing, which allows the bladder to become full and triggers massive vasoconstriction below the injury site, producing the manifestations of this process.

Rationale 3: The presence of noxious stimuli below the level of the injury triggers autonomic dysreflexia. Respiratory congestion is not likely to be the cause in this patient.

Rationale 4: Diarrhea is not a common trigger for this complication.

Rationale 5: Fecal impaction may provide the noxious stimulus that triggers autonomic dysreflexia.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-5

 

Question 18

Type: MCSA

The nurse is providing community education regarding spinal cord injuries to a group of young adults. Which information should the nurse include?

  1. “The most common cause of spinal cord injury in your age group is trauma from motor vehicle accidents or sports-related accidents.”
  2. “Spinal tumors are the most common cause of all injuries to the spinal cord and are not dependent on age.”
  3. “Young people have a poorer survival rate than do older people.”
  4. “Nontraumatic causes of spinal cord injury such as infection or inflammation are more common in younger people.”

Correct Answer: 1

Rationale 1: Young adults are most likely to suffer a SCI from trauma such as MVAs or sports-related accidents.

Rationale 2: Spinal tumors are not the cause of the majority of SCIs.

Rationale 3: Older patients with severe injury have the poorest survival rates.

Rationale 4: Nontraumatic causes are more common in those over age 40.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-1

 

Question 19

Type: MCMA

The school nurse is teaching a session on ways to prevent spinal cord injuries to a group of middle-school students. Which health promotion information should the nurse include?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Wear a helmet while riding a bicycle or motorcycle.
  2. Eat a well-balanced diet with sufficient calcium.
  3. Wear sunglasses.
  4. Do not dive into unfamiliar water.
  5. Do not ride in a car with someone who has been drinking.

Correct Answer: 1,4,5

Rationale 1: A key to reducing injuries is to protect the head and neck. Wearing a helmet for these activities helps provide that protection.

Rationale 2: Eating a well-balanced diet with sufficient calcium is good health information, but it is not specific to preventing spinal cord injury.

Rationale 3: Sunglasses protect the eyes but are not considered primary protection against injury to the spine.

Rationale 4: Diving into unfamiliar water or into familiar water that is at an unfamiliar level may result in cervical spine injury.

Rationale 5: The combination of friends and alcohol can reduce the driver’s judgment, causing a motor vehicle accident, which is a major cause of SCI.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-1

 

Question 20

Type: MCMA

The nursing assessment confirms that the patient has experienced loss of voluntary motor and sensory function of both upper and lower extremities, as well as bowel and bladder control, due to a spinal cord injury (SCI). The nurse recognizes that which is true regarding this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. This patient has experienced an incomplete spinal injury.
  2. The patient is likely to regain only limited motor control.
  3. All deep tendon reflexes are affected.
  4. The injury was likely a result of trauma to the C1 to C4 level of the spinal cord.
  5. Tetraplegia is the term for the patient’s neurological deficiencies.

Correct Answer: 3,4,5

Rationale 1: A complete spinal cord injury indicates complete loss of voluntary motor and sensory functions below the level of injury.

Rationale 2: The damage to the spinal cord in this type of injury is irreversible.

Rationale 3: The patient’s injuries would result in deep tendon reflex involvement.

Rationale 4: The injury was likely a result of trauma to the C1 to C4 level of the spinal cord. An injury at this level exhibits all the identified symptoms.

Rationale 5: Injuries involving the cervical spinal cord result in tetraplegia, or loss of motor and sensory function involving both upper extremities, both lower extremities, bowel, and bladder.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-2

 

Question 21

Type: MCMA

The nurse is caring for a patient who has been diagnosed with an incomplete spinal cord injury (SCI) that has resulted in central cord syndrome. The nurse expects which findings related to this injury?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. It is likely a result of a hyperextension injury to the cervical spine.
  2. Function, if restored, will occur first in the hands.
  3. Loss of function will be greatest in the lower extremities.
  4. Prognosis for recovery is poor.
  5. The patient may have preexisting degenerative bone changes.

Correct Answer: 1,5

Rationale 1: Central cord syndrome is usually caused by a hyperextension injury resulting in damage to the center of the spinal cord.

Rationale 2: The typical pattern of recovery from central cord syndrome is return of lower extremity function first, followed by return of bladder function. Hand intrinsic function is often the last to return.

Rationale 3: In central cord syndrome, there is greater loss of motor and sensory function in the upper extremities than in the lower extremities.

Rationale 4: The overall prognosis for recovery from central cord syndrome is generally favorable.

Rationale 5: Central cord syndrome is the most common incomplete SCI. This injury can occur at any age, but it is seen most frequently in older patients who have degenerative bony changes in the cervical spine resulting in narrowing of the overall diameter of the spinal canal.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-2

 

Question 22

Type: MCSA

A patient who has experienced an incomplete spinal cord injury (SCI) is most likely to experience which effects?

  1. Only a mild motor deficiency
  2. Restoration of sensory function first
  3. Some neurotransmission of impulses
  4. A good prognosis for recovery

Correct Answer: 3

Rationale 1: The extent of motor deficiency depends on which portions of the cord are undamaged.

Rationale 2: The degree and progression of sensory function return will depend on which sections of the cord are undamaged.

Rationale 3: Patients who have experienced an incomplete spinal cord injury will have some preservation of sensory and/or motor function below the level of injury. In these patients, there is sparing of some of the spinal cord tracts, which allows neurotransmission to occur.

Rationale 4: The extent of recovery depends on which sections of the cord are left undamaged.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-2

 

Question 23

Type: MCMA

A patient with an incomplete spinal cord injury is being transferred from intensive care to the neurological trauma unit. The nurse realizes that in order to minimize the patient’s risk of developing autonomic hyperreflexia, which interventions should be included in the patient’s care plan?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Monitoring skin temperature in lower extremities
  2. Assessing for abdominal distention
  3. Bladder scan postvoiding
  4. Assessing pulse oximetry levels with vital signs
  5. Strict output monitoring

Correct Answer: 2,3,5

Rationale 1: Monitoring lower-extremity skin temperature is appropriate for detecting deep vein thrombosis.

Rationale 2: Causes of autonomic hyperreflexia are impacted stool or constipation, so assessing for abdominal distention is appropriate.

Rationale 3: The nurse caring for spinal cord injury (SCI) patients should be attuned to the prevention of a distended bladder to prevent the chain of events that leads to autonomic hyperreflexia. Scanning the bladder postvoiding can detect residual urine retention.

Rationale 4: Pulse oximetry is effective in monitoring for a decline in oxygen saturation and may be the initial indicator of a pulmonary embolus.

Rationale 5: Tracking urinary output carefully can help detect residual urine retention.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-5

 

Question 24

Type: MCSA

A patient is admitted after a fall that has resulted in spinal shock. When asked by the family how long the paralysis is likely to last, the nurse’s response is based on which understanding?

  1. Spinal shock usually results in temporary paralysis.
  2. There will likely be some minor improvement in the degree of paralysis.
  3. Spinal shock is irreversible and the paralysis is likely to be permanent.
  4. The severity of the injuries cannot be determined until the spinal shock resolves.

Correct Answer: 4

Rationale 1: At this point it is not possible to determine whether the paralysis is temporary or permanent or will lessen.

Rationale 2: There is no assurance that the paralysis will lessen.

Rationale 3: The duration of spinal shock is quite variable, lasting as little as a few hours or as long as several weeks after injury. During this period, it is impossible to determine the extent of the SCI.

Rationale 4: Spinal shock is a state of areflexia in which there is a loss of all motor, sensory, and reflex activity at the level of the injury and below. It is not possible to determine the severity of the injury until spinal shock has abated.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24-3

 

Question 25

Type: MCSA

A patient with a recent spinal cord injury is at risk for complications to the gastrointestinal system. Which nursing intervention is primarily directed at minimizing this risk?

  1. Insertion of a nasogastric tube
  2. Regular assessment of the patient’s bowel sounds
  3. Administration of a lansoprazole (Prevacid)
  4. Elevating the end of the bed to 35 degrees

Correct Answer: 1

Rationale 1: The gastrointestinal effects of spinal shock include gastroparesis, loss of intestinal peristalsis, and ileus. Placement of a nasogastric or oral gastric tube will be necessary in the acute phase of SCI for decompression of the stomach.

Rationale 2: Regular assessment of bowel sounds will help determine the presence or absence of peristalsis, but it is not effective in reducing risk.

Rationale 3: Prevacid is a proton pump inhibitor that is used in the treatment of GERD.

Rationale 4: Elevating the head of the bed will have little effect on the gastrointestinal system and may be contraindicated for other reasons.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24-4

 

Question 26

Type: MCMA

The nurse has assessed a patient who was admitted for rehabilitation after a fall that resulted in hemiplegia. The patient’s care plan may require nursing diagnoses related to which concerns?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Sensory perception
  2. Body image
  3. Cognitive abilities
  4. Role performance
  5. Independence

Correct Answer: 1,2,4,5

Rationale 1: The patient will experience changes in sensory perception that should be addressed in the care plan.

Rationale 2: Patients who have experienced an SCI experience significant psychosocial impact. These patients are faced with changes related to change of body image.

Rationale 3: Injuries resulting in hemiplegia are not likely to change a patient’s cognitive abilities for the long term unless other serious complications also occurred.

Rationale 4: Patients who have experienced an SCI experience significant psychosocial impact. These patients are faced with changes related to previous personal and interpersonal roles.

Rationale 5: Patients who have experienced an SCI experience significant psychosocial impact. These patients are faced with changes related to loss of independence.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 24-6

 

Question 27

Type: MCSA

The nurse is preparing to discuss discharge planning with a patient who is hemiplegic as a result of a diving accident and with the patient’s wife, who will be his primary caregiver. Which statement by the nurse would specifically address the needs of the caregiving wife?

  1. “We will begin bowel and bladder training in 2 weeks.”
  2. “You will experience some role changes in your relationship.”
  3. “The vocational rehabilitation company will contact you next week to set up your schedule.”
  4. “You should plan respite time away from your husband every week.”

Correct Answer: 4

Rationale 1: Bowel and bladder training is very important and will be a significant change for both the patient and the wife, but this is not the most important option statement.

Rationale 2: These role changes have already begun, so this is not the best option.

Rationale 3: All of the rehab visits, home health nurse visits, physician office visits, etc. are very important, but this is not the most important option provided.

Rationale 4: This wife is at high risk for caregiver role strain. Respite is essential. It is important for the nurse to make this statement so both the husband and wife recognize its importance.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-6

 

Question 28

Type: MCSA

A female patient who sustained a spinal cord injury resulting in paraplegia asks the nurse if she will ever be able to have children. How should the nurse respond?

  1. “You should consider adoption if you want to have a family.”
  2. “Sexual intercourse will not be pleasurable for you any longer.”
  3. “Your rehabilitation specialist will talk to you about this concern.”
  4. “It is possible for some women with spinal cord injuries to become pregnant and bear children.”

Correct Answer: 4

Rationale 1: It is premature for the nurse to suggest adoption.

Rationale 2: The patient has asked about having children, not about sexual intercourse.

Rationale 3: Return to sexual activity is discussed in rehabilitation education, but the patient is asking questions now. The nurse should be prepared to address this concern.

Rationale 4: The nurse should provide valid information without promising that this particular patient will be able to bear children.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-6

 

Question 29

Type: MCMA

The nurse recognizes that the rehabilitation goal for a patient who has experienced a spinal cord injury (SCI) is to assist the patient in which activities?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Adapting to the realization of the patient’s limitations
  2. Providing the emotional support required for this adjustment
  3. Reaching the patient’s highest potential for independence
  4. Managing the physical pain such injuries cause
  5. Assimilating back into the patient’s home environment

Correct Answer: 1,3,5

Rationale 1: Rehabilitation for patients with SCI consists of a comprehensive program designed to help them adapt to the limitations imposed by their injury.

Rationale 2: Providing emotional support is not a goal for rehabilitation but a means for assisting the patient to achieve goals.

Rationale 3: Rehabilitation for patients with SCI consists of a comprehensive program designed to help them reach the highest level of independence possible.

Rationale 4: Managing pain is a way to help the patient meet the goals of rehabilitation. The goal statement would be to reach the desired level of pain control.

Rationale 5: Rehabilitation for patients with SCI consists of a comprehensive program designed to help them reintegrate into the home environment and community.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24-6

 

Question 30

Type: MCSA

The nurse is assessing the psychosocial status of a patient who experienced a spinal cord injury. What would provide the best subjective evidence of the patient’s state of mind?

  1. The nurse asks the patient to identify members of his support system.
  2. The patient says, “I would enjoy some fast food for lunch.”
  3. The nurse enters the room and finds the patient crying.
  4. The patient tells the nurse he was once treated for depression.

Correct Answer: 1

Rationale 1: Assessment of a patient’s psychosocial state is best achieved by assessing the patient’s own perception of the presence of a support system.

Rationale 2: It is possible that asking for food that the patient would “enjoy” reflects a positive psychosocial state. However, there could be many reasons for this statement. It is not the best subjective assessment.

Rationale 3: Crying is an objective sign.

Rationale 4: A history of depression is not necessarily proof of current depression.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-3

 

Question 31

Type: MCMA

A patient with a spinal cord injury (SCI) has a nursing diagnosis of Risk for Ineffective Tissue Perfusion related to the effects of neurogenic shock. The nurse includes which intervention in the patient’s plan of care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Fit the patient for an abdominal binder and thigh-length compression stockings.
  2. Monitor administration of atropine and other vasoactive agents as ordered or by protocol.
  3. Administer anticoagulant medication as ordered.
  4. Measure and record the diameter of the calf every shift.
  5. Measure and record intake and output.

Correct Answer: 1,2,5

Rationale 1: Use of an abdominal binder and thigh-high compression stockings will help venous blood return and minimize blood pooling in the abdomen and lower extremities.

Rationale 2: Vasoactive agents will support blood pressure and heart rate, thereby having a positive effect on cardiac output.

Rationale 3: Anticoagulant medications will not reverse the cardiovascular effects of neurogenic shock.

Rationale 4: Measuring the diameter of the calves is an intervention associated with treatment of deep vein thrombosis.

Rationale 5: Measuring and recording intake and output will help assess fluid volume status. Dehydration reduces tissue perfusion.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24-4

 

Question 32

Type: MCMA

Risk for Constipation related to impaired gastric motility is added to the nursing care plan of a patient with a new spinal cord injury (SCI). The nurse would plan which interventions to address this diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Check each stool for occult blood.
  2. Administer stool softener as prescribed.
  3. Institute chemical stimulation to initiate bowel evacuation.
  4. Place the patient in an adult incontinence garment.
  5. Manage parenteral feedings as ordered.

Correct Answer: 2,3,5

Rationale 1: Testing stool for occult blood is directed toward monitoring for a bleeding gastric ulcer. This patient has a potential for gastric ulceration related to the stress of this critical injury.

Rationale 2: To minimize the risk of constipation in a patient with SCI, the nurse should institute a bowel regimen of stool softener to help establish a regular bowel elimination pattern.

Rationale 3: To minimize the risk of constipation in a patient with SCI, the nurse should institute a bowel regimen of chemical stimulation such as a suppository to establish a regular bowel elimination pattern. The patient’s bowel elimination pattern should be monitored closely to ensure adequate bowel evacuation.

Rationale 4: There is no indication that an incontinence garment is necessary.

Rationale 5: Early nutritional support is often achieved through parenteral feedings until enteral feedings are introduced and tolerated.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24-4

 

Question 33

Type: MCSA

A patient was admitted after falling from the roof of a one-story building. Assessment reveals presence of a patellar reflex, but loss of sensation in part of both feet. The nurse would plan for which level of bowel and bladder function?

  1. Bladder function only
  2. Bowel function only
  3. Intact bladder and bowel function
  4. Loss of both bladder and bowel function

Correct Answer: 4

Rationale 1: This assessment indicates a lesion around L3 or L4. Bladder continence would be lost.

Rationale 2: This assessment indicates a lesion around L3 or L4. Bowel continence would be lost.

Rationale 3: This assessment indicates a lesion around L3 or L4. Bladder and bowel continence would be lost.

Rationale 4: This assessment indicates a lesion around L3 or L4. Bladder and bowel continence would be lost.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24-5

 

Question 34

Type: MCSA

A patient sustained a C4 fracture in a diving accident. The patient’s wife says, “I’ll be so glad when he gets off the ventilator so that he can communicate with me.” How should the nurse respond to this statement?

  1. “It may be a few weeks before he is strong enough to breathe on his own.”
  2. “We don’t know if he will be able to talk when we get him off the ventilator.”
  3. “There are ways we can teach both of you to communicate that will not require his being off the ventilator.”
  4. “We need to focus on his getting better, not on how he will communicate.”

Correct Answer: 3

Rationale 1: Injuries at C4 or higher cause paralysis of the diaphragm. Mechanical ventilation is likely to be necessary for the rest of the patient’s life.

Rationale 2: This patient’s injury will probably necessitate mechanical ventilation for life.

Rationale 3: The patient will likely be on the ventilator for the rest of his life. There are communication methods that can be used while the patient is still on the ventilator.

Rationale 4: The wife needs to be given realistic hope for a way to communicate with her husband. This statement is not therapeutic.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-3

 

Question 35

Type: MCSA

Prehospital emergency personnel have placed a patient in a head brace and on a backboard after a motor vehicle accident. The nurse would advocate for the patient to be removed from this immobilization at what time?

  1. As soon as the patient arrives in the emergency department
  2. As soon as assessment is completed and a treatment plan is established
  3. As soon as a cross-table lateral cervical spine X-ray is taken
  4. As soon as the patient is admitted to the neurological intensive care unit

Correct Answer: 2

Rationale 1: The patient should remain immobilized until some assessment is performed.

Rationale 2: The patient should remain immobilized until initial assessment is completed and evaluated and a treatment plan has been established.

Rationale 3: The patient should remain immobilized until evaluation is complete.

Rationale 4: The time for discontinuing immobilization is related to the patient’s condition, not to where the patient is located in the hospital.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-2

Osborn, Medical-Surgical Nursing, 2e
Chapter 36

Question 1

Type: MCSA

Which question would the nurse ask to most effectively assess the patient’s pattern of elimination?

  1. “Are you having any bowel problems?”
  2. “Have you had any recent difficulties with your stools?”
  3. “Tell me about your usual bowel habits.”
  4. “Are your bowel movements normal?”

Correct Answer: 3

Rationale 1: Open-ended questions elicit the greatest amount of information. Questions that allow the patient to respond with a yes or no can limit communication and data gathering.

Rationale 2: Open-ended questions elicit the greatest amount of information. Questions that allow the patient to respond with a yes or no can limit communication and data gathering.

Rationale 3: Open-ended questions elicit the greatest amount of information.

Rationale 4: Open-ended questions elicit the greatest amount of information. Questions that allow the patient to respond with a yes or no can limit communication and data gathering.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-2

 

Question 2

Type: SEQ

Arrange the four parts of abdominal assessment in the order the nurse should follow.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Percussion

Choice 2. Inspection

Choice 3. Palpation

Choice 4. Auscultation

Correct Answer: 2,4,1,3

Rationale 1: Percussion in each quadrant is the third step in the assessment sequence.

Rationale 2: First, the nurse should look at the abdomen for symmetry, contour, and general appearance.

Rationale 3: Palpation is the final step. It may cause discomfort and should be performed last.

Rationale 4: Second, the abdomen should be assessed for the presence of bowel sounds (auscultation).

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-3

 

Question 3

Type: MCSA

During an assessment of a patient’s abdomen, frequent pulsations are noted in the epigastric region. What action by the nurse is indicated?

  1. Document the findings as hyperactive bowel sounds.
  2. Review the patient’s medical records for signs and symptoms of cirrhosis, which may indicate ascites.
  3. Note the time when the patient last voided.
  4. Auscultate for a bruit.

Correct Answer: 4

Rationale 1: Bowel sounds are audible, not visible.

Rationale 2: Ascites is the collection of fluid.

Rationale 3: Bladder distention is not manifested as a pulsation. Bladder distention can be detected by palpation.

Rationale 4: The nurse should carefully listen over this area for a bruit that can be associated with aortic aneurysm.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-4

 

Question 4

Type: MCSA

The nurse evaluates which patient observation as indicating the patient correctly understands the functions of the stomach?

  1. “The process of absorption of nutrients begins in my stomach.”
  2. “My stomach turns food into liquid so it can be digested.”
  3. “My stomach begins the digestion of carbohydrates.”
  4. “Sulfuric acid is secreted by the stomach.”

Correct Answer: 2

Rationale 1: The process of absorption begins in the small intestine.

Rationale 2: In the stomach, food continues to be turned to liquid so that it may ultimately be absorbed into the bloodstream.

Rationale 3: Carbohydrate digestion begins in the mouth.

Rationale 4: The stomach secretes hydrochloride, not sulfuric acid.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 36-1

 

Question 5

Type: MCSA

A nurse preceptor is reviewing the skill of percussing a patient’s abdomen with a newly licensed nurse. The preceptor will intervene when the nurse makes which statement?

  1. “I will percuss the abdomen using a systematic path.”
  2. “I anticipate hearing tympany over stool-filled intestines.”
  3. “Dullness is the expected percussion over the liver.”
  4. “Percussion is a useful tool for assessing the spleen, kidneys, and liver.”

Correct Answer: 2

Rationale 1: The nurse should establish a system of assessment.

Rationale 2: Tympany is heard over air-filled organs such as gas-filled intestines. Intestines that are stool-filled, such as in a patient with an ileus or constipation, present dull sounds.

Rationale 3: The liver gives off a dull sound.

Rationale 4: The nurse would percuss over the spleen, kidneys, and liver.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 36-3

 

Question 6

Type: MCSA

When assessing a patient who is scheduled to have a CT scan of the kidneys, which finding would prompt the nurse to notify the primary health care provider?

  1. Allergy to iodine and seafood
  2. Urinary output of 1,200 mL in 24 hours
  3. Last bowel movement one day ago
  4. Height 5’8” and weight 160 pounds

Correct Answer: 1

Rationale 1: A CT scan of the kidneys requires the injection of a radiopaque dye that contains iodine.

Rationale 2: This is a normal finding and does not require that the physician be notified.

Rationale 3: This is a normal finding and does not require that the physician be notified.

Rationale 4: These are normal findings and do not require that the physician be notified.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-5

 

Question 7

Type: MCSA

The nurse is assessing a 68-year-old female patient who states, “I am having episodes of urinary incontinence.” The nurse should recognize that this statement indicates which situation?

  1. An abnormal finding requiring further testing
  2. The presence of a urinary infection
  3. A normal outcome of the aging process
  4. The result of having several children

Correct Answer: 1

Rationale 1: Incontinence is not a normal part of the aging process and will require further investigation to identify the cause.

Rationale 2: Although frequency and urgency can be symptoms of a urinary tract infection, a culture and sensitivity test is necessary to determine the presence of infection.

Rationale 3: Incontinence is not normal.

Rationale 4: Incontinence is not normal and is not necessarily the result of having had several children.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-2

 

Question 8

Type: MCSA

The nurse is teaching a patient who has a diagnosis of a kidney stone in the left ureter. The nurse knows the patient understands the instruction when the patient makes which statement?

  1. “My kidney stone is in the tube that empties my bladder.”
  2. “The stone in my kidney is causing my pain.”
  3. “If my kidney stone keeps moving down the ureter, it will eventually move into my bladder.”
  4. “The kidney contracts and pushes the stone down my ureter.”

Correct Answer: 3

Rationale 1: The patient’s statement identifies the urethra, not the ureter.

Rationale 2: The stone is not in the patient’s kidney.

Rationale 3: The ureter connects to the bladder, so if the stone continues to move, it will eventually fall into the bladder.

Rationale 4: The ureter itself is muscular and produces peristaltic waves that propel the stone along its length. The kidney does not contract.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 36-1

 

Question 9

Type: MCSA

Which assessment finding alerts the nurse to the likelihood that the patient has a distended bladder?

  1. Percussion in the middle of the lower abdomen elicits a dull sound.
  2. The patient states, “My back is killing me.”
  3. Percussion over the costovertebral angle produces pain.
  4. The patient complains of colicky pain in the side.

Correct Answer: 1

Rationale 1: Percussion over a full bladder produces a dull percussion sound.

Rationale 2: Kidney pain is experienced in the back and the costovertebral angle (the angle between the lower ribs and adjacent vertebrae) and may spread toward the umbilicus. Discomfort from a distended bladder would more likely be felt elsewhere.

Rationale 3: Pain elicited by percussion over the costovertebral angle is likely due to kidney damage or infection.

Rationale 4: Colicky pain may be due to a kidney stone.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-2

 

Question 10

Type: MCSA

A newly licensed nurse is assessing a patient who reports constant dull pain over the lower abdomen. The nurse inspects, percusses, palpates, and auscultates the patient’s abdomen. After leaving the patient’s room, the preceptor says, “Your assessment findings may not be accurate.” What is the rationale for the preceptor’s statement?

  1. The nurse palpated prior to auscultating.
  2. The nurse inspected prior to palpating.
  3. The nurse inspected prior to auscultating.
  4. The nurse percusses before palpating.

Correct Answer: 1

Rationale 1: Auscultation should follow immediately after inspection because percussion or palpation may increase bowel motility and interfere with sound transmission during auscultation.

Rationale 2: Inspection is performed prior to palpating.

Rationale 3: Inspection is performed prior to auscultation.

Rationale 4: Percussion is performed before palpation.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-3

 

Question 11

Type: MCMA

The nurse is caring for an adolescent who experienced trauma to the spleen that requires its removal. When discussing the proposed surgery with the patient’s parents, the nurse would provide which information?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. The spleen is located in the left upper abdominal quadrant.
  2. The spleen is involved in the return of bile to the liver.
  3. The spleen has a minimal vascular system.
  4. The spleen acts as a blood filtration system.
  5. The spleen destroys aged red blood cells.

Correct Answer: 1,4,5

Rationale 1: The spleen can be found in the left upper quadrant of the abdomen.

Rationale 2: A primary purpose of the spleen is to filter blood, destroy aged red blood cells, and return their by-products, particularly bilirubin, to the liver.

Rationale 3: Because of its extensive vascular nature, trauma to the spleen can be life- threatening.

Rationale 4: A primary purpose of the spleen is to filter blood.

Rationale 5: A primary purpose of the spleen is to destroy aged red blood cells.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-1

 

Question 12

Type: MCSA

An older adult patient states, “My mouth is always dry.” The nurse recognizes that which priority health promotion problem should be addressed?

  1. Poorly chewed food will remain in the patient’s mouth, supporting bacterial growth.
  2. The normal aging process reduces the antibacterial properties of saliva.
  3. A lack of salivary gland lubrication makes chewing the food difficult, resulting in gum trauma.
  4. A dry mouth lacks bacteria-fighting immunoglobulin A.

Correct Answer: 4

Rationale 1: While poorly chewed food that remains in the oral cavity does support bacterial growth and a lack of oral lubrication may make chewing food more difficult, they are not the primary risk factors in this scenario.

Rationale 2: Normal aging does not appear to have an effect on the antibacterial properties of saliva.

Rationale 3: There is no indication of gum trauma.

Rationale 4: Saliva contains large amounts of ions, such as immunoglobulin A, a vital component for destroying oral bacteria. A lack of saliva increases the risk of infection from oral pathogens.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-1

 

Question 13

Type: MCSA

The patient reports feeling pain in the right lower quadrant. The nurse shows an understanding of the anatomical location of organs in the abdomen by asking the patient which question?

  1. “Do you have any problems eating fatty foods?”
  2. “Can you tell me about your bowel habits?”
  3. “When you eat, do you experience any nausea?”
  4. “Do you get clammy when you miss a meal?”

Correct Answer: 2

Rationale 1: Problems eating fatty food would relate to the gallbladder, which is located in the right upper quadrant.

Rationale 2: The right lower quadrant contains the ascending colon. Discussing bowel habits is indicated.

Rationale 3: Nausea after eating is not a primary assessment finding associated with the bowels located in the right lower quadrant.

Rationale 4: Clamminess after missing a meal could be related to blood glucose abnormalities, which are associated with the pancreas. The pancreas is located in the left upper quadrant.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-1

 

Question 14

Type: MCSA

The nurse is preparing to assess a patient who reports abdominal pain as 6 on a scale of 0 to 10. To best facilitate the abdominal assessment, what nursing action is indicated?

  1. First medicate the patient for the pain.
  2. Palpate the patient’s abdomen last.
  3. Assist the patient into the knees-bent supine position.
  4. Encourage the patient to take slow, deep breaths.

Correct Answer: 3

Rationale 1: Medication for pain may not be prescribed if the cause of the pain is still undetermined.

Rationale 2: Palpation of the abdomen may cause pain and should be performed last, but the patient is already experiencing pain, so palpation will not have as much impact on the assessment as will another action.

Rationale 3: The nurse should work with the patient in establishing a comfortable position. This will make the examination more productive and help the patient to be cooperative during the procedure. The knees-bent supine position is often more comfortable than lying flat on the back.

Rationale 4: Slow, deep breathing may help the patient manage the pain, but it would not have the same impact on the assessment as another action.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 36-3

 

Question 15

Type: MCMA

The nurse is initiating a history and physical assessment on a patient who reports intermittent right-sided abdomen pain, especially after eating fatty foods. How should the nurse conduct the history?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Encourage the patient to express his or her concerns.
  2. Include documentation of the patient’s own words.
  3. Direct questions toward ruling out a gallbladder problem
  4. Use direct questioning so the interview remains nurse-driven.
  5. Establish the nurse–patient relationship.

Correct Answer: 1,2,5

Rationale 1: It is important to allow the patient to express concerns and explain the problem in his or her own words during the history interview.

Rationale 2: Direct patient quotes should be documented as a part of the interview process.

Rationale 3: The nurse should keep an open mind, because sometimes information that is initially thought of as trivial can be the answer to the problem.

Rationale 4: It is important to allow the patient to direct the history interview by expressing concerns and explaining the problem in his or her own words. Interruptions should be kept to a minimum, but clarifying questions should be asked.

Rationale 5: Taking a history is a very important encounter with a patient. This is when the relationship with a patient begins.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-2

 

Question 16

Type: MCMA

A patient is reporting intermittent pain in the left upper abdomen. To best assess the characteristics of the pain, the nurse would ask which questions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. “Can you describe the pain for me?”
  2. “What do you think is causing the pain?”
  3. “When did you first notice the pain?”
  4. “Can you do anything that makes the pain go away?”
  5. “Does anything make the pain worse?”

Correct Answer: 1,3,4,5

Rationale 1: An interview regarding the characteristics of pain should include questions directed toward a description of how it feels.

Rationale 2: While asking the patient’s opinion as to the cause of the pain is appropriate, it does not contribute to the understanding of the characteristics of the pain itself.

Rationale 3: An interview regarding the characteristics of pain should include questions directed toward the onset and duration of the pain.

Rationale 4: Actions that affect the pain (increase, decrease, or eliminate) are important to the interview.

Rationale 5: Actions that affect the pain (increase, decrease, or eliminate) are important to the interview.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-2

 

Question 17

Type: MCSA

When assessing a patient’s abdomen, the nurse recognizes the importance of reserving palpation as the last technique. What rationale would the nurse provide for this sequence?

  1. Early palpation may result in rebound pain.
  2. The technique is likely to increase the patient’s level of anxiety.
  3. Most patients do not like being touched.
  4. The pressure of palpation can interfere with hearing bowel sounds.

Correct Answer: 4

Rationale 1: The technique does not cause rebound pain, although it can cause general pain in the abdomen.

Rationale 2: Palpation itself does not generally contribute to a patient’s anxiety.

Rationale 3: While some patients may be uncomfortable with being touched, that is not the reason for delaying the technique until last.

Rationale 4: Palpation is performed last in the assessment sequence because pressure on the abdominal wall and contents may interfere with bowel sounds and cause pain.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 36-3

 

Question 18

Type: MCSA

The nurse is percussing a patient’s kidneys as part of the physical assessment. Which nursing action displays a need for further instruction regarding this assessment technique?

  1. The nurse focuses the examination at the patient’s costal vertebral angles.
  2. The nurse asks the patient to sit on the side of the examination table.
  3. The nurse gently strikes the patient with the palmar surface of the hand.
  4. The nurse applies the technique to either side of the spine between the last rib and the lumbar vertebrae.

Correct Answer: 3

Rationale 1: Percussion should take place at the costal vertebral angle.

Rationale 2: The patient must be lying on one side or be in a sitting position.

Rationale 3: The nurse should make a fist and gently strike the patient with the ulnar surface of the fist.

Rationale 4: The nurse should gently strike in the costal vertebral angle on either side of the vertebral column between the last rib and the lumbar vertebrae.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-2

 

Question 19

Type: MCSA

When percussing a patient’s abdomen to gather assessment data, the nurse must rely most heavily on which ability?

  1. Locating the margins of the various abdominal organs
  2. Differentiating the various elicited sounds
  3. Supplementing the technique with fine finger dexterity
  4. Observing subtle variations in the contour of the abdomen

Correct Answer: 2

Rationale 1: Locating the margins of organs is not the most important ability in percussion.

Rationale 2: Percussing the abdomen elicits different sounds. The nurse should be able to hear the difference between the sounds.

Rationale 3: Fine finger dexterity is not necessary for adequate percussion.

Rationale 4: Visual observation is not an essential component of percussion.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-3

 

Question 20

Type: MCSA

It is thought that a patient may be experiencing pancreatitis. Which nursing action would be useful in helping diagnose this disorder?

  1. The patient bends the right knee and flexes the right hip, while the nurse flexes the thigh to a right angle and externally and internally rotates the leg.
  2. The nurse inquires with radiology when an endoscopy can be scheduled for the patient.
  3. The nurse anticipates that the patient’s health care provider will order a barium enema.
  4. Placing the hand on the lateral surface of the patient’s flexed right thigh, the nurse asks the patient to push against the applied resistance.

Correct Answer: 4

Rationale 1: The obturator sign (painful external and internal rotation of a flexed hip and thigh) is positive in patients with inflammation along the obturator internus muscle. It is not a test for pancreatitis.

Rationale 2: Endoscopy allows the clinician to visualize the intraluminal space of the upper GI tract.

Rationale 3: A barium enema would enhance intraluminal processes such as colon cancer or diverticular disease.

Rationale 4: This option describes the iliopsoas sign test. A positive test (produces pain) indicates an inflammation of the iliopsoas muscle group. When there is intra-abdominal inflammation or disease of the pancreas or other structures, movement of the iliopsoas causes pain.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-4

 

Question 21

Type: MCSA

The nurse assesses for a positive Murphy’s sign in a patient suspected of having which disorder?

  1. Urinary retention
  2. Diverticulitis
  3. Cholecystitis
  4. Renal calculi

Correct Answer: 3

Rationale 1: A positive Murphy’s sign is not associated with urinary retention.

Rationale 2: A positive Murphy’s sign is not associated with diverticulitis.

Rationale 3: Murphy’s sign is positive when a person has inflammation of the gallbladder, as seen in cholecystitis.

Rationale 4: A positive Murphy’s sign is not associated with renal calculi.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-4

 

Question 22

Type: MCMA

Which data would the nurse document regarding a patient’s complaint of abdominal pain?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. The patient fears losing her job if pain causes another absence.
  2. The patient describes the pain as sharp and stabbing.
  3. Walking exacerbates the pain.
  4. Belching has lessened the pain.
  5. The pain began 24 hours ago.

Correct Answer: 2,3,4,5

Rationale 1: While the patient is expressing a fear, it does not relate to the cause of the pain itself but rather a possible outcome of the pain.

Rationale 2: A description of the problem (what is wrong) helps define the chief complaint.

Rationale 3: The exacerbation of symptoms helps define the chief complaint.

Rationale 4: The diminishment of symptoms helps define the chief complaint.

Rationale 5: The duration of the problem helps define the chief complaint.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-4

 

Question 23

Type: MCSA

The nurse recognizes that a patient diagnosed with poorly controlled type 2 diabetes is at risk for developing which gastrointestinal complication?

  1. Paralytic ileus
  2. Peptic ulcer
  3. Gastroparesis
  4. Gastric reflux disease

Correct Answer: 3

Rationale 1: Paralytic ileus does not appear to have a direct connection to diabetes.

Rationale 2: Peptic ulcer does not appear to have a direct connection to diabetes.

Rationale 3: A person whose diabetes is poorly controlled may develop gastroparesis, a slowing in the emptying of the stomach due to the diabetes.

Rationale 4: Gastric reflux disease does not appear to have a direct connection to diabetes.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-4

 

Question 24

Type: MCMA

The nurse includes which data when documenting a patient’s biographic and demographic information?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. The patient has a high school diploma.
  2. The patient drinks two to three beers per day.
  3. The patient is male.
  4. The patient lives on a farm in a rural area.
  5. The patient is 24 years old.

Correct Answer: 1,3,4,5

Rationale 1: Biographical data should include educational background.

Rationale 2: Alcohol consumption would be a part of the medical history.

Rationale 3: Biographical data should include gender.

Rationale 4: Demographic data such as whether the patient lives in an urban, rural, or suburban setting is appropriate.

Rationale 5: Biographical data should include age.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-2

 

Question 25

Type: MCMA

A patient is hospitalized with possible pancreatitis. The nurse would evaluate which laboratory test results as supporting that diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Increased serum amylase
  2. Increased serum lipase
  3. Decreased serum indirect bilirubin
  4. Increased blood urea nitrogen
  5. Increased partial thromboplastin time (PTT)

Correct Answer: 1,2

Rationale 1: Serum amylase increases may indicate pancreatitis.

Rationale 2: An increase in serum lipase is characteristic of pancreatitis.

Rationale 3: Indirect bilirubin increases with liver injury.

Rationale 4: BUN increases with renal disorders or dehydration.

Rationale 5: PTT increases with severe liver dysfunction or heparin therapy.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 36-5

 

Question 26

Type: MCMA

The nurse would recommend avoiding ginger as complimentary therapy for gastrointestinal distress in which individuals?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. A patient with peptic ulcer disease
  2. Persons younger than 30 years of age
  3. Persons taking anticoagulants for atrial fibrillation
  4. Women
  5. Patients with documented sun sensitivity

Correct Answer: 1,3

Rationale 1: Ginger can cause increased bleeding, which should be avoided in those with peptic ulcer disease.

Rationale 2: There is no age-related contraindication for ginger.

Rationale 3: Ginger can increase bleeding tendencies and should not be added to the regimen of a patient already taking anticoagulants.

Rationale 4: There is no gender-related contraindication for use of ginger.

Rationale 5: There is no relationship between ginger and sun sensitivity.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-2

 

Question 27

Type: MCSA

A patient reports epigastric pain that occurs after meals and often awakens the patient at night. The nurse would ask additional assessment questions about which disorder?

  1. Urinary tract infection
  2. Duodenal ulcer
  3. Gastric ulcer
  4. Intussusception

Correct Answer: 2

Rationale 1: Epigastric pain would not be a common assessment finding in urinary tract infection.

Rationale 2: Pain from a duodenal ulcer often is postprandial and awakens the patient at night.

Rationale 3: Pain from a gastric ulcer is often precipitated by food.

Rationale 4: Intussusception is a disorder of infants and is not seen in adults.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-4

 

Question 28

Type: MCMA

The preceptor would intervene if the newly licensed nurse planned to test for the iliopsoas sign in which patients?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. A patient immobilized after sustaining a neck injury
  2. A 70-year-old patient hospitalized with abdominal pain
  3. A patient who had hip-replacement surgery 6 years ago
  4. A patient with suspected inflammation of the cecum
  5. A patient who may have appendicitis

Correct Answer: 1,2,3

Rationale 1: The iliopsoas sign test should not be performed on an immobilized patient.

Rationale 2: The iliopsoas sign test should be performed only with great caution in older adults.

Rationale 3: Patients with hip replacements should not have the iliopsoas sign test.

Rationale 4: The iliopsoas sign test is useful in the assessment of a patient with suspected inflammation of the cecum.

Rationale 5: The iliopsoas sign test is useful in the assessment of a patient with suspected appendicitis.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-2

 

Question 29

Type: MCMA

Which techniques would the nurse use to elicit rebound tenderness in a patient’s abdomen?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Start in an area away from the painful area.
  2. Start with deep palpation.
  3. Release pressure on the abdomen quickly.
  4. Stop the assessment as soon as rebound tenderness is elicited.
  5. Start the assessment by gently stroking the painful area of the abdomen.

Correct Answer: 1,3,4

Rationale 1: The nurse should begin this testing in an area distant from the area reported to be painful.

Rationale 2: The nurse should start with light palpation.

Rationale 3: The nurse should release pressure quickly enough so that the underlying tissue “rebounds” against the abdominal wall, causing pain.

Rationale 4: Once the tenderness is noted, there is no reason to keep making the patient uncomfortable.

Rationale 5: The nurse should avoid touching the painful area until the test is in progress.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-2

 

Question 30

Type: MCSA

A patient is having diagnostic testing done after experiencing new-onset abdominal pain. Laboratory results reveal that the serum creatinine is elevated. The nurse would look for additional assessment findings of which disorder?

  1. Appendicitis
  2. Renal failure
  3. GERD
  4. Constipation

Correct Answer: 2

Rationale 1: Increased creatinine is not associated with appendicitis.

Rationale 2: Increased serum creatinine indicates renal failure.

Rationale 3: Increased creatinine is not associated with GERD.

Rationale 4: Increased creatinine is not associated with constipation.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-5

Osborn,_2e
Chapter 66

Question 1

Type: MCSA

The prehospital nurse is screening several people injured in a store robbery. Of those injured, the nurse should encourage which one to seek additional care at the nearest emergency department?

  1. Male in his mid-20s who had several light boxes of products fall on him while the robbers ran through the store
  2. Teenage female who took cover under a shelving unit and sustained a scratch on her arm
  3. Middle-age female who crouched down in a corner of the room and strained her knee
  4. Elderly male who was briefly unconscious

Correct Answer: 4

Rationale 1: Because this patient is young and the boxes were light, emergency care will probably not be needed.

Rationale 2: This teenager sustained only a minor injury that could be treated at the scene. She should be referred to her primary care physician for follow-up if necessary.

Rationale 3: A knee strain can likely be managed at home or through follow-up with her personal primary care physician.

Rationale 4: An older patient who was briefly unconscious may have suffered a cardiac or neurologic event, or may have simply fainted. The patient should be evaluated for the reason for the unconsciousness.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-2

 

Question 2

Type: MCSA

The nurse provides care in a hospital in an inner-city with a large immigrant population. How can the nurse provide the most culturally competent care?

  1. Approach the care of every patient in the same manner.
  2. Plan to attend educational programs to understand ethnic differences in health values.
  3. Discuss with the supervisor the types of patients for whom the nurse feels prepared to provide care.
  4. Realize that the best care is standardized care.

Correct Answer: 2

Rationale 1: The nurse should not approach the care of every patient in the same manner but should consider cultural differences.

Rationale 2: There are challenges with providing care to a diverse population. To provide the best culturally sensitive care, the nurse should attend education programs to understand ethnic differences in health values.

Rationale 3: The nurse should provide quality care for all patients, not discuss preferred types of patients with the supervisor.

Rationale 4: The best care is not standardized but rather is individualized.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 66-1

 

Question 3

Type: MCSA

A paramedic was asked by family members to take a patient complaining of chest pain to the local hospital. However, the patient is being taken to a hospital that is farther away and harder for the family to reach. The decision to take the patient to a different hospital is the result of which factor?

  1. The patient does not have sufficient insurance.
  2. The paramedic did not understand the request.
  3. The emergency department at the local hospital would not accept the patient.
  4. The patient was taken to the care center that provides the optimal care for the problem.

Correct Answer: 4

Rationale 1: The paramedic may or may not be aware of the type of insurance the patient has.

Rationale 2: There is no evidence that the family did not make their wishes known.

Rationale 3: Because of the Emergency Medical Transport and Active Labor Act, the local hospital would not refuse to see the patient.

Rationale 4: One of the Institute of Medicine recommendations for emergency care in the United States is to transport patients to the care center that can provide the optimal care for the patient.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-3

 

Question 4

Type: MCSA

The nurse assessing a patient who walked into the emergency department decides the patient is in no acute distress. Which patient condition would support the nurse’s decision?

  1. Limping and walking with the assistance of a possible family member or friend
  2. Gasping for breath and holding a bloody tissue to the nose
  3. Ambulating, breathing without difficulty, possible right arm/shoulder pain because holding arm bent and close to body
  4. Calling for help while limping with the use of a cane

Correct Answer: 3

Rationale 1: This patient has an obvious sign of illness or injury.

Rationale 2: This patient has an obvious sign of illness or injury that could progress to a more serious condition such as airway occlusion.

Rationale 3: Of the individuals described, the patient who is able to ambulate, breathe without difficulty, but might have right arm/shoulder discomfort would be the one with the least amount of distress.

Rationale 4: Limping and calling for help indicate the need for immediate assessment.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-3

 

Question 5

Type: MCSA

The nurse works in an emergency department (ED) that implements the spot check triage system. Which activity will the nurse triaging patients perform?

  1. Starting intravenous access lines
  2. Applying cardiac monitoring leads on patients
  3. Determining patients’ urgency for care
  4. Drawing serum laboratory samples

Correct Answer: 3

Rationale 1: IV lines are typically started once the patient is admitted to the ED.

Rationale 2: Cardiac monitor leads are typically applied after the patient is admitted to the ED.

Rationale 3: The purpose and goals of triage include early and brief patient assessment, determination of the patients’ urgency for care, and documentation of findings.

Rationale 4: Drawing serum for laboratory samples is generally done after admission to the ED.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-2

 

Question 6

Type: MCSA

A nurse working in the emergency department (ED) decides which cubicles to place patients in to be seen by the health care provider. The nurse talks with one patient about the fall he sustained from his motorcycle and whether he is able to move all four extremities independently. What part of the role of the emergency department nurse is this nurse fulfilling?

  1. Triage
  2. Referral to hospital-identified policies and procedures
  3. Following physician orders for admitting a patient
  4. Following evidence-based practice

Correct Answer: 1

Rationale 1: The goals of triage include early and brief patient assessment, assignment of patients to the appropriate care area, and initiation of diagnostic and therapeutic interventions.

Rationale 2: The ED nurse must make on-the-spot decisions about how to prioritize care. There is insufficient time to refer to policy and procedures with each decision.

Rationale 3: The nurse is making an independent nursing judgment regarding which patient has the most urgent need to be seen and which cubicle provides the correct equipment and access.

Rationale 4: As there is no information about where this patient was placed based on the nurse’s assessment, it is not possible to tell if evidence-based care was considered.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-2

 

Question 7

Type: MCSA

A patient, assigned the category of nonurgent in the emergency department, begins to have shortness of breath and is dizzy. What should be done to assist this patient?

  1. Immediately reassess the patient and assign the category of urgent.
  2. Immediately reassess the patient and assign the category of resuscitation.
  3. Remind the individual to be patient and wait to be seen.
  4. Immediately reassess the patient and assign the category of emergent.

Correct Answer: 4

Rationale 1: An urgent patient will need to wait a bit longer; this patient must be treated immediately.

Rationale 2: The patient does not need resuscitation.

Rationale 3: The patient should not be scolded for needing help.

Rationale 4: After patients have been assigned a triage category their condition might change, so patients who are waiting to be seen should be reassessed at regular intervals. This patient has an immediately life-threatening problem.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-2

 

Question 8

Type: MCSA

A patient arrives by ambulance to the emergency department. A paramedic is administering a breathing bag to help with the patient’s respirations. Which triage level will the nurse assign?

  1. Nonurgent
  2. Resuscitative
  3. Emergent
  4. Urgent

Correct Answer: 2

Rationale 1: A patient in the nonurgent category is stable enough to wait for care.

Rationale 2: For a patient in the resuscitative category, resuscitative interventions must be implemented immediately. This patient is already receiving resuscitative measures.

Rationale 3: The status of emergent means the patient has an immediate life-threatening problem but is not imminently dying.

Rationale 4: A patient in the urgent category can wait a little longer but should be seen as soon as possible.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-2

 

Question 9

Type: MCSA

The nurse is reviewing the current status of patients who have been waiting in the emergency department for several hours. At the time of first arrival, each of the patients was identified as nonurgent. Which nonurgent patient should be seen and treated first?

  1. Male child holding left arm in sling, fingers and wrist intact to sensation, motion, and pulse
  2. Female with swollen ankle, leg elevated, ice pack currently applied, pulse present
  3. Elderly male whose swollen hand now is slightly blue-tinged with a faint pulse
  4. Adolescent male with bruised right eye, ice pack applied, no further bleeding from nose

Correct Answer: 3

Rationale 1: This patient remains stable and is not the current priority patient.

Rationale 2: This patient remains stable and is not the current priority patient.

Rationale 3: The nurse needs to reprioritize the patients who were all identified at first as nonurgent. At this time, the elderly male has the most dramatic status change.

Rationale 4: This patient remains stable and is not the current priority patient.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-1

 

Question 10

Type: MCSA

A patient without health insurance comes to the emergency department limping and dripping blood from a head wound. Which intervention should be performed first with this patient?

  1. Tell the patient that there are no orthopedic doctors available and that the hospital in the next town will be better able to help him.
  2. Determine the patient’s triage level, examine, and treat as needed.
  3. Have the patient sign in and provide method of payment for services.
  4. Tell the patient that he will have to go to the emergency room at a hospital that treats people who do not have health insurance.

Correct Answer: 2

Rationale 1: The patient should not be told that because the hospital does not have the resources to provide the care he needs, he will have to go to a hospital in another town.

Rationale 2: According to the Emergency Medical Treatment and Active Labor Act, no patient can be turned away from care for financial reasons. Although the patient does not have health insurance, he should be triaged, examined, and treated.

Rationale 3: The patient is in obvious distress, and the hospital cannot delay appropriate medical screening or treatment to inquire about the patient’s ability to pay for services.

Rationale 4: The patient should not be told to go to another hospital.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-3

 

Question 11

Type: MCSA

A patient comes to the emergency department and signs a general consent for treatment. While waiting to be seen, the patient experiences cardiac arrest and is subsequently resuscitated, stabilized, and admitted to the intensive care unit. The emergency nurse acted on which type of consent?

  1. Implied
  2. Blanket
  3. Expected
  4. Informed

Correct Answer: 1

Rationale 1: Implied consent allows for treatment in an emergency situation. It is based on the premise that if the patient were able to, he or she would give permission for treatment.

Rationale 2: Blanket consent is what the patient signed upon entering the emergency department; it is a general consent agreement used for evaluation and treatment. If more invasive tests are needed, additional consent is necessary.

Rationale 3: Expected does not describe a type of consent.

Rationale 4: Informed consent involves the patient stating that he or she has full understanding of a procedure, including risks, and is competent to give consent.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-4

 

Question 12

Type: MCSA

The nurse is collecting evidence of sexual assault from a female patient. What should the nurse do with damp clothing?

  1. Place the clothing in a plastic bag and document the time it was collected.
  2. Drape the clothing over a chair in the room and give it to law enforcement officers when they arrive.
  3. Allow the clothing to dry, place it in a paper bag, and label it appropriately.
  4. Secure the clothing on a wire hanger and label it appropriately.

Correct Answer: 3

Rationale 1: Evidence should be placed in a paper bag.

Rationale 2: The clothing should not be draped over a chair to be picked up later by law enforcement officers.

Rationale 3: Nurses who collect and preserve evidence and the chain of custody must remember that evidence that is wet should always be dried before packaging. Evidence should always be placed in a paper bag.

Rationale 4: The clothing should not be secured on a wire hanger.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-4

 

Question 13

Type: MCSA

The nurse has worked for 8 years on an adult medical-surgical unit and is transferring to become an emergency department nurse. Which type of training will this nurse most likely need to become proficient in providing emergency nursing care?

  1. Pediatric and obstetric nursing care
  2. Managing the care of four or five patients simultaneously
  3. Basic cardiac life support
  4. Neurologic emergencies with the elderly

Correct Answer: 1

Rationale 1: The nurse will need training related to patient populations with which she or he has had minimal experience, such as pediatrics and obstetrics.

Rationale 2: A nurse who has worked on a medical-surgical unit probably has experience caring for four or five patients simultaneously.

Rationale 3: The nurse probably already has basic cardiac life-support training.

Rationale 4: The nurse has provided care to adult medical-surgical patients for 8 years. This nurse will not need training in neurologic emergencies with the elderly.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 66-5

 

Question 14

Type: MCSA

The nurse is discharging a patient from the emergency department. The patient will need to walk with crutches for a sprained ankle. What should the nurse do to ensure that the patient will safely use the crutches at home?

  1. Instruct a family member on the use of the crutches and suggest that he or she access the Internet for any questions.
  2. Demonstrate the use of the crutches while the patient observes from the wheelchair.
  3. Demonstrate the use of the crutches and ask for a return demonstration before discharge.
  4. Provide a written handout on the use of crutches.

Correct Answer: 3

Rationale 1: Instructing the family on the use of crutches and referring them to the Internet for any questions is inappropriate.

Rationale 2: Demonstrating the use without a return demonstration will not assess the patient’s understanding.

Rationale 3: Discharge instructions are an important part of the care emergency nurses provide. The best way for the nurse to assess if the patient understands the instructions about crutch use would be for the nurse to demonstrate and then ask the patient to return the demonstration.

Rationale 4: A written handout might not be enough for the patient. It also does not ensure that instructions are understood.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-1

 

Question 15

Type: MCSA

The emergency department (ED) nurses are planning a community education program during Summer Safety Week at the hospital. Including which topic in this program would support the Emergency Nurses Association (ENA) initiatives?

  1. Clean House: Eliminate Winter Pathogens Just in Time for Spring!
  2. Bicycles and Helmets: Friends for Life!
  3. Recycle Your Clothing: Help a Friend in Need!
  4. Get Out and Walk!

Correct Answer: 2

Rationale 1: Environmental cleanliness is not specifically focused on injury prevention.

Rationale 2: One role of the ED nurse is to participate in injury and disease prevention education. These nurses should include a topic related to a summer activity, such as bicycle riding, and related safety issues.

Rationale 3: Community support through recycling clothing is not focused on injury prevention.

Rationale 4: Fitness by walking is not specifically focused on injury prevention.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 66-1

 

Question 16

Type: MCMA

A nurse who is considering transfer to the emergency department (ED) asks, “How is ED nursing different from what I have been doing?” How would the experienced ED nurse answer this question?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. “It is episodic.”
  2. “We focus on primary care.”
  3. “Most of what we do is acute care or critical care.”
  4. “ED nurses provide care to patients of all ages.”
  5. “Most of the time we are providing care to patients without a medical diagnosis.”

Correct Answer: 1,3,4,5

Rationale 1: ED nurses do not provide care for long periods or through the course of an illness. They provide care during a short episode, and the patient is either admitted or dismissed.

Rationale 2: ED care can be primary, secondary, or tertiary.

Rationale 3: The care provided in the ED is generally acute or critical care.

Rationale 4: Patients seen in the ED are of all ages.

Rationale 5: At least initially, most ED patients do not have a medical diagnosis and are being seen to determine what is wrong.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-1

 

Question 17

Type: MCSA

A patient from another country is brought to the emergency department (ED) after sustaining a serious leg wound. The ED nurse asks how the wound would be treated in the patient’s country of origin. The nurse is practicing which part of the ABCDE Diversity Practice Model?

  1. “A” or assumptions
  2. “B” or beliefs
  3. “C” or communication
  4. “D” or diversity

Correct Answer: 4

Rationale 1: Assumption is the act of taking for granted or supposing that a thought or idea about a group is true. This nurse is not assuming how care would be provided, but has asked for information.

Rationale 2: Beliefs are shared ideas about how a group operates. The nurse is asking for information rather than acting on beliefs.

Rationale 3: Communication is the two-way sharing of information that results in an understanding between receiver and sender. This is not the purpose of the nurse’s inquiry.

Rationale 4: Diversity is the way in which people differ and the effect that these differences have on health perception and health care. The nurse’s question is an attempt to understand that diversity.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-1

 

Question 18

Type: MCMA

Which patient statement would the nurse evaluate as reflecting the current trend in use of the emergency department?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. “I had to wait for 3 hours to be seen for my head cold.”
  2. “My dad had to stay in the ED overnight until a bed was available in the intensive care unit.”
  3. “I wanted to go to an ED across town, but they aren’t accepting any ambulance patients right now.”
  4. “The lady in the office told me I should go somewhere else for care, but I am just too sick.”
  5. “The waiting room is packed with people who are sneezing and coughing.”

Correct Answer: 1,2,3,5

Rationale 1: Wait times are lengthening as more patients are using the ED for primary care.

Rationale 2: Critically ill patients are sometimes “boarded” in the ED while awaiting a bed in a specialty unit.

Rationale 3: EDs have become so overwhelmed that they periodically have to go on divert status to allow staff to provide care to the patients already admitted to the ED.

Rationale 4: According to the Emergency Medical Transport and Active Labor Act, people who present to the ED for care cannot be turned away.

Rationale 5: Waiting rooms are often crowded with people who do not need emergency care but have nowhere else to turn.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 66-1

 

Question 19

Type: MCMA

Which characteristics of the emergency department (ED) would the nurse cite as causing long waits and overcrowded conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. “We are open 24 hours a day and 7 days a week.”
  2. “So many of our patients don’t have any insurance.”
  3. “We cannot turn people away even if they don’t have an emergent condition.”
  4. “Patients don’t want to wait at the doctor’s office and they think they can be seen here faster.”
  5. “We have such a large population of older people in our community.”

Correct Answer: 1,2,3

Rationale 1: The 24-hour accessibility of the ED is attractive to patients who require medical services after hours.

Rationale 2: People who do not have insurance usually cannot afford private health care and go to the ED instead.

Rationale 3: Open access and the prohibition against turning patients away have increased the numbers of patients in the ED.

Rationale 4: Typically the wait times in the ED are much longer for nonurgent illnesses.

Rationale 5: Fully one third of all ED visits are by people less than 25 years old, so it is hard to prove that overuse by the older population has caused overcrowding.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-1

 

Question 20

Type: MCMA

Which statements by an emergency department nurse reflect poor compliance with the “A” portion of the diversity practice model?

 

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. “If patients are going to live in the U.S., they should at least attempt to learn English.”
  2. “Her clothes are dirty, so I bet she doesn’t have any insurance.”
  3. “This patient is weird. He has all kinds of marks on his skin and says they will make him feel better.”
  4. “You know how it is with these young mothers; they never follow instructions on how to prevent their kids from getting ear infections.”
  5. “Oh no, another old man with influenza. You take care of him. They all stink.”

Correct Answer: 2,4,5

Rationale 1: This statement violates the “C” or communication portion of the model.

Rationale 2: This is a violation of the “A” or assumptions part of the model. The nurse should not assume that dirty clothing equates to having no insurance.

Rationale 3: These marks may be a form of cultural ritual for healing. The nurse should attempt to understand the ritual rather than classifying the patient as “weird.” This violates the “D” or diversity component of the model.

Rationale 4: This nurse has grouped all young mothers together as unable to follow instructions. This violates the “A” or assumptions portion of the model.

Rationale 5: This nurse has grouped all “old” men as smelling bad. This is an assumption regarding older people and violates the “A” or assumptions part of the model.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-1

 

Question 21

Type: MCMA

A hospital nurse administrator is working to help the emergency department meet the Institute of Medicine (IOM) recommendations for emergency care. Which initiatives should be included in this work?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Funding for a new pediatric coordinator position in the ED
  2. Revision of the ED physical layout to improve patient flow
  3. Decreasing the number of standards that affect the operation of the ED
  4. Advocating for payment for all ED care provided
  5. Development of a clinical decision unit

Correct Answer: 1,2,4,5

Rationale 1: The IOM recommends that a pediatric coordinator be hired to ensure that appropriate equipment, training, and services are provided concerning children.

Rationale 2: The IOM recommends that tools from other disciplines such as engineering and operations research be used to improve patient flow.

Rationale 3: The IOM advocates the development of well-defined standards and performance improvement measures.

Rationale 4: The IOM supports measures that would ensure that hospitals are reimbursed for all care delivered in the ED.

Rationale 5: A clinical decision unit is a short-stay unit where patients are admitted until a decision is made about the best course of treatment. Use of these units would reduce the numbers of patients who are boarded or kept for long periods in the ED.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 66-1

 

Question 22

Type: MCSA

A patient has returned to the emergency department (ED) numerous times over the past 3 months. The patient has newly diagnosed diabetes and cannot afford testing supplies. Which ED nurse referral is indicated?

  1. Nurse educator
  2. Emergency nurse practitioner (ENP)
  3. Emergency clinical nurse specialist (ECNS)
  4. Case manager

Correct Answer: 4

Rationale 1: The nurse educator may discuss the need for testing with the patient, but is not the best resource for this situation.

Rationale 2: The ENP may provide diabetes-specific care for this patient, but is not the best resource for the current situation.

Rationale 3: The ECNS may support provision of excellent care for the patient, but is not the best resource for the current situation.

Rationale 4: This patient requires the services of a case manager who can interact with other departments and agencies to assist the patient in obtaining necessary supplies.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-1

 

Question 23

Type: MCSA

The nurse manager makes a quick visit with patients in the emergency department (ED) waiting area. The manager is concerned about one patient who was originally assigned nonurgent status, even though there is no specific change from the triage assessment. What action should the manager take?

  1. Check on the patient in another 15 minutes.
  2. Tell the admittance clerk to keep an eye on the patient.
  3. Change the triage tag to urgent and admit the patient to the ED.
  4. Blame the concern on the number of patients still waiting to be seen.

Correct Answer: 3

Rationale 1: The manager should not wait 15 minutes for another assessment.

Rationale 2: The admittance clerk is not a nurse and should not be placed in this position.

Rationale 3: The nurse’s intuition may be correct that this patient is sicker than the assessment indicates. The nurse should act on this “sixth sense.”

Rationale 4: The nurse should not dismiss this concern.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-3

 

Question 24

Type: MCMA

Nursing administrators are trying to decide if they want a “traffic director,” “spot check,” or “comprehensive” form of triage in the emergency department. What information should be considered when making this decision?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. All forms will require employment of a registered nurse.
  2. All forms will include evaluation of the patient.
  3. Both spot check and comprehensive triage nurses order lab or radiographs according to established protocol.
  4. A comprehensive triage plan results in patients receiving pain medications earlier.
  5. Both the spot check and comprehensive triage nurses assign urgency categories.

Correct Answer: 4,5

Rationale 1: The traffic director form of triage can be performed by a nonnurse.

Rationale 2: The traffic director does not evaluate the patient but only records chief complaints.

Rationale 3: Comprehensive triage nurses order some interventions; spot check triage nurses do not.

Rationale 4: The nurse providing comprehensive triage can administer pain medication.

Rationale 5: In both types of triage, urgency categories are assigned. This is not true of traffic director triage.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 66-2

 

Question 25

Type: MCMA

The emergency department (ED) nurse is using the CIAMPEDS mnemonic to triage an 8-year-old patient. Which questions would the nurse ask?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. “C”: What is the chief complaint?
  2. “I”: Has the child been exposed to anything requiring isolation?
  3. “P”: What do you think is the problem?
  4. “E”: Has the patient ever had these symptoms before today?
  5. “D”: Has the patient’s diet or appetite changed?

Correct Answer: 1,2,3,5

Rationale 1: The “C” of the mnemonic represents chief complaint.

Rationale 2: The “I” of the mnemonic is related to isolation or immunizations.

Rationale 3: The “P” of the mnemonic represents the parents’ or caregivers’ impression of the patient’s problem.

Rationale 4: The “E” in the mnemonic represents the events surrounding the illness or injury.

Rationale 5: The “D” in the mnemonic represents diet or diapers, signifying output.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-3

 

Question 26

Type: MCSA

Workmen preparing to paint have set up equipment near the emergency department entrance and have taken down all the signage. What is the primary reason the nurse manager is concerned when this is mentioned in the shift report?

  1. Inappropriate signage can result in loss of federal funding.
  2. Patients and families may get lost if signs are not present.
  3. Fumes from paint can impair the breathing ability of patients with lung disorders.
  4. The presence of painting equipment is a fall hazard for patients and nurses.

Correct Answer: 1

Rationale 1: The Emergency Medical Treatment and Active Labor Act (EMTALA) requires posting of signs to advise patients of their rights to emergency treatment. Violation of this posting law can result in loss of federal funding.

Rationale 2: Patients and families may get lost, but this is not the primary reason the manager is upset.

Rationale 3: The manager may be concerned about fumes, but this is not the primary concern.

Rationale 4: The equipment is near the entrance, not in the entrance, so the workmen have taken appropriate precautions to prevent injury.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-1

 

Question 27

Type: MCMA

A patient is being transferred from the emergency department to another hospital. The nurse would expect which conditions to be documented before this transfer occurs?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. The current facility does not have the capacity to provide the needed care.
  2. The medical benefits of the transfer outweigh the risks of transfer.
  3. A medical screening exam has been conducted.
  4. No physician with admitting privileges at the current hospital will assume the care of the patient.
  5. The appropriate level of care must be provided during the transfer.

Correct Answer: 1,2,3,5

Rationale 1: Transfers from the ED require documentation that the current facility cannot provide the care needed.

Rationale 2: There must be documentation that the risks of transfer are not as great as the expected benefits.

Rationale 3: The current hospital must verify that a medical screening exam has been done.

Rationale 4: There is no need to document that no physician at the current hospital will assume the patient’s care. If the patient needs care and transfer is not indicated, a physician must be assigned to the patient’s care.

Rationale 5: The patient must have care during the transfer that is assessed to be adequate and appropriate.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-4

 

Question 28

Type: MCMA

The patient signed a consent for treatment when admitted to the emergency department. This consent would allow which procedures?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Vital signs
  2. Drawing lab work
  3. Endoscopy
  4. X-rays without contrast
  5. Medication administration

Correct Answer: 1,2,4,5

Rationale 1: The blanket consent would allow for evaluation such as vital signs.

Rationale 2: Evaluative tests such as lab work are covered by the blanket consent.

Rationale 3: Endoscopy is an invasive procedure that may require conscious sedation. Additional consent is required.

Rationale 4: The blanket consent allows plain x-rays to be taken.

Rationale 5: The blanket consent allows for administration of medication.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-4

 

Question 29

Type: MCSA

A patient being cared for in the emergency department (ED) will require endoscopy to remove a foreign object from the esophagus. Whose responsibility is it to obtain informed consent for this procedure?

  1. The admittance clerk
  2. The nurse who admitted the patient to the ED
  3. The nurse who will assist in the procedure room
  4. The health care provider performing the procedure.

Correct Answer: 4

Rationale 1: The admittance clerk cannot obtain informed consent.

Rationale 2: The nurse cannot obtain informed consent.

Rationale 3: The nurse cannot obtain informed consent.

Rationale 4: The health care provider must explain the procedure, its benefits and risks, and obtain informed consent.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-4

 

Question 30

Type: MCSA

A 17-year-old unmarried female presents to the emergency department and says, “I am pregnant and I have a urinary tract infection.” There is no parent present. How should the nurse proceed regarding consent?

  1. Assume consent because the patient came to the ED seeking help.
  2. Assume consent is legal because the patient is pregnant.
  3. Ask the patient to call her parents to give telephone consent.
  4. Refer to the hospital policy and procedure manual about conditions of consent.

Correct Answer: 4

Rationale 1: It is generally assumed that a patient who presents to the ED is giving consent for treatment, but this patient is underage.

Rationale 2: Laws vary from state to state regarding pregnancy and the legal ability to give consent. The nurse is also assuming that the patient is in fact pregnant.

Rationale 3: This may be an option, but it is not clearly indicated. This is not the best answer.

Rationale 4: The hospital policy and procedure manual must address conditions of consent according to state law. The nurse should refer to this manual and document the thought processes leading to assuming consent.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-4

 

Question 31

Type: MCSA

A patient is admitted to the emergency department with multiple wounds inflicted by an unknown assailant. What action should the nurse take?

  1. Clean and dress the wounds as soon as initial assessment is completed.
  2. Dispose of bloody clothing in a biohazard bag.
  3. Change gloves often during patient care.
  4. Keep evidence in the patient’s room until it is released to authorities.

Correct Answer: 3

Rationale 1: Wound care should not be performed until photographs of the wounds have been taken.

Rationale 2: The clothing may be evidence and should not be discarded.

Rationale 3: To preserve any evidence on the patient’s body, the nurse should change gloves often during care. This helps to prevent transferring evidence from one wound to another. It also helps protect evidence from environmental contamination in the ED.

Rationale 4: The evidence must be secured so that the chain of custody is maintained. Evidence bags should be placed in a secure, locked area.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-4

 

Question 32

Type: MCMA

The nurse has removed clothing with gunshot residue from a murder victim. What information should the nurse include when labeling the bag containing this clothing?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Patient’s name
  2. Attending physician
  3. Date
  4. Time
  5. The name of the person who collected the evidence

Correct Answer: 1,3,4,5

Rationale 1: The bag must be identified with the patient’s name.

Rationale 2: It is not necessary to document the attending physician on the evidence bag.

Rationale 3: It is essential to accurately document the date the clothing was placed in the bag.

Rationale 4: The time of collection is essential documentation.

Rationale 5: The nurse should indicate the name of the person who put the evidence in the bag.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-4

 

Question 33

Type: MCMA

A nurse who has worked in the hospital for 10 years has committed to a new job in the emergency department. The nurse should expect to attend which courses to help prepare for this position?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Basic Life Support (BLS) instructor course
  2. Advanced Cardiac Life Support (ACLS)
  3. Pediatric Advanced Life Support (PALS)
  4. Trauma Nursing Core Course (TNCC)
  5. Emergency Nursing Pediatric Course (ENPC)

Correct Answer: 2,3,4,5

Rationale 1: Having the BLS instructor course certification is a benefit to the nurse, who can then teach BLS to others, but it is not a general requirement for work in the ED.

Rationale 2: The nurse should expect that attendance at an ACLS course will be required in the new position.

Rationale 3: The nurse should anticipate taking a PALS course.

Rationale 4: The nurse should anticipate taking the TNCC course for the new position.

Rationale 5: The nurse should anticipate taking the ENPC course for the new position.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 66-5

 

Question 34

Type: MCMA

The nurse is concerned that the chain of custody for evidence collected in the emergency department may have been breached. Which situation would support the nurse’s concern?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. The evidence was placed at the foot of the patient’s bed while the nurse who collected it went to get an evidence bag.
  2. The nurse who collected the evidence sealed it in a bag and placed a label on the bag.
  3. The nurse who collected the evidence left it at the busy nurses’ station for law enforcement authorities to pick up.
  4. The nurse handed the sealed and labeled evidence bag to a law enforcement officer.
  5. The wet clothing was hung in the utility room to dry before bagging.

Correct Answer: 1,3,5

Rationale 1: If the person who collected the evidence leaves it unattended in an unlocked area, the chain of custody has been breached.

Rationale 2: Sealing the evidence in a bag and labeling the bag helps to maintain the chain of custody.

Rationale 3: If the nurse did not lock the evidence in a secure area and it was left unattended in the nurse’s station, the chain of evidence was breached.

Rationale 4: The chain of evidence went from the nurse to the law enforcement officer without being breached.

Rationale 5: If the clothing was left unattended in the utility room, the chain of custody was breached.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-4

 

Question 35

Type: MCMA

The nurse is planning to conduct research on the top 10 most common reasons for visiting the emergency department. Which chief complaints would the nurse include in this work?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. “I have had stomach pain for the last 2 hours.”
  2. “I have been vomiting since I ate a chicken salad sandwich for lunch.”
  3. “I hit a curb and the airbag in my car deployed.”
  4. “I cut my hand when a glass broke as I was washing dishes.”
  5. “I have a terrible headache.”

Correct Answer: 1,2,5

Rationale 1: Stomach pain is the leading reason for visiting the ED.

Rationale 2: Vomiting is one of the top 10 reasons for visiting the ED. This vomiting may occur for a variety of reasons.

Rationale 3: Automobile accidents are not specifically listed as one of the top 10 reasons for ED visits.

Rationale 4: Lacerations are not listed as one of the top 10 reasons for ED visits.

Rationale 5: Headache is listed as the fifth most common cause of ED visits.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-1

 

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