13. A patient with multiple sclerosis must be fed, bathed, and dressed. How should the nurse assess this
... [Show More] patient?
a. Disabled
b. Disadvantaged
c. Handicapped
d. Impaired
ANS: D
Feeding oneself, dressing, and bathing are activities of daily living. The patient is impaired in this scenario.
DIF: Cognitive Level: Analysis REF: p. 15 OBJ: 7
TOP: Principles of Rehabilitation | Defining Levels of Loss of Functioning Independently KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
14. Which law initially provided for rehabilitation of disabled Americans?
a. Vocational Rehabilitation Act of 1920
b. Social Security Act of 1935
c. Rehabilitation Act of 1973
d. Americans with Disabilities Act of 1990
ANS: A
The U.S. government has passed four pieces of legislation to identify and meet the needs of disabled individuals with each one being more inclusive. The first one was passed in 1920.
DIF: Cognitive Level: Knowledge REF: p. 16 OBJ: 8 TOP: Rehabilitation Legislation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
15. A client was admitted to a long-term residential care facility. On what should the admitting nurse tell the family the concepts of long-term care are based?
a. Amount of activities the resident can do for herself
b. Maintenance care with an emphasis on incontinence
c. Successful adaptation to the regulations of the home
d. Maintenance of as much function as possible
ANS: D
Maintenance of function and encouraging autonomy and independence are some of the basic concepts of long-term care.
DIF: Cognitive Level: Comprehension REF: p. 18 OBJ: 11
TOP: Principles of Nursing Home Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
16. A 58-year-old patient with diabetes is recuperating from a broken hip and is concerned about how to pay for rehabilitation. The nurse should inform this patient that funds for rehabilitation are available from which resource?
a. Vocational Rehabilitation Act of 1920
b. Rehabilitation Act of 1973
c. Disabled American Veterans Act of 1990
d. Title V, Health of Crippled Americans 1935
ANS: B
The Rehabilitation Act of 1973 assists in paying for rehabilitation for those who are younger than 65 years of age and who will benefit from vocational rehabilitation through teaching.
DIF: Cognitive Level: Comprehension REF: p. 16 OBJ: 8 TOP: Legislation for Funding Health Care
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
17. What is an example of a description of community health nursing?
a. Visiting patients in their homes after hospital discharge to assess their personal health status
b. Asking a nursing assistant (NA) to identify the health services most needed in the patient’s personal life
c. Meeting with residents of low-income housing to identify their health care needs
d. Developing a hospital-based home health care service
ANS: C
Whereas community-based nursing looks at identified community needs and provides care at all levels of wellness and illness, community health nursing seeks to provide services to groups to modify or create systems of care.
DIF: Cognitive Level: Comprehension REF: pp. 10-11 OBJ: 2 TOP: Defining Community-Based Nursing versus Community Health Nursing KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care
18. Home health nurses have some different nursing activities than those of community health nurses. Which statement best describes the home health nurse’s activities?
a. Conducting health education classes in a senior citizens’ common residence building
b. Conducting blood pressure screening on a regular basis at a local mall
c. Visiting and assessing the home care and further teaching needs of a patient who has been recently discharged from the hospital
d. Acting as a nurse consultant to a chronic psychiatric section in a state institution
ANS: C
The home health nurse works with individuals in the home; the other descriptors are community nurse activities.
DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: 1 | 5
TOP: Activities of the Home Health Nurse KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
19. Based on guidelines from the Americans with Disability Act (ADA), which question is an appropriate choice for the director of nurses to ask a nurse with an artificial leg who is applying for a staff position in an extended care facility?
a. “How long have you had your prosthesis?”
b. “How many flights of stairs are you able to climb without assistance?”
c. “Are you able to lift a load of 45 lb?”
d. “Has your disability caused you to miss work?”
ANS: C
Queries to disabled job applicants can be made relative to specific job functions, but they cannot be asked relative to the severity of the disability or the degree of disability in general.
DIF: Cognitive Level: Application REF: p. 16 OBJ: 7 | 8
TOP: ADA KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
20. A nurse reminds a resident in a long-term care facility that he has autonomy in many aspects of his institutionalization. What is an example of autonomy?
a. Selection of medication times
b. Availability of his own small electrical appliances
c. Smoking in the privacy of his own room
d. Application of advance directives
ANS: D
The application of advance directives is an autonomous decision. Agency protocols relative to medication times, access to private electrical devices, and smoking are rarely waived; these policies are not in the control of the resident.
DIF: Cognitive Level: Comprehension REF: p. 22 OBJ: 10 TOP: Autonomy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
MULTIPLE RESPONSE
1. What care skills are safe and appropriate for the licensed practical nurse (LPN) to teach family members in the home health care setting? (Select all that apply.)
a. Insulin injection
b. Sterile dressing changes
c. Venipunctures
d. Periodic Foley catheter insertions
e. Instillation of eye drops
f. Changing dressings on small wounds
ANS: A, E, F
Insulin injections, instillation of eye drops, and small wound dressing changes are safe to teach a nonprofessional caregiver. Sterile dressings, venipunctures, and inserting Foley catheters are considered skilled, and the costs for these are reimbursed by Medicare.
DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: 3 TOP: Skills Taught by Home Health Nurse
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
2. The nursing care plan in a long-term care facility calls for the documentation of regressive behavior of a newly admitted 82-year-old resident who has had congestive heart failure and osteoarthritis. Of these behaviors observed by the nurse, which should be documented as regression? (Select all that apply.)
a. Talks nonstop to staff and other residents.
b. Wets and soils self several times a day.
c. Wakes in the middle of the night and is unable to return to sleep.
d. Wears the same clothes day after day.
e. Cries frequently for no apparent reason.
ANS: B, D, E
Behaviors that are infantile or immature in the absence of dementia are considered regressive. Frequent episodes of crying and inattention to personal hygiene are regressive in nature. Excessive talking and wakefulness may be related to relocation anxiety, but they are not considered regressive.
DIF: Cognitive Level: Analysis REF: pp. 20-21 OBJ: 10
TOP: Impact of Relocation KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
3. From what do most quality-of-care problems in home health care result? (Select all that apply.)
a. Patient’s noncompliance
b. Family’s reluctance to participate in the care
c. Inadequate documentation
d. Limited funding
e. Defective communication among care team members
ANS: C, E
Inadequate communication and incomplete documentation create most of the quality-of-care problems.
DIF: Cognitive Level: Comprehension REF: pp. 11-12 OBJ: 2 TOP: Communication in Home Health Setting
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
4. An 80-year-old man is newly admitted to a long-term care facility and suddenly becomes incontinent of urine at night. What nursing interventions should be used to help restore self-toileting? (Select all that apply.)
a. Waking the resident every 2 hours and escorting him to the bathroom
b. Leaving a night-light on
c. Discouraging the use of long-legged pajama bottoms
d. Placing a urinal at the bedside
e. Keeping the room uncluttered
ANS: B, C, D, E
Providing light in an uncluttered room, encouraging clothing that does not impede self-toileting, and making the urinal available increase independence and alleviate
situations that make self-toileting difficult. Waking a resident not only disturbs his or her rest, but doing so also increases dependency on the staff.
DIF: Cognitive Level: Application REF: pp. 11-12 OBJ: 10 | 11 TOP: Independence in Long-Term Care Center
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
1. The nurse clarifies that an impairment that creates a measurable diminished capacity to work is a(n) .
ANS:
disability
When there is a measurable impairment that changes the individual’s lifestyle, it is referred to as a disability.
DIF: Cognitive Level: Knowledge REF: p. 15 OBJ: N/A
TOP: Rehabilitation Concepts KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care
2. What should the home health nurse do when teaching a family member the skill of injecting insulin effectively? Prioritize these nursing interventions for this situation.
(Place the events in the appropriate sequence. Do not separate answers with a space or punctuation. Example: ABCD.)
a. Offer instruction at an appropriate pace.
b. Write down the steps of the procedure.
c. Assess the level of knowledge of the family member.
d. Inquire about the preferred learning style.
e. Evaluate the family member’s performance.
ANS:
CBDAE
Effective teaching depends on assessing the level of knowledge, breaking down the skill in steps, offering instruction in the preferred style, pacing the instruction appropriately, and evaluating the performance.
DIF: Cognitive Level: Application REF: p. 14 OBJ: 1
TOP: Home Health Teaching KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
3. Prioritize the steps in solving an ethical dilemma. (Place the events in the appropriate sequence. Do not separate answers with a space or punctuation. Example: ABCD.)
a. Evaluate the outcome.
b. Plan an approach.
c. Visualize the consequences.
d. Take action.
e. Identify the problem.
ANS:
EBCDA
To solve an ethical dilemma, one must clearly identify the problem, plan an approach, visualize the consequences, take action, and evaluate the outcome.
DIF: Cognitive Level: Comprehension REF: p. 11 OBJ: 7 TOP: Solving an Ethical Dilemma KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
Chapter 03: Medical-Surgical Patients: Individuals, Families, and Communities Linton: Medical-Surgical Nursing, 7th Edition
MULTIPLE CHOICE
1. What should be included in a patient’s care plan in consideration of cultural similarities?
a. Family, educational background, and economic level should all be considered.
b. Subtle communication involving languages should be considered.
c. Families have strong patriarchal leaders.
d. Culture is learned, shared, and expressed similarly among members.
ANS: D
Different cultures have some similarities and some differences. How the culture is expressed in health care settings will be diverse.
DIF: Cognitive Level: Comprehension REF: p. 26 OBJ: 4
TOP: Similarities among Cultures KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care
2. What is the basis for the health–illness continuum?
a. Prevention of acute illness
b. Individual response to health or illness
c. Promotion of health and wellness
d. Variation in degree of health or illness
ANS: D
Currently, health and illness are viewed as relative states along a continuum. Individuals are at neither absolute health nor absolute illness but are in an ever-changing state of being.
DIF: Cognitive Level: Comprehension REF: pp. 25-26 OBJ: 5 TOP: Current View of Health-Illness Continuum
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control
3. What is the current concern of the health care system?
a. Treating illness
b. Preventing illness
c. Promoting optimal function in the chronically ill
d. Caring for patients with acute and chronic illness
ANS: B
Health promotion activities are directed toward maintaining or enhancing well-being as a protection against illness.
DIF: Cognitive Level: Knowledge REF: pp. 25-26 OBJ: 2 | 5
TOP: Health Promotion KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control
4. What is the primary reason that family is an important unit in society?
a. Offers unconditional love and acceptance.
b. Provides emotional support and security.
c. Is essential to life and society.
d. Promotes cultural values and attitudes.
ANS: B
A family is defined as being joined together by bonds of sharing and emotional closeness.
DIF: Cognitive Level: Comprehension REF: p. 33 OBJ: 8 TOP: The Family Unit KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
5. What should a nurse assess when a patient comes from an extended family?
a. Multiple wage earners
b. Three generations living together
c. Children from previous marriages
d. Parents of different ethnic origins
ANS: B
The extended family consists of relatives of either spouse who live with the nuclear family. Children, regardless of their parentage, are considered part of the nuclear family.
DIF: Cognitive Level: Comprehension REF: p. 33 OBJ: 8
TOP: Types of Families KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
6. A nurse is designing a home care plan for a child with a congenital disease and is assessing the family values regarding home care. What is the best resource for the nurse to use?
a. Current literature on congenital deformities
b. General knowledge of the culture
c. Patient’s family
d. Written survey
ANS: C
Determining the family’s values, beliefs, customs, and behaviors that influence health needs and health care practice is important. The best source is the family itself.
DIF: Cognitive Level: Comprehension REF: p. 34 OBJ: 11
TOP: Cultural Aspects KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
7. A nurse counsels a family regarding the stage of families with adolescents. Which developmental task is appropriate for the nurse to include?
a. Maintaining relationships with the extended family
b. Developing parental roles to meet the needs of children
c. Maintaining a satisfying marital relationship
d. Maintaining open communication between parent and children
ANS: D
The family developmental tasks at this stage include balancing freedom with responsibility and maintaining communication between parents and children.
DIF: Cognitive Level: Comprehension REF: p. 34|Table 3.3 OBJ: 8 TOP: Family Life Cycles
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
8. Which developmental task should families master in later life?
a. Becoming role models for their grandchildren
b. Making a significant contribution to society
c. Abandoning the parental role to grown children
d. Maintaining a satisfactory living arrangement
ANS: D [Show Less]