Test Bank For An Interprofessional Approach 10th
Edition by Jane W. Ball,(Exit Exam AND Chapter 01-
26) NEW EXAM 2023 With SATISFIED SOLUTIONS
EXIT
... [Show More] EXAM AND MULTI-CHAPTERS
An older adult is receiving hospice care. Which nursing intervention(s) help the patient cope with feelings related to death
and dying? (Select all that apply.)
Teaching the patient how to use guided imagery
Encouraging the family to visit the patient frequently
Taking the patient's vital signs every time the nurse visits
Teaching the patient how to manage pain and take pain medications
Helping the patient put significant photographs in a scrapbook for the family
Which of the following questions would best assess a patient's level of connectedness?
What gives your life meaning?
Which aspects of your spirituality would you like to discuss right now?
Who do you consider to be the most important person in your life at this time?
How do you feel about the accomplishments you've made in your life so far?
A nurse is using the B-E-L-I-E-F tool to complete a spiritual assessment on a 12-year-old male who has recently been
diagnosed with acute lymphocytic leukemia. Which of the following questions would the nurse use to assess the child's
involvement in the spiritual community?
Which church do you attend?
Which sports do you like to play?
Are there any foods you cannot eat?
In which church activities do you participate?
A nurse is caring for a patient who refuses to eat until after the sun sets. Which religion does this patient most likely
practice?
Islam
Sikhism
Hinduism
Catholicism
A Catholic patient with diabetes receives the following items on his meal tray on the Friday before Easter. For which of the
foods does the nurse offer to substitute?
Apple sauce
Cheese and crackers
Spaghetti with meat sauce
Tossed salad with ranch dressing
A nurse is working in a health clinic on a Navajo reservation. He or she plans care for the patients knowing which of the
following is true?
The patients may not be on time for their appointments.
The patients most likely do not trust the doctors and nurses.
The patients probably are not comfortable if they have to remove their undergarments.
Terminally ill patients probably want to receive the sacrament, the anointing of the sick.
A 62-year-old male patient has just been told he has a terminal illness. Which of the following statements supports a
nursing diagnosis of spiritual distress related to diagnosis of terminal illness?
"I have nothing to live for now."
"What will happen to my wife when I die?"
"How much longer do I have to live?"
"I need to go to church and pray for a miracle."
Which of the following would be the most appropriate outcome for a patient who has a nursing diagnosis of spiritual distress
related to loneliness?
Encourage the patient to meditate 2 to 3 times a week.
The patient will set up a time to speak to a close friend in 1 week.
Encourage the patient to phone his brother and set up a time to go out for dinner.
The patient will experience greater connections with family members in 2 months. Agnostic - answer-Individual who
believes that any ultimate reality is unknown or unknowable.
Atheist - answer-Individual who does not believe in the existence of God.
Connectedness - answer-Having close spiritual relationships with oneself, others, and God or another spiritual being.
Faith - answer-Set of beliefs and a way of relating to self, others, and a Supreme Being.
Holistic - answer-Of or pertaining to the whole; considering all factors.
Hope - answer-Confident but uncertain expectation of achieving a future goal.
Self-transcendence - answer-Sense of authentically connecting to one's inner self.
Spiritual distress - answer-State of being out of harmony with a system of beliefs, a Supreme Being, or God.
Spirituality - answer-Spiritual dimension of a person, including the relationship with humanity, nature, and a supreme being.
Spiritual well being - answer-Individual's spirituality that enables a person to love, have faith and hope, seek meaning in life,
and nurture relationships with others.
Which of the following statements made by an older adult whose husband recently died most indicates the need for followup by the nurse?
"I planted a tree at church in my husband's honor."
"I have been unable to talk with my children lately."
"My friends think that I need to go to a grief support group."
"I believe that someday I'll meet my husband in heaven." - answer-"I have been unable to talk with my children lately."
Which of the following nursing interventions support(s) a healing relationship with a patient? (Select all that apply):
Praying with the patient
Giving pain medications before a painful procedure
Telling a patient that it is time to take a bath before family arrive to visit
Making the patient's bed following hospital protocol
Helping a patient see positive aspects related to a chronic illness - answer-Praying with the patient
Helping a patient see positive aspects related to a chronic illness
A patient expresses the desire to learn how to meditate. What does the nurse need to do first?
Answer the patient's questions
Help the patient get into a comfortable position
Select a teaching environment that is free from distractions
Encourage the patient to meditate for 10 to 20 minutes 2 times a day - answer-Select a teaching environment that is free
from distractions
Transcendence - answer-The belief that there is a force outside of and greater than the person that exists beyond the
material world.
Religion - answer-the system of organized beliefs and worship that a person practices to outwardly express spirituality
Near Death Experience - answer-psychological phenomenon of people who either have been close to clinical death or have
recovered after being declared dead. It is not associated with a mental disorder.
BELIEF Assessment - answer-Belief system; Ethics or values; Lifestyle; Involvement in a spiritual community; Education;
Future events
Hinduism - answer-Allow time for prayer and purity rituals.
Allow use of amulets, rituals, and symbols.
Sikhism - answer-Provide time for devotional prayer.
Allow use of religious symbols.
Buddhism - answer-Health is an important part of life.
Good health is maintained by caring for self and others.
Medications are not always accepted because of belief that chemical substances in the body are harmful.
Islam - answer-Women prefer female health care providers.
During month of Ramadan Muslims do not eat until after the sun goes down.
Health and spirituality are connected.
Family and friends visit during time of illness.
They usually do not consider organ transplantation or donation and postmortem examinations.
Judaism - answer-Believe that it is important to stay healthy.
They expect the nurse to provide competent health care.
Allow patients to express their feelings.
Allow family to stay with dying patient.
Christianity - answer-Usually in favor of organ donation.
Health is important to maintain.
Allow time for patients to pray by themselves, with family or friends.
Navajos - answer-Prefer holistic approach to health care.
They often are not on time for appointments.
Promote physical, mental, spiritual, and social health of persons, families, and communities.
Allow family members to visit.
Provide teaching about wellness, not disease prevention, when possible.
Appalachians - answer-They become anxious in unfamiliar settings.
Encourage communication with family and friends when ill.
Three factors are evident when a healing relationship develops between nurse and patient: - answer-Mobilizing hope for the
nurse and patient
Finding an interpretation or understanding of the illness, pain, anxiety, or other stressful emotion that is acceptable to the
patient
Helping the patient use social, emotional, and spiritual resources
Regarding the request for organ and tissue donation at the time of death, the nurse needs to be aware that:
Specially educated personnel make requests.
Requests are usually made by the nurse caring for the patient at the time of death.
Only patients who have given prior instruction regarding donation become donors.
Professionals need to be very selective in whom they ask for organ and tissue donation. - answer-Specially educated
personnel make requests.
The nurse notes that a woman who recently began cancer treatment appears quiet and withdrawn, states that she does not
believe the treatments will make any difference, does not ask about her progress, and missed two chemotherapy sessions.
Based on the above assessment data, the nurse gathers more information to consider making which of the following nursing
diagnoses?
Anxiety
Hopelessness
Spiritual distress
Complicated grieving - answer-Hopelessness
A family member asks a home care nurse what he should do if the patient's serious chronic illness worsens even with
increased medical interventions. How does the nurse best begin a conversation about the goals of care at the end of life?
Encourage the family member to think more positively about the patient's new therapy
Avoid the discussion because it has to do with medical, not nursing, diagnoses
Initiate a discussion about advance directives with the patient, family, and health care team
Begin the discussion by asking the patient to identify his or her beliefs about the goals of care while the family member is
present - answer-Begin the discussion by asking the patient to identify his or her beliefs about the goals of care while the
family member is present
Which of the following nursing actions best reflects sensitivity to cultural differences related to end-of-life care?
Practice honesty with everyone, telling patients about their illness, even if the news is not good.
Ask family members if they prefer to help with the care of the body after death.
Provide postmortem care at the time of death to relieve family members of this difficult job.
Value patient self-determination, understanding that each person makes his or her own decisions. - answer-Ask family
members if they prefer to help with the care of the body after death.
A young man is diagnosed with a serious, life-changing illness. His conversations during his first 2 days of hospitalization
are abrupt, superficial, and unrelated to his illness. What understanding about communication enhances your therapeutic
communication with this patient?
Younger patients are usually less talkative about their diagnosis.
All patients benefit by talking about their feelings with another person.
Avoid discussing illness-related topics with quiet patients.
Remain alert for signals that the patient wants to discuss his illness. - answer-Remain alert for signals that the patient
wants to discuss his illness.
A woman experiences the loss of a very early-term pregnancy. Her friends do not mention the loss, and someone suggests
to her that she can "always try again." The woman feels confusion over her sadness and stops talking about it with others.
What type of grief response is she most likely experiencing?
Delayed
Anticipated
Exaggerated
Disenfranchised - answer-Disenfranchised
A nurse has the responsibility of managing a deceased patient's post-mortem care. Arrange the steps for post-mortem care
in the proper order.
Bathe the body of the deceased.
Collect any needed specimens.
Remove all tubes and indwelling lines.
Position the body for family visit/viewing.
Speak to the family members about their possible participation.
Confirm that request for organ/tissue donation and/or autopsy has been made.
Notify a support person (e.g., spiritual care provider, bereavement specialist) for the family.
Accurately tag the body, indicating the identity of the deceased and safety issues regarding infection control.
Elevate the head of the bed. - answer-6-9-2-5-7-3-1-4-8
A family member of a recently deceased patient talks casually with the nurse at the time of the patient ' s death and
expresses relief that she will not have to visit at the hospital anymore. What theoretical description of grief best applies to
this family member?
Denial
Anticipatory grief
Dysfunctional grief
Yearning and searching - answer-Anticipatory grief
A self-care goal you set when caring for dying and grieving patients includes:
Learning not to take losses so seriously.
Limiting involvement with patients who are grieving.
Maintaining life balance and reflecting on the meaning of your work.
Admitting that you are not well suited to care for people who are grieving and asking the charge nurse not to assign you to
care for these patients. - answer-Maintaining life balance and reflecting on the meaning of your work.
A nurse is providing postmortem care. Which action is the priority?
Locating the patient's clothing
Providing culturally and religiously sensitive care in body preparation
Transporting the body to the morgue as soon as possible to prevent body decomposition
Providing all postmortem care to protect the family of the deceased from having to see the body - answer-Providing
culturally and religiously sensitive care in body preparation
Which approach to helping grieving people is most consistent with postmodern grief theories?
Help the patient identify the tasks to be accomplished during his or her grief.
Encourage people to recognize stages of grieving in anticipation of what is to come.
Listen carefully to a person's story of how his or her grief experience is unfolding.
Offer general grief timelines to help the person know when a phase will pass. - answer-Listen carefully to a person's story
of how his or her grief experience is unfolding.
A patient who has a serious, life-limiting chronic illness wants to continue to engage in self-care and live as normally as
possible. Which of the following nursing responses reflect a helpful understanding of patient self-care at the end of life?
"Learning to accept that you can't perform some activities anymore will bring you more acceptance and peace."
"Which activities are most important to you, and how can you continue to do them?"
"People in your life want to help you with things; allow them to do what they want for you."
"Spending more of your time resting or reading will conserve your energy." - answer-"Which activities are most important to
you, and how can you continue to do them?"
The nurse suggests that a patient receive a palliative care consultation for symptom management related to anxiety and
increasing pain. A family member asks the nurse if this means that the patient is dying and is now "in hospice." What does
the nurse tell the family member about palliative care? (Select all that apply.)
Hospice and palliative care are the same thing.
Palliative care is for any patient, any time, any disease, in any setting.
Palliative care strategies are primarily designed to treat the patient's illness.
Palliative care interventions relieve the symptoms of illness and treatment. - answer-Palliative care is for any patient, any
time, any disease, in any setting.
Palliative care interventions relieve the symptoms of illness and treatment.
You have identified three nursing diagnoses for a patient who is having anxiety and hopelessness as a result of a loss. Which
general approach do you take to prioritize the nursing diagnoses? (Select all that apply.)
Use family members and physician orders as primary resources for prioritizing your actions.
Address the nursing diagnosis that most affects the medical diagnosis.
Ask the patient to identify the most distressing symptom and first address that diagnosis.
Use nursing knowledge to address the problem that is the underlying cause of other diagnoses. - answer-Ask the patient to
identify the most distressing symptom and first address that diagnosis.
Use nursing knowledge to address the problem that is the underlying cause of other diagnoses.
Regarding grief in older adults, which understanding helps guide your relationship with an elderly patient?
Older adults have usually sustained many losses in life, which influence the current loss.
Older adults with a poor memory experience grief less intensely.
Older adults generally handle loss better because they have more experience with it.
Social support is less important because an older adult's circle of friends has become smaller. - answer-Older adults have
usually sustained many losses in life, which influence the current loss.
Actual loss - answer-Loss of an object, person, body part or function, or emotion that is overt and easily identifiable.
anticipatory grief - answer-Grief response in which the person begins the grieving process before an actual loss.
Bereavement - answer-Response to loss through death; a subjective experience that a person suffers after losing a person
with whom there has been a significant relationship.
Disorganized and despair - answer-One of Bowlby's four phases of mourning in which an individual endlessly examines how
and why the loss occurred.
grief - answer-Form of sorrow involving the person's thoughts, feelings, and behaviors that occurs as a response to an
actual or perceived loss.
Hope - answer-Confident but uncertain expectation of achieving a future goal.
Hospice - answer-System of family-centered care designed to help terminally ill people be comfortable and maintain a
satisfactory lifestyle throughout the terminal phase of their illness.
Maturational loss - answer-Loss, usually of an aspect of self, resulting from the normal changes of growth and
development.
Mourning - answer-Process of grieving.
Numbing - answer-One of Bowlby's four phases of mourning. It is characterized by the lack of feeling or feeling stunned by
the loss; may last a few days or many weeks.
Palliative care - answer-Level of care that is designed to relieve or reduce intensity of uncomfortable symptoms but not to
produce a cure. Palliative care relies on comfort measures and use of alternative therapies to help individuals become more
at peace during end of life.
Postmortem care - answer-Care of a patient's body after death.
Perceived loss - answer-Loss that is less obvious to the individual experiencing it. Although easily overlooked or
misunderstood, a perceived loss results in the same grief process as an actual loss.
Reminiscence - answer-Recalling the past to assign new meaning to past experiences.
reorganization - answer-Last phase of Bowlby's phases of mourning. During this phase, which sometimes requires a year or
more, the person begins to accept unaccustomed roles, acquire new skills, and build new relationships.
Situational loss - answer-Loss of a person, thing, or quality resulting from a change in a life situation, including changes
related to illness, body image, environment, and death.
Normal (uncomplicated) grief - answer-common, universal reaction characterized by complex emotional, cognitive, social,
physical, behavioral, and spiritual responses to loss and death.
Disenfranchised grief - answer-when their relationship to the deceased person is not socially sanctioned, cannot be openly
shared, or seems of lesser significance. The person's loss and grief do not meet the norms of grief acknowledged by his or
her culture, cutting the grieving person off from social support and the sympathy given to persons with "legitimate" losses.
The grieving person often wonders if he or she should call the experience a loss.
Ambiguous loss - answer-a type of disenfranchised grief, occurs when the lost person is physically present but not
psychologically available, as in cases of severe dementia or severe brain injury.
Complicated grief - answer-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.
Exaggerated grief - answer-often exhibits self-destructive or maladaptive behavior, obsessions, or psychiatric disorders.
Suicide is a risk for these people.
Delayed grief - answer-response is unusually delayed or postponed, often because the loss is so overwhelming that the
person must avoid the full realization of the loss.
Masked grief - answer-behaves in ways that interfere with normal functioning but is unaware that the disruptive behavior is
a result of the loss and ineffective grief resolution
Kubler-Ross's five stages of dying - answer-denial, anger, bargaining, depression, and acceptance.
Bowlby's four stages of mourning - answer-numbing, yearning and searching, disorganization and despair, and
reorganization
Yearning & searching - answer-Emotional outbursts of tearful sobbing and acute distress
Worden's four tasks of task-based grief theory - answer-Accept the reality of the loss; Experience the pain of grief; Adjust to
a world in which the deceased is missing; emotionally relocate the deceased and move on with life
Rando' R process model - answer-recognizing the loss, reacting to the pain of separation, reminiscing, relinquishing old
attachments, and readjusting to life after loss
Dual process model - answer-describes the everyday life experiences of grief as moving back and forth between lossoriented and restoration-oriented activities
loss-orientated behaviors - answer-include grief work, dwelling on the loss, breaking connections with the deceased
person, and resisting activities to move past the grief
restoration-orientated behaviors - answer-attending to life changes, finding new roles or relationships, coping with
finances, and participating in distractions provide balance
Spiritual distress - answer-State of being out of harmony with a system of beliefs, a Supreme Being, or God.
Compassion fatigue - answer-described as physical, emotional, and spiritual exhaustion resulting from seeing patients
suffer, leads to a decreased capacity to show compassion or empathize with suffering people
Rigor mortis - answer-stiffening of the body, developing 2-4 hours after death
Algor mortis - answer-reduction in body temperature with loss of skin elasticity
Livor mortis - answer-purplish discoloration of the skin in dependent areas
Non vital tissues - answer-corneas, skin, long bones, middle ear bones, ligaments, tendons, heart valves
vital organs - answer-heart, liver, lungs, kidneys, pancreas, intestine
Five important characteristics of quality documentation and reporting - answer-factual, accurate, complete, current, and
organized.
Factual record contains - answer-descriptive, objective information about what a nurse sees, hears, feels, and smells. An
objective description is the result of direct observation and measurement.
Accurate documentation - answer-The use of exact measurements
Complete documentation - answer-the information within a recorded entry or a report must be complete, containing
appropriate and essential information.
Current documentation - answer-Timely entries are essential in a patient's ongoing care. Delays in documentation lead to
unsafe patient care.
What should you document at the time of occurrence? - answer-Vital signs
Pain assessment
Administration of medications and treatments
Preparation for diagnostic tests or surgery, including preoperative checklist
Change in patient's status and who was notified (e.g., physician, manager, patient's family)
Admission, transfer, discharge, or death of a patient
Treatment for sudden change in patient's status
Patient's response to treatment or intervention
Organized documentation - answer-Communicate information in a logical order. It is also more effective when notes are
concise, clear, and to the point.
Narrative documentation - answer-the traditional method for recording nursing care. It is simply the use of a story-like
format to document information specific to patient conditions and nursing care.
Problem-orientated medical record - answer-Method of recording data about the health status of a patient that fosters a
collaborative problem-solving approach by all members of the health care team.
SOAP - answer-Subjective—Objective—Assessment—Plan
PIE - answer-Problem—Intervention—Evaluation
DAR - answer-Data—Action—Response
Focus charting - answer-Charting methodology for structuring progress notes according to the focus of the note (e.g.,
symptoms and nursing diagnosis). Each note includes data, actions, and patient response.
Charting by exception - answer-Charting methodology in which data are entered only when there is an exception from that
which is normal or expected; reduces time spent documenting in charting. It is a shorthand method for documenting normal
findings and routine care.
Case management - answer-organized system for delivering health care to an individual patient or group of patients across
an episode of illness and/or a continuum of care; includes assessment and development of a plan of care, coordination of all
services, referral, and follow-up; usually assigned to one professional.
Critical pathways - answer-Tools used in managed care that incorporate the treatment interventions of caregivers from all
disciplines who normally care for a patient. Designed for a specific care type, a pathway is used to manage the care of a
patient throughout a projected length of stay.
variances - answer-Unexpected event that occurs during patient care and that is different from CareMap predictions.
Variances or exceptions are interventions or outcomes that are not achieved as anticipated. May be positive or negative.
Flow sheets - answer-Documents on which frequent observations or specific measurements are recorded.
Kardex - answer-Trade name for card-filing system that allows quick reference to the particular need of the patient for
certain aspects of nursing care.
Standardize care plans - answer-Written care plans used for groups of patients who have similar health care problems.
Hand-off reports - answer-happen any time one health care provider transfers care of a patient to another health care
provider. The purpose is to provide better continuity and individualized care for patients.
A nurse caring for a patient with pneumonia sits the patient up in bed and suctions his airway. After suctioning, the patient
describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of water.
Which of the following is an evaluative measure used by the nurse?
Suctioning the airway
Sitting patient up in bed
Auscultating lung sounds
Patient describing type of discomfort - answer-Auscultating lung sounds
A nurse caring for a patient with pneumonia sits the patient up in bed and suctions the patient's airway. After suctioning, the
patient describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of
water. Which of the following would be appropriate evaluative criteria used by the nurse? (Select all that apply.)
Patient drinks contents of water glass.
Patient's lungs are clear to auscultation in bases.
Patient reports abdominal pain on scale of 0 to 10.
Patient's rate and depth of breathing are normal with head of bed elevated. - answer-Patient's lungs are clear to
auscultation in bases.
Patient's rate and depth of breathing are normal with head of bed elevated.
The evaluation process includes interpretation of findings as one of its five elements. Which of the following is an example of
interpretation?
Evaluating the patient's response to selected nursing interventions
Selecting an observable or measurable state or behavior that reflects goal achievement
Reviewing the patient's nursing diagnoses and establishing goals and outcome statements
Matching the results of evaluative measures with expected outcomes to determine patient's status - answer-Matching the
results of evaluative measures with expected outcomes to determine patient's status
A goal specifies the expected behavior or response that indicates:
The specific nursing action was completed.
The validation of the nurse's physical assessment.
The nurse has made the correct nursing diagnoses.
Resolution of a nursing diagnosis or maintenance of a healthy state. - answer-Resolution of a nursing diagnosis or
maintenance of a healthy state.
A patient is recovering from surgery for removal of an ovarian tumor. It is 1 day after her surgery. Because she has an
abdominal incision and dressing and a history of diabetes, the nurse has selected a nursing diagnosis of risk for infection.
Which of the following is an appropriate goal statement for the diagnosis?
Patient will remain afebrile to discharge.
Patient's wound will remain free of infection by discharge.
Patient will receive ordered antibiotic on time over next 3 days.
Patient's abdominal incision will be covered with a sterile dressing for 2 days. - answer-Patient's wound will remain free of [Show Less]