Readiness Test 1 2011

Readiness test 1 2011 Green denotes the correct answer you provided. Blue denotes the correct answer.
Red denotes the incorrect answer you provided. Questions 1 Question 1

Mr. Harris is a 38-year-old single male who works full time for a community police force. He has lived with bipolar affective disorder type II for 10 years and has a history of two severe depressive episodes and three hypomanic episodes. He continues to take antidepressant medication (a selective serotonin re-uptake inhibitor) daily, and his bipolar disorder is stable at present. Mr. Harris is currently on sick leave from his work while he recovers from surgery to his right knee. He has developed drainage from the surgical site and is referred to a home care nurse. The home care nurse is unfamiliar with details of care for a client with bipolar disorder. What is the most appropriate first step in planning care for this client? 1) Consult a nurse expert in mental health. Rationale: This deals with accountability and values. It is appropriate to consult an experienced colleague. 2) Determine whether Mr. Harris is taking his antidepressant as prescribed. Rationale: The client is a good source of information about his own care, but a knowledgeable professional will provide more accurate and general information about the condition. It is the nurses professional responsibility to be accountable. 3) Consult Mr. Harris psychiatrist for assistance. Rationale: The client shows no evidence of an inability to cope with bipolar disorder. Consulting the psychiatrist is unnecessary at this time. 4) Contact the Canadian Mental Health Association. Rationale: The association provides essential information and services. The nurse needs more specific nursing knowledge in order to plan care.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 60-61. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 99-100. 2 Question 2
Mr. Harris is a 38-year-old single male who works full time for a community police force. He has lived with bipolar affective disorder type II for 10 years and has a history of two severe depressive episodes and three hypomanic episodes. He continues to take antidepressant medication (a selective serotonin re-uptake inhibitor) daily, and his bipolar disorder is stable at present. Mr. Harris is currently on sick leave from his work while he recovers from surgery to his right knee. He has developed drainage from the surgical site and is referred to a home care nurse. Although the physician has stated that Mr. Harris may bear full weight on his knee, Mr. Harris tells the nurse that his knee gets very tired and sore if he walks for too long. What is the best action for the nurse to take to address Mr. Harris concern? 1) Arrange for a referral to a physiotherapist.
Rationale: A referral to the appropriate service would facilitate his mobility and address his concerns. 2) Suggest that he decrease his activities and elevate his knee on a pillow. Rationale: This fails to address the clients concerns with mobility. 3) Reassure him that his knee will improve. Rationale: This is false reassurance and does not address the clients concerns with mobility. 4) Suggest that he call his supervisor about returning to limited duty. Rationale: Although this would help with the clients socialization, it does not directly address his immediate concerns with mobility.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 28. Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 2042. 3 Question 3
Mr. Harris is a 38-year-old single male who works full time for a community police force. He has lived with bipolar affective disorder type II for 10 years and has a history of two severe depressive episodes and three hypomanic episodes. He continues to take antidepressant medication (a selective serotonin re-uptake inhibitor) daily, and his bipolar disorder is stable at present. Mr. Harris is currently on sick leave from his work while he recovers from surgery to his right knee. He has developed drainage from the surgical site and is referred to a home care nurse. Mr. Harris tells the nurse that he is thinking about stopping his antidepressant because it is interfering with his sexual enjoyment. What is the nurses best action in this situation? 1) Advise Mr. Harris to consult his psychiatrist about a medication change. Rationale: While this side-effect is not life-threatening, it is an important reason for non-compliance with this category of medications. A change in medication may alleviate side-effects. 2) Notify Mr. Harris psychiatrist immediately. Rationale: This situation is not considered an emergency. 3) Refer Mr. Harris to a sexual counsellor for alternate therapies. Rationale: This is unnecessary as the central cause of the problem is the drug. 4) Suggest that the dose of the antidepressant be reduced. Rationale: Reducing the dosage of the selective serotonin re-uptake inhibitor may cause loss of control of the bipolar disorder and is inappropriate.
References: Abrams, A. C., Pennington, S. S., &Lammon, B. (2007). Clinical drug therapy: Rationales for
nursing practice (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 176-178. Brophy, K. M., Scarlett-Ferguson, H., & Webber, K. S. (2008). Clinical drug therapy for Canadian practice (1st Canadian ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 177183. 4 Question 4
Mr. Harris is a 38-year-old single male who works full time for a community police force. He has lived with bipolar affective disorder type II for 10 years and has a history of two severe depressive episodes and three hypomanic episodes. He continues to take antidepressant medication (a selective serotonin re-uptake inhibitor) daily, and his bipolar disorder is stable at present. Mr. Harris is currently on sick leave from his work while he recovers from surgery to his right knee. He has developed drainage from the surgical site and is referred to a home care nurse. Mr. Harris reports that his antidepressant is causing dry mouth and occasional episodes of diarrhea. What initial suggestion should the nurse make to the client? 1) Take dimenhydrinate (Gravol). Rationale: Both selective serotonin re-uptake inhibitors (SSRIs) and dimenhydrinate (Gravol) cause dizziness, drowsiness and dry mouth. Taking these medications concurrently is likely to increase other sideeffects. 2) Eat small frequent meals. Rationale: Nausea is secondary to gastric irritation with this class of drugs. 3) Increase fluid intake and chew sugarless gum. Rationale: Increased fluid intake is necessary to replace fluids lost through diarrhea. 4) Take loperamide (Imodium) and suck on lemon-flavoured candy. Rationale: This is not appropriate for this level of side-effect.
References: Abrams, A. C., Pennington, S. S., &Lammon, B. (2007). Clinical drug therapy: Rationales for nursing practice (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 176-178. Brophy, K. M., Scarlett-Ferguson, H., & Webber, K. S. (2008). Clinical drug therapy for Canadian practice (1st Canadian ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 183. 5 Question 5
Mr. Harris is a 38-year-old single male who works full time for a community police force. He has lived with bipolar affective disorder type II for 10 years and has a history of two severe depressive episodes and three hypomanic episodes. He continues to take antidepressant medication (a selective serotonin re-uptake inhibitor) daily, and his bipolar disorder is stable at present. Mr. Harris is currently on sick leave from his work while he recovers from surgery to his right knee. He has developed drainage from the surgical site and is referred to a home care nurse. Mr. Harris father dies suddenly. Shortly after the funeral, the nurse visits Mr. Harris. He states that he does not want to see anybody, feels no enjoyment in anything, and feels hopeless and useless. What is the most pertinent question for the nurse to ask during the visit? 1) Is it your fathers death that is affecting you? Rationale: It is important to show empathy, but this is not the most pertinent question given his symptom
cluster. 2) How are you managing after all your troubles? Rationale: The question is too vague and non-specific. He may not ask for help because he feels helpless and hopeless. 3) Have you thought of harming yourself? Rationale: He has access to lethal methods (guns). Knowing the ineffectiveness of the medications and the recent stress, the nurse must assess suicidal ideation. 4) Would you like to tell me about your worries? Rationale: This response shows empathy, but is not the most pertinent question.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 281. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 391. 6 Question 6
A teacher invites a non-Aboriginal nurse to a First Nations high school to discuss health risks associated with tobacco use among adolescent females. In this school, most of the young women between the ages of 14 and 16 smoke on a regular basis. Prior to teaching the session, the nurse wants to identify the learning needs of participants. Which action would be most effective in identifying these learning needs? 1) Organize a group discussion with the students about the effects of tobacco. Rationale: Involvement of participants in a needs assessment process will likely result in the identification of learning needs specific to that group of learners. Consultation with actual learners is the best approach. 2) Consult with a band elder about the learning needs of adolescents who smoke. Rationale: The learning needs identified for one group of learners are not necessarily relevant to the current group. The data collection needs to be more specific. 3) Consult with the high school teacher about the students current knowledge level. Rationale: The high school teacher could be a good resource but learners are the best source of information about their learning needs. 4) Refer to a textbook to identify adolescents learning needs about smoking. Rationale: Reference to the literature is helpful, but will not necessarily identify the needs of this specific group of learners.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 349-350.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 320-324. 7 Question 7
A teacher invites a non-Aboriginal nurse to a First Nations high school to discuss health risks associated with tobacco use among adolescent females. In this school, most of the young women between the ages of 14 and 16 smoke on a regular basis. Which approach should the nurse use to interest these students in smoking cessation? 1) Ask one of the non-smoking students to explain her decision not to smoke. Rationale: This strategy places undue stress on one participant. The participants decision not to smoke may not be related to health and would not necessarily identify the link between smoking and health outcomes. 2) Show a video on the health hazards of smoking. Rationale: Class participants need to be actively involved in discussing the health benefits of a non-smoking lifestyle. The nurse can add additional information to the discussion. 3) Discuss the risks associated with smoking. Rationale: Adolescents have a belief of invincibility. Things happen to other people not to them. 4) Invite the students to identify the benefits of a non-smoking lifestyle. Rationale: Group discussion and active participation is a good teaching strategy. It allows the group to confront health issues and change their behaviour.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 683. Nies, M. A., & McEwen, M. (2007). Community/Public health nursing: Promoting the health of populations (4th ed.). St. Louis, MO: Elsevier Saunders, pp. 124-126. 8 Question 8
A teacher invites a non-Aboriginal nurse to a First Nations high school to discuss health risks associated with tobacco use among adolescent females. In this school, most of the young women between the ages of 14 and 16 smoke on a regular basis. The nurse wants to explore with the students the cultural significance of tobacco use. Which approach would most effectively meet this goal? 1) Quiz the participants about cultural practices associated with tobacco use. Rationale: The participants may not have a clear understanding of usual cultural practices. It is not the role of young people to interpret culture. 2) Have a respected elder speak about the cultural practices associated with tobacco use. Rationale: The community elder is likely to be in a better position to correctly interpret the connection between tobacco use, culture and health. 3) Research and provide an interpretation of cultural practices involving tobacco use.
Rationale: A non-Aboriginal nurse may not be in a position to correctly interpret cultural practices to members of the cultural group. 4) Ask the teacher to explain usual cultural practices involving tobacco use. Rationale: Focusing attention on a single person to explain the cultural position of the community is likely inappropriate in this cultural setting.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 345-350. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 323, 328. 9 Question 9
A teacher invites a non-Aboriginal nurse to a First Nations high school to discuss health risks associated with tobacco use among adolescent females. In this school, most of the young women between the ages of 14 and 16 smoke on a regular basis. Several students in the group are successful in their plans to stop smoking. These students express an interest in promoting non-smoking among their classmates. Which action should the nurse suggest as the most effective in promoting non-smoking among the student population? 1) The school principal sets a non-smoking policy for the school. Rationale: Although the school official can affect a policy about smoking in the school setting, this policy will likely have little effect on student health behaviours. 2) The nurse provides smoking cessation seminars to other students. Rationale: The nurse can provide information about non-smoking, but may not be the most effective lobbyist with other students. 3) Students are involved in advocating for a smoke-free environment. Rationale: Effective lobbying involves collaborating with respected individuals within a particular setting. Student peers are very important in influencing the values and decisions of students. 4) Former smokers instruct the adolescents about the dangers of smoking. Rationale: Former smokers will carry little importance if they are not part of the adolescent peer group.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 358. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 331-333. 10 Question 10
Mrs. Marchand, 75 years old, is lethargic and presents with a state of confusion. She is admitted to the hospital for observation. On admission, her husband tells the nurse that his wife has been taking a number of different
medications over the past 3 months. It is suspected that Mrs. Marchand has been overmedicated. Which aspect of a neurological assessment is critical for the nurse to complete during Mrs. Marchands initial examination? 1) Babinskis reflex Rationale: Babinskis reflex is part of a neurological assessment but does not relate specifically to overmedication and is more likely related to increasing intracranial pressure. 2) Visual acuity Rationale: Visual acuity may be affected by overmedication, but it is not the most critical aspect of a neurological assessment for Mrs. Marchand. 3) Mental status Rationale: Mental function is important to assess to determine higher cerebral dysfunction. Mental status is most likely to be affected by overmedication. 4) Cranial nerve check Rationale: A cranial nerve assessment is not the most critical aspect of a neurological assessment for Mrs. Marchand. Cranial nerves should not be affected by overmedication.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 661. Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 1928. 11 Question 11
Mrs. Marchand, 75 years old, is lethargic and presents with a state of confusion. She is admitted to the hospital for observation. On admission, her husband tells the nurse that his wife has been taking a number of different medications over the past 3 months. It is suspected that Mrs. Marchand has been overmedicated. Which observation by the nurse indicates that Mrs. Marchands condition is becoming more critical and requires immediate intervention? 1) RR 10 breaths/min Rationale: Mrs. Marchand is experiencing respiratory depression, which is a cardinal sign of central nervous system depression. She is in a life-threatening situation and needs immediate attention. The normal respiratory rate for older adults is 16-25 breaths/min. 2) Incontinent of urine and feces Rationale: Incontinence can be a sign of confusion, but it is not life-threatening. 3) Picking at the air Rationale: Picking at the air can be a sign of confusion or hallucinations, but it is not life-threatening. 4) HR 100 beats/min
Rationale: This pulse rate is still within the acceptable range. Slight elevation may be due to anxiety.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 433. Miller, C. A. (2009). Nursing for wellness in older adults (5th ed.). Philadelphia, PA: Wolters Kluwer Health, p. 451. 12 Question 12
Mrs. Marchand, 75 years old, is lethargic and presents with a state of confusion. She is admitted to the hospital for observation. On admission, her husband tells the nurse that his wife has been taking a number of different medications over the past 3 months. It is suspected that Mrs. Marchand has been overmedicated. Although Mrs. Marchand remains in a confused state, her condition has stabilized. Which action by the nurse should assist Mrs. Marchand to carry out her own activities of daily living? 1) Allow Mrs. Marchand to set her own schedule. Rationale: It may be difficult for Mrs. Marchand to set her own schedule because she is confused. 2) Give Mrs. Marchand adequate time to complete her personal care. Rationale: The nurse must allow Mrs. Marchand adequate time to perform care. This will foster independence for Mrs. Marchand. 3) Have Mrs. Marchand complete her own menu selections. Rationale: It may be difficult for Mrs. Marchand to select her own menus because she is confused. 4) Negotiate with Mr. Marchand to have him assist in her care. Rationale: Having Mr. Marchand assist does not allow Mrs. Marchand independence within her present limitations.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 710-711. Miller, C. A. (2009). Nursing for wellness in older adults (5th ed.). Philadelphia, PA: Wolters Kluwer Health, p. 108. 13 Question 13
Mrs. Marchand, 75 years old, is lethargic and presents with a state of confusion. She is admitted to the hospital for observation. On admission, her husband tells the nurse that his wife has been taking a number of different medications over the past 3 months. It is suspected that Mrs. Marchand has been overmedicated. Mr. Marchand is distressed by the news of his wifes discharge and tells the nurse that he is afraid to take her home. Mr. Marchand is concerned that his wife will take too many pills again. Which response by the nurse best demonstrates advocacy? 1) I understand your concerns. However, in her home environment she will function much better.
Rationale: This is false reassurance. 2) If you are still feeling afraid, you can always call a community health nurse to assist you with medications. Rationale: The nurse is shifting care of the client to another nurse. 3) If you are worried about her medications, would you consider placing your wife in a long-term care facility? Rationale: The nurse is proposing a relatively extreme measure for the husbands worry. 4) You seem worried. Would you like to meet with the home care nurse so you may discuss your concerns? Rationale: The nurse is acting as a client advocate by presenting the clients concerns regarding imminent discharge.
Mr. Jones, 60 years old, had a myocardial infarction. He is admitted to a medical unit after 2 days in the coronary care unit. He reports severe tightness and pain in his chest. Which pain-related characteristic is associated with myocardial infarction? 1) Radiating only to the left side Rationale: Pain could radiate anywhere with a myocardial infarction. 2) Usually precipitated by exertion Rationale: Myocardial infarction often occurs without exertion. 3) Not relieved by nitroglycerin Rationale: Myocardial infarction is relieved by opioids and is usually resistant to nitroglycerin. 4) Lasting for less than 5 minutes Rationale: Pain lasts longer than 15 minutes in a myocardial infarction.
References: Black, J. M., &Hokanson Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Elsevier Saunders, pp. 1359-1360. Timby, B. K., & Smith, N. E. (2007). Introductory medical-surgical nursing (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 479. 15 Question 15
Mr. Jones, 60 years old, had a myocardial infarction. He is admitted to a medical unit after 2 days in the coronary
care unit. He reports severe tightness and pain in his chest. Mr. Jones systolic BP drops below 80 mmHg and his pulse increases. He appears grey with diaphoresis. After administering oxygen, what should the nurse do next? 1) Ensure IV access according to protocol. Rationale: This is important because the client will most likely receive IV fluids and medications necessary to prevent circulatory collapse. 2) Complete a 12-lead electrocardiogram according to protocol. Rationale: This will likely need to be done, but it is not the priority. The priority is to prevent circulatory collapse. 3) Maintain warm body temperature. Rationale: This is a less important intervention at this time. The priority is to prevent circulatory collapse. 4) Monitor urine output. Rationale: This is a less important intervention at this time. The priority is to prevent circulatory collapse.
References: Black, J. M., &Hokanson Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Elsevier Saunders, p. 1495. Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 773-775. 16 Question 16
Mr. Jones, 60 years old, had a myocardial infarction. He is admitted to a medical unit after 2 days in the coronary care unit. He reports severe tightness and pain in his chest. Two days later, Mr. Jones begins to verbalize feelings of despair about his illness. He states, I will never be able to return to work. Which statement should the nurse record in the care plan to reflect Mr. Jones present problem? 1) Anxiety and fear related to hospital admission Rationale: No mention is made that the client is anxious about being in hospital. 2) Powerlessness related to anticipated role changes Rationale: The client has decreased feelings of control over his present situation and future outcomes. 3) Altered health maintenance related to myocardial infarction Rationale: This does not capture the sense of what the client expressed. 4) Activity intolerance related to myocardial infarction Rationale: This does not capture the sense of what the client expressed.
References:
Black, J. M., &Hokanson Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Elsevier Saunders, p. 1561. Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 733. 17 Question 17
Mrs. Spencer, 28 years old, calls for an ambulance because her 2-month-old son is not breathing. She tells the ambulance attendant that when she went in to feed him, he was blue and she could not wake him up. Her husband is out of town on business. The baby is dead on arrival at the hospital. In order to establish a rapport with Mrs. Spencer, which action by the emergency nurse would be most appropriate? 1) Accompany her to a quiet area. Rationale: Providing Mrs. Spencer with a calming environment where she is not alone will assist in establishing a warm, caring relationship in a time of crisis. 2) Offer to try to contact Mr. Spencer. Rationale: It is important to notify her spouse as soon as possible. However, Mrs. Spencer first needs to be made as comfortable as possible in a supportive environment. 3) Clarify the nurses role in this situation. Rationale: This focuses on the nurse and ignores the client. Establishing a therapeutic relationship is more important. 4) Ask her if she wants a friend contacted. Rationale: The nurse needs to establish rapport before asking questions.
References: James, S. R., &Ashwill, J. W. (2007). Nursing care of children: Principles and practice (3rd ed.). St. Louis, MO: Elsevier Saunders, p. 636. Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, p. 683. 18 Question 18
Mrs. Spencer, 28 years old, calls for an ambulance because her 2-month-old son is not breathing. She tells the ambulance attendant that when she went in to feed him, he was blue and she could not wake him up. Her husband is out of town on business. The baby is dead on arrival at the hospital. Mrs. Spencer screams and cries out loudly for her baby. Which action by the nurse is most appropriate in dealing with this situation? 1) Reassure her that it is good to cry. Rationale: This suggests that crying is the appropriate behaviour and does not show compassion or understanding. 2) Ask her if she needs time alone.
Rationale: This is not helpful and could cause further emotional outbursts. The mother should not be left alone. 3) Tell her that it is not her fault. Rationale: This is supportive, but does not acknowledge the clients feelings. 4) Acknowledge that her baby's death must be a terrible shock. Rationale: This shows acceptance and understanding of the situation and opens communication in a supportive way.
References: Betz, C., & Snowden, L. (2008). Mosbys pediatric nursing reference. St. Louis: Mosby, p. 660. Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, p. 681. 19 Question 19
Mrs. Spencer, 28 years old, calls for an ambulance because her 2-month-old son is not breathing. She tells the ambulance attendant that when she went in to feed him, he was blue and she could not wake him up. Her husband is out of town on business. The baby is dead on arrival at the hospital. The nurse recognizes the need for emotional support for Mrs. Spencer. What is the most appropriate initial action by the nurse? 1) Refer her to a sudden infant death syndrome (SIDS) support group. Rationale: This will be done at a later time after confirmation of the cause of death. 2) Ensure that pastoral services are involved with Mrs. Spencer. Rationale: This assumes that Mrs. Spencer would want to have the clergy involved. 3) Ensure that someone stays with Mrs. Spencer. Rationale: It is important to have a support person with the mother because this is a stressful time. The mother may also feel guilty about her sons death. 4) Provide her with information on SIDS. Rationale: This is premature.
References: Hockenberry, M. J., & Wilson, D. (2009). Essentials of pediatric nursing (8th ed.). St. Louis, MO: Elsevier, p. 270. James, S. R., &Ashwill, J. W. (2007). Nursing care of children: Principles and practice (3rd ed.). St. Louis, MO: Elsevier Saunders, p. 636. 20 Question 20
Mrs. Spencer, 28 years old, calls for an ambulance because her 2-month-old son is not breathing. She tells the ambulance attendant that when she went in to feed him, he was blue and she could not wake him up. Her husband is
out of town on business. The baby is dead on arrival at the hospital. Before Mrs. Spencer leaves the Emergency Department, what is the most effective strategy to help her appropriately deal with her grief? 1) Discuss with her the indicators of prolonged grief. Rationale: Mrs. Spencer may not be ready to deal with new information because she is still absorbing her loss. 2) Provide the name of a contact person for bereavement support. Rationale: Support groups may be useful. Information should be in written form because Mrs. Spencer is not in an optimal state for learning. 3) Explore her feelings regarding another pregnancy. Rationale: This is inappropriate and negates Mrs. Spencer's loss 4) Refer her to a psychologist for bereavement and grief counselling. Rationale: There is no evidence that Mrs. Spencer needs a psychologist at this time.
References: Hockenberry, M. J., & Wilson, D. (2009). Essentials of pediatric nursing (8th ed.). St. Louis, MO: Elsevier, p. 270. Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2008). Fundamentals of nursing: The art and science of nursing care (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 1008. 21 Question 21
Nicholas, 8 years old, has a history of asthma and has been brought to the Emergency Department by his mother. Nicholas is experiencing shortness of breath, chest tightness and wheezing. Nursing assessment of Nicholas reveals the following: RR 56, HR 140, oxygen saturation 88% and bilateral wheezes with diminished breath sounds upon auscultation. Which prescribed medication would be most appropriate to administer at this time? 1) Sodium cromoglycate (Intal) Rationale: This is used prophylactically and can be used to prevent an asthma attack. 2) Fluticasone (Flovent) Rationale: This may suppress underlying causes of asthma. 3) Budesonide (Pulmicort) Rationale: This is a preventative medication, not a primary treatment. 4) Salbutamol sulfate (Ventolin) Rationale: This is a short-acting drug that will provide relief for bronchospasm by causing bronchodilation and vasodilation.
References:
Lilley, L. L., Harrington, S., Snyder, J. S., & Swart, B. (2007). Pharmacology and the nursing process in Canada. St. Louis, MO: Elsevier Mosby, pp. 603, 610. Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, pp. 1451-1456. 22 Question 22
Nicholas, 8 years old, has a history of asthma and has been brought to the Emergency Department by his mother. Nicholas is experiencing shortness of breath, chest tightness and wheezing. The Emergency Department physician orders Nicholas oxygen by mask. How can the nurse be sure that the appropriate rate of oxygen is being delivered? 1) Use a Venturi mask to deliver oxygen at specific concentrations and then wean as his condition improves. Rationale: A Venturi mask may cause Nicholas to feel afraid that he will suffocate. A Venturi mask is also used on clients who need 35-60% oxygen or a flow rate of 6-10 mL/minute. 2) Monitor arterial blood gases and adjust the rate of oxygen flow to maintain PaO2 above 100 mmHg. Rationale: The collection of arterial blood gases is an invasive procedure that requires a medical order. Levels above 100 mmHg are too high and could result in oxygen narcosis. 3) Monitor oxygen saturation and adjust the rate of oxygen flow to maintain results above 95%. Rationale: Pulse oximetry is non-invasive and is within the nurses scope of practice. Ninety percent saturation reflects adequate oxygenation. 4) Begin by delivering oxygen at 70% and then reduce the concentration as dyspnea diminishes. Rationale: There are no criteria provided to assess if this rate is sufficient. In addition, initial therapy should not exceed 40% to prevent the loss of stimulus for respiration.
References: Wilkinson, J. M., & Van Leuven, K. (2007). Fundamentals of nursing: Theory, concepts and applications. Philadelphia, PA: F. A. Davis Company, p. 868. Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, p. 1408. 23 Question 23
Nicholas, 8 years old, has a history of asthma and has been brought to the Emergency Department by his mother. Nicholas is experiencing shortness of breath, chest tightness and wheezing. Nicholas is ordered amoxicillin (Amoxil) t.i.d. to treat a concurrent infection. The recommended dose of this medication is 40 mg/kg/day. Nicholas weighs 18.2 kg. What is the appropriate single dose of amoxicillin for Nicholas? 1) 24.2 mg Rationale: The dose is too small. The formula is daily dose/3 = weight x 40 mg/day. 2) 72.8 mg
Rationale: The dose is too small. The formula is daily dose/3 = weight x 40 mg/day. 3) 242 mg Rationale: The appropriate dose is 18.2 kg x 40 mg/kg/day = 728 mg/day or 242 mg/dose. 4) 728 mg Rationale: This exceeds the recommended dose.
References: Elkin, M. K., Perry, A. G., & Potter, P. A. (2007). Nursing interventions and clinical skills (4th ed.). St. Louis, MO: Elsevier Health Sciences, p. 373. Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2008). Fundamentals of nursing: The art and science of nursing care (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 373. 24 Question 24
Nicholas, 8 years old, has a history of asthma and has been brought to the Emergency Department by his mother. Nicholas is experiencing shortness of breath, chest tightness and wheezing. Nicholas' condition has improved and the nurse is teaching him how to administer his medications by metered dose inhaler (MDI). What should the nurse consider when planning the teaching session? 1) Children Nicholas age are interested in how things work. Rationale: The developmental task of industry vs. inferiority includes a desire to learn how things work. 2) Nicholas may lack the manual dexterity to handle a MDI safely. Rationale: An 8-year-old child has sufficient manual dexterity. 3) Learning will be enhanced by his mother teaching him. Rationale: Although it may be helpful to have Nicolas mother present, her performing the teaching may or may not enhance his learning. 4) School-age children need reassurance that treatment is not punishment. Rationale: This is true in the pre-school age group.
References: Leifer, G. (2007). Introduction to maternity and pediatric nursing (5th ed.). St. Louis, MO: Elsevier, pp. 432-434. Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, p. 943. 25 Question 25
Nicholas, 8 years old, has a history of asthma and has been brought to the Emergency Department by his mother. Nicholas is experiencing shortness of breath, chest tightness and wheezing. What is the best way to assess if Nicholas is administering his metered dose inhaler (MDI) correctly? 1) Monitor the number of doses that he administered before emptying the canister.
Rationale: He may have been removing medication from the canister but not using the MDI correctly. 2) Auscultate lungs one half hour after administration of the medication. Rationale: This will not assess the effectiveness of administration of all medications given by MDI. 3) Observe him using the MDI, looking for vapour after inhalation. Rationale: The client is performing a return demonstration of the procedure. If MDI is not used correctly, there will be vapour. 4) Listen for a whistling sound during inhalation of the medication. Rationale: A whistling sound does not indicate proper technique in administration by MDI.
References: Hockenberry, M. J., & Wilson, D. (2009). Essentials of pediatric nursing (8th ed.). St. Louis, MO: Elsevier, p. 678. deWit, S. C. (2009). Fundamental concepts and skills for nursing (3rd ed.). St. Louis, MO: Elsevier, p. 124. 26 Question 26
Mrs. Smith, 64 years old, is an outpatient with metastatic breast cancer. She has been experiencing pain and is currently receiving morphine 10 mg p.o. q.4h and morphine 5 mg p.o. q.4h p.r.n. for breakthrough pain. The nurse provides information to Mrs. Smith about pain. Which statement is correct regarding pain? 1) Many people exaggerate the severity of their pain. Rationale: Very few people lie about the severity of the pain. 2) The majority of people taking morphine become addicted. Rationale: Very few clients develop an addiction (less than 0.1%). 3) People need pain medication when they are awake and asleep. Rationale: Administering analgesics on a consistent or fixed schedule provides more stable plasma levels of drugs 4) People eventually develop a tolerance to morphine. Rationale: Strong opioids such as morphine do not have a ceiling effect.
References: Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2008). Fundamentals of nursing: The art and science of nursing care (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 13901391. Timby, B. K., & Smith, N. E. (2007). Introductory medical-surgical nursing (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 181, 184-186.
27 Question 27
Mrs. Smith, 64 years old, is an outpatient with metastatic breast cancer. She has been experiencing pain and is currently receiving morphine 10 mg p.o. q.4h and morphine 5 mg p.o. q.4h p.r.n. for breakthrough pain. Today, Mrs. Smith rates her pain as 8 on a scale of 0 to 10. She states that she is comfortable when her pain level is 3. During the past 48 hours, Mrs. Smith has taken 10 mg p.o. morphine q.4h. What should the nurse do initially to assist Mrs. Smith in managing her pain? 1) Consult the physician about switching to IV morphine. Rationale: Morphine for breakthrough pain should be tried first. 2) Recommend to Mrs. Smith that she take her breakthrough doses of morphine. Rationale: Rescue doses of an opioid on an as needed basis should be available to clients for breakthrough pain. The breakthrough dose should equal approximately 5-15% of the 24-hour fixed-schedule opioid dose. 3) Consult the physician about changing Mrs. Smiths analgesic. Rationale: Morphine for breakthrough pain should be tried first. 4) Remind Mrs. Smith that the pain medication will never relieve all her pain. Rationale: Although pain is a common symptom in clients with cancer, not everyone with cancer has pain (studies suggest 40-80% of clients with cancer experience pain and 70-90% of clients with advanced cancer experience moderate to severe pain). In addition, the goal is to best manage the pain.
References: Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2008). Fundamentals of nursing: The art and science of nursing care (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 1394. Timby, B. K., & Smith, N. E. (2007). Introductory medical-surgical nursing (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 185-186. 28 Question 28
Mrs. Smith, 64 years old, is an outpatient with metastatic breast cancer. She has been experiencing pain and is currently receiving morphine 10 mg p.o. q.4h and morphine 5 mg p.o. q.4h p.r.n. for breakthrough pain. Mrs. Smith tells the nurse that she has heard from her friend that non-pharmacological methods of pain relief are better than pharmacological methods. She wants to stop all her pain medication and use only guided imagery to relieve her pain. What type of information should the nurse give Mrs. Smith? 1) Non-pharmacological measures are best used in combination with pharmacological measures. Rationale: Non-pharmacological approaches are best used in combination with pharmacological measures, often in addition to analgesics, because analgesics have been tailored to the clients needs. 2) The effectiveness of non-pharmacological measures for pain management has been well researched. Rationale: Research related to non-pharmacological measures is limited and the results are often conflicting. Non-drug measures for pain management are not a substitute for appropriate analgesic. 3) Non-pharmacological measures should be used instead of ineffective pharmacological measures. Rationale: Non-pharmacological measures are never a substitute for appropriate pharmacological measures.
4) Non-pharmacological measures must be performed by professionals trained in these areas. Rationale: Although non-pharmacological measures may be performed by professionals, they are often performed by the client and families themselves.
References: Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2008). Fundamentals of nursing: The art and science of nursing care (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 13881390. Timby, B. K., & Smith, N. E. (2007). Introductory medical-surgical nursing (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 183. 29 Question 29
Jane, 18 years old, is brought to the hospital by her mother after she intentionally slashed her left wrist. Janes mother tells the nurse that prior to this incident her daughter had been distraught over a breakup with her boyfriend. As the nurse is assessing Janes wounds, Jane expresses a desire to kill herself. She is to be admitted to the psychiatric unit for observation. What is the appropriate sequence of nursing actions? 1) Dress the wounds, ensure that Jane cannot harm herself and prepare her for admission. Rationale: When in question, client safety should always be dealt with first. 2) Ensure that Jane cannot harm herself, prepare her for admission and dress the wounds. Rationale: Psychological preparation can wait until the client is stabilized physiologically. 3) Ensure that Jane cannot harm herself, dress the wounds and prepare her for admission. Rationale: Appropriate prioritization of client needs is as follows: (1) ensure client safety, (2) stabilize the client physiologically, and (3) prepare the client psychologically. 4) Dress the wounds, prepare Jane for admission and ensure that she cannot harm herself. Rationale: When in question, client safety should always be dealt with first.
Jane, 18 years old, is brought to the hospital by her mother after she intentionally slashed her left wrist. Janes mother tells the nurse that prior to this incident her daughter had been distraught over a breakup with her boyfriend. On admission to the psychiatric unit, what should the nurse do after completing the initial assessment? 1) Validate the information with Janes mother. Rationale: Validation of information is part of the initial assessment; however, it needs to be done with the client.
2) Record the information in the chart. Rationale: This is the first step following the initial assessment and forms the clients database. 3) Arrange appointments with members of the health-care team. Rationale: Although this may be important, it is not done immediately following initial assessment. 4) Ask Jane if she would like to talk to her boyfriend. Rationale: This is inappropriate since Jane recently broke up with her boyfriend. Also, this would not be done after completing the initial assessment.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 24. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 234-235. 31 Question 31
Jane, 18 years old, is brought to the hospital by her mother after she intentionally slashed her left wrist. Janes mother tells the nurse that prior to this incident her daughter had been distraught over a breakup with her boyfriend. Jane begins to cry while the nurse is dressing the wrist wound. What is the most appropriate nursing response? 1) I see you are crying. Would you like to talk about it? Rationale: This demonstrates empathy by acknowledging the clients feelings and encouraging her to express her feelings in a healthier response by crying. 2) Can you tell me why you are crying? Rationale: Why questions may be legitimate, but often make the client feel threatened. They may cause the client to become defensive or protective. A better approach is to rephrase the why question to be less direct. 3) It's all right to cry. Is your wrist painful? Rationale: This assumes that the client is crying due to physical pain. 4) Does looking at the wound upset you? Rationale: This does not demonstrate the nurses awareness of the clients feelings.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 334-338. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, pp. 259-260. 32 Question 32
Jane, 18 years old, is brought to the hospital by her mother after she intentionally slashed her left wrist. Janes mother
tells the nurse that prior to this incident her daughter had been distraught over a breakup with her boyfriend. The nurse finds Jane with the dressing removed and the wound bleeding profusely. What should the nurse do first? 1) Wrap a tourniquet around the arm above the wound. Rationale: This is not an appropriate first response. 2) Apply direct pressure to the wound. Rationale: Direct pressure is appropriate to control the bleeding. 3) Apply a sterile dressing. Rationale: The bleeding should be controlled by applying pressure. A sterile dressing will not provide sufficient pressure to control the bleeding. 4) Call for help. Rationale: The bleeding should be controlled before calling the physician.
References: Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 2164-2168. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, p. 1323. 33 Question 33
Jane, 18 years old, is brought to the hospital by her mother after she intentionally slashed her left wrist. Janes mother tells the nurse that prior to this incident her daughter had been distraught over a breakup with her boyfriend. What manifestation indicates that Jane may be going into shock? 1) Dilated pupils Rationale: Pupil dilation does not occur with shock. 2) Decreased blood pressure Rationale: This is one of the earliest signs of shock. 3) Decreased respiratory rate Rationale: Respirations usually become rapid and shallow with shock. 4) Decreased pulse rate Rationale: The pulse often becomes rapid and thready with shock.
References: Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia, PA: Lippincott Williams &
Wilkins, pp. 303-308. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 1643. 34 Question 34
Mr. Wong, 61 years old, has undergone treatment for weakness and diarrhea. He and his wife immigrated to Canada 5 years ago from Hong Kong. They speak very little English, and Mr. Wong avoids talking to the nursing staff. When caring for Mr. Wong, what should the nurse consider? 1) Members of a culture hold the same values and beliefs. Rationale: This stereotypes people based on their country of origin. They may have the same language but not all members of a culture will share the same beliefs. The nurse needs to assess each individuals beliefs prior to adapting care. 2) The culture of an individual should be preserved in the new society. Rationale: Cultural preservation may impact treatment adversely. The nurse should understand how culture impacts health and illness. 3) Adaptation to a new culture is difficult. Rationale: Adaptation to a new culture will depend on a variety of factors (e.g., age, reason for immigrating, education, community where they live). The nurse cannot generalize that it is difficult for this client. 4) Culture is a factor in how an individual views health and health services. Rationale: The impact of culture on health care is an important factor in nursing care.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 317-319. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, pp. 120-121. 35 Question 35
Mr. Wong, 61 years old, has undergone treatment for weakness and diarrhea. He and his wife immigrated to Canada 5 years ago from Hong Kong. They speak very little English, and Mr. Wong avoids talking to the nursing staff. When caring for Mr. Wong, the nurse recognizes that some of her common gestures and expressions may be offensive or misunderstood. Which statement best describes the nurses approach? 1) The nurse should be sensitive to how her behaviours may be perceived by Mr. Wong. Rationale: Nurses who recognize key concepts of other cultures can be more effective and demonstrate a greater understanding of clients from other cultures. 2) The nurse should not be expected to change her way of giving care to suit a clients beliefs. Rationale: This is not appropriate; individualizing care is an expectation in nursing. 3) The nurse must ensure that her caregiving meets hospital protocol and policy.
Rationale: This is inaccurate; care is done to meet client needs and not protocols or policy, although those boundaries exist to delineate standards. 4) The nurse should advise Mr. Wongs family to provide him with a translator. Rationale: This puts the responsibility on the family and takes it away from the nurse.
Mr. Wong, 61 years old, has undergone treatment for weakness and diarrhea. He and his wife immigrated to Canada 5 years ago from Hong Kong. They speak very little English, and Mr. Wong avoids talking to the nursing staff. The nurse is assisting Mr. Wong into a wheelchair and explaining that he is going for an abdominal series Xray. He is shaking his head and speaking quickly in a language the nurse does not understand. His family has gone home. What should the nurse do to ensure Mr. Wong understands the procedure? 1) Call his wife so she can talk to him, calm him down and explain the test to him. Rationale: This assumes that his wife could explain the medical test so he could give informed consent. Use of a family member as an interpreter can be culturally inappropriate. 2) Wait until he becomes calm and then assist him into the wheelchair. Rationale: This does not address Mr. Wongs concern, nor does it ensure that he understands what the procedure involves. 3) Notify the Radiology Department that Mr. Wong is not well-informed about the procedure. Rationale: This is not the problem; the client needs to understand the test so he can consent. He is indicating no by shaking his head, which cannot be ignored. 4) Contact a person who is able to translate and then explain the procedure. Rationale: Mr. Wong must be given the opportunity to consent. It is recommended that an official interpreter be used whenever possible to decrease bias and misinformation.
Mr. Wong, 61 years old, has undergone treatment for weakness and diarrhea. He and his wife immigrated to Canada 5 years ago from Hong Kong. They speak very little English, and Mr. Wong avoids talking to the nursing staff.
What is the benefit of providing Mr. Wong with a back rub during evening care? 1) To enhance endorphin release Rationale: Massage does not do this. 2) To redistribute energy flow Rationale: This does not apply to this modality. 3) To relax muscles Rationale: This increases comfort through relaxation. 4) To promote rapid eye movement (REM) sleep Rationale: This is relaxing but not sedation.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 718-719. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 1033. 38 Question 38
Mr. Wong, 61 years old, has undergone treatment for weakness and diarrhea. He and his wife immigrated to Canada 5 years ago from Hong Kong. They speak very little English, and Mr. Wong avoids talking to the nursing staff. What best describes appropriate skin care to prevent anal excoriation due to the diarrhea Mr. Wong is experiencing? 1) Use dry tissue and gently wipe the area clean. Rationale: The dry tissue is abrasive and would add to the irritation. 2) Use a disinfectant towelette to cleanse and allow to air dry. Rationale: The disinfectant could burn the skin or at least be irritating. 3) Cleanse with mild soap and apply a barrier cream. Rationale: This would cleanse the irritated area and provide protection. 4) Dry the area thoroughly and apply a mild antibacterial lotion. Rationale: This is too abrasive and irritating to the skin.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 1009. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 1430.
39 Question 39
Chantelle, 16 years old, comes to the womens health centre 2 weeks following the completion of screening for sexually transmitted infections (STIs). The screening results were positive for gonorrhea and Chlamydia. The nurse wants to provide information that will assist Chantelle to reduce her future risk for pregnancy and sexually transmitted infections. What is the most realistic and effective option to reduce these risks? 1) Use a diaphragm along with the withdrawal method. Rationale: A diaphragm may be an inconvenient and cumbersome birth control method for this age group. The withdrawal method will not protect against STIs. 2) Use latex condoms along with hormonal birth control method. Rationale: This is the most realistic option because it does not eliminate the choice for sexual intercourse. It is also the most effective means of preventing STIs and pregnancy. 3) Use a spermacide along with the withdrawal method. Rationale: The withdrawal method will not eliminate the risk of STIs. A small amount of seminal fluid is released during the excitement phase and prior to ejaculation. This method will not provide protection against human papillomavirus (HPV) or infections transmitted via open lesions on the genitals (e.g., herpes, syphilis). 4) Refrain from sexual intercourse and engage only in extracoital activities. Rationale: Pregnancy can occur with outer genital contact if seminal fluid is introduced into the vaginal opening. STIs, such as HPV and those transmitted via open lesions on the genitals, are still a risk.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 671, 1377. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 466-470. 40 Question 40
Chantelle, 16 years old, comes to the womens health centre 2 weeks following the completion of screening for sexually transmitted infections (STIs). The screening results were positive for gonorrhea and Chlamydia. Chantelle reveals that she has been sexually active for the past year and that she has had several different sexual partners. What is the best approach to help Chantelle reduce her vulnerability for future sexual health problems? 1) Inform Chantelle of the risks she is taking by having unprotected sex with multiple partners. Rationale: This is a directive approach rather than a collaborative one. 2) Explore Chantelles beliefs about the benefits and risks associated with high-risk sexual behaviours. Rationale: This non-judgmental approach does not imply that Chantelle has been engaging in high-risk behaviours, and explores her perceptions of possible benefits of having multiple partners. Chantelles rationale for her behaviour might provide clues about the possible existence of unresolved developmental tasks. 3) Encourage Chantelle to discuss her sexual activities with a supportive friend. Rationale: Most females of this age will talk to a friend who may not have accurate information. The nurse
needs to provide accurate information. 4) Give Chantelle some pamphlets on how to protect herself from STIs and unwanted pregnancy. Rationale: The opportunity for exploration of issues and correcting misconceptions is lost. Chantelle may have further questions that may not be addressed in the pamphlet.
References: Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 468-469. Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, pp. 120-121, 68-69. 41 Question 41
Chantelle, 16 years old, comes to the womens health centre 2 weeks following the completion of screening for sexually transmitted infections (STIs). The screening results were positive for gonorrhea and Chlamydia. Chantelle tells the nurse that her current partner does not like to use condoms. She wants him to use a condom but is afraid that he will leave her if she insists. What is the most useful intervention? 1) Assist Chantelle to develop strategies for negotiating with her partner about condom use. Rationale: With the history of multiple sexual partners and positive STI screening results, Chantelle is at high risk for future STIs. The most effective means of prevention is the consistent and proper use of condoms. Assisting her to develop strategies will give her the tools to negotiate condom use with potential future partners. 2) Explore Chantelles reasons for having sex and her fear of abandonment. Rationale: This does not address the immediate problem. 3) Suggest that Chantelle ask her partner to be tested for STIs. Rationale: This would be helpful information, but it does not address the immediate problem. 4) Encourage Chantelle to look for a partner who would be more respectful of her wishes. Rationale: This is directive and insensitive and does not consider Chantelles desire to continue in this relationship.
References: Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 468. Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, pp. 68-69, 121. 42 Question 42
Mr. Nobis, 82 years old, had ignored the occurrence of melena stools until he passed out and was rushed to hospital by a neighbour. Extensive gastric surgery is required. During the preoperative interview, the nurse notes that Mr. Nobis uses the bedpan frequently to pass loose black stools. He appears to be confused, restless and dehydrated. His pulse rate is increasing, his respirations
are rapid and shallow, and he is hypotensive. What nursing intervention is necessary at this time? 1) Complete the preoperative assessment. Rationale: The client is demonstrating signs and symptoms of hypovolemia, and valuable treatment time will be lost by continuing with the interview. 2) Allow Mr. Nobis to rest. Rationale: The data demonstrate that the clients condition is worsening; leaving him alone is unsafe. 3) Call the physician to report Mr. Nobis condition. Rationale: The client is demonstrating early signs of shock. The physician needs to be advised of his condition, and orders from the physician are needed for further treatment. 4) Administer a sedative as ordered for his restlessness. Rationale: The clients condition warrants immediate treatment; sedatives will mask his condition further.
References: Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 1643. Smeltzer, S. C., Bare, B., Hinkle, J. L., & Cheever, K. H. (2007). Brunner and Suddarths textbook of medical-surgical nursing (11th ed.). Philadelphia, PA: Lippincott Williams &Wilkins, pp. 303-308, 1023-1025. 43 Question 43
Mr. Nobis, 82 years old, had ignored the occurrence of melena stools until he passed out and was rushed to hospital by a neighbour. Extensive gastric surgery is required. The physician has ordered the insertion of an indwelling urinary catheter. After a difficult insertion of the catheter, the nurse notes that no urine appears to be draining. What should the nurse do initially? 1) Assess the placement of the catheter. Rationale: If no urine appears, the placement of the catheter should be checked first before assuming anuria. 2) Remove and re-insert the catheter. Rationale: Removal comes after the placement of the catheter has been checked. 3) Palpate the bladder for distension. Rationale: The bladder is not likely to be distended with an n.p.o. for surgery. 4) Check the catheter drainage by irrigating it. Rationale: This is not ordered and is unnecessary at this time
References: Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 1366-1370.
Smeltzer, S. C., Bare, B., Hinkle, J. L., & Cheever, K. H. (2007). Brunner and Suddarths textbook of medical-surgical nursing (11th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 1286-1287. 44 Question 44
Mr. Nobis, 82 years old, had ignored the occurrence of melena stools until he passed out and was rushed to hospital by a neighbour. Extensive gastric surgery is required. Mr. Nobis condition deteriorates and his vital signs are worsening. His skin is cold and pale, and he is disoriented and agitated. His pulse oximetry is 76% and his BP 85/50 mmHg. What should the nurse do first? 1) Increase the IV rate. Rationale: At this time, increasing the IV is not the priority and would require the physicians order. 2) Administer oxygen. Rationale: This would be the nurses first action because the client is demonstrating hypoxia. 3) Call the physician stat. Rationale: The physician would be called but it is not the first action. 4) Continue monitoring. Rationale: The clients condition warrants immediate medical intervention.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 825-826, 925. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 1090. 45 Question 45
Mr. Nobis, 82 years old, had ignored the occurrence of melena stools until he passed out and was rushed to hospital by a neighbour. Extensive gastric surgery is required. The physician has ordered an IV of Ringers lactate at 150 mL/h. Which findings would indicate a restoration of fluid balance? 1) Urine output of 500 mL per 24 hours, elevated blood urea nitrogen (BUN), elevated serum sodium Rationale: Output remains decreased from normal and the blood work is elevated, indicating hemoconcentration and fluid volume deficit. 2) Decreased BUN, decreased serum sodium, urine output of 30 mL per hour Rationale: These are indicators of normal fluid balance. 3) Urine output of 300 mL per 24 hours, BUN normal, increased serum sodium Rationale: The output is decreased with sodium remaining elevated, indicating fluid volume deficit. 4) Increased serum sodium, increased hematocrit, moist mucous membranes
Rationale: The blood work remains elevated, indicating hemoconcentration and fluid volume deficit.
References: Craven, R. F., &Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 925, 941. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 1151-1154. 46 Question 46
John, 15 years old, is admitted to hospital with a diagnosis of leukemia. John is started on chemotherapy for leukemia. What intervention should the nurse include in Johns plan of care? 1) Teach John to perform mouth care every 4 hours. Rationale: Mouth care should be performed every 4 hours to reduce the risk of infection. 2) Allow John to eat his meals in the cafeteria with his family and friends. Rationale: Socializing increases Johns exposure to infection. 3) Monitor Johns white blood cell count twice a day. Rationale: This needs a physicians order. This is not necessary and increases risk of bleeding and infection. 4) Encourage John to eat raw fruits and vegetables that he finds appealing. Rationale: A low-bacteria diet (e.g., no raw fruits and vegetables) is appropriate.
References: Hockenberry, M. J., & Wilson, D. (2009). Essentials of pediatric nursing (8th ed.). St. Louis, MO: Elsevier, p. 916. Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, pp. 1621-1624. 47 Question 47
John, 15 years old, is admitted to hospital with a diagnosis of leukemia. Which statement by the nurse will help John understand the chemotherapy? 1) These medications will help to destroy the cancer cells in your body. Rationale: Anti-cancer medications destroy the rapid growth of cancer cells. 2) These medications stimulate the normal cells to grow faster than the cancer cells. Rationale: Anti-cancer medications destroy some normal cells. 3) There are side-effects from these medications but they can be easily controlled. Rationale: There are many side-effects from anti-cancer medications, some of which cannot be easily
controlled. 4) You may be on these medications for the rest of your life. Rationale: Chemotherapeutic agents are given for a prescribed period of time.
References: Black, J. M., &Hokanson Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Elsevier Saunders, p. 277. Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, pp. 1620-1630. 48 Question 48
John, 15 years old, is admitted to hospital with a diagnosis of leukemia. While assisting John with his morning care, the nurse observes that he has become extremely fatigued. What should the nurse do? 1) Allow him to rest if he wishes. Rationale: Resting conserves the clients energy. 2) Encourage him to complete the care as quickly as possible. Rationale: It is more important for John to conserve his energy. 3) Get another nurse to help finish the care. Rationale: This would not relieve the fatigue and may even increase his fatigue if two nurses are caring for him. 4) Chemotherapeutic agents are given for a prescribed period of time. Rationale: This would not help to relieve the clients fatigue.
References: Hockenberry, M. J., & Wilson, D. (2009). Essentials of pediatric nursing (8th ed.). St. Louis, MO: Elsevier, p. 962. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 529. 49 Question 49
John, 15 years old, is admitted to hospital with a diagnosis of leukemia. After discharge, John has a temperature of 39.5 oC and is to be readmitted to hospital. The only vacant bed is in a two-bed room. What should the nurse do? 1) Inform the admission office that John should be transferred to another facility because there are no single rooms. Rationale: For continuity of care, it would be preferable to have John remain at the same facility. Other options, such as bed transfers, should be considered before transferring to another facility.
2) Move the client who has a fracture from a single room to the two-bed room, and assign John to the single room. Rationale: This would be the best solution. This client is not at risk of spreading or developing an infection. 3) Move the client who has chickenpox from a single room to the two-bed room, and assign John to the single room. Rationale: The client who has chickenpox is still contagious and could infect others on the unit. 4) Assign John to the two-bed room with another teenage client with leukemia. Rationale: John has an elevated temperature so an infection is suspected. He could infect another immunosuppressed client.
References: Black, J. M., &Hokanson Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Elsevier Saunders, p. 2121. Hockenberry, M. J., & Wilson, D. (2009). Essentials of pediatric nursing (8th ed.). St. Louis, MO: Elsevier, p. 935. 50 Question 50
Mr. Potter, 62 years old, states that after discussion with his family, he has decided not to continue with chemotherapy for his terminal cancer. What response should the nurse make? 1) Tell me, how did you reach this decision? Rationale: The nurse is accepting the clients decision without introducing any value judgment. 2) Would you like to talk to someone else about this decision? Rationale: The nurse is not accepting the clients decision. 3) Are you very sure that you have considered all the consequences of this decision? Rationale: The client indicated that he has made his decision after careful consideration and the nurse is not accepting this. 4) Has the physician clearly explained the benefits of this chemotherapy? Rationale: This option does not accept the clients decision and puts the physicians wishes before those of the client.
References: Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa, ON: Author, p. 11. Wilkinson, J. M., & Van Leuven, K. (2007). Fundamentals of nursing: Theory, concepts and applications. Philadelphia, PA: F. A. Davis Company, p. 346. 51 Question 51
When asking a 78-year-old client who wears a hearing aid a question about her diet, the nurse receives an unrelated answer. What should the nurse do initially?
1) Assess the clients level of orientation. Rationale: The nurse has assumed that the client heard clearly what was said without validating that fact by repeating the statement at a slower pace and lower pitch. 2) Repeat the question with a slower and lower pitched voice. Rationale: The ability to hear high frequency sounds decreases with age. The older adult hears a slower, lower-pitched voice best. 3) Repeat the question increasing the volume and pitch of voice. Rationale: Ability to hear high-pitched sounds decreases first with age. Speaking too loudly may exceed the clients hearing threshold and be heard as disturbing loudness. 4) Rephrase the question in very simple terms. Rationale: This would be done if the client still did not hear the question after repeating it in a slower and deeper voice.
References: Ebersole, P., Hess, P., Touhy, T., Jett, K., &Luggen, A. (2008). Toward healthy aging (7th Ed.). St. Louis, MO: Elsevier, p. 560. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 270. 52 Question 52
Julia, a community health nurse, is a member of an interprofessional team and facilitates discussions at case conferences. She has noticed that these meetings are becoming increasingly difficult and that tension exists among certain team members. What is the most appropriate action for Julia to take? 1) Meet with each team member separately to try to break the tension. Rationale: All members of a group need to understand the cause of tension and work together to resolve it. 2) Address the subject at the next case conference. Rationale: This will take the focus away from the case. There should be a separate meeting to address the issue of increasing tension at meetings. 3) Inform the director of Human Resources of the problem. Rationale: The nurse should attempt to resolve the tension before seeking outside help. 4) Call a team meeting to try to resolve the issue. Rationale: The team members should meet to discuss the tension and allow members to express their feelings. This will help to strengthen the team.
References: Arnold, E. C., & Underman Boggs, K. (2007). Interpersonal relationships: Professional communication skills for nurses (5th ed.). St. Louis, MO: Elsevier Saunders, pp. 480-482.
Stanhope, M., & Lancaster, J. (2008). Community health nursing in Canada (1st Canadian ed.). Toronto, ON: Elsevier, p. 34. 53 Question 53
When should rehabilitation of a client begin? 1) When the client feels comfortable with the nurse Rationale: Rehabilitation efforts should begin with the initial contact with the client. The client may not be comfortable with the nurse during the initial contact. 2) When the physician orders rehabilitative therapy Rationale: Rehabilitation begins with the initial contact with the nurse and is based on the initial assessment. Rehabilitative therapy may be ordered at any time. 3) During the clients admission and history interview Rationale: This is when the initial contact with the nurse occurs and when rehabilitation should be initiated. 4) After the rehabilitation goals have been prescribed Rationale: Rehabilitative goals based on individual assessment are established with the client and are ongoing in the hospital and in the community.
References: deWit, S. C. (2009). Fundamental concepts and skills for nursing (3rd ed.). St. Louis, MO: Elsevier, p. 399. Potter, P. A., & Griffin Perry, A. (2007). Basic nursing: Essentials for practice (6th ed.). St. Louis, MO: Mosby, pp. 28-29. 54 Question 54
A nurse is asked to speak to a group of adults attending a marriage preparation course. What is the most appropriate strategy for the nurse to use when developing a learning plan? 1) Ask the course instructor what topics to include in the presentation. Rationale: This may not allow for variation in cultural and religious values. 2) Utilize the previous groups evaluation responses. Rationale: This is not the most appropriate option, since the current groups needs must be assessed. However, the previous groups needs may be informative. 3) Survey the participants about their learning needs. Rationale: This allows for the learners to participate and allows the nurse to develop a learning plan to meet their needs. 4) Arrange for a lecture by a marriage counsellor. Rationale: The nurse is not assessing the learning needs, but simply assuming the needs of the group.
References:
Bastable, S. (2008). Nurse as educator: Principles of teaching and learning for nursing practice (3rd ed.). Boston, MA: Jones & Bartlett, p. 97. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, pp. 301-302. 55 Question 55
Mrs. Dufour is admitted to a long-term care facility with a diagnosis of Alzheimers disease. Mrs. Dufours husband has been caring for her at home. Mr. Dufour states, I dont know what Im going to do at home. Ill miss my wife so much. How should the nurse respond to Mr. Dufour? 1) Mrs. Dufour will be taken care of here. This will allow you to spend more time with her. Rationale: This response minimizes the clients statement. 2) I understand that you will miss your wife. Tell me what you mean by not knowing what to do at home? Rationale: This response acknowledges the statement made by Mr. Dufour and correctly asks for clarification. 3) Mr. Dufour, have you thought about developing a hobby? Tell me about your interests. Rationale: This response offers a solution to the stated concern before exploring the concern with the client. 4) Mr. Dufour, it sounds as though you feel guilty about not caring for Mrs. Dufour at home. Rationale: The response demonstrates reflection of emotional content that is not present in the clients statement.
References: Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa, ON: Author, p. 13. Riley, J. B. (2008). Communication in nursing (6th ed.). St. Louis, MO: Mosby, p. 100. 56 Question 56
Mr. Toth, 64 years old, has advanced multiple sclerosis. He is having difficulty chewing and swallowing, and frequently chokes and aspirates. The nurse offers him a soft diet meal and he refuses, stating, I won't eat this. Feed me some real food. He is fully aware of the implications and consequences of this decision to continue with a regular diet. What should the nurse do? 1) Document his informed decision to eat a regular diet. Rationale: An informed client has the absolute right to refuse care. 2) Continue to provide the soft diet to prevent aspiration. Rationale: Continuing to provide the soft diet ignores the clients wishes. 3) Collaborate with family members to convince him to change his mind. Rationale: Collaborating with family members to convince Mr. Toth to change his mind is coercive. 4) Collaborate with the physician to order a soft diet.
Rationale: Collaborating with the physician to write the soft diet as a prescribed order is ignoring Mr. Toths wishes.
Mrs. Andrews, 80 years old, is admitted to a long-term care facility. Mrs. Andrews is very quiet during the admission procedure and responds to the nurse only when she is spoken to. While the nurse is helping Mrs. Andrews to unpack her belongings, Mrs. Andrews begins to cry. How should the nurse respond? 1) Mrs. Andrews, why are you unhappy to be here? Rationale: Asking the client for an explanation of her feelings does not promote open communication. Why questions may place the client on the defensive and are usually a barrier to communication. 2) Is there anything I can do to help you, Mrs. Andrews? Rationale: This is a nurse-focused question rather than a client-focused question. In addition, it is a closedended question, which is a barrier to communication. 3) Mrs. Andrews, the other residents are happy here. Don't you think you will be too? Rationale: This statement diminishes Mrs. Andrews feelings at this time and focuses on the other clients. This is a barrier to communication. 4) This seems to be very difficult for you, Mrs. Andrews. Rationale: In this statement the nurse is showing empathy for Mrs. Andrews and is giving her an opportunity to talk about her feelings.
What response would be most helpful when a nursing colleague asks for feedback on her communication skills after having difficulty in dealing with an aggressive client? 1) You really preserved his self-esteem. I liked how you handled the situation, but you were just not firm enough. Rationale: This response is vague. 2) I do not feel comfortable giving you feedback. I think feedback about your performance should come from the supervisor.
Rationale: Peer feedback is an important aspect of professional development. 3) You are such a kind person, but in nursing, you need to be able to take control in situations like this. You need to be more assertive. Rationale: This response provides advice and focuses on personality traits rather than behaviours in the situation. 4) I saw that when you called him by his first name, he really relaxed. Perhaps if you had a firmer tone of voice, he might have listened to you. Rationale: This response focuses on observations of specific behaviours. It includes positive feedback, as well as areas for improvement
References: deWit, S. C. (2009). Fundamental concepts and skills for nursing (3rd ed.). St. Louis, MO: Elsevier, p. 131. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby. 59 Question 59
While helping at a career day in a high school, a nurse is approached by a 40-year-old teacher who requests a blood pressure assessment. The teacher has been receiving medical treatment for stress-related hypertension since the beginning of the school year. What are the priority nursing actions for health promotion? 1) Assess blood pressure and refer the teacher to a stress-management clinic. Rationale: This does not address collaboration or provide an opportunity for discussion. More information is required before a referral would be made. 2) Recommend exploring a decreased workload and counselling to manage stress. Rationale: This does not address collaboration or provide an opportunity for discussion. Work overload is an assumption. 3) Assess blood pressure and explore current stress management strategies that the teacher is using. Rationale: Emphasis is placed on collaboration and provides an opportunity for discussion. Also, hypertension is one physiological response of the body to prolonged stress. 4) Recommend exploring a decrease in workload and provide information on current prescribed medications. Rationale: This does not address collaboration or provide an opportunity for discussion.
References: deWit, S. C. (2009). Fundamental concepts and skills for nursing (3rd ed.). St. Louis, MO: Elsevier, p. 119. Wilkinson, J. M., & Van Leuven, K. (2007). Fundamentals of nursing: Theory, concepts and applications. Philadelphia, PA: F. A. Davis Company, p. 1005. 60 Question 60
Susie, 8 years old, is admitted to hospital for regulation of her insulin requirements. Her insulin orders for this
morning are: insulin isophane (Humulin-N) 5 units and regular insulin (Humulin-R) 5 units q.a.m. What should the nurse do when preparing these medications? 1) Shake both vials to mix the insulins. Rationale: The insulin vial should be rolled between the palms. Shaking may result in an inaccurate dose. 2) Use a 27-gauge, 2.5 cm needle. Rationale: The length of the needle is appropriate for IM injections, not subcutaneous injections. 3) Check the expiry dates on the vials. Rationale: Expiry dates should always be checked before preparing medication to confirm that the medication is not outdated. 4) Check the results of bedtime blood glucose monitoring. Rationale: Blood glucose monitoring should be done just prior to the administration of insulin.
References: Berman, A. J., Snyder, S., Kozier, B., &Erb, G. (2008). Fundamentals of nursing: Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Prentice-Hall, p. 866. Karch, A. M. (2008). 2008 Lippincotts nursing drug guide. Philadelphia, PA: Lippincott Williams & Wilkins, p. 614. 61 Question 61
Geoff is a nurse caring for Mrs. Khan. Mrs. Khans husband states that their religious beliefs prevent a man from looking after a woman. What should be Geoffs response to Mr. Khan? 1) I will speak to the nurse-in-charge to rearrange the assignment so that your wife has a female nurse. Rationale: This demonstrates sensitivity to the clients cultural and religious needs. 2) I appreciate your religious beliefs. However, I assure you that I will provide respectful care to your wife. Rationale: This is not an issue of whether Geoff can provide respectful care. 3) I respect your chosen religion, but it does not comply with my beliefs about gender equality. Rationale: This response demonstrates a focus on the nurses needs, rather than the clients needs. 4) I cannot change the assignment at this time. Perhaps tomorrow we can find a female nurse. Rationale: This does not demonstrate sensitivity to the clients stated beliefs. It implies that the problem is not important and can be deferred to another day.
References: Berman, A. J., Snyder, S., Kozier, B., &Erb, G. (2008). Fundamentals of nursing: Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Prentice-Hall, pp. 314-315. Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa, ON: Author, p. 11.
62 Question 62
Health records indicate that there has been a significant decline in the number of immunizations administered over the past 15 years in a community of 10,000 people. What is the most efficient first step to identify the reason for this decline in immunizations? 1) Analyze the age characteristics of the community using the most recent census data. Rationale: Census data would provide an efficient means of reviewing the age profile of the community. 2) Review hospital admission data at the community hospital. Rationale: Hospital admission data would reflect only occurrences of illness that necessitated hospitalization, which is a small percentage of the preventable diseases in question. 3) Conduct a series of home visits in the community asking about immunization practices. Rationale: Home visits would be an effective but very inefficient means of gathering this data and should be considered only after preliminary data analysis indicates that home visits are warranted. 4) Review disease-specific mortality and morbidity data from Statistics Canada. Rationale: Statistics Canada data would be a crude, and therefore inaccurate, reflection of a community of 10,000.
References: Stanhope, M., & Lancaster, J. (2006). Foundations of nursing in the community: Communityoriented practice (2nd ed.). Toronto, ON: Mosby, p. 171. Stanhope, M., & Lancaster, J. (2008). Community health nursing in Canada (1st Canadian ed.). Toronto, ON: Elsevier, p. 38. 63 Question 63
Mr. Clark, 19 years old, is admitted to hospital for pneumonia and has just been told that he is HIV positive. He asks the nurse not to reveal the diagnosis to his wife, even if she asks a lot of questions. What should the nurse do initially? 1) Avoid conversation with Mrs. Clark. Rationale: This is unrealistic and may make Mrs. Clark suspicious. 2) Refrain from revealing the clients diagnosis to Mrs. Clark. Rationale: This maintains Mr. Clarks privacy and confidentiality 3) Inform Mrs. Clark only if she asks about the cause of the pneumonia. Rationale: This would be a breach of Mr. Clarks confidentiality. 4) Tell Mr. Clark that he is required to immediately inform his wife of the diagnosis. Rationale: There is no basis for forcing Mr. Clark to tell his wife.
References: Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa, ON: Author, pp. 15-16.
Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, p. 91. 64 Question 64
The nurse is visiting a family living in city housing adjacent to a landfill site. During the discussion, the mother states that there are often bad odours that seep into their apartment building. What is the most important information for the nurse to collect to complete the assessment? 1) Whether the community is organized to address this problem Rationale: The nurse has identified an area for health promotion. 2) Whether the family has considered moving Rationale: Moving may not be an option or a desired resolution by the family. 3) Whether the mother is involved with the housing governing council Rationale: This implies expectations of involvement, which may not be possible for this family. 4) Whether the odours are a seasonal problem Rationale: Even seasonal odours can be harmful.
References: Stanhope, M., & Lancaster, J. (2006). Foundations of nursing in the community: Communityoriented practice (2nd ed.). Toronto, ON: Mosby, pp. 217, 222. Stanhope, M., & Lancaster, J. (2008). Community health nursing in Canada (1st Canadian ed.). Toronto, ON: Elsevier, pp. 263-264. 65 Question 65
Mrs. Mackay is the caregiver for her 85-year-old father. Mrs. Mackay would like to take a 2-week vacation with her husband. She approaches the community health nurse for assistance in accessing community resources. What is the most appropriate resource for the nurse to suggest to Mrs. Mackay? 1) Admission to a local hospital for 2 weeks Rationale: This is expensive and not the best support for the family. 2) Placement with another family member Rationale: The family is asking about community services. 3) Respite services in a local long-term care facility Rationale: This is a short-term stay in a facility to provide support for the caregiving family. 4) Admission to a seniors daycare Rationale: This is a source of support, but not appropriate for the needs of this family at this time.
References: Lewis, S., McLean Heitkemper, M., Ruff Dirksen, S., Goldsworthy, S., & Barry, M. A. (2006).
Medical-surgical nursing in Canada: Assessment and management of clinical problems (1st Canadian ed.). Toronto, ON: Mosby, p. 77. Rice, R. (2006). Home care nursing practice: Concepts and application (4th ed.). St. Louis, MO: Mosby, p. 447. 66 Question 66
A case of pertussis is reported in a childrens daycare centre. What should the community health nurse do? 1) Close the daycare centre until the risk of transmission is minimal. Rationale: This is not an effective strategy and is not the nurses role. Children and staff have already been exposed. 2) Immunize all the children and staff in the daycare centre. Rationale: This is not effective to reduce immediate transmission. The nurse needs the parents permission and cooperation. 3) Report the case to the public health authorities. Rationale: It is required by law to report communicable diseases. 4) Test all the children and staff in the daycare centre for pertussis. Rationale: This is not the nurses role.
References: Hockenberry, M. J., & Wilson, D. (2007). Wongs nursing care of infants and children (8th ed.). St. Louis, MO: Elsevier Mosby, pp. 672-673. Stanhope, M., & Lancaster, J. (2006). Foundations of nursing in the community: Communityoriented practice (2nd ed.). St. Louis, MO: Mosby, p. 522. 67 Question 67
Mrs. Hatch, 64 years old, has been living with chronic arthritic pain for 3 years. She reports the pain as 7 out of 10 on a pain scale. Her blood pressure and pulse are within normal ranges for her age. What does the nurse need to be aware of in order to accurately understand Mrs. Hatchs pain experience? 1) Elevated blood pressure and increased pulse rate should accompany her level of pain. Rationale: Using physiologic signs to indicate pain is unreliable because these responses are short-lived as the bodys autonomic system adapts to the stress of the pain. 2) Her pain tolerance has increased because mental adaptation has occurred. Rationale: A person with chronic non-cancer pain often does not show overt symptoms and does not adapt to the pain. Rather the person suffers more because of mental exhaustion and depression. 3) Pain is expected to increase as she moves into older adulthood. Rationale: This is a myth because pain is not an inevitable result of aging. 4) Her pain scale rating of 7 is the most reliable indicator of her pain.
Rationale: The clients report of pain is the most reliable indicator of pain because pain is a subjective experience (American Pain Society).
References: Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and Suddarth's textbook of medicalsurgical nursing. (1st Canadian ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 1020. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, p. 234. 68 Question 68
Mr. Lord was discharged from the hospital to home care this morning. The nurse realizes that she forgot to include important information in the discharge summary. What is the best action by the nurse to ensure continuity of care with the home care agency? 1) Phone Mr. Lord and ask him to give the home care nurse the information. Rationale: This is not a reliable method of communication between professionals. 2) Document the omission in Mr. Lords hospital record and phone the home care agency. Rationale: Written communication between agencies would be more reliable. 3) Phone the home care agency and leave a recorded message. Rationale: Written communication between agencies would be more reliable. 4) Fax an updated discharge summary to the home care agency and follow up with a phone call. Rationale: Written communication between agencies is more reliable. A follow-up phone call would help to ensure that the message was received.
References: Berman, A. J., Snyder, S., Kozier, B., &Erb, G. (2008). Fundamentals of nursing: Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Prentice-Hall, pp. 126-128. Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 17. 69 Question 69
The community health nurse is visiting an 81-year-old man who is receiving palliative care. The client states, My doctor doesnt know anything; theres nothing wrong with me. Look, Im stronger today and Im going to be fine in a month or so. How should the nurse respond? 1) Listen as he expresses denial. Rationale: This provides acceptance without giving false hope. 2) Tell him that he may be right. Rationale: This is giving him false hope.
3) Observe for signs of anger. Rationale: This is avoiding his grief work. 4) Suggest that he talk to his physician. Rationale: This is avoiding his grief work.
References: Berman, A. J., Snyder, S., Kozier, B., &Erb, G. (2008). Fundamentals of nursing: Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Prentice-Hall, p. 473. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 271. 70 Question 70
During the change of shift report, the nurse notices that a co-worker is using sarcastic and disrespectful terms to describe the clients. How should the nurse respond? 1) Report the incident to the supervisor. Rationale: This creates distrust among team members and administration and is disrespectful to the coworker. 2) Discuss the incident with the co-worker. Rationale: This shows respect for the colleague. 3) Report the nurse to the professional association. Rationale: This will not stop the behaviour. 4) Ask other co-workers how to deal with this situation. Rationale: This creates distrust among team members and is disrespectful to the co-worker.
References: Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa, ON: Author, p. 13. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 1661. 71 Question 71
A client with terminal lung cancer informs the nurse of his decision to commit suicide. He tells the nurse that this is a secret between them. What is the nurses responsibility? 1) Convey this information to the other members of the health-care team. Rationale: The nurse has a duty to convey information that may result in an injury to a client or third party. 2) Respect the confidentiality of information obtained while caring for the client. Rationale: Maintaining confidentiality may adversely impact the client.
3) Inform the family of the clients intentions. Rationale: The family may be a valuable resource, but the health-care team must be told. 4) Refer the client to an organization that supports assisted suicide. Rationale: A referral to a support group does not ensure that the client will go, and the client may commit suicide while waiting to see someone else.
References: Stuart, G. W., &Laraia, M. T. (2009). Principles and practice of psychiatric nursing (9th ed.). St. Louis, MO: Elsevier Mosby, pp. 122-123, 137, 326-327. Varcolis, E. M., & Halter, M. J. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care. St. Louis, MO: Saunders Elsevier, p. 526. 72 Question 72
Michael, 2 years old, has been admitted with respiratory distress. When the nurse approaches him to conduct a respiratory assessment, Michael becomes very upset and starts crying and clinging to his mother, who is also crying. What is the best action for the nurse to take? 1) Ask Michaels mother to leave the room. Rationale: This will increase anxiety for the mother and child. It is also not compatible with principles of traumatic care. 2) Come back later when Michael has calmed down. Rationale: It is unsafe to leave Michael alone because respiratory distress may be life-threatening. 3) Speak slowly and attempt to reason with Michael. Rationale: This is not within the cognitive ability of a 2-year-old child. 4) Complete an initial assessment with Michael held in his mothers arms. Rationale: This allows the nurse to conduct a focused assessment to determine the severity of distress and allows the mother and child to maintain a sense of control.
References: Arnold, E. C., & Underman Boggs, K. (2007). Interpersonal relationships: Professional communication skills for nurses (5th ed.). St. Louis, MO: Elsevier Saunders, pp. 399-401. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 277. 73 Question 73
The relationship between nurses and physicians in a health-care agency has become strained because of disagreement about certain medical practices. What initial approach by the nurse would be helpful in resolving this conflict? 1) Hold a meeting with nurses and physicians. Rationale: Conflict resolution involves consideration of all points of view and an attempt to reach a win-win
solution. 2) Engage the services of a conflict mediator. Rationale: An attempt should be made to resolve the conflict among the group members. 3) Arrange for nurses to receive conflict management training. Rationale: An attempt should be made to resolve the conflict first. 4) Discuss nursing concerns with the union representative. Rationale: This is an inappropriate chain of communication. All parties must be a part of the conflict resolution process.
References: Arnold, E. C., & Underman Boggs, K. (2007). Interpersonal relationships: Professional communication skills for nurses (5th ed.). St. Louis, MO: Elsevier Saunders, pp. 481-483. Austin, W., & Boyd, M. A. (2008). Psychiatric nursing for Canadian practice. Philadelphia, PA: Lippincott Williams & Wilkins, p. 107. 74 Question 74
A 69-year-old man with chronic bronchitis tells the home care nurse that his dyspnea gets worse only when he attends the pulmonary rehabilitation classes. He does not want to return to the classes. What is the nurses best approach in this situation? 1) Encourage the client to see his physician to assess the change in medical condition. Rationale: Clients are encouraged to report early signs of respiratory infection. The nurse needs more information before making a referral to the physician. 2) Explore with the client other aspects such as medication compliance and finances. Rationale: The nurse is not addressing the clients immediate concerns. 3) Discuss with the client his experience in attending the classes. Rationale: The nurse needs to specifically address the clients immediate concerns. 4) Support the clients decision not to return to class. Rationale: A better approach is to assess the reasons for the clients feelings.
References: Arnold, E. C., & Underman Boggs, K. (2007). Interpersonal relationships: Professional communication skills for nurses (5th ed.). St. Louis, MO: Elsevier Saunders, p. 201. Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 581. 75 Question 75
Mr. Porter is unconscious following a traumatic brain injury 3 days ago. What is the most important intervention to optimize his rehabilitation outcome? 1) Passive range-of-motion exercises q.i.d. Rationale: This decreases the risk of contractures and loss of range of movement. 2) Positioning in semi-Fowlers t.i.d. Rationale: This position is used continuously to decrease intracranial pressure. 3) Anti-embolism stockings b.i.d. Rationale: This strategy is related to stability of medical condition rather than preserving functional capacity. Stockings should be used continuously and removed periodically. 4) Intermittent catheterization q.i.d. Rationale: Intermittent catheterization starts after the condition is stable.
References: Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 1941-1942. Mantik Lewis, S., McLean Heitkemper, M., Ruff Dirksen, S., Goldsworthy, S., & Barry, M. A. (2006). Medical-Surgical nursing in Canada: Assessment and management of clinical problems (1st Canadian ed.). Toronto, ON: Mosby, p. 1513. 76 Question 76
Julie, 16 years old, is admitted to the pediatric unit after fainting at school. She recently lost a great deal of weight and will not eat her hospital meals. She tearfully admits that she has to start eating more but is afraid to do so because she is too fat. What is the nurses best response? 1) You are not fat. You are within the normal weight range for your height. Rationale: This response is very condescending and does not validate Julies concerns. 2) You think you are fat? Lets go to the scale and weigh you. Rationale: This response does not validate Julies concerns, and a scale is the worst thing a client with anorexia can use. 3) You see yourself as fat? That must be hard for you. Rationale: This response validates Julies concern of being fat and encourages her to continue to speak. The nurse is also demonstrating empathy, which will help gain the clients trust. 4) You look fine to me. Look at that pretty young girl in the mirror. Rationale: This response does not validate Julies concerns and is patronizing. A mirror is a most stressful place for a client with anorexia.
References: Austin, W., & Boyd, M. A. (2008). Psychiatric nursing for Canadian practice. Philadelphia, PA:
Lippincott Williams & Wilkins, pp. 104-105. Videbeck, S. L. (2008). Psychiatric mental health nursing (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 106-109. 77 Question 77
As a result of reading research related to the practice setting, the nurse identifies the need to change some of the existing unit protocols. How should the nurse initiate the change? 1) Meet with the unit manager to discuss the current literature. Rationale: Literature needs to be reviewed and be sufficiently developed to guide practice. The unit manager can provide input regarding organizational support and alignment with strategic goals. 2) Lobby peers to gain support for the change. Rationale: This occurs once a decision has been made to institute change. 3) Revise the protocol for presentation to the unit manager. Rationale: Administration needs to support the change before any revision to the protocol is made, otherwise the change may not be accepted. 4) Contact the researchers to explore implementation strategies. Rationale: This could occur after a review and critique have been conducted and administrative approval has been gained.
References: LoBiondo-Wood, G., Haber, J., Cameron, C., & Singh, M. (2005). Nursing research in Canada: Methods, critical appraisal, and utilization (1st Canadian ed.). St. Louis, MO: Mosby, pp. 11-12. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 90. 78 Question 78
Ms. Parker presents to the Emergency Department with her partner, Ms. Broderick. Ms. Parker has a discoloured and painful contusion to her left periorbital area. Her partner states that Ms. Parker fell down the stairs the night before. How should the nurse proceed? 1) Immediately apply a warm pack to Ms. Parkers periorbital area. Rationale: An ice pack would be more appropriate. In addition, the client needs to be screened for abuse if it is suspected. 2) Ask Ms. Broderick to leave for a few minutes so that the nurse can speak to Ms. Parker alone. Rationale: The client should be interviewed alone when there is the slightest suspicion that the injury does not match the history. All women should be screened; abuse also occurs in lesbian relationships. 3) Question Ms. Parker and Ms. Broderick more closely as to the exact nature of the fall. Rationale: If Ms. Broderick is the perpetrator, the nurse may not be able to identify the real cause of the abuse when interviewing both women together.
4) Administer an analgesic to treat Ms. Parkers pain. Rationale: The head injury needs to be assessed fully prior to the administration of analgesia.
References: Austin, W., & Boyd, M. A. (2008). Psychiatric nursing for Canadian practice. Philadelphia, PA: Lippincott Williams & Wilkins, p. 886. Videbeck, S. L. (2008). Psychiatric mental health nursing (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 192. 79 Question 79
Which statement about addictive behaviours is true? 1) Inborn tolerance is not a factor in substance abuse. Rationale: Inborn tolerance may result in excessive alcohol or other drug intake. 2) Nurses are less at risk for alcoholism than the general population. Rationale: Nurses are equally at risk for developing substance abuse problems. 3) Substance disorders are usually diagnosed in the psychiatric setting. Rationale: Substance disorders are often under-diagnosed in the psychiatric setting. 4) Genetic predisposition is a risk factor for alcoholism. Rationale: There is a genetic predisposition.
References: Austin, W., & Boyd, M. A. (2008). Psychiatric nursing for Canadian practice. Philadelphia, PA: Lippincott Williams & Wilkins, pp. 506-507. Videbeck, S. L. (2008). Psychiatric mental health nursing (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, pp. 192, 371-372. 80 Question 80
Mrs. Davis, 72 years old, has left-sided hemiparesis and attends daily therapy sessions to assist with ambulation. She will live with her daughter temporarily. Family members express concern about how they will meet her needs. Which action by the nurse will be most effective in preparing them for this role? 1) Explain to them the rehabilitation goals. Rationale: This information will not prepare the family to meet these goals. 2) Encourage them to participate in her therapy sessions. Rationale: Active participation will prepare the family to continue Mrs. Davis exercises at home. 3) Encourage them to spend as much time as possible with her. Rationale: This may cause the family to become overprotective. 4) Discuss with them the importance of a safe home environment.
Rationale: A safe environment is necessary; however, this does not address active participation in Mrs. Davis care following discharge.
References: Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 163. Hoeman, S. (2008). Rehabilitation nursing: Prevention, intervention, and outcomes (4th ed.). St. Louis, MO: Mosby, p. 466. 81 Question 81
There has been an outbreak of diarrhea at the daycare centre. What action should the public health nurse implement to prevent the spread of gastroenteritis? 1) Teach the daycare staff the importance of meticulous hand-washing. Rationale: This is the most important and most basic technique in preventing and controlling transmission of a communicable disease. 2) Recommend that all the daycare children be given dextrose-electrolytes (Pedialyte). Rationale: This may not be advisable and does not address the present problem. 3) Advise the staff to disinfect the childrens play area. Rationale: Disinfecting the play area would not solve the problem. 4) Recommend that the daycare centre be isolated until the problem is resolved. Rationale: Isolation precautions may not be feasible.
References: Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 799. Stanhope, M., & Lancaster, J. (2006). Foundations of nursing in the community: Communityoriented practice (2nd ed.). St. Louis, MO: Mosby, p. 517. 82 Question 82
Mrs. Lombardo, 92 years old, is admitted to hospital with abdominal pain. She is anxious and constantly ringing her call bell. A nurse on the unit overhears a colleague tell Mrs. Lombardo to use the call bell only if she requires pain medication. What should the nurse do? 1) Respond to Mrs. Lombardo when she rings the call bell. Rationale: The nurse has a responsibility to discuss the incident with the colleague. 2) Report the colleague to the nursing supervisor. Rationale: This would not be done initially. The nurse should first approach the colleague and discuss the issue. 3) Discuss the overheard comment with the colleague.
Rationale: The nurse is practising in a manner that is consistent with professional values by intervening when colleagues perform questionable actions. 4) Ask Mrs. Lombardo why she is constantly ringing the call bell. Rationale: This does not address the issue of intervening when there are questionable actions of colleagues.
References: Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa, ON: Author, p. 9. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, pp. 92, 99. 83 Question 83
A client asks for information on herbal medicine. What information should the nurse give the client? 1) The concentration of ingredients in herbal medicine often varies. Rationale: This is accurate. Clients taking herbs should be aware of this. 2) Herbal medicines contain natural ingredients that are often more effective. Rationale: This is unsubstantiated information. Clients should also be aware of potential problems. 3) Herbal medicine is usually a safe alternative to traditional medicine. Rationale: This may not be accurate in all cases and is misleading information for the client. 4) Herbal medicine should be used only as a supplement to traditional medicine. Rationale: This is misleading information; herbal medicines may interact with prescribed medication.
References: Berman, A. J., Snyder, S., Kozier, B., &Erb, G. (2006). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Prentice-Hall, pp. 334-335. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 936-937. 84 Question 84
Mr. OConell, a 19-year-old skateboarder, has been treated for a Colles fracture. He is now ready to go home. What is the most appropriate action to prevent further injury? 1) Instruct him to refrain from skateboarding for 1 week. Rationale: There is a risk of re-injury during this time. He should refrain from skateboarding until healing is complete. 2) Ask him what protective gear he has for this sport. Rationale: The nurse has an opportunity to encourage the client to use safety measures at a time when the client is more likely to understand their importance.
3) Tell him that he should be more careful about the sports he chooses. Rationale: This does not address the issue of encouraging safety and is not therapeutic communication. 4) Tell him that he should have worn wrist guards to prevent this injury. Rationale: The client is already aware of this. This does not encourage him to use protective gear in the future.
References: Berman, A. J., Snyder, S., Kozier, B., &Erb, G. (2008). Fundamentals of nursing: Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Prentice-Hall, pp. 516-517. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 982. 85 Question 85
Susan, a newly graduated registered nurse, has difficulty completing her work on time. She feels overwhelmed and is worried that she will miss deadlines for client care. Which action would be most effective in managing her time? 1) Report for work earlier each day. Rationale: This will increase feelings of fatigue. 2) Take shorter breaks during the shift. Rationale: This will increase fatigue. The nurse needs adequate rest periods for relaxation. 3) Ask the nurse manager for a lighter workload. Rationale: This will not help with the issue of time management. 4) Plan a scheduled time for all priority activities. Rationale: Planning is the most important because the nurse needs to learn to prioritize.
References: Berman, A. J., Snyder, S., Kozier, B., &Erb, G. (2008). Fundamentals of nursing: Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Prentice-Hall, pp. 516-517. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 154-155. 86 Question 86
Mr. Bell, 60 years old, is terminally ill. He wishes to say goodbye to his dog but the nurse in charge tells him that no pets are allowed on the medical unit. What action is appropriate for Mr. Bells nurse to take? 1) Apologize to Mr. Bell and explain that nurses must follow hospital policy. Rationale: Nurses should not passively accept policies that are not in line with client needs. 2) Allow the family to bring the dog for a visit late in the evening. Rationale: This avoids the problem and does not change policy for future clients who may have similar
wishes. 3) Consult with the nurse-in-charge about making an exception to the policy. Rationale: Nurses should advocate for their clients and should challenge policies that are obsolete or inconsistent with client needs. 4) Suggest that his family meet with the hospital administrator to obtain permission. Rationale: Mr. Bells family is dealing with his dying and should not be expected to fill the role of change agent.
References: Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa, ON: Author, pp. 8-9. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 100. 87 Question 87
A nurse teaching older women about osteoporosis identifies social isolation as an additional challenge. Which social group would be most appropriate for this population? 1) Coffee club Rationale: Coffee will make the osteoporosis worse. 2) Baking club Rationale: Baking may increase the weight of these women, thereby increasing their risk of injury from osteoporosis. 3) Walking club Rationale: Walking will promote strong bones, and walking together will promote socialization. 4) Book club Rationale: Reading and discussion will promote socialization but will not help with the osteoporosis.
References: Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 2072. Mantik Lewis, S., McLean Heitkemper, M., Ruff Dirksen, S., Goldsworthy, S., & Barry, M. A. (2006). Medical-Surgical nursing in Canada: Assessment and management of clinical problems (1st Canadian ed.). Toronto, ON: Mosby, p. 1718. 88 Question 88
Marie, 18 years old, is 3 months pregnant. She had a small amount of vaginal bleeding and her physician has ordered a pelvic ultrasound. What should the nurse do prior to this test? 1) Have the client void 15 minutes before.
Rationale: For the sound waves to reflect best, the client needs to have a full bladder. 2) Explain to the client that this test is similar to an X-ray. Rationale: This is incorrect information and may increase Maries anxiety. X-rays are not used in ultrasounds. 3) Ensure that the client has a full bladder. Rationale: A full bladder holds the uterus stable and reflects the sound waves the best. 4) Offer the client an analgesic. Rationale: The discomfort is due to the full bladder and the client does not require an analgesic for this procedure.
References: Leifer, G. (2007). Introduction to maternity and pediatric nursing (5th ed.). St. Louis, MO: Elsevier, p. 66. Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, p. 217. 89 Question 89
Which client would be at the greatest risk for developing testicular cancer? 1) A 13-year-old boy who was circumcised as a newborn Rationale: A 13-year-old boy is not in the high-risk age bracket. 2) A 28-year-old man who has an undescended testicle Rationale: Testicular cancer is the most prevalent form of cancer in men 15-35 years of age. The risk of testicular cancer is greater in men who have had an undescended testicle. 3) A 30-year-old man who was hit by a hockey puck in the groin last year Rationale: He is in the high-risk age bracket, but clients with a history of an undescended testicle are at a higher risk. 4) A 62-year-old man who has an enlarged prostate Rationale: He is not in a high-risk bracket for this cancer.
References: Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Mantik Lewis, S., McLean Heitkemper, M., Ruff Dirksen, S., Goldsworthy, S., & Barry, M. A. (2006). Medical-Surgical nursing in Canada: Assessment and management of clinical problems (1st Canadian ed.). Toronto, ON: Mosby, p. 1462.
90 Question 90
What topic would be most important for a community health nurse to discuss with a group of parents of toddlers? 1) Bicycle safety Rationale: This is important, but not for this age group. 2) Carbon monoxide poisoning Rationale: This is important, but not specific to this age group. 3) Sudden infant death syndrome precautions Rationale: This is important, but not for this age group. 4) Water safety Rationale: Drowning is a significant cause of accidental death in toddlers. Toddlers are curious, active, and developing a sense of independence. The need to supervise them near any source of water is essential.
References: Berman, A. J., Snyder, S., Kozier, B., &Erb, G. (2008). Fundamentals of nursing: Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Prentice-Hall, p. 376. Hockenberry, M. J., & Wilson, D. (2007). Wongs nursing care of infants and children (8th ed.). St. Louis, MO: Elsevier Mosby, p. 631. 91 Question 91
When assessing Billy, a 2-year-old Asian Canadian, the nurse notes that his height and weight fall within the fourth percentile on a growth chart. What is the appropriate nursing action? 1) Identify the findings as reflecting failure to thrive and notify the physician. Rationale: Growth charts are based on norms for Caucasian children. 2) Discuss the childs diet with the mother and refer the family to a dietitian. Rationale: It may be appropriate to discuss the diet with the mother. There is no need to refer to a dietitian at this time. 3) Recognize that growth charts may not be applicable to all children and discuss his growth pattern with his parents. Rationale: Growth charts are based on norms for Caucasian children. A chart designed for Asian children should be used. 4) Suspect that the child may have a gastrointestinal problem and notify the physician so the necessary diagnostic tests can be initiated. Rationale: In the absence of other data, it is unlikely that the child has a physiological problem and invasive diagnostic testing of children should be avoided.
References: Hockenberry, M. J., & Wilson, D. (2007). Wongs nursing care of infants and children (8th ed.).
St. Louis, MO: Elsevier Mosby, pp. 166-168. Leonard Lowdermilk, D., & Perry, E. S. (2006). Maternity nursing (7th ed.). St. Louis, MO: Elsevier Mosby, pp. 985-990, 1892. 92 Question 92
Ms. Laverty, 69 years old, has an advanced pressure ulcer. She is 160 cm tall and weighs 72 kg. What food selection would be most effective to help her heal? 1) Yogurt, nuts and fresh fruit Rationale: This provides the high-calorie, high-protein diet needed for healing. Weight loss is a lower priority until the ulcer is healed. 2) Tossed salad, prunes and bran muffins Rationale: This provides high fibre to manage bowel elimination problems from immobility, but is not high in protein. 3) Skim milk, fresh fruit and vegetables Rationale: This is not a high-calorie or high-protein diet. 4) Whole grain breads, low-fat margarine and chicken soup Rationale: This is not high in calories or protein, which is necessary to promote healing.
References: Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 181. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 1510. 93 Question 93
The nurse has recently taken a position on a Urology Unit. After completing the unit orientation, the nurse identifies several specific learning needs. What should be the priority action? 1) Join a urology special interest group. Rationale: This is appropriate, but not the first priority because results are more long term. 2) Apply to attend an educational conference. Rationale: This could be appropriate in the future, but the nurse needs a more concrete learning opportunity. 3) Request mentorship from a senior nurse. Rationale: Mentorship facilitates the nurses entry into this field, will help meet the nurses learning needs and is a long-term strategy. 4) Apply for CNA certification in urology.
Rationale: CNA certification has a minimal requirement of experience prior to being eligible for certification.
References: Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, p. 35. Ross-Kerr, J. C., & Wood, M. J. (2003). Canadian nursing: Issues and perspectives (4th ed.). Toronto, ON: Elsevier, p. 416. 94 Question 94
A 30-year-old female client who lives with schizophrenia attends an outpatient clinic. She tells the nurse that she is having sexual intercourse with strangers she meets on the street. How should the nurse respond? 1) Advise the client that she is engaging in risky behaviour and provide health teaching about sexually transmitted infections. Rationale: Clients who have a psychotic illness often have impaired judgment and may not be able to understand or control sexual impulses, resulting in sexual activity that may be detrimental to their health. While health teaching is an important component of the nursing care plan, it does not go far enough. 2) Ask the client to provide a urine sample for a pregnancy test and suggest that she refrain from further sexual activity until she speaks to her physician. Rationale: The client should have a pregnancy test. However, a client who is suffering from a chronic psychotic illness is unlikely to stop the dangerous sexual behaviour because of suggestions from the nurse. 3) Explore the clients knowledge about risky sexual practices and supply her with birth control pills. Rationale: Birth control pills will protect the client from pregnancies, if she is compliant. However, the use of condoms is necessary to protect her from sexually transmitted infections. 4) Provide health teaching about safer sex practices, supply the client with condoms and advise the physician of the clients behaviour. Rationale: Providing the client with condoms along with health teaching about safer sex practices is an important nursing intervention. While the client may not always use a condom, even frequent use will decrease her risk for sexually transmitted infections. Advising the physician of the clients behaviour will initiate a plan for administering the appropriate medication.
References: Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, pp. 466-469. Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2006). Maternal child nursing care (3rd ed.). St. Louis, MO: Elsevier Mosby, pp. 120-121. 95 Question 95
Mrs. Atkins, 66 years old, had a right total hip replacement yesterday. How should the nurse position the clients right leg? 1) Adducted and in neutral rotation Rationale: Leg should not be adducted because this may dislocate the joint. 2) Abducted and in neutral rotation
Rationale: The desirable position for a postoperative total hip replacement includes abduction, neutral or external rotation and flexion of less than 90 degrees. 3) Abducted and internally rotated Rationale: The leg should not be adducted or internally rotated. 4) Adducted and externally rotated Rationale: The leg should not be adducted because this may dislocate the joint.
References: Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and Suddarth's textbook of medical-surgical nursing (1st Canadian ed). Philadelphia, PA: Lippincott Williams & Wilkins, p. 2042. Mantik Lewis, S., McLean Heitkemper, M., Ruff Dirksen, S., Goldsworthy, S., & Barry, M. A. (2006). Medical-Surgical nursing in Canada: Assessment and management of clinical problems (1st Canadian ed.). Toronto, ON: Mosby, p. 1694. 96 Question 96
A 30-year-old client is admitted to the Emergency Department, accompanied by the police. He has a laceration on his forehead, is intoxicated and verbally aggressive. How can the nurse promote safety while performing care? 1) Ask the police officers to immobilize the client while he is receiving care. Rationale: The client is verbally aggressive. Asking the police to restrain him may escalate his aggression. 2) Ask the physician to prescribe a tranquilizer. Rationale: The client is intoxicated and aggressive. Giving a tranquilizer may interact with the alcohol and increase his aggression. 3) Assess the status of the client in the presence of a colleague. Rationale: This allows the nurse to assess the client and minimize personal injury by having the colleague present. 4) Avoid personal injury by letting the client rest. Rationale: The client needs to be assessed to determine the extent of his injury.
References: Stuart, G. W., &Laraia, M. T. (2009). Principles and practice of psychiatric nursing (9th ed.). St. Louis, MO: Elsevier Mosby, pp. 575, 578-580. Varcolis, E. M., & Halter, M. J. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care. St. Louis, MO: Saunders Elsevier, pp. 429-430. 97 Question 97
Mr. Stinson, 64 years old, has a peripherally inserted central catheter (PICC) for chemotherapy. What should
the nurse do? 1) Change the dressing at the PICC site b.i.d. Rationale: Although institutional guidelines vary, it is unnecessary to change the dressing this frequently because it increases the risk of infection. 2) Check for correct placement daily. Rationale: Placement is checked via X-ray post-insertion. 3) Splint the forearm comfortably. Rationale: This would impede the mobility of the clients arm. PICCs are usually inserted above the antecubital space. 4) Tape the PICC tubing securely. Rationale: This stabilizes the PICC and promotes client safety.
References: Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and Suddarths textbook of medical-surgical nursing (1st Canadian ed.). Philadelphia, PA: Lippincott Williams & Wilkins, p. 1010. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2006). Canadian fundamentals of nursing (3rd ed.). St. Louis, MO: Mosby, p. 1317. 98 Question 98
The home care nurse discovers a multitude of medications in the clients bathroom. There is a combination of prescribed, expired and over-the-counter medications. The nurse offers to return the medications to the pharmacy for disposal, but the client becomes upset saying, I have paid for these pills and I cant be going to the doctor all the time. What should the nurse do? 1) Inform the physician about this clients medication usage. Rationale: This is within the scope of nursing, not the physicians responsibility. The nurse needs to educate the client. 2) Consult the pharmacist and remove all expired medication. Rationale: This is not providing any teaching regarding the safe use of medication and polypharmacy. 3) Develop a contract with the client that he will not take any of the medications. Rationale: The nurse is asking the client to make a decision without adequate information. Some of the medications may be essential to his health. 4) Provide health teaching about the effects of taking these drugs. Rationale: Ethically, the nurse must provide adequate information on which the client can base his decision. Counselling can bring about a change in his attitude.
References: deWit, S. C. (2009). Fundamental concepts and skills for nursing (3rd ed.). St. Louis, MO:
Elsevier, pp. 643, 841-842. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., & Wood, M. J. (2009). Canadian fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, pp. 697-701. 99 Question 99
A registered nurse, Thomas, coming on duty asks, Who wants to do the narcotics count with me? His colleague, Sue, on the outgoing shift responds, The count has been done. You just have to sign it. What should Thomas do? 1) Insist that one of the nurses on the outgoing shift verify the count with him. Rationale: At the end of each shift, controlled drugs are counted by the nurse on the outgoing shift and the nurse on the incoming shift. Any errors must be identified and corrected before the outgoing nurses are dismissed. 2) Perform the count by himself and sign the narcotics record sheet if correct. Rationale: Two nurses must do the count of controlled drugs together. 3) Ask a colleague on his shift to co-sign the narcotics record sheet with him. Rationale: A nurse from the outgoing shift and a nurse from the incoming shift must do the count together. 4) Sign the count and clarify the agency policy on narcotics with Sue. Rationale: To sign that the count was correct without verifying that it is demonstrates a lack of responsibility.
References: Craven, R. F., Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia, PA: Lippincott Williams Wilkins, p. 504. Potter, P. A., Griffin Perry, A., Ross-Kerr, J. C., Wood, M. J. (2009). Canadian fundamentals of nursing (4th ed.). St. Louis, MO: Mosby, p. 678. 100 Question 100
What dietary supplement should the nurse recommend a woman begin taking prior to conception in order to decrease the incidence of neural tube defects? 1) Vitamin A Rationale: This is not linked to neural tube defects. 2) Calcium Rationale: Calcium is necessary for the growth and mineralization of fetal bones. 3) Ascorbic acid Rationale: This is not linked to neural tube defects. 4) Folic acid Rationale: Studies have shown a link between folic acid deficiency and neural tube defects. Taking folic acid
supplements prior to conception reduces the occurrence of neural tube defects.
References: Hockenberry, M. J., & Wilson, D. (2007). Wong's nursing care of infants and children (8th ed.). St. Louis, MO: Elsevier Mosby, p. 571. Leonard Lowdermilk, D., & Perry, E. S. (2006). Maternity nursing (7th ed.). St. Louis, MO: Elsevier Mosby, p. 184.

Readiness Test 1 2011

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Readiness test 1 2011 Green denotes the correct answer you provided. Blue denotes the correct answer.

Red denotes the incorrect answer you provided. Questions 1 Question 1

supplements prior to conception reduces the occurrence of neural tube defects.

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