Exam (elaborations) STUDY GUIDE FOR BRUNNER AND SUDDARTH ’S TEXTBOOK OF MEDICAL SURGICAL NURSING 12TH EDITION

Exam (elaborations) STUDY GUIDE FOR BRUNNER AND SUDDARTH ’S TEXTBOOK OF MEDICAL SURGICAL NURSING 12TH EDITION Brunner & Suddarth's Textbook of Medical-surgical Nursing, ISBN: 5891 Contents 1. Health Care Delivery and Nursing Practice 1 2. Community-Based Nursing Practice 8 3. Critical Thinking, Ethical Decision Making, and the Nursing Process 12 4. Health Education and Health Promotion 21 5. Adult Health and Nutritional Assessment 26 6. Homeostasis, Stress, and Adaptation 31 7. Individual and Family Considerations Related to Illness 40 8. Perspectives in Transcultural Nursing 45 9. Genetics and Genomics Perspectives in Nursing 49 10. Chronic Illness and Disability 53 11. Principles and Practices of Rehabilitation 57 12. Health Care of the Older Adult 63 13. Pain Management 68 14. Fluid and Electrolytes: Balance and Disturbance 73 15. Shock and Multiple Organ Dysfunction Syndrome 85 16. Oncology: Nursing Management in Cancer Care 93 17. End-of-Life Care 101 18. Preoperative Concepts and Nursing Management 104 19. Intraoperative Nursing Management 109 20. Postoperative Nursing Management 114 21. Assessment of Respiratory Function 120 22. Management of Patients With Upper Respiratory Tract Disorders 127 23. Management of Patients With Chest and Lower Respiratory Tract Disorders 134 24. Management of Patients With Chronic Pulmonary Disease 143 25. Respiratory Care Modalities 149 26. Assessment of Cardiovascular Function 158 27. Management of Patients With Dysrhythmias and Conduction Problems 165 28. Management of Patients With Coronary Vascular Disorders 173 29. Management of Patients With Structural, Infectious, and Inflammatory Cardiac Disorders 181 30. Management of Patients With Complications From Heart Disease 187 31. Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation 194 32. Assessment and Management of Patients With Hypertension 200 33. Assessment and Management of Patients With Hematologic Disorders 204 34. Assessment of Digestive and Gastrointestinal Function 212 35. Management of Patients With Oral and Esophageal Disorders 218 36. Gastrointestinal Intubation and Special Nutritional Modalities 224 37. Management of Patients With Gastric and Duodenal Disorders 230 38. Management of Patients With Intestinal and Rectal Disorders 236 39. Assessment and Management of Patients With Hepatic Disorders 243 40. Assessment and Management of Patients With Biliary Disorders 250 41. Assessment and Management of Patients With Diabetes Mellitus 254 42. Assessment and Management of Patients With Endocrine Disorders 263 43. Assessment of Renal and Urinary Tract Function 271 44. Management of Patients With Renal Disorders 274 45. Management of Patients With Urinary Disorders 281 46. Assessment and Management of Female Physiologic Processes 285 47. Management of Patients With Female Reproductive Disorders 291 48. Assessment and Management of Patients With Breast Disorders 297 49. Assessment and Management of Problems Related to Male Reproductive Processes 303 50. Assessment of Immune Function 308 51. Management of Patients With Immunodeficiency 312 52. Management of Patients With HIV Infection and AIDS 315 53. Assessment and Management of Patients With Allergic Disorders 320 54. Assessment and Management of Patients With Rheumatic Disorders 324 55. Assessment of Integumentary Function 330 56. Management of Patients With Dermatologic Problems 334 57. Management of Patients With Burn Injury 341 58. Assessment and Management of Patients With Eye and Vision Disorders 347 viii Contents 59. Assessment and Management of Patients With Hearing and Balance Disorders 353 60. Assessment of Neurologic Function 358 61. Management of Patients With Neurologic Dysfunction 363 62. Management of Patients With Cerebrovascular Disorders 368 63. Management of Patients With Neurologic Trauma 372 64. Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies 376 65. Management of Patients With Oncologic or Degenerative Neurologic Disorders 380 66. Assessment of Musculoskeletal Function 384 67. Musculoskeletal Care Modalities 388 68. Management of Patients With Musculoskeletal Disorders 394 69. Management of Patients With Musculoskeletal Trauma 398 70. Management of Patients With Infectious Diseases 404 71. Emergency Nursing 409 72. Terrorism, Mass Casualty, and Disaster Nursing 414 Answer Key 417 Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. 1 Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. I. Interpretation, Completion, and Comparison MULTIPLE CHOICE Read each question carefully. Circle your answer. 1. The definition of nursing has evolved over time. According to the Social Policy Statement (2003) of the American Nurses Association (ANA), registered nurses can and should: CHAPTER 1 Health Care Delivery and Nursing Practice a. diagnose human responses to illness. b. promote optimum levels of wellness. c. prevent illness and maintain health. d. do all of the above. 2. An underlying focus in any definition of nursing is the registered nurse’s responsibility to: a. appraise and enhance an individual’s healthseeking perspective. b. coordinate a patient’s total health management with all disciplines. c. diagnose acute pathology. d. treat acute clinical reactions to chronic illness. 3. A Jewish patient who adheres to the dietary laws of his faith is in traction and confined to bed. He needs assistance with his evening meal of chicken, rice, beans, a roll, and a carton of milk. Choose the nursing approach that is most representative of promoting wellness. a. Nurse “A” removes items from the overbed table to make room for the dinner tray. b. Nurse “B” pushes the overbed table toward the bed so that it will be within the patient’s reach when the dinner tray arrives. c. Nurse “C” asks a family member to assist the patient with the tray and the overbed table while the nurse straightens the area in an attempt to provide a pleasant atmosphere for eating. d. Nurse “D” prepares the environment and the overbed table and inspects the contents of the dinner tray. The nurse asks the patient whether he would like to make any substitutions in the foods and fluids he has received. 4. Using the concept of the wellness–illness continuum, a nursing care plan for a chronically ill patient would outline steps to: a. educate the patient about every possible complication associated with the specific illness. b. encourage positive health characteristics within the limits of the specific illness. c. limit all activities because of the progressive deterioration associated with all chronic illnesses. d. recommend activity beyond the scope of tolerance to prevent early deterioration. 10. Common features that characterize managed care include all of the following except: 2 CHAPTER 1 ■ Health Care Delivery and Nursing Practice Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. 5. To be responsive to the changing health care needs of our society, registered nurses will need to: a. focus their care on the traditional diseaseoriented approach to patient care, because hospitalized patients today are more acutely ill than they were 10 years ago. b. learn how to delegate discharge planning to ancillary personnel so that registered nurses can spend their time managing the “high tech” equipment needed for patient care. c. place increasing emphasis on wellness, health promotion, and self-care, because the majority of Americans today suffer from chronic debilitative illness. d. stress the curative aspects of illness, especially the acute, infectious disease processes. 6. Continuous quality improvement (CQI) was mandated in health care organizations in 1992. This system focuses on all of the following processes except: a. analyzing similar clinical situations. b. assessing the impact of financial decisions on patient care delivery. c. examining processes that affect patient care. d. reviewing medication errors for individual patients. 7. Quality assurance programs created in the 1980s required that hospitals be accountable for all of the following except: a. appropriateness of care related to established standards. b. cost of services. c. staff–patient ratios for nursing care. d. quality delivery of services. 8. The primary focus of the nurse advocacy role in managing a clinical pathway is: a. continuity of care. b. cost-containment practices. c. effective utilization of services. d. a patient’s progress toward desired outcomes. 9. Nursing practice in the home and community requires competence and experience in the techniques of: a. decision making. b. health teaching. c. physical assessment. d. all of the above. a. fixed-price reimbursement. b. mandatory precertification. c. preferred provider choice. d. prenegotiated payment rates. SHORT ANSWER Read each statement carefully. Write your response in the space provided. 1. List four phenomena frequently identified by the American Nurses Association (ANA) in 2003 as the focus of nursing care and research. An example is given: Pain and discomfort (Example) __________________________________________________, __________________, ______________, and ________________. 2. List six significant changes (socioeconomic, political, scientific, and technological) that have evolved over the last hundred years that have influenced where nurses practice. _____________________________, and __________________________________________________________ _____________________________, and __________________________________________________________ _____________________________, and __________________________________________________________ 3. List four major health care concerns that practitioners are facing today with the shift from acute to chronic illnesses: ___________________________, __________________________, _____________________________, and ____________________. 4. Choose four health and illness problems and write a human response to each that would require nursing intervention. An example is provided. Health and Illness Problems Human Response Requiring Nursing Intervention Fractured right arm (Example) Self-care limitations (Example) 1. __________________________ __________________________________________ 2. __________________________ __________________________________________ 3. __________________________ __________________________________________ 4. __________________________ __________________________________________ 5. According to Hood and Leddy (2007), wellness involves proactively working toward physical, psychological, and spiritual well-being. Four major concepts supporting wellness are: ________________________________, ________________________________, ________________________________, and _________________________________. 6. List Maslow’s hierarchy of needs, and give an example for each need. The first need is provided as an example. Need Example Physiologic (Example) Food and water (Example) _________________________________ __________________________________________ _________________________________ __________________________________________ _________________________________ __________________________________________ _________________________________ __________________________________________ _________________________________ __________________________________________ _________________________________ __________________________________________ _________________________________ __________________________________________ 7. Health promotion efforts today target negative lifestyle behaviors. List six examples. __________________________________ __________________________________________ __________________________________ __________________________________________ __________________________________ __________________________________________ 8. Three infectious diseases that presently seem to be on the rise are: __________________________, ____________________________, and _________________________. 9. List four comorbidities that are associated with the major health concern of obesity: ______________, _________________, _________________, and ____________________. CHAPTER 1 ■ Health Care Delivery and Nursing Practice 3 Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. 10. Define the term evidence-based practice (EBP). _________________________________________________________________________________________________________ 11. Define the term clinical pathway as it relates to the concept of managed care. _________________________________________________________________________________________________________ 12. In addition to clinical pathways, there are four other EBP tools a nurse can use. They are: ____________________, ______________________, ______________________, and ____________________. 13. Explain when “care mapping” may be more beneficial than “clinical pathways” for managing care. _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 14. List five common features of managed care: ____________________, ________________________, ____________________, ____________________, and _____________________________. 15. List the purpose and goals of case management. _________________________________________________________________________________________________________ 16. List four categories of advanced practice nurses: ________________, _______________, ________________, and _______________________. II. Critical Thinking Questions and Exercises DISCUSSION AND ANALYSIS Discuss the following topics with your classmates. 1. Review the clinical pathway for acute ischemic stroke that is presented in Appendix B. Discuss the range of assessments, expected outcomes, nursing diagnoses, and treatment modalities listed in the chart. 2. Discuss the primary differences between community-based nursing and community-oriented/public health nursing. 3. Discuss the current and future role of the advanced practice nurse (APN). SUPPORTING ARGUMENTS Read the paragraph below. Fill in the space provided with the best response. Many recent changes in health care have significantly affected nursing care delivery and nursing education, including the aging population, increased cultural diversity, changing patterns of disease, the rising cost of health care, and federally legislated health care reform. Choose one factor that you believe has had the most impact on nursing care in the last 5 years, and support your argument with data. The most important factor is: ________________________________________________________________________________________________ Supporting argument: ________________________________________________________________________________________________ 4 CHAPTER 1 ■ Health Care Delivery and Nursing Practice Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. RECOGNIZING CONTRADICTIONS Rewrite each statement correctly. Underline the key concepts. 1. The majority of health problems in the United States today are of an infectious and acute nature. ______________________________________________________________________________________________ 2. A person with a chronic illness can never attain a high level of wellness, because part of his or her health potential will never be reached. _____________________________________________________________________________________________. 3. It is predicted that by the year 2030, people older than 65 years of age in the United States will constitute about 35% of the total population; racial and minority groups could approach 60% of the population. _____________________________________________________________________________________________ 4. Those individuals with infectious diseases are the largest group of health care consumers in the United States. _____________________________________________________________________________________________ 5. The largest group of health care consumers in the United States is children and the middle-aged. _____________________________________________________________________________________________ 6. Home health care nursing is a major component of public health nursing. _____________________________________________________________________________________________ EXAMINING ASSOCIATIONS Answer the following. 1. Examine the progression of Maslow’s hierarchy of needs in Figure 1-1. Consider one or more recent clinical situations where the patient’s physical symptoms prevented him or her from attending to higher level needs. _____________________________________________________________________________________________ _____________________________________________________________________________________________ 2. Using Figure 1-2 in the text, examine and explain the expected behaviors among the physician, patient, nurse, and ancillary personnel in the collaborative practice model. _____________________________________________________________________________________________ 3. Compare the two most common models of nursing care delivery in practice today: primary nursing and patient-focused or patient-centered care. _____________________________________________________________________________________________ CHAPTER 1 ■ Health Care Delivery and Nursing Practice 5 Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. 6 CHAPTER 1 ■ Health Care Delivery and Nursing Practice Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. FIGURE 1-1. This scheme of Maslow’s hierarchy of human needs shows how a person moves from fulfillment of basic needs to higher levels of needs, with the ultimate goal being integrated human functioning and health. FIGURE 1-2. 2. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandated in 1992 that health care organizations move toward implementation of CQI. A cause-and-effect diagram can illustrate potential causes of a process so that the cause can be examined and corrected and patient care improved. Complete the following diagram. CLINICAL SITUATIONS Complete the following flow charts. 1. Continuous quality improvement (CQI) mandates the standardization of processes that are implemented and improved on a continuous basis. Complete the blank lines on the flow chart for the process of radial pulse assessment. CHAPTER 1 ■ Health Care Delivery and Nursing Practice 7 Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. 8 Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. I. Interpretation, Completion, and Comparison MULTIPLE CHOICE Read each question carefully. Circle your answer. 1. The shift in health care delivery from acute care to community-based care is primarily the result of: CHAPTER 2 Community-Based Nursing Practice a. alternative health care delivery systems. b. changes in federal legislation. c. tighter insurance regulations. d. the interfacing of all three conditions. 2. Choose an alternative health care delivery system that has dramatically reduced patient-care days in acute care settings. a. Health Maintenance Organizations. b. Managed Health Care Systems. c. Preferred Provider Organizations. d. Each of the three is equally significant. 3. The most frequent users of home health services are: a. children with chronic, debilitating disorders. b. newborns who are sent home with apnea monitors. c. the frail and elderly who need skilled care. d. young adults on prolonged intravenous therapy. 4. Discharge planning from the hospital to home care begins when the: 5. Nurses working in elementary schools are trained to deal with one of the most frequent health care problems: a. discharge order is written. b. nurse receives the physician’s order for discharge. a. eating disorders. b. emotional problems. c. infections. d. drug abuse. 6. Nurses working with high school students are prepared to deal with the common health care problem of: a. influenza. b. cancer. c. alcohol and drug abuse. d. pneumonia. c. physician notifies the insurance company. d. patient is admitted to the hospital. Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. CHAPTER 2 ■ Community-Based Nursing Practice 9 SHORT ANSWER Read each statement carefully. Write your response in the space provided. 1. Name three chronic conditions that are increasing in prevalence and causing an increased need for community health services: _______________________, ________________________, and _______________________. 2. List four factors that have affected the shift of health care delivery from inpatient to outpatient settings: _________________________________, ___________________, ___________________, and _________________________. 3. List specific skills a nurse will need to function in community-based care. ____________________________________________________________________________________ 4. Community-based nursing practice focuses on three primary goals: __________________________, ______________________, and _________________________. 5. List the four primary concepts supporting community-based nursing care: _________________________, ___________________, ___________________, and ______________________________. 6. List several examples of “skilled” nursing services provided by home care. ____________________________________________________________________________________________ 7. The first step in preparing for a home visit is for the nurse to: ____________________________________________________________________________________________ 8. Explain the purpose of the initial home visit. ____________________________________________________________________________________________ ____________________________________________________________________________________________ 9. List the range of nursing responsibilities within ambulatory health care settings. ____________________________________________________________________________________________ ____________________________________________________________________________________________ 10. The homeless have high rates of health care problems such as: ____________________________________________________________________________________________ II. Critical Thinking Questions and Exercises DISCUSSION AND ANALYSIS Discuss the following topics with your classmates. 1. Distinguish among primary, secondary, and tertiary levels of preventive care and cite a clinical case example for each level. 2. Discuss one of the major financial incentives for discharging patients from acute care facilities prior to full recovery. Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. 10 CHAPTER 2 ■ Community-Based Nursing Practice 3. Explain the concept of “telehealth” and its implications for nursing care. Refer to the book, Community and Public Health Nursing, by M. Stanhope and S. Lancaster, 2008, St. Louis, Mosby. CLINICAL SITUATIONS CASE STUDY: Assessing the Need for a Home Visit Read the following case study and assess the patients’ need for a home visit. Mrs. Flynn is an 85-year-old lady who suffered a stroke on December 28. She was admitted to the emergency department and suffered another stroke on December 30. The left occipital area and the cerebellum were affected resulting in the loss of 50% of vision (right half of each eye) and loss of balance. After 2 weeks in the hospital and 10 days in a rehabilitation treatment center, Mrs. Flynn will be discharged to her one-floor home where she lives alone. Her son and daughter both live an hour away. She is capable of walking with a walker. Before the stroke, Mrs. Flynn was independent, an active member of several citizen groups, and participated in water walking at the YMCA three times a week. Her driver’s license was revoked. Using Chart 2-2 in the text, complete the outline to assess Mrs. Flynn’s need for a home visit. Create your own answers to several of the questions so you can complete the assessment. Current Health Status 1. How well is the patient progressing? 2. How serious are the present signs and symptoms? 3. Has the patient shown signs of progressing as expected, or does it seem that recovery will be delayed? Home Environment 1. Are worrisome safety factors apparent? 2. Are family or friends available to provide care, or is the patient alone? Level of Self-Care Ability 1. Is the patient capable of self-care? 2. What is the patient’s level of independence? 3. Is the patient ambulatory or bedridden? 4. Does the patient have sufficient energy or is she frail and easily fatigued? Level of Nursing Care Needed 1. What level of nursing care does the patient require? 2. Does the care require basic skills or more complex interventions? Prognosis 1. What is the expectation for recovery in this particular instance? 2. What are the chances that complications may develop if nursing care is not provided? Educational Needs 1. How well has the patient or family grasped the teaching points made? 2. Is there a need for further follow-up and retraining? 3. What level of proficiency does the patient or family show in carrying out the necessary care? Mental Status 1. How alert is the patient? 2. Are there signs of confusion or thinking difficulties? Level of Adherence 1. Is the patient following the instructions provided? 2. Does the patient seem capable of following the instructions? 3. Are the family members helpful, or are they unwilling or unable to assist in caring for the patient as expected? CHAPTER 2 ■ Community-Based Nursing Practice 11 Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. 12 Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. I. Interpretation, Completion, and Comparison MULTIPLE CHOICE Read each question carefully. Circle your answer. 1. The least effective decision-making process used in critical thinking is: CHAPTER 3 Critical Thinking, Ethical Decision Making, and the Nursing Process a. analyzing data. b. establishing assumptions. c. formulating conclusions. d. synthesizing information. 2. The term metacognition refers to the critical-thinking skill of: a. consultation. b. data analysis. c. self-reasoning. d. validation. 3. Morality is defined as: a. adherence to specific codes of conduct. b. commitment to informal, personal values. c. dependence on specified principles of behavior. d. an understanding of defined rules of behavior. 4. When an ethical decision is made based on the reasoning of the “greatest good for the greatest number,” the nurse is following the: 5. Individual patient rights regarding the freedom of choice and the right to privacy are subsumed under the ethical principle of: a. deontological theory. b. formalist theory. a. autonomy. b. beneficence. c. fidelity. d. paternalism. 6. Consider the ethical situation in which a nurse moves a confused, disruptive patient to a private room at the end of the hall so that other patients can rest, even though the confused patient becomes more agitated. The nurse’s judgment is consistent with reasoning based on: a. “consequentialism,” by which good consequences for the greatest number are maximized. b. “duty of obligation,” by which an action, regardless of its results, is justified if the decision making was based on moral principles. c. “prima facie” duty, by which an action is justified if it does not conflict with a stronger duty. d. the “categorical imperative,” by which the results of an action are deemed less important than the means to the end. c. moral-justification theory. d. utilitarian theory. CHAPTER 3 ■ Critical Thinking, Ethical Decision Making, and the Nursing Process 13 Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. 7. A hospital board of directors decided to close a pediatric burn treatment center (BTC) that annually admits 50 patients and to open a treatment center for terminally ill AIDS patients (with an expected annual admission of 200). This decision meant that the nearest BTC for children was 300 miles away. The board’s decision was an example of ethical reasoning consistent with: a. a formalist approach. b. obligation or duty. c. “the means justifies the end.” d. utilitarianism. 8. A terminally ill patient asks the nurse whether she is dying. The nurse’s response is influenced by the moral obligation to: a. communicate the patient’s wishes to the family. b. consult with the physician. c. provide correct information to the patient. d. consider all of the above measures before disclosing specific information. 10. Choose the situation that most accurately represents a moral problem in contrast to a moral dilemma. a. Three days after surgery, a patient requests narcotic pain medication every 3 hours. The nurse administers a placebo that reduces pain. b. A 32-year-old father of three with advanced cancer of the lungs asks that everything be done to prolong his life, even though his chemotherapy treatments are no longer effective. c. A confused 80-year-old needs restraints for protection from injury, even though the restraints increase agitation. d. A young patient with AIDS has asked not to receive tube feedings to prolong life because of intense pain. 9. A patient with a “Do Not Resuscitate” order requires large doses of a narcotic (which may significantly reduce respiratory function) for excruciating pain. After the patient requests pain medication, the nurse assesses a respiratory rate of 12 breaths per minute. The nurse’s ethical decision should be to: a. ask the patient to wait 20 minutes and reassess. b. give half of the prescribed dose. c. give the pain medication without fear of respiratory depression. d. withhold the pain medication and contact the physician. 11. Assessment, the first of five steps in the nursing process, begins with initial patient contact. Nursing activities during this component of the nursing process include: a. interviewing and obtaining a nursing history. b. observing for altered symptomatology. c. collecting and analyzing data. d. all of the above. 12. The end result of data analysis during the assessment process is: a. actualization of the plan of care. b. determination of the patient’s responses to care. c. collection and analysis of data. d. identification of actual or potential health problems. 14. An example of a medical diagnosis, in contrast to a nursing diagnosis, is: a. fever of unknown origin. b. fluid volume excess. c. risk for falls. d. sleep-pattern disturbances. 13. A therapeutic communication technique that validates what the nurse believes to be the main idea of an interaction is known as: a. acknowledgment. b. focusing. c. restating. d. summarizing. 14 CHAPTER 3 ■ Critical Thinking, Ethical Decision Making, and the Nursing Process Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. SHORT ANSWER Read each statement carefully. Write your response in the space provided. 1. There are three consistent themes threaded through all definitions of critical thinking. These themes are: __________________, ______________________, and ________________________. 2. List 10 characteristics of critical thinkers as identified by Alfaro-LeFevre (2008). ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 17. Registered nurses are responsible for delegating patient care responsibilities to licensed practical nurses (LPNs) and ancillary personnel. The most appropriate task to delegate to a nurse aide is: a. assessing the degree of lower leg edema in a patient on bed rest. b. making the bed of an ambulatory patient. c. measuring the circumference of a patient’s calf for edema. d. recording the size and appearance of a bed sore. 16. Consider the following nursing diagnosis: “Imbalanced nutrition, less than body requirements, related to inability to feed self.” An example of an immediate nursing goal is that the patient will: a. acquire competence in managing cookware designed for handicapped people. b. assume independent responsibility for meeting self-nutrition needs. c. learn about food products that require minimal preparation yet meet individual needs for a balanced diet. d. master the use of special eating utensils to feed self. a. administer pain medication to an orthopedic patient 30 minutes before transportation to physical therapy for crutch-walking exercises. b. discourage a terminally ill patient from participating in a plan of care, to minimize fears about death. c. help a patient walk to the shower while the breakfast tray waits on the overbed table, because the shower area is vacant at this time. d. interrupt a family’s visit with a depressed patient to assess blood pressure measurement, because it is time to take the scheduled vital signs. 15. In choosing the nursing action that illustrates planned nursing care prioritized according to Maslow’s hierarchy of needs, a nurse would: CHAPTER 3 ■ Critical Thinking, Ethical Decision Making, and the Nursing Process 15 Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. 3. List six skills that are needed for nurses to be critical thinkers. ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 4. Explain this statement: How a nurse perceives a situation and employs critical thinking skills depends on the “lens” through which she sees the situation. ____________________________________________________________________________________________ 5. Compare and contrast the meaning of the following terms: moral dilemma, moral problem, moral uncertainty, and moral distress. ____________________________________________________________________________________________ ____________________________________________________________________________________________ 6. Write the definition of nursing as proposed in Nursing’s Social Policy Statement (ANA, 2003). ____________________________________________________________________________________________ ____________________________________________________________________________________________ 7. List five of the most common ethical issues that nurses face today: ______________, __________________, __________________, ____________________, and ___________________. 8. List two types of “advance directives” that specify a patient’s wishes before hospitalization: ________________________ and ___________________________. 9. Explain the concept of a “durable power of attorney.” ____________________________________________________________________________________________ ____________________________________________________________________________________________ 10. Suggest an opening statement that a nurse can use during the interview process. ____________________________________________________________________________________________ 11. Discuss how formulation of a nursing diagnosis and identification of collaborative problems differs from making a medical diagnosis. ____________________________________________________________________________________________ ____________________________________________________________________________________________ 12. Discuss the significance of establishing expected outcomes during the evaluation phase of the nursing process. ____________________________________________________________________________________________ ____________________________________________________________________________________________ NURSING OR COLLABORATIVE PROBLEM Read each statement below. Put “N” in front of every nursing diagnosis and “C” in front of every collaborative problem. 1. ______ Anxiety related to impending surgery. 2. ______ Constipation related to altered nutrition. 3. ______ Potential complication: paralytic ileus secondary to postoperative inactivity. 4. ______ Potential complication: sacral decubiti secondary to bed rest. 5. ______ Risk for impaired skin integrity related to prolonged bed rest. 6. ______ Ineffective breastfeeding related to fear of discomfort. 7. ______ Potential complication: hypoglycemia related to inadequate food intake. 8. ______ Potential complication: phlebitis related to intravenous therapy. 9. ______ Risk for posttraumatic syndrome related to an accident. 10. ______ Potential complication: oral lesions related to chemotherapy. MATCHING Match the critical-thinking strategy in column II with the nursing process skill listed in column I. Column I Column II 1. __________ Categorize information 2. __________ Design a plan of care 3. __________ Determine assessment processes 4. __________ Evaluate outcomes 5. __________ Implement a standard plan 6. __________ Make a nursing diagnosis 7. __________ Manage collaborative problems Match the definitions of ethical principles listed in column II with their associated terms listed in column I. Column I Column II 1. __________ Autonomy 2. __________ Beneficence 3. __________ Justice 4. __________ Nonmaleficence 5. __________ Paternalism 6. __________ Veracity 16 CHAPTER 3 ■ Critical Thinking, Ethical Decision Making, and the Nursing Process Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. a. Assert a practice role b. Formulate a relationship c. Generate a hypothesis d. Provide an explanation e. Recognize a pattern f. Search for information g. Set priorities a. Limiting one’s autonomy based on the welfare of another b. Similar cases should be treated the same c. The commitment to not deceive d. Freedom of choice e. The duty to do good and not inflict harm f. The expectation that harm will not be done II. Critical Thinking Questions and Exercises DISCUSSION AND ANALYSIS Discuss the following topics with your classmates. Planning nursing care involves setting priorities and distinguishing problems that need urgent attention from those that can be deferred to a later time or referred to a physician. For each of the following patient care problems, circle the initial priority of nursing care from among the choices provided and write a rationale for your choice. For standardized interventions from the Nursing Interventions Classification (NIC), see Chart 3- 7 in the text. 1. Activity intolerance, related to inadequate oxygenation: a. dyspnea b. fatigue c. hypotension Rationale for choice: _____________________________________________________________________________________________ _____________________________________________________________________________________________ 2. Alterations in bowel elimination: constipation, related to prolonged bed rest: a. abdominal pressure and bloating b. palpable impaction c. straining at stool Rationale for choice: _____________________________________________________________________________________________ _____________________________________________________________________________________________ 3. Altered oral mucous membrane, related to stomatitis: a. erythema of oral mucosa b. intolerance to hot foods c. oral pain Rationale for choice: _____________________________________________________________________________________________ _____________________________________________________________________________________________ RECOGNIZING CONTRADICTIONS Rewrite each statement correctly. Underline the key concepts. 1. Nursing ethics is considered an applied form of medical ethics because nurses work only under the direction of a physician. _____________________________________________________________________________________________ 2. A nurse experiences moral uncertainty when he or she is prevented from doing what he or she believes is the correct action. _____________________________________________________________________________________________ CHAPTER 3 ■ Critical Thinking, Ethical Decision Making, and the Nursing Process 17 Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. 3. A nurse should always honor a terminally ill patient’s request to withhold food and hydration if the patient is competent. _____________________________________________________________________________________________ 4. By design, living wills are very prescriptive and are always honored as legally binding documents. _____________________________________________________________________________________________ SUPPORTING ARGUMENTS Read each paragraph. Offer logical supporting rationales for each answer. 1. In vitro fertilization, based on sophisticated technology, has resulted in women in their 50s and 60s giving birth. Physicians argue that this is ethically sound if the woman meets the criteria that she is healthy and could live another 25 years. List three rationales to support this argument. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 2. You are asked to defend the statement that “life support measures should never be used for anyone with a terminal illness.” Develop three supporting arguments. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 3. List two rationales to support the argument that age should be used as a criterion for determining the allocation of health care resources. _____________________________________________________________________________________________ _____________________________________________________________________________________________ CLINICAL SITUATIONS Read each nursing diagnosis. Write a specific outcome. The planning phase of the nursing process incorporates documented expected patient outcomes for specific nursing diagnoses (ND). Resources include the Nursing-Sensitive Outcomes Classification (NOC) (see Chart 3-6 in the text). Write one outcome that indicates an improvement for each diagnosis. 1. ND: Activity intolerance, related to dyspnea Outcome: ____________________________________________________________________________________ 2. ND: Impaired physical mobility, related to total hip replacement Outcome: ____________________________________________________________________________________ 3. ND: Fluid volume excess, related to compromised cardiac output Outcome: ____________________________________________________________________________________ 4. ND: Imbalanced nutrition: less than body requirements, related to anorexia Outcome: ____________________________________________________________________________________ 18 CHAPTER 3 ■ Critical Thinking, Ethical Decision Making, and the Nursing Process Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. 5. ND: Disturbed sleep-pattern disturbance, related to pain Outcome: ____________________________________________________________________________________ CASE STUDY: Ethical Analysis Read the following case study. Fill in the blanks below. You are a registered nurse and a board member of American Red Cross Disaster Relief Services. When a smallpox epidemic erupted among thousands in Washington, DC, as a result of terrorist activity, the board was asked by the Office of Homeland Security to allocate limited resources. The board decided that those with the greatest chance of survival and those working for the government would be treated. Those individuals with preexisting or terminal conditions would not be treated. The decision resulted in multiple deaths while preserving the lives of those most likely to survive. The framework for decision making followed the utilitarian approach. Assessment Write your response in the space provided. 1. List two possible conflicts between ethical principles and professional obligations. CHAPTER 3 ■ Critical Thinking, Ethical Decision Making, and the Nursing Process 19 Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. a. ______________________________________ b. ______________________________________ 2. People involved in the decision: a. ______________________________________ b. ______________________________________ c. ______________________________________ 2. Medical facts: a. ______________________________________ b. ______________________________________ 3. Those affected by the decision: a. ______________________________________ b. ______________________________________ c. ______________________________________ Planning 1. Treatment options: a. ______________________________________ b. ______________________________________ 3. Influencing information: a. ______________________________________ b. ______________________________________ 4. Ethical/moral issues: a. ______________________________________ b. ______________________________________ 5. Competing claims: a. ______________________________________ b. ______________________________________ 20 CHAPTER 3 ■ Critical Thinking, Ethical Decision Making, and the Nursing Process Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. Implementation Compare the Utilitarian and the Deontological approaches. Utilitarian Deontological or Formalist 1. Basis of ethical principles: a. __________________________ a. ______________________ b. __________________________ b. ______________________ 2. Predict consequences of actions: a. __________________________ a. ______________________ b. __________________________ b. ______________________ 3. Assign a positive or negative value to each consequence. a. __________________________ a. ______________________ b. __________________________ b._______________________ 4. Choose the consequence, decision, or action that predicts the highest positive value: a. __________________________ a. _______________________ b. __________________________ b. _______________________ Evaluation Finish the following statements. 1. The best, morally correct action is to: _____________________________________________________________________________________________ _____________________________________________________________________________________________ 2. This decision is based on the ethical reasoning that: _____________________________________________________________________________________________ _____________________________________________________________________________________________ 3. The decision can be defended based on the following arguments: a. ___________________________________________________________________________________________ b. ___________________________________________________________________________________________ c. ___________________________________________________________________________________________ I. Interpretation, Completion, and Comparison MULTIPLE CHOICE Read each question carefully. Circle your answer. 1. Health education is: CHAPTER 4 Health Education and Health Promotion a. a primary nursing responsibility. b. an essential component of nursing care. c. an independent nursing function. d. consistent with all of the above. 2. Nursing responsibilities associated with patient teaching include: a. determining individual needs for teaching. b. motivating each person to learn. c. presenting information at the level of the learner. d. all of the above. 3. A nurse assesses that a patient is emotionally ready to learn when the patient: a. has accepted the therapeutic regimen. b. is motivated. c. recognizes the need to learn. d. demonstrates all of the above. 4. Nursing actions that can be used to motivate a patient to learn include all of the following except: a. feedback in the form of constructive encouragement when a person has been unsuccessful in the learning process. b. negative criticism when the patient is unsuccessful, so that inappropriate behavior patterns will not be learned. 5. Normal aging results in changes in cognition. Therefore, when teaching an elderly patient how to administer insulin, the nurse should: a. repeat the information frequently for reinforcement. b. present all the information at one time so that the patient is not confused by pieces of information. c. speed up the demonstration because the patient will tire easily. d. do all of the above. c. the creation of a positive atmosphere in which the patient is encouraged to express anxiety. d. the establishment of realistic learning goals based on individual needs. Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. 21 Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. 6. The nurse reviews a medication administration calendar with an elderly patient. Being aware of sensory changes associated with aging, the nurse should: a. print directions in large, bold type, preferably using black ink. b. highlight or shade important dates and times with contrasting colors. c. use several different colors to emphasize special dates. d. do all of the above. 22 CHAPTER 4 ■ Health Education and Health Promotion Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. 7. A nursing action that involves modifying a teaching program because a learner is not experientially ready is: 8. A nurse identifies a patient’s inability to pour a liquid medication into a measuring spoon. This diagnosis is part of the nursing process known as: a. assessment. b. planning. c. implementation. d. evaluation. a. changing the wording in a teaching pamphlet so that a patient with a fourth-grade reading level can understand it. b. contacting family members to assist in goal development to help stimulate motivation. c. postponing a teaching session with a patient until pain has subsided. d. all of the above. 9. A nurse develops a program of increased ambulation for a patient with an orthopedic disorder. This goal setting is a component of the nursing process known as: a. assessment. b. planning. c. implementation. d. evaluation. 10. Outcome criteria are expressed as expected outcomes of patient behavior resulting from teaching strategies. An example is: a. ability to climb a flight of stairs without experiencing difficulty in breathing. b. altered lifestyle resulting from inadequate lung expansion. c. inadequate ventilation associated with pulmonary congestion. d. potential oxygenation deficit related to ventilatory insufficiency. SHORT ANSWER Read each statement carefully. Write your response in the space provided. 1. List three significant factors for a nurse to consider when planning patient education: __________________________, __________________________, and __________________________. 2. Explain why health education is so essential for those with a chronic illness. ____________________________________________________________________________________________ 3. List five common examples of specific activities that promote and maintain health: ___________________, ________________, __________________, ___________________, and ___________________________________________. 4. Define the term adherence as it relates to a person’s therapeutic regimen. _________________________________________________________________________________________________________ 12. The single, most important factor in determining health status and longevity is: a. adherence to a plan. b. good nutrition. c. motivation to change. d. stress reduction. 11. Select the health promotion model that identifies why some people choose actions to foster health and others refuse to participate: a. Health Belief Model b. Resource Model of Preventive Health c. Achieving Health for All Model d. Social Learning Theory Model CHAPTER 4 ■ Health Education and Health Promotion 23 Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. 5. Name four classifications of variables (factors) that influence a person’s ability to adhere to a program of care: ___________________, ________________________, ____________________________, and ______________________. 6. There is a positive correlation between patient motivation and adherence to a teaching plan. Three significant variables affecting motivation and learning are: ________________________, ______________________, and ___________________________. 7. List the six stages of personal change that an individual experiences as he or she moves toward a healthy behavior. ____________________________________________ ___________________________________________________________ ____________________________________________ ___________________________________________________________ ____________________________________________ ___________________________________________________________ 8. Describe the nature of the teaching–learning process. _________________________________________________________________________________________________________ 9. List at least six variables that make adherence to a therapeutic regimen difficult for the elderly. ____________________________________________ ___________________________________________________________ ____________________________________________ ___________________________________________________________ ____________________________________________ ___________________________________________________________ 10. Increased age affects cognition by decreasing: ________________________, _______________________, and _____________________. 11. Discuss how learner readiness affects a learner and the learning situation. _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 12. Identify six teaching techniques the nurses frequently use: ____________________________________________ ___________________________________________________________ ____________________________________________ ___________________________________________________________ ____________________________________________ ___________________________________________________________ 13. Two major goals from the Healthy People 2010 report are: _____________________________ and ___________________________________. 14. Health promotion activities are grounded in four active processes: _________________________________, _________________________, ___________________________, and ______________________________________. II. Critical Thinking Questions and Exercises DISCUSSION AND ANALYSIS Discuss the following topics with your classmates. 1. Using Table 4-1 in the text, design two teaching plans: one for a teenage diabetic patient who has an emotional disability and another for a 70-year-old individual with a visual impairment who had a stroke. 2. Discuss the positive relationship between health and physical fitness. Explain at least five ways that exercise can promote health. RECOGNIZING CONTRADICTIONS Rewrite each statement correctly. Underline the key concepts. 1. Health education is a dependent function of nursing practice that requires physician approval. __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ 2. The largest groups of people in need of health education today are children and those with infectious diseases. __________________________________________________________________________________________________________ 3. Patients are encouraged to evidence compliance with their therapeutic regimen. __________________________________________________________________________________________________________ 4. Evaluation, the final step in the teaching process, should be summative (done at the end of the teaching process). __________________________________________________________________________________________________________ 5. Elderly persons rarely experience significant improvement from health promotion activities. __________________________________________________________________________________________________________ 6. About 50% of elderly persons have one or more chronic illnesses. __________________________________________________________________________________________________________ EXAMINING ASSOCIATIONS The health status of residents of the United States is a serious concern to individuals, health care practitioners, and health-promotion groups. A nation’s health status can be measured by evaluating certain indicators. (Refer to Chart 4-3 in the text.) After reading Healthy People 2010 (U.S. Department of Health and Human Services, 2000), complete the following chart. For each indicator listed, assign a rating score (1  not relevant, 2  important, and 3  very significant) reflecting the degree to which the indicator affects an individual’s health, the rationale for the score, and an activity to improve the score. The first row has been filled in as an example. 24 CHAPTER 4 ■ Health Education and Health Promotion Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. CHAPTER 4 ■ Health Education and Health Promotion 25 Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. 26 Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. I. Interpretation, Completion, and Comparison MULTIPLE CHOICE Read each question carefully. Circle your answer. 1. The health history obtained by the nurse should focus on nursing’s concern about: CHAPTER 5 Adult Health and Nutritional Assessment a. a comprehensive body systems review. b. current and past health problems. c. the family history. d. all of the above. 2. A patient has certain rights concerning data collection, such as the right to know: a. how information will be used. b. that selected information will be held confidential. c. why information is sought. d. all of the above. 3. Open-ended questions help persons describe their chief complaint. Choose the sentence that is not an open-ended question. a. “Describe the pain.” b. “Tell me more about your feelings.” c. “How did the accident happen?” d. “Is the pain sharp and piercing?” 4. The single most important factor in helping the nurse and physician arrive at a diagnosis is the: a. family history. b. history of the present illness. c. past health history. d. results of the systems review. 5. Choose the best question an interviewer would use to obtain educational or occupational information. a. “Are you a blue-collar worker?” b. “Do you have difficulty meeting your financial commitments?” c. “Is your income more than $20,000 per year?” d. “What college did you attend?” 6. Which of the following is an inappropriate interviewer response to the patient statement, “I will not take pain medication when I am in pain”? a. “Is there another way you have learned to lessen pain when you experience it?” b. “Let a nurse know when you are in pain so you can be helped to decrease stimuli that may exaggerate your pain experience.” c. “Refusing medication can only hurt you by increasing your awareness of the pain experience.” d. “You have the right to make that decision. How can the nurses help you cope with your pain?” CHAPTER 5 ■ Adult Health and Nutritional Assessment 27 Copyright © 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins. Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 12th edition. 7. All of the following are questions that will provide information about a person’s lifestyle except: a. “Do you have any food preferences?” b. “Have you always lived in this geographic area?” c. “How many hours of sleep do you require each day?” d. “What type of exercise do you prefer?” 8. When obtaining a health history from an older adult patient, the nurse must remember to: a. ask questions slowly, directly, and in a voice loud enough to be heard by those who are hearing-impaired. b. clarify the frequency, severity, and history of signs and symptoms of the present illness. c. conduct the interview in a calm, unrushed manner using eye-to-eye contact. d. do all of the above. 9. On initial impression, the nurse assesses a patient’s posture, stature, and body movements. This assessment is part of the physical examination process known as: a. auscultation. b. inspection. c. palpation. d. percussion. 10. An examiner needs to determine the upper borde