NSG 3009/ NSG3009 Exam 4 (2026/2027 Updated Edition) Principles of Assessment | Q&A | 100% verified Solutions | – South University

NSG 3009/ NSG3009 Exam 4 (2026/2027 Updated Edition) Principles of Assessment | Q&A | 100% verified Solutions | – South University Q. A nurse is reviewing the stages of infection with new nurses. Place the stages in the order in which they occur. A. Prodromal B. Convalescence C. Incubation D. Illness ANSWER C, A, D, B Q. A nurse is caring for a client who has an infection. Sort the manifestations the nurse would expect to find if the infection is Localized or Systemic. A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate ANSWER Systemic: A, B, , E Localized: C, D Q. A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse suggest?? (Select all that apply.) A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that might result in contamination from secretions. ANSWER B, C, E Q. The nurse is reviewing the use of transmission-based isolation precautions with a group of new nurses. Sort the following infectious diseases by the type of precautions required. (Contact, Droplet, Airborne) A. Tuberculosis B. SARS-CoV-2 (COVID-19) C. Influenza D. C. difficile E. MRSA ANSWER Contact: D, E Droplet: C Airborne: A, B Q. A nurse is reviewing the wound healing process with a group of newly licensed nurses. The nurse should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply.) A. Stage 3 pressure injury B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area ANSWER A, E Q. A client who had abdominal surgery 24 hr ago suddenly eports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply.) A. Cover the area with saline-soaked sterile dressings. B. Apply an abdominal binder snugly around the abdomen. C. Use sterile gauze to apply gentle pressure to the exposed tissues. D. Position the client supine with the hips and knees bent. E. Offer the client a warm beverage (herbal tea. ANSWER A, D Q. A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (Select all that apply.) A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst ANSWER A, B, C Q. A nurse is caring for a 45-year-old client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (Select all that apply.) A. Age B. Chronic illness C. Low hemoglobin D. Malnutrition E. Poor wound care ANSWER B, C, D Q. A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply.) A. Keep the head of the bed elevated 30°. B. Massage the client's bony prominences frequently. C. Apply cornstarch liberally to the skin after bathing. D. Have the client sit on a gel cushion when in a chair. E. Reposition the client every 3 hr while in bed. ANSWER A, D Q. A nurse is discussing modes of transmission at a staff education session. Which of the following should the nurse include as examples of the direct contact mode of transmission? (Select all that apply.) A. Blood spurting from an arterial wound splashes into a nurse's eye. B. A nurse has a needlestick injury. C. A mosquito bites a hiker in the woods. D. A nurse finds a hole in their glove while handling a soiled dressing. E. A person fails to wash their hands after using the bathroom and touches a client. ANSWER A, E Q. Sort the following examples into the correct link in the chain of infection: Infectious Agent, Reservoir, Mode of Transmission, Susceptible Host, or Portal of Exit and Entry. (Some examples may be used in more than one link.) A. Virus B. Parasite C. Human D. Soil E. Food F. Respiratory tract G. Mucous membranes H. Genitourinary tract I. Contact with an infected person J. Droplets in the air K. Vectors L. Older adults M. Immunocompromised N. Client who is burned O. Bacterium ANSWER Infectious Agent: A, B, O Reservoir: C, D, E Mode of Transmission: I, J, K Susceptible Host: L, M, N Portal of Exit and Entry: F, G, H Q. A nurse in a residential care facility is assessing an older adult client. Which of the following findings should the nurse identity as atypical indications of infection in this client? (Select all that apply.) A. Urinary incontinence B. Malaise C. Acute confusion D. Fever E. Agitation ANSWER A, C, E Q. A nurse is preparing to admit a client who is suspected to have pulmonary tuberculosis. Which of the following actions should the nurse plan to perform first? A. Implement airborne precautions. B. Obtain a sputum culture. C. Administer antituberculosis medications. D. Recommend a screening test for family members. ANSWER A Q. A charge nurse is teaching a newly licensed nurse about the care of a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements should the charge nurse identify as an indication that the newly licensed nurse understands the teaching? A. "I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial. B. "MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed." C. "I will protect others from exposure when I transport the client outside the room." D. "To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile." ANSWER C Q. A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests that the client has postherpetic neuralgia? A. Linear clusters of vesicles on the right shoulder B. Purulent drainage from both eyes C. Decreased white blood cell count D. Report of continued pain following resolution of the rash ANSWER D A 50-year-old woman is recovering from a bilateral mastectomy. She refuses to eat, discourages visitors, and pays little attention to her appearance. One morning the nurse enters the room to see the patient with her hair combed and makeup applied. Which of the following is the best response from the nurse? "I see that you've combed your hair and put on makeup." A 30-year-old patient diagnosed with major depressive disorder has a nursing diagnosis of Situational Low Self-Esteem related to negative view of self. Which of the following are appropriate interventions by the nurse? (Select all that apply) focus on identifying strengths and accomplishments. provide time for journaling to explore underlying thoughts and feelings. A patient who is depressed is crying and verbalize his feelings of low self-esteem and self-worth such as, "I'm such a failure, I can't do anything right." What is the nurse's best response? remain with the patient until he or she validates feeling more stable. A 20-year-old patient diagnosed with an eating disorder has a nursing diagnosis of Situational Low Self-Esteem. Which of the following nursing interventions are appropriate to address self-esteem? (Select all that apply.) Offer independent decision making opportunities. Review previously successful coping strategies. The nurse can increase a patient's self-awareness and self- concept through which of the following actions? (Select all that apply.) Helping the patient define personal problems clearly. Allowing the patient to openly explore thoughts and feelings. Reframing the patient's thoughts and feeling. Which of the following assessment findings suggest an altered self-concept? (Select all that apply.) slumped posture and poor personal hygiene avoidance of eye contact when answering a question The home health nurses visiting a 90-year-old man who lives with this 89-year-old wife. He is legally blind and is 3 weeks post right hip replacement. He ambulates with difficulty with a walker. He comments that he is saddened now that his wife has to do more for him and he is doing less for her. Which of the following is the priority nursing diagnosis? Risk for Situational Low Self-Esteem A nurse is working with an older adult who recently moved to an assisted-living Center because of declining physical capabilities associated with normal aging process. Which nursing interventions are directed at promoting self esteem in this patient? Commending the patient's efforts at completing self-care tasks The nurse is caring for a 40-year-old male diagnosed with Crohn's disease several years ago, resulting in numerous hospitalizations each year for the past 3 years. Which of the following behaviors interfere with the developmental task of middle adulthood? (Select all that apply.) Refuses visitors while hospitalized Self-absorbed in physical and psychological issues Rationale: intimacy versus isolation is from the late teens to the mid 40s. When assessing a patient's adjustment to the role changes brought about by a medical condition such as a stroke, the nurse asks about which of the following? (Select all that apply.) What are your thoughts about returning to work? How has your health affected your relationship with your partner? What level of physical activity are you able to perform? A 16-year-old female tells the school nurse that she doesn't need that human papilloma virus (HPV) vaccine since her partner always uses condoms. The best response by the nurse to this statement is: "The HPV 9-valent vaccine is recommended for males and females even if they use condoms because it targets the specific viruses that cause cancer and genital warts." An adolescent who is pregnant for the first time is at her initial prenatal visit. The women's health nurse practitioner (WHNP) informs the patient that she will be screening her for sexually transmitted infections (STIs). The patient replies, "I know I don't have an STI because I don't have any symptoms." Which responses by the WHNP would be appropriate? (select all that apply.) "Untreated STIs can cause serious complications in pregnancy, so we routinely screen pregnant women. "Chlamydia screening is recommended for all sexually active women up to age 25 even if asymptomatic." "People between the ages of 15 and 24 are often asymptomatic and have the highest incidence of STIs." A nurse who recently graduated from nursing school is providing discharge instructions to a patient who suffered a myocardial infarction (MI). The nurse knows that sexual issues are common after an MI but feels uncomfortable bringing up this topic. What is the best way for the nurse to handle this situation? (Select all that apply.) 1. Instruct the patient to discuss any sexual concerns with his or her partner after discharge. 2. Avoid discussing the topic unless the patient brings it up. 3. Ask a more experienced nurse to cover this with the patient and learn from the example. 4. Plan to attend conferences or training soon on how to discuss such issues. 5. Encourage the patient to discuss any personal concerns with the cardiologist. 3. Ask a more experienced nurse to cover this with the patient and learn from the example. 4. Plan to attend conferences or training soon on how to discuss such issues. The nurse is gathering a history from a 72-year-old male patient being admitted to a nursing home. The patient requests a private room. The nurse understands that: The patient may be requesting a private room to facilitate an intimate relationship with his partner. A patient has just learned she has been diagnosed with malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. The nurse has been caring for her for only 2 hours but has a good relationship with her. What is the most appropriate intervention for support of her spiritual well-being at this time? Sit down and talk with the patient; have her discuss her feelings and listen attentively. A nurse is preparing to teach an older adult who has chronic arthritis how to practice meditation. Which of the following strategies are appropriate? (Select all that apply.) Have patient identify a quiet room in the home that has minimal interruptions. Suggest the use of a quiet fan running in the room. Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer. A nursing student is developing a plan of care for a 74-year- old female patient who has spiritual distress over losing a spouse. As the student develops appropriate interventions, which characteristics of older adults should be considered? (Select all that apply.) Older adults achieve spiritual resilience through frequent expressions of gratitude. Have the patient determine whether her husband left a legacy behind. Offer the patient her choice of rituals or participation in exercise. A nurse used spiritual rituals as an intervention in a patient's care. Which of the following questions is most appropriate to evaluate its efficacy? 1. Do you want me to contact the hospital chaplain to visit you? 2. What can I do to help you feel more at peace? 3. Did either prayer or meditation prove helpful to you? 4. Should we plan on having your family try to visit you more often in the hospital? 3. Did either prayer or meditation prove helpful to you? The nurse is caring for a 50-year-old woman visiting the outpatient medicine clinic. The patient has has type 1 diabetes since age 13. She has numerous complications from her disease, including reduced vision, heart disease and severe numbness and tingling of the extremities. Knowing that spirituality helps patients cope with chronic illness which of the following principles should the nurse apply in practice? (Select all that apply.) Pay attention to the patient's spiritual identity throughout the course of her illness. Listen to the patient story each visit to the clinic and offer a compassionate presence. Three levels of prevention Primary Prevention Secondary Prevention Tertiary Prevention primary prevention health promotion: health education, good nutrition based on developmental stage, provision of adequate housing, recreation, and working conditions, marriage counseling, sex education, and genetic screening specific protection: providing immunizations, attention to personal hygiene, use of environmental sanitation, protection from occupational hazards, protection from accidents and carcinogens. secondary prevention Early diagnosis and prompt treatment before disease becomes advanced and disability severe: -individual mass screening surveys -focused examinations to cure and prevent diseases, prevent spread of communicable diseases, prevent complications, limit disability, and prevent death. Disability limitations: -adequate treatment to stop disease process and prevent further complications -provision of facilities to limit disability and prevent death tertiary prevention restoration and rehabilitation: -providing retraining and education to return to highest level of functioning -helping people with disabilities find work and accommodating them in the workplace. Precontemplation Not intending to make changes within the next 6 months "There is nothing I really need to change" contemplation considering a change within the next 6 months "I have a problem that I think I need to work on" preparation making small changes in preparation for a change in the next month "I started running once, but I didn't keep it up. I think I might try again in a few weeks." Action Actively engaged in strategies to change behavior; lasts up to 6 months "I am really working hard to stop smoking." maintenance stage sustained change over time; begins 6 months after action has started and continues indefinitely "I need to avoid people who smoke so I won't be tempted to start smoking again" Healthy People 2020 Focus on promoting health and preventing disease. A patient discharged a week ago following a stroke is currently participating in rehabilitation sessions provided by nurses, physical therapists, and registered dietitians in an outpatient setting. In what level of prevention is the patient participating? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Transtheoretical prevention c. Tertiary prevention Rationale: The patient has already had a stroke so it would not be Primary or Secondary. He is going through rehab to help with disabilities from the stroke and prevent future disabilities. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration. Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities. The nurse is working in a clinic that is designed to provide health education and immunizations. Which type of preventive care is the nurse providing? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Risk factor prevention a. Primary prevention Based on the Transtheoretical Model of Change, what is the most appropriate response to a patient who states: "Me, stop smoking? I've been smoking since I was 16!" a. "That's fine. Some people who smoke live a long life." b. "OK. I want you to decrease the number of cigarettes you smoke by one each day, and I'll see you in 1 month." c. "What do you think is the greatest reason why stopping smoking would be challenging for you?" d. "I'd like you to attend a smoking-cessation class this week and use nicotine replacement patches as directed." c. "What do you think is the greatest reason why stopping smoking would be challenging for you?" Rationale: This person has no intention of quitting smoking and would be in the pre-contemplation stage. Upon completing a health history, the nurse finds that a client has risk factors for developing lung disease. How should the nurse interpret this finding? a. The disease is guaranteed not to develop if the risk factor is controlled. b. A person with the risk factor will get the disease. c. The chances of getting the disease are increased. d. Risk modification will have no effect on disease prevention. c. The chances of getting the disease are increased. Rationale: A risk factor is any attribute, quality, environmental situation, or trait that increases the vulnerability of an individual or group to an illness or accident. The presence of risk factors does not mean that a disease will develop, but risk factors increase the chances that the individual will experience a particular disease or dysfunction. The nurse is caring for a patient who has been trying to quit smoking. The patient has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate? a. The patient must pick up the attempt right where the patient left off. b. The patient does not want to and will never quit smoking. c. The patient will need to adopt a new lifestyle for change to be effective. d. The patient will return to the contemplation or precontemplation phase. d. The patient will return to the contemplation or precontemplation phase. Rationale: When relapse occurs, the person will return to the contemplation or precontemplation stage before attempting the change again. It is believed that change involves movement through a series of stages (precontemplation, contemplation, preparation, action, and maintenance). A female patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. The patient is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. Which stage is the patient displaying? a. Contemplation b. Preparation c. Precontemplation d. Action a. Contemplation Rationale: This patient is planning to make the change within the next 6 months and is in the contemplation stage. A nurse working on a medical patient care unit states, "I am having trouble sleeping, and I eat nonstop when I get home. All I can think of when I get to work is how I can't wait for my shift to be over. I wish I felt happy again." What are the best responses from the nurse manager? Select all that apply. b. "I know several nurses who feel this way every now and then. Tell me about the patients you have cared for recently. Did you find it difficult to care for them?" d. "Describe for me what you do with your time when you are not working." e. "The hospital just started a group where nurses get together to talk about feelings. Would you like for me to e-mail the schedule to you?" A patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his marriage of 15 years and has been praying daily to help him through this difficult time. He does not have a primary health care provider because he has never really been sick, and his parents never took him to a physician when he was a child. Which external variables influence the patient's health practices? Select all that apply. a. Difficulty paying his bills b. Praying daily c. Age of patient (46 years) d. Stress from the divorce and the loss of a job e. Family practice of not routinely seeing a health care provider a. Difficulty paying his bills e. Family practice of not routinely seeing a health care provider Rationale: Difficulty paying bills and family practices of not routinely seeing a HCP are external factors. Praying daily (Spiritual factor), the age of the patient (developmental factor), and the stress (emotional factor) they are going through are internal factors. A nurse is using Maslow's hierarchy to prioritize care for an anxious client that is not eating and will not see family members. Which area should the nurse address first? a. Not eating b. Not seeing family members c. Mental health d. Anxiety a. Not eating Rationale: According to Maslow, in all cases an emergent physiological need takes precedence over a higher-level need. Nutrition is a physiological need and should be addressed first. Anxiety, mental health, and not seeing family members are all higher-level needs. A nurse is teaching about the goals of Healthy People 2020. Which information should the nurse include in the teaching session? a. Eliminate healthy life in America. b. Eliminate health behaviors in America. c. Eliminate quality of life in America. d. Eliminate health disparities in America. d. Eliminate health disparities in America. Rationale: The nurse should include eliminating health disparities in America. Healthy People 2020 promotes a society in which all people live long, healthy lives. There are four overarching goals: (1) attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; (2) achieve health equity, eliminate disparities, and improve the health of all groups; (3) create social and physical environments that promote good health for all; and (4) promote quality of life, healthy development, and healthy behaviors across all life stages. A nurse attends a seminar on teaching/learning. Which statement indicates the nurse has a good understanding of teaching/learning? a. "Learning is an interactive process that promotes teaching." b. "Learning consists of a conscious, deliberate set of actions designed to help the teacher." c. "Teaching is most effective when it responds to the learner's needs." d. "Teaching and learning can be separated." c. "Teaching is most effective when it responds to the learner's needs." A patient asks a nurse to provide instruction on how to perform a breast self-exam. Which domains are required to learn this skill? Select all that apply c. Cognitive domain e. Psychomotor domain Rationale: Learning occurs in three domains: cognitive (understanding), affective (attitudes), and psychomotor (motor skills). The most effective learning takes place when all three of these domains are utilized. You often work with patients who need to learn in each domain. For example, patients who have undergone surgery for colon cancer and who have an ostomy to manage need to learn how the ostomy is affected by diet, medications, and activity (cognitive domain). In addition, a patient begins to learn coping skills to accept the change in body image created by the ostomy (affective domain). The patient with an ostomy needs to learn how to change an ostomy pouch and provide skin care (psychomotor domain). The characteristics of learning within each domain influence your teaching and evaluation methods. Understanding each learning domain prepares you to select proper teaching techniques and apply the basic principles of learning (Box 25.2). A nurse is caring for a young patient who has been told he has multiple sclerosis. The nurse has planned time to conduct a teaching session that will focus on the disease and principles of management. The nurse chooses to use the EDUCATE model to proceed with instruction. Which of the following are components of the model? Select all that apply. b. Repeat the most important information. c. Practice empathetic skills. d. Be aware of nonverbal messages. Rationale: EDUCATE model is an evidence-based model to improve outcomes from verbal instruction. It is a process-based model that leads a nurse educator through five stages of verbal education to reach teaching and education goals. The EDUCATE model is simple but enables all health care providers to better guide verbal education and ensure that education is more patient- and family-centered. Table 25.4 pg 357 Enhance Comprehension and Retention Deliver Patient-Centered Education Understand the Learner Communicate Clearly and Effectively Address Health Literacy and Cultural Competence Teaching and Education Goals An adult male has been in the hospital over a week following surgical complications. The patient has had limited activity but is now finally ordered to begin a mobility program. The patient just returned from several diagnostic tests and tells the nurse he is feeling quite fatigued. The nurse prepares to instruct the patient on the mobility program protocol. Which of the following learning principles will likely be affected by this patient's condition? d. Readiness to learn A patient recovering from open heart surgery is taught how to cough and deep breathe using a pillow to support or splint the chest incision. Following the teaching session, which of the following is the best way for the nurse to evaluate whether learning has taken place? c. Return demonstration Rationale: Use demonstrations when teaching psychomotor skills such as preparing a syringe, bathing an infant, crutch walking, or taking a pulse. Demonstrations are most effective when learners first observe the educator and during a return demonstration have the chance to practice the skill. Combine a demonstration with discussion to clarify concepts and feelings. An effective demonstration requires advanced planning: •1. Be sure that the learner can see each step of the demonstration easily. Position the learner to provide a clear view of the skill being performed. •2. Assemble and organize the equipment. Make sure that all equipment works. •3. Perform each step slowly and accurately in sequence while analyzing the knowledge and skills involved, and allow the patient to handle the equipment. •4. Review the rationale and steps of the procedure. •5. Encourage the patient to ask questions so that he or she understands each step. •6. Judge proper speed and timing of the demonstration on the basis of the patient's cognitive abilities and anxiety level. •7. 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. For example, when a patient needs to learn to walk with crutches, simulate the home environment. If the patient's home has stairs, the patient would practice going up and down a staircase in the hospital. • The Cloze test is a test in which one is asked to supply words that have been removed from a passage in order to measure one's ability to comprehend text. A nurse is preparing to teach a patient who has sleep apnea how to use a CPAP machine at night. Which action is most appropriate for the nurse to perform first? c. Set mutual goals for the education session. Which of the following scenarios demonstrate that learning has taken place? Select all that apply. a. A patient listens to a nurse's review of the warning signs of a stroke. b. A patient describes how to set up a pill organizer for newly ordered medicines. c. A patient attends a spinal cord injury support group. d. A patient demonstrates how to take his blood pressure at home. e. A patient reviews written information about resources for cancer survivors. b. A patient describes how to set up a pill organizer for newly ordered medicines. d. A patient demonstrates how to take his blood pressure at home A 63-year-old woman is a family caregiver for her 88-year-old mother who has dementia. The caregiver asked the home health nurse how to manage her mother when she becomes confused and violent. The best instructional method a nurse can use for this situation is: c. Role-playing Delirium acute confusional state, is a potentially reversible cognitive impairment that occurs suddenly and worsens at night. Delirium often has a physiological cause. Physiological causes include electrolyte imbalances, untreated pain, infection, cerebral anoxia, hypoglycemia, medication effects, tumors, subdural hematomas, and cerebrovascular infarction or hemorrhage. A new onset of delirium should trigger the nurse to assess for signs and symptoms of infections such as pneumonia and UTI. Delirium may also be caused by environmental factors such as sensory deprivation or overstimulation, unfamiliar surroundings, or sleep deprivation or psychosocial factors such as emotional distress such as being admitted to an acute care center. The cognitive impairment usually reverses once health care providers identify and treat the cause of delirium. Dementia §Generalized impairment of intellectual functioning §Term for: Alzheimer's disease, Lewy body disease, frontal-temporal dementia, and vascular dementia §Cognitive function deterioration leads to a decline in the ability to perform ADLs §Gradual, progressive, and irreversible decline in cerebral function Depression -The most common, yet most undetected and untreated impairment in older adulthood -Not a normal part of aging. Sometimes exists and is exacerbated in patients with other health problems -Loss of a significant loved one can cause depression -Admission to a nursing center can cause depression A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing: b. Depression. A nurse is completing a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer's disease 1 year ago but became extremely confused last evening and was hallucinating. She was unable to calm her, and her mother thought she was a stranger. On the basis of this history, the nurse suspects that the patient is experiencing: b. Delirium. Rationale: Dementia is an additional risk factor that greatly increases the risk for delirium; it is possible for delirium and dementia to occur at the same time. A nurse is assessing internal variables that are affecting the patient's health status. Which area should the nurse assess? Perception of functioning Explanation: Internal variables include a person's developmental stage, intellectual background, perception of functioning, and emotional and spiritual factors. External variables influencing a person's health beliefs and practices include family practices, socioeconomic factors, and cultural background. (Potter et al, 2021, p. 70) You conduct an assessment of your patient who is a 65-year-old male with hypertension. Which modifiable risk factors will you address with the patient that could affect hypertension? Select all that apply. Patient's high sodium diet Patient's activity level You are assigned to care for a patient who has just undergone a mastectomy for a malignant tumor. How would you most appropriately classify this self-concept stressor? body image stressor You are in the process of admitting an ethnically diverse patient. To plan culturally competent care, you will conduct a cultural assessment that includes which of the following? biocultural history Explanation: A focused cultural assessment is a method of evaluating a patient's ethnohistory (significant historical experiences of a particular group), biocultural history (skin color, heredity, genetics, drug metabolism), social organization, and religious and spiritual beliefs to find issues that are most relevant to the problem at hand. Ethnocentrism means to apply one's own culture or ethnicity as a frame of reference to judge other cultures, practices, behaviors, beliefs, and people, instead of using the standards of the particular culture involved. Ageism is stereotyping and/or discrimination against individuals or groups on the basis of their age. Health disparities are unequal burdens of disease morbidity and mortality rates experienced by racial and ethnic groups. What can exacerbate these disparities? A. bias B. stereotyping C. prejudice D. all the above D. all the above What is the best action a nurse can take to assess, evaluate, and support a patient's spirituality? determine the patient's perceptions and belief system A nurse is preparing to teach a kinesthetic learner about exercise. Which technique will the nurse use? Let the patient touch and use the exercise equipment. Explanation: 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 prefers learning by listening or reading. 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. (Potter et al, 2021, p. 345; 351) You are caring for a patient who is depressed because the only child has gone away to college. What type of depression is the patient experiencing? maturational loss Explanation: A maturational loss is a form of necessary loss and includes all normally expected life changes across the life span. A toddler experiences separation anxiety from a parent when starting preschool. A grade school child may not want to lose a favorite teacher and classroom. A college student may not want to leave the campus community. Maturational losses associated with normal life transitions help people develop coping skills to use when they experience unplanned, unwanted, or unexpected loss. When life keeps moving, such as kids growing up and moving away, it is considered maturational loss. Which area should the nurse assess to determine the effects of external variables on a patient's illness? Patient's socioeconomic status Explanation: External variables influencing a patient's illness behavior include the visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, and social support. Internal variables include the patient's perceptions of symptoms and the nature of the illness, as well as the patient's coping skills and locus of control. (Potter et al, 2021, p. 72) A nurse is caring for a patient who states, "I just want to die." For the nurse to comply with this request, the nurse should discuss: advance directives/living wills Explanation: Advance directives are written documents that outlay the patient's wishes, should he or she become incapacitated. An advance directive is a document developed by the patient that instructs others to do tasks before, during, and after his or her death. At a minimum, an advance directive includes a statement of the patient's wishes if a respiratory or cardiac arrest occurs and a copy of the patient's durable power of attorney for health care (DPAHC ). Living wills also include information about a patient's preferences regarding end-of-life care 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? role-playing Explanation: 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. (Potter et al, 2021, p. 358) If a nurse decides to withhold a medication because it might further lower the patient's blood pressure, the nurse will be practicing which principle? accountability Explanation: Accountability refers to answering for your own actions. If a nurse decides to withhold medication, despite a provider's order, the nurse is then accountable for his/her/their actions, as the nurse made the independent decision because of the knowledge of the patient and the patient's situation at that moment in time. 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? Establish rapport Explanation: 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 (if needed) all occur after rapport/trust is established. (Potter et al, 2021, p. 359) P.T.'s self-esteem lessens as his recovery and rehabilitation move slowly. His self-concept has changed from that of a strong laborer, one who did his own plumbing and car repairs, to a man who must rely on others. Although his spouse works, they have not saved enough money to meet monthly expenses or to educate their children without both incomes. P.T.'s role as primary breadwinner will change if he does not improve. How does an inability to work affect self-esteem? An inability to work might make a person feel worthless and not able to provide for their family. A student nurse employed as a nursing assistant may perform care: as identified in the hospital's job description A patient comes from a close-knit family. The patient's family functions as context. What will you need to evaluate? attainment of patient's needs Explanation: When you view a family as context, the primary focus is on the health and development of an individual member existing within a specific family environment. Although you focus on the health of an individual family member, also assess how much the family provides the individual's basic needs. Needs vary, depending on an individual's developmental level and situation. Consider the family's ability to help your patient meet physical as well as psychological needs when viewing a family as context. Review text pgs 124 - 125 (family as context, family as patient, and family as system) As a first-year nursing student, you are assigned to care for a dying patient. To best prepare you for this assignment, what will you want to do? develop a personal understanding of your own feelings about grief and death Explanation: The nurse cannot provide patient-centered nursing if the nurse does not understand their own feelings about death and dying. Be open to patients' perceptions about death and dying as well. A nurse is following the goals of the Healthy People Initiative to provide care. Which action should the nurse take? Create social and physical environments that promote good health. L.D. is a 55-year-old Bosnian immigrant. She is overweight and is concerned about her health. She has come for her yearly physical. Ashley is a 23-year-old nursing student assigned to care for L.D.. During their first visit, the patient states, "I am interested in getting some information to help me become healthier and lose some weight." The patient is likely in which stage of health behavior change? contemplation Explanation: Precontemplation: no intent to make changes within the next 6 months. Contemplation: considering a change within the next 6 months. Preparation: making small changes in preparation for a change in the next month. Action: actively engaged in strategies to change behaviors; lasts up to 6 months. Maintenance stage: sustained change over time; begins 6 months after action has started and continues indefinitely. You are caring for an adolescent patient who underwent a gastric banding procedure 6 months previously. She tells you, "There is still a fat person inside of me." This type of statement illustrates which type of issue? body image Explanation: Because the patient statement reflects her looks, this would be a body image issue. A change in the appearance, structure, or function of a body part requires an adjustment in body image. An individual's perception of the change and the relative importance placed on body image affects the significance of a loss of function or change in appearance. See page 693, section entitled "Factors Affecting Self-Concept." Your textbook reviews each type of stressor and Figure 33.3 gives some great examples. Fig. 33.3 p. 694 Your patient is having a significantly difficult time moving forward after the unexpected loss of her partner. After a year, she is still having trouble accepting the death and tells you she feels "emotionally numb." Which type of grief is this patient likely experiencing? complicated grief Explanation: In complicated grief a person has a prolonged or significantly difficult time moving forward after a loss. He or she experiences a chronic and disruptive yearning for the deceased; has trouble accepting the death and trusting others; and/or feels excessively bitter, emotionally numb, or anxious about the future. Complicated grief has prolonged symptoms of painful emotions and sorrow for more than 1 year (Mughal and. Siddiqui, 2019). Complicated grief can also be understood as persistent grief that is so severe that it impacts normal functioning and quality of life (Perng and Renz, 2018). Upon admission, what should the nurse do when gathering a patient's sexual history? include questions related to sexual function Explanation: Sexual function is an important part of taking a sexual history, as it can indicate other problems the patient may be having. A patient newly diagnosed with diabetes needs to learn how to use a glucometer. Use of a glucometer constitutes learning in which domain? psychomotor Explanation: Psychomotor learning involves acquiring motor skills that require coordination and the integration of mental and physical movements, such as using a glucometer. P.T., a 58-year-old man, suffered an unexpected and sudden stroke. He did not know that he had hypertension because he did not get yearly checkups. He awoke in the hospital bed to find that he could not move his hand. He was not able to care for himself or even turn himself for days. His body image has dramatically changed from that of a man of strength to that of a helpless individual. What stressors is P.T. experiencing? How does stroke affect self-concept? Body image, identity, and role-performance Upon completing a past medical history, the nurse finds that a client has risk factors for lung disease. How should the nurse interpret this finding The chances of getting the disease are increased. Explanation: The presence of risk factors does not mean a disease will develop, but risk factors increase the chances the individual will experience a particular disease or dysfunction. Control of risk factors does not guarantee that a disease will not develop. However, risk factor modification can assist patients in adopting activities to promote health and decrease risks of illness. (Potter, et al, 2021, p. 74) When caring for patients, the nurse must understand the difference between religion and spirituality. The nurse providing religious care is helping patients do what? maintain their belief systems and worship practices Explanation: Religion is associated with the "state of doing," or a specific system of practices associated with a particular denomination, sect, or form of worship. It is a system of organized beliefs and worship that a person practices to outwardly express spirituality. Religious care helps patients maintain their faithfulness to their belief systems and worship practices. Spiritual care helps people identify meaning and purpose in life, look beyond the present, and maintain personal relationships and a relationship with a higher being or life force. What is presbycusis? Age-related hearing loss (or presbycusis) is the gradual loss of hearing in both ears. It's a common problem linked to aging. One in 3 adults over age 65 has hearing loss. Because of the gradual change in hearing, some people are not aware of the change at first. Before she meets with L.D. again, Ashley decides to read about the Bosnian culture. Among other things, she learns that Bosnians tend to have strong ties with their families and communities. When they speak again, Ashley asks about L.D.'s community and learns that she is very close to her children and neighbors. How can Ashley tailor her plan for L.D. based on this information? Many times, people who are successful at sticking to an exercise plan exercise with other people. Therefore, Ashley helps L.D. develop an exercise routine that includes her children and friends. 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? Focus on a patient's learning needs and objectives. Explanation: 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. (Potter et al, 2021, p. 342) Your patient has a sudden onset of confusion with altered incoherent speech. The nurse notices cloudy urine and the patient has a fever. What issue is most likely in this case? delirium related to UTI Explanation: Delirium, or acute confusional state, is a potentially reversible cognitive impairment that occurs suddenly and worsens at night (Touhy, 2018d). Delirium often has a physiological cause. Physiological causes include electrolyte imbalances, untreated pain, infection, cerebral anoxia, hypoglycemia, medication effects, tumors, subdural hematomas, and cerebrovascular infarction or hemorrhage. A new onset of delirium should trigger the nurse to assess for signs and symptoms of infections such as pneumonia and UTI. Delirium may also be caused by environmental factors such as sensory deprivation or overstimulation, unfamiliar surroundings, or sleep deprivation or psychosocial factors such as emotional distress. Although it occurs in any setting, an older adult in the acute care setting is especially at risk because of predisposing factors (physiological, psychosocial, and environmental) in combination with underlying medical conditions. Between 11% and 42% of hospitalized older adults develop delirium (Touhy, 2018d). Dementia is an additional risk factor that greatly increases the risk for delirium; it is possible for delirium and dementia to occur at the same time. The presence of delirium is a medical emergency and requires prompt assessment and intervention. Nurses are at the bedside 24/7 and in a position to recognize delirium development and report it. The cognitive impairment usually reverses once health care providers identify and treat the cause of delirium. You are assigned to care for a patient who retired months ago. While providing care, you identify that this patient is struggling emotionally with change. This situation is most likely associated with which self-concept component? role performance stressor Explanation: Retirement is a role-performance stressor, as it is related to a lifetime of working, then a sudden change of no longer being employed. Fig. 33.3 p. 694 A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. Which level of preventive care is the patient receiving? Tertiary prevention Explanation: Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration. A nurse is using Maslow's hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first? Not eating Explanation: According to Maslow, in all cases an emergent physiological need takes precedence over a higher-level need. Nutrition is a physiological need and should be addressed first. Anxiety, mental health, and not seeing family members are all higher-level needs. (Potter et al, 2021, p. 69) Over the last couple of weeks, a nurse on your unit has been chronically absent and performing poorly. The nurse does not seem to display empathy for patients and makes poor judgments. Based on these symptoms, what is the nurse most likely experiencing? compassion fatigue Explanation: To be able to provide competent, quality, and safe care, nurses need to take care of themselves to ensure they remain healthy. Nurses are particularly susceptible to the development of compassion fatigue, which is a combination of secondary traumatic stress (STS) and burnout (BO) (see Chapter 1). Secondary traumatic stress develops because of the relationships that nurses develop with their patients and families, whereas BO stems from conflicts or nurse job dissatisfaction within the work setting (Kelly and Lefton, 2017). Compassion fatigue frequently affects a nurse's health, often leading to a decline in health, changes in sleep and eating patterns, emotional exhaustion, irritability, restlessness, impaired ability to focus and engage with patients, feelings of hopelessness, inability to take pleasure from activities, and anxiety (Kelly and Lefton, 2017; Henson, 2017). In the workplace the effects of compassion fatigue are often manifested by diminished performance, reduced ability to feel empathy, depersonalization of the patient, poor judgment, chronic absenteeism, high turnover rates, and conflict between nurses (Henson, 2017). It is important for nurses to engage in personal and professional strategies to help combat compassion fatigue and promote resiliency. What personal and professional strategies could you use to combat compassion fatigue in your own life? Your patient is about to undergo a controversial orthopedic procedure. The procedure may cause periods of pain. Although nurses agree to do no harm, this procedure may be the patient's only treatment choice. This example describes which ethical principle? nonmaleficence Explanation: Sometimes to improve a patient's condition, it is necessary to perform a procedure that will cause pain for the patient. The nurse must weigh the benefits and the risks with the patient in their quest to do no harm. Which of the following populations have the highest incidence of STI? Select all that apply. African American men ages 15 - 24 years Hispanic women ages 15 - 24 years Explanation: The highest incidence of STI occurs in the 15-to-24-year-old age group and in Hispanic and African American populations. You are caring for a patient. Visitors at the bedside include the patient's life partner, widowed father, brother, and niece. The nurse acknowledges that current trends in American families include: a very different look from 15 years ago Explanation: Although the institution of the family remains strong, the family itself is changing. Nikki is a nursing student who volunteers at a free health clinic in a medium-size college town. Nikki enjoys volunteering at the clinic because the nurses allow her to provide health care education to the young women who frequent the clinic. Much of Nikki's teaching involves education about sexually transmitted infections (STIs) and reliable birth control methods. What challenges do you suppose Nikki faces? Explanation: A major problem in dealing with STIs is finding and treating the people who have them. Some people do not know that they are infected because symptoms are sometimes absent or go unnoticed. Common symptoms of an STI include discharge from the vagina, penis, anus, or throat; pain during sex or when urinating; and unexplained rash or lesions. Because sexual behavior often includes the whole body rather than just the genitalia, many parts of the body are potential sites for an STI. The perineum, anus, and rectum frequently are involved in sexual activity. Furthermore, any contact with another person's body fluids around the head or an open lesion on the skin, anus, or genitalia can transmit an STI (LeVay et al., 2019). Sometimes people do not seek treatment because they are embarrassed to discuss sexual symptoms or concerns. Often they are hesitant to talk about their sexual behavior if they believe that it is not "normal." Any sexual behavior that embarrasses a patient often hinders the detection of an STI. Develop communication skills and a nonjudgmental attitude to provide effective care for those diagnosed with one. Detect valuable clues about an STI by establishing trust, talking with patients in a matter-of-fact manner, and asking questions in a caring manner. Assess attitudes toward sexuality and adjust the intervention to make it acceptable to the patient's sexual value system. During a teaching session, the nurse tells a patient with a recent neck injury that damage to the nerves is comparable to a water hose that has been pinched off. During this teaching session, the nurse is using what teaching process? analogy Explanation: Analogy is used to compare a situation with another situation that may be familiar to the patient to help with understanding. You are about to administer an oral medication and you question the dosage. What do you do next? hold the dose and notify the physician Explanation: If you find one to be erroneous or harmful, further clarification from the health care provider is necessary. If the health care provider confirms an order and you still believe that it is inappropriate, use the agency chain of command to inform your direct supervisor. A nurse cares for the family's as well as the patient's needs using available resources. Which approach is the nurse using? Family as a system Rationale: caring for each family member would be family context. Family as a system is how all family members work together with the pt. Which skills can a nursing student who is employed as a nursing assistant perform? The skills that have been identified in the hospital's job description. Upon completing a past medical history, the nurse finds that the client has risk factors for lung disease. How should the nurse interpret this finding? The chances of getting the disease are increased. The nurse is caring for an older-adults patient at home who requires teaching for dressing changes. The spouse and adult child are also involved in changing the dressing. Which statement by the nurse will most likely elicit a positive response from the patient and family? "You're hesitant about changing the dressing like I was before I was shown an easier way; would you like to see?" A nurse is assessing internal variables that are affecting the patients health status. Which area should the nurse assess? Intellectual background Rationale: Internal variables include a persons developmental stage, intellectual background, perception of functioning, emotional and spiritual factors. Family practices, cultural background, socioeconomic background are external variables. The nurse recognizes that which factors influence Marge's approach to death? Select all that apply. Culture Spirituality Personal beliefs Previous experiences and death Which interventions does a nurse implement to help Marge at the end of life maintain autonomy while in the hospital? Select all that apply. Allow the patient to determine timing and scheduling of interventions. Allow patients to have visitors at any time. Encourage the patient to eat whenever he or she is hungry. Rationale: Autonomy means they get to make their own decisions. Be able to do things they choose. Patients have a Bill of Rights when dying. Right as a living human until they die. Have rights to participate in decision concerning care. Have rights to continuing medical and nursing attention even though cure goals have to be changed to comfort goals. Have right to have questions answered honestly. Have rights to retain individuality and not be judged by my decisions that might be contrary to the belief of others. Palliative care Promote a pts quality of life, provide holistic care, working still to reduce and prevent symptoms. hospice care No longer focused on curative treatment, pt has Less than 6 months to live, about comfort care for pts Which comments to Marge by a new nurse regarding palliative care needs are correct? Select all that apply. "Even though your continuing treatment, palliative care is something we might want to talk about." "Palliative care is appropriate for people with any diagnosis." "Children are able to receive palliative care." A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks whether the patient is dying and now in "hospice." What does the nurse tell the family member about palliative care? Select all that apply. Palliative care is for any patient, any time, any disease, in any setting. Palliative care relieves the symptoms of illness and treatment. A hospice nurse is caring for Marge and her husband. The nurse focuses on symptom management for Marge and on helping the spouse with developing coping skills. This approach is an example of which of the following? Family as patient Rationale: Family as context = focus on an individual member Family as a patient = family as patient, the whole family Family as a system = we have family as pt and family as context combine plus resources (environmental, social, psychological, community) What are the physical circulatory changes that occur when death approaches? Mottling Pallor Cyanosis Rationale: Heart unable to pump blood effectively, blood not flowing how it needs to Box 36.8 in text To best assist a patient in the grieving process, which of the following is most helpful to determine? 1. Previous experiences with grief and loss 2. Religious affiliation and denomination 3. Ethnic background and cultural practices 4. Current financial status 5. Current medications Previous experiences with grief and loss Religious affiliation and denomination Ethnic background and cultural practices Rationale: Pg 741 in textbook ch 36 go through types of grief and know those. When planning care for Marge, which interventions promote the patient's dignity? Select all that apply Providing respect Viewing the patient as a whole Showing interest Being present A nurse has the responsibility of managing a patient's postmortem care. What is the proper order for postmortem care when there is no autopsy ordered? Ensure that the request for organ/tissue donation and/or autopsy was completed. Elevate the head of the bed. Collect any needed specimens. Speak to the family members about their possible participation. Notify support person (e.g., spiritual care provider, bereavement specialist) for the family. Remove all tubes and indwelling lines. Bathe the body of the deceased Position the body for family viewing Accurately tag the body, including the identity of the deceased and safety issues regarding infection control. When providing postmortem care, which action is necessary for the nurse to complete? Providing culturally and religiously sensitive care in body preparation. Rationale: Know box 36.9 in textbook to know what a nurse can document. Which actions by the nurse help grieving families? (Select all that apply.) 1. Encourage involvement in nonthreatening group social activities. 2. Provide support only right after the loss occurs. 3. Remind them that feelings of sadness or pain can return around anniversaries. 4. Encourage survivors to ask for help. 5. Watch for ineffective coping, such as overuse of alcohol, sleeping aids, or street drugs. 1. Encour