Basic Adult Care (Brunner & Suddarth's Textbook Of
Medical-Surgical Nursing 15th Edition): Qs & As
An 80-year-old client is admitted with a diagnosis of community-acquired
pneumonia. During admission the client states, "I have a living will." What
implication of this should the nurse recognize? Right Ans - This document
specifies the client's wishes before hospitalization.
The nurse, in collaboration with the client's family, is determining priorities
related to the care of the client. The nurse explains that it is important to
consider the urgency of specific problems when setting priorities. What
should the nurse adopt as the best framework for prioritizing client
problems? Right Ans - Maslow hierarchy of needs
The nurse is providing care for a client who has a diagnosis of pneumonia due
to Streptococcus pneumonia infection. What aspect of nursing care would
constitute part of the planning phase of the nursing process? Right Ans -
Achieve SaO2 92% at all times
While developing the plan of care for a new client on the unit, the nurse must
identify expected outcomes that are appropriate for the new client. What
resource should the nurse prioritize for identifying these appropriate
outcomes? Right Ans - The Nursing-Sensitive Outcomes Classification
(NOC)
The nurse has been asked to speak to members of a self-care education
program. What topic would the nurse most likely address? Right Ans -
Management of illness
A nurse is aware that an increasing emphasis is being placed on health, health
promotion, wellness, and self-care. Which of the following activities would
best demonstrate the principles of health promotion? Right Ans - Creation
of a smoking prevention program undertaken in a middle school
A nurse is collaborating with a team of community nurses to identify the
vision and mission for community care. What is the central focus of nursing?
Right Ans - Promoting and maintaining the health of individuals and families
,A nurse provides community-based care and acts as the case manager for a
small town about 60 miles (100 km) from a major health care center. When
planning care in the community, what is the most important variable in
community-based nursing that the nurse should integrate into planning?
Right Ans - Community resources available to clients
The nurse is assessing a new client and the client's home environment
following a referral for community-based care. What action should the nurse
prioritize during this initial visit? Right Ans - Encourage the client and
family to connect with appropriate community resources.
A community-based case manager is sending a community nurse to perform
an initial home assessment of a newly referred client. To ensure safety, the
case manager must make the nurse aware of which of the following? Right
Ans - The potential for at-risk working environments
A home health nurse has completed a scheduled home visit to a client with a
chronic sacral ulcer. The nurse is now evaluating and documenting the need
for future visits and the frequency of those visits. What question should the
nurse use when attempting to determine this need? Right Ans - "Is the
client's family willing to participate in care?"
The home care nurse is assessing a clients use of crutches in the home. Which
of the following actions by the client indicates that the client is using the
crutches effectively? Right Ans - Placing the crutches on lower step and
moving the affected leg first when descending stairs
The home health nurse receives a referral from the hospital for a client who
needs a home visit for wound care. After obtaining the referral, what action
should the nurse first take? Right Ans - Call the client to obtain permission
to visit
A hospital nurse is transitioning to a home health nurse position. The nurse
has that the client smokes while at home. What will the nurse need to do to
work therapeutically with the client in the home setting? Right Ans -
Resolve to convey respect for the client's beliefs and choices
The nurse is taking a health history on an adult client who is new to the clinic.
The client states that the client's mother has type 1 diabetes. What is the
,primary significance of this information to the health history? Right Ans -
The client may be at risk for developing diabetes
The nurse is teaching a nutrition education class for a group of older adults at
a senior center. When planning this education, the nurse should be aware that
individuals at this point in the lifespan have which of the following? Right
Ans - A decreased need for calories
The school nurse is performing a sports physical on a healthy adolescent girl
who is planning to try out for the volleyball team. When it comes time to listen
to the student's heart and lungs, what is the best nursing action? Right Ans
- Perform auscultation with the diaphragm placed firmly on the client's skin to
minimize extra noise
The nurse is admitting a 75-year-old client who is accompanied by a spouse.
The spouse wants to know where the information being obtained is going to
be kept, and the nurse describes the system of electronic health records. The
spouse states, "I sure am not comfortable with that. It is too easy for someone
to break into computer records these days." What is the nurse's best
response? Right Ans - "This hospital is concerned about keeping our
clients' records private, so we take special precautions to prevent
unauthorized access."
A family whose religion limits the use of some forms of technology is
admitting their grandparent to the nurse's unit. They express skepticism
about the fact that the nurse is recording the admission data on a laptop
computer. What would be the nurse's best response to their concerns?
Right Ans - "It's been found that using computers improves our clients' care
and improves communication."
The nurse is providing care for a client who has several missing teeth. What is
the most likely nutritional consequence the nurse should anticipate for this
client? Right Ans - Inadequate intake of high-fiber foods
The nurse is explaining the safe and effective administration of nasal spray to
a patient with seasonal allergies. What information is most important to
include in this teaching? Right Ans - Overuse of nasal spray can cause
rebound congestion
, The nurse is caring for a client with epistaxis. What information should the
nurse include in patient discharge teaching as a way to prevent epistaxis?
Right Ans - Humidify the indoor environment.
A nurse practitioner has provided care for three different clients with chronic
pharyngitis over the past several months. Which clients are at greatest risk for
developing chronic pharyngitis? Right Ans - Patients who are habitual
users of alcohol and tobacco
The nurse is performing the health interview of a patient with chronic
rhinosinusitis who experiences frequent nose bleeds. The nurse asks the
patient about her current medication regimen. Which medication would put
the patient at a higher risk for recurrent epistaxis? Right Ans -
Beclomethasone
The client has just been diagnosed with squamous cell carcinoma of the neck.
While the nurse is doing health education, the patient asks if this kind of
cancer will spread to other parts of the body. What is the nurse's best
response? Right Ans - "This cancer usually does not spread to distant sites
in the body."
A client's total laryngectomy has created a need for a laryngeal speech which
will be achieved through the use of the tracheoesophageal puncture. What
action should the nurse describe to the client when teaching about this
process? Right Ans - Fitting for a voice prosthesis
The nurse is caring for a client suspected of having acute respiratory distress
syndrome. What is the most likely diagnostic test ordered in the early stages
of this disease? Right Ans - Brain-natriuretic peptide levels (BNP)
The nurse is caring for a client at risk for atelectasis. The nurse implements a
first line measure to prevent atelectasis development in the client. What is
implemented? Right Ans - Incentive spirometry
While planning a client's care, the nurse identifies nursing actions to maintain
the client's pleuritic pain. What intervention should the nurse include in this
plan of care? Right Ans - Administer an analgesic before coughing and deep
breathing
Medical-Surgical Nursing 15th Edition): Qs & As
An 80-year-old client is admitted with a diagnosis of community-acquired
pneumonia. During admission the client states, "I have a living will." What
implication of this should the nurse recognize? Right Ans - This document
specifies the client's wishes before hospitalization.
The nurse, in collaboration with the client's family, is determining priorities
related to the care of the client. The nurse explains that it is important to
consider the urgency of specific problems when setting priorities. What
should the nurse adopt as the best framework for prioritizing client
problems? Right Ans - Maslow hierarchy of needs
The nurse is providing care for a client who has a diagnosis of pneumonia due
to Streptococcus pneumonia infection. What aspect of nursing care would
constitute part of the planning phase of the nursing process? Right Ans -
Achieve SaO2 92% at all times
While developing the plan of care for a new client on the unit, the nurse must
identify expected outcomes that are appropriate for the new client. What
resource should the nurse prioritize for identifying these appropriate
outcomes? Right Ans - The Nursing-Sensitive Outcomes Classification
(NOC)
The nurse has been asked to speak to members of a self-care education
program. What topic would the nurse most likely address? Right Ans -
Management of illness
A nurse is aware that an increasing emphasis is being placed on health, health
promotion, wellness, and self-care. Which of the following activities would
best demonstrate the principles of health promotion? Right Ans - Creation
of a smoking prevention program undertaken in a middle school
A nurse is collaborating with a team of community nurses to identify the
vision and mission for community care. What is the central focus of nursing?
Right Ans - Promoting and maintaining the health of individuals and families
,A nurse provides community-based care and acts as the case manager for a
small town about 60 miles (100 km) from a major health care center. When
planning care in the community, what is the most important variable in
community-based nursing that the nurse should integrate into planning?
Right Ans - Community resources available to clients
The nurse is assessing a new client and the client's home environment
following a referral for community-based care. What action should the nurse
prioritize during this initial visit? Right Ans - Encourage the client and
family to connect with appropriate community resources.
A community-based case manager is sending a community nurse to perform
an initial home assessment of a newly referred client. To ensure safety, the
case manager must make the nurse aware of which of the following? Right
Ans - The potential for at-risk working environments
A home health nurse has completed a scheduled home visit to a client with a
chronic sacral ulcer. The nurse is now evaluating and documenting the need
for future visits and the frequency of those visits. What question should the
nurse use when attempting to determine this need? Right Ans - "Is the
client's family willing to participate in care?"
The home care nurse is assessing a clients use of crutches in the home. Which
of the following actions by the client indicates that the client is using the
crutches effectively? Right Ans - Placing the crutches on lower step and
moving the affected leg first when descending stairs
The home health nurse receives a referral from the hospital for a client who
needs a home visit for wound care. After obtaining the referral, what action
should the nurse first take? Right Ans - Call the client to obtain permission
to visit
A hospital nurse is transitioning to a home health nurse position. The nurse
has that the client smokes while at home. What will the nurse need to do to
work therapeutically with the client in the home setting? Right Ans -
Resolve to convey respect for the client's beliefs and choices
The nurse is taking a health history on an adult client who is new to the clinic.
The client states that the client's mother has type 1 diabetes. What is the
,primary significance of this information to the health history? Right Ans -
The client may be at risk for developing diabetes
The nurse is teaching a nutrition education class for a group of older adults at
a senior center. When planning this education, the nurse should be aware that
individuals at this point in the lifespan have which of the following? Right
Ans - A decreased need for calories
The school nurse is performing a sports physical on a healthy adolescent girl
who is planning to try out for the volleyball team. When it comes time to listen
to the student's heart and lungs, what is the best nursing action? Right Ans
- Perform auscultation with the diaphragm placed firmly on the client's skin to
minimize extra noise
The nurse is admitting a 75-year-old client who is accompanied by a spouse.
The spouse wants to know where the information being obtained is going to
be kept, and the nurse describes the system of electronic health records. The
spouse states, "I sure am not comfortable with that. It is too easy for someone
to break into computer records these days." What is the nurse's best
response? Right Ans - "This hospital is concerned about keeping our
clients' records private, so we take special precautions to prevent
unauthorized access."
A family whose religion limits the use of some forms of technology is
admitting their grandparent to the nurse's unit. They express skepticism
about the fact that the nurse is recording the admission data on a laptop
computer. What would be the nurse's best response to their concerns?
Right Ans - "It's been found that using computers improves our clients' care
and improves communication."
The nurse is providing care for a client who has several missing teeth. What is
the most likely nutritional consequence the nurse should anticipate for this
client? Right Ans - Inadequate intake of high-fiber foods
The nurse is explaining the safe and effective administration of nasal spray to
a patient with seasonal allergies. What information is most important to
include in this teaching? Right Ans - Overuse of nasal spray can cause
rebound congestion
, The nurse is caring for a client with epistaxis. What information should the
nurse include in patient discharge teaching as a way to prevent epistaxis?
Right Ans - Humidify the indoor environment.
A nurse practitioner has provided care for three different clients with chronic
pharyngitis over the past several months. Which clients are at greatest risk for
developing chronic pharyngitis? Right Ans - Patients who are habitual
users of alcohol and tobacco
The nurse is performing the health interview of a patient with chronic
rhinosinusitis who experiences frequent nose bleeds. The nurse asks the
patient about her current medication regimen. Which medication would put
the patient at a higher risk for recurrent epistaxis? Right Ans -
Beclomethasone
The client has just been diagnosed with squamous cell carcinoma of the neck.
While the nurse is doing health education, the patient asks if this kind of
cancer will spread to other parts of the body. What is the nurse's best
response? Right Ans - "This cancer usually does not spread to distant sites
in the body."
A client's total laryngectomy has created a need for a laryngeal speech which
will be achieved through the use of the tracheoesophageal puncture. What
action should the nurse describe to the client when teaching about this
process? Right Ans - Fitting for a voice prosthesis
The nurse is caring for a client suspected of having acute respiratory distress
syndrome. What is the most likely diagnostic test ordered in the early stages
of this disease? Right Ans - Brain-natriuretic peptide levels (BNP)
The nurse is caring for a client at risk for atelectasis. The nurse implements a
first line measure to prevent atelectasis development in the client. What is
implemented? Right Ans - Incentive spirometry
While planning a client's care, the nurse identifies nursing actions to maintain
the client's pleuritic pain. What intervention should the nurse include in this
plan of care? Right Ans - Administer an analgesic before coughing and deep
breathing
