Description

A&E I Comprehensive Test bank

Sexuality____________________________________________________________________69
Spiritual Health______________________________________________________________78
Week 2 Critical Thinking, The Nursing Process, Loss, Death, and Grief
Critical Thinking in Nursing Practice_____________________________________________86
Nursing Assessment___________________________________________________________94
Nursing Diagnosis___________________________________________________________102
Planning Nursing Care________________________________________________________110
Implementing Nursing Care____________________________________________________119
Evaluation__________________________________________________________________128
The Experience of Loss, Death and Grief__________________________________________136
Week 3 Safety and Fall Prevention among Older Adults, Preventing
Complications of Immobility
Patient Safety and Quality_____________________________________________________146
Immobility__________________________________________________________________163
Activity and Exercise__________________________________________________________181
Week 4 Skin and Wound Care Hygiene, Introduction to Pharmacology and
Medication Administration
Medication Administration_____________________________________________________194
Hygiene____________________________________________________________________212
Skin Integrity and Wound Care__________________________________________________231
Week 5 Fluid & Electrolytes, Dehydration
Fluid, Electrolyte and Acid-Base Balance_________________________________________251
Week 6 Pain and Sleep
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A&E I Comprehensive Testbank
Pain Management____________________________________________________________268
Sleep______________________________________________________________________280
Week 7 Concepts related to Oxygenation, Circulation, and Tissue Perfusion,
Chronic Obstructive Pulmonary Disease
Oxygenation________________________________________________________________295
Obstructive Pulmonary Diseases________________________________________________314
Week 8 Diabetes Mellitus
Diabetes Mellitus____________________________________________________________331
Week 9 Hypertension, Stroke
Hypertension________________________________________________________________341
Stroke_____________________________________________________________________356
Week 10 Documentation and Informatics
Documentation and Informatics______________________________________368
Week 11 Nutrition, Dysphagia_____________________________________382
Week 12 Care of the Surgical Patient________________________________398
Week 1
Care of Older Adults: Culture, Spirituality, Communication,
Sexuality, Infection Control
Chapter 05: Chronic Illness and Older Adults Lewis: Medical-Surgical Nursing,
10th Edition
MULTIPLE CHOICE
1. When caring for an older patient with hypertension who has been hospitalized after a transient
ischemic (TIA), which topic is the most important for the nurse to include in the discharge
teaching?
a) Effect of atherosclerosis on blood vessels
b) Mechanism of action of anticoagulant drug therapy
c) Symptoms indicating that the patient should contact the health care provider
d) Impact of the patient’s family history on likelihood of developing a serious stroke
ANS: C
One of the tasks for patients with chronic illnesses is to prevent and manage a crisis. The patient
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A&E I Comprehensive Testbank
needs instruction on recognition of symptoms of hypertension and TIA and appropriate actions to
take if these symptoms occur. The other information may also be included in patient teaching but
is not as essential in the patient’s self-management of the illness.
2. The nurse performs a comprehensive assessment of an older patient who is considering
admission to an assisted living facility. Which question is the most important for the nurse to
ask?
a) “Have you had any recent infections?”
b) “How frequently do you see a doctor?”
c) “Do you have a history of heart disease?”
d) “Are you able to prepare your own meals?”
ANS: D
The patient’s functional abilities, rather than the presence of an acute or chronic illness, are more
useful in determining how well the patient might adapt to an assisted living situation. The other
questions will also provide helpful information but are not as useful in providing a basis for
determining patient needs or for developing interventions for the older patient.
3. An alert older patient who takes multiple medications for chronic cardiac and pulmonary
diseases lives with a daughter who works during the day. During a clinic visit, the patient
verbalizes to the nurse that she has a strained relationship with her daughter and does not enjoy
being alone all day. Which nursing diagnosis should the nurse assign as the priority for this
patient?
a) Social isolation related to fatigue
b) Risk for injury related to drug interactions
c) Caregiver role strain related to family employment schedule
d) Compromised family coping related to the patient’s care needs
ANS: B
The patient’s age and multiple medications indicate a risk for injury caused by interactions
between the multiple drugs being taken and a decreased drug metabolism rate. Problems with
social isolation, caregiver role strain, or compromised family coping are not physiologic
priorities. Drug–drug interactions could cause the most harm to the patient and are therefore the
priority.
4. Which method should the nurse use to gather the most complete assessment of an older
patient?
a) Review the patient’s health record for previous assessments.
b) Use a geriatric assessment instrument to evaluate the patient.
c) Ask the patient to write down medical problems and medications.
d) Interview both the patient and the primary caregiver for the patient.
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ANS: B
The most complete information about the patient will be obtained through the use of an
assessment instrument specific to the geriatric population, which includes information about both
medical diagnoses and treatments and about functional health patterns and abilities. A review of
the medical record, interviews with the patient and caregiver, and written information by the
patient are all included in a comprehensive geriatric assessment.
5. Which intervention should the nurse implement to provide optimal care for an older patient
who is hospitalized with pneumonia?
a) Plan for transfer to a long-term care facility.
b) Minimize activity level during hospitalization.
c) Consider the preadmission functional abilities.
d) Use an approved standardized geriatric nursing care plan.
ANS: C
The plan of care for older adults should be individualized and based on the patient’s current
functional abilities. A standardized geriatric nursing care plan will not address individual patient
needs and strengths. A patient’s need for discharge to a long-term care facility is variable.
Activity level should be designed to allow the patient to retain functional abilities while
hospitalized and also to allow any additional rest needed for recovery from the acute process.
6. The nurse cares for an older adult patient who lives in a rural area. Which intervention should
the nurse plan to implement to meet this patient’s needs?
a) Suggest that the patient move closer to health care providers.
b) Obtain extra medications for the patient to last for 4 to 6 months.
c) Ensure transportation to appointments with the health care provider.
d) Assess the patient for chronic diseases that are unique to rural areas.
ANS: C
Transportation can be a barrier to accessing health services in rural areas. The patient living in a
rural area may lose the benefits of a familiar situation and social support by moving to an urban
area. There are no chronic diseases unique to rural areas. Because medications may change, the
nurse should help the patient plan for obtaining medications through alternate means such as the
mail or delivery services, not by purchasing large quantities of the medications.
7. Which nursing action will be most helpful in decreasing the risk for drug-drug interactions in
an older adult?
a) Teach the patient to have all prescriptions filled at the same pharmacy.
b) Make a schedule for the patient as a reminder of when to take each medication.
c) Instruct the patient to avoid taking over-the-counter (OTC) medications or supplements.
d) Ask the patient to bring all medications, supplements, and herbs to each appointment.
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ANS: D
The most information about drug use and possible interactions is obtained when the patient
brings all prescribed medications, OTC medications, and supplements to every health care
appointment. The patient should discuss the use of any OTC medications with the health care
provider and obtain all prescribed medications from the same pharmacy, but use of supplements
and herbal medications also need to be considered in order to prevent drug–drug interactions.
Use of a medication schedule will help the patient take medications as scheduled, but will not
prevent drug–drug interactions.
8. A patient who has just moved to a long-term care facility has a nursing diagnosis of relocation
stress syndrome. Which action should the nurse include in the plan of care?
a) Remind the patient that making changes is usually stressful.
b) Discuss the reason for the move to the facility with the patient.
c) Restrict family visits until the patient is accustomed to the facility.
d) Have staff members write notes welcoming the patient to the facility.
ANS: D
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Having staff members write notes will make the patient feel more welcome and comfortable at
the long-term care facility. Discussing the reason for the move and reminding the patient that
change is usually stressful will not decrease the patient’s stress about the move. Family member
visits will decrease the patient’s sense of stress about the relocation.
9. An older patient complains of having “no energy” and feeling increasingly weak. The patient
has had a 12-lb weight loss over the past year. Which action should the nurse take initially?
a) Ask the patient about daily dietary intake.
b) Schedule regular range-of-motion exercise.
c) Discuss long-term care placement with the patient.
d) Describe normal changes associated with aging to the patient.
ANS: A
In a frail older patient, nutrition is frequently compromised, and the nurse’s initial action should
be to assess the patient’s nutritional status. Active range of motion may be helpful in improving
the patient’s strength and endurance, but nutritional assessment is the priority because the patient
has had a significant weight loss. The patient may be a candidate for long-term care placement,
but more assessment is needed before this can be determined. The patient’s assessment data are
not consistent with normal changes associated with aging.
10. The nurse is admitting an acutely ill, older patient to the hospital. Which action should the
nurse take?
a) Speak slowly and loudly while facing the patient.
b) Obtain a detailed medical history from the patient.
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c) Perform the physical assessment before interviewing the patient.
d) Ask a family member to go home and retrieve the patient’s cane.
ANS: C
When a patient is acutely ill, the physical assessment should be accomplished first to detect any
physiologic changes that require immediate action. Not all older patients have hearing deficits,
and it is insensitive of the nurse to speak loudly and slowly to all older patients. To avoid tiring
the patient, much of the medical history can be obtained from medical records. After the initial
physical assessment to determine the patient’s current condition, then the nurse could ask
someone to obtain any assistive devices for the patient if applicable.
11. The nurse cares for an alert, homeless older adult patient who was admitted to the hospital
with a chronic foot infection. Which intervention is the most appropriate for the nurse to include
in the discharge plan for this patient?
a) Teach the patient how to assess and care for the foot infection.
b) Refer the patient to social services for assessment of resources.
c) Schedule the patient to return to outpatient services for foot care.
d) Give the patient written information about shelters and meal sites.
ANS: B
An interprofessional approach, including social services, is needed when caring for homeless
older adults. Even with appropriate teaching, a homeless individual may not be able to maintain
adequate foot care because of a lack of supplies or a suitable place to accomplish care. Older
homeless individuals are less likely to use shelters or meal sites. A homeless person may fail to
keep appointments for outpatient services because of factors such as fear of institutionalization
or lack of transportation.
12. The home health nurse cares for an older adult patient who lives alone and takes several
different prescribed medications for chronic health problems. Which intervention, if
implemented by the nurse, would best encourage medication compliance?
a) Use a marked pillbox to set up the patient’s medications.
b) Discuss the option of moving to an assisted living facility.
c) Remind the patient about the importance of taking medications.
d) Visit the patient daily to administer the prescribed medications.
ANS: A
Because forgetting to take medications is a common cause of medication errors in older adults,
the use of medication reminder devices is helpful when older adults have multiple medications to
take. There is no indication that the patient needs to move to assisted living or that the patient
does not understand the importance of medication compliance. Home health care is not designed
for the patient who needs ongoing assistance with activities of daily living or instrumental ADLs.
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13. The home health nurse visits an older patient with mild forgetfulness. Which new information
is of most concern to the nurse?
a) The patient tells the nurse that a close friend recently died.
b) The patient has lost 10 lb (4.5 kg) during the past month.
c) The patient is cared for by a daughter during the day and stays with a son at night.
d) The patient’s son uses a marked pillbox to set up the patient’s medications weekly.
ANS: B
A 10-pound weight loss may be an indication of elder neglect or depression and requires further
assessment by the nurse. The use of a marked pillbox and planning by the family for 24-hour
care are appropriate for this patient. It is not unusual that an 86-yr-old would have friends who
have died.
14. Which statement, if made by an older adult patient, would be of most concern to the nurse? a.
“I prefer to manage my life without much help from other people.”
a) “I prefer to manage my life without much help from other people.”
b) “I take three different medications for my heart and joint problems.”
c) “I don’t go on daily walks anymore since I had pneumonia 3 months ago.”
d) “I set up my medications in a marked pillbox so I don’t forget to take them.”
ANS: C
Inactivity and immobility lead rapidly to loss of function in older adults. The nurse should
develop a plan to prevent further deconditioning and restore function for the patient. Selfmanagement
is appropriate for independently living older adults. On average, an older adult
takes seven different medications so the use of three medications is not unusual for this patient.
The use of memory devices to assist with safe medication administration is recommended for
older adults.
15. The nurse assesses an older patient who takes diuretics and has a possible urinary tract
infection (UTI). Which action should the nurse take first?
a) Palpate over the suprapubic area.
b) Inspect for abdominal distention.
c) Question the patient about hematuria.
d) Request the patient empty the bladder.
ANS: D
Before beginning the assessment of an older patient with a UTI and on diuretics, the nurse
should have the patient empty the bladder because bladder fullness or discomfort will distract
from the patient’s ability to provide accurate information. The patient may seem disoriented if
distracted by pain or urgency. The physical assessment data are obtained after the patient is as
comfortable as possible.
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16. Which patient is most likely to need long-term nursing care management?
a) 72-yr-old who had a hip replacement after a fall at home
b) 64-yr-old who developed sepsis after a ruptured peptic ulcer
c) 76-yr-old who had a cholecystectomy and bile duct drainage
d) 63-yr-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg)
ANS: D
Osteoarthritis and obesity are chronic problems that will require planning for long-term
interventions such as physical therapy and nutrition counseling. The other patients have acute
problems that are not likely to require long-term management.
17. An older adult being admitted is assessed at high risk for falls. Which action should the nurse
take first?
a) Use a bed alarm system on the patient’s bed.
b) Administer the prescribed PRN sedative medication.
c) Ask the health care provider to order a vest restraint.
d) Place the patient in a “geri-chair” near the nurse’s station.
ANS: A
The use of the least restrictive restraint alternative is required. Physical or chemical restraints
may be necessary, but the nurse’s first action should be an alternative such as a bed alarm.
18. An older adult patient presents with a broken arm and visible scattered bruises healing at
different stages. Which action should the nurse take first?
a) Notify an elder protective services agency about possible abuse.
b) Make a referral for a home assessment visit by the home health nurse.
c) Have the family member stay in the waiting area while the patient is assessed.
d) Ask the patient how the injury occurred and observe the family member’s reaction.
ANS: C
The initial action should be assessment and interviewing of the patient. The patient should be
interviewed alone because the patient will be unlikely to give accurate information if the abuser
is present. If abuse is occurring, the patient should not be discharged home for a later assessment
by a home health nurse. The nurse needs to collect and document data before notifying the elder
protective services agency.
19. The family of an older patient with chronic health problems and increasing weakness is
considering placement in a long-term care (LTC) facility. Which action by the nurse will be most
helpful in assisting the patient to make this transition?
a) Have the family select a LTC facility that is relatively new.
b) Ask the patient’s preference for the choice of a LTC facility.
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c) Explain the reasons for the need to live in LTC to the patient.
d) Request that the patient be placed in a private room at the facility.
ANS: B
The stress of relocation is likely to be less when the patient has input into the choice of the
facility. The age of the long-term care facility does not indicate a better fit for the patient or
better quality of care. Although some patients may prefer a private room, others may adjust
better when given a well-suited roommate. The patient should understand the reasons for the
move but will make the best adjustment when involved with the choice to move and the choice
of the facility.
20. The nurse manages the care of older adults in an adult health day care center. Which action
can the nurse delegate to unlicensed assistive personnel (UAP)?
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a) Obtain information about food and medication allergies from patients.
b) Take blood pressures daily and document in individual patient records.
c) Choose social activities based on the individual patient needs and desires.
d) Teach family members how to cope with patients who are cognitively impaired.
ANS: B
Measurement and documentation of vital signs are included in UAP education and scope of
practice. Obtaining patient health history, planning activities based on the patient assessment,
and patient education are all actions that require critical thinking and will be done by the
registered nurse.
MULTIPLE RESPONSE
1. Which nursing actions will the nurse take to assess for possible malnutrition in an older adult
patient (select all that apply)?
a) Assess for depression.
b) Review laboratory results.
c) Determine food preferences.
d) Inspect teeth and oral mucosa.
e) Ask about transportation needs.
ANS: A, B, D, E
The laboratory results, especially albumin and cholesterol levels, may indicate chronic poor
protein intake or high-fat or high-cholesterol intake. Transportation affects the patient’s ability to
shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor
condition may decrease the ability to chew and swallow. Food likes and dislikes are not
necessarily associated with malnutrition.
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A&E I Comprehensive Testbank
Chapter 09: Cultural Awareness
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. A nurse is working at a health fair screening people for liver cancer. Which population group should the
nurse monitor most closely for liver cancer?
ANS: B
While Asian Americans generally have lower cancer rates than the non-Hispanic Caucasian population, they
also have the highest incidence rates of liver cancer for both sexes compared with Hispanic, non-Hispanic
Caucasians, or non-Hispanic African-Americans.
2. A nurse is caring for an immigrant with low income. Which information should the nurse consider when
planning care for this patient?
ANS: B
Populations with health disparities (immigrant with low income) have a significantly increased incidence of
disease or increased morbidity and mortality when compared with the general population. Although
Americans’ health overall has improved during the past few decades, the health of members of marginalized
groups has actually declined.
3. A nurse is assessing the health care disparities among population groups. Which area is the nurse
monitoring?
ANS: A
While health disparities are the differences among populations in the incidence, prevalence, and outcomes of
health conditions, diseases and related complications, health care disparities are differences among populations
in the availability, accessibility, and quality of health care services (e.g. screening, diagnostic, treatment,
management, and rehabilitation) aimed at prevention, treatment, and management of diseases and their
complications.
4. A nurse is providing care to a patient from a different culture. Which action by the nurse indicates cultural
competence?
a. Hispanic
b. Asian Americans
c. Non-Hispanic Caucasians
d. Non-Hispanic African-Americans
a. There is a decreased frequency of morbidity.
b. There is an increased incidence of disease.
c. There is an increased level of health.
d. There is a decreased mortality rate.
a. Accessibility of health care services
b. Outcomes of health conditions
c. Prevalence of complications
d. Incidence of diseases
a. Communicates effectively in a multicultural context
b. Functions effectively in a multicultural context
c. Visits a foreign country
d. Speaks a different language
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ANS: B
Cultural competence refers to a developmental process that evolves over time that impacts ability to effectively
function in the multicultural context. Communicates effectively and speaking a different language indicates
linguistic competence. Visiting a foreign country does not indicate cultural competence.
5. The nurse learns about cultural issues involved in the patient’s health care belief system and enables patients
and families to achieve meaningful and supportive care. Which concept is the nurse demonstrating?
ANS: D
The nurse is demonstrating culturally congruent care. Culturally congruent care, or care that fits a person’s life
patterns, values, and system of meaning, provides meaningful and beneficial nursing care. Marginalized groups
are populations left out or excluded. Health care disparities are differences among populations in the
availability, accessibility, and quality of health care services (e.g. screening, diagnostic, treatment,
management, and rehabilitation) aimed at prevention, treatment, and management of diseases and their
complications. Transcultural nursing is a comparative study of cultures in order to understand their similarities
(culture that is universal) and the differences among them (culture that is specific to particular groups).
6. A nurse is beginning to use patient-centered care and cultural competence to improve nursing care. Which
step should the nurse take first?
ANS: A
Becoming more aware of your biases and attitudes about human behavior is the first step in providing patientcentered
care, leading to culturally competent care. It is helpful to think about cultural competence as a lifelong
process of learning about others and also about yourself. Learning about the world view, developing cultural
skills, and understanding organizational forces are not the first steps.
7. A nurse is performing a cultural assessment using the ETHNIC mnemonic for communication. Which area
will the nurse assess for the “H”?
ANS: B
The “H” in ETHNIC stands for healers: Has the patient sought advice from alternative health practitioners?
While health, history, and homeland are important, they are not components of “H.”
8. The nurse is caring for a patient of Hispanic descent who speaks no English. The nurse is working with an
interpreter. Which action should the nurse take?
a. Marginalized groups
b. Health care disparity
c. Transcultural nursing
d. Culturally congruent care
a. Assessing own biases and attitude
b. Learning about the world view of others
c. Understanding organizational forces
d. Developing cultural skills
a. Health
b. Healers
c. History
d. Homeland
a. Use long sentences when talking.
b. Look at the patient when talking.
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ANS: B
Direct your questions to the patient. Look at the patient, instead of looking at the interpreter. Pace your speech
by using short sentences, but do not break your sentences. Observe the patient’s nonverbal and verbal
behaviors.
9. Which action indicates the nurse is meeting a primary goal of cultural competent care for patients?
ANS: A
Although cultural competence and patient-centered care both aim to improve health care quality, their focus is
slightly different. The primary aim of cultural competence care is to reduce health disparities and increase
health equity and fairness by concentrating on people of color and other marginalized groups, like transgender
patients. Patient-centered care, rather than cultural competence care, provides individualized care and restores
an emphasis on personal relationships; it aims to elevate quality for all patients.
10. The nurse is caring for a Chinese patient using the Teach-Back technique. Which action by the nurse
indicates successful implementation of this technique?
ANS: C
The Teach-Back technique asks open-ended questions, like what will you tell your spouse about changing the
dressing, to verify a patient’s understanding. When using the Teach-Back technique do not ask a patient, “Do
you understand?” or “Do you have any questions?” Does this make sense and do you think you can do this at
home are closed-ended questions. Would you tell me if you don’t understand something so we can go over it is
not verifying a patient’s understanding about the teaching.
11. A nurse is using core measures to reduce health disparities. Which group should the nurse focus on to cause
the most improvement in core measures?
ANS: B
To improve results, the nurse should focus on the highest disparity. Poor people received worse care than highincome
people for about 60% of core measures. American Indians and Alaska Natives received worse care than
Caucasians for about 30% of core measures.
12. A nurse is designing a form for lesbian, gay, bisexual, and transgender (LGBT) patients. Which design
should the nurse use?
c. Use breaks in sentences when talking.
d. Look at only nonverbal behaviors when talking.
a. Provides care to transgender patients
b. Provides care to restore relationships
c. Provides care to patients that is individualized
d. Provides care to surgical patients
a. Asks, “Does this make sense?”
b. Asks, “Do you think you can do this at home?”
c. Asks, “What will you tell your spouse about changing the dressing?”
d. Asks, “Would you tell me if you don’t understand something so we can go over it?”
a. Caucasians
b. Poor people
c. Alaska Natives
d. American Indians
a. Use partnered rather than married.
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ANS: A
Include LGBT-inclusive language on forms and assessments to facilitate disclosure, knowing that disclosure is
a choice impacted by many factors. For example, provide options such as “partnered” under relationship status.
For parents, use parent/guardian, instead of mother/father. Use neutral and inclusive language when talking
with patients (e.g., partner or significant other), listening and reflecting patient’s choice. Remember that some
LGBT patients are also legally married.
13. A nurse is assessing population groups for the risk of suicide requiring medical attention. Which group
should the nurse monitor mostclosely?
ANS: A
Gay, lesbian, and bisexual young people have a significantly increased risk for depression, anxiety, suicide
attempts, and substance use disorders, being 4 times as likely as their straight peers to make suicide attempts
that require medical attention. Caucasian youth, Asian Americans, and African-Americans are not as likely to
attempt suicide resulting in medical attention.
14. A nurse is assessing a patient’s ethnohistory. Which question should the nurse ask?
ANS: B
An ethnohistory question is the following: How different is your life here from back home? Caring beliefs and
practice questions include the following: Which caregivers do you seek when you are sick and How different is
what we do from what your family does when you are sick? The language and communication is the
following: What language do you speak at home?
15. A nurse is teaching patients about health care information. Which patient will the nurse assess closely for
health literacy?
ANS: B
About 9 out of 10 people in the United States experience challenges in using health care information. Patients
who are especially vulnerable are the elderly (age 65+), immigrants, persons with low incomes, persons who
do not have a high-school diploma or GED, and persons with chronic mental and/or physical health conditions.
A 35-year-old patient and patients with high-school and college education are not identified in the vulnerable
populations.
b. Use mother rather than father.
c. Use parents rather than guardian.
d. Use wife/husband rather than significant other.
a. Young bisexuals
b. Young caucasians
c. Asian Americans
d. African-Americans
a. What language do you speak at home?
b. How different is your life here from back home?
c. Which caregivers do you seek when you are sick?
d. How different is what we do from what your family does when you are sick?
a. A patient 35 years old
b. A patient 68 years old
c. A patient with a college degree
d. A patient with a high-school diploma
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16. A nurse works at a hospital that uses equity-focused quality improvement. Which strategy is the hospital
using?
ANS: D
Organizations can implement equity-focused quality improvement by recognizing disparities and committing
to reducing them. Staff diversity is a priority for equity-focused quality improvement, not staff satisfaction.
While the family is important, the focus is on the patients. Organizations should start by implementing a
change on a small scale (pilot testing), learning from each test, and refining the intervention through
performance improvement cycles (e.g., plan, do, study, and act).
17. A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful
in the role of providing culturally congruent care?
ANS: A
The goal of transcultural nursing is to provide culturally congruent care, or care that fits the person’s life
patterns, values, and system of meaning. Patterns and meanings are generated from people themselves, rather
than from predetermined criteria. Discovering patients’ cultural values, beliefs, and practices as they relate to
nursing and health care requires you to assume the role of learner (not become the leader) and to partner with
your patients and their families to determine what is needed to provide meaningful and beneficial nursing care.
Culturally congruent care is sometimes different from the values and meanings of the professional health care
system.
18. A nurse is assessing the patient’s meaning of illness. Which area of focus by the nurse is priority?
ANS: A
To provide culturally congruent care, you need to understand the difference between disease and illness. Illness
is the way that individuals and families react to disease, whereas disease is a malfunctioning of biological or
psychological processes. The way a patient interacts to family/social interactions is communication processes
and family dynamics.
MULTIPLE RESPONSE
1. A nurse is using Campinha-Bacote’s model of cultural competency. Which areas will the nurse focus on to
become competent? (Select all that apply.)
a. Document staff satisfaction.
b. Focus on the family.
c. Implement change on a grand scale.
d. Reduce disparities.
a. Provides care that fits the patient’s valued life patterns and set of meanings
b. Provides care that is based on meanings generated by predetermined criteria
c. Provides care that makes the nurse the leader in determining what is needed
d. Provides care that is the same as the values of the professional health care system
a. On the way a patient reacts to disease
b. On the malfunctioning of biological processes
c. On the malfunctioning of psychological processes
d. On the way a patient reacts to family/social interactions
a. Cultural skills
b. Cultural desire
c. Cultural transition
d. Cultural knowledge
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ANS: A, B, D, E
Campinha-Bacote’s model of cultural competency has five interrelated components: cultural awareness;
cultural knowledge; cultural skills; cultural encounters; and cultural desire. Cultural transition is not a
component of this model.
2. A nurse is using the RESPECT mnemonic to establish rapport, the “R” in RESPECT. Which actions should
the nurse take? (Select all that apply.)
ANS: A, C
The “R” in RESPECT stands for rapport and includes the following behaviors: connect on a social level; seek
the patient’s point of view; and consciously attempt to suspend judgment. The “S” stands for support and
includes the behavior of helping the patient overcome barriers. The “P” stands for partnership and includes the
following behaviors: be flexible with regard to issues of control and stress that you will be working together to
address medical problems. The “C” stands for cultural competence and includes the behavior of knowing your
limitations in addressing medical issues across cultures.
3. A nurse is using the explanatory model to determine the etiology of an illness. Which questions should the
nurse ask? (Select all that apply.)
ANS: B, C, E
The questions for etiology include “What do you call your problem?” and “What name does it have?”
Recommended treatment is asked by the question “How should your sickness be treated?” Pathophysiology is
asked by the question “How does this illness work inside your body?” The course of illness is asked by the
question “What do you fear most about your sickness?”
MATCHING
A nurse is using Campinha-Bacote’s model of cultural competency to improve cultural care. Which actions
describe the components the nurse is using?
e. Cultural encounters
a. Connect on a social level.
b. Help the patient overcome barriers.
c. Consciously attempt to suspend judgment.
d. Stress that they will be working together to address problems.
e. Know limitations in addressing medical issues across cultures.
a. How should your sickness be treated?
b. What do you call your problem?
c. How does this illness work inside your body?
d. What do you fear most about your sickness?
e. What name does it have?
a. In-depth self-examination of one’s own background
b. Ability to assess factors that influence treatment and care
c. Sufficient comparative understanding of diverse groups
d. Motivation and commitment to continue learning about cultures
e. Cross-cultural interaction that develops communication skills
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A&E I Comprehensive Testbank
Chapter 14: Older Adult
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. A nurse is obtaining a history on an older adult. Which finding will the nurse most typically find?
ANS: B
In 2012, 57% of older adults in non-institutional settings lived with a spouse (45% of older women, 71% of
older men); 28% lived alone (35% of older women, 19% of older men); and only 3.5% of all older adults
resided in institutions such as nursing homes or centers. Most older adults have lost a spouse due to death
rather than divorce.
2. A nurse is developing a plan of care for an older adult. Which information will the nurse consider?
ANS: B
Every older adult is unique, and the nurse needs to approach each one as a unique individual. The nursing care
of older adults poses special challenges because of great variation in their physiological, cognitive, and
psychosocial health. Aging does not automatically lead to disability and dependence. Chronological age often
has little relation to the reality of aging for an older adult.
3. Which information from a co-worker on a gerontological unit will cause the nurse to intervene?
ANS: A
Most older people remain functionally independent despite the increasing prevalence of chronic disease;
therefore, this misconception should be addressed. It is critical for you to respect older adults and actively
involve them in care decisions and activities. You also need to identify an older adult’s strengths and abilities
during the assessment and encourage independence as an integral part of your plan of care.
4. A nurse suspects an older-adult patient is experiencing caregiver neglect. Which assessment findings are
consistent with the nurse’s suspicions?
ANS: A
a. Lives in a nursing home
b. Lives with a spouse
c. Lives divorced
d. Lives alone
a.
Should be standardized because most geriatric patients have the same
needs
b. Needs to be individualized to the patient’s unique needs
c. Focuses on the disabilities that all aging persons face
d. Must be based on chronological age alone
a. Most older people have dependent functioning.
b. Most older people have strengths we should focus on.
c. Most older people should be involved in care decision.
d. Most older people should be encouraged to have independence.
a. Flea bites and lice infestation
b. Left at a grocery store
c. Refuses to take a bath
d. Cuts and bruises
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Caregiver neglect includes unsafe and unclean living conditions, soiled bedding, and animal or insect
infestation. Abandonment includes desertion at a hospital, nursing facility, or public location such as a
shopping center. Self-neglect includes refusal or failure to provide oneself with basic necessities such as food,
water, clothing, shelter, personal hygiene, medication, and safety. Physical abuse includes hitting, beating,
pushing, slapping, kicking, physical restraint, inappropriate use of drugs, fractures, lacerations, rope burns, and
untreated injuries.
5. A nurse is teaching a group of older-adult patients. Which teaching strategy is best for the nurse to use?
ANS: C
Teaching strategies include the use of past experiences to connect new learning with previous knowledge,
focusing on a single topic to help the patient concentrate, giving the patient enough time in which to respond
because older adults’ reaction times are longer than those of younger persons, and keeping the tone of voice
low; older adults are able to hear low sounds better than high-frequency sounds.
6. An older patient has fallen and suffered a hip fracture. As a consequence, the patient’s family is concerned
about the patient’s ability to care for self, especially during this convalescence. What should the nurse do?
ANS: D
Nurses help older adults and their families by providing information and answering questions as they make
choices among care options. Some older adults deny functional declines and refuse to ask for assistance with
tasks that place their safety at great risk. The decision to enter a nursing center is never final, and a nursing
center resident sometimes is discharged to home or to another less-acute residence. What defines quality of life
varies and is unique for each person.
7. What is the best suggestion a nurse could make to a family requesting help in selecting a local nursing
center?
ANS: C
a.
Provide several topics of discussion at once to promote independence
and making choices.
b.
Avoid uncomfortable silences after questions by helping patients
complete their statements.
c.
Ask patients to recall past experiences that correspond with their
interests.
d. Speak in a high pitch to help patients hear better.
a. Stress that older patients usually ask for help when needed.
b.
Inform the family that placement in a nursing center is a permanent
solution.
c.
Tell the family to enroll the patient in a ceramics class to maintain
quality of life.
d.
Provide information and answer questions as family members make
choices among care options.
a.
Have the family members evaluate nursing home staff according to
their ability to get tasks done efficiently and safely.
b.
Make sure that nursing home staff members get patients out of bed
and dressed according to staff’s preferences.
c.
Explain that it is important for the family to visit the center and
inspect it personally.
d.
Suggest a nursing center that has standards as close to hospital
standards as possible.
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A&E I Comprehensive Testbank
An important step in the process of selecting a nursing home is to visit the nursing home. The nursing home
should not feel like a hospital. It is a home, a place where people live. Members of the nursing home staff
should focus on the person, not the task. Residents should be out of bed and dressed according to their
preferences, not staff preferences.
8. A 70-year-old patient who suffers from worsening dementia is no longer able to live alone. The nurse is
discussing health care services and possible long-term living arrangements with the patient’s only son. What
will the nurse suggest?
ANS: C
Some family caregivers consider nursing center placement when in-home care becomes increasingly difficult
or when convalescence from hospitalization requires more assistance than the family is able to provide. An
apartment setting and the use of home health visits are not appropriate because living at home is unsafe.
Dementia is not a time of inactivity but an impairment of intellectual functioning.
9. A nurse is caring for an older adult. Which goal is priority?
ANS: C
Adjusting to retirement is one of the developmental tasks for an older person. A young or middle-aged adult
has to adjust to career and/or divorce. A middle-aged adult has to adjust to grandchildren.
10. A nurse is observing for the universal loss in an older-adult patient. What is the nurse assessing?
ANS: B
The universal loss for older adults usually revolves around the loss of relationships through death. Life
transitions, of which loss is a major component, include retirement and the associated financial changes,
changes in roles and relationships, alterations in health and functional ability, changes in one’s social network,
and relocation. However, these are not the universal loss.
11. A nurse is discussing sexuality with an older adult. Which action will the nurse take?
a. An apartment setting with neighbors close by
b. Having the patient utilize weekly home health visits
c. A nursing center because home care is no longer safe
d.
That placement is irrelevant because the patient is retreating to a place
of inactivity
a. Adjusting to career
b. Adjusting to divorce
c. Adjusting to retirement
d. Adjusting to grandchildren
a. Loss of finances through changes in income
b. Loss of relationships through death
c. Loss of career through retirement
d. Loss of home through relocation
a.
Ask closed-ended questions about specific symptoms the patient may
experience.
b.
Provide information about the prevention of sexually transmitted
infections.
c. Discuss the issues of sexuality in a group in a private room.
d. Explain that sexuality is not necessary as one ages.
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ANS: B
Include information about the prevention of sexually transmitted infections when appropriate. Open-ended
questions inviting an older adult to explain sexual activities or concerns elicit more information than a list of
closed-ended questions about specific activities or symptoms. You need to provide privacy for any discussion
of sexuality and maintain a nonjudgmental attitude. Sexuality and the need to express sexual feelings remain
throughout the human life span.
12. A nurse is teaching a health promotion class for older adults. In which order will the nurse list the most
common to least common conditions that can lead to death in older adults?
1. Chronic obstructive lung disease
2. Cerebrovascular accidents
3. Heart disease
4. Cancer
ANS: B
Heart disease is the leading cause of death in older adults followed by cancer, chronic lung disease, and stroke
(cerebrovascular accidents).
13. A nurse is observing skin integrity of an older adult. Which finding will the nurse document as a normal
finding?
ANS: C
Loss of skin elasticity is a common finding in the older adult. Other common findings include pigmentation
changes, glandular atrophy (oil, moisture, and sweat glands), thinning hair (facial hair: decreased in men,
increased in women), slower nail growth, and atrophy of epidermal arterioles.
14. An older-adult patient in no acute distress reports being less able to taste and smell. What is the
nurse’s best response to this information?
ANS: D
Diminished taste and smell senses are common findings in older adults. Scheduling an appointment at a smell
and taste disorders clinic, testing the vestibulocochlear nerve, or an attempt to rule out cranial nerve damage is
unnecessary at this time as per the information provided.
15. A nurse is assessing an older adult for cognitive changes. Which symptom will the nurse report as normal?
a. 4, 1, 2, 3
b. 3, 4, 1, 2
c. 2, 3, 4, 1
d. 1, 2, 3, 4
a. Oily skin
b. Faster nail growth
c. Decreased elasticity
d. Increased facial hair in men
a.
Notify the health care provider immediately to rule out cranial nerve
damage.
b.
Schedule the patient for an appointment at a smell and taste disorders
clinic.
c. Perform testing on the vestibulocochlear nerve and a hearing test.
d. Explain to the patient that diminished senses are normal findings.
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ANS: C
Slower reaction time is a common change in the older adult. Symptoms of cognitive impairment, such as
disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are not normal aging
changes and require further investigation of underlying causes.
16. An older patient with dementia and confusion is admitted to the nursing unit after hip replacement surgery.
Which action will the nurse include in the plan of care?
ANS: A
Patients with dementia need a routine. Continuing to reorient a patient with dementia is nonproductive and not
advised. Patients with dementia need limited choices. Social interaction based on the patient’s abilities is to be
promoted.
17. A nurse is helping an older-adult patient with instrumental activities of daily living. The nurse will be
assisting the patient with which activity?
ANS: C
Instrumental activities of daily living or IADLs (such as the ability to write a check, shop, prepare meals, or
make phone calls) and activities of daily living or ADLs (such as bathing, dressing, and toileting) are essential
to independent living.
18. A male older-adult patient expresses concern and anxiety about decreased penile firmness during an
erection. What is the nurse’s best response?
ANS: D
Aging men typically experience an erection that is less firm and shorter acting and have a less forceful
ejaculation. Testosterone lessens with age and sometimes (not always) leads to a loss of libido. However, for
both men and women sexual desires, thoughts, and actions continue throughout all decades of life. Sexuality
involves love, warmth, sharing, and touching, not just the act of intercourse. Touch complements traditional
sexual methods or serves as an alternative sexual expression when physical intercourse is not desired or
a. Disorientation
b. Poor judgment
c. Slower reaction time
d. Loss of language skills
a. Keep a routine.
b. Continue to reorient.
c. Allow several choices.
d. Socially isolate patient.
a. Taking a bath
b. Getting dressed
c. Making a phone call
d. Going to the bathroom
a.
Tell the patient that libido will always decrease, as well as the sexual
desires.
b.
Tell the patient that touching should be avoided unless intercourse is
planned.
c. Tell the patient that heterosexuality will help maintain stronger libido.
d. Tell the patient that this change is expected in aging adults.
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A&E I Comprehensive Testbank
possible. Clearly not all older adults are heterosexual, and there is emerging research on older adult, lesbian,
gay, bisexual, and transgender individuals and their health care needs.
19. A patient asks the nurse what the term polypharmacy means. Which information should the nurse share
with the patient?
ANS: D
Polypharmacy refers to the concurrent use of many medications. It does not have anything to do with side
effects, adverse drug effects, or risks of medication use due to aging.
20. An outcome for an older-adult patient living alone is to be free from falls. Which statement indicates the
patient correctly understands the teaching on safety concerns?
ANS: A
Postural hypotension is an intrinsic factor that can cause falls. Changing positions slowly indicates a correct
understanding of this concept. Environmental hazards outside and within the home such as poor lighting,
slippery or wet flooring, and items on floor that are easy to trip over such as throw rugs are other factors that
can lead to falls. Impaired vision and poor lighting are other risk factors for falls and should be avoided (dim
lighting). Inappropriate footwear such as smooth bottom socks also contributes to falls.
21. A nurse’s goal for an older adult is to reduce the risk of adverse medication effects. Which action will the
nurse take?
ANS: A
Strategies for reducing the risk for adverse medication effects include reviewing the medications with older
adults at each visit; examining for potential interactions with food or other medications; simplifying and
individualizing medication regimens; taking every opportunity to inform older adults and their families about
all aspects of medication use; and encouraging older adults to question their health care providers about all
prescribed and over-the-counter medications. Although polypharmacy often reflects inappropriate prescribing,
the concurrent use of multiple medications is often necessary when an older adult has multiple acute and
chronic conditions. Older adults are at risk for adverse drug effects because of age-related changes in the
absorption, distribution, metabolism, and excretion of drugs. Work collaboratively with the older adult to
ensure safe and appropriate use of all medications—both prescribed medications and over-the-counter
medications and herbal options.
22. An older-adult patient has developed acute confusion. The patient has been on tranquilizers for the past
week. The patient’s vital signs are normal. What should the nurse do?
a. This is multiple side effects experienced when taking medications.
b. This is many adverse drug effects reported to the pharmacy.
c. This is the multiple risks of medication effects due to aging.
d. This is concurrent use of many medications.
a. “I’ll take my time getting up from the bed or chair.”
b. “I should dim the lighting outside to decrease the glare in my eyes.”
c.
“I’ll leave my throw rugs in place so that my feet won’t touch the cold
tile.”
d.
“I should wear my favorite smooth bottom socks to protect my feet
when walking around.”
a. Review the patient’s list of medications at each visit.
b. Teach that polypharmacy is to be avoided at all cost.
c. Avoid information about adverse effects.
d. Focus only on prescribed medications.
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A&E I Comprehensive Testbank
ANS: A
Some sedatives and tranquilizers prescribed for acutely confused older adults sometimes cause or exacerbate
confusion. Carefully administer drugs used to manage confused behaviors, taking into account age-related
changes in body systems that affect pharmacokinetic activity. When confusion has a physiological cause (such
as an infection), specifically treat that cause, rather than the confused behavior. When confusion varies by time
of day or is related to environmental factors, nonpharmacological measures such as making the environment
more meaningful, providing adequate light, etc., should be used. Making phone calls to friends or family
members allows older adults to hear reassuring voices, which may be beneficial.
23. Which assessment finding of an older adult, who has a urinary tract infection, requires an immediate
nursing intervention?
ANS: A
Confusion is a common manifestation in older adults with urinary tract infection; however, the cause requires
further assessment. There may be another reason for the confusion. Confusion is not a normal finding in the
older adult, even though it is commonly seen with concurrent infections. Difficulty hearing, presbycusis, is an
expected finding in an older adult. Older adults tend to have lower core temperatures. Coping with the death of
a spouse is a psychosocial concern to be addressed after the acute physiological concern in this case.
24. Which patient statement is the most reliable indicator that an older adult has the correct understanding of
health promotion activities?
ANS: B
General preventive measures for the nurse to recommend to older adults include keeping regular dental
appointments to promote good oral hygiene, eating a low-fat, well-balanced diet, exercising regularly, and
maintaining immunizations for seasonal influenza, tetanus, diphtheria and pertussis, shingles, and
pneumococcal disease.
25. A 72-year-old woman was recently widowed. She worked as a teller at a bank for 40 years and has been
retired for the past 5 years. She never learned how to drive. She lives in a rural area that does not have public
transportation. Which psychosocial change does the nurse focus on as a priority?
a.
Take into account age-related changes in body systems that affect
pharmacokinetic activity.
b.
Increase the dose of tranquilizer if the cause of the confusion is an
infection.
c. Note when the confusion occurs and medicate before that time.
d. Restrict phone calls to prevent further confusion.
a. Confusion
b. Presbycusis
c. Temperature of 97.9° F
d. Death of a spouse 2 months ago
a. “I need to increase my fat intake and limit protein.”
b.
“I still keep my dentist appointments even though I have partials
now.”
c. “I should discontinue my fitness club membership for safety reasons.”
d.
“I’m up-to-date on my immunizations, but at my age, I don’t need the
influenza vaccine.”
a. Sexuality
b. Retirement
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A&E I Comprehensive Testbank
ANS: D
The highest priority at this time is the potential for social isolation. This woman does not know how to drive
and lives in a rural community that does not have public transportation. All of these factors contribute to her
social isolation. Other possible changes she may be going through right now include sexuality related to her
advanced age and recent death of her spouse; however, this is not the priority at this time. She has been retired
for 5 years, so this is also not an immediate need. She may eventually experience needs related to environment,
but the data do not support this as an issue at this time.
MULTIPLE RESPONSE
1. A recently widowed older-adult patient is dehydrated and is admitted to the hospital for intravenous fluid
replacement. During the evening shift, the patient becomes acutely confused. Which possible reversible causes
will the nurse consider when assessing this patient? (Select all that apply.)
ANS: A, B, C, D
Delirium, or acute confusional state, is a potentially reversible cognitive impairment that is often due to a
physiological event. Physiological causes include electrolyte imbalances, untreated pain, infection, cerebral
anoxia, hypoglycemia, medication effects, tumors, subdural hematomas, and cerebrovascular infarction or
hemorrhage. Sometimes it is also caused by environmental factors such as sensory deprivation or
overstimulation, unfamiliar surroundings, or sleep deprivation or psychosocial factors such as emotional
distress. Dementia is a gradual, progressive, and irreversible cerebral dysfunction.
MATCHING
A nurse is using different strategies to meet older patients’ psychosocial needs. Match the strategy the nurse is
using to its description.
1. Body image
2. Validation therapy
3. Therapeutic communication
4. Reality orientation
5. Reminiscence
1.ANS:E2.ANS:D3.ANS:A4.ANS:B5.ANS:C
Chapter 24: Communication
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. Which types of nurses make the best communicators with patients?
c. Environment
d. Social isolation
a. Electrolyte imbalance
b. Sensory deprivation
c. Hypoglycemia
d. Drug effects
e. Dementia
a. Respecting the older adult’s uniqueness
b. Improving level of awareness
c. Listening to the patient’s past recollections
d. Accepting describing of patient’s perspective
e. Offering help with grooming and hygiene
a. Those who learn effective psychomotor skills
b. Those who develop critical thinking skills
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A&E I Comprehensive Testbank
ANS: B
Nurses who develop critical thinking skills make the best communicators. Just liking people does not make an
effective communicator because it is important to apply critical thinking standards to ensure sound effective
communication. Just learning psychomotor skills does not ensure that the nurse will use those techniques, and
communication involves more than psychomotor skills.Critical thinking helps the nurse overcome perceptual
biases or human tendencies that interfere with accurately perceiving and interpreting messages from others.
Nurses who maintain perceptual biases do not make good communicators.
2. A nurse believes that the nurse-patient relationship is a partnership and that both are equal participants.
Which term should the nurse use to describe this belief?
ANS: C
Effective interpersonal communication requires a sense of mutuality, a belief that the nurse-patient relationship
is a partnership and that both are equal participants. Critical thinking in nursing, based on established standards
of nursing care and ethical standards, promotes effective communication and uses standards such as humility,
self-confidence, independent attitude, and fairness. To be authentic (one’s self) and to respond appropriately to
the other person are important for interpersonal relationships but do not mean mutuality. Attending is giving all
of your attention to the patient.
3. A nurse wants to present information about flu immunizations to the older adults in the community. Which
type of communication should the nurse use?
ANS: A
Public communication is interaction with an audience. Nurses have opportunities to speak with groups of
consumers about health-related topics, present scholarly work to colleagues at conferences, or lead classroom
discussions with peers or students. When nurses work on committees or participate in patient care conferences,
they use a small group communication process. Interpersonal communication is one-on-one interaction
between a nurse and another person that often occurs face to face. Intrapersonal communication is a powerful
form of communication that you use as a professional nurse. This level of communication is also called selftalk.
4. A nurse is using therapeutic communication with a patient. Which technique will the nurse use to ensure
effective communication?
ANS: C
c. Those who like different kinds of people
d. Those who maintain perceptual biases
a. Critical thinking
b. Authentic
c. Mutuality
d. Attend
a. Public
b. Small group
c. Interpersonal
d. Intrapersonal
a.
Interpersonal communication to change negative self-talk to positive
self-talk
b. Small group communication to present information to an audience
c. Electronic communication to assess a patient in another city
d. Intrapersonal communication to build strong teams
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A&E I Comprehensive Testbank
Electronic communication is the use of technology to create ongoing relationships with patients and their
health care team. Intrapersonal communication is self-talk. Interpersonal communication is one-on-one
interaction between a nurse and another person that often occurs face to face. Public communication is used to
present information to an audience. Small group communication is interaction that occurs when a small
number of persons meet. When nurses work on committees or participate in patient care conferences, they use
a small group communication process.
5. A nurse is standing beside the patient’s bed.
Nurse: How are you doing?
Patient: I don’t feel good.
Which element will the nurse identify as feedback?
ANS: D
“I don’t feel good” is the feedback because the feedback is the message the receiver returns. The sender is the
person who encodes and delivers the message, and the receiver is the person who receives and decodes the
message. The nurse is the sender. The patient is the receiver. “How are you doing?” is the message.
6. A nurse is sitting at the patient’s bedside taking a nursing history. Which zone of personal space is the nurse
using?
ANS: B
Personal space is 18 inches to 4 feet and involves things such as sitting at a patient’s bedside, taking a patient’s
nursing history, or teaching an individual patient. Intimate space is 0 to 18 inches and involves things such as
performing a physical assessment, bathing, grooming, dressing, feeding, and toileting a patient. The socioconsultative
zone is 9 to 12 feet and involves things such as giving directions to visitors in the hallway and
giving verbal report to a group of nurses. The public zone is 12 feet and greater and involves things such as
speaking at a community forum, testifying at a legislative hearing, or lecturing.
7. A smiling patient angrily states, “I will not cough and deep breathe.” How will the nurse interpret this
finding?
ANS: C
An inappropriate affect is a facial expression that does not match the content of a verbal message (e.g., smiling
when describing a sad situation). The patient is smiling but is angry, which indicates an inappropriate affect.
The patient’s personal space was not violated. The patient’s vocabulary is not poor. Individuals who use a
common language share denotative meaning: baseball has the same meaning for everyone who speaks English,
but code denotes cardiac arrest primarily to health care providers. The patient’s denotative meaning is correct
for cough and deep breathe.
a. Nurse
b. Patient
c. How are you doing?
d. I don’t feel good.
a. Socio-consultative
b. Personal
c. Intimate
d. Public
a. The patient’s denotative meaning is wrong.
b. The patient’s personal space was violated.
c. The patient’s affect is inappropriate.
d. The patient’s vocabulary is poor.
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8. The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which
form of communication did the patient use?
ANS: B
The patient gestured (pointed), which is a type of nonverbal communication. Gestures emphasize, punctuate,
and clarify the spoken word. Pointing to an area of pain is sometimes more accurate than describing its
location. Verbal is the spoken word or message. Intonation or tone of voice dramatically affects the meaning of
a message. Vocabulary consists of words used for verbal communication.
9. A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal
story about the care that has been received. Which interaction is the nurse using?
ANS: C
In a therapeutic relationship, nurses often encourage patients to share personal stories. Sharing stories is called
narrative interaction. Socializing is an important initial component of interpersonal communication. It helps
people get to know one another and relax. It is easy, superficial, and not deeply personal. Nonjudgmental
acceptance of the patient is an important characteristic of the relationship. Acceptance conveys a willingness to
hear a message or acknowledge feelings; it is not a technique that involves personal stories. SBAR is a popular
communication tool that helps standardize communication among health care providers. SBAR stands for
Situation, Background, Assessment, and Recommendation.
10. Before meeting the patient, a nurse talks to other caregivers about the patient. Which phase of the helping
relationship is the nurse in with this patient?
ANS: A
The time before the nurse meets the patient is called the preinteraction phase. This phase can involve things
such as reviewing available data, including the medical and nursing history, talking to other caregivers who
have information about the patient, or anticipating health concerns or issues that can arise. The orientation
phase occurs when the nurse and the patient meet and get to know one another. This phase can involve things
such as setting the tone for the relationship by adopting a warm, empathetic, caring manner. The working
phase occurs when the nurse and the patient work together to solve problems and accomplish goals. The
termination phase occurs during the ending of the relationship. This phase can involve things such as
reminding the patient that termination is near.
11. During the initial home visit, a home health nurse lets the patient know that the visits are expected to end in
about a month. Which phase of the helping relationship is the nurse in with this patient?
a. Verbal
b. Nonverbal
c. Intonation
d. Vocabulary
a. Nonjudgmental
b. Socializing
c. Narrative
d. SBAR
a. Preinteraction
b. Orientation
c. Working
d. Termination
a. Preinteraction
b. Orientation
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A&E I Comprehensive Testbank
ANS: B
Letting the patient know when to expect the relationship to be terminated occurs in the orientation phase.
Preinteraction occurs before the nurse meets the patient. Working occurs when the nurse and the patient work
together to solve problems and accomplish goals. Termination occurs during the ending of the relationship.
12. A nurse and a patient work on strategies to reduce weight. Which phase of the helping relationship is the
nurse in with this patient?
ANS: C
The working phase occurs when the nurse and the patient work together to solve problems and accomplish
goals. Preinteraction occurs before the nurse meets the patient. Orientation occurs when the nurse and the
patient meet and get to know each other. Termination occurs during the ending of the relationship.
13. A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the
nurse’s action?
ANS: D
SBAR is a popular communication tool that helps standardize communication among health care providers.
Common courtesy is part of professional communication but is not the purpose of SBAR. Being trustworthy
means helping others without hesitation. Autonomy is being self-directed and independent in accomplishing
goals and advocating for others.
14. A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest
pain with a pulse rate of 108. Which piece of data will the nurse use for “B” when using SBAR?
ANS: C
The B in SBAR stands for background information. The background information in this situation is the history
of angina. Having chest pain is the Situation (S). Pulse rate of 108 is the Assessment (A). Oxygen is needed is
the Recommendation (R).
15. A patient just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy?
c. Working
d. Termination
a. Preinteraction
b. Orientation
c. Working
d. Termination
a. To promote autonomy
b. To use common courtesy
c. To establish trustworthiness
d. To standardize communication
a. Having chest pain
b. Pulse rate of 108
c. History of angina
d. Oxygen is needed
a. “Tomorrow will be better.”
b. “This must be hard news to hear.”
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A&E I Comprehensive Testbank
ANS: B
“This must be hard” is an example of empathy. Empathy is the ability to understand and accept another
person’s reality, accurately perceive feelings, and communicate this understanding to the other. An example of
false reassurance is “Tomorrow will be better.” “I believe you can overcome this” is an example of sharing
hope. “What is your biggest fear?” is an open-ended question that allows patients to take the conversational
lead and introduces pertinent information about a topic.
16. A nurse is taking a history on a patient who cannot speak English. Which action will the nurse take?
ANS: A
Interpreters are often necessary for patients who speak a foreign language. Using a family member can lead to
legal issues, speech therapists help patients with aphasia, and mental health nurse specialists help angry or
highly anxious patients to communicate more effectively.
17. A nurse is using SOLER to facilitate active listening. Which technique should the nurse use for R?
ANS: A
In SOLER, the R stands for relax. It is important to communicate a sense of being relaxed and comfortable
with the patient. Active listening enhances trust because the nurse communicates acceptance and respect for
the patient, but it is not the R in SOLER. Reminisce is a therapeutic communication technique, especially
when used with the elderly. Reassuring can be therapeutic if the nurse reassures patients that there are many
kinds of hope and that meaning and personal growth can come from illness experiences. However, false
reassurance can block communication.
18. An older-adult patient is wearing a hearing aid. Which technique should the nurse use to facilitate
communication?
ANS: B
Turning off the television will facilitate communication. Patients who are hearing impaired benefit when the
following techniques are used: check for hearing aids and glasses, reduce environmental noise, get the patient’s
attention before speaking, do not chew gum, and speak at normal volume—do not shout. Using at least 14-
point print is for sight/visually impaired, not hearing impaired.
19. When making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning.
Which therapeutic response is most appropriate?
c. “What’s your biggest fear about this diagnosis?”
d.
“I believe you can overcome this because I’ve seen how strong you
are.”
a. Obtain an interpreter.
b. Refer to a speech therapist.
c. Let a close family member talk.
d. Find a mental health nurse specialist.
a. Relax
b. Respect
c. Reminisce
d. Reassure
a. Chew gum.
b. Turn off the television.
c. Speak clearly and loudly.
d. Use at least 14-point print.
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ANS: D
“It must be difficult not to know what the surgeon will find. What can I do to help?” is using therapeutic
communication techniques of empathy and asking relevant questions. False reassurances (“You will be okay”
and “Don’t worry”) tend to block communication. Patients frequently interpret “why” questions as accusations
or think the nurse knows the reason and is simply testing them.
20. Which situation will cause the nurse to intervene and follow up on the nursing assistive personnel’s (NAP)
behavior?
ANS: A
The nurse needs to intervene to correct the use of “honey.” Avoid terms of endearment such as “honey,” “dear,”
“grandma,” or “sweetheart.” Communicate with older adults on an adult level, and avoid patronizing or
speaking in a condescending manner. Facing an older-adult patient, making sure the older adult has clean
glasses, and allowing time to respond facilitate communication with older-adult patients and should be
encouraged, not stopped.
21. A confused older-adult patient is wearing thick glasses and a hearing aid. Which intervention is
the priorityto facilitate communication?
ANS: B
Allowing time for patients to respond will facilitate communication, especially for a confused, older patient.
Focusing on tasks to be completed and limiting conversations do not facilitate communication; in fact, they
block communication. Using gestures and other nonverbal cues is not effective for visually impaired (thick
glasses) patients or for patients who are confused.
22. The staff is having a hard time getting an older-adult patient to communicate. Which technique should the
nurse suggest the staff use?
a. “You will be okay. Your surgeon will talk to you in the morning.”
b. “Why can’t you sleep? You have the best surgeon in the hospital.”
c. “Don’t worry. The surgeon ordered a sleeping pill to help you sleep.”
d.
“It must be difficult not to know what the surgeon will find. What can
I do to help?”
a.
The nursing assistive personnel is calling the older-adult patient
“honey.”
b.
The nursing assistive personnel is facing the older-adult patient when
talking.
c.
The nursing assistive personnel cleans the older-adult patient’s glasses
gently.
d.
The nursing assistive personnel allows time for the older-adult patient
to respond.
a. Focus on tasks to be completed.
b. Allow time for the patient to respond.
c. Limit conversations with the patient.
d. Use gestures and other nonverbal cues.
a. Try changing topics often.
b. Allow the patient to reminisce.
c. Ask the patient for explanations.
d. Involve only the patient in conversations.
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A&E I Comprehensive Testbank
ANS: B
Encouraging older adults to share life stories and reminisce about the past has a therapeutic effect and
increases their sense of well-being. Avoid sudden shifts from subject to subject. It is helpful to include the
patient’s family and friends and to become familiar with the patient’s favorite topics for conversation. Asking
for explanations is a nontherapeutic technique.
23. A nurse is implementing nursing care measures for patients’ special communication needs. Which patient
will need the most nursing care measures?
ANS: D
Facial trauma, laryngeal cancer, or endotracheal intubation often prevents movement of air past vocal cords or
mobility of the tongue, resulting in inability to articulate words. An extremely breathless person needs to use
oxygen to breathe rather than speak. Persons with high anxiety are sometimes unable to perceive
environmental stimuli or hear explanations. People who are alert, have strong self-esteem, and are cooperative
and pain free do not cause communication concerns. Although hunger, blindness, and difficulty hearing can
cause communication concerns, dyspnea, tracheostomy, and anxiety all contribute to communication concerns.
24. A patient is aphasic, and the nurse notices that the patient’s hands shake intermittently. Which nursing
action is most appropriate to facilitate communication?
ANS: A
Using a pen and paper can be frustrating for a nonverbal (aphasic) patient whose handwriting is shaky; the
nurse can revise the care plan to include use of a picture board instead. An interpreter is used for a patient who
speaks a foreign language. A hearing aid is used for the hard of hearing, not for an aphasic patient.
25. Which behavior indicates the nurse is using a process recording correctly to enhance communication with
patients?
ANS: D
Analysis of a process recording enables a nurse to evaluate the following: examine whether nursing responses
blocked or facilitated the patient’s efforts to communicate. Sympathy is concern, sorrow, or pity felt for the
patient and is nontherapeutic. Clichés and stereotyped remarks are automatic responses that communicate the
nurse is not taking concerns seriously or responding thoughtfully. Passive responses serve to avoid conflict or
to sidestep issues.
26. A patient says, “You are the worst nurse I have ever had.” Which response by the nurse is most assertive?
a. The patient who is oriented, pain free, and blind
b. The patient who is alert, hungry, and has strong self-esteem
c. The patient who is cooperative, depressed, and hard of hearing
d. The patient who is dyspneic, anxious, and has a tracheostomy
a. Use a picture board.
b. Use pen and paper.
c. Use an interpreter.
d. Use a hearing aid.
a. Shows sympathy appropriately
b. Uses automatic responses fluently
c. Demonstrates passive remarks accurately
d. Self-examines personal communication skills
a. “I think you’ve had a hard day.”
b. “I feel uncomfortable hearing that statement.”
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ANS: B
Assertive responses contain “I” messages such as “I want,” “I need,” “I think,” or “I feel.” While all of these
start with “I,” the only one that is the most assertive is “I feel uncomfortable hearing that statement.” An
assertive nurse communicates self-assurance; communicates feelings; takes responsibility for choices; and is
respectful of others’ feelings, ideas, and choices. “I think you’ve had a hard day” is not addressing the
problem. Arguing (“How can you say that?”) is not assertive or therapeutic. Showing disapproval (using words
like right) is not assertive or therapeutic.
MULTIPLE RESPONSE
1. Which behaviors indicate the nurse is using critical thinking standards when communicating with patients?
(Select all that apply.)
ANS: B, C, E
A self-confident attitude is important because the nurse who conveys confidence and comfort while
communicating more readily establishes an interpersonal helping-trusting relationship. In addition, an
independent attitude encourages the nurse to communicate with colleagues and share ideas about nursing
interventions. An attitude of humility is necessary to recognize and communicate the need for more
information before making a decision. Faith and supportiveness are attributes of caring, not critical thinking
standards.
2. A nurse is implementing nursing care measures for patients with challenging communication issues. Which
types of patients will need these nursing care measures? (Select all that apply.)
ANS: A, B, C, F
Challenging communication situations include patients who are flirtatious, demanding, frightened, or
developmentally delayed. A child who has received little environmental stimulation possibly is behind in
language development, thus making communication more challenging. Patients who are cooperative and have
good eyesight (see small print) do not cause challenging communication situations.
MATCHING
A nurse is using AIDET to communicate with patients and families. Match the letters of the acronym to the
behavior a nurse will use.
c. “I don’t think you should say things like that. It is not right.”
d. “I have been checking on you regularly. How can you say that?”
a. Instills faith
b. Uses humility
c. Portrays self-confidence
d. Exhibits supportiveness
e. Demonstrates independent attitude
a. A child who is developmentally delayed
b. An older-adult patient who is demanding
c. A female patient who is outgoing and flirty
d. A male patient who is cooperative with treatments
e. An older-adult patient who can clearly see small print
f. A teenager frightened by the prospect of impending surgery
a. Nurse describes procedures and tests.
b. Nurse lets the patient know how long the procedure will last.
c. Nurse recognizes the person with a positive attitude.
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A&E I Comprehensive Testbank
1.A
2.I
3.D
4.E
5.T
1.ANS:C2.ANS:E3.ANS:B4.ANS:A5.ANS:D
Chapter 25: Patient Education
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. A nurse is teaching a patient’s family member about permanent tube feedings at home. Which purpose of
patient education is the nurse meeting?
ANS: D
Teach family members to help the patient with health care management (e.g., giving medications through
gastric tubes and doing passive range-of-motion exercises) when coping with impaired functions. Not all
patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations.
Health promotion involves healthy people staying healthy, while illness prevention is prevention of diseases.
Restoration of health occurs if the teaching is about a temporary tube feeding, not a permanent tube feeding.
2. A nurse is teaching a group of healthy adults about the benefits of flu immunizations. Which type of patient
education is the nurse providing?
ANS: D
As a nurse, you are a visible, competent resource for patients who want to improve their physical and
psychological well-being. In the school, home, clinic, or workplace, you promote health and prevent illness by
providing information and skills that enable patients to assume healthier behaviors. Injured and ill patients
need information and skills to help them regain or maintain their level of health; this is referred to as
restoration of health. Not all patients fully recover from illness or injury. Many have to learn to cope with
permanent health alterations; this is known as coping with impaired functions. Analogies supplement verbal
instruction with familiar images that make complex information more real and understandable. For example,
when explaining arterial blood pressure, use an analogy of the flow of water through a hose.
3. A nurse’s goal is to provide teaching for restoration of health. Which situation indicates the nurse is meeting
this goal?
d. Nurse thanks the patient.
e. Nurse tells the patient “I am an RN and will be managing your care.”
a. Health promotion
b. Illness prevention
c. Restoration of health
d. Coping with impaired functions
a. Health analogies
b. Restoration of health
c. Coping with impaired functions
d. Promotion of health and illness prevention
a.
Teaching a family member to provide passive range of motion for a
stroke patient
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ANS: D
Injured or ill patients need information and skills to help them regain or maintain their levels of health. An
example includes teaching a teenager with a broken leg how to use crutches. Not all patients fully recover from
illness or injury. Many have to learn to cope with permanent health alterations. New knowledge and skills are
often necessary for patients and/or family members to continue activities of daily living. Teaching family
members to help the patient with health care management (e.g., giving medications through gastric tubes,
doing passive range-of-motion exercises) is an example of coping with long-term impaired functions. For a
woman with a hysterectomy, teaching about adoption is not restoration of health; restoration of health in this
situation would involve activity restrictions and incision care if needed. In childbearing classes, you teach
expectant parents about physical and psychological changes in the woman and about fetal development; this is
part of health maintenance.
4. A nurse attends a seminar on teaching/learning. Which statement indicates the nurse has a good
understanding of teaching/learning?
ANS: C
Teaching is most effective when it responds to the learner’s needs. It is impossible to separate teaching from
learning. Teaching is an interactive process that promotes learning. Teaching consists of a conscious, deliberate
set of actions that help individuals gain new knowledge, change attitudes, adopt new behaviors, or perform
new skills.
5. A nurse is determining if teaching is effective. Which finding best indicates learning has occurred?
ANS: B
Learning is the purposeful acquisition of new knowledge, attitudes, behaviors, and skills: patient demonstrates
how to inject insulin. A new mother exhibits learning when she demonstrates how to bathe her newborn. A
nurse presenting information and a primary care provider handing a pamphlet to a patient are examples of
teaching. A family member listening to a lecture does not indicate that learning occurred; a change in
knowledge, attitudes, behaviors, and/or skills must be evident.
6. A nurse is teaching a patient about the Speak Up Initiatives. Which information should the nurse include in
the teaching session?
b.
Teaching a woman who recently had a hysterectomy about possible
adoption
c. Teaching expectant parents about changes in childbearing women
d. Teaching a teenager with a broken leg how to use crutches
a. “Teaching and learning can be separated.”
b. “Learning is an interactive process that promotes teaching.”
c. “Teaching is most effective when it responds to the learner’s needs.”
d.
“Learning consists of a conscious, deliberate set of actions designed to
help the teacher.”
a. A nurse presents information about diabetes.
b. A patient demonstrates how to inject insulin.
c. A family member listens to a lecture on diabetes.
d. A primary care provider hands a diabetes pamphlet to the patient.
a. If you still do not understand, ask again.
b. Ask a nurse to be your advocate or supporter.
c. The nurse is the center of the health care team.
d. Inappropriate medical tests are the most common mistakes.
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ANS: A
If you still do not understand, ask again is part of the S portion of the Speak Up Initiatives. Speak up if you
have questions or concerns. You (the patient) are the center of the health care team, not the nurse. Ask a trusted
family member or friend to be your advocate (advisor or supporter), not a nurse. Medication errors are the
most common health care mistakes, not inappropriate medical tests.
7. A nurse teaches a patient with heart failure healthy food choices. The patient states that eating yogurt is
better than eating cake. Which element represents feedback?
ANS: D
Feedback needs to demonstrate the success of the learner in achieving objectives (i.e., the learner verbalizes
information or provides a return demonstration of skills learned). The nurse is the sender. The patient (learner)
is the receiver. The teaching is the message.
8. While preparing a teaching plan, the nurse describes what the learner will be able to accomplish after the
teaching session about healthy eating. Which action is the nurse completing?
ANS: A
Learning objectives describe what the learner will exhibit as a result of successful instruction. Positive
reinforcement follows feedback and reinforces good behavior and promotes continued compliance.
Interpersonal communication is necessary for the teaching/learning process, but describing what the learner
will be able to do after successful instruction constitutes learning objectives. Facts and knowledge will be
presented in the teaching session.
9. A patient learns that a normal adult heartbeat is 60 to 100 beats/min after a teaching session with a nurse. In
which domain did learning take place?
ANS: B
The patient acquired knowledge, which is cognitive. Cognitive learning includes all intellectual skills and
requires thinking. In the hierarchy of cognitive behaviors, the simplest behavior is acquiring knowledge.
Kinesthetic is a type of learner who learns best with a hands-on approach. Affective learning deals with
expression of feelings and development of attitudes, beliefs, or values. Psychomotor learning involves
acquiring skills that require integration of mental and physical activities, such as the ability to walk or use an
eating utensil.
10. A nurse is trying to help a patient begin to accept the chronic nature of diabetes. Which teaching technique
should the nurse use to enhance learning?
a. The nurse
b. The patient
c. The nurse teaching about healthy food choices
d. The patient stating that eating yogurt is better than eating cake
a. Developing learning objectives
b. Providing positive reinforcement
c. Presenting facts and knowledge
d. Implementing interpersonal communication
a. Kinesthetic
b. Cognitive
c. Affective
d. Psychomotor
a. Lecture
b. Role play
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ANS: B
Affective learning deals with expression of feelings and acceptance of attitudes, beliefs, or values. Role play
and discussion (one-on-one and group) are effective teaching methods for the affective domain. Lecture and
question and answer sessions are effective teaching methods for the cognitive domain. Demonstration is an
effective teaching method for the psychomotor domain.
11. A nurse is describing a patient’s perceived ability to successfully complete a task. Which term should the
nurse use to describe this attribute?
ANS: A
Self-efficacy, a concept included in social learning theory, refers to a person’s perceived ability to successfully
complete a task. Motivation is a force that acts on or within a person (e.g., an idea, an emotion, a physical
need) to cause the person to behave in a particular way. An attentional set is the mental state that allows the
learner to focus on and comprehend a learning activity. Learning occurs when the patient is actively involved
in the educational session.
12. A toddler is going to have surgery on the right ear. Which teaching method is most appropriate for this
developmental stage?
ANS: C
Use play to teach a procedure or activity (e.g., handling examination equipment, applying a bandage to a doll)
to toddlers. Encouraging independent learning is for the young or middle adult. Use of discussion is for older
children, adolescents, and adults, not for toddlers. Use problem solving to help adolescents make choices.
Problem solving is too advanced for a toddler.
13. A nurse is preparing to teach a patient about smoking cessation. Which factors should the nurse assess to
determine a patient’s ability to learn?
ANS: C
Developmental and physical capabilities reflect one’s ability to learn. Sociocultural background and motivation
are factors determining readiness to learn. Psychosocial adaptation to illness and active participation are factors
in readiness to learn. Readiness to learn is related to the stage of grieving. Overall physical health does reflect
ability to learn; however, because it is paired here with stage of grieving (which is a readiness to learn factor),
this is incorrect.
14. A nurse is teaching a patient about heart failure. Which environment will the nurse use?
c. Demonstration
d. Question and answer sessions
a. Self-efficacy
b. Motivation
c. Attentional set
d. Active participation
a. Encourage independent learning.
b. Develop a problem-solving scenario.
c. Wrap a bandage around a stuffed animal’s ear.
d. Use discussion throughout the teaching session.
a. Sociocultural background and motivation
b. Stage of grieving and overall physical health
c. Developmental capabilities and physical capabilities
d. Psychosocial adaptation to illness and active participation
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A&E I Comprehensive Testbank
ANS: B
The ideal environment for learning is a room that is well lit and has good ventilation, appropriate furniture, and
a comfortable temperature. Although a quiet room is appropriate, a darkened room interferes with the patient’s
ability to watch your actions, especially when demonstrating a skill or using visual aids such as posters or
pamphlets. A room that is cold, hot, or stuffy makes the patient too uncomfortable to focus on the information
being presented. Learning in a group of six or less is more effective and avoids distracting behaviors.
15. Which assessment finding will cause the nurse to begin teaching a patient because the patient is ready to
learn?
ANS: C
Motivation underlies a person’s desire or willingness to learn. Motivation is a force that acts on or within a
person (e.g., an idea, emotion, or a physical need) to cause the person to behave in a particular way. For
example, a patient with a below-the-knee amputation is motivated to learn how to walk with assistive devices,
indicating a readiness to learn. Do not confuse readiness to learn with ability to learn. All the other answers are
examples of ability to learn because this often depends on the patient’s level of physical development and
overall physical health. To learn psychomotor skills, a patient needs to possess a certain level of strength,
coordination, and sensory acuity. For example, it is useless to teach a patient to transfer from a bed to a
wheelchair if he or she has insufficient upper body strength. An older patient with poor eyesight or an inability
to grasp objects tightly cannot learn to apply an elastic bandage or handle a syringe.
16. A nurse is teaching a patient with a risk for hypertension how to take a blood pressure. Which action by the
nurse is the priority?
ANS: D
The teaching process focuses on the patient’s learning needs, motivation, and ability to learn; writing learning
objectives and goals is also included. Nursing and teaching processes are not the same. Assessing laboratory
results for high cholesterol and performing nursing care therapies are all components of the nursing process,
not the teaching process.
17. A patient has heart failure and kidney failure. The patient needs teaching about dialysis. Which nursing
action is most appropriate for assessing this patient’s learning needs?
a. A darkened, quiet room
b. A well-lit, ventilated room
c. A private room at 85° F temperature
d. A group room for 10 to 12 patients with heart failure
a. A patient has the ability to grasp and apply the elastic bandage.
b.
A patient has sufficient upper body strength to move from a bed to a
wheelchair.
c.
A patient with a below-the-knee amputation is motivated about how to
walk with assistive devices.
d.
A patient has normal eyesight to identify the markings on a syringe
and coordination to handle a syringe.
a. Assess laboratory results for high cholesterol and other data.
b. Identify that teaching is the same as the nursing process.
c. Perform nursing care therapies to address hypertension.
d. Focus on a patient’s learning needs and objectives.
a. Assess the patient’s total health care needs.
b. Assess the patient’s health literacy.
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ANS: B
Because health literacy influences how you deliver teaching strategies, it is critical for you to assess a patient’s
health literacy before providing instruction. The nursing process requires assessment of all sources of data to
determine a patient’s total health care needs. Evaluation of the teaching process involves determining outcomes
of the teaching/learning process and the achievement of learning objectives; assessing the goals of patient care
is the evaluation component of the nursing process.
18. A nurse is teaching a patient about hypertension. In which order from first to last will the nurse implement
the steps of the teaching process?
1. Set mutual goals for knowledge of hypertension.
2. Teach what the patient wants to know about hypertension.
3. Assess what the patient already knows about hypertension.
4. Evaluate the outcomes of patient education for hypertension.
ANS: C
Assessment is the first step of any teaching session, then diagnosing, planning (goals), implementation, and
evaluation.
19. A patient had a stroke and must use a cane for support. A nurse is preparing to teach the patient about the
cane. Which learning objective/outcome is most appropriate for the nurse to include in the teaching plan?
ANS: A
Outcomes often describe a behavior that identifies the patient’s ability to do something on completion of
teaching such as will empty a colostomy bag or will administer an injection. Understand, learn, and know are
not behaviors that can be observed or evaluated.
20. Which learning objective/outcome has the highest priority for a patient with life-threatening, severe food
allergies that require an EpiPen (epinephrine)?
ANS: D
Once you assist in meeting patient needs related to basic survival (how to give epinephrine), you can discuss
other topics, such as nutritional needs and side effects of medications. For example, a patient recently
diagnosed with coronary artery disease has deficient knowledge related to the illness and its implications. The
c. Assess all sources of patient data.
d. Assess the goals of patient care.
a. 1, 3, 2, 4
b. 2, 3, 1, 4
c. 3, 1, 2, 4
d. 3, 2, 1, 4
a. The patient will walk to the bathroom and back to bed using a cane.
b. The patient will understand the importance of using a cane.
c. The patient will know the correct use of a cane.
d. The patient will learn how to use a cane.
a. The patient will identify the main ingredients in several foods.
b. The patient will list the side effects of epinephrine.
c. The patient will learn about food labels.
d. The patient will administer epinephrine.
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patient benefits most by first learning about the correct way to take nitroglycerin and how long to wait before
calling for help when chest pain occurs. Thus, in this situation, the patient benefits most by first learning about
the correct way to take epinephrine. “The patient will learn about food labels” is not objective and measurable
and is not correctly written.
21. After a teaching session on taking blood pressures, the nurse tells the patient, “You took that blood pressure
like an experienced nurse.” Which type of reinforcement did the nurse use?
ANS: A
Reinforcers come in the form of social acknowledgments (e.g., nods, smiles, words of encouragement),
pleasurable activities (e.g., walks or play time), and tangible rewards (e.g., toys or food). The entrusting
approach is a teaching approach that provides a patient the opportunity to manage self-care. It is not a type of
reinforcement.
22. A patient with heart failure is learning to reduce salt in the diet. When will be the best time for the nurse to
address this topic?
ANS: C
In this situation, because the teaching is about food, coordinating it with routine nursing care that involves
food can be effective. Many nurses find that they are able to teach more effectively while delivering nursing
care. For example, while hanging blood, you explain to the patient why the blood is necessary and the
symptoms of a transfusion reaction that need to be reported immediately. At bedtime would be a good time to
discuss routines that enhance sleep. At bath time would be a good time to describe skin care and how to
prevent pressure ulcers. At medication time would be a good time to explain the purposes and side effects of
the medication.
23. A nurse is teaching a patient who has low health literacy about chronic obstructive pulmonary disease
(COPD) while giving COPD medications. Which technique is most appropriate for the nurse to use?
ANS: D
Include the most important information at the beginning of the session for patients with literacy or learning
disabilities. Also, use visual cues and simple, not complex, analogies when appropriate. Another technique is to
frequently ask patients for feedback to determine whether they comprehend the information. Additionally,
provide teaching materials that reflect the reading level of the patient, with attention given to short words and
sentences, large type, and simple format (generally, information written on a fifth grade reading level is
recommended for adult learners).
a. Social acknowledgment
b. Pleasurable activity
c. Tangible reward
d. Entrusting
a. At bedtime, while the patient is relaxed
b. At bath time, when the nurse is cleaning the patient
c. At lunchtime, while the nurse is preparing the food tray
d.
At medication time, when the nurse is administering patient
medication
a. Use complex analogies to describe COPD.
b.
Ask for feedback to assess understanding of COPD at the end of the
session.
c.
Offer pamphlets about COPD written at the eighth grade level with
large type.
d.
Include the most important information on COPD at the beginning of
the session.
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24. A nurse is teaching a culturally diverse patient with a learning disability about nutritional needs. What must
the nurse do first before starting the teaching session?
ANS: C
Establishing trust is important for all patients, especially culturally diverse and learning disabled patients,
before starting teaching sessions. Obtaining pictures of food, getting an interpreter, and referring to a dietitian
all occur after rapport/trust is established.
25. A nurse is teaching an older-adult patient about strokes. Which teaching technique is most appropriate for
the nurse to use?
ANS: C
With older adults, keep the teaching session short with small amounts of information. Also, if using written
material, assess the patient’s ability to read and use information that is printed in large type and in a color that
contrasts highly with the background (e.g., black 14-point print on matte white paper). Avoid blues and greens
because they are more difficult to see. Speak in a low tone of voice (lower tones are easier to hear than higher
tones). Directly face the older-adult learner when speaking.
26. A patient who is going to surgery has been taught how to cough and deep breathe. Which evaluation
method will the nurse use?
ANS: A
To demonstrate mastery of the skill, have the patient perform a return demonstration under the same conditions
that will be experienced at home or in the place where the skill is to be performed. Computer instruction is use
of a programmed instruction format in which computers store response patterns for learners and select further
lessons on the basis of these patterns (programs can be individualized). Computer instruction is a teaching tool,
rather than an evaluation tool. Verbalization of steps can be an evaluation tool, but it is not as effective as a
return demonstration when evaluating a psychomotor skill. The Cloze test, a test of reading comprehension,
asks patients to fill in the blanks that are in a written paragraph.
27. A patient has been taught how to change a colostomy bag but is having trouble measuring and
manipulating the equipment and has many questions. What is the nurse’s next action?
a. Obtain pictures of food.
b. Get an interpreter.
c. Establish a rapport.
d. Refer to a dietitian.
a. Speak in a high tone of voice to describe strokes.
b. Use a pamphlet about strokes with large font in blues and greens.
c. Provide specific information about strokes in short, small amounts.
d.
Begin the teaching session facing the teaching white board with stroke
information.
a. Return demonstration
b. Computer instruction
c. Verbalization of steps
d. Cloze test
a. Refer to a mental health specialist.
b. Refer to a wound care specialist.
c. Refer to an ostomy specialist.
d. Refer to a dietitian.
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ANS: C
Resources that specialize in a particular health need (e.g., wound care or ostomy specialists) are integral to
successful patient education. A mental health specialist is helpful for emotional issues rather than for physical
problems. A dietitian is a resource for nutritional needs. A wound care specialist provides complex wound care.
28. A nurse is teaching a patient about healthy eating habits. Which learning objective/outcome for the
affective domain will the nurse add to the teaching plan?
ANS: C
Affective learning deals with expression of feelings and acceptance of attitudes, beliefs, or values. Having the
patient value healthy eating habits falls within the affective domain. Stating three facts or identifying two foods
for a healthy snack falls within the cognitive domain. Cooking falls within the psychomotor domain.
29. A nurse is assessing the ability to learn of a patient who has recently experienced a stroke. Which question/
statement will best assess the patient’s ability to learn?
ANS: B
A patient’s reading level affects ability to learn. One way to assess a patient’s reading level and level of
understanding is to ask the patient to read instructions from an educational handout and then explain their
meaning. Reading level is often difficult to assess because patients who are functionally illiterate are often able
to conceal it by using excuses such as not having the time or not being able to see. Asking patients what they
want to know identifies previous learning and learning needs and preferences; it does not assess ability to
learn. Motivation (desire to learn) is related to readiness to learn, not ability to learn. Just asking a patient if he
or she feels strong is not as effective as actually assessing the patient’s strength.
30. A nurse is preparing to teach a kinesthetic learner about exercise. Which technique will the nurse use?
ANS: A
Kinesthetic learners process knowledge by moving and participating in hands-on activities. Return
demonstrations and role playing work well with these learners. Patients who are visual-spatial learners enjoy
learning through pictures and visual charts to explain concepts. The verbal/linguistic learner demonstrates
strength in the language arts and therefore prefers learning by listening or reading information. Patients who
learn through logical-mathematical reasoning think in terms of cause and effect, and respond best when
required to predict logical outcomes. Specific teaching strategies could include open-ended questioning or
problem solving exercises, like a case study.
MULTIPLE RESPONSE
1. A nurse is asked by a co-worker why patient education/teaching is important. Which statements will the
nurse share with the co-worker? (Select all that apply.)
a. The patient will state three facts about healthy eating.
b. The patient will identify two foods for a healthy snack.
c. The patient will verbalize the value of eating healthy.
d. The patient will cook a meal with low-fat oil.
a. “What do you want to know about strokes?”
b. “Please read this handout and tell me what it means.”
c. “Do you feel strong enough to perform the tasks I will teach you?”
d. “On a scale from 1 to 10, tell me where you rank your desire to learn.”
a. Let the patient touch and use the exercise equipment.
b. Provide the patient with pictures of the exercise equipment.
c. Let the patient listen to a video about the exercise equipment.
d. Provide the patient with a case study about the exercise equipment.
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ANS: A, B, C, D
Patient education has long been a standard for professional nursing practice. All state Nurse Practice Acts
acknowledge that patient teaching falls within the scope of nursing practice. Patient education is an essential
component of providing safe, patient-centered care. It is important to document evidence of successful patient
education in patients’ medical records. Patient education is effective for children. Different techniques must be
used with children. Creating a well-designed, comprehensive teaching plan that fits a patient’s unique learning
needs reduces health care costs, improves quality of care, and ultimately changes behaviors to improve patient
outcomes.
2. A nurse is preparing to teach patients. Which patient finding will cause the nurse to postpone a teaching
session? (Select all that apply.)
ANS: A, B, E
Any condition (e.g., pain, fatigue) that depletes a person’s energy also impairs the ability to learn, so the
session should be postponed until the pain is relieved and the patient is rested. Postpone teaching when an
illness becomes aggravated by complications such as a high fever or respiratory difficulty. A mild level of
anxiety motivates learning. When patients are ready to learn, they frequently ask questions. When the patient
enters the stage of acceptance, the stage compatible with learning, introduce a teaching plan.
Chapter 29: Infection Prevention and Control
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. The nurse and a new nurse in orientation are caring for a patient with pneumonia. Which statement by the
new nurse will indicate a correct understanding of this condition?
ANS: A
Infections are infectious and/or communicable. Infectious diseases may not pose a risk for transmission to
others, although they are serious for the patient. Pneumonia is not a communicable disease—a disease that is
transmitted directly from one individual to the next, so there is no need for isolation. A private negative–air
a.
“Patient education is an essential component of safe, patient-centered
care.”
b. “Patient education is a standard for professional nursing practice.”
c. “Patient teaching falls within the scope of nursing practice.”
d. “Patient teaching is documented and part of the chart.”
e. “Patient education is not effective with children.”
f. “Patient teaching can increase health care costs.”
a. The patient is hurting.
b. The patient is fatigued.
c. The patient is mildly anxious.
d. The patient is asking questions.
e. The patient is febrile (high fever).
f. The patient is in the acceptance phase.
a. “An infectious disease like pneumonia may not pose a risk to others.”
b. “We need to isolate the patient in a private negative-pressure room.”
c. “Clinical signs and symptoms are not present in pneumonia.”
d. “The patient will not be able to return home.”
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pressure room is used for tuberculosis, not pneumonia. Clinical signs and symptoms are present in pneumonia.
Frequently, patients with pneumonia do return home unless there are extenuating circumstances.
2. The patient and the nurse are discussing Rickettsia rickettsii—Rocky Mountain spotted fever. Which patient
statement to the nurse indicates understanding regarding the mode of transmission for this disease?
ANS: C
Rocky Mountain spotted fever is caused by bacteria transmitted by the bite of ticks. Wearing a repellent that is
designed for repelling ticks, mosquitoes, and other insects can help in preventing transmission of this disease.
Drinking plenty of uncontaminated water, wearing sunscreen, and using alcohol-based hand gels for cleaning
hands are all important activities to participate in while camping, but they do not contribute to or prevent
transmission of this disease.
3. The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group
about the most important thing to do to prevent the spread of infection. Which information did the nurse share
with the preschool workers?
ANS: D
The single most important thing that individuals can do to prevent the spread of infection is to wash their
hands before and after eating, going to the bathroom, changing a diaper, and wiping a nose and between
touching each individual child. It is important for preschool children to have a nutritious diet; a healthy
individual can fight infection more effectively. A health care provider, along with the parent, makes decisions
about dietary supplements. Cleaning the toys can decrease the number of pathogens but is not the most
important thing to do in this scenario.
4. The nurse is admitting a patient with an infectious disease process. Which question will be most appropriate
for a nurse to ask about the patient’s susceptibility to this infectious process?
ANS: B
Multiple factors influence a patient’s susceptibility to infection. Patients with chronic diseases such as diabetes
mellitus and multiple sclerosis are also more susceptible to infection because of general debilitation and
nutritional impairment. Other factors include age, nutritional status, trauma, and smoking. The other questions
are part of an admission assessment process but are not pertinent to the infectious disease process.
5. The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days
postoperatively, the nurse’s assessment indicates that the incision is red and has a small amount of purulent
drainage. The patient reports tenderness at the incision site. The patient’s temperature is 100.5° F, and the
WBC is 10,500/mm3. Which action should the nurse take first?
a. “When camping, I will use sunscreen.”
b. “When camping, I will drink bottled water.”
c. “When camping, I will wear insect repellent.”
d. “When camping, I will wash my hands with hand gel.”
a. Encourage preschool children to eat a nutritious diet.
b. Suggest that parents provide a multivitamin to the children.
c. Clean the toys every afternoon before putting them away.
d. Wash their hands between each interaction with children.
a. “Do you have a spouse?”
b. “Do you have a chronic disease?”
c. “Do you have any children living in the home?”
d. “Do you have any religious beliefs that will influence your care?”
a. Plan to change the surgical dressing during the shift.
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ANS: B
The nursing assessment indicates signs and symptoms of infection, requiring the primary health care provider
to be notified of the patient’s needs. SBAR—Situation, Background, Assessment, and Recommendation—can
be utilized to organize thoughts and data and to provide a thorough explanation of the patient’s current status.
The reevaluation of temperature is a good choice, but it will take longer than 4 hours to make a change in the
white blood cells. Changing the dressing may be a need during the shift but is not a first priority. Checking to
see about the skin preparation used 2 days ago may or may not be useful information at this time.
6. The nurse is providing an education session to an adult community group about the effects of smoking on
infection. Which information is most important for the nurse to include in the educational session?
ANS: B
A normal defense mechanism against infection in the respiratory tract is the cilia lining the upper airways of
the lungs and normal mucus. When a patient inhales a microbe, the cilia and mucus trap the microbe and
sweep them up and out to be expectorated or swallowed. Smoking may alter this defense mechanism and
increase the patient’s potential for infection. Smoking can be expensive, the smell does cling to hair and
clothing, and the tar within the smoke can alter the color of a patient’s nails. This information can be included
in the education but does not constitute the most important point.
7. A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal area.
A nurse is taking a health history. Which question is the priority?
ANS: C
Antibiotics and oral contraceptives can disrupt normal flora in the vagina, causing an overgrowth of Candida
albicans in that area. It is important to ask the patient about current medications to obtain information that may
assist with diagnosis. The body contains normal flora (microorganisms) that live on the surface of skin, saliva,
oral mucosa, gastrointestinal tract, and genitourinary tract. The normal flora of the vagina causes vaginal
secretions to achieve a low pH, inhibiting the growth of many microorganisms. Visiting the primary health care
provider is important for the patient’s health maintenance but is not the priority. Learning about the patient’s
eating and sleeping habits will assist in the plan of care but is not the priority.
8. The nurse is caring for a school-aged child who has injured the right leg after a bicycle accident. Which
signs and symptoms will the nurse assess for to determine if the child is experiencing a localized inflammatory
response?
b. Utilize SBAR to notify the primary health care provider.
c. Reevaluate the temperature and white blood cell count in 4 hours.
d. Check to see what solution was used for skin preparation in surgery.
a. Smoke from tobacco products clings to your clothing and hair.
b. Smoking affects the cilia lining the upper airways in the lungs.
c. Smoking can affect the color of the patient’s fingernails.
d. Smoking tobacco products can be very expensive.
a.
“When was the last time you visited your primary health care
provider?”
b. “Has this condition affected your eating habits in any way?”
c. “What medications are you currently taking?”
d. “Are you able to sleep at night?”
a.
Malaise, anorexia, enlarged lymph nodes, and increased white blood
cells
b. Chest pain, shortness of breath, and nausea and vomiting
c. Dizziness and disorientation to time, date, and place
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ANS: D
The body’s cellular response to an injury is seen as inflammation. Signs of localized inflammation include
swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. Systemic signs of
inflammation include fever, malaise, and anorexia, as well as enlarged lymph nodes and increased white blood
cells. Chest pain, shortness of breath, and nausea and vomiting are signs and symptoms of a cardiac alteration.
Dizziness and disorientation to time, date, and place may indicate a neurologic alteration.
9. Which interventions utilized by the nurse will indicate the ability to recognize a localized inflammatory
response?
ANS: D
Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the
affected body part. One sign of the inflammatory response, particularly after an injury, is swelling or edema.
Resting the affected injured area, using ice as ordered, wrapping the area to provide support—particularly if it
is an extremity—and elevating the injured area will help to decrease swelling or edema. Turning, coughing,
and deep breathing are utilized for postoperative patients and for immobilized patients to help prevent an
infectious process such as pneumonia. Orientation to date, time, and place is an intervention utilized with many
different types of patients who may be confused. Vigorous range of motion would irritate the inflammatory
process. Range of motion is utilized for individuals who need to improve movement of their extremities,
including immobilized patients.
10. The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for developing an
infection?
ANS: C
The patient who is recovering from a right total hip surgery has a large incision from the surgery. This break in
the skin increases the likelihood of infection. Any break in the integrity of the skin and mucous membranes
allows pathogens to enter and exit the body. The patient has had anesthesia, which depresses the respiratory
system and has the potential to decrease the expansion of alveoli and to increase the chance of infection in the
respiratory system. A patient who is having chest pain, experiencing dehydration, or being admitted with heart
problems does not have open incisions that break the skin; therefore, his or her infection risk is lower.
11. The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular access
(IV) device. Which nursing intervention is a priority in this procedure?
ANS: C
d. Edema, redness, tenderness, and loss of function
a. Vigorous range-of-motion exercises
b. Turn, cough, and deep breathe
c. Orient to date, time, and place
d. Rest, ice, and elevation
a. A patient who is in observation for chest pain
b. A patient who has been admitted with dehydration
c. A patient who is recovering from a right total hip surgery
d. A patient who has been admitted for stabilization of heart problems
a. Review the procedure with the patient.
b. Position the patient comfortably.
c. Maintain surgical aseptic technique.
d. Gather available supplies.
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You maintain surgical aseptic technique at the patient’s bedside (e.g., when inserting IV or urinary catheters,
suctioning the tracheobronchial airway, and sterile dressing changes) because patients with disease processes
of the immune system are at particular risk for infection. These diseases include leukemia, AIDS, lymphoma,
and aplastic anemia. These disease processes weaken the defenses against an infectious organism. Reviewing
the procedure with the patient, positioning the patient, and gathering the supplies are all important steps in the
procedure but are not the priority in the procedure since the patient already has a compromised immune
response.
12. The nurse is caring for an adult patient in the clinic who has been evacuated and is a victim of flooding.
The nurse teaches the patient about rest, exercise, and eating properly and how to utilize deep breathing and
visualization. What is the primary rationale for the nurse’s actions related to the teaching?
ANS: C
The body responds to emotional or physical stress by the general adaptation syndrome. If stress extends for
long periods of time, this can lead to exhaustion, whereby energy stores are depleted and the body has no
defenses against invading organisms. Techniques of deep breathing and visualization may be helpful with pain,
but they are not the primary reason. The teachings listed are not all standard interventions taught at every
health care visit. There is no data to indicate the patient requested this information for the family.
13. The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in
an educational session to decrease the risk of infection?
ANS: C
A patient’s nutritional health directly influences susceptibility to infection. A reduction in the intake of protein
and other nutrients such as carbohydrates and fats reduces body defenses against infection and impairs wound
healing. This is the only teaching point that directly influences risk. Teaching the patient how to take a
temperature can help the patient assess if there is a fever, but it is not related to decreasing the individual’s risk
for infection. Teaching the patient about fall prevention or about the effects of alcohol does not decrease the
risk of infection.
14. A diabetic patient presents to the clinic for a dressing change. The wound is located on the right foot and
has purulent yellow drainage. Which action will the nurse take to prevent the spread of infection?
ANS: D
Localized infections are most common in the skin or with mucous membrane breakdown. Wear gloves and
other personal protective equipment as appropriate when examining or providing treatment to localized
a. Topics taught are standard information taught during health care visits.
b.
The patient requested this information to teach the extended family
members.
c.
Stress for long periods of time can lead to exhaustion and decreased
resistance to infection.
d.
These techniques will help the patient manage the pain and loss of
personal belongings.
a. Teaching the patient about fall prevention
b. Teaching the patient to take a temperature
c. Teaching the patient to select nutritious foods
d. Teaching the patient about the effects of alcohol
a. Position the patient comfortably on the stretcher.
b. Explain the procedure for dressing change to the patient.
c. Review the medication list that the patient brought from home.
d. Don gloves and other appropriate personal protective equipment.
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infected areas to create a protective barrier. Positioning the patient, explaining the procedure, and reviewing
the medication list are all tasks that need to be completed, but they do not prevent the spread of infection.
15. A patient presents with pneumonia. Which priorityintervention should be included in the plan of care for
this patient?
ANS: A
Systemic infection, like pneumonia, causes more generalized symptoms than local infection. This type of
infection can result in fever, fatigue, nausea and vomiting, and malaise; be alert for changes in the patient’s
level of activity and responsiveness. Nurses do not assume but assess and communicate with the patient about
pain. While providing the patient with ice chips may be appropriate, it is not a priority and there is no reason
for the patient to be limited to ice. Maintaining the room temperature at 65° F is too cold.
16. The nurse is caring for a patient in an intensive care unit who needs a bath. Which priority action will the
nurse take to decrease the potential for a health care–associated infection?
ANS: C
The Centers for Disease Control and Prevention (CDC) recommends the use of chlorhexidine (CHG) bathing
for patients in intensive care units, patients who are scheduled for surgery, and all patients with invasive central
line catheters as part of MRSA reduction efforts. Using local anesthetics, nonallergenic tape, and filtered water
does not affect the cause of a health care–associated infection by, for example, decreasing microbial counts like
a CHG bath.
17. The infection control nurse is reviewing data for the medical-surgical unit. The nurse notices an increase in
postoperative infections from Aspergillus. Which type of health care–associated infection will the nurse report?
ANS: B
An exogenous infection comes from microorganisms found outside the individual such
as Salmonella, Clostridium tetani, and Aspergillus. They do not exist as normal floras. A vector transmits
microorganisms and is usually a type of insect or organism. Endogenous infection occurs when part of the
patient’s flora becomes altered and an overgrowth results (e.g., staphylococci, enterococci, yeasts, and
streptococci). This often happens when a patient receives broad-spectrum antibiotics that alter the normal
floras. A suprainfection develops when broad-spectrum antibiotics eliminate a wide range of normal flora
organisms, not just those causing infection.
18. The patient has contracted a urinary tract infection (UTI) while in the hospital. Which action
will most likely increase the risk of a patient contracting a UTI?
a. Observe the patient for decreased activity tolerance.
b. Assume the patient is in pain and treat accordingly.
c. Provide the patient ice chips as requested.
d. Maintain the room temperature at 65° F.
a. Use local anesthetic on reddened areas.
b. Use nonallergenic tape on dressings.
c. Use a chlorhexidine wash.
d. Use filtered water.
a. Vector
b. Exogenous
c. Endogenous
d. Suprainfection
a. Reusing the patient’s graduated receptacle to empty the drainage bag.
b. Allowing the drainage bag port to touch the graduated receptacle.
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ANS: B
Allowing the urinary drainage bag port to touch contaminated items (graduated receptacle) may introduce
bacteria into the urinary system and contribute to a urinary tract infection. The urinary drainage bag should be
emptied at least once a shift. Patients should have their own receptacle for measurement to prevent crosscontamination.
Repeated catheter irrigations increase the chance so irrigating infrequently will be beneficial in
reducing the risk.
19. Which nursing action will most likely increase a patient’s risk for developing a health care–associated
infection?
ANS: B
Using clean technique (medical asepsis) to insert a urinary catheter would place the patient at risk for a health
care–associated infection. Urinary catheters need to be inserted using sterile technique, which is also referred
to as surgical asepsis. Surgical aseptic technique (also called sterile technique) should be used when suctioning
an airway because it is considered a sterile body cavity. Washing from clean to dirty (urinary meatus toward
rectum) is correct for decreasing infection risk. Bottled solutions may be used repeatedly during a 24-hour
period; however, special care is needed to ensure that the solution in the bottle remains sterile. After 24 hours,
the solution should be discarded.
20. The nurse is caring for a patient in labor and delivery. When near completing an assessment of the patient’s
cervix, the electronic infusion device being used on the intravenous (IV) infusion alarms. Which sequence of
actions is most appropriate for the nurse to take?
ANS: C
Completing the assessment while wearing gloves, removing gloves, washing hands after contact with body
fluids, and then assessing the intravenous infusion will assist in the prevention and transfer of any potential
organisms to this intravenous line. Completing the assessment, removing gloves, and silencing the alarm
leaves out the crucial step of decontaminating and washing the hands. Discontinuing the assessment and
assessing the IV leaves out removing the gloves and decontamination, as well as completing the assessment for
the patient. Discontinuing the assessment, removing gloves, using hand gel, and assessing the IV is incorrect
because upon exposure to body fluids, washing hands is appropriate.
21. The nurse is dressed and is preparing to care for a patient in the perioperative area. The nurse has scrubbed
hands and has donned a sterile gown and gloves. Which action will indicate a break in sterile technique?
c. Emptying the urinary drainage bag at least once a shift.
d. Irrigating the catheter infrequently.
a. Uses surgical aseptic technique to suction an airway
b. Uses a clean technique for inserting a urinary catheter
c. Uses a cleaning stroke from the urinary meatus toward the rectum
d. Uses a sterile bottled solution more than once within a 24-hour period
a. Complete the assessment, remove gloves, and silence the alarm.
b.
Discontinue the assessment, silence the alarm, and assess the
intravenous site.
c.
Complete the assessment, remove gloves, wash hands, and assess the
intravenous infusion.
d.
Discontinue the assessment, remove gloves, use hand gel, and assess
the intravenous infusion.
a. Touching clean protective eyewear
b. Standing with hands above waist area
c. Accepting sterile supplies from the surgeon
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ANS: A
Touching nonsterile (clean) protective eyewear once gowned and gloved with sterile gown and gloves would
indicate a break in sterile technique. Sterile objects remain sterile only when touched by another sterile object.
Standing with hands folded on the chest is common practice and prevents arms and hands from touching
unsterile objects. Accepting sterile supplies from the surgeon who has opened them with the appropriate
technique is acceptable. Staying with a sterile table once opened is a common practice to ascertain that no one
or nothing has contaminated the table.
22. The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of
medical and surgical asepsis for a sterile dressing change?
ANS: C
Utilize clean gloves (medical asepsis) to remove contaminated dressings and sterile supplies, including gloves
and dressings (surgical asepsis–sterile technique) to reapply sterile dressings. Wearing sterile gowns and gloves
is not necessary when removing soiled dressings. Donning clean gloves to dress a sterile wound would
contaminate the sterile supplies. Utilizing clean supplies for a sterile dressing would not help in decreasing the
number of microbes at the incision site.
23. The nurse is caring for a patient in the endoscopy area. The nurse observes the technician performing these
tasks. Which observation will require the nurse to intervene?
ANS: C
Standard precautions are used to prevent and control the spread of infection. Transferring contaminated
equipment without the protection of gloves can assist in the spread of microbes to inanimate objects and to the
person doing the transfer; therefore, the nurse must intervene. Utilizing gloves, washing hands, covering
contaminated supplies during transfer, and disinfecting equipment in the appropriate way in the appropriate
places utilize principles of basic medical asepsis and standard precautions and can break the chain of infection.
24. The nurse is caring for a patient who is at risk for infection. Which action by the nurse indicates correct
understanding about standard precautions?
ANS: D
Standard precautions include the wearing of eyewear whenever there is a possibility of a splash or splatter, like
when emptying the urinary drainage bag. Teaching the patient about good nutrition is positive but does not
apply to standard precautions. Standard precautions apply to contact with blood, body fluid (except sweat),
d. Staying with the sterile table once it is open
a. Donning clean goggles, gown, and gloves to dress the wound
b. Donning sterile gown and gloves to remove the wound dressing
c.
Utilizing clean gloves to remove the dressing and sterile supplies for
the new dressing
d.
Utilizing clean gloves to remove the dressing and clean supplies for
the new dressing
a. Washing hands after removing gloves
b. Disinfecting endoscopes in the workroom
c. Removing gloves to transfer the endoscope
d. Placing the endoscope in a container for transfer
a. Teaches the patient about good nutrition
b. Dons gloves when wearing artificial nails
c. Disposes an uncapped needle in the designated container
d. Wears eyewear when emptying the urinary drainage bag
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nonintact skin, and mucous membranes from all patients. Artificial nails are not worn when using standard
precautions. Any needles should be disposed of uncapped, or a mechanical safety device is activated for
recapping.
25. The nurse is caring for a patient who has just delivered a neonate. The nurse is checking the patient for
excessive vaginal drainage. Which precaution will the nurse use?
ANS: C
Standard precautions apply to contact with blood, body fluid, nonintact skin, and mucous membranes of all
patients. Contact precautions apply to individuals with infections that can be transmitted by direct or indirect
contact. Protective environment precautions apply to individuals who have undergone transplantations and
gene therapy. Droplet precautions focus on diseases that are transmitted by large droplets.
26. The nurse is caring for a patient in the hospital. The nurse observes the nursing assistive personnel (NAP)
turning off the handle faucet with bare hands. Which professional practice principle supports the need for
follow-up with the NAP?
ANS: A
The nurse is responsible for providing a safe environment for the patient. The effectiveness of infection control
practices depends on conscientiousness and consistency in using effective aseptic technique by all health care
providers. After washing hands, turn off a handle faucet with a dry paper towel, and avoid touching the handles
with your hands to assist in preventing the transfer of microorganisms. Wet towels and hands allow the transfer
of pathogens from faucet to hands. The principles and procedures for washing hands are universal and apply to
all members of health care teams. Being resourceful and aware of the cost of health care is important, but
taking shortcuts that may endanger an individual’s health is not a prudent practice.
27. The nurse is caring for a patient who becomes nauseated and vomits without warning. The nurse has
contaminated hands. Which action is best for the nurse to take next?
ANS: A
The Centers for Disease Control and Prevention (CDC) recommends that when hands are visibly soiled, one
should wash with a non-antimicrobial soap or with antimicrobial soap. Cleaning hands with wipes or using
waterless hand gel does not meet this standard. If hands are not visibly soiled, use an alcohol-based waterless
antiseptic agent for routinely decontaminating hands. Wiping hands with a dry paper towel will occur after the
nurse has washed both hands.
28. The nurse is performing hand hygiene before assisting a health care provider with insertion of a chest tube.
While washing hands, the nurse touches the sink. Which action will the nurse take next?
a. Contact
b. Droplet
c. Standard
d. Protective environment
a.
The nurse is responsible for providing a safe environment for the
patient.
b. Different scopes of practice allow modification of procedures.
c. Allowing the water to run is a waste of resources and money.
d. This is a key step in the procedure for washing hands.
a. Wash hands with an antimicrobial soap and water.
b. Clean hands with wipes from the bedside table.
c. Use an alcohol-based waterless hand gel.
d. Wipe hands with a dry paper towel.
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ANS: D
The inside of the sink and the edges of the sink, faucet, and handles are considered contaminated areas. If the
hands touch any of these areas during handwashing, repeat the handwashing procedure utilizing antiseptic
soap. There is no need to inform the health care provider or be relieved of this assignment. If the hands are
contaminated when touching the sink, drying hands and proceeding with the procedure could possibly
contaminate and contribute to increased microbial counts during the procedure, resulting in infection for the
patient. Extending the time for washing the hands (although this is what will happen when the procedure is
repeated) is not the focus. The focus is to repeat the whole hand hygiene procedure utilizing antiseptic soap.
29. The nurse on the surgical team and the surgeon have completed a surgery. After donning gloves, gathering
instruments, and placing in the transport carrier, what is the next step in handling the instruments used during
the procedure?
ANS: A
Surgical instruments need to be cleaned and sterilized. Disinfecting, boiling, or cleaning is not utilized on
critical items that will be reused on patients in the hospital environment. Items that are used on sterile tissue or
in the vascular system present a high risk of infection if they become contaminated with bacteria.
30. The nurse is observing a family member changing a dressing for a patient in the home health environment.
Which observation indicates the family member has a correct understanding of how to manage contaminated
dressings?
ANS: A
Contaminated dressings and other infectious, disposable items should be placed in impervious plastic or brown
paper bags and then disposed of properly in garbage containers. Gloves should be worn during this process.
Parts of the dressing should not be saved, even though they may seem clean, because microbes may be present.
31. The nurse is caring for a group of patients. Which patient will the nurse see first?
ANS: A
a. Inform the health care provider and recruit another nurse to assist.
b. Rinse and dry hands, and begin assisting the health care provider.
c. Extend the handwashing procedure to 5 minutes.
d. Repeat handwashing using antiseptic soap.
a. Sending to central sterile for cleaning and sterilization
b. Sending to central sterile for cleaning and disinfection
c. Sending to central sterile for cleaning and boiling
d. Sending to central sterile for cleaning
a. The family member places the used dressings in a plastic bag.
b. The family member saves part of the dressing because it is clean.
c. The family member removes gloves and gathers items for disposal.
d.
The family member wraps the used dressing in toilet tissue before
placing in trash.
a. A patient with Clostridium difficile in droplet precautions
b. A patient with tuberculosis in airborne precautions
c. A patient with MRSA infection in contact precautions
d. A patient with a lung transplant in protective environment precautions
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A patient with Clostridium difficile should be on contact precautions, not droplet; therefore, the nurse will see
this patient first to correct the precautions. All the rest are on correct precautions. Patients with tuberculosis
belong in airborne precautions; patients with MRSA infection belong in contact precautions; and patients with
lung transplants belong in protective environment precautions.
32. The home health nurse is teaching a patient and family about hand hygiene in the home. Which situation
will cause the nurse to emphasize washing hands before and after?
ANS: B
Patients and family members should perform hand hygiene before and after treatments and when coming in
contact with body fluids. Shaking hands does not require washing of hands before and after. Washing hands
before and after opening the refrigerator and using the computer is not required.
33. The surgical mask the perioperative nurse is wearing becomes moist. Which action will the perioperative
nurse take next?
ANS: A
After the mask is worn for several hours, it can become moist. The mask should be changed as soon as
possible because moisture does not provide a barrier to microorganisms and is ineffective. Waiting to change
the mask, air-drying it, or wearing it because it is comfortable does not support the principles of infection
control.
34. The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent
the spread of disease?
ANS: D
Contact precautions are a type of isolation precaution used for patients with illness that can be transmitted
through direct or indirect contact. Patients who are on contact precautions should have dedicated equipment
wherever possible. This would mean, for example, that one blood pressure cuff and one stethoscope would stay
in the room with the patient and would be used for that patient only. A gown and gloves may be required for
interactions with a patient who is on contact precautions. A face mask and goggles are not part of contact
precautions. A room with negative airflow is needed for patients placed on airborne precautions; it is not
necessary for a patient on contact precautions. When a patient on contact precautions needs to be transported,
the patient should wear clean gown, and hands cleaned, and the infectious material is contained or covered.
35. The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which action will the
nurse take next?
a. Shaking hands
b. Performing treatments
c. Opening the refrigerator
d. Working on a computer
a. Apply a new mask.
b. Reapply the mask after it air-dries.
c. Change the mask when relieved by next shift.
d. Do not change the mask if the nurse is comfortable.
a. Place the patient in a room with negative airflow.
b.
Wear a gown, gloves, face mask, and goggles for interactions with the
patient.
c.
Transport the patient safely and quickly when going to the radiology
department.
d.
Use a dedicated blood pressure cuff that stays in the room and is used
for that patient only.
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ANS: A
Clostridium difficile is a spore-forming organism that can be transmitted through direct and indirect patient
contact. Because Clostridium difficile is a spore-forming organism, hand sanitizer is not effective in preventing
its transmission. Hands must be washed with soap and water to prevent transmission. This organism is not
transmitted via the droplet route; therefore, droplet precautions are not needed. An N95 respirator is used
primarily for patients with airborne illness, especially tuberculosis. While all patients should be taught cough
etiquette, this action is not specifically related to the patient having Clostridium difficile.
36. The nurse is changing linens for a postoperative patient and feels a prick in the left hand. A nonactivated
safe needle is noted in the linens. For which condition is the nurse most at risk?
ANS: B
Bloodborne pathogens such as those associated with hepatitis B and C are most commonly transmitted by
contaminated needles. Clostridium difficile and MRSA are spread by contact. Diphtheria is spread by droplets
when one is within 3 feet of the patient.
37. The nurse is caring for a patient who has a bloodborne pathogen. The nurse splashes blood above the glove
to intact skin while discontinuing an intravenous (IV) infusion. Which step(s) will the nurse take next?
ANS: B
After getting splashed with blood from a patient who has a known bloodborne pathogen, it is important to
cleanse the site immediately and thoroughly with soap and running water and notify the manager for guidance
on next steps in the process. Removing the blood with an alcohol swab, delaying washing, and doing nothing
because the splash was to intact skin could possibly spread the blood within the room and could spread the
infection. Contain contamination immediately to prevent contact spread.
38. Which process will be required after exposure of a nurse to blood by a cut from a used scalpel in the
operative area?
a. Instruct assistive personnel to use soap and water rather than sanitizer.
b. Wear an N95 respirator when entering the patient room.
c. Place the patient on droplet precautions.
d. Teach the patient cough etiquette.
a. Diphtheria
b. Hepatitis B
c. Clostridium difficile
d. Methicillin-resistant Staphylococcus aureus
a.
Obtain an alcohol swab, remove the blood with an alcohol swab, and
continue care.
b.
Immediately wash the site with soap and running water, and seek
guidance from the manager.
c.
Do nothing; accidentally getting splashed with blood happens
frequently and is part of the job.
d.
Delay washing of the site until the nurse is finished providing care to
the patient.
a. Placing the scalpel in a needle safe container
b. Testing the patient and offering treatment to the nurse
c. Removing sterile gloves and disposing of in kick bucket
d. Providing a medical evaluation of the nurse to the manager
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ANS: B
Follow-up for risk of infection begins with patient testing. Patients should be tested for HIV and hepatitis B
and C. Testing of the nurse is dependent on the results of patient testing; if the patient is positive for one of
these infections, the nurse will be started on testing and treatment. Removing sterile gloves and placing sharps
in appropriate containers are always part of the perioperative process and are not the process for postexposure.
A confidential medical evaluation is provided to the nurse, not the manager.
39. The nurse is caring for a patient who needs a protective environment. The nurse has provided the care
needed and is now leaving the room. In which order will the nurse remove the personal protective equipment,
beginning with the first step?
1. Remove eyewear/face shield and goggles.
2. Perform hand hygiene, leave room, and close door.
3. Remove gloves.
4. Untie gown, allow gown to fall from shoulders, and do not touch outside of gown; dispose of properly.
5. Remove mask by strings; do not touch outside of mask.
6. Dispose of all contaminated supplies and equipment in designated receptacles.
ANS: D
The correct order for removing personal protective equipment for a patient in a protective environment and for
performing associated tasks is to remove gloves, remove eyewear, remove gown, remove mask, perform hand
hygiene, leave room and close doors, and dispose of all contaminated supplies and equipment in a manner that
prevents the spread of microorganisms.
40. The nurse manager is evaluating current infection control data for the intensive care unit. The nurse
compares past patient data with current data to look for trends. The nurse manager examines the infection
chain for possible solutions. In which order will the nurse arrange the items for the infection chain beginning
with the first step?
1. A mode of transmission
2. An infectious agent or pathogen
3. A susceptible host
4. A reservoir or source for pathogen growth
5. A portal of entry to a host
6. A portal of exit from the reservoir
ANS: D
For spread of infection, the chain has to be uninterrupted with an infectious agent, a reservoir and portal of
exit, a mode of transmission, a portal of entry, and a susceptible host. The nurse manager is evaluating the
chain of infection to determine actions that could be implemented to influence the spread of infection in the
a. 3, 1, 4, 5, 6, 2
b. 1, 4, 5, 3, 6, 2
c. 1, 4, 5, 3, 2, 6
d. 3, 1, 4, 5, 2, 6
a. 3, 2, 4, 1, 5, 6
b. 1, 3, 5, 4, 6, 2
c. 4, 2, 1, 6, 3, 5
d. 2, 4, 6, 1, 5, 3
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intensive care unit. Understanding the spread of infection and directing actions toward those steps have the
potential to decrease infection in the setting.
MULTIPLE RESPONSE
1. The nurse is caring for a patient in protective environment. Which actions will the nurse take? (Select all
that apply.)
ANS: B, D, E
This form of isolation requires a specialized room with positive airflow. The airflow rate is set at greater than
12 air exchanges/hr, and all air is filtered through a HEPA filter. Isolation disrupts normal social relationships
with visitors and caregivers. Take the opportunity to listen to a patient’s concerns or interests. Open drapes or
shades and remove excess supplies and equipment. Patients are not allowed to have dried or fresh flowers or
potted plants in these rooms. All health care personnel wear an N95 respirator every time they enter the room
for patients, and a private room with negative airflow is required for patients on airborne precautions.
2. The nurse is assessing a new patient admitted to home health. Which questions will be most appropriate for
the nurse to ask to determine the risk of infection? (Select all that apply.)
ANS: A, B, C, D
In the home setting, the objective is that the patient and/or family will utilize proper infection control
techniques. Asking the patient and family about handwashing, risk of infection, recent travel, and signs and
symptoms of infection is important in evaluating the patient’s knowledge based on infection control strategies.
Activity assessment is important for evaluation of the overall status of the patient, and knowing who runs
errands gives you information on who is helping to meet the needs of the patient, but neither of these relates to
decreasing the risk of infection.
3. The circulating nurse in the operating room is observing the surgical technologist while applying a sterile
gown and gloves to care for a patient having an appendectomy. Which behaviors indicate to the nurse that the
procedure by the surgical technologist is correct? (Select all that apply.)
a. Wear an N95 respirator when entering the patient’s room.
b. Maintain airflow rate greater than 12 air exchanges/hr.
c. Place in special room with negative-pressure airflow.
d. Open drapes during the daytime.
e. Listen to the patient’s interests.
f. Place dried flowers in a plastic vase.
a. “Can you explain the risk for infection in your home?”
b. “Have you traveled outside of the United States?”
c. “Will you demonstrate how to wash your hands?”
d. “What are the signs and symptoms of infection?”
e. “Are you able to walk to the mailbox?”
f. “Who runs errands for you?”
a. Ties the back of own gown
b. Touches only the inside of gown
c. Slips arms into arm holes simultaneously
d. Extended fingers fully into both of the gloves
e. Uses hands covered by sleeves to open gloves
f. Applies surgical cap and face mask in the operating suite
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ANS: B, C, D, E
To maintain sterility, the surgical technologist (ST) touches the inside of the gown that will be against the body.
Arms are slipped simultaneously into the gown to prevent contamination. Using the sleeves covering the hands
maintains the principle of sterile only touching sterile to open gloves. Extending the fingers fully into both
gloves ensures that the ST has full dexterity while using the sterile gloved hand. Surgical cap, face mask, and
eye wear are applied before entering the surgical area and completing the surgical scrub. Reaching behind to
tie the back of the gown will contaminate the sterile area of the gown.
4. The nurse is preparing to insert a urinary catheter. The nurse is using open gloving to apply the sterile
gloves. Which steps will the nurse take? (Select all that apply.)
ANS: B, D, E, F
Sterile objects held below the waist are considered contaminated. Gloving the dominant hand helps to improve
dexterity. Slipping the fingers underneath the second glove cuff helps to keep the gloved fingers sterile.
Interlocking fingers ensures a smooth fit over the fingers. Sterile supplies are opened by carefully separating
and peeling apart the sides of the package. This prevents the sterile contents from accidentally opening and
touching contaminated objects. While putting on the first glove, touching only the outside surface of the glove
will contaminate the sterile item; touch only the inside of the glove—the piece that will be against the skin.
5. The nurse has received a report from the emergency department that a patient with tuberculosis will be
coming to the unit. Which items will the nurse need to care for this patient? (Select all that apply.)
ANS: A, B, D, F
Caring for this patient requires a private room, negative-pressure airflow in room, and wearing an N95
respirator that has been fit-tested, gloves, gown, and eyewear. Tuberculosis is a disease that is transmitted by
droplets that remain in the air for long periods of time, requiring airborne precautions. This patient will not be
in droplet precautions and instead requires airborne precaution signs. This type of patient requires more than
the average surgical mask for protection.
6. The nurse and the student nurse are caring for two different patients on the medical-surgical unit. One
patient is in airborne precautions, and one is in contact precautions. The nurse explains to the student different
interventions for care. Which information will the nurse include in the teaching session? (Select all that apply.)
a.
While putting on the first glove, touch only the outside surface of the
glove.
b.
With gloved dominant hand, slip fingers underneath second glove
cuff.
c. Remove outer glove package by tearing the package open.
d. Lay glove package on clean flat surface above waistline.
e. Glove the dominant hand of the nurse first.
f. After second glove is on, interlock hands.
a. Private room
b. Negative-pressure airflow in room
c. Surgical mask, gown, gloves, eyewear
d. N95 respirator, gown, gloves, eyewear
e. Communication signs for droplet precautions
f. Communication signs for airborne precautions
a. Dispose of supplies to prevent the spread of microorganisms.
b. Wash hands before entering and leaving both of the patients’ rooms.
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ANS: A, B, D, E
Washing hands, properly disposing of supplies, applying knowledge of the disease process, and having patients
in airborne precautions wear a mask during transfer are all principles to follow when caring for patients in
isolation. Multiple differences are evident among these types of isolation, including the type of room used for
the patient and what the nurse wears while caring for the patient. It is important to check the working order of
a negative-pressure room before admitting a patient to the room, each shift the patient is in the room, and if
and when the device alarms. Checking the working order of the negative-pressure rooms at discharge is not
necessary.
Chapter 35: Sexuality
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. A nurse is caring for a 15-year-old who in the past 6 months has had multiple male and female sexual
partners. Which response by the nurse will be mosteffective?
ANS: A
Some adolescents participate in risky behaviors. The nurse should acknowledge this feeling to the patient and
offer education and alternatives, while giving the patient the autonomy to make his or her own decisions.
Adolescents who engage in sexual risk behaviors experience negative health outcomes such as STIs and
unintended pregnancy. In addition, the pattern of risk-taking behavior tends to be established and continue
throughout life. The nurse should not force the patient to make a choice of orientation and should not pass
judgment on a patient’s sexual orientation or social network; this would make the patient feel defensive and
would eliminate the trust in the relationship. Involving parents is not the first line of action; parents should be
notified only if the child is in a life or death situation.
2. A nurse is caring for a patient who expresses a desire to have an elective abortion. The nurse’s religious and
ethical values are strongly opposed. How should the nurse best handle the situation?
c.
Be consistent in nursing interventions since there is only one
difference in the precautions.
d.
Apply the knowledge the nurse has of the disease process to prevent
the spread of microorganisms.
e.
Have patients in airborne precautions wear a mask during
transportation to other departments.
f.
Check the working order of the negative-pressure room for the
airborne precaution patient on admission and at discharge.
a.
“Sexually transmitted infections and unwanted pregnancy are a real
risk. Let’s discuss what you think is the best method for protecting
yourself.”
b.
“Having sexual interaction with both males and females places you at
higher risk for STIs. To protect yourself, you need to decide which
orientation you are.”
c.
“Your current friends are leading you to make poor choices. You
should find new friends to hang out with.”
d.
“I think it’s best to notify your parents. They know what’s best for you
and can help make sure you practice safe sex.”
a. Attempt to educate the patient about the consequences of abortion.
b.
Refer the patient to a family planning center or another health
professional.
c.
Continue to care for the patient, and limit conversation as much as
possible.
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ANS: B
The nurse must be aware of personal beliefs and values and is not required to participate in counseling or
procedures that compromise those values. However, the patient is entitled to nonjudgmental care and should be
referred to someone who can create a trusting environment. The nurse should not care for a patient if the
quality of care could be jeopardized. The nurse should not attempt to push personal values onto a patient. The
nurse also should not create tension by informing the patient that he or she does not have the same morals; this
could cause the patient to feel guilty or defensive when receiving care from any health care professional.
3. Which patient is most in need of a nurse’s referral to adoption services?
ANS: B
Adoption is an option for someone with infertility, especially if infertility treatments are unavailable owing to
religious or financial constraints. A patient who wishes to have an elective abortion may be educated about all
the possibilities, but the nurse should approach the patient in a nonjudgmental manner and should accept the
patient’s decision. When a patient has recently miscarried, the nurse should assess the patient’s feelings about
the loss and should address any concerns the patient may have about fertility. Infertility is the inability to
conceive after 1 year of unprotected intercourse; therefore, talking about adoption after one miscarriage or
after only 3 months of attempting conception would be too soon.
4. The nurse is caring for a patient who recently had unprotected sex with a partner who has HIV. Which
response by the nurse is best?
ANS: C
Highly active retroviral therapy increases the survival time of a person with HIV or AIDS. HIV antibodies will
not show up in blood work for 6 weeks to 3 months. The infection stage of HIV lasts for about a month after
the virus is contracted; during that time, the patient may experience flu-like symptoms. A support group may
be beneficial for a patient who contracts HIV; however, it is unknown whether the patient has contracted HIV,
and antiretroviral therapy has helped people live beyond the 10 years expected if HIV goes untreated.
5. An 18-year-old male patient informs the nurse that he isn’t sure if he is homosexual because he is attracted
to both genders. Which response by the nurse will help establish a trusting relationship?
ANS: C
d.
Inform the patient that, because of immoral issues, another nurse will
have to care for her.
a. A woman considering abortion for an unwanted pregnancy
b. An infertile couple religiously opposed to artificial insemination
c. A woman who suffered miscarriage during her first pregnancy
d. An infertile couple who has been attempting conception for 3 months
a.
“You should have your blood drawn today to see if you were
infected.”
b. “If you have the virus, you will have flu-like symptoms in 6 months.”
c.
“Highly active antiretroviral therapy has been shown effective in
slowing the disease process.”
d.
“I will set you up with a support group to help you cope with dying
within the next 10 years.”
a. “Don’t worry. It’s just a phase you will grow out of.”
b. “Those are abnormal impulses. You should seek therapy.”
c. “At your age, it is normal to be curious about both genders.”
d.
“Having questions about sexuality is normal but if these sexual
activities make you feel bad you should stop.”
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Adolescents have questions about sexuality. The patient will feel most comfortable discussing his sexual
concerns further if the nurse establishes that it is normal to ask questions about sexuality. The nurse can then
discuss in greater detail. Although it is normal for young adults to be curious about sexuality, the nurse should
use caution in giving advice on taking sexual action. The nurse should promote safe sex practices. Telling the
patient not to worry dismisses his concern. Telling the patient that he is abnormal might offend the patient and
prevent him from establishing an open relationship.
6. A nurse is caring for a 35-year-old female patient who recently started taking antidepressants after repeated
attempts at fertility treatment. The patient tells the nurse, “I feel happier, but my sex drive is gone.” Which
nursing diagnosis has the highest priority?
ANS: A
Antidepressants have adverse effects on sexual desire and response. The nurse should be sure to educate the
patient on the potential for these side effects and how to correct for them, for example, using lubricant to ease
discomfort. The patient has taken steps toward effective coping by seeking therapy. The patient has not
expressed a reason for the nurse to be concerned about contraceptives. The nurse should always assess for
concerns about violence in a patient’s life. Although some antidepressants have been related to self-directed
violence, this patient focus is on becoming pregnant (fertility treatments) but sex drive is gone.
7. A nurse is using the PLISSIT model when caring for a patient with dyspareunia from diminished vaginal
secretions. The nurse suggests using water-soluble lubricants. Which component of PLISSIT is the nurse
using?
ANS: C
The nurse is using the specific suggestions (SS). The PLISSIT model is as follows:
Permission to discuss sexuality issues
Limited Information related to sexual health problems being experienced
Specific Suggestions—only when the nurse is clear about the problem
Intensive Therapy—referral to professional with advanced training if necessary
8. A patient who has had several sexual partners in the past month expresses a desire to use a contraceptive.
Which contraceptive method should the nurse recommend?
ANS: A
Condoms are both a contraceptive and a barrier against STIs and HIV; proper use will greatly reduce the risk.
Spermicides, diaphragms, and oral contraceptives all protect against pregnancy; however, they are not a barrier
and do not prevent bodily fluids from coming in contact with the patient during sexual intercourse.
a. Sexual dysfunction
b. Ineffective coping
c. Risk for self-directed violence
d. Deficient knowledge about contraception
a. P
b. LI
c. SS
d. IT
a. Condom
b. Diaphragm
c. Spermicide
d. Oral contraceptive
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9. A woman who has been in a monogamous relationship for the past 6 months presents to clinic with herpes
on her labia. The patient is distraught because her partner must have cheated on her. Which response by the
nurse is most effective in establishing an open rapport with a patient?
ANS: B
If open communication is to be established with the patient, the patient must know that she can trust health
care team members. By telling the patient that all encounters are confidential, the nurse establishes trust.
Sharing a story brings the focus to the nurse, inhibiting open rapport. The nurse does not tell the patient what
to do, because that should be the patient’s decision. Forcing the patient to confide by sharing every sexual
encounter may hinder a trusting relationship.
10. A nurse is preparing a community class about sexually transmitted infections. Which primary group will
the nurse focus on for this class?
ANS: B
About 20 million people in the United States are diagnosed with an STI each year, with the highest incidence
occurring in men who have sex with men, bisexual men, and youths between the ages of 15 and 24. While
bisexual women, youths between the ages of 24 and 27, and pregnant women and their partners are important,
they are not the primary groups affected by STIs.
11. The nurse is leading a seminar about menopause and age-related changes. Which response from a group
member indicates the nurse needs to follow up?
ANS: B
Believing that orgasms are no long achievable requires follow-up to correct this misconception. Orgasms are
achievable at any age; however, it may take longer with aging. All other statements indicate that the patient
does have an understanding of age-related changes and needs no follow-up. Both genders experience a reduced
availability of sex hormones. The excitement phase prolongs in both men and women. Men often have
erections that are less firm and shorter acting.
12. A patient who had a colostomy placed 1 month ago is feeling depressed and does not want to participate in
sexual activities anymore. The patient is afraid that the partner does not want sex. The patient is afraid the
ostomy is physically unattractive. Which initial nursing intervention will be most effective in helping this
patient resume sexual activity?
a. Share a story.
b. Inform the patient that all encounters are confidential.
c. Encourage the patient to break up with her partner for cheating.
d.
Tell the patient that she must be honest about every sexual experience
she has had.
a. Bisexual women
b. Men who have sex with men
c. Youths between the ages of 24 and 27
d. Pregnant women and their partners
a. “Hormones of sexual regulation decrease with aging.”
b. “Orgasms are no longer achievable after menopause.”
c. “The excitement phase is prolonged as we age.”
d. “As men age, their erection may be less firm.”
a. Inform the patient about a support group for people with colostomies.
b.
Reassure the patient that lots of people resume sex the same week the
colostomy is placed.
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ANS: D
The nurse should first address the patient’s need to be comfortable with his or her own body image; once the
patient’s issues related to body image are resolved, intimacy may follow. Reassuring the patient that others
manage to have sexual intercourse with an ostomy may help to decrease anxiety but may have the unintended
effect of making the patient feel abnormal because he or she has not yet resumed sexual activity. Support
groups may be helpful for the patient, but this is not the most effective initial intervention a nurse can provide;
this may be helpful later. The patient is worried about the ostomy; incorporating it into intimate activities is
insensitive and can even be damaging to the stoma.
13. A mother brings her 12-year-old daughter into a clinic and inquires about getting a human papillomavirus
(HPV) vaccine that day. Which information will the nurse share with the mother and daughter about the HPV
vaccine?
ANS: B
The HPV vaccine is effective against the four most common types of HPVs that can cause cervical cancer. It is
not effective against HIV, chlamydia, or pregnancy.
14. A parent asks about the human papillomavirus (HPV) vaccine. Which information will the nurse include in
the teaching session?
ANS: B
The vaccine is safe for girls as young as 9 years old and is recommended for females ages 11 to 26 if they have
not already completed the three required injections. Booster doses currently are not recommended. The vaccine
is most effective if administered before sexual activity or exposure.
15. A nursing student is providing education to a group of older adults who are in an independent living
retirement village. Which statement made by the nursing student requires the nurse to intervene?
ANS: C
c.
Teach the patient about intimate activities that can be done to
incorporate the ostomy.
d.
Discuss ways to adapt to new body image so the patient will be
comfortable in resuming intimacy.
a. Protects against human immunodeficiency virus (HIV)
b. Protects against cervical cancer
c. Protects against chlamydia
d. Protects against pregnancy
a. It is recommended for girls 6 to 9 years old.
b. It is recommended for females ages 11 to 26.
c. It is recommended that booster injections be given.
d. It is recommended to receive four required injections.
a. “Avoiding alcohol use will enhance your sexual functioning.”
b.
“You need to tell your partner how you feel about sex and any fears
you may have.”
c.
“You do not need to worry about getting a sexually transmitted
infection at this point in your life.”
d.
“Using pillows and taking pain medication if needed before having
sexual intercourse often help alleviate pain and improve sexual
functioning.”
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Research indicates many older adults are more sexuality active than previously thought and engage in high-risk
sexual encounters, resulting in a steady increase HIV and STI rates over the past 12 years. Therefore, the nurse
needs to intervene when the student tells the older adults that they are not at risk for developing an STI.
Avoiding the use of alcohol; using pillows; taking pain medications before having intercourse if needed; and
communicating thoughts, fears, and feelings about sex all enhance sexual functioning.
16. A nurse is interviewing a woman who uses a diaphragm. Which information from the patient will require
the nurse to follow up?
ANS: A
The woman needs to be refitted after a significant change in weight (10-pound gain or loss) or pregnancy. The
diaphragm is a round, rubber dome that has a flexible spring around the edge. It is used with a contraceptive
cream or jelly and is inserted in the vagina so it provides a contraceptive barrier over the cervical opening.
17. A nurse is conducting a sexual assessment. Which question is appropriate for the nurse to ask?
ANS: A
Asking about any changes in the way you feel about yourself is an appropriate question to ask during a sexual
assessment. Asking about favorite sex position with men and/or women is inappropriate and invasive. The
assessment needs to focus on the patient, not the partner. Asking “why” questions is nontherapeutic and is
judgmental in this scenario.
18. A 15-year-old patient is concerned because her mother wants her to receive the human papillomavirus
(HPV) vaccination, but the patient is unsure if she wants it. Which response by the nurse is most therapeutic?
ANS: A
The nurse should encourage health promotion behaviors but first must consider the autonomy of the patient
and assess the patient for more data. The nurse should value the input of the patient in making a decision and
assess what the patient is thinking to address any concerns the patient may have. The HPV vaccine is a
preventative treatment; whether or not the patient is sexually active (asking about how many sexual partners)
does not matter in this case. The nurse should not make assumptions about a patient’s home life (mother knows
best); instead, the nurse should ask questions while establishing a therapeutic relationship. Recommending the
patient get the vaccine as soon as possible is in violation of the patient’s rights.
19. A nurse is reviewing a patient’s history. Which priority finding will alert the nurse to assess the patient for
possible sexual dysfunction?
a. “I have lost 12 pounds on this diet.”
b. “I use the diaphragm to prevent pregnancy.”
c. “I use a contraceptive cream with my diaphragm.”
d. “I know this provides a barrier over the cervical opening.”
a. Have you noticed any changes in the way you feel about yourself?
b. What is your favorite sex position with men and with women?
c. Do you think your partner is attractive?
d. Why do you like men over women?
a. Ask the patient what concerns she may have about the vaccination.
b. Inquire about how many sexual partners she has had in the past year.
c.
Remind her that her mother knows best and that she should respect her
parents’ wishes.
d.
Promote the importance of the vaccine, and recommend that the
patient get the vaccine as soon as possible.
a. Takes vacations out of the country
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ANS: B
Medications that can affect sexual functioning include antihypertensive, antipsychotics, antidepressants, and
antianxiety. Taking vacations out of the country, exercise classes, and afternoon naps are not as priority for
sexual functioning as medications.
20. A nurse is assessing a child for sexual abuse. Which assessment findings will the nurse expect?
ANS: A
Behavioral signs of sexual abuse in a child include physical aggression, sleep disturbance, poor peer
relationships, and substance abuse. Panic attacks, anorexia, anxiety, and depression are behavioral signs for
adults.
21. The nurse is teaching a patient how to use a condom. Which instructions will the nurse provide?
ANS: D
Teach patients to pull out right after ejaculating and to hold onto the condom when pulling out. Store condoms
in a cool, dry place away from sunlight. Instruct patient to never reuse a condom or use a damaged condom.
Instruct patient to only use water-based lubricants (e.g., K-Y jelly) to prevent the condom from breaking; do
not use petroleum jelly, massage oils, body lotions, or cooking oil.
22. A nurse is caring for a patient with dyspareunia. In which order will the nurse provide care, starting with
the first step?
1. Determine which signs and symptoms of dyspareunia the patient has.
2. Mutually decide upon goals and objectives for dyspareunia.
3. Ask the patient if the dyspareunia is improving.
4. Develop a nursing diagnosis for the patient.
5. Use resources to help resolve the problem.
ANS: B
The nurse should use the nursing process when caring for patients with sexual dysfunction. Determine signs
and symptoms (assessment); develop a nursing diagnosis (diagnosis); mutually decide upon goals (planning);
b. Takes antianxiety medication
c. Takes exercise classes
d. Takes afternoon naps
a. Physical aggression and sleep disturbances
b. Many peers and no drug usage
c. Panic attacks and anorexia
d. Anxiety and depression
a. Store in a warm lit space.
b. Use massage oils for lubrication.
c. Rinse and reuse the condom if needed.
d. Hold onto the condom when pulling out.
a. 5, 3, 1, 4, 2
b. 1, 4, 2, 5, 3
c. 3, 1, 4, 2, 5
d. 4, 2, 5, 3, 1
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use resources to help resolve the problem (implementation); and ask if the dyspareunia is improving
(evaluation).
MULTIPLE RESPONSE
1. An older couple expresses concern because they are easily fatigued during sexual intercourse and cannot
reach climax. Which strategies to increase sexual stamina will the nurse offer? (Select all that apply.)
ANS: A, E, F
Alcohol, tobacco, and certain medications (such as narcotics for pain) may cause drowsiness and fatigue and
negatively affect sexual stamina. Eating well-balanced meals can help to increase energy levels. Planning
sexual activity when the couple is well rested will help them not get fatigued as quickly. Encouraging intimate
touching may help increase libido but not energy levels. Extra lubrication and taking pain medications may
ease the discomfort of sexual intercourse but are not appropriate interventions for fatigue.
Chapter 36: Spiritual Health
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. A co-worker asks the nurse to explain spirituality. What is the nurse’s best response?
ANS: B
Spirituality is often defined as an awareness of one’s inner self and a sense of connection to a higher being, to
nature, or to some purpose greater than oneself. Spirituality is an important factor that helps individuals
achieve the balance needed to maintain health and well-being and to cope with illness. Florence Nightingale
believed that spirituality was a force that provided energy needed to promote a healthy hospital environment
and that caring for a person’s spiritual needs was just as essential as caring for his or her physical needs. The
word spiritualitycomes from the Latin word spiritus, which refers to breath or wind. The spirit gives life to a
person.
2. The nurse is caring for a patient who is an agnostic. Which information should the nurse consider when
planning care for this patient?
ANS: C
Some people do not believe in the existence of God (atheist), or they believe that there is no known ultimate
reality (agnostic). Nonetheless, spirituality is important regardless of a person’s religious beliefs. Agnostics
discover meaning in what they do or how they live because they find no ultimate meaning for the way things
are. They believe that people bring meaning to what they do.
a. Plan sexual activity around a time when the couple feels rested.
b. Encourage intimate touching, such as hugging and kissing.
c. Use extra lubrication to decrease discomfort.
d. Take pain medication before intercourse.
e. Avoid alcohol and tobacco.
f. Eat well-balanced meals.
a. It has a minor effect on health.
b. It is awareness of one’s inner self.
c. It is not as essential as physical needs.
d. It refers to fire or giving of life to a person.
a. The patient is devoid of spirituality.
b. The patient does not believe in God.
c. The patient believes there is no known ultimate reality.
d. The patient finds no meaning through relationship with others.
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3. The nurse is caring for an Islam patient who wants a snack. Which action by the nurse is most appropriate?
ANS: B
Islam religion does allow beef. Islam does not allow pork or alcohol. Ham and bacon are pork. Kosher is
allowed for Judaism.
4. A nurse is teaching a patient how to meditate. Which information from the patient indicates effective
learning?
ANS: C
The steps of meditation include sitting in a comfortable position with the back straight; breathe slowly; and
focus on a sound, prayer, or image. Meditation should occur for 10 to 20 minutes twice a day.
5. The nurse is admitting a patient to the hospital. The patient is a very spiritual person but does not practice
any specific religion. How will the nurse interpret this finding?
ANS: C
The patient’s statement is reasonable and is not contradictory. Many people tend to use the
terms spiritualityand religion interchangeably. Although closely associated, these terms are not synonymous.
Religious practices encompass spirituality, but spirituality does not need to include religious practice. When a
person has the attitude of something to live for and look forward to, hope is present.
6. A nurse hears the following comments from different patients. Which patient comment does the nurse
identify as faith?
ANS: B
Faith allows people to have firm beliefs despite lack of physical evidence (life after death). Religion refers to