Fundamentals Adaptive Quizzing Questions With Complete
Solutions
"But you don't understand" is a common statement associated
with adolescents. What is the nurse's best response when hearing
this? Correct Answers It would be helpful to understand; let's
talk.
"It would be helpful to understand; let's talk" attempts to open
the communication process. Reflecting the words, not the
feelings, serves to entrench the communicant's position and does
little to open the flow of communication. Saying "I was a
teenager once too" shifts the focus away from the client. Telling
the client to try to understand others is authoritative and closes
the flow of communication.
A 3-year-old child has eczema of the face and arms. The nurse
finds the toddler scratching so intensely that the child's arms are
bleeding. The nurse then ties the toddler's arms to the crib sides,
saying, "I'm going to teach you one way or another." How
should the nurse's behavior be interpreted? Correct Answers
These actions can be construed as assault and battery.
Assault is a threat or an attempt to do violence to another, and
battery means touching an individual in an offensive manner or
actually injuring another person. The nurse's behavior
demonstrates anger and does not take into account the growth
and developmental needs of children in this age group. Although
the behavior (scratching) needs to be decreased, this can be done
with mittens, not immobilization. A 3-year-old child does not
have the capacity to understand cause (scratching) and effect
(bleeding).
,A 50-year-old client being seen for a routine physical asks why
a stool specimen for occult blood testing has been prescribed
when there is no history of health problems. What is an
appropriate nursing response? Correct Answers "It is performed
routinely starting at your age as part of an assessment for colon
cancer."
The primary reason for a stool specimen for guaiac occult blood
testing is that it is part of a routine examination for colon cancer
in any client over the age of 40. Age, family history of polyps,
and a positive finding after a digital rectal examination are
factors related to colon cancer and secondary reasons for the
occult blood test (guaiac test).
A caregiver fails to give medications on time to an older adult.
Which type of abuse is this? Correct Answers Neglect
Neglect occurs when a caregiver intentionally or unintentionally
causes harm by failing to provide appropriate care. Physical
abuse is causing someone harm with physical force. Sexual
abuse is nonconsensual sexual contact of any kind, including
with someone who is incapable of giving consent. Psychological
or emotional abuse involves the infliction of agony, emotional
pain, or distress through verbal or nonverbal acts.
A child belonging to a strict religious faith is brought into the
emergency department following an accident. The child has
suffered massive blood loss and needs an immediate blood
transfusion. The parents refuse to let their child have the blood
transfusion because it is against their religious practices, but the
health-care provider goes ahead with the blood transfusion
anyway. Which is the primary ethical principle that has guided
,the health-care provider's decision? Correct Answers
Beneficence
The principle of beneficence means doing good or acting for
someone's good. In the context of health care, this means all
health-care providers have an ethical duty to protect life and
promote the well-being of all clients. By giving the child blood
transfusion he urgently needed, the health-care provider
followed the ethical principle of beneficence even though it is
against the health practices of the parents. Since the child is a
minor and not legally able to make a decision for him or herself,
the hospital is legally able to disregard the family's wishes in
this case. The principle of fairness or justice means that all
clients have the same right to nursing interventions. While this
principle implies that the child in question has the right to a
blood transfusion, it is not the primary ethical principle that
guided the health-care provider's choice. Autonomy refers to
freedom of personal choice and implies that the health-care
providers do not have the right to make decisions for the client.
Legally, this client is not autonomous, so this is not the ethical
principle that guided the health-care provider's decision. The
ethical principle of truthfulness involves declaring the truth to
the client; this principle is relevant in this situation but not
relevant to the health-care provider's decision.
A client becomes hostile when learning that amputation of a
gangrenous toe is being considered. After the client's initial
reaction, what is the best indication that the nurse-client
interaction has been therapeutic? Correct Answers Relaxation
of tensed muscles
Relaxation of muscles and facial expression are examples of
nonverbal behavior; nonverbal behavior is an excellent index of
, feelings because it is less likely to be consciously controlled.
Increased activity may be an expression of anger or hostility.
Clients may suppress verbal outbursts despite feelings and
become withdrawn. Refusing to talk may be a sign that the client
is just not ready to discuss feelings.
A client has a platelet count of 49,000/mL. The nurse should
instruct the client to avoid which activity? Correct Answers
Blowing the nose
Patients with thrombocytopenia are at a greater risk of excessive
bleeding in response to minimal trauma. The nurse should
instruct the patient to avoid blowing their nose as this activity
can increase the risk of bleeding. The following activities are not
contraindicated with thrombocytopenia: ambulation, visiting
with children, and semi-Fowler's position.
A client has a stage III pressure ulcer. Which nursing
intervention can prevent further injury by eliminating shearing
force? Correct Answers With the help of another staff member,
use a drawsheet when lifting the client in bed.
A client has been diagnosed as "brain dead". What does the
nurse understand that this means? Correct Answers A client
who is declared as being brain dead has no function of the
cerebral cortex and a flat EEG. The client may have some
spontaneous breathing and a heartbeat. The guidelines
established by the American Association of Neurology include
coma or unresponsiveness, absence of brainstem reflexes, and
apnea. There are specific assessments to validate the findings.
The other answer options do not fit the definition of "brain
dead."
Solutions
"But you don't understand" is a common statement associated
with adolescents. What is the nurse's best response when hearing
this? Correct Answers It would be helpful to understand; let's
talk.
"It would be helpful to understand; let's talk" attempts to open
the communication process. Reflecting the words, not the
feelings, serves to entrench the communicant's position and does
little to open the flow of communication. Saying "I was a
teenager once too" shifts the focus away from the client. Telling
the client to try to understand others is authoritative and closes
the flow of communication.
A 3-year-old child has eczema of the face and arms. The nurse
finds the toddler scratching so intensely that the child's arms are
bleeding. The nurse then ties the toddler's arms to the crib sides,
saying, "I'm going to teach you one way or another." How
should the nurse's behavior be interpreted? Correct Answers
These actions can be construed as assault and battery.
Assault is a threat or an attempt to do violence to another, and
battery means touching an individual in an offensive manner or
actually injuring another person. The nurse's behavior
demonstrates anger and does not take into account the growth
and developmental needs of children in this age group. Although
the behavior (scratching) needs to be decreased, this can be done
with mittens, not immobilization. A 3-year-old child does not
have the capacity to understand cause (scratching) and effect
(bleeding).
,A 50-year-old client being seen for a routine physical asks why
a stool specimen for occult blood testing has been prescribed
when there is no history of health problems. What is an
appropriate nursing response? Correct Answers "It is performed
routinely starting at your age as part of an assessment for colon
cancer."
The primary reason for a stool specimen for guaiac occult blood
testing is that it is part of a routine examination for colon cancer
in any client over the age of 40. Age, family history of polyps,
and a positive finding after a digital rectal examination are
factors related to colon cancer and secondary reasons for the
occult blood test (guaiac test).
A caregiver fails to give medications on time to an older adult.
Which type of abuse is this? Correct Answers Neglect
Neglect occurs when a caregiver intentionally or unintentionally
causes harm by failing to provide appropriate care. Physical
abuse is causing someone harm with physical force. Sexual
abuse is nonconsensual sexual contact of any kind, including
with someone who is incapable of giving consent. Psychological
or emotional abuse involves the infliction of agony, emotional
pain, or distress through verbal or nonverbal acts.
A child belonging to a strict religious faith is brought into the
emergency department following an accident. The child has
suffered massive blood loss and needs an immediate blood
transfusion. The parents refuse to let their child have the blood
transfusion because it is against their religious practices, but the
health-care provider goes ahead with the blood transfusion
anyway. Which is the primary ethical principle that has guided
,the health-care provider's decision? Correct Answers
Beneficence
The principle of beneficence means doing good or acting for
someone's good. In the context of health care, this means all
health-care providers have an ethical duty to protect life and
promote the well-being of all clients. By giving the child blood
transfusion he urgently needed, the health-care provider
followed the ethical principle of beneficence even though it is
against the health practices of the parents. Since the child is a
minor and not legally able to make a decision for him or herself,
the hospital is legally able to disregard the family's wishes in
this case. The principle of fairness or justice means that all
clients have the same right to nursing interventions. While this
principle implies that the child in question has the right to a
blood transfusion, it is not the primary ethical principle that
guided the health-care provider's choice. Autonomy refers to
freedom of personal choice and implies that the health-care
providers do not have the right to make decisions for the client.
Legally, this client is not autonomous, so this is not the ethical
principle that guided the health-care provider's decision. The
ethical principle of truthfulness involves declaring the truth to
the client; this principle is relevant in this situation but not
relevant to the health-care provider's decision.
A client becomes hostile when learning that amputation of a
gangrenous toe is being considered. After the client's initial
reaction, what is the best indication that the nurse-client
interaction has been therapeutic? Correct Answers Relaxation
of tensed muscles
Relaxation of muscles and facial expression are examples of
nonverbal behavior; nonverbal behavior is an excellent index of
, feelings because it is less likely to be consciously controlled.
Increased activity may be an expression of anger or hostility.
Clients may suppress verbal outbursts despite feelings and
become withdrawn. Refusing to talk may be a sign that the client
is just not ready to discuss feelings.
A client has a platelet count of 49,000/mL. The nurse should
instruct the client to avoid which activity? Correct Answers
Blowing the nose
Patients with thrombocytopenia are at a greater risk of excessive
bleeding in response to minimal trauma. The nurse should
instruct the patient to avoid blowing their nose as this activity
can increase the risk of bleeding. The following activities are not
contraindicated with thrombocytopenia: ambulation, visiting
with children, and semi-Fowler's position.
A client has a stage III pressure ulcer. Which nursing
intervention can prevent further injury by eliminating shearing
force? Correct Answers With the help of another staff member,
use a drawsheet when lifting the client in bed.
A client has been diagnosed as "brain dead". What does the
nurse understand that this means? Correct Answers A client
who is declared as being brain dead has no function of the
cerebral cortex and a flat EEG. The client may have some
spontaneous breathing and a heartbeat. The guidelines
established by the American Association of Neurology include
coma or unresponsiveness, absence of brainstem reflexes, and
apnea. There are specific assessments to validate the findings.
The other answer options do not fit the definition of "brain
dead."
