PREFACE Students entering the field of nursing have a tremendous amount to learn in a very short time. This concise study guide has been developed to help you learn and apply key concepts and Show
procedures, and master critical thinking skills based on Kozier & Erb’s Fundamentals of Nursing, Tenth Edition. On the nursingpearsonhighered.com website you will find a variety of activities such as Case Studies and Application Activities that help you apply concepts to clinical scenarios. In addition, each chapter of this study guide includes a variety of questions and activities to help you comprehend difficult concepts and reinforce basic knowledge gained from textbook reading assignments. The following is a list of features included in this edition that will enhance your learning experience: 0 Key Term Review help you review the important terms in each chapter. 0 Key Topic Review exercises contain matching, fill—in-the—blank, and true/false questions on key terms and key topics from each chapter. 0 Focused Study Tips help you recall the important nursing concepts from each chapter. 0 Case Studies provide clinical settings for critical thinking and the opportunity to apply learned processes and procedures. 0 Review Questions are NCLEX®—style questions to help you prepare for the NCLEX®. 0 Answers with complete rationales are included in the answer key to provide immediate reinforcement and to permit you to check the accuracy of your work. It is our hope that this study guide will serve as a valuable learning tool and will contribute to your success in the nursing profession. Preface iii CONTENTS Chapter Historical and Contemporary Nursing Practice .............................................. 1 Chapter Evidence-Based Practice and Research in Nursing ......................................... 7 Chapter Nursing Theories and Conceptual Frameworks ............................................ 13 Chapter Legal Aspects of Nursing .................................................................................. 18 Chapter Values, Ethics, and Advocacy .......................................................................... 26 Chapter Health Care Delivery Systems ......................................................................... 31 Chapter Community Nursing and Care Continuity ..................................................... 36 Chapter Home Care ......................................................................................................... 40 Chapter Electronic Health Records and Information Technology ............................. 44 Chapter 10 Critical Thinking and Clinical Reasoning ...................................................... 49 Chapter 11 Assessing ............................................................................................................ 54 Chapter 12 Diagnosing ......................................................................................................... 59 Chapter 13 Planning ............................................................................................................. 64 Chapter 14 Implementing and Evaluating ......................................................................... 69 Chapter 15 Documenting and Reporting ............................................................................ 73 Chapter 16 Health Promotion .............................................................................................. 78 Chapter 17 Health, Wellness, and Illness ........................................................................... 83 Chapter 18 Culturally Responsive Nursing Care .............................................................. 87 Chapter 19 Complementary and Alternative Healing Modalities ................................... 92 Chapter 20 Concepts of Growth and Development ........................................................... 97 Chapter 21 Promoting Health from Conception through Adolescence ......................... 101 iv Contents Chapter 22 Promoting Health in Young and Middle-Aged Adults ................................ 106 Chapter 23 Promoting Health in Older Adults ................................................................ 110 Chapter 24 Promoting Family Health ............................................................................... 114 Chapter 25 Caring Chapter 26‘ Communicating ............................................................................................... 121 Chapter 27 Teaching ........................................................................................................... 126 Chapter 28 Leading, Managing, and Delegating ............................................................. 131 Chapter 29 Vital Signs ........................................................................................................ 136 Chapter 30 Health Assessment .......................................................................................... 142 Chapter 31 Asepsis .............................................................................................................. 148 Chapter 32 Safety ................................................................................................................ 154 Chapter 33 Hygiene ............................................................................................................ 160 Chapter 34 Diagnostic Testing ........................................................................................... 166 Chapter 35 Medications ..................................................................................................... 172 Chapter 36 Skin Integrity and Wound Care .................................................................... 178 Chapter 37 Perioperative Nursing .................................................................................... 184 Chapter 38 Sensory Perception ......................................................................................... 190 Chapter 39 Self-Concept .................................................................................................... 195 Chapter 40 Sexuality Chapter 41 Spirituality ....................................................................................................... 206 Chapter 42 Stress and Coping ........................................................................................... 212 Chapter 43 Loss, Grieving, and Death .............................................................................. 218 Chapter 44 Activity and Exercise ...................................................................................... 223 .............. 117 ........................................................... 200 Contents v 45 Sleep ................................................................................................................. 229 Chapter 46 Pain Management ........................................................................................... 235 Chapter 47 Nutrition .......................................................................................................... 241 Chapter 48 Urinary Elimination ....................................................................................... 247 Chapter 49 Fecal Elimination ............................................................................................ 253 Chapter 50 Oxygenation ..................................................................................................... 259 Chapter 51 Circulation ....................................................................................................... 265 Chapter 52 Fluid, Electrolyte, and Acid—Base Balance ................................................... 271 Chapter Answer Key ...................................................................................................... 277 vi Contents CHAPTER 1 HISTORICAL AND CONTEMPORARY NURSING PRACTICE KEY TERM REVIEW Match each term with its appropriate definition. 1. Caregiver 2. Case manager 3. Client 4. Client advocate 5. __ Communicator 6 7 , Consumer 7. Continuing education (CE) 8. Counseling 9. Demography . Degree of wellness or well—being that the client experiences . Role the nurse assumes to help clients learn about their health and the health care procedures they need to perform to restore or maintain their health. ‘. Process of helping a client to recognize and cope with stressful psychological or social problems; to promote personal growth . Process by which people learn to become members of groups and societies 10. Florence Nightingale 11. Governance . Influences others to work together to accomplish a specific goal 12. # Harriet Tubman . An occupation that requires extensive education 13. Health 14. In-service education 15, Leader 16. Manager 17. _fifi Profession 18. Patient Self—Determination Act (PSDA) l9. Professionalism 20. Socialization 21. Standards of Practice 22. g. Recipient of nursing care . A role that traditionally included those activities that assist the client physically '. Nursing role of pleading the cause of a client '. Nurse who works with the multidisciplinary health care team to measure the effectiveness of the case management plan and to monitor outcomes. . A role that requires knowledge about organizational structure, leadership, advocacy, delegation, supervision, and evaluation # Standards of Professional Performance 23. Teacher 24. Telehealth 25. Telenursing © 2016 by Pearson Education, Inc. . An individual who is skilled at communication and conveying concepts 2 CHAPTER 1 / Historical and Contemporary Nursing Practice m. An individual, a group of people, or a community that uses a service or commodity . Describe behaviors expected in the professional . Refers to formalized experiences designed to enhance the knowledge or skills ofpracticing professionals A specific type of CE program offered by an employer that is designed to upgrade the knowledge or skills of employees, as well as to validate continuing competence in selected procedures and areas of practice . The study of population, including statistics about distribution by age and place of residence, mortality (death), and morbidity (incidence of disease) . Also known as the “Lady with the Lamp”; work during Crimean War established hospital and procedure reform The establishment and maintenance of social, political, and economic arrangements by which practitioners control their practice, their selfdiscipline, their working conditions, and their professional affairs Requires that every competent adult be informed in writing on admission to a health care institution about his or her rights to accept or refuse medical care and to use advance directives nursing role . Refers to professional character, spirit, or methods; a set of attributes, a way of life that implies responsibility and commitment '. Provided care and safety to slaves fleeing to the North during the Civil War on the Underground Railroad . Use of medical information exchanged from one site to another via electronic communica- tions to improve the patient’s health status . The use of telecommunications and information technology to provide nursing practice at a distance . Describe the responsibilities for which nurses are accountable KEY TOPIC REVIEW 1. The four functions identified within the scope of nursing practice are: a. b. c. d. 2. The role of religious orders in the development of nursing includes: a. instilling the values of hard work. b. influencing the image of nursing. c. identifying an increased need for nurses. d. imprinting the profession as involving hard work. e. improving the status of nursing. 3. The contemporary nursing leader who defined nursing is: a. Clara Barton. b. Florence Nightingale. c. Linda Richards. d. Virginia Henderson. © 2016 by Pearson Education, Inc, CHAPTER 1 / Historical and Contemporary Nursing Practice 3 4. A nurse registered to practice in one state is relocating to another neighboring state. What should this nurse do to ensure the ability to work as a nurse in the new state? a. Nothing. The nurse is registered as a nurse. b. Contact the state’s department ofnursing. c. Enroll in a school ofnursing in the new state. (1. File the paperwork to take the new state’s nursing licensing examination. 5. From the following list, select the definition that best defines these terms: a. Caregiver f Helps the client modify behaviors. b. Communicator _ This can be provided by the nurse or delegated to someone else. 0. Teacher _ Supervises and evaluates performance. d. Client advocate #__ Uses the outcomes of scientific study to improve the delivery of care. e. Counselor _ Acts to protect the client. f. Change agent _ Influences others to work together to reach a common goal. g. Leader __ Done verbally or written. h. Manager _ Care is oriented to the client and controls costs. i. Case manager __ Helps promote personal growth. j. Research consumer iA Assesses readiness to learn. 6. The terms used to identify the recipients of nursing are: a. b. c. 7. Of the following nursing roles, select the ones that provide more autonomy within the practice of nursing. a. Nurse anesthetist b. Staff nurse on an orthopedic unit 0. Operating room nurse d. Clinical nurse specialist e. Nurse in a physician’s office 8. The process a nurse undergoes in an effort to be viewed as an integral member of the discipline of nursing is termed 9. A nurse is interested in participating with the American Nurses Association. Participating with this organization is an example of: a. autonomy. b. governance. 0. extended education. (1. service. CC) 2016 by Pearson Education, Inc. 4 CHAPTER 1 / Historical and Contemporary Nursing Practice 10. The purpose of nursing students working together on projects is to: a. begin the process of socialization into the profession. b. get more work done faster. c. help each other through difficult courses. (1. make new friends. ll. The payments for hospital services implemented by Medicare are termed (DRGs). 12. A nurse who provides care to a client over the telephone will need to: a. obtain licensure in the client’s state of residence. b, take a course in telenursing. c. find out if the client’s state is one of mutual recognition for licensure. d. do nothing. 13. The Patient Self-Determination Act requires that every client be provided with and a, programs are the responsibility of all nurses to maintain constant professional updating 14. and growth. FOCUSED STUDY TIPS 1. Why is it important to review the history of nursing as one of the first steps in the education of a new nurse? What value does understanding the history of nursing provide to the contemporary nursing student? . What are the characteristics of a profession? How does nursing address each of these characteristics? . What are Benner’s five stages ofnursing practice? In which stage is a nurse considered proficient? Why? . How have economics, consumer demands, and the family structure impacted the profession of nursing? . A nurse who has been in the profession for over 25 years does not know how to operate a computer. What suggestions do you have to help this nurse? Why should this nurse be concerned with the inability to utilize current technology? Identify the reasons for the current nursing shortage. How will this affect the future education of new nurses entering the profession? The nurses in a hospital are contacting a labor union. Why do you think the nurses are contacting this union? What benefits will be gained by working with a union? What disadvantages are associated with nurses working with a union? . What do Sigma Theta Tau and the Association of Colleges of Nursing (ACN) represent in nursing? What are the differences between the two organizations and what are the similarities? Which organization offers continuing units for nurses? Compare these organizations with others such as the American Nursing Association (ANA) and the American Academy of Colleges in Nursing (AACN). Why is it important for nurses to practice under a license? Why is a standardized licensing exam appropriate for all nurses? © 2016 by Pearson Education, Inc. CHAPTER 1 / Historical and Contemporary Nursing Practice 5 CASE STUDY A client with adult-onset asthma is attempting to quit his two-pack-per-day tobacco habit. The nurse, who has been practicing for 4 years, is assisting the client with supportive measures to improve his health status. The nurse is discussing the plan ofcare with the physician. 1. What role is the nurse acting in by representing the client’s needs and wishes and assisting the client in behavior modification plans? 2. The nurse is in the process of assisting the client to recognize and cope with both the asthma condition and the tobacco cessation program. The nurse is acting as a change agent, and what other role is the nurse representing? 3. According to Benner’s stages of nursing expertise, in what stage is the nurse functioning? REVIEW QUESTIONS 1. A female is considering a career as a nurse because of the aspects of caring and nurturing. This individual is using which factor of nursing to base her decision? 1. Women’s roles 2. Religion 3. War 4. Economics 2. A registered nurse is considering additional education so that she can provide nonemergent acute care in an ambulatory clinic. This nurse is considering which expanded career role? 1. Nurse anesthetist 2. Clinical nurse specialist 3. Nurse practitioner 4. Nurse administrator 3. A nurse is able to provide care to several complex clients and focuses on those items that are the most important. Within which stage of Benner’s stages of nursing expertise is this nurse functioning? 1. Stage II 2. Stage III 3. Stage IV 4. Stac 4. The organization recently added a new wing to the hospital. What factor is likely to be influencing this organization related to the nursing shortage they are experiencing? 1. Aging workforce 2. Aging population 3. Increased demand for nurses 4. Workplace issues © 2016 by Pearson Education, Inc. 6 CHAPTER 1 / Historical and Contemporary Nursing Practice 5. Which of the following actions performed by an organization would best improve the image of nursing? l. Offering scholarships to high school students to attend nursing school 2. Television commercials showing nurses and doctors providing care together 3. A print advertisement with the statement “Nursing~The hardest job you’ll ever love” 4. An ANA-sponsored radio commercial explaining the role of nurses in society today 6. The nurse, who is working in a well-baby clinic, administers routine immunizations and recognizes this as practicing within what area of nursing practice? 1. Promoting health and wellness 2. Preventing illness 3. Restoring health 4. Providing care to the dying 7. While attending a continuing education seminar, several nurses from different states are discussing their indi— vidual state requirements for nursing licensure. Which of the following is the one common thread between all of the states’ departments of nursing? 1. Protect the public. 2. Further nursing education. 3. Obtain continuing education contact hours. 4. Gain specialization. 8. A new nursing student is disappointed because classes so far are focused on topics such as communication and planning, and she wanted to be a nurse to “provide care.” This nursing student is describing which role of the nurse? 1. Teacher 2. Client advocate 3. Caregiver 4. Counselor 9. The student nurse is learning how to fit into the nursing profession by learning the rules defining relationships, the behavior expected of a nurse, and to see the world in a manner similar to other nurses. This is known as: 1. case management. 2. professionalization. 3. socialization. 4. governance. 10. The nurse moves to a new area of the country and learns the new area has many people of South African descent, a higher incidence of hypertension, and people whose average age is 37. This information would be considered: 1. news. 2. health statistics. 3. a targeted area of study. 4. demography. © 2016 by Pearson Education, Inc. CHAPTER 2 EVIDENCE-BASED PRACTICE AND RESEARCH IN NURSING KEY TERM REVIEW Match each term With its appropriate definition. 1. Comparative analysis 13. Naturalism 2 Content analysis 14. Pilot study 3 Dependent variable 15. Protocol 4 Descriptive statistics 16. Qualitative research 5 Evidence-based practice 17. Quantitative research 6. Hypothesis 18. Reliability 7 Independent variable 19. Sample 8 lnferential statistics 20. Scientific validation 9 Logical positivism 21. Statistically significant 22. Target population 10. ‘k Measures of central tendency 1 1. Measures of variability 12. Methodology C 2016 by Pearson Education, Inc. 23. 7 7 Validity 8 CHAPTER 2/ Evidence-Based Practice and Research in Nursing a. A behavior, characteristic, or outcome that the researcher wishes to explain or predict . Detailed instructions . Completeness and conceptual accuracy of measures . Thorough critique ofa study for its conceptual and methodological integrity . Results that are not likely to have occurred only by chance . A predictive statement about the relationship between two or more variables . The presumed cause of or influence on the behavior wished to be explained ‘ Refers to the consistency of measures '. Involves assessing study findings for their implementation potential ‘. Group of individuals in which information is desired . The logistics or mechanics of a study . Using research findings and other sources of evidence to guide decisions about client care . Data analysis that involves searching for themes and patterns . Procedures that organize and summarize large volumes of data, including measures of central tendency and measures ofvariability . Involves testing hypotheses about relationships between variables or differences between groups . Philosophical perspective of quantitative research that maintains the “truth” is absolute and can be discovered by careful measurement . Statistical procedure that provides a single numerical value that denotes the “average” value for a variable . Statistical procedure that describes how values for a variable are dispersed or spread out . A “dress rehearsal” before an actual study begins . The systematic collection and thematic analysis of narrative data . The systematic collection, statistical analysis, and interpretation of numerical data . Source of information for a study; may be humans, events, behaviors, documents, or biological specimens . Maintains that reality is relative or contextual and constructed by individuals who are experiencing a phenomenon KEY TOPIC REVIEW l. is clinical decision making based on the simultaneous use of the best evidence, clinical expertise, and patients’ values. 2. The four rights of human subjects that nurses must safeguard are: a. b. c. d. means that any information a client relates will not be made public or available to 3. The term others without the patient’s consent. 4. What is the definition of research? 5. According to the “Standards of Clinical Nursing” published by the ANA (1998), is included as one of the standards of professional performance. © 2016 by Pearson Education, Inc. CHAPTER 2/ Evidence-Based Practice and Research in Nursing 9 . Select and mark either (1) for quantitative research or (2) for qualitative research for the following items with regard to research: a. Associated with naturalistic inquiry that explores subjective and complex experiences of human beings b. c. Data collection and analysis occur concurrently A systematic, logical sequence based on a specific plan designed to collect information in controlled conditions; analyzed using statistical procedures d. Theory or framework is developed after the data are analyzed to identify patterns and/or themes 6. Viewed as “hard science” . Change in practice requires: (Select all that apply.) a. assessing the need for change. 0 b. locating and analyzing the best evidence. . providing nurses with information essential to nursing practice. d. integrating and maintaining the change. e. implementing and evaluating the practice change. . Correctly identify the order of the steps in conducting quantitative research. a. Review the related literature. b. Communicate conclusions and implications. c. Define the study’s purpose or rationale. Analyze the data. Formulate hypotheses and define variables. Collect the data. Select the population, sample, and setting. )—I. arrows» d. Conduct a pilot study. State a research question or problem. j. Select a research design to test the hypothesis. . From the following list, select the definition that best defines the elements of an ideal study. a. Research problem Protection of human rights, standards of beneficence, respect for human dignity, approved by Institutional Review Board b. Review of literature c. Study framework Is appropriate, clearly informs, enhances study _‘ Significant, addresses an issue that is important to nursing, addresses a researchable problem, is feasible to address in a study setting d. Data collection Relevant, thorough, current, authoritative 0. Ethical considerations Appropriate for variables and sample, yields appro— priate level of measure, reliable and valid, safe and humane © 2016 by Pearson Education, Inc. 10 CHAPTER 2 / Evidence-Based Practice and Research in Nursing 10. Describe the two major approaches nurse researchers use to investigate client’s responses to health alterations and nursing interventions. a. b. 1 1. The bachelor of science in nursing (BSN) is the usual level of preparation for the research nurse who: a. conducts independent research. b. focuses on the evaluation and use of research. 0. evaluates research findings. d. understands and applies research findings from nursing and other disciplines in clinical practice. 12. According to the “Standards of Clinical Nursing” published by the ANA (1998), research is included as one of the standards of professional performance. a. True b. False 13. Qualitative research uses measurement in its methods. a. True b. False 14. pertains to the availability of time as well as the material and human resources needed to investigate a research problem or question. 15. A is conducted prior to the actual study to assess the adequacy of the data collection plan and to identify any potential flaws in the study. FOCUSED STUDY TIPS QP‘PWN 1. What are data collection strategies that nurse researchers use? Describe three research questions for which a quantitative approach to research is useful. List three examples of documented nursing research in nursing magazines. Which right ofreseareh study participants do you think is overlooked most often? Explain, List four ways for a nurse to provide for patient confidentiality. While many believe that evidence-based practice is best practice for nursing, others would argue that it has its flaws. What are two disadvantages to evidence-based practice? CASE STUDY The nurse, who is working on a medical unit with a large number of older adults diagnosed with diabetes, reads a research article that indicates a direct correlation between instability of blood glucose levels and age with the oldest individuals most likely to demonstrate the largest drop in blood glucose levels if they must fast for diagnostic testing. 1. Is this adequate evidence for the nurse to promote changing the practice of having clients fast in preparation for diagnostic testing? 2. What should the nurse do next? 3. The research article includes a graph with age of clients across the bottom and percentage decrease in blood sugar levels along the side axis. What type of study is this? © 2016 by Pearson Education, Inc. v CHAPTER 2 / Evidence-Based Practice and Research in Nursing 11 REVIEW QUESTIONS 1. Which of the following is a violation of a client’s right to self-determination? 1. Hidden inducements 2. Sharing a client’s information with a pharmaceutical company 3. Providing basic care to the client 4. Giving the client information about what participating in a study will involve 2. Upon successful completion of the NCLEX-RN®, the registered nurse is asked to participate in a research study on the coping and adjustment skills of a newly graduated registered nurse. The plan is to use an oral, recorded interview with a grounded theory. What type of research study is being conducted? 1. Pilot study 2. Quantitative study 3. Qualitative study 4. Ethnographic study 3. Which of the following activities are examples of how a professional nurse may participate in research? (Select all that apply.) 1. Critiquing research for application to practice 2. Identifying clinical problems suitable for nursing research 3. Encouraging patient participation in a study without informed consent 4. Using research findings in the development of policies, procedures, and practice guidelines for patient care 4. A nursing student documents the client’s full name and date of birth on the required paperwork for a clinical course and turns it in to the instructor. Which of the following client rights is being violated? 1. Right not to be harmed 2. Right to full disclosure 3. Right of self-determination 4. Right of privacy and confidentiality 5. Which ofthe following identifies the “C” in PICO? 1. Comprehension 2. Comparison 3. Challenging 4. Confidentiality 6. Formulating a research problem is often facilitated by the researcher performing: l. a feasibility study. 2. a literature review. 3, a methodology evaluation. 4 . a pilot study. @ 2016 by Pearson Education, Inc. 12 CHAPTER 2/ Evidence—Based Practice and Research in Nursing . Data analysis involves the application of which of the following procedures? (Select all that apply.) 1. Descriptive statistics 2. Inferential statistics 3. Measures of central tendency 4. Measures of variability Continuing education is the responsibility of the nurse to keep abreast of changes within the nursing profession. and changes and also 1. Scientific and technologic 2. Medical and technologic 3. Scientific and human responses 4. Cardiac and neurologic As a nurse researcher, what is involved in a research project? (Select all that apply.) 9‘95“.“ 1. Identifying a research question or problem Writing a thesis paper Collecting data using various means such as computer searches and/or questionnaires Analyzing the data and writing up the results Publishing or presenting the research findings to expand the body of nursing knowledge 10. One of the major responsibilities the nurse has when conducting nursing research is: l. encouraging thc participation ofclicnts in nursing research. 2. being aware of and advocating on behalf of clients’ rights. 3. exposing clients to the possibility of injury from the research. 4. pressuring clients into participating in the study. ll. What is the term used to describe a behavior, characteristic, or outcome that the researcher wishes to explain or predict? l. Dependent variable 2. Independent variable 3. Hypothesis 4. Sample © 2016 by Pearson Education, Inc. CHAPTER 3 NURSING THEORIES AND CONCEPTUAL FRAMEWORKS KEY TERM REVIEW Match each term with its appropriate definition. 1. Client 3 ‘ Conceptual framework . . . Critical theories 4 Environment 5 Grand theories 2 W alth . 6 fl He Metaparadigm 7 8 9 10. 1 1. 1 . 2 13. 7 Midlevel theories _ Nursing . Paradigm . _ Philosophy t‘ d' ci line rac we 18 p Theory P . Degree of wellness or well-being that the client e e 'enccs Xp r1 . Attributes, characteristics, and actions that provide care . . . . . on behalf of, or in conjunction With the client . ‘. Focus on the exploration of concepts _ A belief system . . . . Those that articulate a broad range of Significant relationships among the concepts of a discipline . Recipient of nursing care . A system of ideas that is proposed to explain a given henomenon p . Those that help elucidate how social structures affect a . . . Wide variety of human experiences . . . A group of related ideas, statements, or concepts '. The internal and external surroundings that affect the client . Major concepts that can be superimposed on almost any work of nursing . A pattern of shared understandings and assumptions about reality and the world m. Term used for fields of study in which the central focus is performance of a professional role. © 2016 by Pearson Education, Inc 13 14 CHAPTER 3/ Nursing Theories and Conceptual Frameworks KEY TOPIC REVIEW 1. Define theory. List two characteristics of a theory. 2. What is the main function oftheory (and research) in a practice discipline? 3. During the latter halfof the 20th century, disciplines seeking to establish themselves in universities had to demonstrate something that Nightingale had not envisioned for nursingw-a unique body of theoretical knowledge. a. b. True False 4. Disciplines without a strong theory and research base were referred to as “ ” natural sciences. with the “ ,” a negative comparison 5. What is the term encompassing the “building blocks” of theories? 6. A w is a group of related ideas, statements, or concepts. It may also be called a theory or 7. The term refers to a pattern of shared understandings and assumptions about reality and the world. It includes a person’s notions of reality that are largely unconscious or taken for granted. 8. What four major concepts are related to the metaparadigm for nursing? 9. According to Figure 3—1 in your text, what are some of the prevalent foundational theories in nursing? 10. Match each theorist with the appropriate term. a. Philosophies Orem b. Conceptual models Nightingale (3. Midlevel theories Pcplau Parse Henderson Roy Neuman Rogers Leininger Watson King 11. Who is considered to be the first nurse theorist? 12. An early effort to define nursing phenomena. serves as the basis for later theoretical formulations. l3. Debates about the role of theory in nursing practice provide evidence that nursing is maturing as both an academic discipline and a clinical profession. a. True © 2016 by Pearson Education, Inc. b. False CHAPTER 3/ Nursing Theories and Conceptual Frameworks 15 14. Define the following terms: a. Client (person) b. Environment c. Health d. Nursing 15. Why is nursing considered to be a practice discipline? FOCUSED STUDY TIPS 1. Describe the two paradigms of nursing theories. 2. List the major points of the following nursing theories: a. Nightingale’s environmental theory b. Peplau’s interpersonal relations model C. Henderson’s definition of nursing . Roger’s science of unitary human beings Orem’s general theory of nursing King’s goal attainment theory . Neuman’s systems model . Roy’s adaptation model Leininger’s cultural care diversity and universality theory j. Watson’s human caring theory k. Parse’s human becoming theory 3. Read the Evidence-Based Practice feature titled “How Well Does a Levine—Based Theory Apply to the Care of Preterm Infants?” that is in this chapter in the text. Identify the implications for nursing practice. 4. Although the various nursing models have been widely used for centuries to care for clients, some may critique the use of nursing theories. Describe one critique against nursing theories that McCrae identified. CASE STUDY The chief executive officer (CEO) has requested that the director of nursing (DON) revise the current philosophy of nursing that is being used for both a long—term care facility and an assisted living facility. The DON wants to develop the philosophy based on a nursing theory that adequately reflects both the healthy and ill clients housed in the facilities. The facilities’ mission statements embrace the ideal of clients improving and sustaining independent functions, and encourage individualized goals for all clients to meet their individual needs. The DON wants to emphasize the nurses’ responsibilities during the process of nurseAclient interactions as well as the outcomes of nursing care. 1. Choose the best nursing theory on which to base the revised philosophy of nursing for this particular facility. 2. Explain your rationale for using the theory that you have chosen. © 2016 by Pearson Education, Inc. 16 CHAPTER 3/ Nursing Theories and Conceptual Frameworks REVIEW QUESTIONS 1. A supposition or system of ideas that is proposed to explain a given phenomenon or something significant is called a: l. concept. 2. theory. 3. paradigm. 4. conceptual model. . Some examples of concepts, which are defined as labels given to ideas, objects, or events, are: 1. intelligence, motivation, and obesity. 2. comfort, fatigue, pain, depression, and/or environment. 3. self-care, adaptation, caring, behavioral system, and/or nurse—client transactions. 4. humanistic endeavors, unitary man, and/or learned helplessness. Which theorist addresses hospice nursing issues during end—of—life care? 1. Imogene King 2. Callista Roy 3. Dorothea Orem 4. Jean Watson An example ofa middle-range nursing theory is: l. Peplau’s psychodynamic nursing model. 2. Jean Watson’s model ofhuman caring. 3. Roy’s adaptation model. 4. Imogene King’s theory of goal attainment. This theorist based her theory of nursing on the principle that nursing assists clients with 14 essential functions that move them toward independence. 1. Myra Estrin Levine 2. Dorothea Orem 3. Madeline Leininger 4. Virginia Henderson One of the goals of Betty Neuman’s health care systems model is: l. maintenance of system equilibrium. 2. assisting the client to achieve the highest level of self-care. 3. promoting internal and external stimuli that influence the client’s well-being. 4. to heal the client and make the bed available for sicker clients. © 2016 by Pearson Education, Inc. CHAPTER 3 / Nursing Theories and Conceptual Frameworks 17 Nightingale, Henderson, and Watson developed philosophies of nursing. Why are their works considered philosophies when discussed in nursing? 1. Because they were the first three nursing theorists. 2. Because it was an early effort to define nursing phenomena that serves as the basis for later theoretical Formulations. 3. Because they had grand theories of nursing and not middle—level theories. 4. Because it was a late effort to define nursing. Disciplines without a strong theory and research base were historically referred to as: 1. hard. 2. concrete. 3. soft. 4. medium. A conceptual framework is considered to be: 1. a group of related ideas, statements, or concepts. 2. a pattern of shared understandings and assumptions about reality and the world 3. the way to elucidate how social structures affect a wide variety of human experiences, from art to social practices. 4. a belief system, often an early effort to define nursing phenomena that serves as the basis for later theoretical formulations. 10. In the late 20th century, much of the theoretical work in nursing focused on articulating relationships among four major concepts. (Select the major concepts.) 1. Person 2. Environment 3. Nursing 4. Professionalism 5. Health 11. Match the early nurse theorist who developed the nursing action stated below. 1. A nurse performing noncontact therapeutic touch. a. Florence Nightingale 2. A nurse measuring the client’s intake and output b. Hildegard Peplau 3. A nurse demonstrating therapeutic communication with a client who has been diagnosed with depression C. Martha Rogers 4. A nurse who plans care with the client to establish (1. Imogene King mutual goals and outcomes © 2016 by Pearson Education, Inc. CHAPTER 4 LEGAL ASPECTS OF NURSING KEY TERM REVIEW I. Assault WWF‘OEhr'eP’!“ Autopsy Battery Breach of duty Burden of proof Causation Civil law Common law Complaint t—‘O Contract L"EV Defamation __.eu Seme- t—ID—l H... Match each term with its appropriate definition. . . Laws evolving from court decisions ' . Harm that occurred as a direct result of failure to follow standards of care . Examination of the body after death . Agreement between competent persons, on sufficient consideration to do or not do a legal act . Communication that is false, and results in injury to the reputation of a person . Defines and enforces duties and rights among private individuals that are not based on contractual agreements Euthanasia . Defamation by means of print, writing, or pictures False imprisonment . The requirement that, by law, requires nurses to Informed consent Injury _ Interstate compact Liability report abuse, neglect, or exploitation '. Document filed by a person claiming that legal rights have been infringed upon '. A standard of care that is not observed . The willful touching ofa person that may or may l8. Libel 19. Living will 20. Mandated reporters 21. Plaintiff . Deals with relationships among individuals 22. Responded! superior . The duty of proving an assertion of wrongdoing 23. Right 24. Tort law . The unjustifiable detention ol‘a person without legal warrant to confine the person 25. Unprofessional conduct © 2016 by Pearson Education. Inc. not cause harm . An attempt or threat to touch a person unjustifiably . Type of harm 18 CHAPTER 4/ Legal Aspects of Nursing 19 A privilege or fundamental power to which an individual is entitled unless revoked by law or given up voluntarily State of being legally responsible for one’s obligations and actions, and to make financial restitution for wrongful acts Provides specific instructions about what medical treatment the client chooses to omit or refuse in the event that the client is unable to make those decisions Includes incompetence or gross negligence, conviction for practicing without a license, falsification of client records, illegally obtaining, using, or possessing controlled substances . Person who claims that his or her rights have been infringed on by one or more persons . Legal relationship by which the employer assumes responsibility for the conduct of the employee . Agreement by a client to accept a course of treatment alter being provided complete information . The mechanism used to create mutual recognition among states . The act of painlessly putting to death people suffering from an incurable or chronically painful disease KEY TOPIC REVIEW 1. Why is it important for nurses to know the basics of legal concepts? 2. What is accountability, and what are two reasons it is needed in nursing? a. b. . Name two functions oflaws in nursing. a. b. The Constitution of the United States is the supreme law of the state. a. True b. False Regulation of nursing is a function of state law. a. True b. False List two types of laws and give the definition of each type. a. b. Choose the correct definition of criminal action, the correct example of criminal action, and the potential results if a person is found guilty in a criminal trial. (Select all that apply.) a. Deals with the relationships among individuals in society. b. Deals with disputes between an individual and the society as a whole. C. If found guilty, the defendant may have to pay a sum of money. If found guilty, the defendant may lose money, bejailed, be executed, and/or lose any professional licenses. One example of this type of legal infraction is a nurse who deliberately delivers a lethal dose of medication to a client. f. One example of this type of legal action is a malpractice suit. 8. The action ofa lawsuit is called © 2012 by Pearson Education, Inc. 20 CHAPTER 4/ Legal Aspects of Nursing 9. Organize the five steps in the civil judicial process according to the procedural rules. a. A document, called a complaint, is filed by an individual referred to as the plaintiff, who claims that his or her legal rights have been infringed on by one or more other individuals or entities referred to as defendants. b. In the trial ofthe case, all the relevant facts are presented to ajury or only to ajudge. c. The judge renders a decision, or the jury renders a verdict. lfthe outcome is not acceptable to one ofthe parties, an appeal can be made for another trial. d. Both parties engage in pretrial activities, referred to as discovery, in an effort to obtain all the facts of the situation. e. A written response, called an answer, is made by the defendants. 10. What is the legal purpose for defining the scope of nursing, licensing requirements, and standards of care? (Select all that apply.) a. For the protection of the nurse b. For the protection of the client c. For the protection of the public d. To maintain client confidentiality e. For the protection of the physician . Each state has an obligation to define its scope of nursing practice and licensing requirements. b. False a. True model. It allows for multistate . The name ofthe newly developed regulatory model is the licensure for nurses. Nurses can practice in states bordering their own state if both states have an _ compact. 13. is the voluntary practice of validating that an individual nurse has met minimum standards of nursing competence in specialty areas such as maternal—child health, pediatrics, metal health, gerontology, and school nursing. 14. Define standards of care and list the two classifications. a. b. 15. List four examples of external standards of care: a. b. c. d. 16. A written contract cannot be changed legally by an oral agreement. a. True b. False 17. Describe the difference between an expressed contract and an implied contract. Give an example of each type. 18. Explain the difference between a right and a responsibility and give an example of each. 19. A is an organized work stoppage by a group of employees to express a grievance, enforce a demand for changes in conditions of employment, or solve a dispute with management. Usually, it is a result of failed collective bargaining between the parties. © 2016 by Pearson Education, Inc. CHAPTER 4/ Legal Aspects of Nursing 21 20. What are the two types of informed consent? a. b. 21. It is the nurse’s responsibility to have the informed consent form signed prior to an invasive procedure. a. True b. False 22. What three things does the nurse’s signature confirm with the signed consent form? a. b. c. 23. if a client refuses to sign the consent form, what actions does the nurse need to take? 24. What are two reasons for nurses to be knowledgeable regarding the Nurse Practice Act in their state of practice? 25. Nurses are included as mandated reporters of violence, abuse, and/or neglect. a. True b. False 26. How is the nurse involved in the Americans with Disabilities Act? Explain your answer. 27. State laws regulate the distribution and use of controlled substances such as narcotics, depressants, stimulants, and hallucinogens. a. True b. False is cited as one of the main reasons for chemical dependence in health care workers. 28. 29. Define the terms and list any nursing responsibilities about the following legal issues surrounding death: a. Advance directives b. Autopsies c. Certification of death d. Do—not—resuscitate orders (DNRs) e. Euthanasia f. lnquests g. Organ donation 30. law is usually involved with nursing liability. . Choose the types ofinvasion from which the client must be protected. (Select all that apply.) a. Reporting the number of births that occurred in the hospital for statistical analysis b. Reporting of infections and communicable diseases c. Taking photographs or having nursing students observe the client’s care without the client’s consent d. Revealing the name of a client who was treated for domestic violence e. Reporting violent incidents to the local authorities © 2016 by Pearson Education, Inc. 22 CHAPTER 4 / Legal Aspects of Nursing 32. What is the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and why is it important? What are the four specific areas of HIPAA? Refer to the HIPAA website found on the Companion Website. «w 33. What are four categories that nurses must question to protect themselves legally when carrying out health care provider’s orders? FOCUSED STUDY TIPS l. Define and give an example of the following laws. Which is the highest level of law? a. Civil law b. Common law c. Contract law d. Law e. Private law f. Public law g . Statutory law h. Tort law . Refer to Figure 44 in the text. Describe how laws are created from constitutions, statutes, administrative agencies, and decisions of courts. . Why is it important to know the state legislators who represent your state? Name the state legislators for your state. How do you contact your legislators, and why is it necessary to contact them regarding nursing issues? State your position on having malpractice insurance as a registered nurse. Is it your responsibility or the responsibility of your employer? Under what circumstances could you use the malpractice insurance? Refer to the Application Activity: Nurse Practice Act on the Companion Website. . What are the procedures that occur when a nursing license is revoked in the state in which you will practice? Go to the NCSBN website and list the states that have passed the NLC legislation. Refer to Box 4—l in the text for additional information. What are the statutes in your state for “consent”? What is considered the legal age of consent? . Discuss the areas of potential liability in nursing and define the following terms: malpractice, intentional torts. crime, felony, manslaughter, misdemeanors, duty, and torts. . Determine the difference between defamation and slander. Give an example of each that might occur in the health care setting. Who could bring a defamation/slander lawsuit? 10. What are some legal protections in nursing practice to protect the nurse from litigation? Is the Good Samaritan Act designed for nurses? What are the responsibilities of nurses who choose to render emergency care? Does your state require nurses to assist in emergencies? ll. Discuss and defend your position on professional liability insurance. Is it a requirement for all nurses? List the advantages of maintaining professional liability insurance. © 2016 by Pearson Education, Inc. \_/ CHAPTER 4/ Legal Aspects of Nursing 23 12. Why is nurse documentation so important? What is the purpose of nurse documentation? How can it be used in a court of law? Does the nurse need to document if an incident report is filled out in the client’s chart? Refer to the text, Chapter 4, Figure 4—5, for additional information. 13. What measures can nursing students implement in order to fulfill responsibilities to clients and to minimize the chances for liability? Refer to Boxes 45 and 4—6 in Chapter 4 of the text. 14. The nurse is caring for a client who has been declared legally brain dead. The client did not specify if he wishes to be an organ donor. What is the nurse’s best action? 15. Discuss the difference between a crime and a tort. CASE STUDY A client was scheduled for the surgical removal of the left ovary. During the surgery, the surgeon noticed that the appendix of the client was inflamed. He decides to remove it to prevent further problems. The client’s consent for surgery only listed removal of the left ovary. 1. Did the surgeon adhere to the signed consent form that the client signed before the surgery? 2. Under the circumstances, what type of tort is the surgeon liable for? 3. What was the operating nurse’s role in this incident? REVIEW QUESTIONS 1. Which nurse would be considered to be the “best expert witness” for the defense in a case regarding an obstetric patient who died after delivery complications? 1. A nurse who holds a bachelor’s degree in nursing and has been practicing for 2 years 2. A nurse who holds a master’s degree in nursing and has a certification in emergency nursing 3. A nurse who holds a doctorate of nursing science in pediatric care 4. A nurse who holds a master’s degree in nursing and a state certification in matemal—infant nursing 2. Which clients could make decisions regarding health care? (Select all that apply.) 1. A woman who arrives in the emergency department with an altered mental state and the aroma of ethyl alcohol 2. The parents ofa l4-year—old girl involved in a car collision 3. A middle-aged man who has the mental capacity of an 8—year-old 4. A 10-year—old boy who has arrived with friends and has a shallow laceration needing three sutures 5. A competent older adult who requires surgery on a prolapsed bladder 3. A client was discharged after having a l—day surgery on her gallbladder. The nurse discharging the client failed to give the client oral or written discharge instructions. This failure to carry out the provision of discharge instructions could result in charges of: l. malpractice. 2. negligence. 3. assault. 4. battery. © 2016 by Pearson Education, Inc. 24 CHAPTER 4/ Legal Aspects of Nursing 4. Which statement indicates that the client understands informed consent of a surgical procedure? 1. The nurse discovers the signed informed consent form on the bedside table before the surgeon discusses the procedure with the client. 2. The client’s oldest son stated that he explained the procedure to the client and the client told him that he wanted the surgery. 3. The client states that the surgeon explained the procedure to him, allowed him to ask questions, and explained the risks ofnot permitting the surgery. 4. The client been declared legally incompetent; however, the client states understanding of the surgical procedure. 5. While reviewing the transfer papers of a client, the nurse notes that the client has both a living will and a durable power of attorney. A living will differs from a durable power of attorney in that a living will: 1. describes how the client wants his wishes carried out in the event of a terminal illness. 2. designates who should make medical decisions if the client is incapable of making independent decisions. 3. determines which relative gets the house. 4. allows a health care provider to make decisions if the client is unable to make decisions. 6. A nurse threatens to give a loud, disruptive client an injection that will “knock the client out.” The nurse follows through on the threat and gives the injection Without the client’s consent. What has the nurse committed? l. Threat, assault 2. Battery, invasion of privacy 3. Assault, invasion ofprivacy 4. Assault, battery 7. A nurse documents in the client’s chart that the health care provider is incompetent because the health care provider did not respond promptly to the nurse’s call regarding the client. This is an example of and Ut-b-UJN 1. defamation . slander . libel . battery . unprofessional conduct 8. Conviction for practicing nursing without a license, incompetence or gross negligence, falsification of client records, and illegally obtaining, using, or possessing controlled substances is called: 1. libel. 2. slander. 3. unprofessional conduct. 4 . assault. © 2016 by Pearson Education, Inc. CHAPTER 4 / Legal Aspects of Nursing 25 9. Most statutes include conscience clauses that are designed to protect hospitals and nurses in matters dealing with abortion services. These clauses allow the nurse to be protected from: 1. prejudicial statements. 2. discrimination or retaliation. 3. defamation or unjust prejudice. 4. legal liability. 10. Identify the element that is NOT one of the functions of the law in the nursing environment. 1. Accountability helps to maintain a minimum standard of nursing practice. 2. Law differentiates nurses’ responsibilities from those of other health care professionals. 3. Law specifies which nursing actions are legal in caring for clients. 4. Law specifies which hospital policies are legal in caring for clients. © 2016 by Pearson Education, Inc. CHAPTER 5 VALUES, ETHICS, AND ADVOCACY KEY TERM REVIEW 2 Active euthanasia 3 Advocate 4. Assisted suicide 5 Attitudes 6, _ Autonomy 7. 8. 9. Beliefs _ Beneficence Bioethics 10. Code of ethics 11. Fidelity 12. Justice l3. Moral development 14. Moral distress 15. Moral rules 16. Nonmaleficence 17. Nursing ethics 18. Passive euthanasia 19. Personal values 20. Veracity Mental positions or feelings . Fairness an Accountability Telling the truth . Answerable to self and others for one’s own actions :rtmrnsv 1. 5‘9“ Match each term with its appropriate definition. Do no harm One who expresses and defends the cause of another . Actions that bring about the client’s death directly . Rules governing the behavior of nurses related to the morality of human behavior. Withdrawing or withholding life-sustaining therapy . A formal statement of a group’s ideals and values To be faithful to agreements and promises An individual’s enduring beliefs or attitudes about the worth ofa person, object, idea, or action . Process of client taking his or her own life with help from another individual The concept of “doing good” for the benefit of others Interpretations or conclusions that people accept as true p. Ethics as applied to human life or health q. Process oflearning to tell the difference between right and wrong and of learning what should and should not be done Specific prescriptions for action based on an individual’s principles or beliefs. The right to make one’s own decisions Conflict that arises when what the nurse believes needs to be done cannot be carried out due to an obstacle such as client wishes. personal beliefs, or facility regulations. © 2016 by Pearson Education, Inc. 26 CHAPTER 5 / Values, Ethics, and Advocacy 27 r—d KEY TOPIC REVIEW . Define values and describe why values are important in nursing. . Describe the difference between values and beliefs. are mental positions or feelings toward a person, object, or idea. List five values identified by the American Association of Colleges of Nursing (AACN, 2008). Refer to Box 5—1 in the text. a. b. c. d. pouoxu: e. When should the nurse use values clarification as a nursing intervention? Which type of ethics is used when nurses make decisions about the acts of abortion or euthanasia? What is the term that is similar to ethics and often used interchangeably? Moral development is the process of learning to tell the difference between right and wrong. It begins in young adulthood and continues through life. b. False a. True Match the following three moral framework theories with the correct descriptive terms. These theories involve logical and a. Consequence—based (teleological) theories b. Principles-based (deontological) theories formal processes. c. Relations—based (caring) theories , — consequences of an action. These theories look to outcomes or These theories promote the common good or the welfare of the group. These theories stress individual rights. One form of these types of theory is called utilitarianism. These theories focus on issues of fairness. These theories stress courage, generosity, commitment, and the need to nurture and maintain relationships. These theories involve logical, formal processes and emphasize individual rights, duties, and obligations. 10. Within recent years, what statements regarding ethics have been made broader in scope or added to the Code afEthz'csfiN‘ Nurses? Refer to Box 5—3 in the text. 11. What is the goal of ethical reasoning within the context of nursing? 12. What are three functions of the advocacy role that nurses assume? 13. means “doing good.” © 2016 by Pearson Education, Inc. 28 CHAPTER 5 / Values, Ethics, and Advocacy 14. is often referred to as fairness. 15. refers to telling the truth. 16. refers to “the _ means “answerable to oneself and others for one’s own actions,” while specific accountability or liability associated with the performance of duties of a particular role.” FOCUSED STUDY TIPS l. What are your values regarding life, death, health, and illness? 2. Practice assisting someone (a friend, parent, significant other, etc.) in clarifying their values and identifying behaviors that may need further clarification by using the seven values clarification steps listed in Box 5A2 of the text. What are some factors that have led to increased ethical concerns? Why do ethical concerns even exist? List 6 of the 12 rights of the Bill of Rights for clients receiving health care. As a nurse, what are your responsibilities in promoting the Bill of Rights? . What common ethical issues do health care professionals currently face? How do some hospitals resolve ethical issues? Define harm. Give one example of unintentional harm and one example of intentional harm. . When caring for a client with acquired immunodeficiency syndrome (AIDS), what is the moral obligation of the nurse according to the ANA position statement? Define veracity. What is the moral obligation of the nurse to use veracity, even when it is known that using veracity will cause harm? Compare and contrast accountability and responsibility as applied to the nursing profession. CASE STUDIES 1. You are the nurse caring for a 45-year—old client who is in the end stages of acquired immunodeficiency syndrome (AIDS). She is married and has two children, ages 14 and 17. The client is unable to perform the care needed for her children and spouse, and she had to take a leave of absence from employment 8 months ago due to her advanced AIDS. Her family is experiencing emotional turmoil and financial stress due to her prognosis and inability to fully function in her roles as a contributor to income, mother, and wife. The client requests your assistance in deciding what end-of—life decisions she should make. Her family and friends want her to do everything in her power to survive; however, she tells you that she is “so tired.” a. What considerations should you take into account in assisting the client to make these decisions? b. In what way could you assist the client in reaching decisions about further health care? c. Would an ethics committee be involved in this matter? d. What principles of autonomy are applied to this situation? A well—known government official is in the hospital for cosmetic surgery. A story and photograph of the client and his medical information appear in the local paper. The client feels that his privacy has been invaded. a. What are his rights as a client? b. Could he take legal actions? © 2016 by Pearson Education, Inc. CHAPTER 5 / Values, Ethics, and Advocacy 29 REVIEW QUESTIONS 1. When distinguishing between morality and legal correctness, what indicators would the nurse recognize as reflecting the morality of a situation? (Select all that apply.) 1. Feelings such as shame, guilt, or hope 2. Tendency to respond to the situation with words such as Should, rig/it, ought to, or good 3. Legislative regulations requiring or preventing a specific action 4. Infringement on an individual’s human rights 5. Fear of imprisonment What is the best example of altruism exhibited by a nurse? 1. Turning the bed—bound client every 4 hours 2. Withholding scheduled pain medication to a client who has a level 6 pain scale rating 3. lnsisting that a client use the bedpan instead of assisting the client to the restroom because it is easier for the nurse 4. Allowing a Catholic client to keep his rosary beads within reach as a comfort measure What client behavior might indicate unclear self—values? l. A client with coronary heart disease who follows the recommended diet plan to reduce cholesterol and fat 2. A mother with a child diagnosed with asthma stops smoking tobacco 3. A client who has multiple admissions to the chemical dependency program 4 . A client with diabetes who monitors finger-stick blood sugars and other health concerns relating to the diabetic condition . What statement is true regarding ethical committees and the role these committees play in dealing with health care conflicts? 1. Ethical committees ensure that relevant facts of a case are presented 2. Ethical committees are not designed to reduce the institution’s legal risk 3. Ethical committees decide when laws have been violated. 4. Nurses usually do not serve as team members on ethical committees. . What moral framework is the nurse operating under if she refuses to participate in a surgery for a 93—year-old client who has stated on numerous occasions that he does not want further surgery? His family and surgeon are insisting on the client having the surgery. The nurse’s rationale is that the nursewclient relationship commits her to protecting him and meeting his needs. 1. Relationships-based theory 2. Consequences-based theory 3. Deontological—based theory 4. Principles-based theory Which clinical scenario is an example of nonmaleficence and unintentional harm? 1. Not looking a wheelchair and transferring a client into the wheelchair 2. Catching a client who is falling and bruising the client’s arm 3. A client’s allergic reaction to a prescribed medication 4. Administering oxygen at 6 L/min to a client when the order is for 2 L/min © 2016 by Pearson Education, Inc. 30 CHAPTER 5 / Values, Ethics, and Advocacy 7. Identify behaviors that would be classified as an invasion of privacy for a client. (Select all that apply.) I. A nurse who removes articles from a bedside table in order to “clear out some of that junk” 2. A middle-aged, mentally alert client who requests a nursing assistant to “get rid of a bedpan, used ketchup container, and other unused items” 3. A nursing student who documents the client’s name and address on paperwork to hand in to the clinical faculty member 4. A cousin who wants to review the chart for lab results and the health care provider’s orders What is the correct action by the nurse if a health care provider asks the nurse to perform a task in which the nurse does not have adequate knowledge or experience performing? 1. Inform the health care provider about the lack of education and experience, and then perform the task. 2. Do not inform the health care provider and carry out the task. 3. Inform the health care provider regarding the lack of education and/or experience necessary to safely perform the task. Refuse to do the task. 4. Inform the health care provider, and then both parties can attempt to figure it out. What is the best example of documentation by the nurse in the client’s record? 1. All facts and information regarding a person’s condition, treatment, care, progress, any refusal or consent of treatment, and response to illness and treatment are noted. 2. All facts and information regarding a person’s condition, treatment, care, progress, and response to illness and treatment are noted. 3. All facts and information regarding a person’s condition, treatment, care, progress, any refusal or consent of treatment, physician’s competence, and response to illness and treatment are noted. 4. All facts and information regarding a patient that the nurse feels are appropriate are noted. 10. Organ donation prohibits the: (Select all that apply.) 1. donation of organs in clients diagnosed with brain death. 2 . sale of body organs. 3. marketing of body organs. 4 . donation of cartilage and bones. CD 2016 by Pearson Education, Inc. CHAPTER 6 HEALTH CARE DELIVERY SYSTEMS KEY TERM REVIEW Match each term with its appropriate definition. flE’P‘PP’N 1. Case management Coinsurance Critical pathways Diagnosis-related groups (DRGs) Differentiated practice Health care system Health maintenance organization (HMO) . Similar to HMOs, care is provided in offices, where the client pays a fixed amount . Provides direct client care under the direction of a registered nurse, physician or other licensed practitioner . A delivery model that brings services and providers to the clients . Incorporates acute care services, home health care, extended and skilled care facilities, and outpatient services Independent practice associations (IPAs) . A health care system whose goals are to provide cost— effective, quality care Integrated delivery system (IDS) . National and state health insurance program for older adults Licensed vocational (practical) nurse (LVN/LPN) . Federal public assistance program that provides health care coverage to people who require financial assistance ll. Managed care 12. Medicaid . The percentage share of a government-approved charge that is paid by the client 13. Medicare 14 Patient focused care 15. Preferred provider arrangements 16 Preferred provider organization 17. _ Supplemental Security Income A classification system that establishes pretreatment diagnosis billing categories Health care plan that contracts with a group of providers or agency that provides services at a discounted rate . Involves multidisciplinary teams that assume collaborative responsibility for planning, assessing needs, and coordinating, implementing, and evaluating care for groups of clients. An interdisciplinary plan or tool that specifies assessments, interventions, treatments, and outcomes for health—related conditions across a time line . A group health care agency that provides health maintenance and treatment services to voluntary enrollees © 2016 by Pearson Education, Inc. 31 32 CHAPTER 6 / Health Care Delivery Systems n. Government-funded benefits available to people with disabilities p. System in which the best use of nursing personnel is based on the personnel’s educational preparation and o. The totality of services offered by all health disciplines Sklll sets q, Health care plan that contracts with individual health care providers KEY TOPIC REVIEW 1. What are the three types of health care services? a. b. c. 2. What is the purpose of primary prevention health care systems? a. Health promotion and illness prevention b. Rehabilitation, health restoration, and palliative care 0. Diagnosis and treatment (1. To promote the World Health Organization 3. What is the purpose of secondary prevention? a. Health promotion and illness prevention b. Rehabilitation, health restoration, and palliative care c. Diagnosis and treatment d. To promote the World Health Organization 4. What is the purpose of tertiary prevention? a. Health promotion and illness prevention b. Rehabilitation, health restoration, and palliative care c. Diagnosis and treatment d. To promote the World Health Organization 5. What are the primary goals of Healthy People 2020? a. b. c. d. 6. Which is an example of a secondary prevention health care service? a, Health care providers’ offices b. Weight control programs c. Blood pressure clinics (1. Rehabilitation hospitals 7. is the official agency at the federal level for public health. 8. What is the function of an occupational health clinic? Give some examples of the types of roles that a nurse might perform in that environment. © 2010 by Pearson Education, Inc. CHAPTER 6 / Health Care Delivery Systems 33 Name four factors affecting health care delivery in today’s health care environment. a. b. e. d. . According to the US. Census, the expected number of individuals over age 85 will be the million by 2020 and segment in the United States and will number over growing population million by 2030. . What impact does the Health Insurance Portability and Accountability Act (HIPAA) of 1996 have on the health care system? . What are critical pathways, and how are critical pathways used in case management and managed care? 13. What are two advantages of ambulatory care centers? a. b. FOCUSED STUDY TIPS 1. Discuss the World Health Organization (WHO) project and Healthy People 2020. 2. What role does the federal government have in providing care to veterans and merchant mariners? 3. Define the roles ofthe following providers of health care: a. Registered nurse b. Licensed vocational nurse or licensed practical nurse c. Advanced practice nurse (1. Complementary care provider e. Case manager f. Dentist g. Dietitian h. Occupational therapist i. Paramedical technologist j. Pharmacist k. Physical therapist 1. Physician m. Physician assistant n. Podiatrist 0. Respiratory therapist p, Social worker q. Spiritual support personnel r. Unlicensed assistive personnel © 2016 by Pearson Education, Inc. 34 CHAPTER 6 / Health Care Delivery Systems 4. Discuss in depth the uneven distribution of health services in the United States. What are two facets of this problem? 5. Discuss the relationship between technological advances and the rising costs of health care in the United States. CASE STUDIES 1. The nurse is collecting a health and physical assessment from an 80—year-old client who is blind and was recently admitted to the acute care facility. a. What type of health care coverage is the client almost guaranteed of carrying? b. lfthe client’s income is below the poverty level, what type of coverage could also be included in the health care coverage plan? The client is getting ready for discharge. The health care provider has written an order for physical therapy after discharge. In addition, the health care provider requests that a dietitian follow up with additional education regarding the client’s newly diagnosed type 2 diabetes. a. What roles do the physical therapist and dietitian fulfill? b. Where could the client receive the services, and what type of coverage could possibly pay for these services? . Refer to the Evidence-Based Practice feature in the text (Box-21) to answer the following questions regarding the types of nurses and delivery models in hospitals and how those factors influence patient outcomes. a. What is the true regarding clients with chronic conditions or disabilities and access to care? b. What are the nursing implications when caring for clients with chronic conditions or disabilities? REVIEW QUESTIONS 1. Which two frameworks for care are used for the delivery of nursing care that supports continuity of care and costeffectiveness? (Select all that apply.) 1. Managed care 2. Nonfunctional method 3. Secondary nursing 4. Team nursing 2. Medicare is divided into two divisions, Part A and Part B, and one supplemental plan. Part A is the: 1. voluntary prescription drug plan that began in January 2006. 2. voluntary plan that provides partial coverage of outpatient and health care provider services to those who are eligible. 3. plan section providing insurance toward hospitalization, home care, and hospice care. 4. plan section providing very limited financial coverage to low-income persons. . Medicare is divided into two divisions, Part A and Part B, and one supplemental plan. Part B is the: l. voluntary prescription drug plan that began in January 2006. 2. voluntary plan that provides partial coverage of outpatient and health care provider services to those who are eligible. 3. plan section providing insurance toward hospitalization, home care, and hospice care. 4. plan section providing very limited financial coverage to low-income persons. © 2016 by Pearson Education, Inc. V CHAPTER 6 / Health Care Delivery Systems 35 4. Medicare is divided into two divisions, Part A and Part B, and one supplemental plan. Part D is the: 1. voluntary prescription drug plan that began in January 2006. 2. voluntary plan that provides partial coverage of outpatient and physician services to people eligible. 3. plan section providing insurance toward hospitalization, home care, and hospice care. 4. plan section providing very limited financial coverage to low~income persons. 5. Medicaid is described as: 1. a voluntary prescription drug plan that began in January 2006. 2. a voluntary plan that provides partial coverage of outpatient and health care provider services to those who are eligible. 3. a plan providing insurance toward hospitalization, home care, and hospice care. 4. a plan providing very limited financial coverage to low-income persons. 6. Which individuals are eligible for Supplemental Security Income (881)? (Select all that apply.) 1. Individuals who are blind 2. Individuals not eligible for Social Security 3, Children from low-income families that are covered under Medicaid 4. Anyone over age 65 5. Anyone with a diagnosed disability 7. What is the name of the classification system that prospective payment systems utilize? 1. Medicare 2. Medicaid 3. State Children’s Health Insurance Program (SCHIP) 4. Diagnosis-related groups (DRGs) 8. Third-party reimbursement refers to the insurance company that pays the client’s (first party) bill to the provider (second party). This component is part of the: 1. private health insurance plan. 2. diagnosis—related group (DRG). 3. group health insurance plan. 4. preferred provider organization. 9. Prepaid group plans for insurance include: I. Medicare and Medicaid. 2. Blue Cross and Blue Shield. 3. HMOs, PPOs, PPAs, lPAs, and PHOs. 4. Social Security and Supplemental Security Income. 10. What is an example of illness prevention? 1. Immunizing children against chickenpox 2. Caring for a dying client 3. Assisting a stroke victim to the highest rehabilitation level possible 4. Secondary prevention © 2016 by Pearson Education, Inc. CHAPTER 7 COMMUNITY NURSING AND CARE CONTINUITY KEY TERM REVIEW Collaboration 2. Community Community-based health care 995703.099; 1. U) Match each term with its appropriate definition. -. Community-based nursing their time . Provides primary care to specific populations and is staffed by nurse practitioners and community health nurses . Composed of people who share some common characteristic but who do not necessarily interact with each other Community health nursing Community nursing centers Continuity ofcare __ Discharge planning Integrated health care system . Provision of integrated, accessible health care services by clinicians who are accountable for addressing a majority of personal health care services . A philosophy of nursing that guides nursing care provided for individuals and families wherever the individuals are, including where they live, work, play, or go to school Population Primary care 12. . Provides health—related services in places where people spend Primary health care . Emphasizes the promotion and preservation of the health of groups . A collegial working relationship with another health care provider in the provision of patient care . Health care based on practical, scientifically sound and socially acceptable methods and technology made accessible to individuals and families '. A collection of people who share some attribute of their lives I Process of preparing a client to leave one level of care for another . Coordination of health care services by health care providers for clients moving from one health care setting to another. . Makes all levels of care available in an integrated form— primary care, secondary care, and tertiary care (C 2016 by Pearson Education, Inc. 36 CHAPTER 7 / Community Nursing and Care Continuity 37 KEY TOPIC REVIEW 1. What are four of the factors motivating change in the health care system? a. Escalating health care costs b. Decreasing technology c. Changing patterns of demographics d. Shorter hospital stays e. Decreased patient acuity f. Limited access to health care 2. List four characteristics ofprimary care. a. b. c. d. 3. List four characteristics of primary health care. a. b. d. 4. A is a collection of people who share some attribute of their lives and interact with each other in some way. It is also defined as a social system in which the members interact formally or informally and form networks that operate for the benefit of all people in the community. 5. A _ is composed of people who share some common characteristics but do not necessarily interact with each other. 6. List four types of community—based frameworks and give the definition of each. a. Type: Definition: '0 b. Type: Definition: Type: Definition: d. Type: Definition: 7. Easy access is needed for an effective community—based health care system. a. True © 2016 by Pearson Education, Inc. b. False 38 CHAPTER 7 / Community Nursing and Care Continuity 8, Choose the community-based settings for nursing practice. (Select all that apply.) a. Community nursing centers b. Long—term care facilities c. Parish nursing d. Telehealth e. Hospitals 9. Community-based nursing focuses on care of individuals in geographically local settings, whereas community health nursing emphasizes the promotion and preservation of the health of groups. a. True b. False 10. Both primary health care and primary care strive for universal access to and affordability of health care. a. True b. False FOCUSED STUDY TIPS 1. What do the Pew Health Professions Commission competencies for future practitioners include? What are the competencies (listed in the text) that the health care practitioner would require? 2. Primary health care involves five principles. List and explain the five principles in detail. 3. Identify the essential aspects of home health nursing. What makes this community—based role especially challenging? 4. How does the community health care setting differ from traditional settings? 5. Define community-based health care (CBHC). Where is the care directed, and what is involved in CBHC? 6. How are consumers effecting major changes in health care delivery systems? CASE STUDY A nurse has been working as the case manager in a pediatric unit and decides that she wants to be involved in community nursing. 1. What are some types of community nursing that could be considered? 2. What skills would be needed for community nursing that might not be used in the pediatric unit? REVIEW QUESTIONS 1. The key elements necessary for collaboration among health care providers include: l. Mutual respect, trust, and negotiation. 2. Communication skills, mutual respect, and shared decision making. 3. Negotiation, conflict management, and mutual respect. 4. Conflict management, trust, and decision making. © 2016 by Pearson Education, Inc. CHAPTER 7 / Community Nursing and Care Continuity 39 2. As a nurse collaborator, which actions will the nurse perform? (Select all that apply.) I. Sharing personal expertise with other nurses and eliciting the expertise of others to ensure quality client care 2. Seeking opportunities to collaborate with and within professional organizations 3. Offering expert opinions on legislative initiatives related to health care 4 . Collaborating with other health care providers and consumers on health care legislation to best serve the needs ofthe public 3. When does discharge planning begin for a client? 1. Prior to discharge 2. On admission 3. Two days after admission 4. Two hours before discharge 4. Which client would be identified before discharge as needing a referral to a community-based health care facility? 1. An older adult client who has no caregivers to provide the necessary oversight of care 2. A child who has had an uncomplicated removal of the tonsils 3. A mother who delivered a 7-pound baby vaginally the previous day 4. A client who has a well-healed surgical wound to the abdomen 5. What is the major focus of integrated health care systems? 1. Primary health care in the event of an emergency 2. Health promotion and disease prevention 3. Chronic disease management 4. Long-term care of disabilities 6. Choose the correct responses that identify the function of a community (Select all that apply.) 1. Individual support 2. Social control 3. Socialization 4. Production of goods 7. Choose the correct responses that identify the parish nurse’s roles. (Select all that apply.) 1. Personal health counselor 2. Health educator 3. Referral source 4. Integrator of faith and health 8. Which population represents the individuals most likely to be cared for by an advanced practice nurse? (Select all that apply.) 1. Incarcerated adults 2. Healthy school-age children 3. Homeless individuals 4. Healthy adults C 2016 by Pearson Education, Inc. CHAPTER 8 HOME CARE KEY TERM REVIEW Match each term with its appropriate definition. Caregiver role strain . Health services provided in the home setting 2. Durable medical equipment (DME) company . Nursing services and products provided to clients in Home care . Support and care of the terminally ill person and his 99.435” 1. Home health care nursing Hospice nursing Registry the home or her family . Provides health care equipment to the client at home . State of altered health and well-being due to the physical, emotional, social, and financial burdens of caring for another. . Contracts with individual care providers to care for the client in the home KEY TOPIC REVIEW 1. Identify factors that have contributed to the increase and growth in home health care. 2. What does home care involve in today’s health care system? 3. nursing is support and care of the terminally ill person and his or her family, and is considered a subspecialty of home health nursing. 4. What are three advantages of home health nursing? a. b. © 2016 by Pearson Education, Inc. 40 CHAPTER 8/ Home Care 41 What are three disadvantages of home health nursing? a. b. 0. List four duties that a home health nurse might perform in the home setting. a. b. c. d. Any individual involved with the care of a client may identify the need for home health. a. True b. False Match the following types of home health agencies with the appropriate description. Institutions that rely on private a. Official or public agencies pay sources or “third-party” reimbursement b. Voluntary or private not-for-profit agencies c. Private, proprietary agencies United Way _ ‘ (1. Institution-based agencies Hospital home health agencies State health department List four topics regarding infection control that the home health nurse will educate the patient on in the home. a. b. c. d. FOCUSED STUDY TIPS 1. What is the Visiting Nurse Associations of America’s definition of a home health nurse? Describe the unique aspects of home health nursing. What is involved in the practice of home health nursing? List additional providers in home health and describe their duties or roles. . What does the home health referral process entail? What is necessary from the physician in order to begin home health care? What are the nurse’s responsibilities? How is home health reimbursed? What criteria or guidelines for reimbursement are required by Medicare or Medicaid? . Why is documentation especially critical in home health? Explain the concept of infection control in the home setting. What is the nurse’s major role? How can the nurse minimize risk of infection? . How can infection prevention present a challenge to the home health nurse? © 2016 by Pearson Education, Inc. 42 CHAPTER 8 / Home Care CASE STUDY The home health nurse is caring for Maria Campos, a 72-year-old who has recently been diagnosed with type 2 diabetes. Mrs. Campos has a history of hypertension and hyperlipidemia and has not adhered to her prescribed medication regimen in the past. She speaks very little English. Answer the following questions based on the clinical scenario presented. I. What interventions will the home health nurse likely perform when caring for Mrs. Campos? 2. What unique cultural considerations will the nurse take when caring for Mrs. Campos? 3. What age-related considerations will the nurse plan? REVIEW QUESTIONS 1. What type of company provides health care equipment for home health clients? I. Hospice 2. Private home health agency 3. Durable medical equipment (DME) 4. Durable equipment . The home health nurse is functioning as an educator during a home health visit. Which action or intervention best exemplifies this role? 1. Changing an indwelling Foley catheter 2. Discussing living wills and durable power of attorney and obtaining a social work consultation 3. Instructing a client on a diabetic diet 4. Documentation of care provided by the agency . The home health nurse is functioning as an advocate during an initial assessment. Which action or intervention best exemplifies this role? 1. Changing an indwelling Foley catheter 2. Discussing living wills and durable power of attorney and obtaining a social work consult 3. Instructing a client on a diabetic diet 4. Documentation of care provided by the agency . The home health nurse is functioning as a caregiver during a home health visit. Which action or intervention best exemplifies this role? 1. Changing an indwelling Foley catheter 2. Discussing living wills and durable power of attorney and obtaining a social work consult 3. Instructing a client on a diabetic diet 4. Documentation of care provided by the agency . What is considered to be the core concept of home health care? I. Advocating 2. Caregiving 3. Case managing 4. Educating C 2016 by Pearson Education, Inc. CHAPTER 8/ Home Care 43 6. Identify the clinical manifestations of caregiver role strain. (Select all that apply.) 1. Decreased energy 2. Anxiety 3. Difficulty concentrating 4. Difficulty performing routine tasks 7. An example of a home health service provided by nurses is: 1. Housekeeping duties for the client. 2. Providing a hospital bed for the client. 3. Performing daily wound care for the client. 4. Writing the living will for the client. 8. Hospice nursing provides: 1. Intravenous therapy for nutrition such as total parental nutrition (TPN). 2. Tracheotomy care for a client with COPD. 3. Care to the terminally ill client. 4. Education about acute conditions such as diabetes. 9. When is the most appropriate time for the client and family members to be involved in obtaining home health services? 1. On the initial home health assessment visit by the registered nurse. 2. On admission to the hospital. 3 . Prior to discharge from the hospital. 4. When the client is terminally ill. © 2016 by Pearson Education, Inc. CHAPTER 9 ELECTRONIC HEALTH RECORDS AND INFORMATION TECHNOLOGY KEY TERM REVIEW Match each term with its appropriate definition. [\J 1. Clinical decision a. The science of using computer information systems in the practice of support systems nursing Computer-based patient records Expert who combines computer, information, and nursing science to develop policies and procedures that promote effective and secure use of computerized records by nurses and other health care professionals Data warehousing Distance learning _ Electronic health records (EHRs) Health informatics Hospital information system (HIS) Management information system (MIS) Nurse informaticist N ursing informatics Uses technology to transmit electronic data about clients to persons at distant locations . Electronic forms that incorporate evidence from literature into particular client situations that guide care planning Organizes data from various areas in the hospital such as admissions, medical records, clinical laboratory, pharmacy, order entry, and finance Permit electronic client data entry and retrieval by caregivers, administrators, accreditors, and other persons who require the data g. The management of health care information, using computers Facilitates the structure and application of data to manage an organization or department Educational Opportunities delivered under situations in which the teacher and learner are not in the same place at the same time Accumulation of large amounts of data that are stored over time Permit electronic client data entry and retrieval by caregivers, administrators, accreditors, and other persons who require the data Telemedicine © 2016 by Pearson Education, Inc. 44 CHAPTER 9/ Electronic Health Records and Information Technology 45 KEY TOPIC REVIEW 1. List three areas on which the Technology Informatics Guiding Education Reform (TIGER) Initiative focuses. a. b. c. 2. Client concerns regarding and of health records have arisen as electronic databases and communications have proliferated. 3. What are the two most common types of information systems used by nurses? a. b. 4. What areas of a hospital may use HIS to organize data? a. b. 5. List six examples of the use ofbedside data entry. e. f. 6. The term refers to a computer being connected to other computers in a 7. Indicate one type of computer software used in nursing and list one application used with that software. 8. The fl established legal requirements for the protection, security, and appropriate sharing of patient personal health information (referred to as protected health information or PHI). 9. Name four ways in which computers have enhanced nursing education. a. b. C. (Q 2016 by Pearson Education, Inc. 46 CHAPTER 9 / Electronic Health Records and Information Technology 10. List the four functions of nursing informatics. a. b. c. d. FOCUSED STUDY TIPS 1. Discuss the criteria for evaluating Internet health information. How has the widespread availability of information impacted health care today? . What is the difference between distance education courses and web-enhanced or hybrid courses? . What are the advantages of taking the National Council Licensure Examination (NCLEX®) on a computer? When did the test change from pen—and—paper administration to computer administration? Telemedicine (or telehealth) uses technology to transmit electronic data about clients to persons at distant locations. What are some of the advantages of telemedicine? What are the disadvantages? . One of the main concerns with health care and information technology is privacy issues. As a nurse, how can you impact changes on the state and federal level regarding privacy? Refer to the ANA position statement on privacy. What is the nurse’s role in the privacy issue? . How has the implementation of HIPAA presented a challenge to nurses? CASE STUDY A 45-year-old client is scheduled to have a hysterectomy later this week. She is at the hospital to get her preoperative nursing assessment, several laboratory exams, and chest x-ray. The nurse and laboratory technologist are using a computerized data entry system that is managed on a handheld device. 1. If the client’s results are entered into computer—based patient records (CPRs), who would be able to legally access her medical information? The chest x-ray is abnormal and the primary care provider wishes to consult a respiratory specialist. If he sends the x-ray film electronically to the consulting primary care provider, that is an example of what type of medicine? . What are the advantages of this type of consultation? Does the client have to Sign any consent forms with regard to her electronic medical records? REVIEW QUESTIONS 1. What is an advantage of having “paper” medical records for clients? 1. Paper medical records have had legal standards in place that have been tested effective. 2. Paper medical records are often standardized and thorough. 3. Paper medical records take up less space when being stored. 4. Paper medical records ensure client health information is protected. © 2016 by Pearson Education, Inc. CHAPTER 9 / Electronic Health Records and Information Technology 47 2. The World Wide Web (WWW) refers to: 1. Documents accessed electronically. 2. Complex links among web pages or websites. 3. Universal resource locators. 4. A network designed to facilitate the organization and application of data. 3. Universal resource locators (URLs) are also called: 1. Television stations. 2. Addresses. 3. Links among web pages or websites. 4. Rural addresses. 4. Which of the following computerized systems would assist a physician in Russia to consult with a physician in the United States? 1. Distance learning 2. Computer-based client records 3. Telemedicine 4. Local—area network 5. What does the designation “.org” in a URL denote? 1. Commercial sites 2. Organizations 3. Educational institutions 4. Government sites 6. A group of nursing students located at different sites for a nursing class are participating in classes through two-way audio and video transmissions. In addition, the students use chat and instant messaging. This is an example of which type of distance learning model? 1. Asynchronous distance learning 2. Synchronous distance learning 3. Simultaneous distance learning 4. Self—study distance learning 7. What is one way in which a nurse administrator might use a computer? 1. Following client’s health status during the hospital stay 2. Managing a budget 3. Obtaining the latest information on cardiac diseases 4. Participating in a research study 8. How is computer-assisted instruction (CAI) used in nursing? 1. It makes it easier to adjust to the use of software programs. 2. It allows nurses to share health care information with clients. 3. It is used to test nursing students for the NCLEX. 4 . It is used as a bookkeeping system. © 2016 by Pearson Education, Inc. 48 CHAPTER 9/ Electronic Health Records and Information Technology 9. What role does the Health Insurance Portability and Accountability Act (HIPAA) play in client confidentiality? 1. It provides a database for insurance agencies to utilize. 2. It provides for data standardization. 3. It provides for data classifications. 4. It provides for privacy and confidentiality for clients in health care. 10. Electronic medical records (EMRS) 0r computer-based records (CPRs) pennit electronic client data retrieval by caregivers, administrators, creditors, and other persons who require the data. What agency or act sets legal requirements for the protection, security, and appropriate sharing of client personal health information? 1. Hospitals 2. Patient bill of rights 3. State governments 4. HIPAA © 2016 by Pearson Education, Inc. CHAPTER 10 CRITICAL THINKING AND CLINICAL REASONING KEY TERM REVIEW Match each term with its appropriate definition 1. Clinical judgment A; Clinical reasoning Cognitive 90399:“ processes Concept map ll. A process for clarifying the nature of a problem, suggesting possible solutions, and evaluating the solutions for the best possible choice to implement Generalizations are formed from a set of facts or observations Process of working from general premises to reach a specific conclusion Understanding of things without conscious use ol‘reasoning Creativity A technique one can use to look below the surface to differentiate what one knows from what one merely believes Critical analysis A number of approaches are tried until a solution is found Critical thinking An intentional higher level reasoning that is delineated by several factors as a guide for rational judgment and action 7 Deductive reasoning Inductive reasoning 10. a. Intuition Metacognitive processes 124 7 Nursing process 13. Problem solving 14. __ Socratic questioning Trial and error © 20l6 by Pearson Education, Inc. Thinking that results in the development of new ideas and products Application of a set of questions to a particular situation to determine essential information and discard unneeded information . A decision-making process to ascertain the right nursing action to be implemented at the appropriate time in the client’s care Graphic representation of linear and nonlinear relationships for representing critical thinking A systematic client-centered method for structuring nursing care . The analysis ofa clinical situation as it unfolds or develops The thinking processes based on the knowledge of aspects ofclient care Include reflective thinking and awareness ofthe skills learned by the nurse in caring for the client. 49 50 CHAPTER 10 / Critical Thinking and Clinical Reasoning KEY TOPIC REVIEW 1. Critical thinking consists of high-level cognitive processes that include and 2. Define the following problem-solving methods: a. Trial and error b. Intuition c. Nursing process d. Scientific method e. Modified scientific method 3. is a purposeful mental activity that guides beliefs and actions. 4. Define inductive and deductive reasoning in critical thinking. 5. is a technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view, and differentiate what one knows from what one merely believes. 6. List five characteristics that most critical thinkers have. a .0 b. 7. , at every step of critical thinking and nursing care, helps examine the ways in which the nurse gathers and analyzes data, makes decisions, and determines the effectiveness of interventions. 8. Identify the sequential steps to the decision-making process. a. .393e P- b. 9. What is the definition ofdecision making? Give one example of decision—making. 10. Critical thinkers are willing to admit what they do not know; they are willing to seek new information and to rethink their conclusions in light of new knowledge. a. True © 2016 by Pearson Education, Inc. b. False CHAPTER 10/ Critical Thinking and Clinical Reasoning 51 P- .0“ 9’ ll. Identify and define the four types of concept maps. FOCUSED STUDY TIPS l. What are the four stages of critical thinking? 2. Describe Maslow’s hierarchy of basic human needs. Why is this concept important to nursing? List the characteristics of critical thinking. What are the skills needed by one who uses critical thinking? List and describe the three methods used with critical thinking when problem solving during the nursing process. Why must the nursing process occur in the chronological order of assessment, diagnosing, planning, implementing, and evaluating? CASE STUDY The student nurse should begin using critical thinking in daily life by using it in the clinical environment and during everyday situations. To clarify the critical thinking process for the nursing student, a nonnursing case study will be used for this case study. A close friend states that she is habitually overdrawing her bank checking account. She has asked you for advice with this problem. Using the Socratic questions listed in Box 10—3 of the text, analyze this problem. a. Questions about the decision or problem: b. Questions about assumptions: c. Questions about point of view: d. Questions about evidence and reasons: C. Questions about implications and consequences: REVIEW QUESTIONS 1. What is the least effective decision-making process? 1. Analyzing the data 2. Formulating conclusions 3. Establishing assumptions 4. Synthesizing information What does the trial—and—error method of problem solving lack? 1. Effectiveness 2. Organization 3. Thoughtfuiness 4. Exactness @ 2016 by Pearson Education, Inc. 52 CHAPTER 10 / Critical Thinking and Clinical Reasoning 3. The research process of problem solving is: 1. Most effective when used by experienced nurses. . 2. Least effective when used by experienced nurses. 3. lllogical at times. 4. Lacking in formality. 4. Why is the nursing process method used in nursing? (Select all that apply.) 1. It allows the nurse to work independently without collaboration. 2. It involves the interaction between the client and nurse as they work together. 3. It is used to identify potential or actual health care needs, set goals, devise a plan to meet the client’s needs, and evaluate the plan’s effectiveness. 4. It is designed to work well in all environments. 5. What does critical thinking allow nurses to do during emergency situations? 1. Establish teamwork with other disciplines. 2. Maintain a calm demeanor. 3. Meet the physician’s needs. 4. Recognize important cues. 6. If a child cannot grasp the mechanics behind using an incentive spirometer, the nurse could give the client balloons and/or a jar of bubbles to blow. What does this best demonstrate? (Select all that apply.) 1. Modified scientific method 2. Scientific method 3. Creativity 4. Critical thinking 7. While working in the critical care unit, a nurse is caring for a client after cardiac bypass surgery. The nurse feels that “something is wrong” even though the client has no outward signs or symptoms. What is this an example of? l. Intuition 2. Trial and error 3. Research process 4. Scientific method 8. In the emergency department, the nurse observes that a client is actively bleeding from an abdominal gunshot wound. The nurse assumes that the client is at an increased risk for hypovolemic shock after observing frank red blood Spurting from the wound. What is this an example of? 1. Creativity 2. Deductive reasoning 3. Inductive reasoning 4. Critical analysis (0 2016 by Pearson Education, Inc. , CHAPTER 10 / Critical Thinking and Clinical Reasoning 53 9. While attending a nursing educator’s conference, a nursing instructor obtains information about the use of concept maps and clinical pathways. The nursing instructor returns to work at the university and discusses the new techniques with the other instructors. What is this an example of? 1. Creating an environment that supports critical thinking 2. Seeking information regarding new educational promotions 3. Intellectual humility 4. Judgment 10. What is the definition of the nursing process? 1. A skill essential to safe, competent, skillful nursing practice 2. A type of thinking that results in the development of new ideas and products 3. A critical thinking process for choosing the best actions to meet a desired goal 4. A systematic, rational method of planning and providing individualized nursing care 11. How are nursing cognitive skills learned? 1. Through reading and applying health—related literature 2. Through the use of critical thought 3. Through the application of content the nurse has previously learned 4. Through the application of clinical scenarios the nurse has experienced © 2016 by Pearson Education, Inc. CHAPTER 1 1 ASSESSING KEY TERM REVIEW Match each term with its appropriate definition. 1. Assessing 2 Cephalocaudal 3. Clinical signs 4 Clinical a. Usually closed, and directs the client’s answer . Highly structured, elicits specific information Planned communication . An understanding between two or more people >OP°>‘.°‘\.U‘ symptoms Closed questions Systematic and continuous collection, organization, validation, and documentation of data Cues Generally require only a yes or no answer Data Database Directive . Double checking data, ensuring that objective and related subjective data agree . lnforrnation relayed by the client that cannot be seen or measured by the nurse but must be accepted as the client’s perception interview lnferences 11. Interview 12. Leading question l3. Neutral question 14. Nondirective A client can answer without direction or pressure; is open ended . Subjective data . Objective data Head to toe . Subjective or objective data that can be observed by the nurse . A physical examination briefly conducted of all systems that does not include an in-depth exam of any one system interview . All information about a client 15. Objective data 16. Rapport 17. Review of >973 . Also known as information systems 18. Screening examination 19. Subjective data 20. Validation © 2016 by Pearson Education, Inc. t" . A brief review of essential functioning of various body parts Rapport-building interview Nurse’s interpretation or conclusions based on cues Detectable by an observer, can be measured or tested 54 CHAPTER 11 /Assessing 55 KEY TOPIC REVIEW 1. What are the three purposes of the nursing process? a. b. c. 2. The nursing process is both interpersonal and collaborative between the nurse and the client. a. True b. False 3. Assessing is a continuous process carried out through all the phases of nursing. a. True b. False 4. What are the four different types of assessment? a. b. c. d. 5. According to The Joint Commission, each client must have an initial assessment within hours of admission. 6. What are the four activities involved in the assessment process? a. b. c. d. 7. Determine if the following information is subjective (S) or objective (0) assessment data. a. “I feel tired all the time.” b. Skin warm and dry to touch 0. “I am itching all over.” d. Smell of ammonia in urine e. Purplish discoloration on left forearm f. Temperature of 102 degrees orally 8. Distinguish between the primary (P) and secondary (indirect) (S) sources of data in the assessment process. a “My son has vomited for three days.” b. “I have been coughing for two weeks.” 0. “My wife is forty-five years old.” (1. “l have a rash.” TC) 2016 by Pearson Education, Inc. 56 CHAPTER 11 / Assessing 9. When does the observation portion of data collection occur? a. On the initial assessment b. Prior to the initial assessment 0. It is an ongoing process. d. Observation is not part of data collection. 10. An is a planned communication or conversation with a purpose. FOCUSED STUDY TIPS 1. Explain the difference between the medical model of problem solving and the nursing process. What are the parallels between the two models? 2. Why would it be important to review data from client records such as occupation, religion, marital status, and so on before beginning the nurse health history? 3. Why is sharing of information important in health care? What is pertinent information that needs to be relayed between nursing shifts? 4. Compare and contrast the body systems and cephalocaudal approaches to assessment. What are the advantages and disadvantages to both approaches? 5. Compare and contrast Orem’s self-care model and Roy’s adaptation model. CASE STUDY A client is being transferred to the unit from the recovery room after having an abdominal tumor removed. The recovery room nurse gives a verbal report on the client’s condition, stating that the dressing is dry and intact, vital signs stable, IV of normal saline infusing at 100 mL per hour in the left forearm, intact and patent, medications given, and that the client has no complaints of pain. During the initial assessment, the medical—surgical nurse notes that the abdominal dressing has bright red drainage. The client stated, “I am really hurting bad!” The Vital signs are 140/86 mmHg, RR 24/min, T 368°C (98.20F) orally, and pulse of 90 beats/min. 1. What is the objective data? 2. What is the subjective data? 3. Who is considered the primary source? 4. Who is considered the secondary source? REVIEW QUESTIONS 1. The nurse is assessing the sputum characteristics of a client with pneumonia. What are the senses that the nurse may use in the assessment of the sputum? (Select all that apply.) 1. Vision 2. Smell 3. Hearing 4. Touch © 2016 by Pearson Education, Inc. CHAPTER 11 /Assessing 57 2. What phases of the nursing process are identified by the most current Scope and Standards ofNursing Practice that are not recognized by the national licensure examination for registered nurses (NCLEX-RN)? 1. Outcomes identifications and diagnosis 2. Analysis and diagnosis 3. Outcomes identifications and analysis 4. Assessment and evaluation 3. During the process of data collection, the nurse must be aware of the different cultural aspects in health care. In the interview phase, what will the nurse consider may have a cultural implication? (Select all that apply.) 1. Time of the interview 2. Setting of the interview 3. Physical distance between the nurse and client 4. Seating arrangement 4. What is an example of an open-ended question that the nurse may use in the interview process? 1. “Did you take your medication today?” 2. “Have you ever had to undergo surgery?” 3. “Are you a student at the local college?” 4. “How have you been feeling lately?” 5. What is the name of the head-to-toe approach that usually begins the nurse physical examination? 1. Review of systems 2. Screening examination 3. Cephalocaudal 0\ 4. Caudal approach What framework is based on 11 functional health patterns and collects data about dysfunctional and functional behavior? 1. Orem’s self-care model 2. Gordon’s functional health patterns 3. Roy’s adaptation model 4. The wellness model 7. After completing the health history and the physical assessment, the nurse identifies discrepancies in the information. What is this process called? 1. Assessing 2. Diagnosing 3. Validating 4. Evaluating 8. A client presents to the emergency department with complaints of chest pain. The nurse takes the client’s vital signs. The nurse is performing which phase of the nursing process? 1. Assessing 2. Diagnosing 3. Planning 4. Implementing © 2016 by Pearson Education, Inc. 58 CHAPTER 11 /Assessing 9. The nurse reassesses a client’s temperature 45 minutes after administering acetaminophen. This is an example of what type of an assessment? 1. Ongoing 2. Intermittent 3. Terminal 4. Routine 10. The nurse is measuring the drainage from a Jackson—Pratt drain. What is considered objective data? 1. The client is complaining of abdominal pain. 2. The drainage measurement is 25 mL. 3. The client stated, “I did not empty the drain.” 4. The client stated that he has a pain level of 5. © 2016 by Pearson Education, Inc. CHAPTER 12 DIAGNO SING KEY TERM REVIEW Match each term with its appropriate definition. 1. Defining charac— teristics Dependent func— tions Diagnosis Diagnostic labels . Etiology _ Health promotion diagnosis Independent functions a. Relates to the client’s preparedness for implementing behaviors to improve his or her health condition Generally accepted measure, rule, model, or pattern Basic three—part diagnostic statement . A cluster of signs and symptoms that indicate the presence of a particular diagnostic label Describes a cluster of nursing diagnoses that have similar interventions A classification system or set of categories arranged based on a single principle or set of principles g. Added words to give additional meaning to a diagnostic statement h. Causal relationship between a problem and its related or risk factors Norm Statement or conclusion regarding the nature of a phenomenon Nursing diagno— Areas of health care that are unique to nursing sis Variables that indicate that increased likelihood that a problem could arise 10. PES format ll. Qual i fiers Clinical judgment that a problem does not exist; rather, a problem is likely to develop without nursing intervention 12. Risk factors l3. Risk nursing diagnosis 14. Standard 15. #7 Syndrome diag— . Generally accepted norm . Client’s problem statement, plus etiology , Standardized NANDA names for diagnoses . The nurse’s obligation to carry out physician-prescribed therapies and treatments nosis 16. Taxonomy © 2016 by Pearson Education, Inc. 59 60 CHAPTER 12 / Diagnosing KEY TOPIC REVIEW 1. What is the first stage of the nursing process? 2. What is the second stage of the nursing process? 3. A is a classification system or set of categories based on a single principle or set of principles. 4. What are the parts of the North American Nursing Diagnosis Association (NAN DA) nursing diagnosis? a. b. c. 5. All nurses are responsible for making nursing diagnoses according to the ANA Standards of Practice. a. True b. False 6. The nursing diagnosis is a judgment made only after thorough, systematic data collection. a. True b. False 7. What are the five types ofnursing diagnoses? a. b. c. d. e. 8. To enhance clinical usefulness, diagnostic labels must be as as possible. 9. What five words are identified as qualifiers to give additional meaning to a diagnostic statement? a. b. C. d. 6. 10. What is the definition of etiology? What is the purpose of the etiology statement? 11. Risk diagnoses do not have subjective or objective indications of the presence of the diagnosis found during the assessment phase. a. True b. False 12. For actual nursing diagnoses, the defining characteristics are the client’s signs and symptoms in the assessment phase of the nursing process. a. True © 2016 by Pearson Education, Inc. b. False CHAPTER 12/ Diagnosing 61 FOCUSED STUDY TIPS 1. A nursing diagnosis has three components. List the three components and give an example of each. Why is it important to differentiate among the possible causes in the nursing diagnosis? (Refer to Table 12~2 in the text.) . What are the differentiating factors between a nursing diagnosis and a medical diagnosis? Describe characteristics of the nursing diagnosis. What is a two—part diagnostic statement? What is a three-part diagnostic statement? List two examples each of a one-part, two-part, and three-part diagnostic statement. Refer to the PES diagnosis in the text. 6. Compare and contrast dependent and independent nursing functions. CASE STUDY A newly admitted client will be your responsibility as the registered nurse. The client is a 47—year-old male of Native American heritage with type 2 diabetes. He states that he has not been taking his medication because it doesn’t make him feel better; he also has difficulty remembering to take the medication. The following infonnation pertains to this client: I Fingerstick blood sugar = 213 mg/dL l BP 150/90 mmHg; temp 370C (98.6013) oral; respirations 24/min; pulse 78 beats/min. I “I use the bathroom about eight times per day.” l Ht 6 feet 4 inches; weight 284 pounds . What is an actual nursing diagnosis for this client? . What is a potential nursing diagnosis for this client? Identify one subjective and one objective assessment to substantiate the nursing diagnosis. What is the outcome goal for the client? What are two independent functions the nurse might perform when caring for this client? REVIEW QUESTIONS 1. What is the purpose of data collection and analysis? 1. To carry out the plan of care. 2. To collect and then analyze data. 3. To identify actual or potential health concerns. 4. To identify a client’s response to care. @7 2016 by Pearson Education, Inc. 62 CHAPTER 12/ Diagnosing 2. Which statement is a nursing diagnosis? 1. Fever of unknown origin 2. Pancreatitis 3. Potential for sleep-pattern disturbances 4. Congestive heart failure 3. What is the purpose ofa nursing diagnosis? I. To define a taxonomy of nursing language. 2. To promote a taxonomy of nursing language. 3. To identify a client’s problem and its etiology. 4. To establish a set of principles. 4. Choose the appropriate activities that the nurse may perform during the diagnosing component of the nursing process. (Select all that apply.) 1. Compare data against current nursing standards. 2. Obtain a nursing health history. 3. Cluster or group the data to generate a tentative hypothesis. 4. Review the client records and nursing literature. 5. Identify gaps and inconsistencies in the data. 5. What is a nursing function during the diagnosing phase of the nursing process? 1. Clarify all inconsistencies in the data before making inferences. 2. Identify Gordon’s functional health patterns and compare with the client. 3. Review the literature and review professional journals and textbooks. 4. Document the health assessment in a specific form. 6. Readiness for Enhanced Parenting is an example of which type of diagnosis? 1. Wellness diagnosis 2. Health—seeking diagnosis 3. Two-part diagnosis 4. Three-part diagnosis 7. Which ofthe following nursing diagnostic statements is correct? 1. Fluid Replacement related to fever 2, Impaired Skin Integrity related to immobility 3. Impaired Skin Integrity related to ulceration of sacral area 4. Pain related to severe headache 8. How does the nurse begin a diagnostic label for a collaborative problem? 1. Readinessfine Enhanced Spiritual Well—Being 2. Alteration ofRespiratory Status 3. Potential Complication for Pneumonia: Atelectasis 4. Impaired Respiratory System © 2016 by Pearson Education, Inc. CHAPTER ‘12/ Diagnosing 63 9. The PES format for writing a nursing diagnosis is used for which of the following? 1. Actual nursing diagnoses 2. Potential nursing diagnoses 3. Risk for nursing diagnoses 4. Wellness diagnoses 10. Choose the correct example ofa qualifier for a nursing diagnosis. 1. Syndrome 2. Potential 3. Deficient 4. Riskfor 11. Identify and select the advantages of using a taxonomy of nursing diagnoses. (Select all that apply.) 1, A taxonomy of nursing diagnoses would promote a classification system or set of categories for a single or set of principles for professional nurses. 2. A taxonomy of nursing diagnoses can be used by physicians to define diagnostic nursing terminology. 3. A taxdnomy of nursing diagnoses enhances the professional practice of the nurse in generating and completing a nursing care plan. 4. A taxonomy of nursing diagnoses consists of nursing diagnoses for a single principle or set of principles that were developed by other nursing professionals. 12. Identify the components of a nursing diagnosis. (Select all that apply.) 1. Related factors 2 . Risk factors 3 . Problem 4. Definition 5. Defining characteristics 6 . Medical conditions © 2016 by Pearson Education, Inc. CHAPTER 13 PLANNING KEY TERM REVIEW 1. Collaborative care plans QEOWF‘Qf-"FP’N Collaborative interventions Ux:l>-UJI\J>—‘ D—db—‘h—‘h—lr—dr—l Match each term with its appropriate definition. Concept map Critical pathways Dependent interventions Discharge planning Formal nursing care plan Goals/desired outcomes Independent interventions Indicator . Activities that nurses are licensed to initiate on the basis of their knowledge and skills . Developed to govern the handling of frequently occurring situations . Actions that a nurse performs to enhance client outcomes . Process of establishing a preferential sequence for addressing nursing diagnoses and interventions . Actions the nurse carries out in conjunction with other health team members . Collaborative care plan that sequences care that must be given Individualized care plan . Process of anticipating and planning for release from a facility Informal nursing care plan . A taxonomy of nursing outcome statements Multidisciplinary care plan Nursing interventions Nursing Interventions Classification (NIC) Specific patient state that is most sensitive to nursing interventions and measurable Similar to protocols; specify what is to be done . Gives the nurse authority to carry out specific actions under certain circumstances 16. Nursing Outcomes Classification (NOC) 17. Policies 18. Priority setting 19. Procedures . Outlines care required for clients to include nursing interventions as well as medical treatments to be performed by other members of the health care team 20. Protocols . A critical pathway that sequences care required for client 21. Rationale 22, Standardized care plan 23. Standing order © 2016 by Pearson Education, Inc. Strategy for action that exists in the nurse’s mind . Tailored to meet unique needs of a specific client with common conditions . Activities carried out under the orders or supervision of a licensed physician or other health care provider 64 CHAPTER 13/ Planning 65 q. Actions commonly required for a particular group of clients r. Written or computerized guide that organizes information s. Describe what the nurse hopes to achieve by implementing the nursing interventions u. Evidence-based principle given as the reason for selecting a particular nursing intervention v. Visual tool in which ideas or data are enclosed in circles or boxes connected by lines or arrows to indicate relationships w. A taxonomy of nursing interventions t. Formal plan that specifies the nursing care for groups of clients with common needs KEY TOPIC REVIEW are the actions that a nurse performs to achieve client goals. 1. 2. When does planning begin? 3. Who is responsible for developing the initial comprehensive plan of care, and when is it initiated? 4. List the four purposes the nurse uses to guide daily planning by utilizing ongoing assessment data. a. b. c. d. 5. What four tasks do the nurse and client complete during the planning stage ofthe nursing process? a. b. c. d. 6. Match the four different types of nursing care plans with their correct definitions. a. Informal nursing care plan Tailored to meet the unique needs of a specific client—needs that are not addressed by the standardized plan b. Standardized care plan 0. Individualized care plan A strategy for action that exists in the nurse’s mind A written or computerized guide that organizes information about the client’s care 01. Formal nursing care plan A formal plan that specifies the nursing care for groups of clients with common needs (1) D— .0 9‘ P” 7. Refer to Figure 13—2 in the text. What documents may be included in a complete plan of care? © 2016 by Pearson Education, Inc. 66 CHAPTER 13/ Planning 8. Refer to the standards of care for thrombophlebitis in Figure 1373 of the text. How are standards of care different than individualized care plans? What are the advantages and disadvantages of standards of care? 9. Define concept map and rationale. Why are students asked to complete pathophysiology flow sheets, concept maps, or care plans with rationales? 10. What do the client goals or desired outcomes describe? What is the Nursing Outcomes Classification (NOC)? FOCUSED STUDY TIPS 1. What is planning? What phase of the nursing process is planning? What is the end product of planning called? Who is involved in the planning process? 2. Discuss the three types of planning and list the significant tasks that registered nurses must do during each of the types/stages of planning. 3. Differentiate between protocols, policies, procedures, and standing orders. 4. What are the 10 guidelines for writing nursing care plans? Why is each guideline important? 5. What is meant by the activity of priority setting in the planning process? What factors need to be considered when assigning priorities? 6. What is the purpose of desired goals and/or outcomes? 7. What is the purpose of assigning priorities of care When planning client interventions? 8. Compare and contrast Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC). V CASE STUDIES Outcomes should be SMART (specific, measurable, appropriate, realistic, and timely). Analyze the following nursing care plan: A client has stage 4 pressure ulcers on the coccyx, left and right malleolus, and both heels. He is unable to turn himselfin the bed. His daughter states, “This happened so suddenly; he did not have these sores until he had the stroke and quit eating.” The nurse assesses the client and notes that he is an older adult, appears emaciated, and is immobile with the previously stated pressure ulcers. a. What are the subjective and objective data? b. What nursing diagnosis will fit this situation? c. What are the realistic short-term and long—term goals for this client? d. What are four nursing orders or interventions that can be used for this client? REVIEW QUESTIONS 1. “Client will walk to end of hallway without assistance by Friday” is an example of a: 1. Long—term goal. 2. Short—term goal. 3. Nursing intervention. 4. Rationale. © 2016 by Pearson Education, Inc. iv CHAPTER 13/ Planning 67 . “Client will ambulate 20 yards without assistance in 8 weeks” is an example of a: 1. Long-term goal. 2. Short—term goal. 3. Nursing intervention. 4. Rationale. . The nurse instructs the preoperative client to cough and deep breathe postoperatively to avoid respiratory complications. This is what type of nursing intervention? 1. Independent intervention 2. Dependent intervention 3. Collaborative intervention 4. Variable intervention . The nurse instructs the client on turning, coughing, and deep breathing q2h. What is the relationship of nursing interventions to problem status? 1. Health promotion interventions 2. Treatment interventions 3. Prevention interventions 4. Observation interventions . The home health registered nurse needs to assign a person to insert a Foley catheter on a client. To whom can she delegate this task? 1. The unlicensed personnel with extensive training 2. The licensed practical/vocational nurse 3. The physician 4. The client’s daughter . Planning consists of which component? 1. Reassessing the client 2. Analy7ing data 3. Selecting nursing interventions 4. Determining the nurse’s need for assistance . Consider the following nursing diagnosis: Imbalanced Nutrition: Less Than Boob} Requirements related to inability to feed self. What is an example of a short-term goal for this client? 1. The client will eat 75% of his meals by Friday (September 20) with the use of modified eating utensils to feed self with minimal assistance. 2. The client will learn about nutritious meal planning as exhibited by choosing one correct menu. 3. The client will acquire competence in managing cookware designed for clients with handicaps. 4. The client will learn preparation techniques that are quick and easy to manage. © 2016 by Pearson Education, Inc. 68 CHAPTER 13 / Planning . The nurse admits a client in active labor to the labor and delivery unit of the hospital. When does the planning for client care start? 1. After the physician has delivered the baby 2. After the admission process 3. When the client is discharged to the postpartum unit 4. During the initial meeting Which component is part of the permanent client record? 1. Nursing protocols 2. Client care plan 3. Procedures for client care 4. The nurse’s notebook of daily notes to herself 10. When caring for a client with stage 4 pressure ulcers on the coccyx, the nurse turns the client every 2 hours while in bed. What part of the nursing process is being carried out? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation . What are the benefits of a nursing intervention classification system? (Select all that apply.) 1. It helps demonstrate the impact that nurses have on the health care delivery system. 2. It assists educators to develop curricula that better articulates with clinical practice. 3. It standardizes and defines the knowledge base for nursing curricula and practice. 4 . It facilitates the appropriate selection of a nursing intervention and communication ofnursing treatments to other nurses and other providers. 12. A taxonomy of nursing outcome statements is developed to describe measurable states, behaviors, or perceptions to respond to which part of the nursing process? 1. Nursing assessments 2. Nursing interventions 3. Nursing goals 4. Nursing outcomes © 2016 by Pearson Education, Inc. CHAPTER 14 IMPLEMENTING AND EVALUATING KEY TERM REVIEW Match each term with its appropriate definition. 1. Audit 2. Cognitive skills 3. Concurrent audit 4. Evaluating 5. Evaluation statement 6. Implementing 7. Interpersonal skills 8. 9. _ Outcome evaluation Process evaluation 10. Quality assurance (QA) program 11 Quality improvement (Q1) 12. Retrospective audit 13. 7 fl Root cause analysis 14. Sentinel event 15. Structure evaluation 16. _,_ Technical skills . Process for identifying the factors that bring about deviations in practices that lead to a sentinel event . Evaluation of a client’s record after discharge from an agency . Focuses on the setting in which the care was given . Focuses on demonstrable changes in the client’s health status as a result of nursing care . Unexpected event that involves death or serious physical or psychological injury, or risk thereof . Purposcful hands-on skills . Include problem solving, decision making, thinking and creativity . All of the activities, verbal and nonverbal, individuals use when interacting directly with one another '. A process used to sure the best possible care is delivered with the resulting optimal outcomes '. Review ofa client’s health care while the client is still receiving care . Focuses on how care was given . Planned ongoing activity in which the client and health care professionals determine the client’s progress toward achievement of goals and effectiveness of nursing care plan .Consists oftwo parts: a conclusion and supporting data . Review of records © 2016 by Pearson Education, Inc. 69 70 CHAPTER 14/ Implementing and Evaluating o. Consists of doing and documenting the activities that are specific nursing actions needed to carry p. Ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients out the interventions ,__¢ KEY TOPIC REVIEW directed. , and oriented, . The nursing process is consists of doing and documenting the activities that are specific 2. According to NlC terminology, nursing actions needed to carry out the interventions. skills are used to implement nursing strategies. , and , 3. 4. When does the implementing phase terminate? , 5. The first three nursing phases of actions performed during the implementing step. , and provide the basis for the nursing 6. Match the type of skill with the following activities. a. Cognitive skills _ “May I help you to the restroom?” b. Interpersonal skills Creativity c. Technical skills Problem solving Nurse working effectively with members of the health care team Taking a blood pressure Caring for a dying patient Need self-awareness and sensitivity to others to perform this skill Bandaging a client’s leg 7. What is included in the five processes of implementing? d. e. 8. Nursing activities are communicated verbally as well as in writing. a. True b. False FOCUSED STUDY TIPS 1. What are the guidelines for implementing nursing interventions? 2. What are the five components of the evaluation process? 3. What are the two components of an evaluation statement? LII 4. Explain the difference between quality improvement and quality assurance. . Why should the nurse never document in advance? © 2016 by Pearson Education, Inc. CHAPTER 14 / Implementing and Evaluating 71 6. “How are quality improvement and quality assurance similiar? When would these concepts be used in clinical practice?” 7. What is a root cause analysis? When would this be used? CASE STUDY Mr. Raymond Sanchez is a 57—year-old man who has been diagnosed with pancreatic cancer. He has been hospitalized due to weight loss and acute pain. No further chemotherapy or treatment is planned. Answer the follow ing questions about Mr. Sanchez. 1. List different potential nursing diagnoses for Mr. Sanchez, give an example of subjective and objective data, and list one nursing intervention for each diagnosis. 2. List other comfort measures that the nurse may implement for Mr. Sanchez. REVIEW QUESTIONS 1. Evaluation of the client’s health care while the client is still receiving care from the agency is called a: l. Retrospective audit 2. Audit 3. Concurrent audit 4. Peer review 2. Basic nursing interventions are based 0n: 1. Scientific knowledge, nursing research, and evidence-based practice 2. Creative thinking and intuition 3. Physician’s orders 4. Client’s wishes and nursing research 3. What is the fifth and last phase of the nursing process? 1. Evaluating 2. Assessment 3. Planning 4. Implementing 4. The nurse documents that the goal or desired outcome was met, partially met, or not met. What part of the evaluation statement is the nurse documenting? 1. Supporting data 2. Collecting data 3. Finale 4. Conclusion © 2016 by Pearson Education, Inc. 72 CHAPTER 14/ Implementing and Evaluating 5. While implementing the plan of care for the client, the nurse should: (Select all that apply) 1. Supervise unlicensed support personnel who provide care to the client. 2. Complete every task for the client. 3. Supervise and direct the physician providing care. 4. Evaluate the client’s reactions to the planned interventions. 6. Which skills best describe nursing interpersonal skills? 1. Problem solving, decision making, critical thinking, and creativity 2. All of the activities, verbal and nonverbal, used when interacting directly with others 3. Manipulating equipment, giving injections, and bandaging 4. Leadership management and delegation 7. Which situation will the nurse need assistance with implementing the nursing interventions? 1. Applying Buck's traction for the fifth time 2. Documenting care delivered over the past hour 3. Turning the client in bed without the client experiencing discomfort 4. Transferring a bilateral amputee form bed to chair 8. What are two nursing phases that overlap each other in the nursing process? 1. Assessing; diagnosing 2. Planning; implementing 3. implementing; evaluation 4. Evaluating; assessing 9. The nurse writes an evaluation statement after determining whether a nursing goal or client outcome has been met. What are the two parts in an evaluation statement? 1. Conclusion and implementation 2. Conclusion and supporting data 3. Implementation and summary 4. Implementation and data analysis 10. A quality-assurance (QA) program evaluates and promotes excellence in the health care provided to clients. Select the three components of care that are reviewed during this process: 1. Structure evaluation 2. Process evaluation 3. Outcome evaluation 4. Internal processes and external agency evaluations © 2016 by Pearson Education, Inc. CHAPTER 15 DOCUMENTING AND REPORTING KEY TERM REVIEW Match each term with its appropriate definition. Chart entry made by all health professionals involved in a client’s care 1. Change-of-shift report 2 Chart 3. Charting 4. Charting by exception (CBE) 5 Client record 6. Discussion . Client health record 7 Documenting 8 Flow sheet . Consists of notes that include routine care, normal findings, and client problems 9 Focus charting 10. Handoff communication 1 l. Kardex 12. __ Narrative charting 13. i PIE l4. gF Problem-oriented medical record (POMR) 15. Problem-oriented record (POR) l6. __ Progress note 17. _fi_ Record 18. Recording 19. Report 20. __ SOAP 21. Source-oriented record 22. Variance © 2016 by Pearson Education, Inc. . Also known as a chart Concise method of organizing and recording data about a client making information quickly accessible to all health professionals Chart or record that can be written or computer based . Process in which information about patient care is communicated in a consistent manner including an opportunity to ask and respond to questions . A goal not met in a critical pathway . Problem-oriented record . Data are arranged according to the problems a patient has rather than the source of the information k. Process of charting or documenting Uses specific assessment criteria in a particular format In Acronym for subjective, objective, assessment, and plan . Makes client concerns and strengths the focus of care, usually using three columns 73 74 CHAPTER 15/ Documenting and Reporting 0. Informal oral consideration of a subject by two or more health care personnel to identify a problem . . or establlsh strategies to resolve a problem p. Each person or department makes notations in a , . . . separate section of the client 5 chart . Process of chartin or recordin q g g r. Communication tool used to provide continuity of care for clients by providing critical information to oncoming nurses s. Process of making an entry in a client record ' ‘ t. Docu nentat' ion system in Wth only abnormal 1 or significant findings are recorded v/ u. Acron m for roblems interventions. and ' ’ p y evaluation of nursing care . . . v. Oral, written, or computer-based communication intended to convey information to others KEY TOPIC REVIEW 1. The client’s record is protected legally as a private record of the client’s care. Access to the client’s record is limited to: a. Family members. b. The physician. 0. The physician and client. d. Health care professionals delivering care and the client. The nurse has a to maintain confidentiality of all patient information. ldentify four purposes ofclicnt records: a. b. c. d. . What are the five requirements established by The Joint Commission regarding client record documentation? a b. c. d. 6. . What measures should be taken when faxing confidential health information? Is consent needed? What should be done before hitting the “Send” button? Students or graduates are not bound by a strict ethical code and legal responsibility to hold all information in confidence. a. True b. False Describe source—oriented records. What is a traditional part of a source-oriented record? . List two advantages and three disadvantages of source—oriented chatting. . What is a problem—oriented medical record (POM R) or problem-oriented record (POR)? What are the four components of POMR? © 2016 by Pearson Education, Inc. _,. CHAPTER 15/ Documenting and Reporting 75 IO. List two advantages and two disadvantages of POMR charting. . What is the SOAP format that is used in charting and progress notes? What is meant by the acronyms SOAPIE and SOAPIER? . Explain how charting by exception (CBE) works, and explain why some nurses are uncomfortable with this method. What are the three elements of CBE? 13. List four advantages and one disadvantage of case management. FOCUSED STUDY TIPS 1. Explain the Security Rule of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Name four suggestions for ensuring confidentiality and security of computerized records. What is the PIE system of charting? How does focus chatting work? What are its advantages? . Refer to Box 1572 in the text. Review the pros and cons of computer documentation. Do you agree with this information? What are the requirements for documentation in a long-term care facility? . What is a variance? Explain how the nurse will document a variance in the client’s record. CASE STUDIES 1 . While charting, you notice that you have made an error. You did not write the correct oral temperature down. It should have been 98 degrees orally instead of IOl degrees orally. a. What is the correct method to fix this error? b. Identify an incorrect method for fixing errors in client records. Why is this method incorrect? The nurse has been caring for Michael Branson, a 47—year-old male who. was admitted for the treatment of alcohol withdrawal and is experiencing delirium tremens. It has been 2 days since Mr. Branson’s last intake of alcohol. The client has an infusing IV, is in a room kept dark and quiet to reduce stimuli, and has been monitored closely. The client has been having auditory and visual hallucinations throughout the day, which are re- duced following sedative administration. When hallucinations are minimized, the client is alert and oriented to person, place, time, and date. During periods of hallucinations, the client becomes agitated and his blood pressure, pulse, and respiratory rate increase. When preparing the change-of-shift report for this client, what kind of specific data would you want to report to the oncoming nurse assigned to Mr. Branson’s care? REVIEW QUESTIONS 1 . What is used to organize client data, allowing quick access for health care professionals to review information regarding the client? 1. End—of-shift report 2. SOAPIER notes 3. Variance reports 4. Kardex © 2016 by Pearson Education, Inc. 76 CHAPTER 15 / Documenting and Reporting 2. In long-term care facilities, what two types of care are provided? (Select all that apply.) 1. Easy 2. Skilled 3. Intermediate 4. Unskilled 3. Which client will require more frequent documentation by the nurse? 1. A stable client who is 2 days postvaginal delivery ofa term infant 2. A client presenting to the emergency department with signs/symptoms of a viral respiratory problem 3. An older adult client who is postoperative day 4 of a hip replacement 4. A client admitted to the ICU after a major myocardial infarction 4. If the nurse makes an error while charting, what is the recommended method to correct the mistake? I. Use “correction fluid” and obliterate the error. 2. Draw one line through the error and write “mistaken entry” above it, then sign your name or initials beside it. 3. Draw one line through the error and write “error” above it, then Sign your initials beside it. 4. Do nothing and hope no one notices the error. 5. The client has refused to have a Foley catheter inserted after surgery. What would need to be charted in the client’s chart? 1. The client refused the Foley catheter. The client was educated about the need for the Foley and the consequences of refusing the treatment; client verbalized understanding of the education. 2. The client stubbornly refused the Foley catheter insertion. 3. The client was medicated and the Foley was inserted without difficulty. 4. The client refused the Foley catheter. 9:”?!97‘ 6. Identify the purposes of charting. (Select all that apply.) To fill up the nurse’s spare time. To communicate care and responses to care. To create a legal document. To demonstrate what the nurse did every moment of the shift. To provide a basis for evaluation. 7. The student nurse is learning to chart effectively in the clinical setting. Which action by the student nurse increases the student’s knowledge about effective charting? 1. Chart and hope it is correct. 2. Practice charting and hope it will improve with time. 3. Do nothing now and learn charting after graduation. 4. Read charts to learn from actual situations. 8. Which example of documentation is most correct when charting a client’s behavior? 1. The client was shouting, “I am so mad that I am going to hit you ifyou come any closer.” 2. The client seems angry and moderately aggressive. 3. The client is angry and shouting. 4. The client stated that he was mad and wanted to hit someone. © 2016 by Pearson Education, Inc. CHAPTER 15/ Documenting and Reporting 77 9. During the change-of-shift report, the nurse reports that the client is having “respiratory difficulty.” What should the nurse add to this report? 1. “But she seems okay.” 2. “Her respiratory rate is up to 28 breaths/min; oral temperature is [00 degrees; heart rate is 96 beats/minute; 02 saturation of 90%.” 3. “ I put her on 3 liters ofoxygen.” 4. “1 called the doctor but he didn’t do anything.” 10. When the nurse places a check mark or a dash in an allocated space and uses an asterisk to reflect other pertinent information that has been recorded elsewhere on the chart, this is an example of what type of documentation? 1. Multidisciplinary charting 2. Charting by exception 3. Focus charting 4. Flow sheet chartn 1 1. What measures can the nurse take to maintain confidentiality of client records? (Select all that apply.) 1. Personal passwords are not shared with anyone else. 2. Never leave the computer unattended after logging into the system. 3. Do not leave paperwork with the client’s information in an unsecured location. 4. Discard all unneeded computer-generated worksheets in the trash can. 12. Identify examples that health care professionals may use in order to communicate specific information regarding the client or the client’s care. (Select all that apply.) 1 . Change-of—shift report 2. Discussing the client’s care in the cafeteria 3. Contacting the physician via telephone regarding new orders for medication to decrease an increased temperature 4. Care plan conferences © 2016 by Pearson Education, Inc. CHAPTER 1 6 HEALTH PROMOTION KEY TERM REVIEW Match each term with its appropriate definition. 1. Action stage 15. Open system 2. Boundary 16. Output 3. Closed system 17. Positive feed-back 4. Contemplation stage 18. Precontemplation stage 5. Disease prevention 19. Preparation stage 20. Primary prevention 7. Health promotion 21. Psychological homeostasis 8. Health protection 22. Secondary prevention 9. Health risk assessment (HRA) 23. Self-regulation 10. Holism 24. Termination stage 1 1. Homeostasis 25. Tertiary prevention 12. Input 13. Maintenance stage H :5 6. __ Feedback Negative feed-back @‘ 2016 by Pearson Education, Inc. CHAPTER 16 / Health Promotion 79 Stimulates change . Focuses on early identification of health prob— lems and prompt intervention Assessment and educational tool that indicates a client’s risk for disease or injury during the next 10 years . Occurs when the person actively implements behavioral and cognitive strategies . Generalized health promotion and specific protection against disease Energy, matter, and information move into and out of the system through the system boundary g. Inhibits change h. Person acknowledges having a problem, serious— ly considers changing a specific behavior, and verbalizes a plan to change A Person does not think about changing his or her behavior in the next 6 months . Its focus is to help rehabilitate individuals and restore them to an optimum level of functioning within the constraints of the disability. . Mechanism by which some of the output of a system is returned to the system as input Information, material, or energy that enters the m. Emphasizes the whole person and how one area of concern relates to the entire person . Person strives to prevent relapse by integrating adopted behaviors into his or her lifestyle . Homeostatic mechanisms come into play automatically . Energy, matter, or information given out by the system as a result of its processes . Behavior motivated by a desire to actively avoid illness . Disease prevention . Behavior motivated by the desire to increase well—being . Describes the relative constancy of the internal processes ofthe body . The person intends to take action in the immediate future . Does not exchange information with its environment . The ultimate goal of the transtheoretical model. . A real or imaginary line that differentiates one system from another . Emotional or psychological balance system KEY TOPIC REVIEW 1. List four main characteristics of homeostatic mechanisms. 'd. b. C. d. 2. The nurse must consider all components of health in order to ensure holistic health care. What are the five components ofhealth? a. b. C. © 2016 by Pearson Education, Inc. 80 CHAPTER 16 / Health Promotion 3. Abraham Maslow, a renowned needs theorist, ranks human needs on five levels. List the levels in ascending order and give an example of a need in each level. a b. c. d. e. What did Richard Kalish add to Maslow’s hierarchy of needs, where did he add it, and why did he add it? Healthy People 2020: Understanding and Improving Health (U.S. Department of Health and Human Services, 2010) presents a comprehensive strategy for promoting health and preventing illness, disability, and premature death. a. True b. False List the two major goals of Healthy People 2020 and what is reflected by those goals. a. b. Health—promoting behavior is directed toward attaining positive health outcomes for the client. a. True b. False How do health promotion plans need to be developed to encourage clients to participate in their care? To encourage a client to quit smoking, what strategy of implementation should the nurse use? . Which of the following should be included in a client’s lifestyle assessment that would be relevant to his or her health care? (Select all that apply.) 1. Nutrition 2. Physical activity 3. Drug, alcohol, and cigarette smoking habits 4. Marital status FOCUSED STUDY TIPS 1. How does understanding developmental stage theories enable the nurse to provide knowledgeable care? As a nurse, what is your role in health promotion? How can you enhance health promotion actions in your community? Discuss the Health Promotion Model. Refer to the text, Figure 164. When exploring the stages of change, is change always linear? Why or why not? Why is it important for nurses to understand the stages of change? What is the nurse’s role in health promotion? Do you believe that the nurse should be a good role model for healthy living? How would you feel ifa nurse Who never exercises is attempting to instruct you (a client) in the importance of exercise? . Compare and contrast health promotion and disease prevention. Give one example of each concept. (9' 2016 by Pearson Education, Inc. CHAPTER 16/ Health Promotion 81 CASE STUDY You are caring for Benjamin Conner, a 65—year—old who presents with acute chest pain and shortness of breath. Upon assessment, you learn that Mr. Conner is a 40—pack-year smoker and leads a sedentary lifestyle. After Mr. Con— ner’s condition has been stabilized, you are planning education to provide to Mr. Conner. 1. What health promotion education will you provide? 2. When providing education to Mr. Conner, what type of prevention will you be demonstrating? REVIEW QUESTIONS 1. A client reports that he believes he will “never kick the habit” of smoking because he has tried before and failed. Using the transtheoretical model (TTM), what stage of health behavior change is the client functioning in? 1. Preparation stage 2. Contemplation stage 3. Termination stage 4. Precontemplation stage 2. Identify which of the following are basic types of health promotion activities. (Select all that apply.) 1. A billboard promoting abstinence to prevent sexually transmitted infections and unplanned pregnancies 2. A wellness assessment program 3. A nurse who models healthy lifestyle behaviors 4. A school of nursing that is holding a blood pressure fair 3. The nurse refers a new below-the-knee (BKA) amputation client to a support group for amputees. This is an example of what type of prevention? |\) 1. Primary . Secondary 3. Tertiary 4. Terminal 4. The nurse is providing health education about injury and poisoning prevention to a group of young mothers at a health fair. What type of prevention is the nurse conducting? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Limited prevention 5. A client had surgery for gastrointestinal problems and required a colostomy. What type of preventive care would this client need at this stage? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Limited prevention © 2016 by Pearson Education, Inc. 82 CHAPTER 16/ Health Promotion 6. A community health nurse is teaching a group of older adults about self—examination techniques for breast and testicular cancer. What type of health care prevention is the nurse teaching? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Limited prevention 7. Which client would benefit from Pender’s health promotion model? (Select all that apply.) 1. An active 21—year-old client who does not smoke or drink alcohol 2. A 50-year-old client who exercises four times a week 3. A 32—year—old who has yearly breast exams and other routine health screenings 4. An overweight 29—year-old who engages in risky behaviors 8. A client has complete confidence that she has learned health behaviors that will enable her to maintain her current health status by exercising three to five times a week, monitoring her dietary intake, and by no longer engaging in risky behaviors. What stage of health behavior change is this client experiencing? 1. Maintenance 2. Action 3. Preparation 4. Termination 9. The client is attending Alcoholics Anonymous (AA) meetings for support to assist in remaining sober. It is anticipated that the client will remain in this group for several years. What stage of health behavior change is this client experiencing? 1. Maintenance 2. Action 3. Preparation 4. Termination 10. Who is responsible for developing health promotion plans? 1. Physician 2. Family 3. Client 4. Nurse © 2016 by Pearson Education, Inc. CHAPTER 17 HEALTH, WELLNESS, AND ILLNESS KEY TERM REVIEW Match each term with its appropriate definition. Acute illness . Cause of a disease or condition 2. Adherence . When symptoms dis—appear . A concept from social learning theory that nurses can use to determine whether clients are likely to take action regarding health U) 1. Chronic illness 4. Disease 5. Etiology 6. Exacerbation 7. Health 8. Health behaviors 9. Health beliefs 10. Health status 1 1. ! Illness 12. Illness behavior 13. Lifestyle 14. Locus of control 15. Remission 16. Risk factors 17. _.,,# Well—being 18. Wellness . A subjective perception of vitality and feeling well that can be described, experienced, and measured . Refers to a person’s general way of living . Ways in which individuals describe, monitor, and interpret symptoms, take actions, and use the health care system . Characterized by symptoms of relatively short duration . Characterized by symptoms that last for an extended period, usually 6 months or more '. The extent to which an individual’s behavior coincides with medical or health advice I When symptoms reappear . Alteration in body functions resulting in a reduction of capacities or a shortening of the normal life span . A state of'well-being . Concepts about health that an individual believes are true . A state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity . A highly subjective state that may or may not be related to disease © 2016 by Pearson Education, Inc. 83 84 CHAPTER 17/ Health, Wellness, and Illness p. State of health of an individual at a given time q. Practices that have potentially negative effects on health r. The actions people take to understand their health state, maintain an optimal state of health, prevent illness and injury, and reach their maximum physical and mental potential KEY TOPIC REVIEW . What is the difference between illness and disease? @PONQV‘PE” Match the theorist with the correct theory of the stages and aspects of illness. a. Parsons Outlined five stages of illness b. Suchman Described four aspects of the sick role How is a client’s usual pattern of behavior changed with illness or hospitalization? Explain the internal variables in biologic, psychological, and cognitive dimensions. Explain the differences between well-being and wellness. What are three external influences on health? List the seven dimensions of wellness that Anspaugh, Hanrick, and Rosato proposed. The causation ofa disease is called its What are the four aspects of the sick role that Parson describes? a. b. c. d. . Define the following. .57 llealth behaviors: :qorho Exacerbation: no a. Locus of control: Health beliefs: Health status: Acute illness: Remission: Risk factors: FOCUSED STUDY TIPS l. How are health belief and behavior models useful in nursing? What are two models used for nursing? 2. How can nurses enhance health care adherence? . Why do nurses have to be aware of their own personal definitions of health? How can that enhance their nursing practice? . Explore the various theorists who have described stages and aspects of illness. How does Parson describe the sick role? CO 2016 by Pearson Education, Inc. CHAPTER 17/ Health, Wellness, and Illness 85 5. Illness affects the entire family. How can the nurse best explain the effects on the family to the significant others ofthe ill person? 6. Describe the three elements of the Leavell and Clark agent—host—environment model of health and illness. Discuss the model’s concept of illness prevention and wellness promotion. CASE STUDY A 52-year-old female with a family history of lung cancer requests information about smoking cessation. The client admits that she smokes one pack per day and has smoked for approximately 32 years. 1. With consideration of the goals of Healthy People 2020. how can the nurse assist the client? REVIEW QUESTIONS 1. A client has severe arthritis, yet she still works 40 hours per week and takes care ofher family. This is an ex- ample of which health model? 1. Clinical model 2. Adaptive model 3. Role performance model 4. Eudemonistic model 2. Which health model describes illness as a condition that prevents self-actualization? 1. Clinical model 2. Adaptive model 3. Role performance model 4. Eudemonistic model 3. Osteoporosis and autoimmune diseases are examples of what type of biologic dimension that influences a person’s health? 1. Genetic makeup 2. Gender 3. Age 4. Developmental levels 4. During the first years of life. infants lack physiological and psychological maturity, so their defenses against diseases are lower. This is an example of what type of biologic dimension that influences a person’s health? 1. Genetic makeup 2. Gender 3. Age 4. Developmental levels 5. The impact of illness on an individual may cause: (Select all that apply.) 1. The client to become dependent on the health care provider.. 2. The client to have role changes within the family. 3. The client to become more outgoing and friendly. 4. The client’s self—esteem to greatly increase. © 2016 by Pearson Education, Inc. 86 CHAPTER 17/ Health, Wellness, and Illness 6. A nursing student is instructing a female client on healthy lifestyle choices. What are the correct examples of healthy lifestyle choices? (Select all that apply.) 1. Tobacco use of 1 pack per day 2. Exercising 3 to 4 days per week for 1 hour 3. Regular dental checkup 4. Seat belt use 7. A client who was obese has lost a large amount of weight in order to feel better about himself. What health belief model could the nurse use to assist the client? 1. Health locus of control model 2. Rosenstock’s health belief model 3. Becker’s health belief model 4. Pender’s health belief model 8. A client reports that she has been practicing yoga for the past 2 years in order to reduce stress and increase muscle flexibility. What part of wellness is this client participating in? 1. Physical and emotional 2. Physical and social 3. Social and emotional 4. Intellectual and emotional 9. The nurse is attempting to instruct a client with chronic obstructive pulmonary disease on the benefits ofnot smoking, yet the nurse admits that she also smokes one pack a day. What might be a factor in the client’s re— fusal to quit smoking at this time? l. The client is distressed about quitting the habit ofsmoking. 2. The nurse is not modeling healthy lifestyle choices. 3. The perceived benefits of not smoking are inconclusive at this time. 4. The client’s cultural heritage demands that he smoke two packs of cigarettes per day. 10. Diabetes mellitus is an example of: 1. Acute illness. 2. Adherence. 3. Chronic illness. 4. Exacerbation. @ 2016 by Pearson Education, Inc. V‘ CHAPTER 18 CULTURALLY RESPONSIVE NURSING CARE KEY TERM REVIEW Match each term with its appropriate definition. NNNN—a_._.._._.._.._.._t.—._. owwsewweww WN??99°“9‘F”:‘>W.NE“ 1. 24 Acculturation , Refers to the fact or state of being different Assimilation . Preconceived notion or judgment that is not based on sufficient knowledge Biomedical health belief # Cultural broker Cultural competence Culturally responsive care Culture Discrimination Diversity Ethnicity Ethnocentrism Folk medicine Generalizations _ Health disparities Heritage Holistic health belief Magico-religious health belief Nationality Prejudice Race Racism Religion . Biomedical health beliefs . The thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups . Things passed down from previous generations . Beliefin the superiority ofonc’s own culture and lifestyle . Differential and negative treatment of individuals on the basis of their race, ethnicity, gender, or other group membership . Composed of people who have a distinct identity and yet are related to a larger cultural group ‘. Holds that the forces of nature must be main— tained in balance or illness results '. One who engages both parties effectively and efficiently in accessing the nuances and hidden sociocultural assumptions embedded in each other’s language . Social and cultural characteristics as well as ancestry . Beliefs and practices relating to illness and healing that derive from cultural traditions rather than from modern medicine’s scientific base _,,fi Scientific health belief Subculture Transcultural nursing © 2016 by Pearson Education, Inc. .Based on the belief that life is controlled by physical and biochemical processes that can be manipulated by humans 87 88 CHAPTER 18 / Culturally Responsive Nursing Care . Differences in care experienced by one popula— tion compared with another population . Statements about common cultural patterns I.) . Process by which an individual develops a new cultural identity . Relationship between individuals who believe that they have distinctive characteristics that make them a group A system of beliefs, practices, and ethical values about divine or superhuman power worshipped as the creator and rulers of the universe Centered on the client’s cultural perspectives, integrating the client’s values, and beliefs into the plan of care The ongoing process in which the health care professional continuously strives to achieve the ability and availability to work effectively within the cultural context of the patient (individual, family, community) . Generally refers to the sovereign state or country where an individual has membership, which may be through birth, through inheritance (parents), or through naturalization . View in which health and illness are controlled by supernatural forces . Involuntary process occurs when people incorporate traits from another culture . Assumption held about racial groups that includes belief that races are inherently unequal . Centered on client’s cultural perspectives, integrating client’s values and beliefs into the plan of care {KEY TOPIC REVIEW 1. What is culture? How does it define health? refers to things passed down from previous generations, 2 . The term 3 . What is the purpose of the US. Department of Health and Human Services (USDHHS), in terms of culture? 4. What is a goal of the Centers for Disease Control and Prevention (CDC), in terms of culture? 5 . What is the purpose for the National Center on Minority Health and Health Disparities (NCMHD)? N 6 . Describe what influence the Racial and Ethnic Approaches to Community Health Across the United States (REACH U.S.) program has on nursing care? What is one of the goals of Healthy People 2020? How does the National Healllicare Disparities Report influence current nursing practice? Differentiate between culturally sensitive. culturally appropriate, and culturally competent care in professional nursing. is credited with creating the theory of culture care diversity and universality. FOCUSED STUDY TIPS 5"???) What are the core practice competencies of culturally competent nursing care? What does the magico-religious health beliefview entail? Give an example. How do scientific or biomedical health beliefs differ from holistic health beliefs? How does ethnocentrism differ from cultural beliefs? Describe the LEARN model and the four Cs of culture used in cultural assessments. © 2016 by Pearson Education, Inc. CHAPTER 18 / Culturally Responsive Nursing Care 89 CASE STUDIES 1. While caring for an Asian client who became ill while visiting relatives in the United States, the nurse notices an unusual bruised circular pattern on the trunk of the client. a. If the nurse is culturally competent, what would be an appropriate comment? b. If the nurse has xenophobia, what comment might the nurse make regarding the coining or cupping that occurred? c. Give an example of an ethnocentric statement from the nurse. d. What nursing action would be considered discrimination? 2. A nurse is taking care ofa traditional Hispanic client on a medical—surgical unit following a laparotomy appendectomy. Review Box 18—2 in the text for an overview of the health-related practices of different cultures. a. If the client does not return direct eye contact, is this indicative of a cultural difference or a result of a “shitty,” evasive client? b. The client’s family desires to spend as much time with him as possible, including staying after hours. How does the nurse handle this situation? c. The client does not want to take his preventive medication to prevent stress ulcers. He states that his life and recovery status are in God’s hands, and that he “has no need of pharmaceutical medications.” What action should the nurse take at this time? REVIEW QUESTIONS 1. The major factor contributing to the increased emphasis on the need for proficiency in cultural nursing practice in the United States is which of the following? 1. An increasing birth rate 2. Increased access to health care services 3. Demographic changes 4. A decreasing rate of immigration 2. A client who has a French mother and an Italian father is described as having a(n) 1. Bicultural 2. Diversity 3. Subculture 4. Acculturation 3. A client who is homosexual is described as having: 1. Biculturalism. 2. Acculturation. 3. Diversity. 4. Subculture. 5. Assimilation. © 2016 by Pearson Education, Inc. identification. 90 CHAPTER 18 / Culturally Responsive Nursing Care 4. The involuntary process of occurs when people adapt to or borrow traits from another culture. 9.4;?!” 1. Biculturalism Acculturation Diversity Subculture Assimilation 5. If a citizen of Japan permanently moves to America, then an American citizen. may occur when that individual becomes 1. Biculturalism 2. Diversity 3. Assimilation 4. Subculture 5. Acculturation 6. A nurse caring for a Chinese client orders rice for every meal without consulting the client. What may the nurse be displaying? 1. Prejudice 2. Discrimination. 3. Stereotyping. 4. Racism. 7. Using the HEALTH traditions model, which would be considered an example of spiritual and mental health? 1. Avoiding persons who can cause illnesses 2. Special foods and drinks 3. Acupuncture 4. Healing rituals 8. While caring for a Latin American client who cannot speak or understand English, the nurse recognizes that she will need a(n) in order to care for the client. 1. Family member 2. Translator 3. Representative 4. Interpreter 9. While caring for a diverse cultural population, the nurse must recognize that cultural beliefs and behaviors may lead to: l. Stereotyping. 2. Ethnocentrism.. 3. Placement of the nurse’s culture onto others. 4 . Being confused regarding the many values and beliefs of different cultures. © 2016 by Pearson Education, Inc. CHAPTER 18 / Culturally Responsive Nursing Care 91 10. Identify which nursing interventions would be beneficial when communicating with clients who have limited knowledge of English. (Select all that apply.) 1. Use slang words, limited medical terminology, and no abbreviations. 2. Speak slowly, in a respectful manner, and at a normal volume. 3. Use nonverbal communication, which uses silence, touch, eye movement, facial expressions, and body posture that is acceptable to that particular culture. 4. Ask a member of the client’s family, especially a child or spouse, to act as interpreter. 5. Address the client, not the interpreter. l l. Campinha-Bacote’s model of cultural competence is based on a framework that integrates transcultural nursing, medical anthropology, and multicultural counseling. Identify three of the five constructs of this model of cultural competence. 9‘95“.“ 1. Cultural awareness Cultural appearance Cultural desires Cultural skills Cultural experiences (C) 2016 by Pearson Education, Inc. CHAPTER 19 COMPLEMENTARY AND ALTERNATIVE HEALING MODALITIES KEY TERM REVIEW Match each term with its appropriate definition. 1. Acupressure 14. Homeopathy 2 Acupuncture 15. Hypnotherapy 3 Allopathic medicine 16. Imagery 4 Alternative medicine 17. Massage therapy 5 Aromatherapy 18. Meditation 6. Ayurveda 19. Music therapy 7 Biofeedback 20. Naturopathic medicine 8 Biomedicine 21. Qigong 9 Chiropractic 22. Reflexology Complementary medicine 23. T’ai chi 24. Traditional Chinese medicine 10. l l. 7 Guided imagery 12. _ Herbal medicine \J 25. wYoga l3. _ Holism Q 2016 by Pearson Education, Inc. 92 CHAPTER 19/ Complementary and Alternative Healing Modalities 93 . Application of a trance state in which an individual’s concentration is focused and distraction is minimized . Conventional or allopathic medicine . A self—healing system, assisted by small doses of remedies or medicines . Therapies other than biomedicinc used to promote health and wellness 7. Therapeutic use of essential oils of plants in which the odor or fragrance plays a key role . Use of music to induce relaxation or distract clients . Technique of applying pressure or stimulation to specific points on the body using needles . Chinese discipline consisting of breathing and mental exercises combined with body movement '. System of medicine that emphasizes the interde— pendence of the health of the individual and the quality of societal life ‘. Scientific manipulation of the soft tissues of the body 0. Discipline that combines physical fitness, meditation, and self-defense p. Health profession that believes that health is a state of balance, especially of the nervous and musculoskeletal systems q. Alternative medicine r. System based on the premise that the body’s qi circulates through pathway meridians and can be accessed and manipulated s. General term for a practice that involves relaxing the body and easing the mind t. The belief that people are more than physical bodies, that the combined mental, emotional, spiritual, relationship, and environmental components play a crucial role in a person’s health u. A state of focused attention that encourages changes in attitudes, behavior, and physiological reactions v. A system of medicine and way of life that emphasizes client responsibility, client education, health maintenance, and disease prevention w. Technique of applying pressure or stimulation to . Form of acupressure commonly performed on the feet . The use of plants in treating illness .Method for life that includes ethical models for behavior and mental and physical exercises aimed at producing spiritual enlightenment specific points on the body using finger pressure x. A two-way communication between the conscious and unconscious mind that involves the whole body and all of its senses y. Western medicine . Method by which a person can learn to control certain physiological responses of the body KEY TOPIC REVIEW 1. is the combination of mental, emotional, spiritual, relationship, and environmental factors. 2. What is the mission of the American Holistic Nurses Association (AHNA)? 3. How can the nurse create a healing environment in health care? 4. identify three methods of self-healing for nurses. a. b. C. © 2016 by Pearson Education, Inc. 94 CHAPTER 19/ Complementary and Alternative Healing Modalities . Identify which of the following are manual methods of healing: (Select all that apply.) V a. Massage .0 b. Meditation Hypnotherapy d. Chiropractic 6. Hand-mediated biotield therapies f. Aromatherapy is viewed as the force that integrates the body, mind, and spirit, and connects everything. What is the third largest independent health profession in the Western world after conventional medicine and dentistry? Match the type of prayer with its correct definition. a. Intercessory prayer _ No specific outcome is requested during prayer time b. Nondirected prayer __ An informal talk with God—like talking with a good friend 0. Ritual prayer ‘ Individual who is praying asks for a specific outcome d. Colloquial prayer _ Asking God for things for oneself or others e. Directed prayer _ The use of formal prayers or rituals such as prayers from a prayer book or Jewish siddur f. Meditation prayer Contemplative prayer What are the contraindications for magnetic therapy and, on principle, does this therapy work? 10. Describe chelation therapy and how it works in the body. FOCUSED STUDY TIPS 1. Discuss the six concepts that are common to most alternative practices. . Describe the different mind—body therapies and the benefits ofeach. What issues arise with animal-assisted therapies in health care? Describe the benefits of animal-assisted therapy. Differentiate between conventional medicine, biomedicine, allopathic methods, and alternative or complementary medicines. How are herbs used in medicine? What are some nursing guidelines for herbs used in conjunction with over—the—counter (OTC) medications? Differentiate between mindebody therapies and manual healing methods. © 2016 by Pearson Education, Inc. \_/' CHAPTER 19/ Complementary and Alternative Healing Modalities 95 CASE STUDIES 1. The nurse is conducting the initial assessment interview for Roberta Sinclair, a 72-year-old female, a. What type of questions should the nurse ask to investigate Ms. Sinclair’s use of complementary and alter— native therapies? 2. Gabe Santos, a 57-year-old client, is admitted to the hospital with uncontrolled hypertension. Mr. Santos states that he takes his antihypertension medication as directed, exercises, and watches his sodium intake. Mr. Santos also reports taking an enteric-coated aspirin daily. However, Mr. Santos states he has noted more bruising than usual lately. Refer to the “Practice Guidelines” in the text to answer the following questions. a. Which popular herbal preparations could interfere with Mr. Santos’s current medication regimen? c. Which additional complementary and alternative healing modalities might the nurse suggest to Mr. Santos to help treat his hypertension? REVIEW QUESTIONS 1. Concepts that are common to most alternative practices include: (Select all that apply.) 1. Holism. 2. Balance. 3. Spirituality. 4. Prescription medications. 5 . Technology and instrumentation. 2. What is the name of the system ofmedicine that emphasizes client responsibility, client education, health maintenance, and disease prevention? 1. Naturopathic medicine 2. Nutritional medicine 3. Homeopathic medicine 4. Chiropractic medicine 3. What nursing action is most correct regarding the use of alternative and complementary therapies? 1. Recommend hydrotherapy for the older adult clients. 2. Recommend colonies for clients with Crohn’s disease. 3. Encourage the client to discuss the use of herbs, teas, vitamins, or other natural products. 4. Encourage the client in using alternative therapies, such as acupuncture and yoga. 4. The nurse suggests to a client with osteoarthritis to participate in Pilates. What are the benefits of Pilates for this client? 1. It will give the client an activity to perform to lessen boredom. 2. It encourages a spiritual connection. 3. It may improve flexibility andjoint health, and relieve muscle aches. 4 . It cleanses the colon and promotes a healthy feeling. © 2016 by Pearson Education, Inc. 96 CHAPTER 19 / Complementary and Alternative Healing Modalities 5. Which of the following therapies stimulates the production of catecholamines, hormones, and endorphins? It can be used in establishing relationships, relieving tension and anxiety, and even facilitating learning. 1. Music therapy 2. Hypnotherapy 3. Guided imagery therapies 4. Humor and laughter therapy 6. The American Holistic Nurses Association and an organization called “Beyond Ordinary Healing” offer a nurses’ certificate program in complementary and alternative medicine (CAM).. After successfully passing the certification, what is the nurse certified to perform? 1. Music therapy 2. Hypnotherapy 3. Guided imagery therapies 4. Humor and laughter therapy 7. What do meditation, biofeedback, and guided imagery have in common? 1. The process of physical resting and rhythmic breathing 2. The process of physical activity and music therapy 3. The process of relaxation and sleep 4. The process of utilizing aromatherapy 8. Which of the following genres of music are used to induce relaxation and distract clients from pain? 1. Rap music 2. Opera music 3. Piano and flute melody playing quietly 4. Country music with yodeling 9. A client is on complete bed rest and complains of back pain from lying “in the bed all the time.” What is a 95":‘>.W!\’T‘ nursing intervention that uses a nonpharmacologic method to ease the discomfort? (Select all that apply.) Administering a dose of morphine for pain Assisting the client to a bedside chair Giving the client a back massage Instructing the client that the health care provider will see him tomorrow night Using music that contains no words Instructing the client in guided imagery © 2016 by Pearson Education, Inc. CHAPTER 20 CONCEPTS OF GROWTH AND DEVELOPMENT KEY TERM REVIEW Match each term with its appropriate definition. 1. Accommodation 14. Id 2. Adaptation 15. Libido 3 Adaptive mechanisms 16. Maturation 4 Assimilation 17. Moral 5 Attachment 18. Moral behavior 6. _m __ Cognitive development 19. Moral development 7 Defense mechanisms 20. Morality 8 Development 21. Personality 9 Developmental stages 22. Superego 10. Developmental task 23. Temperament 1 1. Ego 24. Unconscious mind 12. ____ Fixation 13. Growth © 2016 by Pearson Education, Inc. 97 98 CHAPTER 20 / Concepts of Growth and Development a. Arises at a certain period in the life of an individual, successful achievement of which leads to success with later tasks b. Resides in the unconscious, and seeks immediate pleasure and gratification c. Contains the conscience rn. Relating to right and wrong 11. Inability of the personality to proceed to the next stage because of anxiety . Theory that proposes that life is a series of levels of achievement d. The way in which individuals respond to their external and internal environments . Process through which humans encounter and react to new situations by using the mechanisms they already possess e. The way a person perceives the requirements of . Adaptive mechanisms D‘O‘Q 7'7 living in society and responds to them Process of change whereby cognitive processes mature sufficiently to allow the person to solve problems that were unsolvable before The pattern of change in moral behavior with age . The manner in which people learn to think Ability to handle demands made by the . The outward expression of the inner self . The result of conflicts between the id’s impulses and the anxiety created by the conflicts due to social and environmental restrictions j. A process of differentiation and refining of abilities and skills k. The part of a person’s mental life of which the person is unaware environment . The realistic part of the person . Physical change and increase in size . Lasting, strong emotional bond . An increase in the complexity of function and skill progression X. Underlying motivation to human development l. Refers to the requirements necessary for people to live together in society KEY TOPIC REVIEW 1. What is meant by the term growth? What indicators of growth are used? 2. Define development. 3. List four factors that influence growth and development. a b. c. d. 99°F]? Ur 4. What is meant by psychosocial development? Sigmund Freud introduced a number of concepts about development. What are the major concepts in his theory? Define the terms used in his theory. Describe social learning theory. Describe Kohlberg’s theory on moral development. What does the behaviorist learning theory emphasize? Which two theorists describe stages of spiritual development or faith? Describe their concepts in depth. (9 2016 by Pearson Education, Inc. CHAPTER 20 / Concepts of Growth and Development 99 10. Define the following terms: 3. Accommodation b. Adaptation c. Assimilation d. Developmental task FOCUSED STUDY TIPS QMEP’N 1. What is the definition of personality? Why is it hard to define? Describe Erik Erikson’s stages of development. What are Freud’s five stages of development? Describe the moral theories of Kohlberg and Gilligan. Describe Piaget’s phases of cognitive development. Describe the concept of temperament and its relationship to growth and development. CASE STUDY The nurse is caring for a 6-month—old infant at a well-child clinic. Using Piaget’s phases of cognitive development, answer the following questions: I. What primary abilities will the infant use in this phase of cognitive development? 2. Describe the significant behavior noted in this phase of cognitive development. REVIEW QUESTIONS 1. In which direction does growth and development occur from birth if it starts from the head and moves to the trunk, the legs, and the feet? I. Proximodistal direction 2. Simple to complex direction 3. Peripheral to medial direction 4. Cephalocaudal direction 2. The nurse prepares to give an antibiotic injection to a 3-year-old child who has an infection. When the child views the nurse with a needle, he begins to cry and say “no-no” while reaching for his mother. According to Piaget’s phases of cognitive development, what stage/phase is the toddler experiencing? 1. Primary circular phase 2. Concrete operations phase 3. Preconceptual phase 4. Initiative versus guilt phase @ 2016 by Pearson Education, Inc. 100 CHAPTER 20/ Concepts of Growth and Development 3. While caring for a 72-year—old client, the nurse suspects that the client may be experiencing depression when the client states that he feels like he is “falling apart because of age.” According to Robert Peck’s theory regarding adult development, what task is the client struggling with? 1. Ego differentiation versus work-role perception 2. Body transcendence versus body preoccupation 3. Ego transcendence versus ego preoccupation 4. Integrity versus despair 4. A school nurse is teaching high school students about sexually transmitted infections and pregnancy prevention in a health education course. According to Havighurst’s age periods and developmental tasks, why is this the appropriate age to introduce this discussion? 1. Adolescents are achieving new and more mature relations with their peers and are trying to assert their independence. 2. Adolescents are finding a congenial social group and selecting mates. 3. Adolescents are developing a conscience, morality, and a set of values. 4. Adolescents are establishing satisfactory affiliations with one’s age group. 5. A pregnant adolescent client tells the nurse that abortion is wrong, and that it is for this reason the client decided to continue her pregnancy. What concept does the adolescent’s comment reflect? l. Morals 2. Spirituality 3. Religion 4. Psychological development 6. The nurse is exploring activities that would enhance an older adult client’s retirement, per the client’s request. Which theorist would explain this type of adult development? 1. Freud 2. Piaget 3. Kohlberg 4. Peck 7. According to Gould’s study, which is the best example of stage 4? l. A 19-year—old leaving for college 2. A 25-year-old in the military 3. A 30—year—old graduate student 4. A 65—year-old retired schoolteacher 8. A 26—year-old female client makes the statement that she realizes that she has been selfish in her life and she needs to “do more” for her aging parents. According to Carol Gilligan’s research, what stage of moral development is the client in? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4 CC) 2016 by Pearson Education, Inc. CHAPTER 2 l PROMOTING HEALTH FROM CONCEPTION THROUGH ADOLESCENCE KEY TERM REVIEW Match each term with its appropriate definition. 1. Amblyopia 13. Menarche 2 Apgar scoring system 14. Myopic 3 Apocrine glands 15. Primary sexual characteristics 4 Denver Developmental Screening Test (DDST-H) 16. Puberty 5 Embryonic phase 17. Repression 18. _ Sebaceous glands Failure to thrive 19. Secondary sexual characteristics 8 Fetal phase 20. Separation anxiety 9 Hyperopic 21. Stereognosis 10. Identification 22. Strabismus 11. Introjection 23. Teratogen 12. Lanugo 24. Vernix caseosa 6. 7 _ Emmetropic © 2016 by Pearson Education, Inc. 101 102 CHAPTER 21 / Promoting Health From Conception Through Adolescence . Occurs when the child perceives self as similar to another person and behaves like that person . Fine downy hair that covers the body of the fetus . Occurs in the second and third trimester of pregnancy . Onset of menstruation Differentiate male from female but not directly related to reproduction Provides a numeric indicator of the baby’s physiological capacities to adapt to extrauterine life g. Protective covering that develops over the fetal skin h. Failure to establish normal neuropathways of vision that leads to reduced visual acuity in one eye . Ability to identify an unseen object by touch A condition in which the infant shows substandard growth and development . The ability of the eye to refract light normally Fear and frustration that comes with parental absences 0. Standardized test used to screen development of children from birth to 6 years of age p. First stage of adolescence q. Anything that adversely affects normal cellular development in the embryo or fetus r. Eight-week period during which the fertilized ovum develops into an organism with most of the features of the hu— man s. Seerete sebum t. Organs necessary for reproduction u. Cross eye v. Assimilation of the attributes of others into oneself w. Farsighted x. Nearsighted Release sweat onto the skin in response to emotional stimuli only . Removing experiences, thoughts, and impulses from awareness KEY TOPIC REVIEW 1. How long does prenatal development last? are the three periods of pregnancy that last about months. 3. Identify the trimester and/0r phases of fetal development and describe what is taking place with the fetus dur— ing that time. a. b. C. 4. What are the five maternal factors that contribute to higher risks of low-birth-weight babies? a b. e. d. C. 5. Birth weight by the month and 77‘ by the 6. For the infant, how does cognitive development occur? © 2016 by Pearson Education, Inc. month. CHAPTER 21 / Promoting Health From Conception Through Adolescence 103 List three milestones that toddlers develop between ages 12 months to 3 years. a. b. c. According to Erickson, what task are preschoolers, ages 4 to 5, engaged in? In the school-age period the skills learned are particularly important in relation to work later in life and the willingness to try new tasks. a. True b. False 10. Choose the major landmarks of the adolescent period. (Select all that apply.) a. Rapid growth in height b. Deciduous teeth are shed c. Sexual maturity d. Increasing dependence on the family e. Leading causes of death are motor vehicle crashes, homicides, suicides, and other unintentional injuries FOCUSED STUDY TIPS . Why is it important for the nurse to know the normal developmental tasks for each age group? Identify nursing activities to assess and promote health of the fetus and the developmental milestones, noting the average time of occurrence. . Identify nursing activities to assess and promote health of the toddler and the developmental milestones, not— ing the average time of occurrence. Identify nursing activities to assess and promote health of the preschooler and the developmental milestones, noting the average time of occurrence. Identify nursing activities to assess and promote health of the adolescent and the developmental milestones, noting the average time of occurrence. Describe how vision changes from infancy to adulthood. CASE STUDIES 1. The nurse is discussing infant growth and development with the parents of a newborn. The nurse discusses several reflexes that are found in the normal neonate. a. What reflex disappears after 8 months of age? b. If the Babinski reflex persists after 1 year and remains positive, what does that indicate? 2. The mother ofa 15—year-old girl is talking with the pediatric nurse and says, “I don’t know what is wrong with my daughter. She was always such a good kid, but now she talks back, only wants to be with her friends, and won’t participate in family activities.” a. What explanation might the nurse give this mother to explain the adolescent’s behavior? b. What anticipatory guidance will the nurse provide this mother to prepare her for future changes she is likely to see in her daughter? © 2016 by Pearson Education, Inc. 104 CHAPTER 21 / Promoting Health From Conception Through Adolescence 3. The nurse is performing an Apgar score on a newborn who has been born via cesarean section. The newborn’s heart rate is 110 beats/min and respirations are regular. The newborn is crying and active. The newborn’s skin color is pink, except for the extremities, which are blue in color. a. At what time(s) will the nurse perform the Apgar score? b. What is the newborn’s current Apgar score? REVIEW QUESTIONS 1. The nurse is instructing a group of pregnant women about ways to reduce the risks of birth defects. Which of the following statements indicates a need for further instruction and/or clarification? 1. “It is okay for me to use the sauna at the health club but not the hot whirlpool bath.” 2. “I should continue taking the folic acid my health care provider prescribed prior to the confirmation of my pregnancy.” 3. “I need to stop smoking and try to avoid secondhand smoke.” 4. “I should stop drinking alcohol while I am pregnant.” 2. A 10-year-old client has terminal cancer. What does the nurse expect to be the normal concept of death at this age? 1. There is no concept of death at this age. 2. Death only happens to old people. 3. The dead can return, much like a family member returns from a trip. 4. Death is a final and inevitable outcome of life. 3. The most common health risk occurring in today’s environment for school—age children is: 1. Falls. 2. Obesity. 3. Colic. 4. Unprotected sex. 4. A woman who is approximately 5 months pregnant tells the nurse that she is beginning to feel a fluttering in her lower abdomen. She is worried that she is having a miscarriage. Based on the nurse’s knowledge of prenatal development. what is the best response by the nurse? 1. “Is your back hurting bad?” 2. “Fetal movements may be felt around 5 months by the mother.” 3. “Fetal movements start around 3 months and mothers may feel the movement.” 4. “Fetal movement begins at 8 months and you may be feeling that movement.” 5. The Denver Developmental Screening Test (DDST-ll) measures the abilities ofa child compared to those of an average group ofchildren ofthe same age. What are the areas of development screened? (Select all that apply.) 1. Growth and weight 2 . Personal—social development 3 . Fine motor adaptive development 4. Language 5. Gross motor skills 6 . Fine motor skills © 2016 by Pearson Education, Inc. CHAPTER 21 / Promoting Health From Conception Through Adolescence 105 6. A teenage mother questions the nurse about Why her “newborn baby’s head is dented and pointed.” The nurse’s best response is: 1. “His head is dented and pointy looking, almost like an eraser.” 2. “This is a normal process and the head shape will return to normal in 6 months.” 3. “The head will return to a normal shape in approximately 1 week. The baby’s head is often misshapen because molding occurs during vaginal deliveries.” 4. “He looks deformed. I will get a health care provider to check him immediately.” 7. While conducting a newborn assessment, the nurse notes that the newborn baby has a positive Babinski reflex. How does the nurse elicit the Babinski reflex? 1. By holding the baby upright so the feet touch a flat surface~the legs move up and down as if walking 2. By touching the side ofthe cheek, thus causing the baby’s head to turn to the touched side 3. By stroking the sole of the foot and observing the big toe rising and the other toes fanning out 4. By placing an object just beneath the toes that causes the tees to curl around it 8. While working with a pediatric health care provider, a nurse is often questioned about when to begin toilet training. What is the appropriate response by the nurse that indicates when a toddler is ready for toilet training? 1. The toddler stands and walks well and recognizes the need for elimination. 2. The toddler cannot delay elimination consistently. 3. The toddler is still crawling. 4. The toddler is 12 months or older. 9. The nurse is caring for an adolescent client. Which statement would encourage the best communication for this age group? 1. “We need to discuss this situation with your parents.” 2. “Read this article and it will answer all of your questions.” 3. “Watch this cartoon about your problem.” 4. “You are the fifth teenager this week to have these same issues.” 10. Parents ofa newborn boy insist that their son be circumcised on the 8th day after his birth. This is an example ofa cultural religious ritual practiced in Judaism. What should the nurse do regarding the circumcision? 1. Perform it on the second day ot‘birth per routine orders. 2. Notify the health care provider of the parents” request and obtain further orders. 3. Take no action at this time. 4. Inform the parents that circumcision is not allowed in the United States. C 2016 by Pearson Education, Inc. CHAPTER 22 PROMOTING HEALTH IN YOUNG AND MIDDLE-AGED ADULTS KEY TERM REVIEW Match each term with its appropriate definition. 1. Baby boomers a. When menstruation ceases 2. Boomerang kids b. Concern for establishing and guiding the next generation 3' Climacteric d. Born in years 1945—1964 4' Generation X e. Born in years 196571978 5' Generation Y f. Screening examination of cells from the uterine cervical os 6' GeneratiVity g. Born in years 1979—2000 7' Intimacy h. Young adults who move back into their parents’ homes after an initial pe— 8. Maturity 9. Menopause i. State of maximal function and integration Papanicolaou (Pap) test j. Very close friendship 10, CC) 2016 by Pearson Education, Inc. c. Andropause riod of independence 106 CHAPTER 22/ Promoting Health in Young and Middle-Aged Adults 107 KEY TOPIC REVIEW 1. How is adulthood categorized, and what are the age ranges? 2. What three distinct generations are included in adulthood? a. b. 99:58“ C. Health risks for young adults are related to and is the state of maximal function and integration, or the state of being fully developed. is defined as the concern for establishing and guiding the next generation. According to Havighurst, what are four developmental tasks for middle-aged adults? a. b. c. d. 7. What are two health threats that begin to affect persons in middle age? a. b. 8. The mystery of life, of faith, and ofbelief in God is explored actively by some young adults. a. True b. False 9. Erikson’s developmental task for the middle adult is 10. What are four psychosocial concerns for young adults? a. b. c. d. FOCUSED STUDY TIPS 1. What are common health problems in young adults? 2. What sexually transmitted infections (STls) are prevalent among young adults? 3. What is the definition of adulthood? What are the criteria to determine this state? 4. Define the following terms: baby boomers, Generation X, Generation Y, intimacy. maturity. 5. Compare and contrast menopause and andropause. 6. Compare and contrast the various generational groups. © 2016 by Pearson Education, Inc. 108 CHAPTER 22 / Promoting Health in Young and Middle—Aged Adults CASE STUDY 1. Mary and Lou are both 29 years old, employed, and have been married for 2 years. Lou has been going out with friends several nights a week to drink alcohol. a. What health problem could Lou be at risk for, especially since Mary reported to you that he has been staying out late and arrives home with alcohol on his breath? b. How can the nurse help Mary, Lou, and their families in dealing with this concern? 0. What other resources might help the couple resolve their other issues? REVIEW QUESTIONS 1. What is the leading cause of death for individuals 1 to 44 years of age? 1. Suicide 2. Cancer 3. STls 4. Unintentional injury . “Boomerang kids” are young adults who have moved back into their parents’ homes. What are the associated factors that influence these moves? 1. High divorce and unemployment rates 2. Fear of intimacy 3. Lack of supervision 4. Request from parents that the children return . Which population group of young adults has the highest incidence of hypertension? 1. Native American 2. Hispanic American 3. African American 4. Caucasian American . While lecturing a group of young male adults, the nurse discusses the most common neoplasm in men ages 20 to 34. What type of cancer is the nurse instructing the group on? 1. Testicular cancer 2. Lung cancer 3. Kidney cancer 4. Prostate cancer . A 47-year—old female states that she is very hot and breaking out in a sweat, has insomnia, and seems to be gaining weight. What should the nurse consider as a contributory cause for the reported symptoms? 1. Climacteric 2. Menopause 3. Breast cancer 4. Poor diet © 2016 by Pearson Education. Inc. CHAPTER 22/ Promoting Health in Young and Middle-Aged Adults 109 6. The nurse is caring for a 46-year-old female complaining of gaining weight. She wants to know why she has trouble losing weight now. What are leading causes of obesity in middle—aged adults? 1. Decreased physical and metabolic activities 2. Increase in caloric need 3. Lack of time to exercise 4. Unknown at this time 7. During an admission assessment, a client reports that she is very active in civic groups and works at a local homeless soup kitchen. This is an appropriate psychosocial developmental milestone for which group? 1. Middle—aged adults 2. Young adults 3. Older adults 4. Adolescents 8. What comment would be indicative of a young adult client meeting one of the psychosocial development tasks? I. “I go to my parents’ house for lunch every day.” 2. “I am headed in the right direction; I am due for a promotion soon.” 3. “I never go out at night. I don’t have any friends.” 4. “I never see my family.” 9. Ifa client was born in 1963, which generation would that client be identified with? 1. Generation X 2. Generation Y 3. Baby boomer 4. Boomerang kid 10. What concept best describes generativity? 1. The concern for establishing and guiding the next generation 2. The discrimination against an individual based on the individual’s age 3. The differences of opinion among various generations 4. The concern for one’s own generation 1 I. What psychosocial developmental concepts are true regarding the middle—aged adult? (Select all that apply.) 1. The adult is in the generativity versus stagnation phase of Erikson’s stage of development. 2. The adult has leisure activities as a central theme. 3. The adult moves from the conventional level to the postconventional level according to Kohlberg. 4. The adult feels the need to achieve adult civic and social responsibility. 5 . The adult is adjusting to aging parents. 10 2016 by Pearson Education, Inc. CHAPTER 23 PROMOTING HEALTH IN OLDER ADULTS KEY TERM REVIEW 1. Activity theory . Recent memory 2. Adult day care . Progressive loss of cognitive function (A) Match each term with its appropriate definition. Ageism Alzheimer’s disease U] Assisted living Cataracts x Spontaneous fractures . Associated with the medical care of older adults *. Stooping posture Daytime programs that provide health and social services to the older individual who lives at home H, Continuity theory . Lens opacity that impairs vision _ Dementia h. A condition characterized by progressive dementia, memory loss, in- _ Disengagement theory . ability to care for self Dyspnea Proposes that individuals maintain their values, habits, and behavior E-health in old age Geriatrics Momentary perception of stimuli from the environment Gerontology Hypothermia 7 Kyphosis Long—term memory Osteoporosis Pathologic fractures Perception Presbycusis Presbyopia Recent memory Sarcopenia Sensory memory w Short-term memory @ 2016 by Pearson Education, Inc. . Steady decrease in muscle fibers Repository for information stored for periods longer than 72 hours . Body temperature below normal . Difficulty breathing . Used to describe the use oftechnology in the delivery of health care and health information . Activities in the past few minutes to hours . The best way to age is to stay active physically and mentally, according to Havighurst Inability to focus due to loss offlexibility ofthe lens, causing de— creased near vision . A situation in which older adults who do not feel safe living on their own live in a facility that provides meals, activities, and opportunities for socialization Term used to define the study of aging and older adults 110 CHAPTER 23/ Promoting Health in Older Adults 111 u. Describes negative attitudes toward aging or older adults w. Proposes that aging involves mutual withdrawal between older per— son and others in the older person’s environment v. Loss of hearing ability related to aging x. Ability to interpret the environment y. A pathologic decrease in bone density KEY TOPIC REVIEW [\J Why are individuals living longer in today’s world? By the mid-21st century in the United States, the population is projected to outnumber individuals. What category ofthe aging population is the fastest growing of all the age groups in the country? Fill in the correct data in the blanks. are b. Old— years old. to a. The young—old are 7 7 to e. Centenarians are over years old. years old. What are the two new Healthy People 2020 objectives for older adults? a. b. Disease is an outcome of aging. a. True b. False Ageism is a term that celebrates aging within a population or group. a. True b. False Many older adults consider faith, and they display a high level of spirituality. a. True b. False is a term used to define the study of aging and older adults. is associated with the medical care of older adults. 10. Describe gerontological nursing. How do gerontological nurses obtain certification? What degrees are needed to practice as a nurse in this field? 11. What is the objective of long-term care facilities? What types of care are included in long—term care facilities? 12. Describe Alzheimer’s disease (AD) and explain Why specialized units are necessary for patients with AD. 13. What are the three hypotheses ol‘ the wear—and—tear theory of aging? a. b. C. FOCUSED STUDY TIPS What are the physical changes to the integumentary system associated with aging? What are the physical changes to the gastrointestinal system associated with aging? What are positive health practices that can promote health and wellness for all adults? What are the common biologic theories of aging? Which one do you agree with and Why? © 2016 by Pearson Education, Inc. 112 CHAPTER 23/ Promoting Health in Older Adults 5. Review health problems associated with the older adults and list those concerns 6. Differentiate between presbycusis and presbyopia. What are some nursing interventions that may be implemented when caring for clients with these conditions? 7. Describe how the normal aging process may affect the older adult’s nutritional status. What are some nursing interventions that promote adequate nutrition in the older adult? CASE STUDY 1. A retired 90-year-old client lives alone in a rural town. Her children live in various states nearby and lead busy lives. The client insists that she is satisfied with her life. The church that she attends drives her to and from services and her friends visit her daily. Her children believe that their mother is depressed and needs medication, so they take her to a geriatric nurse practitioner. a. What age category of the aging population is this client currently in? b. What is the myth of aging that the client’s children are subscribing to? What is the reality? C. According to Erikson, what developmental task occurs at this phase? REVIEW QUESTIONS 1. An 84-year-old client complains of reduced visual acuity and the presence of glaring around objects. On physical exam, the nurse notices lens opacity. What is the term for this common vision disturbance in the older adult? 1. Presbyopia 2. Cataracts 3. Glaucoma 4. Presbyeusis 2. Identify the normal findings of an older adult client’s cardiovascular system. (Select all that apply.) 9.4;?!“ 1. The working capacity of the heart diminishes with age. The heart rate at rest may increase with age. The response of the heart rate is slower when responding to stressors. Arterial elasticity is reduced. The client may have orthostatic hypotension whenever he or she stands up suddenly. 3. The client reports that she attends a knitting class at the senior citizen center at least three times a week. What psy— chosocial aging theory would explain this activity? 1. Continuity theory 2. Activity theory 3. Disengagement theory 4. Growth and developmental theory 4. A caregiver for a client with Alzheimer’s disease states that she has to attend a conference in another state. She requests information about how arrangements could be made for her mother’s care during that time. What place could the nurse suggest? I. Nursing home 2 . Assisted living facility 3. Adult day care 4 . Home health care © 2016 by Pearson Education, Inc. CHAPTER 23/ Promoting Health in Older Adults 113 5. What is the leading cause of morbidity and mortality among older adult clients? 1. Motor vehicle crashes 2. Drownings 3. Falls 4. Homicides 6. What is the largest—growing population in the United States today? 1. Newborns 2. Adolescents 3. Middle-aged adults 4. Older adults 7. Based on your knowledge of older adult mistreatment, which of the following statements are true? (Select all that apply.) 1. It may affect either gender equally. 2. The abuse may involve physical, psychological, or emotional abuse. 3. Older adults may be beaten and raped by family members or health care workers. 4. Older adult abuse rarely occurs in private settings. 8. The nurse is planning health care interventions for an older adult client who has a nursing diagnosis of“risk for constipation related to complete bed rest/administration of pain medication/sedatives.” Which of the following is the priority nursing intervention? 1. Include adequate roughagc and liquids in the diet. 2. Assess risk factors for older adult abuse. 3. Obtain weight ofthe client daily. 4. Keep side rails of the client’s bed up at all times. 9. What does the endocrine theory of aging propose? 1. The faster an organism lives, the quicker it dies. 2. An organism is genetically programmed for a predetermined number ofcell divisions, and then the cells die. 3. The immune system declines with age. 4. The hypothalamus and pituitary are responsible for changes in hormone production and response, then the organ— ism’s decline. 10. While caring for an older adult client with osteoporosis, the nurse is instructing the client and family on fall prevention measures to take at home. Which measures should the nurse include? (Select all that apply.) 1. Remove throw rugs. 2. Wear sturdy, rubber—soled shoes. 3. Place safety bars in the bathroom. 4. Remove all carpet and keep floors waxed. 5 . Change position slowly to prevent orthostatie hypotension. © 2016 by Pearson Education, Inc. CHAPTER 24 PROMOTING FAMILY HEALTH KEY TERM REVIEW Match each term with its appropriate definition. 1. Ecomap a. A basic unit of society 2. Extended famfly b. Family structure of parents and their offspring Family c. Nursing that considers the health of the family unit in addition to the health of the individual family members Family-centered nursing d. Relatives of the nuclear family Genogram e. Provides _ visual representation of how the family unit interacts with the external community Nuclear famil y f. Visual representations of gender and lines of birth descent through the generations KEY TOPIC REVIEW . The A is a basic unit of society. is a set ofinteracting, identifiable parts or components. to understand not only biological systems but also systems in fami- Nurses are increasingly using lies, communities, and nursing and health care. What is the purpose ofa family assessment? One of the greatest stressors on a two—career family is Employment ofa _will help the nurse visualize how all family members are genetically related to each other and to grasp how patterns of chronic conditions are present Within a family unit. Of all types ofhouseholds, about million are single-parent families, and this number continues to increase; million ofthese families are headed by women and million by men. Describe four stressors ofsingle parenthood: a. b. c. d. is the mechanism by which seine of the output of a system is returned to the system as input. focuses on family structure and function. The structural component of the theory addresses the membership of the family and the relationships among family members, The © 2016 by Pearson Education, Inc. 114 CHAPTER 24 / Promoting Family Health 115 FOCUSED STUDY TIPS 1. Define, compare, and contrast the following terms: nuclear family, extended family, traditional family. 2. Discuss how family communications influence families. What happens when that communication does not correctly flow among family members? 3. The incidence of family violence has increased in recent years. What factors have influenced this increase? 4. How do sociologic factors and poverty influence the different types of families? 5. Review the various theories used when dealing with family health. 6. Define cohabiting families. What are the reasons for cohabiting? CASE STUDY 1. A client presents to the emergency department with injuries that are suspiciously related to common patterns of physical abuse. The client reports that she “fell down several stairs while going to the basement.” The client’s husband is present and seems unwilling to leave the client’s bedside. a. What would be the best interventions by the nurse in this situation? b. What should the nurse be observing during the interactions between herself, the client, and the spouse? REVIEW QUESTIONS 1. A nurse is reviewing data gathered from a family assessment. The single mother of two children has been treated several times for drug overdose and has a history of substance abuse. What nursing diagnoses would be appropriate for this family based on this information? (Select all that apply.) 1. Interrupted Family Processes 2. Readiness for Enhanced Family Coping 3, Impaired Parenting 4. Caregiver Role Strain 2. The client has a history of diabetes in her family as identified by a detailed nursing health history. This data is identified as what type of risk for health problems? 1. Maturity factors 2. Hereditary factors 3. Gender or race factors 4. Lifestyle factors 3. In an effort to try to minimize or prevent the causes of some diseases and disabilities, the nurse is instructing a client on the need for exercise, stress management, and rest. On which area is the nurse focusing his or her instruction? 1. Maturity factors 2. Hereditary factors 3. Gender or race factors 4 . Lifestyle factors 4. A 6-year—old client has been living with her grandparents. The client’s parents are unable to care for the client because of substance abuse. What type of family unit does this client belong to? 1. Foster family 2, Traditional family © 2016 by Pearson Education, Inc. 116 CHAPTER 24 / Promoting Family Health 3. Intragenerational family 4. Cohabiting family 5. Which concept is assessed when the nurse is observing the ways the family expresses affection, love, sorrow, and anger? 1. Family structure 2. Physical health status 3. Interaction patterns 4. Family roles and functions 6. Which concept is assessed when the nurse is evaluating how the family members handle stressful situations and conflicting goals? 1. Coping resources 2. Family values 3. Interaction patterns 4. Family roles and functions 7. What are the late manifestations of family violence? 1. Depression, alcohol and substance abuse, and suicide attempts 2. Burns, cuts, fractures, and death 3. Alcohol and substance abuse and fractures 4. No differentiation from early manifestations 8. The nurse who is committed to family—centered care will do which of the following while caring for a client who is being treated for cancer? 1. Ensure that the client understands the disease and treatment, leaving details out to avoid upsetting the client. 2. Ensure that the client and family members understand the disease, treatment, and other matters related to the diagnosis of cancer. 3. Ensure assessment of how the radiation treatments are affecting the client’s skin. 4. Ensure that the primary care provider understands how the treatment is affecting the family unit. 9. Who does the nurse evaluate when planning health care for family care? 1. Family and community 2. Individual and family 3. Communities, political values, and families 4. Families, individuals, and community 10. The school nurse promotes health of the entire family by presenting what type ofprograms to the third—grade students? (Select all that apply.) I. Hand washing to prevent infection 2. Impact of truancy on education 3. Personal hygiene 4. Treatment for head lice 5. Need for maintaining immunization schedule © 2016 by Pearson Education, Inc. CHAPTER 25 CARING KEY TERM REVIEW 1. Aesthetic knowing 8.091593!” Match each term with its appropriate definition. Caring Caring practice Empirical knowing Ethical knowing Personal knowing Reflection a. Involves connections, mutual recognition, and involvement between nurse and client . Moral awareness Creative action Therapeutic use of self People, relationships, and things matter Thinking from a critical point of view Scientific competence KEY TOPIC REVIEW means that people, relationships, and things matter and is 1. to nursing practice. 2. List the three concepts involved with a caring practice. a. b. C. 3. According to Roach, what are the six C’s of caring? © 2016 by Pearson Education, Inc. 117 118 CHAPTER 25/ Caring 4. A noted philosopher, Melton Mayeroff, proposes that to care for another person is to help him grow and actu— alize himself. a. True b. False For questions 5—10, match each theorist to the correct perception of “caring” in the nursing process. 5. Caring is the moral ideal of nursing whereby the end is protection, enhancement, and preservation of human dignity. The two individuals in a caring transaction are both in a process of being and becoming. Caring is a nurturing behavior that has been a. Leiningerutheory of cultural care diversity and universality b. Ray—theory ofbureaucratic present throughout history and is critical in helping people maintain or regain health. Caring in nursing is contextual and is influ- caring c. Roaehwcaring, the human mode enced by the organizational structure. 10. of being The emphasis is on the nurse knowing self as a caring person. Caring is a lifetime process and respect for persons as carn individuals in nursing is necessary. d. Boykin and Schoenhofertnursing as caring A nurturing way of relating to a valued “other,” toward whom one feels a personal sense of commitment and responsibility. e. Watson~theory of human care Caring is the human mode of being, or the most common, authentic criterion of humanness. Caring is f. Swanson—theory of caring not unique to nursing. is the art of nursing and is expressed by the individual nurse through creativity ll. and style in meeting the needs of client. 12. promotes wholeness and integrity in the personal encounter, achieves engagement rather than detachment, and denies the manipulative or impersonal approach. is thinking from a critical point of view, analyzing why one acted in a certain way and assessing the results of one’s actions. . Nursing school instructors can teach all nursing students how to care. a. True b. False FOCUSED STUDY TIPS 1. Define the following terms used in caring: caring, caring practice, empirical knowing, ethical knowing, personal knowing. . What nursing theory of caring matches your own personal philosophy of caring? Why? . Think about your encounters with various nurses in your lifetime. How does the “caring” nurse differ from others? What made you remember that caring nurse? How does caring relate to the concept of professionalism in nursing? Is it possible to have one without the other? © 2016 by Pearson Education, Inc. V CHAPTER 25/ Caring 119 CASE STUDY 1. Mrs. Al Khalifa has been admitted to the hospital after experiencing a stroke. She is unable to support her right arm, so the nurse has applied a sling. a. What are two additional interventions the nurse may implement to provide comfort measures? 2. A child who was involved in a motor vehicle crash has been admitted to your unit. The parents and a younger brother of the child passed away as a result of injuries sustained in the crash. a. As a student nurse assigned to this client, which ofthe six C’s of caring in nursing do you want to incorpo- rate in your interventions? b. If you are using the caring processes from Swanson’s theory of caring, on what five processes would you base your nursing interventions for this client? c. What type ofknowing would you demonstrate if you are observing and documenting phenomena as they occur in this case? REVIEW QUESTIONS 1. Which nursing theorist developed the theory of culture care diversity and universality that is based on the as— sumption that nurses must understand different cultures in order to function effectively? 1. Watson 2. Miller 3. Leininger 4‘ Swanson 2. When it became apparent that the chaplain might not arrive before the death of a client, the nurse prayed with the dying client who requested a chaplain to Visit. This is an example of what type of caring? 1. Nursing implementation 2. Empowering the client 3. Compassion from the nurse 4. Nursing competence 3. Caring for self means taking time to nurture oneself. What are some ways that a nurse may care for him— or herself? (Select all that apply.) l. Eating a balanced diet 2. Performing regular exercise 3. Obtaining adequate rest and sleep 4. Taking medications for sleep as needed 5. Working part-time shifts 4. The nurse is instructing the client on ways to “self-care” for relief of stress. Identify ways in which the client can lead a healthier lifestyle and carve out enough time to care for herself. (Select all that apply.) 1. Replace negative affirmations with positive affirmations. 2. Delay exercising until stress level and job demands have lessened. 3. Use guided imagery to promote relaxation several times a day. 4. Begin a yoga class to unite the mind, body, and spirit. © 2016 by Pearson Education, Inc. 120 CHAPTER 25/ Caring 5. Which question made by the nurse best demonstrates personal knowing when reflecting about the death of a client who died after suffering a myocardial infarction (MI)? 1. “What are my thoughts and emotions?” 2, “Did I act for the best?” 3. “What additional information was needed?” 4. “Why did 1 respond the way 1 did to the situation?” 6. A nurse quietly sits with a client who is recovering from a spontaneous abortion. This is an example of what type of caring? 1. Knowing the Client 2. Nursing presence 3. Empowerment 4. Resting 7. While caring for an older client with left—sided paralysis, the nurse strongly encourages the client to participate in her activities of daily living. What type of caring is the nurse displaying? 1. Knowing the client 2. Nursing presence 3. Empowering the client 4. Compassion 8. The nurse repositions an immobile client every 2 hours. What type of caring is the nurse displaying? (Select all that apply.) 1. Competence 2, Caring for self 3. Spiritual care 4. Compassionate care 9. The nurse instructs the client on mindibody therapies. Which mind—body therapy is used when the client pictures himself lying on a beach with the sounds of the waves, the cries of the seagull, and the warmth of the sun during periods of stress? 1. Music therapy 2. Guided imagery 3. Yoga 4. Storytelling 10. The postpartum nurse demonstrates caring by which of the following actions? 1. Holding and rocking an infant so the mother can rest quietly for a few hours after being up all night 2. Administering pain medications according to schedule 3. Enforcing the hospital’s visitation hours 4. Performing the newborn assessment in a timely manner ‘9 2016 by Pearson Education, Inc. CHAPTER 26 COMMUNICATING KEY TERM REVIEW Match each term with its appropriate definition. ,_.,...l >—‘D—‘ LAN t—‘O >09°>3©EAPP°N 1. 14. Group 15. Group dynamics Bullying 16. _ Helping relationships Communication 17. Incivility Congruent communication 18. Lateral Violence Decode 19. _, 0 _ Nonverbal communication Elderspeak 20. Personal space Electronic communication 21. _ Process recording 22. Proxemics 23. Territoriality Empathy 24. Therapeutic communication Encoding 25. Verbal communication Attentive listening .2 Boundaries _ Emotional intelligence . Feedback © 2016 by Pearson Education, Inc. 121 122 CHAPTER 26 / Communicating . Ability to form work relationships with colleagues, display maturity, and re— solve conflicts while taking into consid- eration the emotions of others . To relate the message perceived to the receiver’s storehouse of knowledge and experience and to sort out the meaning ofthe message . The response to a message that is sent . Uses gestures, facial expressions, and touch . Communication that uses technology . Communication that takes place in any group . The study of distance between people in their interactions . The exchange of information among two or more people The distance people prefer in interactions with others Promotes understanding and can help establish a constructive relationship; is client and goal directed . Offensive, abusive, intimidating, insult— ing behavior, which makes the recipient feel, upset, threatened, humiliated, or 1. Verbatim account ofa conversation in. Term used to describe physical, verbal, or emotional abuse or aggression directed at RN coworkers at the same organizational level . Message sent by computer to another person or group of people . Limits in which a person may act or refrain from acting within a designated time or place . Rude, discourteous, or disrespectful behavior that reflects a lack of regard for others . Selection of specific signs or symbols to transmit the message Listening actively, using all senses Speech style similar to baby talk that gives the message of dependence and incompetence to older adults Two or more people who have shared needs and goals . Verbal and nonverbal aspects of the message match Uses spoken or written words . The ability to experience, in the present, a situation as an- other did at some time in the past Concept of space and things that an individual considers as belonging to the self Nurse—client relationships that involve a growth— facilitating process vulnerable KEY TOPIC REVIEW 1. Why are good communication skills essential in nursing? 2. Which of the following apply to the nonverbal communication process? (Select all that apply.) a. Pace and intonation b. Adaptability c. Personal appearance d. Posture e. Gestures f. Timing and relevance 3. What are three barriers to communication? a. b. © 2016 by Pearson Education, Inc. \J CHAPTER 26/ Communicating 123 4. What are four ways in which the nurse can demonstrate the actions of “physical attending” when communieating? a. b. c. d. Which of the following signs are components of genuineness in conversation. (Select all that apply.) a. The nurse displays respect. b. The nurse displays sympathy. c. The client is open and nondefensive. d. The client displays honesty. e. The nurse assists the client to be specific rather than general. is a speech style similar to baby talk that gives the message of dependence and incompe— tence and is seen as patronizing by older adults. In ‘_, the verbal and nonverbal aspects of a message match. . When seeking clarification during an initial health assessment, what is the best question the nurse could ask? a. “Would you tell me more?” b. “You smoke one pack of cigarettes a day? Are you trying to kill yourself?” c. “Why did you come to the emergency department?” d. “What are you saying?" 9. What is the difference between teaching groups and self—help groups? FOCUSED STUDY TIPS 1. What is the difference between assertive and nonassertive communication? 2. What are the advantages and disadvantages of electronic communication? When should e-mail not be used in health care? . Describe personal space and proxemics. How is communication altered in accordance with the four distances? What are the four phases of helping relationships? . How does the situational briefing model work in communication? © 2016 by Pearson Education, Inc. 124 CHAPTER 26 / Communicating CASE STUDY 1. An 18—year-old presents with painful urination and severe back pain. She is pale, running a 383°C (101°F) oral temperature, has chills, and is teary eyed. The client states that she has never been to a hospital or health care provider without her mother present. a. What could the nurse do in order to create a more positive environment for the health interview? b. If the nurse shares a similar experience with the client, then what communication technique is the nurse using? c. What are three therapeutic responses the nurse could employ in this situation? REVIEW QUESTIONS 1. The nurse is observing the postsurgical wound of a client who has had abdominal surgery. According to proxemics, what type of distance is the nurse using? 1. Intimate 2. Personal 3. Social 4. Public 2. While assessing a postoperative client for pain, the nurse notices the client is holding the surgical site and making facial grimaces. However, the client states that she is not hurting. What part of the communication process is incongruent? l. Sender 2. Receiver 3. Message 4. Feedback r5935“? 3. Which example best describes personal distance, according to proxemics? The nurse who is positioning an immobile client The nurse who is establishing an intravenous infusion The nurse who is making rounds on all the clients in the unit The nurse who is speaking at a conference 4. The nurse makes direct eye contact and has a pleasant expression on her face when changing a client’s colostomy bag. The nurse tells the client, “The colostomy looks good.” What type of communication is the nurse demonstrating? l. Nonverbal communication 2. Process recoding 3. Congruent communication 4. Incongruent communication © 2016 by Pearson Education, Inc. CHAPTER 26 / Communicating 125 5. The nurse is caring for a client with a major mental illness. What action best demonstrates professional bound— aries? 1. Keeping the focus on the client 2. Sharing personal information with the client 3. Displaying sympathy toward the client 4. Encouraging mutual nurse- client goals 6. A client expresses anxiety about a surgical procedure. What would be the most appropriate therapeutic communication technique to use in this situation? (Select all that apply.) 1. Using open-ended questions 2. Using closed questions 3. Restating or paraphrasing comments made by the client 4. Offering ordered antianxiety medication 5. Giving common advice 7. In which of the following situations would using the therapeutic communication of “touch” be appropriate? 1. When a family member is making inappropriate comments to the nurse, touch is appropriate. 2. Touch is never appropriate in the nursing profession. 3. When an upset spouse is alone and the client has just expired, touch is appropriate. 4. When a young healthy male client asks a young student nurse for a hug, touch is appropriate. 8. During the introductory phase of the nurse—client relationship, what type of behavior is the client exhibiting when he states that he will not need assistance with any aspect of his personal care? 1. Resistant 2. Introductory 3. Preinteraction 4. Trusting 9. The nurse is caring for a client admitted to the hospital due to substance abuse. The nurse and client mutually agree on the overall purpose of the nurSCeclient relationship. Which phase of the helping relationship is demonstrated? 1. Preinteraction 2. Introductory 3. Working 4. Termination 10. An older client asks the nurse if she needs to move into an assisted living facility instead ofliving alone. The nurse responds by telling the client that if the client were his mother, he would tell her to go into the assisted living facility because her meals would be cooked for her and she would not have to clean anything. The nurse is demonstrating what type of barrier to communication? 1. Stereotyping 2. Being defensive 3. Challenging 4. Giving common advice © 2016 by Pearson Education, Inc. CHAPTER 27 TEACHING KEY TERM REVIEW Match each term with its appropriate definition. 1. Adherence . Includes fine and gross motor skills 2. Affective do- . The desire to do something main Andragogy . A change in human disposition or capability that persists and cannot be solely accounted for by growth Behaviorist . Pleasant experience that fosters repetition of an action theory 9.090.“? Cognitive domain Cognitive theory Compliance Geragogy . A system of activities intended to produce learning . Recognize the developmental level of the learner and acknowledge learner’s motivation and environment g. The discipline concerned with helping children learn h. Demonstration of behaviors or cues that reflect motivation at a specific time '. The process by which individuals copy or reproduce what they have ob— Health literacy served Humanistic Believes that attitude and responses respond to changes in the stimulus condition or what occurs after the response learning theory 11. Imitation . Includes emotional and social goals 12. Learning . Commitment or attachment to a regimen 13. Learning need 14. Modeling . Following through with appropriate behaviors that reflect learning 15. Motivation . The capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions 16. v Pedagogy 17. Positive rein— . Learning is believed to be self-motivated, self-initiated, and self-evaluated . Process involved in helping older adults learn forcement . The art and science ofteaching adults Psychomotor domain . Includes six intellectual abilities and thinking processes 19. Readiness 20. Teaching © 2016 by Pearson Education, Inc. . A desire or requirement to know something that is presently unknown to the learner . The process by which a person learns by observing the behavior of others 126 CHAPTER 27 / Teaching 127 KEY TOPIC REVIEW 1. Physiological events such as a critical illness, pain, or sensory deficits inhibit learning. a. True b. False . Motivation is generally greatest when an individual recognizes a need and believes the need will be met through learning. a. True b. False Developmental readiness and individual readiness are key factors associated with cognitive approaches to learning. a. True b. False . Active learning, such as listening to a lecture or watching a film, does not foster optimal learning. a. True b. False . Individuals learn best when they believe they are accepted and will not be judged. a. True #- b. False is the application of the Internet and other related technologies in the health care industry to improve the access, efficiency, effectiveness, and quality of clinical and business processes utilized by health care organizations, practitioners, clients, and consumers in an effort to improve the health status of clients. . A high level of learning. resulting in agitation and the inability to focus or concentrate can also inhibit Repetition of key and facts facilitates retention of newly learned material. A client’s learning style may be based on that client’s 10. The individual who is not ready to learn is more likely to background. the subject or situation. ll. Match the following terms with the correct definition. a. Teaching The term used to describe the process involved in stimulating and helping elders to learn b. Learning need A system of activities intended to produce learning 0. Imitation The art and science of teaching adults (1. Motivation A desire or a requirement to know something that is presently unknown to the learner e. Modeling A change in human disposition or capability that persists and that cannot be solely accounted for by growth f. Learning A commitment or attachment to a regimen g. Geragogy The discipline concerned with helping children learn h. Pedagogy The process by which a person learns by observing the behavior of others i. Andragogy Means to learn is the desire to learn j. Adherence The process by which individuals copy or reproduce what they have observed 12. is the art and science of teaching adults. 13. depicts learning as a complex cognitive activity. © 2016 by Pearson Education, Inc. 128 CHAPTER 27 / Teaching 14. The domain, the “skill” domain, includes motor skills such as giving an injection. 15. Which guidelines will the nurse adhere to when teaching clients from various ethnic backgrounds? (Select all that apply.) a. Obtain teaching materials, pamphlets, and instructions in languages used by clients. b. Use visual aids, such as pictures, charts, or diagrams, to communicate meaning. 0. Invite and encourages questions during teaching. d. Use medical terminology during teaching. . When a nurse is using demonstration as a teaching strategy, which major type of learning would it be? a. Psychomotor b. Cognitive c. Affective d. All types of learning FOCUSED STUDY TIPS 1. How would a nurse know that a client is ready for patient education? . List the seven elements in the nursing history that provide clues to learning needs. . Explain computer-assisted instruction (CAI). Discuss the evaluation tools for cognitive learning. . Describe all types oflearning. Identify the parts of the teaching process that should be documented in the client’s chart. CASE STUDY 1. Melba Whitman is an 86—year—old client who has recently been diagnosed with hypertension. Ms. Whitman’s daughter tells you her mother only completed the sixth grade and gets very anxious when learning something new because of her poor reading skills. a. How will you be able to determine if Ms. Whitman is ready to learn? b. Identify three ways you could facilitate Ms. Whitman’s learning. 0. Describe various teaching aids to help foster Ms. Whitman’s learning. REVIEW QUESTIONS 1. Andragogy is l. The process involved in stimulating and helping elders to learn. 2. The art and science of teaching adults. 3. The discipline concerned with helping children learn. 4. The commitment or attachment to a regimen. © 2016 by Pearson Education, Inc. CHAPTER 27 / Teaching 129 2. What is the process by which an individual learns by observing the behavior of others? 1. Modeling 2. Imitation 3. Trial and error 4. Positive reinforcement 3. Which domain is used when teaching a client how to self-administer insulin? 1. Sensorimotor 2. Psychomotor 3. Cognitive 4. Affective 4. In which situation would the nurse be applying the humanistic theory? I. Encouraging the learner to establish goals and promote self-directed learning 2. Encouraging a positive teacher—learner relationship 3. Providing a social, emotional, and physical environment conducive to learning 4. Selecting multisensory teaching strategies since perception is influenced by the senses 5. When teaching a client about heart disease, the client may need to know the effects of smoking before recog— nizing the need to stop smoking. In this situation, what factor best facilitates client learning? 1. Readiness 2. Active involvement 3. Motivation 4. Allotted time 6. Which of the following is a barrier to learning? (Select all that apply.) 1. Fear 2 . Sensory deficits 3. Muscle weakness 4. Chronic illness 5. Medication use 7. Which of the following client behaviors may cause a nurse to suspect a literacy problem? (Select all that apply.) 1. The client displays a pattern of compliance. 2 . The client reads the instructions slowly. 3. The client states that he or she does not know the information presented. 4. The client displays a pattern of excuses for not reading the instructions. 5 . The client who reads the instructions but cannot explain them in medical terms. © 2016 by Pearson Education, Inc. 130 CHAPTER 27 / Teaching . Which of the following is a learning outcome for a teaching plan? 1. The client knows the factors that affect blood sugar level. 2. The client selects low-fat foods from a menu. 3. The client knows about cardiac risk factors. 4. The client understands a low-salt diet. . E—health includes all of the following EXCEPT l. A client making an online appointment. 2. E-mail access between the client and health care provider. 3. Online health information. 4. C computer—generated billing statement sent to the client’s home address. . Which of the following is NOT an element in the nursing history that provides clues to learning needs? 1. Age 2. Economic factors 3. Support systems 4. Sexual orientation 11. What concept was introduced by behavioral theorist Skinner? 1. Positive reinforcement 2. Imitation 3. Modeling 4. Behaviorism 12. To increase the chance of the client retaining education, what strategies should the nurse implement? (Select all that apply.) P‘PP’N 1. Ask the client to write down the information presented. Road the information to the client several times. Provide handouts when instructing the client. Speak very slow when instructing the client. Encourage the client to be an active participant in the process. © 2016 by Pearson Education, Inc. CHAPTER 28 LEADING, MANAGING, AND DELEGATING KEY TERM REVIEW Match each term with its appropriate definition. 1. Accountability 14. Permissive leader 2. Authoritarian leader 15. Preceptor 16. Productivity 3. _.,_ Autocratic leader 4. Bureaucratic leader 17. Risk management 5. Change agents 18. Role model 6. Charismatic leader 19. Shared governance 7. Democratic leader 20. Shared leadership 8. First—level manager 21. Situational leader 9. Formal leader 22. Top-level managers 10. Informal leader 23. Transactional leader 11. Laissez-faire leader 24. Transformational leader 12. Manager 25. Upper—level managers 13. ___4_ Middle-level manager © 2016 by Pearson Education, Inc. 131 132 CHAPTER 28/ Leading, Managing, and Delegating a. Makes decisions for the group b. Individual who initiates, motivates, and implements change c. Assumes individuals are capable of making decisions d. Flexes task and relationship behaviors, considers staff members’ abilities Characterized by an emotional relationship be— tween the leader and the group members Establish goals, develop strategic plans Setting the example for others to follow Ability and willingness to assume responsibility for one’s actions and to accept the consequences of one’s behavior e. Authoritarian leader Primary responsibility is to motivate staff to accomplish the organization’s goals f. Selected by the organization Laissez-faire leader g. Uses incentives to promote loyalty and performance h. Set goals, make decisions, solve problems i. Supervise a number of first-level managers j. Thought to emerge in relation to the challenges that confront the work group k. Measures effectiveness and efficiency of care 1. in. Having in place a system to reduce danger to clients and staff Relationship in which someone with more experi— ence assists the “new” employee in improving skills andjudgments, as well as instilling under— standing of the institution’s routines, policies, and procedures Fosters independence, individual growth, and change Assumes a hands-off approach, assuming group members are internally motivated Top—level manager Relies on organization’s rules, policies, and proce— dures to direct the group’s work efforts Recognized by the group as its leader Distributes decision making among a group of people KEY TOPIC REVIEW 1. A leader influences others to work together to accomplish a specific goal. a. True b. False 2. The informal leader, or appointed leader, is selected by an organization and given official authority to make decisions and take action. a. True b. False 3. Theories about leadership style describe traits, behaviors, motivations, and choices used by individuals to effectively influence others. a. True b. False 4. An autocratic (authoritarian) leader makes decisions for the group. a. True b. False 5. A leader is an employee of an organization who is given authority, power, and responsibility for planning, organizing, coordinating, and directing the work of others, and for establishing and evaluating standards. a. True b. False 6. A leader encourages group discussion and decision making. 7. A leader recognizes the group’s need for autonomy and self-regulation. Q 2016 by Pearson Education, Inc. U CHAPTER 28/ Leading, Managing, and Delegating 133 leader does not trust self or others to make decisions and instead relies on the organization’s 8. A rules, policies, and procedures to direct the group’s work efforts. leader flexes task and relationship behaviors, considers the staff members” abilities, knows A the nature of the task to be done, and is sensitive to the context or environment in which the task takes place. leader is rare and is characterized by an emotional relationship with the group members. 10. A involves determining responsibilities, communicating expectations, and establishing the chain of command for authority and communication. 12. 13. is defined as the legitimate right to direct the work of others. is a process whereby professional links are established through which people can share ideas, knowledge, and information, offer support and direction to each other, and facilitate accomplishment of pro— fessional goals. 14. is a measure of the resources used in the provision of nursing services. 15. is the transference of responsibility and authority for an activity to a competent individual. FOCUSEDSTUDYTWS 1. Discuss the classic work of Lewin, who developed a model of change that involves three stages: unfreezing, moving, and refreezing. Compare and contrast authoritarian, democratic, and laissez—faire leadership styles. . List several characteristics of effective leaders. Describe the role of the leader/manager in planning for and implementing change. List the five rights of delegation. Describe the characteristics of tasks appropriate to delegate to unlicensed and licensed assistive personnel. Identify the skills and competencies needed by a nurse manager. Discuss the roles and functions of nurse managers. Describe the four functions of management. CASESTUDY 1. Nathaniel Thomas is a nursing director who influences others to work together to accomplish a specific goal. Mr. Thomas also has initiative and the ability and confidence to innovate change, motivate, facilitate, and mentor others. Mr. Thomas actively guides the group toward achieving group goals and assumes that individ— uals are internally motivated and capable of making decisions, and Mr. Thomas values their independence. a. Is Mr. Thomas assuming the role of a leader or manager? b. Compare and contrast the role of a leader and manager. 0. What particular leadership style has Mr. Thomas developed? © 2016 by Pearson Education, Inc. 134 CHAPTER 28/ Leading, Managing, and Delegating REVIEW QUESTIONS 1. A nurse is planning a seminar on leadership styles. Which of the following statements describes a democratic leadership style? 1. The leader assumes a “hands-off" approach. 2. Under this leadership style, the group may feel secure because procedures are well defined and activities are predictable. 3. This leadership style demands that the leader have faith in the group members to accomplish the goals. 4. This leadership style does not trust self or others to make decisions and instead relies on the organization’s rules, policies, and procedures to direct the group’s work efforts. 2. A nursing director who fosters creativity, risk taking, commitment, and collaboration by empowering the group to share in the organization’s vision is which type of leader? 1. Charismatic 2. Transactional 3. Transformational 4. Shared 3. The organizational executives who are primarily responsible for establishing goals and developing strategic plans are considered to be 1. First—level managers. 2. Middle-level managers. 3. Upper-level managers. 4. Supervising managers. 4. The nursing director who has the ability and willingness to assume responsibility for one’s actions and to ac— cept the consequences of one’s behavior is demonstrating what management principle? 1. Accountability 2. Authority 3. Responsibility 4. Coordinating 5. The type of change that is an intended, purposeful attempt by an individual, group, organization, or larger social system to influence its own current status is referred to as 1. Natural. 2. Situational. 3. Unplanned. 4. Planned. 6. A nurse is planning a seminar on the comparison ofleader and manager roles. Which of the following charac— teristics describes a leader role? 1. Influences others toward goal setting, either formally or informally. 2. Maintains an orderly, controlled, rational, and equitable structure. 3. Relates to people according to their roles. 4. Feels rewarded when fulfilling the organizational mission or goals. (0 2016 by Pearson Education, Inc. CHAPTER 28/ Leading, Managing, and Delegating 135 7. Which role is the nurse assuming when initiating, motivating, and implementing change? 1. Advocate 2. Change agent 3. Teacher 4. Change role model 8. Which ofthe following is considered a driving force? 1. Low tolerance for change related to intellectual or emotional insecurity 2. Misunderstanding of the change and its implications 3. Perception that the change will improve the situation 4. Lack of time or energy 9. A nurse is planning a seminar on guidelines for dealing with resistance to change. Which of the following would NOT be an appropriate guideline for dealing with resistance to change? 1. Clarify information and provide accurate information. 2. Explain the positive and negative consequences of the change and how the individual or group will get the change done. 3. Maintain a climate of trust, support, and confidence. 4. Communicate with those who oppose the change. Get to the root of their reasons for opposition. 10. Which actions are true ofa situational leader? (Select all that apply.) 1. Flexes task and relationship behaviors. 2. Considers the staff members’ abilities. 3. Knows the nature of the task to be done. 4. Is sensitive to the context or environment in which the task takes place. 5 . Has a relationship with followers based on an exchange for some resource valued by the follower. © 2016 by Pearson Education, Inc. CHAPTER 29 VITAL SIGNS KEY TERM REVIEW Match each term with its appropriate definition. 1. Apical pulse 14. Inspiration 2. Apnea 15. Orthostatic hypotension 3. Arterial bloodpressure l6. Oxygen satura—tion (SaOz) 4. Bradycardia 17. Peripheral pulse 5. Bradypnea 18. Point of maximal impulse (PMl) 6. Cardiac output 19. Pulse deficit 7. Compliance 20. Pulse pressure 8. Diastolic pressure 21. Respiration 9. Dysrhythmia 22. Systolic pressure Expiration 23. Tachycardia 11. —Hypcrpyrcxia 24. Tachypnca l2. _Hypotensi0n 25. Ventilation 10. 13. .m Hypoventilation © 2016 by Pearson Education, Inc. 136 CHAPTER 29 / Vital Signs 137 The movement of air in and out of the lungs . Abnormally slow respirations Measure of the pressure exerted by the blood as it flows through the arteries . The pressure of the blood as a result of the contraction of the ventricles Volume of blood pumped into the arteries by the . Abnormally fast respirations heart . The act of breathing Intake of air into the lungs A very high fever Pressure when the ventricles are at rest g. A central pulse h. The percentage of all hemoglobin binding sites Very shallow respirations A blood pressure that falls when the client sits or stands Any discrepancy between the apical and radial pulses that are occupied by oxygen . A pulse located away from the heart Absence of breathing . Abnormal cardiac rhythm j. Excessively fast heart rate . A blood pressure that is below normal k. Act of breathing out air from the lungs . The difference between the diastolic and systolic blood pressures 1. The ability of arteries to contract and expand m. A heart rate in an adult less than 60 beats/min The location where the cardiac impulse can be best palpated on the chest wall. KEY TOPIC REVIEW 1. Core temperature reflects the balance between the heat produced and the heat lost from the body, and is measured in heat units called degrees. a. True b. False . Surface temperature is the temperature of the skin, the subcutaneous tissue, and fat. a. True b. False . Cardiac output is the volume of blood pumped into the arteries by the heart and equals the result of the stroke volume (SV) times the heart rate (HR) per minute. b. a. True False . The apical pulse is a pulse located away from the heart, for example, in the foot or wrist. b. a. True False . Body temperature is the temperature of the deep tissues of the body, such as the abdominal cavity and pelvic cavity. b. False a. True Diastolic pressure is the pressure of the blood as a result of the contraction of the ventricles. b. False a. True _77777 Heat are body temperature, pulse, respirations, and blood pressure. is a result of excessive heat and dehydration. , ”_ of the arteries is their ability to contract and expand. A pulse is any discrepancy between the two pulse rates. is a core body temperature below the lower limit of normal. © 2016 by Pearson Education, Inc. 138 CHAPTER 29 / Vital Signs 12. Match the following terms with the correct definition. When the amount of heat produced by the body a. Radiation equals the amount of heat 10st The rate of energy utilization in the body required to b. Conduction maintain essential activities such as breathing c. Convection The transfer of heat from the surface of one object to the surface of another without contact between the two objects, mostly in the form of infrared rays d. Pulse volume The dispersion of heat by air currents e. Basal metabolic rate (BMR) When a Wide range of temperature fluctuations (more than 2°C [3.6°F]) occurs over a 24—hour period, all of which are above normal f. Tachycardia A wave of blood created by contraction of the left ventricle of the heart g. Pulse An excessively fast heart rate. h. Remittent fever Also called the pulse strength or amplitude, refers to the force of blood with each beat i. Heat balance The transfer of heat from one molecule to a molecule of lower temperature 13. “7,7,“..- ,, is the act of breathing. a. Inhalation b. Exhalation c. Ventilation d. Respiration 14. is the absence of breathing. a. Bradypnea b. Apnea c. Tachypnea d. Polypnea 15. refers to very deep, rapid respirations. a. Hypoventilation b. Respiratory rhythm c. Hyperventilation (1. Respiratory quality/character 16. pressure is the pressure when the ventricles are at rest. a. Diastolic b. Arterial blood c. Systolic (1. Pulse “LC 2016 by Pearson Education, Inc. CHAPTER 29 / Vital Signs 139 is a blood pressure that is persistently above normal. . Hypotension 0 0" 93 17. . Orthostatic hypotension . Hypertension d. Pulse oximeter FOCUSED STUDY TIPS 1. List and explain the various Vital signs. Identify when it is appropriate to delegate measurement of vital signs to unlicensed assistive personnel. . Discuss measurement of blood oxygenation using pulse oximetry. Describe methods and sites used to measure blood pressure. Describe five phases of Korotkoff’s sounds. Differentiate systolic from diastolic blood pressure. . Identify the components ofa respiratory assessment. Describe the mechanics ofbreathing and the mechanisms that control respirations. Explain how to measure the apical pulse and the apical—radial pulse. 10. List the characteristics that should be included when assessing pulses. 11. Identify nine sites used to assess the pulse and state the reasons for their use. 12. Describe appropriate nursing care for alterations in body temperature. 13. Compare methods of measuring body temperature. 14. Identify the variations in normal body temperature, pulse, respirations, and blood pressure that occur from infancy to old age. 15. Describe factors that affect the vital signs and accurate measurement of them. 16. Differentiate between ventilation and respiration. CASE STUDY A 20—year—old client is brought into the clinic with complaints of fever, chills, and fatigue. His vital signs upon admission are BP 120/70 mmHg, P 116 beats/min. RR 20/min, T (oral) 389°C (102.1013). His mother reports that his temperature rises to fever level rapidly and then returns to normal within a few hours. The doctor who examines him orders blood work. 1. What are the normal vital signs for a 20—year-old male client? 2. What type of fever is the client most likely experiencing? 3. Why has the doctor ordered blood work? Q“ 2016 by Pearson Education, Inc. 140 CHAPTER 29 / Vital Signs REVIEW QUESTIONS 1. Conduction is: 1. the transfer of heat from one molecule to a molecule of lower temperature. 2. the transfer of heat from the surface of one object to the surface of another without contact between the two objects, mostly in the form of infrared rays. 3. the continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from the skin. 5x) 4. the dispersion ofheat by air currents. Which type of fever is a client experiencing when the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures? 1. intermittent 2. Remittent 3. Relapsing 4. Constant 3. A client reports that he has been exercising in hot weather; he feels warm, is flushed, and is not sweating. His temperature is 41°C (106°F) and he just experienced a seizure. What condition is the client most likely experiencing? 1. Hypothermia 2. Heat exhaustion 3. Heatstroke 4. Hypertension 4. The body temperature is measured in degrees on two scales: Celsius (centigrade) and Fahrenheit. When the Celsius reading is 40, the Fahrenheit reading is: 1. 100. 2. 101. 3. 103. 4. 104. 5. The posterior tibial pulse site is on the medial surface of the ankle where the posterior tibial artery passes behind the: 1. medial malleolus. 2. knee. 3. inguinal ligament. 4. wrist. 6. Which of the following can cause an erroneously low blood pressure result? 1. Cuff wrapped too loosely or unevenly 2. Bladder cuff too narrow 3. Arm above level of the heart 4. Assessing immediately after a meal or while client smokes or has pain (C) 2016 by Pearson Education, Inc. CHAPTER 29 / Vital Signs 141 7. Which of the following actions by a nurse would be incorrect when taking an adult’s temperature using a tyin— panic thermometer? l. Inserting the probe slowly using a circular motion until snug 2. Pointing the probe slightly anteriorly, toward the eardrum 3. Pulling the pinna straight back and upward 4. Not inserting the tympanic thermometer into the client’s ear when cerumen is present 8. A nurse is evaluating a nursing student’s understanding of altered breathing patterns and sounds. Which of the following statements demonstrates a need for further teaching? 1. Stertor is a snoring or sonorous respiration, usually due to a partial obstruction of the upper airway. 2. A wheeze is a continuous, high-pitched musical squeak or whistling sound occurring on expiration and sometimes on inspiration when air moves through a narrowed or partially obstructed airway. 3. Bubbling is a gurgling sound heard as air passes through moist secretions in the respiratory tract. 4. Stridor is difficult and labored breathing during which the individual has a persistent, unsatisfied need for air and feels distressed. 9. A nurse is planning a seminar on secretions and coughing. Which of the following describes a condition in which blood is present in the sputum? 1. Hemoptysis 2. Productive cough 3. Nonproductive cough 4. Orthopnea 10. A nurse is evaluating a nursing student’s understanding of Korotkoff’s sounds. Which of the following state— ments demonstrates a need for further teaching? 1. Phase 1 is the pressure level at which the first faint, clear tapping or thumping sounds are heard. These sounds gradually become more intense. 2. Phase 2 is the period during deflation when the sounds have a muffled, whooshing, or swishing quality. 3. Phase 4 is the time when the sounds become muffled and have a soft, blowing quality. 4. Phase 5 is the first tapping sound heard during deflation of the cuff and is the systolic blood pressure. © 2016 by Pearson Education, Inc. CHAPTER 30 HEALTH ASSESSMENT KEY TERM REVIEW Match each term with its appropriate definition. 1. Angle of Louis 14. Miosis 2 Aphasia 15. Mixed hearing loss _ Astigmatism 3 4 _ Bruit 5 Cataracts 6. Conductive hearing loss 7 Cyanosis 8 Diastole 9 Erythema 1 0. Exophthalmos 1 1. F asciculation 12. v Fremitus 13. Glaucoma © 2016 by Pearson Education, Inc. 16. 7 Mydriasis 17. Nystagmus 18. Pallor 19. Percussion 20. Precordium 21. Resonance 22. Sensorineural hearing loss 23. Stereognosis 24. Systole 25. Thrill 142 CHAPTER 30/ Health Assessment 143 Result of inadequate circulating blood and subsequent reduction in tissue oxygen The act of recognizing objects by touching and manipulating them An uneven curvature of the cornea Combination of conduction and sensorineural loss Rapid involuntary rhythmic eye movement A vibrating sensation like the purring of a cat or water running through a hose Results from damage to the inner ear, auditory nerve, or the hearing center of the brain Result ofinterrupted transmission of sound waves through the outer and middle ear structures Constrieted pupils A blowing or swishing sound Skin redness Protrusion of the eyeballs with elevation of the upper eyelids A bluish tinge Hollow sound elicited by percussion Opacity of the lens or its capsule A disturbance in the circulation of aqueous fluid, which increases intraocular pressure Any defect in or loss of the power to express oneself by speech, writing, or signs, or to comprehend spoken or written language The act of striking the body surface to elicit sounds or vibrations The junction between the body of the sternum and the manubrium Period in which the ventricle relaxes Period in which the ventricles contract Faintly perceptible vibration An abnormal contraction of a bundle of muscle Enlarged pupils fibers that appears as a twitch Area ofthe chest overlaying the heart KEY TOPIC REVIEW 1. Inspection is the visual examination—that is, assessing by using the sense of sight. a. True b. False . Percussion is the examination of the body using the sense of touch. a. True b. False . The middle finger of the nondominant hand is referred to as the pleximeter, a. True b. False Tympany is a musical or drumlike sound produced from an air-filled stomach. a. True b. False . Palpation is the act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt. a. True b. False is a sound created by turbulence of blood flow due to either a narrowed arterial lumen or a condition, such as anemia or hyperthyroidism, that elevates cardiac output. Any defects in or loss of the power to express oneself by speech, writing, or signs, or to comprehend spoken or written language due to disease or injury of the cerebral cortex is called A A is an automatic response of the body to a stimulus. is a protrusion of the intestine through the inguinal wall or canal. is the ability to sense whether one or two areas of the skin are being stimulated by pressure. © 2016 by Pearson Education, Inc. 144 CHAPTER 30/ Health Assessment 11. Match the following terms with the correct definitions. a. Hyperopia b. Otoscope c. Cerumen The process of listening to sounds produced within the body ___ Nearsightedness Loss of elasticity ofthe lens and thus loss of ability to see close objects (1. Astigmatism An uneven curvature of the cornea that prevents horizontal and vertical rays from focusing on the retina; is a common problem that may occur in conjunction with myopia and hyperopia e. Eustachian tube A disturbance in the circulation of aqueous fluid, which causes an increase in intraocular pressure; is the most frequent cause of blindness in people over age 40 f. Glaucoma Constricted pupils that may indicate an inflammation of the iris or result from such drugs as morphine or pilocarpine g. Miosis An instrument for examining the interior of the ear, especially the eardrum, consisting essentially of a magnifying lens and a light h. Myopia j A part of the middle ear that connects the middle ear to the nasopharynx i. Auscultation _ Earwax that lubricates and protects the canal j. Presbyopia m Farsightedness 12. _ is an extremely dull sound produced by very dense tissue, such as muscle or bone. a. Dullness b. Flatness c. Resonance d. Hyperresonance 13. ___ refers to the loudness or softness ofa sound. a. Pitch b. Quality c. Duration d. Intensity 14. is the result ofinadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation. a. Cyanosis b. Erythcma C. Jaundice d. Pallor © 2016 by Pearson Education, Inc. _ , V CHAPTER 30 / Health Assessment 145 is the presence of excess interstitial fluid. a: 15. . Vitiligo b. Alopecia c. Edema d. Clubbing 16. __ is what a normal head size is referred to. a. Exophthalmos b. Visual acuity c. Normocephalic d. Visual fields FOCUSED STUDY TIPS 1. Define dullness, flatness. and resonance. 2. List the common refractive errors of the lens of the eye. 3. Explain the process of air-conducted transmission of sound. 4. Define thrill and bruit. 5. Describe common inflammatory visual problems. 6. Identify the client positions that are frequently required during the physical assessment. 7. Define clubbing and describe two clinical examples of when clubbing may be present. 8. Discuss variations in examination techniques appropriate for clients of different ages. 9. Describe suggested sequencing to conduct a physical health examination in an orderly fashion. 10. Identify the steps in selected examination procedures. 11. Identify expected outcomes of health assessment. 12. Explain the significance of alterations in normal skin color. Describe two clinical examples when this may occur. 13. Explain the four methods used in physical examination. 14. Identify the purposes of the physical examination. 15. Summarize auscultated sounds that are described according to their pitch, intensity. duration, and quality. © 2016 by Pearson Education. Inc. 146 CHAPTER 30 / Health Assessment CASE STUDY 1. A nursing student is preparing for her clinical rotation at a clinic. She has been told that she will be responsible for preparing clients for physical examinations. 21. Discuss the purposes of the physical examination. b. Several client positions are frequently required during the physical assessment. List six client positions used during the physical assessment and provide a description of each one. c. List the equipment and supplies used for a health examination. REVIEW QUESTIONS 1. A client asks the nurse “What is the purpose of a physical examination?” What is the nurse’s best response? (Select all that apply.) 1. “To obtain data at any given time about a client’s functional abilities.” 2, “To obtain data that will help establish nursing diagnoses and plans ofcare.” 3. “To identify areas for health promotion and disease prevention.” 4. “To supplement, confirm, or refute data obtained in the nursing history.” 5 . “To implement appropriate, individualized care.” . Auscultation is the: 1. Visual examination—that is, assessing by using the sense of sight. 2. Examination of the body using the sense of touch. 3. Act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt. 4. Process of listening to sounds produced within the body. . Jaundice is: l . The result of inadequate circulating blood or hemoglobin and a subsequent reduction in tissue oxygenation. 2. A bluish tinge and is most evident in the nail beds, lips, and buccal mucosa. 3. A yellowish tinge that may first be evident in the sclera of the eyes and then in the mucous membranes and the skin. 4. A redness associated with a variety of rashes. Which of the following terms means nearsightedncss? l. Myopia 2. Hyperopia 3. Presbyopia 4. Astigmatism A nurse is evaluating a nursing student’s understanding ofthe air-conducted sound transmission process. Which of the following statements demonstrates a need for further teaching? 1. A sound stimulus enters the external canal and reaches the tympanic membrane. 2. The sound waves vibrate the tragus and reach the ossicles. 3. The sound waves travel from the ossicles to the opening in the inner ear (oval window). 4. The cochlea receives the sound vibrations. © 2016 by Pearson Education, Inc. CHAPTER 30 / Health Assessment 147 6. A nurse is planning a seminar on the organs in the nine abdominal regions. Which of the following information is incorrect? l. The epigastric region includes the aorta, the pyloric end of the stomach, part of the duodenum, and the pancreas. 2. The umbilical region includes the omentum, the mesentery, the lower part of the duodenum, and part of the jejunum and ileum. 3. The right lumbar region includes the ascending colon, the lower half of the right kidney, and part of the duodenum and jejunum. 4. The left lumbar region includes the stomach, the spleen, the tail of the pancreas, the splenic flexure of the colon, the upper half of the left kidney, and the suprarenal gland. 7. A nurse is evaluating a nursing student’s understanding of cranial nerves. Which of the following statements demonstrates a need for further teaching? 1. Cranial nerve I is assessed by asking the client to close his or her eyes and identify different mild aromas, such as coffee, vanilla, peanut butter, orange/lemon, or chocolate. 2. Cranial nerve IV is assessed by asking the client to read a Snellen-type chart. 3. Cranial nerve V1 is assessed by observing the client’s directions of gaze. 4. Cranial nerve VII is assessed by asking the client to smile, raise the eyebrows, frown, puff out cheeks, close eyes tightly. 8. Which adventitious breath sound is a superficial grating or creaking sound heard during inspiration and expiration? l. Friction rub 2. Crackles 3. tcze 4. Gurgles 9. A nurse is preparing to complete a physical examination on a client’s pelvis and vagina. The position the client is placed in for this examination is: l. Prone. 2. Supine. 3. Lithotomy. 4. Sitting. 10. Which of the following actions is most correct for the nurse assessing a client who has just had a cast applied to the lower leg? 1. Assess tissue turgor, fluid intake and output, and vital signs. 2. Assess peripheral perfusion oftoes, capillary blanch test, pedal pulse if able, and vital signs. 3. Assess apical pulse and compare with baseline data. 4 . Assess level of consciousness using Glasgow Coma Scale; assess pupils for reaction to light and accommodation; assess vital signs. @ 2016 by Pearson Education, Inc. CHAPTER 3 1 ASEPSIS KEY TERM REVIEW Match each term with its appropriate definition 1. _Acquired immunity 14. Leukocytosis 2. Active immunity 15. Local infection 3. Antibodies 16. Medical asepsis 4. Antigen 17. Nosocomial infections 5. Asepsis 18. Passive immunity 6. >_ Bacteremia 19. Resident flora _ Sepsis 7. Cell-mediated defenses 20. 8. Cellular immunity 21. Septicemia 9. Circulating immunity 22. Sterile technique 10. Exudate 23. Sterilization 11. Granulation tissue 24. Surgical asepsis 12. Humoral immunity 25. Virulence 13. Immunoglobulins © 2016 by Pearson Education, Inc. 148 CHAPTER 31 /Asepsis 149 a. Part ofbody‘s plasma proteins, produced 1. by B cell b. c. When bacteremia results in a systemic in— fection Substance that induces a state of sensitivity or immunit y Consisting of lluid that escaped from the blood vessels, dead phagocytic cells, and dead tissue cells and products that they re- m. Antibodies n. . . . Host produces antibodies In response to natural or artificial antigens 0. Includes all practices intended to confine a specific microorganism to a specific area lease (1. Process that destroys all microorganisms, including spores and Viruses p. q. Infections that originate in the hospltal Also known as acquired immunity e. Host receives natural or artificial antibodies from another source r. Normal bacteria in one part of the body, yet produce infection in another f. Condition in which microorganisms are s. Immunity a newborn baby is born with found in a person 5 blood t. Surgical asepsis u. . . Practlces that keep an area or object free of all microorganisms v. F ree d 0m from dlsease ' - caustng ' ' mlcroorgan The t t of infection sae On exposure to an antigen, the lymphoid tissues release large numbers of activated T . cells into the lymph system isms 1' j. Cell-mediated defenses A fragile gelatinous tissue, appearing pink w. Limited to the specific part ofthe body where the microorganisms remain x. k. or red Al oknown as circulatin immunit S g y Ability to produce diseases . The production and release of large numbers of leukocytes into the bloodstream y. KEY TOPIC REVIEW 1. A disease is an invasion of body tissue by microorganisms and their growth within that tissue. a. True b. False Virulence is the ability to produce disease. a. True b. False Pathogenicity is the ability to produce disease; thus a pathogen is a microorganism that causes disease. a. True b. False Surgical asepsis, or sterile technique, includes all practices intended to confine a specific microorganism to a specific area, limiting the number, growth, and transmission of microorganisms. a. True b. False . Sepsis is a state ofinfection and can take many forms, including septic shock. a. True b. False If the infectious agent can be transmitted to an individual by direct or indirect contact or as an airborne in feetion, the resulting condition is called a disease. 9° . A(An) pathogen causes disease only in a susceptible individual. is the freedom from disease—causing microorganisms. © 2016 by Pearson Education, Inc. 150 CHAPTER 31 /Asepsis are by far the most common infection-causing microorganisms. 9. 10. In medical asepsis, objects are considered clean or 1 1. Match the following terms with the correct definition. a. Vehicle Consist primarily of nucleic acid and therefore must enter living cells in order to reproduce b. Iatrogenic infections Include yeasts and molds c. Compromised host Live on other living organisms d. Colonization The process by which strains of microorganisms become resident flora e. Nonspecific defenses The direct result ofdiagnostic or therapeutic procedures f. Parasites A person or animal reservoir of a specific infectious agent that usually does not manifest any clinical signs of disease g. Vector Any substance that serves as an intermediate means to transport and introduces an infectious agent into a susceptible host through a suitable portal of entry h. Fungi An animal or flying or crawling insect that serves as an intermediate means of transporting the infectious agent i. Carrier A person at increased risk, an individual who for one or more reasons is more likely than others to acquire an infection j. Viruses Protect the person against all microorganisms, regardless of prior exposure is limited to the specific part of the body where the microorganisms remain. 12. a. Bacteremia 0 . Local infection infections are classified as infections that are associated with the delivery of health care services in a health care facility. {1) 13. . Septicemia CL b. Systemic infection . Acute U‘ . Nosocomial c. Chronic d. Endogenous 14. W is a local and nonspecific defensive response of the tissues to an injurious or infectious agent. a. Hypcremia b. Leukocytes c. Inflammation d. Leukocytosis © 2016 by Pearson Education, Inc. CHAPTER 31 /Asepsis 151 15. is the replacement of destroyed tissue cells by cells that are identical or similar in structure and function. a. Regeneration b. Antigen e. Immunity (1. Antibodies 16. are agents that inhibit the growth of some microorganisms. a. Sterilization b. Antiseptics e. Airborne precautions d. Disinfectants FOCUSED STUDY TIPS l. Discuss the relationship between hygiene, rest, activity, and nutrition in the chain of infection. 2 . Discuss the use of antimicrobial soaps and effective disinfectants. . Describe the steps to take in the event ofa bloodborne pathogen exposure. . Explain aseptic practices, including hand washing; donning and removing a face mask, gown, and disposable gloves; managing equipment used for isolation clients; and maintaining a sterile field. . Compare and contrast category-specific, disease-specific, universal. body substance, standard, and transmis— sion-based isolation precaution systems. Identify measures that break each link in the chain of infection. Identify interventions used to reduce risks for infection. . Identify relevant nursing diagnoses and contributing factors for clients at risk for infection, and for clients who have an infection. Identify signs of localized and systemic infections. 10. Identify factors influencing a microorganism’s capability to produce an infectious process. ll. Differentiate active from passive immunity. . Identify anatomic and physiologic barriers that defend the body against microorganisms. . Identify risks for nosocomial infections. . Explain the concepts of medical and surgical asepsis. . Define virulence. What is its relationship to infection? 16. Describe variances in immunity across the life span. © 2016 by Pearson Education, Inc. 152 CHAPTER 31 /Asepsis CASE STUDY 1. Brent is a new nursing student. You will be his preceptor for the next 3 days. On the first day, Brent asks you the following questions: a. What is the difference between asepsis and sepsis, and between medical asepsis and surgical asepsis? b. What four major categories of microorganisms cause infection in humans? c. Explain the difference between standard precautions and transmission-based precautions. REVIEW QUESTIONS 1. Which of the following means freedom from disease-causing microorganisms? 1. Medical asepsis 2. Asepsis 3. Surgical asepsis 4. Sepsis 2. Which of the following consists primarily of nucleic acid and therefore must enter living cells in order to reproduce? l. Fungi 2. Bacteria 3. Viruses 4. Parasites 3. Inflammation is a local and nonspecific defensive response of the tissues to an injurious or infectious agent. Which of the following is NOT a sign of inflammation? 1. Pain 2. Swelling 3. Redness 4. Fatigue 4. Four commonly used methods of sterilization are moist heat, gas, boiling water, and radiation. Which of the following is the most practical and inexpensive method for sterilizing in the home? 1. Gas 2. Moist heat 3. Radiation 4. Boiling water 5. A nurse is evaluating a nursing student’s understanding ofthe various types of infections. Which ofthe fol— lowing statements demonstrates a need for further teaching? 1. A local infection is limited to the specific part ofthe body where the microorganisms remain. 2. If the microorganisms spread and damage different parts of the body, it is a systemic infection, 3. Acute infections may occur slowly, over a very long period, and may last months or years. 4 . Nosocomial infections are classified as infections that are associated with the delivery of health care services in a health care facility. © 2016 by Pearson Education, Inc, CHAPTER 31 lAsepsiS 153 . A nurse is planning a seminar on the chain of infection. Which of the following is NOT one of the six links? 1. Etiologic agent 2. Reservoir 3. Hand hygiene 4. Mode of transmission . An antigen is a: 1. Host that produces antibodies in response to natural antigens (e.g., infectious microorganisms) or artificial antigens (e.g., vaccines). 2. Substance that induces a state of sensitivity or immune responsiveness (immunity). 3. Host that receives natural (e.g., from a nursing mother) or artificial (e.g.. from an injection ofimmune serum) antibodies produced by another source. 4. Part of the body’s plasma proteins. The CDC recommends antimicrobial hand cleansing agents in all of the following situations EXCEPT: 1. When there are unknown multiple nonresistant bacteria. 2. Before invasive procedures. 3. In special care units, such as nurseries and ICUs. 4. Before caring for severely immunocompromised clients. Which of the following statements about disinfectants is incorrect? 1. A disinfectant is a chemical preparation, such as a phenol or iodine compound, used on inanimate objects. 2. Disinfectants are frequently caustic and toxic to tissues. 3. Disinfectants and antiseptics often have similar chemical components, but the disinfectant is a less concentrated solution. 4. A disinfectant is an agent that destroys pathogens other than spores. 10. Which types of precautions are used for clients known or suspected to have serious illnesses transmitted by particle droplets larger than 5 microns? l. Airborne 2. Droplet 3. Contact 4. Connection © 2016 by Pearson Education, Inc. CHAPTER 32 SAFETY KEY TERM REVIEW Match each term with its appropriate definition. 959999.09???) [Ur—t ._.,_. ,_. 1. Asphyxiation Medications used to control socially disruptive behavior __ Bioterrorism Any manual method or physical or mechanical Burn device attached to the client’s body that restricts movement Carbon monoxide Chemical restraints Occurs when a current travels through the body to the ground rather than through electric wiring Electric shock Heimlich maneuver Safety measures taken to protect clients from injury should they have a seizure Physical restraints _ Restraints Procedure that can dislodge foreign objects lodged in the throat Safety monitoring devices Used to detect when clients are attempting to move or get out of bed Scald Seizure ,_. U) Suffocation Seizure precautions A burn from a hot liquid or vapor Results from excessive exposure to thermal, electric, chemical, or radioactive agents A single temporary event that consists of uncontrolled electrical neuronal discharge of the brain resulting in an interruption of normal brain function The use of biologic agents as a weapon that poses a pathogenic risk to a large number of people, and poses a risk to national security An odorless, colorless, tasteless gas that is very toxic m. Protective devices used to limit the physical activity of the client or a part of the body © 2016 by Pearson Education, Inc. 154 CHAPTER 32/ Safety 155 KEY TOPIC REVIEW 1. Individuals with impaired touch perception, hearing, taste, smell, and vision are highly susceptible to injury. a. True b. False 2. Restraints are used for staff convenience or client punishment. a. True b. False 3. The universal sign of distress is the victim’s grasping the anterior neck and being unable to speak or cough. 4; a. True b. False . Generalized seizures (also called focal) involve electrical discharges from one area of the brain. U] a. True b. False . People of any age can fall, but infants and elders are particularly prone to falling and causing serious injury. 33.90.“? a. True 10. b. False can include chemical, biological, or nuclear weapons. Suicide and g are two leading causes of death among teenagers. is a burn from a hot liquid or vapor, such as steam. A injury can occur from overexposure to radioactive materials used in diagnostic and therapeutic procedures. assessment tools are available to determine clients at risk both for specific kinds of injury, such as falls, or for the general safety of the home and health care setting. 1 1. Match the following terms with the correct definition. a. Seizure An intentional attack using weapons ofviruses, bacteria, and other infectious agents b. Asphyxiation A bed or chair has a position-sensitive switch that triggers an audio alarm when the client attempts to get out of the bed or chair 0. Electric shock A sudden onset of excessive electrical discharges in one or more areas of the brain d. Chemical restraints Safety measures taken by the nurse to protect clients from injury should they have a seizure e. Restraints An odorless, colorless, tasteless gas that is very toxic f. Safety monitoring device Suffocation, or breathing g. Heimlich maneuver .. , is lack of oxygen due to interrupted The emergency response is the , or abdominal thrust, which can dislodge the foreign object and reestablish an airway h. Bioterrorism Protective devices used to limit the physical activity of the client or a part ofthe body i. Seizure precautions Occurs when a current travels through the body to the ground rather than through electric wiring, or from static electricity that builds tip on the body j. Carbon monoxide (CO) Medications such as neuroleptics, anxiolytics, sedatives, and psychotropic agents used to control socially disruptive behavior © 2016 by Pearson Education, Inc. 156 CHAPTER 32/ Safety 12 Which of the following is NOT a type of restraint? a. Jacket b. Mitt c. Foot d. Limb 13. restraints are any manual method or physical or mechanical device, material, or equipment attached to the client’s body; they cannot be removed easily and they restrict the client’s movement. a. Chemical b. Physical 0. Medical d. Standard 14. Health care organizations are now expected to address which ofthe four specific phases of disaster planning? a. Preparedness b. Recovery c. Response d. Migration 15. Which of the following is NOT a basic firearm safety rule? a. Store the bullets in a different location from the guns. b. Ensure the firearm is unloaded and the action is open when handing it to someone else. 0. Tell children never to touch a gun or stay in a friend’s house where a gun is accessible. (1. Have firearms that are regularly used inspected by a qualified gunsmith at least every 5 years. 16. Excessive noise is a health hazard that can cause hearing loss, depending on all of the following EXCEPT: a. The overall level of noise. b. The frequency range of the noise. 0. The individual family history. (1. The duration of exposure. FOCUSED STUDY TIPS [\1 l. How is excessive noise a health hazard? List the types of restraints. . Explain how to promote safety across the life span. Discuss the factors affecting safety. . Describe the five criteria a nurse should use when selecting a restraint. Identify the four sequential priorities a nurse should follow during a fire. Summarize the legal implications of restraints. © 2016 by Pearson Education, Inc. CHAPTER 32/ Safety 157 Compare and contrast a scald and a burn. . Define electric shock. . Recall the common home hazards causing scalds. . Discuss risk factors and preventive measures for falls. . Describe alternatives to restraints. 13. Explain the home hazard appraisal. 14. Define seizure and seizure precautions. 15. List the 2014 National Patient Safety Goals. 16. Describe the key risk factors for suicide among older adults. CASE STUDY 1. A couple just purchased a new home last week. During your assessment, the couple tells you they do not have a fire plan, fire extinguishers, carbon monoxide alarms, or working smoke alarms in their home. a. What preventive measures do you need to teach the couple? b. Explain the three categories offires. REVIEW QUESTIONS 1. According to the 2014 National Patient Safety Goals (NPSGS), what are the ways to improve accuracy ofpatient information? (Select all that apply.) >-—4 .2 . Use at least two patient identifiers when providing care, treatment, and services. 2 . Report critical results of tests and diagnostic procedures on a timely basis. 3 . Eliminate transfusion errors related to patient misidentification. 4. Maintain and communicate accurate patient medication information. 5 . Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. . When evaluating a parent’s understanding of safety measures for an infant, which of the following statements indicates a need for further teaching? 1. “I will store all household chemicals in the garage.” 2. “I will make sure my infant is in his car seat before starting the car.” 3. “I will keep small crafting beads locked in the cabinet.” 4. “1 will keep the trash bags in the kitchen on the bottom shelf by the sink.” . A nurse planning a safety instruction class for parents of adolescents knows that the focus of the class should be on: 1. Teaching adolescents to sleep on a low bed. 2. Teaching adolescents about driver safety. 3. Teaching adolescents not to ingest lead paint chips. 4. Teaching adolescents not to run or ride a tricycle into the street. CG 2016 by Pearson Education, Inc. 158 CHAPTER 32 / Safety 4. Suicide and homicide are two leading causes of death among teenagers. When planning a workshop on ado- lescent suicide and homicide, the nurse knows that which of the following is NOT among the most common factors influencing the high suicide and homicide rates? 1. Economic deprivation 2. Strong emotions toward friendships 3. Availability of firearms 4. Family breakup 5. A nurse teaching a safety class for parents identifies the main causes of death for school—age children. Which ofthe following is NOT one ofthe leading causes? 1. Natural disasters 2. Fires 3. Drownings 4. Firearms 6. When planning a safety in-service program for an independent living community for older adults, the nurse will include information on which of the following as the leading causes of injury among older adults? (Select all that apply.) [\J 1. Firearms . Drownings 3. Suicide 4. Falls \1 5 . Natural disasters Which of the following actions by the nurse indicates that the nurse needs further instruction on the nursing assessment prior to applying restraints on a client? 1. The nurse checks the status of skin to which a restraint is to be applied. 2. The nurse checks the circulatory status proximal to restraints. 3. The nurse takes consideration of other protective measures that may be implemented before applying a restraint. 4. The nurse determines underlying cause for assessed behavior. 8. When evaluating a parent’s understanding of poisoning prevention, which of the following statements indicates a need for further teaching? 1. “We’ll store toxic liquids or solids in food containers, such as soft drink bottles, peanut butterjars, or milk cartons.” 2. “We’ll display the phone number ofthe poison control center near or on all telephones in our home so that it is available to babysitters, family, and friends.” 3. “We’ll teach our children never to eat any part of an unknown plant or mushroom and not to put leaves, stems, bark, seeds, nuts, or berries from any plant into their mouths.” 4. “We’ll not refer to medicine as candy or pretend false enjoyment when taking medications in front of our children.” © 2016 by Pearson Education, Inc. CHAPTER 32/ Safety 159 9. A nurse who is planning care for a client requiring seizure precautions should plan to include which of the following? 1. Provide education to the client and family regarding the need to wear a medical identification tag. 2. Assist the client in alerting all persons in the community about their seizure disorder. 3. Provide education regarding safety precautions for inside of the home only. 4. Discuss with the client, family, and persons in the community factors that may precipitate a seizure. 10. Which of the following would NOT be a preventive measure for an older client with poor vision? 1. Ensure eyeglasses are functional. 2. Ensure appropriate lighting. 3. Mark doorways only. 4. Keep the environment tidy. © 2016 by Pearson Education, Inc. CHAPTER 33 HYGIENE KEY TERM REVIEW Alopecia 14. Hirsutism Apocrine glands 15. Hygiene Bactericidal 16. Ingrown toenail p_i._. ,_. 1. QPWSP‘Ve’N Match each term with its appropriate definition. ._. U.) l2. _ Callus 17‘ _A Lanugo Cerumen 18. g“ Pediculosis Cleansing baths 19. Periodontal disease 20. Plaque Dandruff 21. Plantar warts Dental caries 22. Pyorrhea Eccrine glands 23. Scabies Fissures 24. Sebum Gingiva 25. Sudoriferous glands 7 Com Gingivitis © 2016 by Pearson Education, Inc. 160 CHAPTER 33/Hygiene 161 Advanced periodontal disease with loose teeth; pus expresses when gums are pressed . Appears as a diffuse scaling of the scalp Growth of excessrve body hair . Sweat glands located in the axillae and anogenital 1. Gums m Bacteria killing n. Dcep grooves 0. Red, swollen gums . , areas; they begin to function at puberty h‘ Afl f h . G' p. Science ofhealth and its maintenance Parasrtlc mSCCtS that infest mammals r. Appear on sole of the foot, caused by papovavirus 1ven c it. y or ygiene purposes . Characterized by a lesion that is short, wavy, brown or black, threadlike . A keratosis caused by friction and pressure from a . shoe, usually on a bony prominence q. Invisible soft film that adheres to the enamel sur- face ofteeth hominis s. Earwax t. Fine hair on the body of the fetus . Growth of nail into the lateral corners of the nail u. Thickened bed v. Cavities Produce sweat that cools body through evaporation w. Characterized by gingivitis, bleeding, formation of pockets between teeth and gums . Oily substance secreted by the skin that softens and lubricates the hair and skin o t' f ‘d ' p r ion 0 epi ermis X~ Produce sweat from almost all bOd)’ surfaces y_ Hair loss KEY TOPIC REVIEW 1. A dry mouth can be aggravated by poor fluid intake, heavy smoking, alcohol use, high salt intake, anxiety, and many medications. a. True b. False . Most dentists recommend that dental hygiene should begin after the fifth tooth erupts. a. True b. False Fluoride toothpaste is often recommended because of its antibacterial protection. a. True b. False An initial dental visit for a child should be at about 2 or 3 years of age, as soon as all 20 primary teeth have erupted. a. True b. False Water used for the shampoo should be 461°C (115°F) for an adult or child to be comfortable and not injure the scalp. 9.090.“? a. True b. False is the condition of infestation of licc. is a contagious skin infestation by the itch mite. The growth of excessive body hair is called i _ is the fine hair on the body of the fetus, also referred to as down or woolly hair. is an invisible soft film that adheres to the enamel surface of teeth; it consists of bacteria, molecules of saliva, and remnants of epithelial cells and leukocytes. © 2016 by Pearson Education, Inc. 162 CHAPTER 33/ Hygiene 1 1. Match the following terms with the correct definition. a. Tinea pedis is the self—care by which people attend to such Personal functions as bathing, toileting, general body hygiene, and grooming b. Ingrown toe nail Are on all body surfaces except the lips and parts of the genitals The c. Therapeutic baths , located largely in the axillae and anogenital areas, begin to function at puberty under the influence of androgens. Given for physical effects, such as to soothe irritated skin or to treat an area (e.g., the perineum) d. Apocrine glands e. Callus 12. ... ,, Thickened portion of epidermis, a mass of keratotic material f. Fissures A keratosis caused by friction and pressure from a shoe g. Tartar Deep grooves that frequently occur between the toes as a result of dryness and cracking of the skin h. Hygiene Athlete’s foot, or a fungus i. Sudoriferous (sweat) glands The growing inward of the nail into the soft tissues around it; most often results from improper nail trimming j. Corn A visible, hard deposit of plaque and dead bacteria that forms at the gum lines (ringworm of the foot), is caused by tends to cling to clothing, so that when a client undresses, the lice may not be in evidence on the body; these lice suck blood from the person and lay their eggs on the clothing. a. Pediculus corporis b. Pediculus pubis c. Pediculus capitis d. Scabies 13. Dry mouth, also called i, occurs when the supply of saliva is reduced. a. Xeroma b. Xerostomia c. Xerosis d. Xerotic 14. Dental caries occur frequently during the period, often as a result of the excessive intake of sweets or a prolonged use of the bottle during naps and at bedtime. a. Infant b. Toddler 0. School-age d. Newborn (C) 2016 by Pearson Education, Inc. CHAPTER 33/ Hygiene 163 15. _ are usually conical (circular and raised). a. Plantar warts b. Calluses c. Coms d. Fissures 16. The is the most widely used type because it fits snugly behind the ear. The hearing aid case, which holds the microphone, amplifier, and receiver, is attached to the earmold by a plastic tube. a. ln»-the-canal (lTC) aid 0 . Behind—the-ear (BTE, or postaural) aid 9.. b. Body hearing aid . ln—the-ear aid (ITE, or intra-aural) FOCUSED STUDY TIPS 1. What is the proper way to make a hospital bed? 2. List the six different types of baths that could be given to a client. 3. Explain the factors affecting client hygiene practices. 4. Discuss the importance ofbrushing and combing a client’s hair. 5. Describe Pediculus capitis, Pediculus corporis, and Pediculus pubis. 6. Identify the diseases that ticks can transmit. 7. Summarize a variety of ways to shampoo a client’s hair. 8. Compare and contrast sudoriferous glands, eccrine glands, and apocrine glands. 9. Define plaque, tartar, and gingivitis. 10. List the elements of contact lens care. 1 1. Discuss eyeglass care. 12. Describe general hearing aid care. 13. Explain how to insert a contact lens. 14. Define dental caries and periodontal disease. 15. Describe a method of correct dental hygiene. © 2016 by Pearson Education, Inc. 164 CHAPTER 33 / Hygiene CASE STUDY 1. You are assigned to give a bath to an 83—year-old man who has cognitive problems. a. What is the proper water temperature for the client’s bath? b. List two reasons why a nurse should check the temperature of the bath water. c. Why is it important to verify the temperature of the water for this client? REVIEW QUESTIONS 1. A nurse is making the client’s bed. Which of the following actions should the nurse perform? (Select all that apply.) 1. Hold the soiled linen close to his or her uniform to conserve energy. 2. Avoid shaking soiled linen in the air because shaking can disseminate secretions and excretions and the microorganisms they contain. 3. When stripping and making a bed, conserve time and energy by stripping and making up one side as much as possible before working on the other side. 4. Place the clean linens on another client’s bed if needed, in order to strip the client’s dirty linens. 5. Raise the bed to a comfortable working height when stripping and making the bed. 2. What is the correct bath water temperature for an adult client? I. l10°F to 125°F 2. 90°F to 100°F 3. 100°F to 115°F 4. 125°F to 135"F 3. The parent of a toddler is cleaning the child’s teeth. Which of the following statements indicates a need for further teaching? 1. “I’ll brush my child’s teeth with a hard toothbrush.” 2. “I’ll give a fluoride supplement daily or as recommended by the physician or dentist, unless the drinking water is fluoridated.” 3. “I’ll schedule an initial dental visit for my child at about 2 or 3 years of age or as soon as all 20 primary teeth have erupted.” 4. “I’ll seek professional dental attention for any problems such as discoloring of the teeth, chipping, or signs of infection such as redness and swelling.” 4. During discharge planning, the nurse is teaching a client how to prevent dry skin. Which of the following statements by the client indicates the need for further teaching? 1. “Bathe using soap or detergent only.” 2. “Use bath oils, but take precautions to prevent falls caused by slippery tub surfaces.” 3. “Humidify the air with a humidifier or by keeping a tub or sink full of water.” 4 . “Use moisturizing or emollient creams that contain lanolin, petroleum jelly, or cocoa butter to retain skin moisture.” © 2016 by Pearson Education, Inc. CHAPTER 33/ Hygiene 165 5. When providing foot care for a client, the nurse would perform which of the following? 1. When washing, inspect the skin of the feet for breaks or red or swollen areas. 2. Do not cover the feet and between the toes with creams or lotions to moisten the skin. 3. Do not check the water temperature before immersing the feet. 4. Wash the feet every other day, and dry them well, especially between the toes. 6. A nurse is evaluating a client’s understanding of nail hygiene. Which of the following statements indicates a need for further teaching? 1. “I should have clean, short nails with smooth edges.” 2. “I should have intact cuticles.” 3. “I will avoid trimming or digging into nails at the lateral corners.” 4. “I’ll cut or file around the end of the fingernail or toenail.” 7. A nurse is evaluating a client’s understanding of dental care. Which of the following statements indicates a need for further teaching? 1. Brush the teeth thoroughly after meals and at bedtime. >J>~UJN . Floss the teeth daily. , Avoid sweet foods and drinks between meals. . Have a checkup by a dentist every year. male client is having his facial hair shaved with a razor. Which action by the student nurse is NOT correct? I” 1. The student nurse holds the skin taut, particularly around creases, to prevent cutting the skin. The student nurse wears gloves in case facial nicks occur and she comes in contact with blood. 3. The student nurse applies shaving cream or soap and water to soften the bristles and make the skin more pliable. 4. The student nurse holds the razor so that the blade is at a 90° angle to the skin, and shaves in short, firm strokes in the direction of hair growth. 9. Which of the following actions is NOT appropriate for the nurse bathing a person with dementia? 1. Move quickly and let the person know when you are going to move him or her. 2. Use a supportive, calm approach and praise the person often. 3. Gather everything that you will need for the bath (e.g., towels, washcloths, clothes) before approaching the person. 4. Help the person feel in control. 10. The nurse needs to insert a hearing aid into a client’s ear. Which of the following actions is NOT correct? [0 . Gently press the earmold into the ear while rotating it forward. 9) . Inspect the earmold to identify the ear canal portion. A 1. Determine from the client if the earmold is for the left or the right ear. . Check that the earmold fits snugly by asking the client if it feels secure and comfortable. © 2016 by Pearson Education, Inc. CHAPTER 34 DIAGNOSTIC TESTING KEY TERM REVIEW Match each term With its appropriate definition. 1. Abdominal paracentesis a. A test for occult blood 2. Angiography b. A procedure performed to obtain a speci- 3. men of cerebrospinal fluid through a nee— m Anoscopy 4. Arterial blood gases 5. Blood urea nitrogen (BUN) 6. Colonoscopy 7. Computed to mography (CT) 8. Creatinine 9. Cystoscopy 10. Echocardiogram 1 1. Electrocardiogram (ECG) 12. Guaiac test 13. _ Hemoglobin A1C (HbAlC) dle inserted into the subarachnoid space of the spinal canal c. visualized d Viewing ofthe large intestine e. Uses ECGs to assess the client’s response to an increased cardiac workload during exercise f. A measure of the solute concentration of the blood used to evaluate fluid balance g' 14. _ Intravenous pyelography (IVP) 15. _ Lumbar puncture 16. _ Magnetic resonance imaging (MRI) h' 17. __ Occult blood 18. APeak level 19. ___ Positive emission tomography (PET) i' 21. # Retrograde pyelography j. 22. w Serum osmolality k. 24. _ Thoracentesis 25. Radiographic studies used to evaluate the urinary tract during which contrast medium is instilled directly into the renal pelvis via the urethra, bladder, and ureters A radiopaque dye is injected into the vessels to be examined, and flow through the vessels is assessed and areas of narrowing or blockage can be observed Produced by the muscles, excreted by the kidneys, and related to renal excretory function 20. __ Proctoscopy 23. _ Stress electrocardiography Procedure during which the bladder, ure~ teral orifices, and urethra can be directly Viewing of the rectum A noninvasive test that uses ultrasound to visualize structures of the heart and evalu- ate left ventricular function Trough level (L) 2016 by Pearson Education, Inc. 166 CHAPTER 34/ Diagnostic Testing 167 Indicates the highest concentration of a drug in the blood serum Measurement of blood glucose that is bound to hemoglobin; is a reflection of how well blood glucose levels have been the organ or structure; has the capability of distinguishing minor differences in the density oftissucs Radiographic studies used to evaluate the urinary tract during which contrast medium controlled during the prior 3 to 4 months is injected intravenously A noninvasive radiologic study that involves injection or inhalation of a radioiso- Procedure during which ascites is removed for laboratory study from the abdominal cavity to relieve pressure or obtain a fluid specimen tope Procedure used to remove excess fluid or air to ease breathing Hidden blood; a test performed on stool The recorded waveforms of the electrical impulses of the heart to detect dysrhythmi— as and alterations in conduction Measurement of the end product of protein metabolism A painless, noninvasive x—ray procedure that produces a three-dimensional image of Taking of arterial blood specimen from the radial, brachial, or femoral artery Viewing of the anal canal Noninvasive diagnostic scanning technique in which the client is placed in a magnetic field Represents the lowest concentration of a drug in the blood serum KEY TOPIC REVIEW 1 . Prior to radiologic studies, it is important to ask female clients ifpregnancy is possible. a. True b. False Blood tests are one of the most commonly used diagnostic tests and can provide valuable information about the hematologic system and many other body systems. a. True b. False Elevated RBC counts are indicative of anemia. a. True b. False The leukocyte or white blood cell (WBC) count determines the number of circulating WBCs per cubic millimeter of whole blood. a. True b. False . Serum electrolytes are often routinely ordered for any client admitted to a hospital as a screening test for electrolyte and acid base imbalances. a. True b. False Sputum and throat culture specimens help determine the presence of disease—producing is a short procedure, generally performed at the client’s bedside, in which a sample of liver tissue is aspirated. A liver During a lumbar puncture, the physician frequently takes CSF pressure readings using a _7, a glass or plastic tube calibrated in millimeters. is the withdrawal of fluid that has abnormally collected (e.g., pleural cavity, abdominal cavity) or to obtain a specimen (e.g., cerebral spinal fluid). , is the concentration of RBCs in the blood, expressed as a percentage (%). ”Q 2016 by Pearson Education, Inc. 168 CHAPTER 34 / Diagnostic Testing 1 1. Match the following terms with the correct definitions. a. Phlebotomist A person from a laboratory who performs venipuncture to collect a blood specimen for tests ordered by a physician b. Complete blood count (CBC) The number of RBCs per cubic millimeter ofwhole blood c. Hemoglobin The main intracellular protein of erythrocytes d. Hematocrit Produced in relatively constant quantities by the muscles and is excreted by the kidneys e. Red blood cell (RBC) count Substance used in a chemical reaction to detect a specific substance f. C reatinine A measure of the solute concentration of urine and a more exact measurement of urine concentration than specific gravity g. Serum osmolality An indicator of urine concentration, or the amount of solutes (metabolic wastes and electrolytes) present in the urine h. Reagent A measure of the solute concentration of the blood i. Urine osmolality Measures the percentage of red blood cells in the total blood volume j. Specific gravity Includes hemoglobin and hematocrit measurements, erythrocyte (RBC) count, leukocyte (WBC) count, red blood cell (RBC) indices, and a differential white cell count are basic elements in the blood that promote coagulation. 12. a. Hemoglobin b. Neutrophils c, Platelets d. Leukocytes [3. Which ofthe following is the viewing ofthe rectum and sigmoid colon? a. Proctosigmoidoscopy b. Anoscopy c. Proctoscopy d. Sigmoidoscopy 14. is a noninvasive test that uses ultrasound to visualize structures of the heart and evaluate left ventricu- . Angiography O 0" 93 lar function. . Echocardiogram . Electrocardiography d. Electrocardiogram ’C‘» 2016 by Pearson Education, Inc. CHAPTER 34 / Diagnostic Testing 169 15. is a painless, noninvasive x-ray procedure that has the unique capability of distinguishing minor differences in the density oftissues. a. Magnetic resonance imaging b. Positron emission tomography c. Aspiration d. Computed tomography , a person from a laboratory who performs venipuncture, collects a blood specimen for tests or16. The dered by a physician. 3. Venipuncturist b. Erotologist c. Phlebotomist d. Physician FOCUSED STUDY TIPS 1. Discuss some of the environments in which diagnostic testing occurs. . Give some examples of aspiration/biopsy tests. . Explain some of the reasons/tests for which nurses collect urine specimens. Discuss the three phases of diagnostic testing. What are some of the nursing responsibilities associated with specimen collection? List several blood chemistry tests that may be performed on blood serum (the liquid portion of the blood). . Summarize the measurement of arterial blood gases as an important diagnostic procedure. Discuss what occult blood is and how it is tested for. Discuss some tests performed and the purpose for timed urine specimens. List some examples of indirect and direct visualization procedures. ll. Discuss how to collect a stool specimen correctly. 12. What is a clean-catch or midstream voided specimen? 13. Explain what may cause inaccurate test results. 14. List and describe several of the different urine tests. 15. List some examples of aspiration/biopsy tests. © 2016 by Pearson Education, Inc. 170 CHAPTER 34 / Diagnostic Testing CASE STUDY 1. A 73-year-old female was brought into the hospital by her son. The son tells you, “My mother has lost weight and has been having night sweats. She is also spitting up blood.” The health care provider orders the client to have three sputum samples for acid-fast bacillus (AFB). a. Why did the health care provider order sputum specimens? b. How will you collect the sputum specimens? c. What PPE should you wear when you collect the sputum specimens? (1. What information should you document in the client medical record after collecting the sputum specimens? 6. How should the specimens be stored until they are transported to the laboratory? REVIEW QUESTIONS 1. The nurse is assessing an admitted female client’s serum laboratory values. Which of the following is abnor- mal and should be reported immediately? 1. Hemoglobin 13 g/dL 2. RBC 5.1 million/mm3 3. Hematocrit 25% 4. MCV 102 um3 2. Which serum laboratory value is abnormal and would require the nurse to report immediately? 1. Sodium 137 mEq/L 2. Potassium 2.5 mEq/L 3. Chloride 97 mEq/L 4. Magnesium 1.9 inEq/L 3. The nurse assessing a client’s serum laboratory values recognizes that the normal hematocrit level for an adult male is: 1. 37%419%. 2. 13%—18%. 3. 13.8718 g/dL. 4. 37—49 g/dL. 4. Which tcchnique is NOT correct when collecting a urine specimen for culture and sensitivity by clean catch? 1. Explain to the client that a urine specimen is required, give the reason, and explain the method to be used to collect it. 2. Perform hand hygiene and observe other appropriate infection control procedures. 3. Explain to female clients that a circular motion should be used to clean the urinary meatus. 4. Ensure that the specimen label is attached to the specimen cup, not the lid, and that the laboratory requisition provides the correct information. © 2016 by Pearson Education, Inc. CHAPTER 34/ Diagnostic Testing 171 5. Which of the following is the correct position for a client during a bone marrow biopsy? 1. Kneeichest 2. Prone 3. Lithotomy 4. Dorsal recumbent 6. Which is the correct position for a client after a lumbar puncture? 1. Knee—chest 2. Prone 3. Lithotomy 4. Dorsal recumbent 7. After a client returns from a thoracentesis, the nurse should have the client lie on the unaffected side with the head of the bed elevated degrees for at least 30 minutes. I. 10 2. 15 3. 30 4. 90 8. Which ofthe following situations during an abdominal paracentesis is correct? 1. The maximum amount of fluid, 1,500 mL, was drained at one time. 2. The fluid was drained at several time intervals. 3. The fluid was drained quickly. 4. Sterile technique is not necessary. 9. The nurse is providing patient education about a fecal occult blood test. Which of the following statements is correct? 1. “Take the sample from the center ofa formed stool to ensure a uniform sample.” 2. “Use a pencil to label the specimens with your name, address, age, and date of specimen.” 3. “Urine or toilet tissue will not contaminate the specimen.” 4. “You can collect the specimens during your menstrual period.” 10. The nurse needs to obtain a throat culture from a child client. Which of following techniques is correct? 1. The nurse wears sterile gloves during the procedure. 2. The nurse wears clean gloves during the procedure. 3. The nurse inserts the swab into the oropharynx and rttns the swab along the adenoids and areas on the larynx that are reddened or contain exudate. 4. The nurse has the client say “ugh” to relax the throat muscles and to help minimize dilation of the constrictor muscle ofthe larynx. © 2016 by Pearson Education, Inc. CHAPTER 35 MEDICATIONS KEY TERM REVIEW Match each term with its appropriate definition. 1. Anaphylactic reaction 14. Intradermal (ID) 2. Antagonist 15. Intramuscular (1M) 3. Buccal l6. _ Intraspinal 4. Drug allergy l7. Intrathecal 5. Drug dependence l8. Metered—dose inhaler (MDI) 6. Drug half-life 19. Ophthalmic 7. Drug tolerance 20. Ot 8. Drug toxicity 21. Peak plasma level 9. Elimination half-life 22. Percutaneous 10. Epidural 23. Physiological dependence 1 1. Iatrogenic disease 24. Potentiating effect 12, Idiosyncratic effect 25. 13. Inhibiting effect © 2016 by Pearson Education, Inc. V , Psychological dependence 172 CHAPTER 35 / Medications 173 A drug that inhibits cell function by occupying receptor sites; it blocks the effect of a natural body substance or other drugs A person’s reliance on or need to take a drug or substance Time required for the elimination process to reduce the concentration of the drug to one half of what it was at initial administration Deleterious effects of a drug on an organism or tissue Parenteral administration into the epidural space Drug half—life Under the epidermis Into a muscle Intraspinal administration of medication A handheld nebulizer that releases medication through a mouthpiece Medications for the eyes lntrathecal parenteral administration These biochemical changes in body tissues Disease caused unintentionally by medical ther— come to require a substance for normal functioning apy Immunologic reaction to a drug Medication held in the mouth against the mu— cous membranes of the cheek until the drug dis— solves An unusually low physiological response to a drug; increases in the dosage are required to maintain a given therapeutic effect Effect that is unexpected; may be individual to a client A severe allergic reaction usually occurring immediately after the administration of a drug A drug interaction in which the effect of one or both drugs is decreased Instillations or irrigations of the external auditory canal Highest plasma level achieved by a single close when the elimination rate of a drug equals the absorption rate Absorption through the skin A drug interaction in which the effect of one or both drugs is increased Emotional reliance on a drug to maintain a sense of well—being accompanied by feelings of need or cravings for that drug KEY TOPIC REVIEW 1. Medications cannot have natural (e.g., plant, mineral, and animal) sources; they must be synthesized in the laboratory. a. True b. False Medications vary in strength and activity. a. True b. False . Medications must be pure and of uniform strength if drug dosages are to be predictable in their effect. a. True b. False The action of a drug in the body can be described in terms of its half-life, the time interval required for the body’s elimination processes to reduce the concentration of the drug in the body by 25%. a. True b. False © 2016 by Pearson Education, Inc. 174 CHAPTER 35/ Medications 5. Parenteral administration is the most common, least expensive, and most convenient route for most clients. a. True b. False 6. Medications for the , called ophthalmic medications, are instilled in the form ofliquids or ointments. 7. A major consideration in the administration of away from large blood vessels, nerves, and bone. 8. A _ injections is the selection ofa safe site located is a small glass bottle with a sealed rubber cap. 9. A needle has three discernible parts: the hub, which fits onto the syringe; the cannula, or shaft, which is attached to the hub; and the , which is the slanted part at the tip of the needle. 10. Syringes have three parts: the tip, which connects with the needle; the barrel, or outside part, on which the scales are printed; and the , which fits inside the barrel. 1 1. Match the following terms with the correct definition. a. Prescription The written direction for the preparation and administration of a drug b. Medication __ A drug’s name given by the drug manufacturer C. Generic name __ The study of the effect of drugs on living organisms (1. Trade name __ A book containing a list of products used in medicine, with descriptions of the product, chemical tests for determining identity and purity, and formulas and prescriptions e. Pharmacology A secondary effect ofa drug, one that is unintended f. Pharmacy Deleterious effects of a drug on an organism or tissue that results from overdosage, ingestion ofa drug intended for external use, and buildup ofthe drug in the blood because of impaired metabolism or excretion (cumulative effect) g. Pharmacopoeia ofa drug, also referred to as the desired effect, The is the primary effect intended, that is, the reason the drug is prescribed. h. Therapeutic effect The art of preparing, compounding, and dispensing drugs i. Side effect Given before a drug officially becomes an approved medication j. Drug toxicity A substance administered for the diagnosis, cure, treatment, or relief of a symptom or for prevention of disease. is the process by which a drug changes the body (e.g., alters cell physiology). 12. a. Receptor b. Pharmaeodynamics c. Agonist d. Antagonist 13. A order indicates that the medication is to be given immediately and only once. a. pm b. Standing c. Single (1. Stat CC: 2016 by Pearson Education, Inc. CHAPTER 35/ Medications 175 14 . The study of the effect of drugs on living organisms is called: a. Pharmacopoeia. b. Pharmacist. c. Pharmacy. d. Pharmacology. 15. When two different drugs increase the action of one or another drug, this effect is termed: a. Synergistic. b. Drug tolerance. 0. Drug interaction. d. Cumulative effect. 16. A(An) syringe comes in l-,3—, and S-mL sizes. This syringe may have two scales marked on it: the minim and the milliliter. The milliliter scale is the one normally used; the minim scale is used for very small dosages. a. Insulin b. Tuberculin e. Hypodermic d. None of the above FOCUSED STUDY TIPS [\J 1 . Discuss the medication ordering process. . List three places hospitals correctly keep controlled substances. Explain how to properly handle controlled substances wasted during preparation. Discuss how the client’s environment can affect the action of drugs. Describe how the time of administration of oral medications affects the relative speed with which they act. Identify and list three factors that indicate the size and length of the needle to be used. Summarize the absorption process by which a drug passes into the bloodstream. . Compare and contrast the three systems of measurements used in North America. .List three routes for parenteral administration. 10. Define and discuss the types oftopical applications. ll. List and describe the essential parts of a drug order. 12. Describe how to instruct a client on taking a sublingual medication. 13. Describe how to correctly insert a rectal suppository and describe its advantages. 14. List and describe the different kinds syringes used for irrigations. © 2016 by Pearson Education, Inc. 176 CHAPTER 35 / Medications CASE STUDY 1. The health care provider has ordered Compazine 10 mg IM every 4 hours pm for a 37-year-old male client who is awake and alert. The client tells you that he is not currently taking any other medications or natural supplements. a. What are the 10 “rights” of medication administration? b. The Compazine is available in an ampule. How will you properly prepare the Compazine from the ampule? 0. Describe the process of administering Compazine by intramuscular injection. REVIEW QUESTIONS 1. The nurse is preparing a subcutaneous injection for a client. Which of the following statements is correct? 1. A 450 angle is used when 1 inch oftissue can be grasped at the site. 2. A 90° angle is used when 1 inch oftissue can be grasped at the site. 3. Generally a 3- to 5-mL syringe is used for most subcutaneous injections. 4. A #28—gauge, l/2-inch needle is used for adults of normal weight. 2. The nurse knows and understands that a drug that produces the same type of response as the physiological or endogenous substance is called a(an): l. Agonist. 2. Antagonist. 3. Receptor. 4. Biotransformation. 3. A nurse is preparing a seminar on drug misuse. Which of the following terms describes a mild form of psychological dependence, where the individual develops the habit of taking the substance and feels better after tak— ing it, and the individual tends to continue the habit even though it may be injurious to health? 1. Drug dependence 2. Drug habituation 3. Physiological dependence 4. Psychological dependence 4. A client weighs 1 10 lb. What is the correct kilogram amount a nurse should calculate if he or she understands how to convert pounds to kilograms? l. 25 kg 2. 50 kg 3. 75 kg 4. 100kg 5. Erythromycin 500 mg is ordered. It is supplied in a liquid form containing 250 mg in 5 mL. How many milliliters would the nurse administer? l. 10 2. 20 3. 30 4. 40 © 2016 by Pearson Education, Inc. CHAPTER 35/ Medications 177 . The nurse is preparing a Compazine injection to be given to a client. Which of the following statements is correct? 1. When handling a syringe, the nurse may touch the outside of the barrel and the handle of the plunger. 2. The nurse may touch the tip ofthe barrel with an unsterile object. 3. The nurse may touch the shaft of the plunger with an unsterilized object. 4. The nurse may touch the tip of the needle with an unsterilized object. A client in the emergency department is to receive a rectal suppository. Which of the following nursing actions is NOT correct for administering a rectal suppository? 1. The client can be placed in a left Sims’ 'position. 2. The smooth, rounded end of the rectal suppository is lubricated. 3. After inserting the rectal suppository, press the client’s buttocks together for a few minutes. 4. Have the client remain in the left lateral position for 1 minute to help retain the suppository. The nurse is performing an ear irrigation. Which nursing action is correct? 1. The nurse explains that the client may experience a feeling of fullness, warmth, and, occasionally, discomfort when the fluid comes in contact with the tympanic membrane. 2. The nurse angles the ear canal prior to inserting the tip of the syringe into the auditory meatus. 3. The nurse pushes the solution gently downward against the bottom of the canal. 4. The nurse places a cotton-tipped applicator in the auditory meatus to absorb the excess fluid after the procedure. When evaluating a client’s understanding of administering a vaginal foam, which of the following statements indicates a need for further teaching? 1. “1 will gently insert the applicator into the vagina about 5 cm (2 in.).” 2. “I will remain lying in the supine position for 2 minutes following the insertion ofthe vaginal foam.” 3. “I will slowly push the plunger of the applicator until the applicator is empty.” 4. “I will discard the applicator if it is a disposable type.” 10. A nurse is evaluating a nursing student’s transdermal patch application to a comatose client. Which of the following actions demonstrates a need for further teaching? The student: 1. Selects a clean, dry area that is free of hair. 2. Removes the patch from its protective covering. 3. Holds the patch by touching the adhesive edges. 4. Applies the patch by pressing firmly with the palm of the hand for about 10 seconds. © 2016 by Pearson Education, Inc. CHAPTER 36 SKIN INTEGRITY AND WOUND CARE KEY TERM REVIEW Match each term with its appropriate definition. A wound covering of dried plasma proteins and dead cells that occurs if the wound does not close by epithelialization 1. Aerobic 2. Anaerobic 3. Approximated 4. Debridement 5. Dehiscence The initial translucent, fragile tissue that forms during the proliferative phase of wound healing 6. Eschar Protrusion of the internal viscera through 7. Evisceration 8. Excoriation 9. Exudate an incision The process of pus formation 10. Fibrin Material that has escaped from blood vessels during the inflammatory process and is deposited in the tissue or on tissue surfaces ll. Granulation tissue Hypertrophic scar 12. Hematoma Bloody 13. Hemorrhage Growing only in the presence of oxygen 1 4. Hemostasis Removal of necrotic material 15. Keloid 16. Maceration The process during which macrophages engulf cellular debris and microorganisms 17. Phagocytosis 18. Primary intention healing 19. Purulent exudate 20. Reactive hyperemia 21. Sanguineous exudate Occurs where the tissue surfaces have been approximatcd, and there is minimal or no tissue loss Red flush of skin that occurs when pressure is relieved from an area Occurs in a wound that is extensive, and the edges cannot be approximated 22. Secondary intention healing 23. Serosanguineous 24. Suppuration Cessation of bleeding 25. Tertiary intention Massive bleeding © 2016 by Pearson Education, Inc. Growing only in the absence of oxygen ‘1 178 CHAPTER 36 / Skin Integrity and Wound Care 179 q. r. s. t. u. Closed . . Partial or total rupturing of a sutured wound Tissue softened by prolonged wetting or soakin g A localized collection of blood underneath the skin that may appear as reddish—blue swelling . . Connective tissue w. Wounds left open for 3 to 5 days, then surgically closed x. Area ofloss of the superficial layers of the . skm Thicker, yellow—, blue-, or green-tinged exudate y. V. M'1x ed (1 rainage ' ‘ t‘mg of c l ear and con51s blood-tinged material KEY TOPIC REVIEW 1. The skin is the largest organ in the body and serves a variety of important functions in maintaining health and protecting the individual from injury. a. True b. False . Hypoproteinemia is an abnormally high protein content in the blood. a. True b. False Wound beds that are too dry or disturbed too often fail to heal. a. True b. False Although an inadequate intake of calories, protein, vitamins, and iron is believed to be a risk factor for pressure ulcer development, nutritional supplements should not be considered for nutritionally compromised clients. a. True b. False Any at—risk client confined to bed, even when a special support mattress is used, should be repositioned at least every 2 hours, depending on the client’s need, to allow another body surface to bear the weight. a. True b. False The appearance of the skin and skin integrity are influenced by internal factors such as genetics, age, and the of the individual as well as external factors such as activity. underlying (tissue softened by prolonged wetting or soaking) and Moisture from incontinence promotes skin makes the epidermis more easily eroded and susceptible to injury. involves the removal of debris (i.e., foreign materials, excess slough, necrotic tissue, bacteria, Wound and other microorganisms). syringes instead of bulb syringes to irrigate a wound reduces the risk of aspirating drainage and . Using provides safe, effective pressure. is the largest organ in the body and serves a variety of important functions in maintaining health . The and protecting the individual from injury. C: 2016 by Pearson Education. Inc. 180 CHAPTER 36 / Skin Integrity and Wound Care 11. Match the following terms with the correct definitions. a. Regeneration b. H emostasis Exudate . Bandage A force acting parallel to the skin surface A reduction in the amount and control of movement a person has Renewal oftissues The cessation of bleeding that results from vasoconstriction of the larger blood vessels in the affected area, retraction (drawing back) ol‘injured blood vessels, the deposition of fibrin (connective tissue), and the formation of blood clots in the area lsehemia A whitish protein substance that adds tensile strength to the wound Irrigation (lavage) . Pressure ulcer h. Collagen Friction j. Immobility n: 12. The _, A material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces The washing or flushing out of an area A strip of cloth used to wrap some part of the body Any lesion caused by unrelieved pressure (a compressing downward force on a body area) that results in damage to underlying tissue, as defined by the US, Public Health Service’s Panel for the Prediction and Prevention of Pressure Ulcers in Adults A deficiency in the blood supply to the tissue _ phase, the second phase in healing, extends from day 3 or 4 to about day 21 postinjury. . Maturation . Proliferative . Inflammatory . Remodeling 13. is a process in which extra blood flows to the area to compensate for the preceding period of impeded blood flow. a . Vasodilation b . Friction c . Shearing force d . Immobility 14. If a wound does not close by epithelialization, the area becomes covered with dried plasma proteins and dead c ells. This is called a . Keloid b . Eschar C . Exudate . Suppuration CC) 2016 by Pearson Education, Inc. CHAPTER 36 / Skin integrity and Wound Care 181 15. The risk of hemorrhage is greatest during the first hours after surgery. a. 48 b. 72 c. 96 d. 120 16. __ is the partial or total rupturing of a sutured wound. a. Evisceration b. Debridement c. Dehiscence d. Protein FOCUSED STUDY TIPS 1. Describe the phases ofhealing. 2. List the four recognized stages of pressure ulcers related to observable tissue damage. 3., Discuss some of the chronic illnesses and their treatments and how they can affect skin integrity. 4. Discuss some of the factors contributing to the formation of pressure ulcers. 5. Discuss some changes in the skin and its supporting structures associated with the aging process. 6. List the three phases into which the wound healing process can be broken down. 7. Discuss the four different ways debridement may be achieved. 8. Compare and contrast the proper procedures for untreated wounds versus treated wounds. 9. List some of the purposes for which wound dressings would be applied. 10. Discuss gauze packing using the wet-to—moist technique. 11. Discuss some of the items that may cause hemorrhage from a wound. 12. Describe what the nurse notes when a pressure ulcer is present. 13. Discuss some ofthe different types of dressings. 14. List the type of heat and cold applications. 15. Discuss basic turns for roller bandages. 16. Describe the differences between friction and shearing forces, and list an example of each. 17. Differentiate between maceration and excoriation. © 2016 by Pearson Education, Inc. 182 CHAPTER 36 / Skin Integrity and Wound Care CASE STUDY 1. A 17-year—old high school senior sustained a left ankle injury during a soccer game 1 hour ago. The health care provider has ordered an ice pack to be applied to the injured area for 20 minutes. a. Explain the local effects of cold. b. Explain the systemic effects of cold. c. List some indications for applying ice to the injured ankle. d. Summarize the guidelines a nurse should follow for all local cold applications. REVIEW QUESTIONS 1. The nurse is assessing a wound and notes that the exudate is purulent. What would you expect the exudate to look like? 1. The exudate is thick with the presence of pus and is yellow in color. 2. The exudate is clear and appears blood tinged. 3. The exudate is red to pink and watery. 4. The exudate is bright red and bloody. 2. During discharge planning, the nurse is teaching a client how to apply an electric heat pad to his back. Which of the following statements indicates that the patient requires further teaching? 1. “I will not insert any sharp objects into the electric heating pad because the pin could damage a wire and cause an electric shock.” 2. “I will ensure that my back is dry unless there is a waterproof cover on the electric heating pad because electricity in the presence of water can cause a shock.” 3. “I do not need to use an electric heating pad with a preset heating switch.” 4. “I will not lie on top of the electric heating pad because the heat will not dissipate, and I may be burned.” 3. Which of the following actions taken by a client self-administering a hot water bottle to his back indicates to the nurse the need for further teaching? 1 _ The client fills the bag two thirds full with water. 2. After filling the bag with water, the client dries the bag and holds it upside down to test it for leakage. 3. The client expels the remaining air out of the bag before securing the top. 4. The client fills the bag with water at a temperature of 135°F. 4. The nurse is assessing a student nurse’s knowledge of bandages. Which of the following statements from the student nurse indicates a need for further teaching? 1. “Bandages can be used to support a wound.” 2. “Bandages can be used to immobilize a wound.” 3. “Bandages can be used to apply pressure to a wound.” 4. “Bandages can be firm and tight.” © 2016 by Pearson Education, Inc. CHAPTER 36 / Skin Integrity and Wound Care 183 5. A nurse is planning a seminar on dressing wounds. Which of the following is NOT correct information about the purpose of dressing wounds? Dressings are applied to: 1. Protect the wound from mechanical injury. 2. Prevent hemorrhage. 3. Prevent thermal insulation. 4. Protect the wound from microbial contamination. 6. During a discharge teaching session with a client, which statement by the client indicates a need for further teaching? 1. “Transparent dressings act as temporary skin.” 2. “Transparent dressings are nonporous, nonabsorbent, and self-adhesive.” 3. “Transparent dressings cannot be placed over a joint without disrupting mobility.” 4. “Transparent dressings adhere only to the skin area around the wound and not to the wound itself because they keep the wound moist.” 7. The nurse is caring for a client who has a wound covered with thick necrotic tissue, or eschar, and it requires debridement. What color would this wound most likely be? 1. Red 2. Yellow 3. Black 4. Blue 8. Any at—risk client confined to bed, even when a special support mattress is used, should be repositioned at least every 2 hours, depending on the client’s need, to allow another body surface to bear the weight. The nurse should NOT place the client in which position? 1. Prone 2. Knee—chest 3. Supine 4. Sims’ 9. The nurse knows albumin is an important indicator of nutritional status. The nurse understands that a value g/dL indicates poor nutrition and may increase the risk of poor healing and infection. below 1. 3.5 2. 3.6 3. 3.8 4. 3.9 10. The nurse is preparing to obtain a wound drainage specimen for culture from a client. Which of the following is part of the preparation? 1. Check the progress notes to determine ifthe specimen is to be collected for an aerobic (growing only in the presence ol’ oxygen) culture. 2. Check the medical orders to determine if the specimen is to be collected for an anaerobic (growing only in the absence of oxygen) culture. 3. Administer an analgesic 90 minutes before the procedure if the client is complaining of pain at the wound site. 4. Administer an analgesic 5 minutes before the procedure if the client is complaining of pain at the wound site. © 2016 by Pearson Education, Inc. CHAPTER 37 PERIOPERATIVE NURSING KEY TERM REVIEW Match each term with its appropriate definition. Atelectasis Injection of anesthetic agent into the epidural space, the area inside the spinal column but Circulating nurse outside the dura mater Closed-wound drainage system Role is to assist the surgeons; often a UAP Conscious sedation Epidural anesthesia Elective surgery Infiltration; injected into a specific area and used for minor surgical procedures Emboli _ Emergency surgery Begins when the decision to have surgery is made; ends when the client is transferred to the operating table Epidural anesthesia lntraoperative phase Local anesthesia Major surgery :qow General anesthesia .—. r—‘D—Ir—‘b—Ib—I LwNH .0990N951‘He5-“P’ 1. Coordinates activities and manages client care A thread used to sew body tissues together Involves a high degree of risk The delivery of nursing care through the framework Minor surgery of the nursing process Nerve block Topical anesthesia 15. Penrose drain 16. Peridural anesthesia 17. Pcrioperative period Refers to minimal depression of the level of consciousness; client retains the ability to maintain a patent airway and respond appropriately to commands 18. Postoperative phase 19. Preoperative phase 20. Regional anesthesia 21. Scrub person 22. Spinal anesthesia 23. Subarachnoid block (SAB) 24. Surface anesthesia 25. Suture © 2016 by Pearson Education, Inc. Temporary interruption of the transmission of nerve impulses to and from a specific area or region of the body A technique in which the anesthetic agent is injected into and around a nerve or small nerve group Performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening 184 CHAPTER 37 / Perioperative Nursing 185 Requires lumbar puncture through one of the interspaces between lumbar disc 2 and the t. Collapse of the alveoli u. A drain that has an open end that drains onto a dressing Pe formed 'mmed" tel to reserve function or r . . 1 . Id y p v. Blood clot that has moved . . The loss of all sensatlon and consc1ousness w. Consists ofa drain connected to either an electric . . . suction or a portable drainage suction x. Spinal anesthesia y. Phase begins when the client is transferred to the operating table and ends when the client is admitted to the postanesthesia care unit sacrum the life of the client Normally involves little risk, produces few complications, and is often performed in an outpatient setting Begins with the admission ofthe client to the postanesthesia area and ends when healing is complete KEY TOPIC REVIEW 1. The intraoperative phase begins when the decision to have surgery is made and ends when the client is transferred to the operating table. a. True b. False An embolus is a blood clot that has moved. a. True b. False . Adequate nutrition is not necessarily required for normal tissue repair. a. True b. False Prior to any surgical procedure, informed consent is required from the client or legal guardian. a. True b. False Surgery is least risky when the client’s general health is good. a. True b. False Pale, cyanotic, cool, and moist skin may be a sign of_ problems. A ___* is a thread used to sew body tissues together. Conscious ___ refers to minimal depression of the level of consciousness in which the client retains the ability to maintain a patent airway and respond appropriately to commands. A thrombus is a stationary adhered to the wall of a vessel. 10. A —wound drainage system consists of a drain connected to either an electric suction or a portable drainage suction. © 2016 by Pearson Education, Inc. 186 CHAPTER 37/ Perioperative Nursing 11. Match the following terms with the correct definition. a. Preoperative phase Begins with the admission of the client to the postancsthesia area and ends when healing is complete b. Intraoperative phase _ A technique in which the anesthetic agent is injected into and around a nerve or small nerve group that supplies sensation to a small area of the body c. Postoperative phase Used most often for procedures involving the arm, wrist, and hand d. Regional anesthesia An injection of an anesthetic agent into the epidural space, the area inside the spinal column but outside the dura mater e. Local anesthesia The passage of blood through the vessels f. Tissue perfusion Begins when the decision to have surgery is made and ends when the client is transferred to the operating table g. Intravenous block (Bier block) (Infiltration) is injected into a specific area and is used for minor surgical procedures such as suturing a small wound or performing a biopsy h. Epidural (peridural) anesthesia Applied directly to the skin and mucous membranes, open skin surfaces, wounds, and burns i. Nerve block The temporary interruption of the transmission of nerve impulses to and from a specific area or region ofthe body j. Topical (surface) anesthesia Begins when the client is transferred to the operating table and ends when the client is admitted to the postanesthesia care unit (PACU), also called the postanesthetic room or recovery room 12. anesthesia is the loss of all sensation and consciousness. a. Regional b. Local c. Topical (1. General 13. Which of the following routine preoperative tests is given to evaluate fluid and electrolyte status? a. Complete blood count (CBC) b. Blood grouping and cross—matching c. Serum electrolytes d. Fasting blood glucose I4. Which of the following routine preoperative tests is given to evaluate liver function? a. Blood urea nitrogen (BUN) and creatininc b. ALT, AST, LDH, and bilirubin c. Serum albumin and total protein d. Urinalysis © 2016 by Pearson Education, Inc. CHAPTER 37/ Perioperative Nursing 187 15. Which of the following routine preoperative tests is given to evaluate respiratory status and heart size? a. Chest x-ray b. Electrocardiogram 0. Pregnancy test (1. Complete blood count (CBC) 16. The complete. phase begins with the admission of the client to the postanesthesia area and ends when healing is a. lntraoperative b. Preoperative c. Postoperative (1. None of the above FOCUSED STUDY TIPS l. Discuss some of the risks involved with surgery. . List some factors affecting the degree of risk involved in a surgical procedure. . Explain the three different types/classifications of anesthesia. . What is preoperative consent? Describe how to properly give a physical assessment. . Identify three commonly used preoperative medications and their uses. List some of the different types of antiembolic stockings and what they are used for. Compare and contrast elective surgery and emergency surgery. State the overall goal during the preoperative period. 10. Discuss the fluid and nutrition requirements before surgery. 11. Discuss elimination requirements before surgery. 12. Describe how to properly prepare for ongoing care of the postoperative client. l3. Discuss proper client hygiene before a surgery. 14. List the three steps involved in the Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. 15. Compare and contrast major surgery and minor surgery. 16. Define atelectasis and describe methods to prevent this condition. 17. List two types of closed-wound drainage systems and describe their purpose. © 2016 by Pearson Education, Inc. 188 CHAPTER 37/ Perioperative Nursing CASE STUDY 1. A 58-year-old client has been admitted for abdominal surgery. After you have taken his vital signs, he asks. “What is the difference between a major surgery and a minor surgery?” He then states “I have a lot of hair on my belly. Will I have that hair shaved off before the surgery?” a. Define major surgery and minor surgery. b. Give two examples of major surgery and two examples of minor surgery. 0. Why would you need to remove the hair on the client’s abdomen before surgery? REVIEW QUESTIONS 1. Surgery is a unique experience of a planned physical alteration encompassing three phases. Which phase begins when the client is transferred to the operating table and ends when the client is admitted to the postanesthesia care unit (PACU)? 1. Preoperative 2. lntraoperative 3. Postoperative 4. Perioperative 2. The regular use of certain medications can increase surgical risk. Which of the following would NOT increase surgical risk as much as the others? 1. Anticoagulants 2. Tranquilizers 3. Diuretics 4. Antibiotics 3. Which of the following is NOT a correct action to reduce the risk of postoperative wound infection? 1. Clean the surgical site only. 2. Remove hair from the surgical site only when necessary. 3. Document surgical skin preparation in the client’s record. 4. Prepare the surgical site with an antimicrobial agent. 4. Which of the following actions is appropriate for the nurse removing skin sutures? l. The nurse puts on exam gloves. 2. The nurse removes the skin sutures without an order. 3. The nurse grasps the suture at the knot with a pair ofclamps. 4. The nurse cuts the suture as close to the skin as possible. © 2016 by Pearson Education, Inc. CHAPTER 37/ Perioperative Nursing 189 5. During discharge planning, the nurse is teaching the client how to maintain comfort, promote healing, and restore wellness. Which of the following actions is NOT correct? I. Instruct the client to use pain medications as ordered, not allowing pain to become severe before taking the prescribed dose. 2. Teach the client to avoid using alcohol or other central nervous system depressants while taking narcotic analgesics. 3. Instruct the client to report promptly to the primary care practitioner any decreased redness, swelling, pain, or discharge from the incision or drain sites. 4. Emphasize the importance of adequate rest for healing and immune function. 6. The spouse ofa client is preparing to apply a sterile dressing. Which ofthe following indicates a need for fur— ther teaching? The spouse: 1. Puts on sterile gloves. 2. Places the bulk of the dressing along the edges of the wound. 3. Secures the dressing with tape or ties. 4. Applies the sterile dressings one at a time over the drain and the incision. 7. A nurse is evaluating a client’s understanding of performing deep—breathing exercises. Which of the following statements indicates a need for further teaching? 1. “I will hold my breath for 6 to 8 seconds.” 2. “I will exhale slowly through the mouth.” 3. “I will always be in a sitting position.” 4. “I will inhale slowly and evenly through the nose until the greatest chest expansion is achieved.” 8. When irrigating a gastrointestinal tube for a client, which of the following would be appropriate? The nurse: I. Attaches the syringe to the nasogastric tube. 2. Aspirates the solution harshly. 3. Draws up 90 mL of irrigating solution into the syringe. 4. Quickly injects the solution. 9. A nurse is evaluating a nursing student who is applying antiembolic stockings to a client. Which of the following actions demonstrates a need for further teaching? 1. Assists the client to a sitting position in bed. 2. Reaches inside the stocking from the top and, grasping the heel, turns the upper portion of the stocking inside out so the foot portion is inside the stocking leg. 3. Has the client point his or her toes, then positions the stocking on the client’s foot. 4. Eases the stocking over the toes, taking care to place the toe and heel portions ofthe stocking appropriately. 10. A nurse is planning a seminar on potential postoperative problems. Which ofthe following describes a condition in which alveoli collapse and are not ventilated? l. Thrombophlebitis 2. Pulmonary embolism 3. Pneumonia 4. Atelectasis © 2016 by Pearson Education, Inc. CHAPTER 38 SENSORY PERCEPTION KEY TERM REVIEW Match each term with its appropriate definition. 1. Acute confusion 2. Auditory 3 Awareness 4 Cultural care deprivation 5. Cultural deprivation 6 Delirium 7 Gustatory 8 Kinesthetic 9. Olfactory The lack of culturally assistive, supportive, or facili— tative acts . Impaired reception, perception, or both of one or more of the senses Touch . Acute confusion Taste Any large organ within the body Ability to perceive and understand an object through touch by its size, shape, and texture 10. Sensoristasis 11. Sensory deficit 12. Sensory deprivation Hearing 13. Sensory overload The state in which a person is in optimal arousal 14. Sensory perception 15. Sensory reception 16. Stereognosis 17. Tactile 18. Visceral 19. Visual . Occurs when a person is unable to process or manage the amount or intensity of sensory stimuli . Involves conscious organization and translation of the data or stimuli into meaningful information Sight . Cultural care deprivation . Has an abrupt onset, and a cause that, when treated, reverses the condition . The ability to perceive internal and external stimuli, and to respond appropriately through thought and action . The process of receiving stimuli or data . Smell Decrease in or lack of meaningful stimuli Awareness of the position and movement of body parts © 2016 by Pearson Education, Inc. 190 CHAPTER 38/ Sensory Perception 191 KEY TOPIC REVIEW 1. Sensory reception is the process of receiving stimuli or data. a. True b. False . Visceral refers to the ability to perceive and understand an object through touch by its size, shape, and texture. a. True b. False Glaucoma is a group of diseases of the eye caused by increased intraocular pressure that can lead to optic nerve damage and eventual vision loss. a. True b. False Confusion can occur in clients of all ages, but is most commonly seen in older people a. True b. False . Sensory overload is generally thought of as a decrease in or lack of meaningful stimuli. 21. True b. False For an individual to be aware of the surroundings, four aspects of the sensory process must be present: a stimulus. a receptor, impulse conduction, and During times of increased sensory stimulation. An individual’s , people may find their senses overloaded and thus seek to decrease often determines the amount of stimulation that an individual considers usual or “normal.” Gaining the communication. 10. Sensory of a client with a hearing impairment is an essential first step toward effective can prevent the brain from ignoring or responding to specific stimuli. % of individuals ages 62 to 88 have mild hearing impairment. a. 10 b. 23 c. 26 d. 30 12. Which of the following states of awareness would be best described as extreme drowsiness but will respond to stimuli? a. Confused b. Somnolent c. Semicomatose d. Coma © 2016 by Pearson Education, Inc. 192 CHAPTER 38 / Sensory Perception V. . Hallucinations. 0" m 13. All of the following would be correctly categorized as an affective change EXCEPT: . Rapid mood swings. c. Depression. (1. Anxiety. . Which of the following states of awareness would be best described as reduced awareness, easily bewildered; poor memory, misinterprets stimuli; impaired judgment? a. Full consciousness b. Disoriented c. Confused d. Somnolent . Age-related macular degeneration (ARMD) is the leading cause of blindness in adults ages and older. a. 50 b. 55 c. 60 d. 65 FOCUSED STUDY TIPS l. Explain how the client’s environment can affect the senses. Discuss some of the techniques used to help prevent sensory deprivation. . Discuss sensory deprivation. Describe some of the tasks nurses need to perform in a health care setting for clients with visual impairments. Explain how physical assessment determines whether the senses are impaired. Discuss the importance of communication, particularly with clients who have sensory deficits. . Explain some of the sensory aids that are available for clients who have visual and hearing deficits. . Discuss sensory overload, . Describe some ofthe techniques used to help prevent sensory overload. . Discuss some of the techniques used in promoting healthy sensory function. . List the four aspects of the sensory process that must be present for an individual to be aware of the surroundings. . Explain some of the techniques used when one sense is lost to promote the use of the other senses. . Discuss some considerations for clients with impaired tactile senses. 14. Discuss some considerations for clients with impaired olfactory senses. © 2016 by Pearson Education, Inc. CHAPTER 38/ Sensory Perception 193 15. Describe some of the tasks nurses need to perform in a health care setting for clients with hearing impairments. 16. Compare and contrast stereognosis and sensory perception. 17. Describe the various states of awareness. CASE STUDY 1. An 87—year—old client was admitted to your floor yesterday. During report you are told that the client has visual and hearing impairments. a. What actions should you take to help with the client’s visual impairment? b. What actions should you take to help with the client’s hearing impairments? c. How can environmental stimuli be adjusted for this client? REVIEW QUESTIONS 1. A nurse is evaluating a nursing student who is assisting a client who has a visual deficit. Which of the following actions demonstrates a need for further teaching? The student nurse: 1. Announces her presence when entering the client’s room and identifies herself by name. 2. Speaks in a louder voice than necessary. 3. Speaks in a warm and pleasant tone of voice. 4. Always explains what she is about to do before touching the client. 2. A nurse planning a seminar on delirium and dementia plans to explain the characteristics differentiating the two. Which of the following describes an alertness that fluctuates—~that is, the client may be alert and oriented during the day, but becomes confused and disoriented at night? 1. Dementia 2. Delirium 3. Hallucinations 4. Delusions 3. During discharge planning, the nurse is teaching the client how to prevent sensory disturbances. Which of the following actions is correct? 1. Wear protective eye goggles when using power tools. 2. Wear ear protectors when working in an environment with low noise levels. 3. When wearing sunglasses, it is acceptable to look directly into the sun. 4. Have health examinations every 5 to 10 years. 4. Which of the following actions is NOT appropriate for the nurse who is promoting a therapeutic environment for a client with acute confusion? 1. “Good morning, Mr. Richards. 1 am Betty Brown. 1 will be your nurse today.” 2. “Today is December 5, and it is 8:00 in the morning.” 3. “Can you tell me where you are right now?” 4. “l’m going to turn on the radio while you read the newspaper, and I’ll leave the window open for you.” © 2016 by Pearson Education, Inc. 194 CHAPTER 38 / Sensory Perception 5. The spouse of a client is preparing sensory aids for the visual and hearing deficits of the client. Which of the following indicates a need for further teaching? The spouse: 1. Gets a phone dialer with large numbers. 2. Gets reading material with cursive print. 3. Gets amplified telephones. 4. Gets a magnifying glass. 6. The nurse is providing care to an unconscious client. Which of the following actions by the nurse is correct? (Select all that apply.) 1. Provides nose care. 2. Performs range-of-motion exercises. 3. Provides a lot ofenvironmental stimuli. 4. Informs client of the care prior to it being provided. 5. Assists client to bedside commode. 7. Stereognosis is: l. The process of receiving stimuli or data. 2. The ability to perceive and understand an object through touch by its size, shape, and texture. 3. The conscious organization and translation of data or stimuli into meaningful information. 4. The term used to describe when a person is in optimal arousal. 8. When planning interventions to prevent sensory deprivation, which of the following would NOT be included in the client’s plan of care? 1. Encourage the client to use eyeglasses and hearing aids only when interacting with someone. 2. Address the client by name and touch the client while speaking if this is not culturally offensive. 3. Provide a telephone, radio and/or TV, clock, and calendar. 4. Encourage the use of self-stimulation techniques such as singing, humming, whistling, or reciting. 9. Which of the following questions by the nurse assesses the gustatory sensory reception? 1. “When did you last visit an eye doctor?” 2. “Have you experienced any dizziness or vertigo?” 3. “Have you experienced any changes in taste?” 4. “Can you distinguish foods by their odors and tell when something is burning?” 10. The nurse is assessing for sensory function. Using a Snellen chart or other reading material, such as a newspaper, and visual fields assesses which ofthe following? 1. Hearing acuity 2. Visual acuity 3. Olfactory senses 4. Tactile senses © 2016 by Pearson Education, Inc. CHAPTER 39 SELF-CONCEPT KEY TERM REVIEW Body image Core self-concept ._.._. ,_. 1. .OfoPoflQEAP‘P’N Match each term with its appropriate definition. Global self Global self-esteem Ideal self Role Role ambiguity Role conflicts . Role development Role mastery Role performance 12. Role strain I3. Self-awareness . Arise from opposing or incompatible expectations . How an individual in a particular role acts in comparison to the behaviors expected of that role . One’s judgment of one’s own worth, how that individual’s standards and performances compare to others, and ideal self . Refers to the relationship between one’s perception of self and others’ perceptions of him or her . When expectations are unclear, individuals do not know What to do or how to do it . The beliefs and images that are most vital to an individual’s identity . How much one likes oneself as a whole '. One’s mental image of oneself '. An individual’s behaviors meet social expectations for a role Self-concept 15. 7 16. . A set of expectations about how the individual occupying one position behaves Self-esteem . How an individual perceives the size, appearance, and functioning of the body and its parts Specific self-esteem . Socialization into a particular role . Collective beliefs and images one holds about oneself; most complcte descriptions that individuals can give of themselves . How we should or would prefer to be . How much one approves ofa certain part of oneself . Occurs when one is frustrated because the individual feels or is made to feel inadequate or unsuited to a role CC 2016 by Pearson Education, Inc. 195 196 CHAPTER 39 / Self-Concept KEY TOPIC REVIEW 1. Self—concept is one’s mental image of oneself. a. True b. False . A client’s attitude to a newly acquired disability is rarely the determining factor in successful rehabilitation. a. True b. False . Individuals who grow up in families Whose members value each other are likely to feel good about themselves. a. True b. False The weavings that form the patterns in one’s life are experiences, knowledge, and dreams. a. True b. False . Self-awareness refers to the relationship between one’s perception of himself or herself and others’ perceptions of him or her. a. True 99°85) b. False A self-concept is essential to an individual’s physical and psychological well—being. Self—esteem is derived from and others. self-esteem is how much one approves of a certain part of oneself. Nursing interventions to promote a positive self~concept include helping a client to identify areas of 10. An individual’s self-perception can differ from the individual’s perception of how others see him or her and self, that is, how the individual would like to be. from the ll. Which of the following would NOT be considered a self—esteem stressor that affects self-concept? a. Loss of body parts b. Lack of positive feedback from significant others c. Abusive relationship d. Loss of financial security 12. Which of the following is NOT one of Erikson’s stages of psychosocial development? a. Infancy: trust vs. mistrust b. Toddlerhood: autonomy vs. shame and doubt c. Early childhood: initiative vs. guilt d. Early adulthood: segregation vs. separation © 2016 by Pearson Education, Inc. CHAPTER 39 / Self-Concept 197 13. is one’s judgment of one’s own worth, that is, how that individual’s standards and performances compare to others and to one’s ideal self. a. Self-esteem b. Self-knowledge c. Self-expectation d. Self—concept 14. All of the following would be considered an identity stressor EXCEPT: a. A change in physical appearance. b. The inability to achieve goals. c. Sexuality concerns. d. Ambiguous or conflicting role expectations. 15. Which one of the following is NOT one of the four dimensions of self-concept? a. Self-knowledge b. Social evaluation 0. Self—expectation d. Self-evaluation FOCUSED STUDY TIPS l. List some strategies nurses can employ to reinforce strengths. . Discuss the stage of development as a factor that can affect self-concept. Discuss the concept of body image, including how and when it develops. List some of the guidelines for conducting a psychosocial assessment. . Discuss family and culture and how they can affect self—concept. Define and discuss personal identity. Discuss the formation of self-concept according to Erikson. . List three of the NANDA nursing diagnostic labels relating specifically to the domain ofself—perception and the classes of self-concept, self-esteem, and body image. . Discuss strcssors as a factor that can affect self—concept. 10. Individuals are thought to base their self—concept on how they perceive and evaluate themselves in several areas. List some ofthese areas. . Discuss resources and how they can affect self—concept. 12. Discuss illness and how it can affect self-concept. © 2016 by Pearson Education, Inc. 198 CHAPTER 39 / Self-Concept 13. Give some examples of questions a nurse can ask to determine a client’s self—esteem. 14. List some nursing techniques that may help clients analyze the problem and enhance the self-concept. 15. Compare and contrast role ambiguity and role strain. 16. Discuss how family and culture influence values. CASE STUDY 1. You are working in a psychiatric facility and caring for an older adult client. The client tells you she has low self-esteem. a. What nursing techniques may help clients analyze the problem and enhance self—concept? b. List five stressors that affect self-concept. c. During your assessment, what questions should you ask the client? REVIEW QUESTIONS 1. When planning interventions to reinforce a client’s strengths, which of the following would NOT be included in the client’s plan of care? 1. Stress self—negation rather than positive thinking. 2. Notice and verbally reinforce client strengths. 3. Provide honest, positive feedback. 4. Encourage the setting of attainable goals. 2. The nurse is conducting a psychosocial assessment. Which of the following actions by the nurse is correct? 1. Create a quiet, private environment. 2. Do not limit interruptions. 3. Use intermittent eye contact. 4. Sit above the eye level of the client. 3. A nurse is planning a seminar on conducting a psychosocial assessment. Which of the following guidelines is appropriate for conducting a psychosocial assessment? 1. Indicate acceptance of the client by not criticizing, frowning, or demonstrating shock. 2. Ask close-ended questions. 3. Maximize the writing of detailed notes during the interview. 4. Ask more personal questions than what are actually needed. 4. A nurse is evaluating a nursing student who is asking a client questions to determine the client’s self-esteem. Which of the following statements demonstrates a need for further teaching? 1. “Are you satisfied with your life?” 2. “How do you feel about yourself?” 3. “Are you accomplishing what you want?” 4 . “What are your responsibilities in the family?” © 2016 by Pearson Education, Inc. CHAPTER 39/ Self-Concept 199 During discharge planning, the nurse is teaching the client how to enhance her son’s self—esteem. Which of the following actions is correct? 1. Give him opportunities to “practice” who he is. 2. Do not allow him to explore and experiment with the world around him. 3. Do not allow him to express himself as a unique individual. 4. Encourage him to stay connected with all memories. 6. Which of the following questions is NOT appropriate for the nurse assessing body image? 1. Is there any part of your body you would like to change? 2. What are your relationships like with your other relatives? 3. Are you comfortable discussing your surgery? 4. How do you feel about your appearance? Ideal selfis: 1. The collective beliefs and images one holds about oneself. 2. How a person perceives the size, appearance, and functioning of the body and its parts. 3. The individual’s perception of how one should behave based on certain personal standards, aspirations, goals, and values. 4. One’s mental image of oneself. According to Erikson’s stages of psychosocial development, the middle adulthood stage is: 1. Identity vs. role confusion. 2. Intimacy vs. isolation. 3. Integrity vs. despair. 4. Generativity vs. stagnation. When a client feels or is made to feel inadequate or unsuited to a role, he or she is experiencing which ofthe following? 1. Role conflict 2. Role strain 3. Role ambiguity 4. Role development 10. Which of the following is considered to be a stressor affecting self—concept? 1. Change or loss ofjob or other significant role 2. Financial security 3. Stable relationship 4. Realistic expectations © 2016 by Pearson Education, Inc. CHAPTER 40 SEXUALITY KEY TERM REVIEW 25. Hypoactive sexual desire disorder Anal stimulation Androgyny 1—‘0 1. >090N9MH>PJN _. Ix) Genital inter-course ._.._. Gender-role behavior 14. Intersex 15. Male erectile disorder 16. Male orgasmic disorder 17. Oral—genital sex 18. Orgasmic phase 19. Resolution phase 2o. Sexual aversion disorder 21. __ Sexual self—concept 22. Transgender 23. WWW_ Vaginismus 24. Vestibulitis ,_l DJ Match each term with its appropriate definition. Cross-dressing Desire phase Dysmenorrhea Dyspareunia Excitement phase Female orgasmic disorder Female sexual arousal disorder Gender identity © 2016 by Pearson Education, Inc. Vulvodynia 200 CHAPTER 40 / Sexuality 201 Involuntaiy climax of sexual tension, accompanied by physiological and psycho- ward appearance consistent with inner identity and gen— logical release der role; increases their comfort with themselves Sexual response stops before orgasm occurs How one values oneself as a sexual being Characterized by two physiological changes, One’s self-image as a female or male vasocongestion and myotonia Flexibility in gender roles: beliefthat most characteristics and behaviors are human qualities and should not be limited to a specific gender Dressing in the clothing of the other gender; makes out- A person whose sexual anatomy is not consistent with gender identity The response cycle starts in the brain, with conscious sexual desires Persistently low or lack of interest in sexual activity Outward expression of a person’s sense of maleness or femaleness and what is per— ceived as gender-appropriate behavior Diagnosis when man has erection problems during 25% or more of his sexual interactions Period of return to unaroused state Pain during or immediately after intercourse Lack of vaginal lubrication causes discom— fort or pain during sexual intercourse Penile—vaginal intercourse (for heterosexual couples) Severe pain only on touch or attempted vaginal entry Painful menstruation Constant, unremitting burning that is local— ized to the vulva with an acute onset Contradictions among chromosomal sex, gonadal sex, internal organs, and external genital appearance Kissing, licking, or sucking male or female genitals Can be a source of sexual pleasure because of the rich nerve supply in the anus A severe distaste for sexual activity, or the thought of sexual activity, which leads to a phobic avoidance of sex Erection can be attained and maintained, but ejaculation is extremely difficult Involuntary spasm of the outer one third of the vaginal muscles, making penetration of the vagina painful, and sometimes impossible KEY TOPIC REVIEW 1. The development of sexuality begins with conception and ends with puberty. a. True b. False . The ability of the human body to experience a sexual response is present before birth. a. True b. False . An individual’s gender identity may be easily changed once established. a. True b. False Sexually transmitted infections (STIs) are the most common bacterial infections among adolescents. a. True b. False © 2016 by Pearson Education, Inc. 202 CHAPTER 40 / Sexuality 5. Older women remain capable of multiple orgasms and may, in fact, experience an increase in sexual desire after menopause. a. True \IO\ b. False . Sexual health includes both freedoms and in all forms of intercourse to prevent the transmission of . Current practice dictates the use of a disease. 8. The sexual response cycle starts in the 9. Sexual refers to the physiological responses and subjective sense of excitement experienced during sexual activity. 10. is the belief that most characteristics and behaviors are human qualities that should not be limited to one specific gender or the other. 1 1. Match the following terms with the correct definition. a. Sexual self—concept Painful menstruation b. Gender-role behavior How one values oneself as a sexual being 0. Masturbation One’s self-image as a female or male d. Sexual aversion disorder The outward expression of a person’s sense of maleness or femaleness as well as the expression of what is perceived as gender-appropriate behavior e. Orgasmic phase Flexibility in gender roles, the belief that most characteristics and behaviors are human qualities that should not be limited to one specific gender or the other f. Resolution phase One’s attraction to people of the same sex, other sex, or both sexes g. Dysmenorrhea The ongoing love affair that each of us has with ourselves throughout our lifetime h. Sexual orientation The involuntary climax of sexual tension, accompanied by physiological and psychological release i. Androgyny The period of return to the unaroused state; may last 10 to 15 minutes after orgasm, or longer if there is no orgasm j. Gender identity A severe distaste for sexual activity or the thought of sexual activity, which then leads to a phobic avoidance of sex 12. is the involuntary spasm of the outer one third of the vaginal muscles, making penetration of the vagina painful and sometimes impossible. a. Vestibulitis b. Vaginismus c. Vulvodynia d. Dyspareunia © 2016 by Pearson Education, Inc. ‘”’ CHAPTER 40/ Sexuality 203 __ is oral stimulation of the penis by licking and sucking. . Masturbation 0" m 13. . Fellatio c. Genital intercourse d. Intersex 14. Which of the following is NOT one of the five critical components of sexual health? a. Freedoms and responsibilities b. Gender-role behavior c. Mental image (1. Body image FOCUSED STUDY TIPS 1. Discuss how older adults may define sexuality. 2. List some of the common sexual messages children get from their families. . Discuss how family influences a person’s sexuality. Discuss the desire phase of the sexual response cycle. . What are some of the health factors that can interfere with people’s expression of sexuality? Discuss how culture influences a person’s sexuality. Identify the forms of male and female sexual dysfunction. Discuss the orgasmic phase of the sexual response cycle. What is rapid ejaculation? 10. Summarize how religion influences a person’s sexuality. 11. Explain sexual pain disorders. 12. Describe physiological changes in males and females during the sexual response cycle. 13. Discuss some of the problems with attaining sexual satisfaction. 14. Discuss the resolution phase of the sexual response cycle. 15. Describe how to correctly perform a breast self-examination and explain its importance. © 2016 by Pearson Education, Inc. 204 CHAPTER 40 / Sexuality CASE STUDY 1. A 21—year-old man is in the clinic today to get an employment physical. The health care provider has asked you to provide the client with education about testicular cancer and STIs. After you are done providing this education, the client makes a sexual advance toward you. a. Explain how to provide client teaching for testicular self-examination. b. Explain how to prevent the transmission of STIs and HIV. c. Summarize the nursing strategies to deal with the client’s inappropriate sexual behavior. REVIEW QUESTIONS 1. During discharge planning, the nurse is teaching the client how to prevent transmission of STIs and HIV. Which of the following actions is correct? 1. Use condoms in monogamous relationships only. 2. Follow safe sex practices only during intercourse. 3. Report to a health care facility for examination only when there are signs of an STI. 4. Notify all partners and encourage them to seek treatment when an STI is diagnosed. . A nurse is evaluating a client’s understanding of performing breast self-examination. Which of the following statements indicates a need for further teaching? 1. Use the finger pads (tips) of the three middle fingers (held together) on your left hand to feel for lumps. 2. Press the breast tissue against the chest wall firmly enough to know how your breast feels. A ridge of firm tissue in the lower curve of each breast is abnormal. 3. Use small circular motions systematically all the way around the breast as many times as necessary until the entire breast is covered. 4. Look for any change in size or shape; lumps or thickenings; any rashes or other skin irritations; dimpled or puckered skin; any discharge or change in the nipples. . A nurse is evaluating a nursing student who is discussing nursing strategies for inappropriate sexual behavior from a client. Which of the following actions demonstrates a need for further teaching? 1. “I will communicate that the behavior is not acceptable.” 2. “I will identify the client behaviors that are acceptable.” 3. “I will set firm limits with the client.” 4. “I will not report the incident to my nursing instructor, charge nurse, or clinical nurse specialist.” A nurse is planning a seminar on methods of contraception. Which ofthc following is NOT a correct method of contraception? 1. Chemical barriers including vaginal diaphragm, cervical cap, and condom 2. Abstinence 3. Surgical sterilization 4. Intrauterine devices (IUDs) © 2016 by Pearson Education, Inc. CHAPTER 40/ Sexuality 205 . The nurse is providing education to a client about effects of medications on sexual function. Which of the following statements by the nurse is correct? 1. “Antipsychotics increase sexual desire.” 2. “Diuretics decrease vaginal lubrication.” 3. “Narcotics increase sexual desire and response.” 4. “Barbiturates in large doses increase sexual desire.” The spouse of a client is verbalizing understanding of common conceptions of sex. Which of the following indicates a need for further teaching? The spouse states: 1. “Sexual ability is not lost due to age.” 2. “There is no evidence that sexual activity weakens a person.” 3. “Chronic alcoholism is associated with erectile dysfunction.” 4. “Alcohol is a sexual stimulant.” . The orgasmic phase is: l. The response cycle that starts in the brain, with conscious sexual desires. 2. The involuntary climax of sexual tension, accompanied by physiological and psychological release. 3. The period of return to the unaroused state, may last 10 to 15 minutes after orgasm, or longer if there is no orgasm. 4. An increase of tension in muscles; may increase until released by orgasm, or it may also simply fade away. Body image is: l. A central part of the sense of self, and is constantly changing. 2. One’s self-image as a female or male. 3. The outward expression ofa person’s sense of maleness or femaleness as well as the expression of what is perceived as gender—appropriate behavior. 4. The belief that most characteristics and behaviors are human qualities that should not be limited to one specific gender or the other. . The nurse who is evaluating a sexual health class recognizes that further teaching is necessary when which of the following statements is made by a participant? 1. “Rapid ejaculation is one of the most common sexual dysfunctions among men.” 2. “Preorgasmic women have experienced an orgasm.” 3. “Vulvodynia is constant, unremitting burning that is localized to the vulva with an acute onset.” 4. “Vestibulitis causes severe pain only on touch or attempted vaginal entry.” 10. One technique nurses can use to help clients with altered sexual function is the _ 1. PLISSIT 2. PLllSlT 3. PLLlSSlT 4. PLISIT © 2016 by Pearson Education, Inc. model. CHAPTER 41 SPIRITUALITY KEY TERM REVIEW Match each term with its appropriate definition. ___H... ePJNr‘ QFOPOSP‘teP’N 1. Agnostic Atheist Holy day Kosher Meditation . Being with a client, listening with full awareness of the privilege of doing so Food prepared according to Jewish law An intuitive, interpersonal, altruistic, and integrative expression that reflects the client’s reality Prayer . Disturbance in the belief or value system that provides strength, hope, meaning to life Presencing . Spiritual health Religion Spiritual care Spiritual development Spiritual distress Spiritual health Spiritual well-being Spirituality A person who doubts the existence of God or a supreme being . The human experience that seeks to transcend self and find meaning and purpose through connection with others, nature, and/or a supreme being Human communication with divine and spiritual entities An organized system of beliefs and practices A person who is without beliefin a deity Manifested by a feeling of being generally alive, purposeful, and fulfilled The act of focusing one’s thoughts or engaging in selfrellcclion or contemplation . A day set aside for special religious observance Specific stages through which individuals may progress while maturing spiritually © 2016 by Pearson Education, Inc. 206 CHAPTER 41 /Spirituality 207 KEY TOPIC REVIEW 1. Religion generally involves a belief in a relationship with some higher power, creative force, divine being, or infinite source of energy. a. True b. False . A holy day is a day set aside for special religious observance. a. True b. False . Prayer is human communication with divine and spiritual entities. a. True b. False Meditation is the act of focusing one’s thoughts or engaging in self-reflection or contemplation. a. True b. False Nursing care that supports clients’ spiritual health will help promote other dimensions of health. a. True b. False Religious law may dictate how food is prepared; for example, many Jewish people require food, which is food prepared according to Jewish law. , which is defined as being present, being there, or just being with a client, is a term that identifies one of the competencies incorporated by expert nurses. In the phase, the nurse identifies interventions to help the client achieve the overall goal of maintaining or restoring spiritual well-being so that spiritual strength, serenity, and satisfaction are realized. symbols include jewelry, medals, amulets, icons, totems, or body ornamentation (e.g., tattoos) that carry religious or spiritual significance. 10. Clients facing imminent death may seek © 2016 by Pearson Education, Inc. from others as well as from God. 208 CHAPTER 41 ISpirituality l 1. Match the following terms with the correct definitions. a. Spiritual distress _ To believe in or be committed to something or someone b. Religion # A concept that incorporates spirituality 0. Atheist __ The belief in more than one God (1. Polytheism _ The belief in the existence of one God e. Spirituality m One without belief in a God f. Faith _ A person who doubts the existence of God or a supreme being or believes the existence of God has not been proved g. Hope An organized system of beliefs and practices h. Monotheism A challenge to the spiritual well—being or to the belief system that provides strength, hope, and meaning to life i. Agnostic Is manifested by a feeling of being “generally alive, purposeful, and fulfilled” j. Spiritual health/well—being Refers to that part of being human that seeks meaningfulness through intra-, inter-, and transpersonal connection 12. Which of the following is NOT one of the aspects of spirituality? a. Meaning b. Value 0. Connection d. Religion 13. will most likely not have insurance coverage and rely on the religious community for support. a. Amish, Mennonites b. Buddhists 0. Christian Scientists d. Hindus l4. avoid alcohol, caffeine, and smoking. They prefer to wear temple undergarments. Arrange for priestly blessing if requested. a. Jehovah’s Witnesses b. Jews 0. Latter-Day Saints/Mormons d. Muslims 15. According to Vardey, organized religions offer all of the following EXCEPT: a. A sense of community bound by common beliefs. b. A place ofaversion. c. The collective study of scripture. d. The performance of ritual. © 2016 by Pearson Education, Inc. CHAPTER 41 / Spirituality 209 . Duress 0" SD refers to a challenge to the spiritual well—being or to the belief system that provides 16. Spiritual strength, hope, and meaning to life. . Interest 0. Guidance d. Distress FOCUSED STUDY TIPS 1. Describe nursing interventions to support clients’ spiritual beliefs and religious practices. 2. Identify the desired outcomes for evaluating the client’s spiritual health. List some of the factors associated with spiritual distress and the manifestations of that stress. Discuss the influence of spiritual and religious beliefs about diet on health care. What are some of the ways people nurture or enhance their spirituality? Describe the spiritual development of the individual across the life span. Discuss the influence of spiritual and religious beliefs about birth and death on health care. Explain the concept of forgiveness. Describe the influence of spiritual and religious beliefs about prayer and meditation on health care. 10. Discuss the concept of hope. ll. Describe the concept of spirituality. 12. List some of the characteristics of spiritual health. 13. Discuss the influence of spiritual and religious beliefs about dress on health care. 14. Briefly explain some of the varying religious beliefs related to birth. 15. What does the acronym FICA stand for? CASE STUDY 1. A 37-year-old male client has been admitted to the hospital with terminal cancer. His condition is rapidly deteriorating. He has been living at home with his mother and father for the past 6 months. He is expressing fear and anger about his condition and states that he does not believe he will be alive much longer. a. The client asks you to pray with him. Describe some ofthe guidelines you should follow. b. Summarize the practice guidelines you should follow to support the client’s religious practices. c. Give some examples of spiritual needs that would be related to others. © 2016 by Pearson Education, Inc. 210 CHAPTER 41 / Spirituality REVIEW QUESTIONS 1. Which religion avoids unnecessary treatments on the Sabbath? 1. Buddhism 2. Jehovah’s Witness 3. Latter-Day Saints (LDS or Mormon) 4. Seventh-Day Adventist 2. Religion is: 1. An organized system of beliefs and practices. It offers a way of spiritual expression that provides guidance for believers in responding to life’s questions and challenges. 2. A challenge to the spiritual well—being or to the belief system that provides strength, hope, and meaning to life. 3. Manifested by a feeling of being “generally alive, purposeful, and fulfilled.” 4. Part of being human that seeks meaningfulness through intra—, inter-, and transpersonal connection. 3. A client tells you he is an atheist. You know this to mean: 1. He is an individual who doubts the existence of God or a supreme being or believes the existence of God has not been proved. 2. He is an individual without a belief in a God. 3. He is an individual who believes in the existence of one God. 4. He is an individual who believes in more than one God. 4. A client’s religion may have rules about which foods and beverages are allowed and which are prohibited. Clients of which religion do not eat shellfish or pork? 1. Buddhism 2. Orthodox Jew 3. Hindu 4. Mormon 5. A nurse is evaluating a nursing student’s understanding of presencing. Which of the following statements demonstrates a need for further teaching? A distinguishing feature of presencing is: 1. “Giving of self in the present moment.” 2. “Being there in a way that is meaningful to yourself.” 3. “Listening, with full awareness ofthe privilege of doing so.” 4. “Being available with all ofthe self.” 6. The nurse who is evaluating a supporting religious practices class recognizes that further teaching is necessary when which of the following statements is made by a participant? 1. “Create a trusting relationship with the client so that any religious concerns or practices can be openly discussed and addressed.” 2. “If unsure of client religious needs, ask how nurses can assist in having these needs met.” 3. “Always discuss personal spiritual beliefs with a client.” 4. “Acquaint yourself with the religions, spiritual practices, and cultures of the area in which you are working.” © 2016 by Pearson Education, Inc. CHAPTER 41 /Spiritua|ity 211 7. A nurse is evaluating a nursing student who is just about to pray with a client. Which of the following actions demonstrates a need for further teaching? The student nurse tells the nurse: 1. “Clients” preferences for prayer reflect their personalities.” 2. “Before praying, assess what clients would like you to pray for.” 3. “Prayer may be the springboard to further discussion or catharsis.” 4. “Prayers should never be personalized.” 8. A nurse caring for a Muslim client recognizes that the client practices prayer that the Muslim client may need assistance to maintain this commitment. times a day and 1. Three 2. Four 3. Five 4. Six 9. When a nurse is planning in relation to a client’s spiritual needs, plans should NOT be designed to do which of the following? 1. Help the client fulfill religious obligations. 2. Help the client draw on and use inner resources more effectively to meet the present situation. 3. Help the client find meaning in existence and the present situation. 4. Promote a sense of hopelessness. 10. A nurse is planning a seminar on spiritual needs. Which of the following is NOT an example of spiritual needs related to the self? 1. Need for meaning and purpose 2. Need to express creativity 3. Need for hope 4. Need to cope with loss ofloved ones (0 2016 by Pearson Education, Inc. CHAPTER 42 STRESS AND COPING KEY TERM REVIEW Match each term with its appropriate definition. 1. Alarm reaction 13. Fear 2. Anger 14. General adaptation syndrome (GAS) 3. Anxiety 15. Local adaptation syndrome (LAS) 4. Bumout l6. Shock phase 5. Caregiver burden 17. Stage of exhaustion 6. Coping 18. Stage of resistance 7. Coping mechanism 19. Stimulus-based stress models 8. Coping strategy 20. Stress 9. Countershock phase 21. Stressor 10. Crisis intervention 22. Transactional stress theory 1 1. Depression 12. Ego defense mechanisms © 2016 by Pearson Education, Inc. 212 CHAPTER 42 / Stress and Coping 213 . An extreme feeling of sadness, despair, dejection, lack of worth . Reaction to long—term stress in family members who take care of a person in the home . Natural or learned way of responding to a changing environment d. The changes produced in the body during shock . Any event or stimulus that causes an individual to experience stress Defines stress as a stimulus, life event, or a set of circumstances that arouses physiological and/or psychological reactions that may increase the individual’s vulnerability to illness g. Initial reaction of the body to stress h. A condition in which a person experiences changes in the normal balanced state Stressor may be perceived consciously or unconsciously; stressors stimulate the sympathetic nervous system Dealing with change . Encompasses a set of cognitive, affective, and adaptive responses that arise out of personeenvironment transactions Characterized by a chain or pattern of physiological events . Short-term helping process of assisting clients to work through a crisis to its resolution . At the end of this stage, the body may either rest and return to normal, or death may be the ultimate consequence . Emotional state consisting of a subjective feeling of animosity or strong displeasure . A complex system of behaviors that can be likened to the exhaustion stage of GAS . Coping mechanism . Body can react locally; one organ or a part of the body reacts alone . Stage during which the body attempts to cope with a stressor, and to limit stressor to smallest area of the body that can deal with it Unconscious psychological adaptive mechanisms that develop as the personality attempts to defend itself, establish compromises, and calm inner tensions . A state of mental uneasiness apprehension, dread, or foreboding . Emotion or feeling of apprehension aroused by impending or seeming danger, pain, or another perceived threat KEY TOPIC REVIEW 1. A stressor is a condition in which the person experiences changes in the normal balanced state. a. True b. False 2. In stimulus—based stress models, stress is defined as a stimulus, a life event, or a set of circumstances that arouses physiological and/or psychological reactions that may increase the individual’s vulnerability to illness. a. True b. False 3. Problem solving involves thinking through a threatening situation, using specific steps to arrive at a solution. a. True b. False 4. Structuring (discipline) is assuming a manner and facial expression that convey a sense of being in control or in charge. a. True b. False © 2016 by Pearson Education, Inc. CHAPTER 42 / Stress and Coping . Self-control is the arrangement or manipulation of a situation so that threatening events do not occur. a. True b. False is consciously and willfully putting a thought or feeling out of mind: “I won’t deal with that today. I’ll do it tomorrow.” , or daydreaming, is likened to make-believe. may be described as dealing with change—successfully or unsuccessfully. . Crisis is a short-term helping process of assisting clients to work through a crisis to its resolution and restore their precrisis level of functioning. (coping mechanism) is a natural or learned way of responding to a changing 10. A coping an, environment or specific problem or situation. ll. Match the following terms with the correct definition. a. Shock phase Unconscious psychological adaptive mechanisms or, according to Sigmund Freud (1946), mental mechanisms that develop as the personality attempts to defend itself, establish compromises among conflicting impulses, and calm inner tensions b. Stage of resistance An extreme feeling of sadness, despair, dejection, lack of worth, or emptiness; affects millions of Americans a year c. Anger An emotional state consisting of a subjective feeling of animosity or strong displeasure d. Stressor An emotion or feeling of apprehension aroused by impending or seeming danger, pain, or other perceived threat e. Ego defense mechanisms A state of mental uneasiness, apprehension, dread, or foreboding or a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationships f. Depression When the body’s adaptation takes place g. Local adaptation syndrome When the changes produced in the body during the shock phase are reversed h. Anxiety The stressor may be perceived consciously or unconsciously by the person i. Countershock phase j. Fear , One organ or a part of the body reacts alone Any event or stimulus that causes an individual to experience stress focuses on solving immediate problems and involves individuals, groups, or families. 12. a. Crisis intervention b. Caregiver burden c. Crisis counseling d. Burnout © 2016 by Pearson Education, Inc. CHAPTER 42 / Stress and Coping 215 13. What concept refers to efforts to improve a situation by making changes or taking action? a. Problem—focused coping b. Emotion—focused coping c. Long-term coping d. Short—term coping 14. is resorting to an earlier, more comfortable level of functioning that is characteristically less demanding and responsible. a. Reaction formation b. Projection c. Minimization (1. Regression 15. is displacement of energy associated With more primitive sexual or aggressive drives into socially acceptable activities. a. Sublimation b. Substitution c. Undoing d. Repression :33 16. Which of the following is NOT a cognitive indicator or thinking response to stress? . Structuring O b. Suppression . Anxiety (1. Problem solving FOCUSED STUDY TIPS l. Compare and contrast anxiety and fear. 2. List and define 10 defense mechanisms. Explain burnout. Summarize ways to mediate anger. . Recall the concepts and sources of stress. . Define general adaptation syndrome (GAS) and local adaptation syndrome (LAS). Describe interventions to help clients minimize and manage stress. . Identify nursing diagnoses related to stress. Identify essential aspects of assessing a client’s stress and coping patterns. 10. Discuss types of coping and coping strategies. ll. Identify behaviors related to specific ego defense mechanisms. © 2016 by Pearson Education, Inc. 216 CHAPTER 42 / Stress and Coping l2. Differentiate four levels of anxiety. l3. Identify physiological, psychological, and cognitive indicators of stress. 14. Describe the three stages of Selye’s general adaptation syndrome. 15. Differentiate the concepts of stress as a stimulus, as a response, and as a transaction. 16. Describe the key difference between effective and ineffective coping. CASE STUDY 1. A 37—year-old client has an inability to relax, concentrate, and focus. She also complains of a headache, dizziness, and nausea. The health care provider has asked for you to provide the client with information about anxiety. a. What level of anxiety is the client most likely experiencing? b. Describe various methods you could teach the client to minimize stress and anxiety. c. Explain the difference between anxiety and fear. REVIEW QUESTIONS 1. A client comes into the clinic with tremors and pitch changes in her voice. She also has facial twitches and shakiness. Her respiratory and heart rates are slightly elevated. At the end of her assessment she tells you, “I feel like I have butterflies in my stomach.” Which level ofanxiety is this client experiencing? l. Mild 2. Moderate 3. Severe 4. Panic 2. The spouse ofa client is discussing the difference between anxiety and fear. Which ofthe following statements indicates a need for further teaching? 1. “The source of anxiety is identifiable and the source of fear may not be identifiable.” 2. “Anxiety is related to the future, that is, to an anticipated event. Fear is related to the present.” 3. “Anxiety is vague, whereas fear is definite.” 4. “Anxiety is the result of psychological or emotional conflict; fear is the result of a discrete physical or psychological entity.” 3. Which of the following is an appropriate strategy for dealing with a client’s anger? 1. Try to understand the meaning of the client’s anger. 2. Do not let clients talk about their anger until you are ready. 3. After the interaction is completed, avoid processing your feelings and responses to the client with your colleagues. 4. Listen to the client, and actjust like the client. 4. Which of the following techniques prevents burnout for nurses? 1. Avoid collegial support groups. 2. Avoid involvement in constructive change efforts. 3. Learn to say no. 4. Engage in exercise when you can to direct energy inward. CC) 2016 by Pearson Education, Inc. CHAPTER 42/ Stress and Coping 217 5. At which developmental stage would a client experience getting married, leaving home, managing a home, getting started in an occupation, continuing one’s education, and having children? 1. Adolescent 2. Young adult 3. Middle adult 4. Older adult 6. Which of the following is an example of the defense mechanism of displacement? l. A husband and wife have an argument, and the husband becomes so angry he hits a door instead of his wife. 2. A woman, though told her father has metastatic cancer, continues to plan a family reunion 18 months in advance. 3. A mother is told her child must repeat a grade in school, and the mother blames this on the teacher’s poor instruction. 4. A woman wants to marry a man exactly like her deceased father, and settles for someone whose appearance resembles her father.. 7. A nurse is taking care of an adult client when he throws a temper tantrum because he does not get his own way. Which defense mechanism is the adult client displaying? 1. Repression 2. Regression 3. Reaction formation 4. Rationalization 8. A nurse is planning a seminar on minimizing stress and anxiety. Which of the following statements is NOT correct? 1. Provide an atmosphere of warmth and trust; convey a sense of caring and empathy. 2. Listen attentively; try to understand the client’s perspective on the situation. 3. Control the environment to minimize additional stressors, such as by reducing noise, limiting the number of individuals in the room, and providing care by the same nurse as much as possible. 4. Communicate in long, detailed sentences. 9. During discharge planning, the nurse is teaching the client common characteristics of crises. Which of the following statements is NOT correct? 1. The person is not aware of a warning signal and does not “see it coming.” 2. The crisis is often experienced as ultimately life threatening, whether this perception is realistic or not. 3. Communication with significant others is often increased. 4. There may be a perceived or real displacement from familiar surroundings or loved ones. 10. A nurse is evaluating a nursing student’s understanding of the clinical manifestations of stress. Which of the following statements by the nursing student demonstrates a need for further teaching? 1. “Pupils constrict to decrease visual perception when serious threats to the body arise.” 2. “Sweat production (diaphoresis) increases to control elevated body heat due to increased metabolism.” 3. “Heart rate and cardiac output increase to transport nutrients and by—products of metabolism more efficiently.” 4. “Skin is pallid because of constriction of peripheral blood vessels, an effect of norepinephrine.” © 2016 by Pearson Education, Inc. CHAPTER 43 Loss, GRIEVING, AND DEATH KEY TERM REVIEW Match each term with its appropriate definition. 1. Actual loss a. Client is not made aware of impending death 2. Algor mortis b. Mortician 3. Anticipatory grief 4. Anticipatory loss 5. Bereavement 6. Cerebral death c. Approach that improves quality of life of clients and their families facing life—threatening illness, through prevention and relief of suffering d . Gradual decrease of the body’s temperature after death 6. A large piece of plastic or cotton material used to enclose a body af- 7. Closed awareness 8. Complicated grief 9. End-of—life care ter death v f. Mottling discoloration that occurs in the lowermost or dependent areas of the body Behavioral process through which grief is eventually resolved or al— tered 10. Grief g' 11. Heart—lung death h 12. Higher brain death 13. Hospice 14. Livor mortis 15. Loss j" 16. Mortician k' 17. Mourning 1' 18. Mutual pretense m 19. Open awareness n. 20. Palliative care 0. 21. Perceived loss 22. Rigor mortis p. Cerebral death 23. Shroud q. Stiffening of the body that occurs about 2 to 4 hours after death 24. Undertaker r. Can be recognized by others © 2016 by Pearson Education, Inc. . Client and others know about impending death and feel comfortable talking about it i. Exists when the strategies to cope with the loss are maladaptive; usually lasts more than 6 months Cessation of apical pulse, respirations, and blood pressure Experienced by one individual but cannot be verified by others Occurs when the cerebral cortex is irreversibly destroyed . Client, family, and health personnel know that the prognosis is terminal but do not talk about it The subjective response experienced by the surviving loved ones An actual or potential situation in which something that is valued is changed or no longer available v/ 218 CHAPTER 43/ Loss, Grieving, and Death 219 S. Total response to the emotional ex~ perience related to loss t. Focuses on support and care of the dying person and family; goal is facilitating a peaceful and dignified death 11. Experienced before the loss actually occurs v. Care provided in the final weeks before death w. Experienced in advance of the event x. An individual trained in care of the dead KEY TOPIC REVIEW 1. Everyone experiences loss, grieving, and death at some time. a. True b. False Actual loss is experienced before the loss actually occurs. a. True b. False . Higher brain death occurs when the higher brain center, the cerebral cortex, is irreversibly destroyed. a. True b. False In closed awareness, the client is not made aware of impending death. a. True b. False With mutual pretense, the client, family, and health personnel know that the prognosis is terminal but do not talk about it and make an effort not to raise the subject. a. True 50“.“? b. False is the stiffening of the body that occurs about 2 to 4 hours after death. Rigor mortis is the gradual decrease of the body’s temperature after death. A is an individual trained in care of the dead. A is a large piece of plastic or cotton material used to enclose a body after death. occurs when the individual perceives no solutions to a problem. 10. . An individual who conducts rituals of mourning (e.g., funeral) is said to be in which of the following of Engel’s stages of grieving? a. Shock and disbelief b. Developing awareness c. Restitution d. Resolving the loss . More than a. 9,000 b. 14,000 C. 18,000 d. 24,000 © 2016 by Pearson Education, Inc. nurses in the United States are nationally certified in hospice and palliative care. 220 CHAPTER 43 / Loss, Grieving, and Death 13 . A(An) is a large piece of plastic or cotton material used to enclose a body after death. a. Undertaker b. Hospice c. Mortician d. Shroud . Which of the following age groups has the following beliefs/attitudes about the concept of death? I Understands death as the inevitable end oflife. l Begins to understand own mortality, expressed as interest in afterlife or as fear of death. a. Infancy to 5 years b. 5 to 9 years c. 9 to 12 years d. 12 to 18 years 15. An individual who is displaying the behavioral response of separation anxiety would be in which of Sander’s phases of bereavement? a. Shock b. Awareness of loss c. Conservation/withdrawal d. Healing: the turning point FOCUSED STUDY TIPS 1 . Discuss the dying person’s bill of rights. 2 . Describe the types and sources of losses. . Discuss selected frameworks for identifying stages of grieving. Identify clinical symptoms Ol‘gricl‘. . Discuss factors affecting a grief response. ldentify measures that facilitate the grieving process. List clinical signs of impending and actual death. Describe helping clients die with dignity. Describe nursing measures for care of the body after death. 10. Describe the role ofthe nurse in working with families or caregivers ofdying clients. 11. Define grief, bereavement, and mourning. 12. List the factors influencing the loss and grief responses. 13. Discuss various responses to dying and death. © 2016 by Pearson Education, Inc. CHAPTER 43/ Loss, Grieving, and Death 221 14. Explain the steps in postmortem care. 15. Discuss the physiological needs ofthe dying client. 16. Discuss the psychosocial needs of the dying client. CASE STUDY 1. You are visiting with a 22-year—old male client. During the assessment phase, you discover his father passed away last week from a terminal illness. The client tells you he was very close to his father. a. Which type of loss is the client experiencing? b. Explain grief, bereavement, and mourning. c. List four appropriate questions to ask during the assessment. REVIEW QUESTIONS 1. Bereavement is: 1. The total response to the emotional experience related to loss. 2. The subjective response experienced by the surviving loved ones after the death ofa person with whom they have shared a significant relationship. 3. The behavioral process through which grief is eventually resolved or altered; it is often influenced by cul— ture, spiritual beliefs, and custom. 4. An actual or potential situation in which something that is valued is changed or no longer available. 2. A nurse’s client just passed away. The nurse understands that rigor mortis is the stiffening of the body that occurs about 7 hours after death. 1. 2to4 2. 5to7 3. 8t010 4.11t013 3. A nurse is taking care of a client who just lost her husband to a terminal illness. The client is refusing to believe that loss is happening. Which of Kubler-Ross’s stages of grieving is the client experiencing? 1. Denial 2. Anger 3. Bargaining 4. Depression 4. A nurse is caring for a client whojust lost her brother to suicide. The client accepts the situation intellectually, but denies it emotionally. Which of Engel’s stages of grieving is the client experiencing? 1. Shock and disbelief 2. Developing awareness 3. Restitution 4. Resolving the loss © 2016 by Pearson Education, Inc. 222 CHAPTER 43/ Loss, Grieving, and Death 5. Which of the following is a correct description of Sander’s conservation/withdrawal phase of bereavement? l. The bereaved move from distress about living without their loved one to learning to live more independently. 2. The survivors feel a need to be alone to conserve and replenish both physical and emotional energy. 3. Friends and family resume normal activities. The bereaved experience the full significance of their loss. 4. The survivors are left with feelings of confusion, unreality, and disbelief that the loss has occurred. 6. A nurse is evaluating a nursing student who is caring for a dying client’s physiological needs. Which of the following actions demonstrates a need for further teaching? 1. For an unconscious client with an airway clearance problem, the nursing student places him in Fowler’s position. 2. The client is diaphoretic; the nursing student gives the client frequent baths and changes the linen. 3. The nursing student regularly changes client’s position. 4. The nursing student provides the client with skin care in response to incontinence of urine or feces. 7. A nurse is planning a seminar on the dying person’s bill of rights. Which of the following statements is NOT part of the dying person’s bill of rights? 1. I have the right to express my feelings and emotions about my approaching death in my own way. 2. I have the right to expect continuing medical and nursing attention even though cure goals must be changed to comfort goals. 3. I have the right to be free from pain. 4. I have the right to die alone. 8. The nurse is providing care to an unconscious client who is dying. Which ofthe following is NOT a clinical manifestation of impending clinical death? 1. Difficulty swallowing and gradual loss of the gag reflex 2. Mottling and cyanosis of the extremities 3. Rapid, shallow, irregular, or abnormally slow respirations 4. Faster and weaker pulse 9. At what age does a client typically believe his or her own death can be reversible? l. Infancy to 5 years 2. 5 to 9 years 3. 9 to 12 years 4. 12 to 18 years 10. Which of the following actions is NOT appropriate for the nurse providing postmortem care? 1. One pillow is placed under the head and shoulders to prevent blood from discoloring the face by settling in it. 2. The eyelids are closed and held in place for a few seconds so they remain closed. 3. Dentures are always removed and placed with the client’s personal belongings. 4. All jewelry is removed, except a wedding band in some instances, which is taped to the finger. © 2016 by Pearson Education, Inc. CHAPTER 44 ACTIVITY AND EXERCISE KEY TERM REVIEW Match each term with its appropriate definition. NIQNNH-—‘—'—‘ WNT‘QF’PC’N997‘; r—‘Q —‘-—‘r—‘D—l owagweww 1. Occurs when a stronger muscle dominates the opposite muscle Active ROM exercises Aerobic exercise Another person moves each of the client’s joints Anabolism through its complete range of movement Anaerobic exercise Protein breakdown Basal metabolic rate Isotonic exercises in which the client moves each joint in the body through its complete range of Catabolism movement Foot drop The ability of the body to perform work Functional strength Involves activity in which the muscles cannot draw Isokinetic (resistive) exercise Isometric (static or setting) exercise out enough oxygen from the bloodstream; used for endurance training Isotonic (dynamic) exercise Protein synthesis Muscle contraction or tension against resistance __ 7 fl Lateral position The minimal energy expended for maintenance of physical and chemical processes of the body Metabolism Orthopneic position Muscle contraction without moving the joint Orthostatic hypotension Crutch positioned in front of feet about 40 cm (15 m Passive ROM exercises in.), out laterally about 15 cm (6 in.) Prone position Activity during which the amount of oxygen taken in the body is greater than that used to perform the activity _ Range of motion (ROM) Relaxation response (RR) Spastic Supine position Tripod (triangle) position Valsalva maneuver m. Client sits either in bed or on the side of the bed with an overbed table across the lap Side—lying position Sum of all the physical and chemical processes by which living substance is formed and maintained, and by which energy is made available for use by the body © 2016 by Pearson Education, Inc. 223 224 CHAPTER 44/ Activity and Exercise p. Decreased blood pressure as a result of q. changing from a sitting or lying position to a standin osition gp Exercise can counteract some of the harmful effects Of stress on the body With too much muscle tone v. r. Client positioned on the abdomen with the head turned to one side The maximum movement that is possible for that joint w. Lying on back; dorsal recumbent 5. t. Refers to holding the breath and straining against a u. closed glottis . . Those in which the muscle shortens to produce muscle contraction and active movement KEY TOPIC REVIEW 1. An activity-exercise pattern refers to an individual’s routine of exercise, activity, leisure, and recreation. a. True b. False . An individual maintains balance as long as the line of gravity (an imaginary horizontal line drawn through the body’s center of gravity) passes through the center of gravity. a. True b. False . The base of support is the foundation on which the body rests. a. True b. False The range of motion (ROM) of a joint is the maximum movement that is possible for that joint. a. True b. False Proprioception is the term used to describe awareness of posture, movement, and changes in equilibrium and the knowledge of position, weight, and resistance of objects in relation to the body. a. True b. False is commonly seen in the arm muscles of a tennis player, the leg muscles of a skater, and the arm and hand muscles of a carpenter. is a condition in which the bones become brittle and fragile due to calcium depletion. Unused muscles , losing most of their strength and normal function. When the muscle fibers are not able to shorten and lengthen, eventually a mobility. 10. Without movement, the collagen tissues at thejoint become © 2016 by Pearson Education, Inc. forms, limiting joint CHAPTER 44/ Activity and Exercise 225 1 1. Match the following terms with the correct definition. Physical activity a. The ability to move freely, easily, rhythmically, and purposefully in the environment; is an essential part of living Bodily movement produced by skeletal muscle contraction that increases energy expenditure . Exercise Isotonic (dynamic) exercises A type of physical activity defined as a planned, structured, and repetitive bodily movement performed to improve or maintain one or more components of physical fitness . Aerobic exercise Exercise in which the muscle shortens to produce muscle contraction and active movement . Mobility Exercise in which there is muscle contraction without moving the joint (muscle length does not change) Anaerobic exercise Involve muscle contraction or tension against resistance; thus, they can be either isotonic or isometric . Isokinetic (resistive) exercises Activity during which the amount of oxygen taken in by the body is greater than that used to perform the activity . Osteoporosis Involves activity in which the muscles cannot draw out enough oxygen from the bloodstream, and anaerobic pathways are used to provide additional energy for a short time . Ventilation Air circulating into and out of the lungs . Isometric (static or setting) exercises A condition in which the bones become brittle and fragile due to calcium depletion 12. Which of the following is defined as having too much muscle tone? Meningitis . Paresis Flaccid Spastic refers to holding the breath and straining against a closed glottis. 13. Valsalva maneuver . Orthostatic hypotension C. Stasis d. Venous vasodilation 14. Which ot‘the following is NOT one of the three factors that collectively predispose a client to the formation of a thrombophlebitis? a. Increased oil in the diet b. Impaired venous return to the heart C. Hypercoagulability of the blood d. Injury to a vessel wall © 2016 by Pearson Education, Inc. 226 CHAPTER 44 / Activity and Exercise refers to the sum of all the physical and chemical processes by which living substance is 15. formed and maintained and by which energy is made available for use by the body. a. Metabolism b. Catabolism c. Anabolism d. Anorexia FOCUSED STUDY TIPS l. Discuss how the US. Department of Health and Human Services defines exercise and physical activity. 2. Describe the effects of exercise on cognitive function. . List some of the factors that affect an individual’s body alignment, mobility, and daily activity level. . Define and discuss the term body mechanics. . Describe the three different ways the intensity of exercise can be measured. . Discuss the importance of the musculoskeletal system. . Describe how to use safe practices when positioning, moving, lifting, and ambulating clients. . Describe a variety of movement interventions and therapies to improve physical health, mobility, strength, balance, mood, and cognition. . Develop nursing diagnoses and outcomes related to activity, exercise, and mobility problems. 10. Discuss the activity—exercise pattern, alignment, mobility capabilities and limitations, activity tolerance, and potential problems related to immobility. 11. Identify factors influencing a person’s body alignment and activity. . Compare the effects of exercise and immobility on body systems. . Differentiate isotonic, isometric, isokinetic, aerobic, and anaerobic exercise. . Describe four basic elements of normal movement. . List some of the factors that increase the potential for lower back injuries. . Describe how increased venous pressure leads to edema. . Describe the factors that predispose a client to the development of thrombophlebitis. © 2016 by Pearson Education, Inc. CHAPTER 44/ Activity and Exercise 227 CASE STUDY 1. A 43-year-old client is recovering from a back injury and is receiving care from a home health nurse. A major aspect of discharge planning involves instru ctional needs of the client and the client’s family. Provide the cli— ent and the client ’sfamily education about thefO/lowing topics: I Maintaining musculoskeletal function I Preventing injury I Managing energy to prevent fatigue I Preventing back injuries REVIEW QUESTIONS 1. A nurse is planning a seminar on preventing back injuries. Which of the following statements is correct? 1. When sitting for a period oftime, periodically move legs and hips, flex one hip and knee, and rest your foot on an object if possible. 2. When sitting, keep your knees slightly lower than your hips. 3. Use a hard mattress and firm pillow that provide good body support at natural body curvatures. 4. Exercise regularly to maintain overall physical condition and regulate weight; include exercises that strengthen the pelvic, abdominal, and spinal muscles. 2. During discharge planning, the nurse is evaluating the client’s understanding of wheelchair safety. Which of the following statements indicates a need for further teaching? 1. Always lock the brakes on both wheels of the wheelchair when the client transfers in or out of it. 2. Lower the footplates before transferring the client into the wheelchair. 3. Lower the footplates after the transfer, and place the client’s feet on them. 4. Ensure the client is positioned well back in the seat of the wheelchair. 3. A nurse is evaluating a nursing student’s understanding of stretcher safety. Which of the following statements demonstrates a need for further teaching? 1. Never leave a client unattended on a stretcher unless the wheels are locked and the side rails are raised on both sides and/or the safety straps are securely fastened across the client. 2. Always push a stretcher from the end where the client’s head is positioned. This position protects the client’s head in the event of a collision. 3. Maneuver the stretcher when entering the elevator so that the client’s feet go in first. 4. Fasten safety straps across the client on a stretcher, and raise the side rails. 4. Which of the following actions is appropriate for the nurse performing active ROM exercises? 1. Perform each ROM exercise as taught to the point ofslight resistance, but not beyond, and never to the point of discomfort. 2. Perform the movements systematically, using a different sequence during each session. 3. Perform each exercise five times. 4. Perform each series of exercises three times daily. C 2016 by Pearson Education, Inc. 228 CHAPTER 44 / Activity and Exercise 5. During discharge planning, the nurse is teaching the client how to control postural hypotension. Which of the following statements is correct? l. Bend down all the way to the floor and stand up quickly after stooping. 2. Wear elastic stockings day and night to inhibit venous pooling in the legs. 3. Use a rocking chair to improve circulation in the lower extremities. 4. Get out of a hot bath very quickly, because high temperatures can lead to venous pooling. 6. Isotonic (dynamic) exercises: I. Are those in which there is muscle contraction without moving the joint (muscle length does not change). 2. Involve muscle contraction or tension against resistance; thus, they can be either isotonic or isometric. 3. Are activities during which the amount of oxygen taken in by the body is greater than that used to perform the activity. 4. Are those in which the muscle shortens to produce muscle contraction and active movement. 7. A nurse is evaluating a nursing student’s understanding of positioning clients. Which of the following statements indicates a need for further teaching? I. Positioning a client in good body alignment and changing the position regularly (every 3 hours) and sys— tematically are essential aspects of nursing practice. Any position, correct or incorrect, can be detrimental ifmaintained for a prolonged period. For all clients, it is important to assess the skin and provide skin care before and after a position change. Frequent change of position helps to prevent muscle discomfort, undue pressure resulting in pressure ulcers, damage to superficial nerves and blood vessels, and contractures. 8. Fowler’s position is a bed position: I. In which the head and trunk are raised 450 to 60°. 2 . In which the client’s head and shoulders are slightly elevated on a small pillow. 3. In which the client lies on the abdomen with the head turned to one side. 4 . In which the person lies on one side of the body. Flexing the top hip and knee and placing this leg in front of the body creates a wider, triangular base of support and achieves greater stability. 9. General guidelines for transfer techniques include all of the following EXCEPT: l . Obtain essential equipment before starting (e. g., transfer belt, wheelchair), and check its function. 2 . Always support or hold equipment rather than the client to ensure safety and dignity. 3. Remove obstacles from the area used for the transfer. 4 . Explain the transfer to the nursing personnel who are helping; specify who will give directions (one person needs to be in charge). 10. Which ofthe following actions is appropriate for the nurse assisting a client with crutches? 1. The client lies in a prone position and the nurse measures from the anterior fold of the axilla to the heel of ix.) the foot and adds 2.5 cm (I in.). The client stands erect and positions the crutch. The nurse makes sure the shoulder rest of the crutch is at least three fingerwidths, that is. 2.5 to 5 cm (i to 2 in.), below the axilla. . The client stands upright and supports the body weight by the axilla. The nurse measures the angle of elbow flexion. It should be about 10°. © 2016 by Pearson Education. Inc. CHAPTER 45 SLEEP KEY TERM REVIEW Match each term with its appropriate definition. __#_.__._. QFOFX’SP‘SJ‘F‘P’N U‘F‘PJb’f 1. l6. Biological rhythms . Orgasm and release of semen during sleep Electroencephalogram (EEG) . Naturally occurring altered state of consciousness in Which perceptions and reactions are decreased Electromyogram (EMG) Electro-oculogram (EOG) Hypersomnia Insomnia Narcolepsy Nocturnal emissions NREM sleep Parasomnia Polysomnography REM sleep Sleep Sleep apnea Sleep architecture Slccp hygiene . Basic organization of normal sleep . Individual obtains sufficient sleep at night but has difficulty staying awake during the day . Excessive daytime sleepiness caused by lack of chemical in area of the CNS that regulates sleep . Use of several monitoring and recording devices used to measure sleep objectively . Occurs about every 90 minutes; essential for psycho— social and mental equilibrium . Controlled within the body and synchronized with environmental factors I Characterized by frequent, short breathing pauses during sleep '. Inability to fall asleep or remain asleep . Records brain waves . Four stages; essential for physiological well-being . Interventions used to promote and enhance the quality of client’s sleep . Records muscle activity . Behavior that may interfere with sleep, and may oc— cur during sleep . Records eye movement © 2016 by Pearson Education, Inc. 229 230 CHAPTER 45/ Sleep KEY TOPIC REVIEW 1. Somnology is the study of sleep. a. True b. False 2. Stage 1 is the deepest stage of sleep. a. True b. False 3. Most dreams take place during REM sleep, but usually will not be remembered unless the individual arouses briefly at the end of the REM period. a. True b. False 4. Sleep apnea is characterized by frequent short breathing pauses during sleep. a. True b. False 5. Sleep hypnotics is a term referring to interventions used to promote sleep. a. True b. False has come to be considered an altered state of consciousness in which the individual’s perception of and reaction to the environment are decreased. exist in plants, animals, and humans. 7. Biological 8. REM sleep usually recurs about every minutes and lasts 5 to 30 minutes. is described as the inability to fall asleep, remain asleep, or awaken feeling rested. 10. is a disorder of excessive daytime sleepiness caused by lack of the chemical hypocretin in the area of the central nervous system that regulates sleep. ll. Match the following terms with the correct definition. a. Sundown syndrome The study of sleep b. Insomnia The basic organization of normal sleep C. Cognitive therapy . Sleep quality A pattern of symptoms (e.g., agitation, anxious, aggressive, and sometimes delusional) that occur in the late afternoon A subjective characteristic, often determined by whether or not a person wakes up feeling energetic or not Narcolepsy The total time the individual sleeps Hypersomnia The most common sleep complaint in America . Quantity ofsleep Learning to develop positive thoughts and beliefs about sleep . Stimulus control Creating a sleep environment that promotes sleep Sleep architecture Conditions where the affected individual obtains sufficient sleep at night but still cannot stay awake during the day Somnology A disorder of excessive daytime sleepiness caused by the lack of the chemical hypocretin in the area of the central nervous system that regulates sleep © 2016 by Pearson Education, Inc. CHAPTER 45/ Sleep 231 12. Newborns sleep hours a day, on an irregular schedule with periods of 1 to 3 hours spent awake. a. 10 to 12 b. 12 to 14 c. 14 to 16 d. 12 to 18 13. Most healthy adults need hours of sleep a night. a. 7 to 9 b. 9 to 11 c. 11 to 13 d. 13 to 15 14. Stress is considered by most sleep experts to be the number culties. cause of short-term sleeping diffi- a. one b. two 0. three (1. four . By the end of the first year, how many hours ofslccp should an infant receive during the day? a. 7to8 b. 9tol2 c. 12tol3 d. 14t015 . Approximately million Americans have a chronic disorder of sleep and wakefulness that hin- P 10 to 30 9‘ ders daily functioning and adversely affects health. 30 to 50 c. 50 to 70 d. 70 to 90 FOCUSED STUDY TIPS 1. Identify factors that affect normal sleep. 2. Describe variations in sleep patterns throughout the life span. . Identify the characteristics of the sleep states of NREM and REM sleep. Explain the functions and the physiology of sleep. . Discuss the following three types of sleep apnea: obstructive apnea, central apnea, and mixed apnea. Identify items included in and the purpose ofa sleep diary. © 2016 by Pearson Education, Inc. 232 CHAPTER 45 / Sleep 7. Summarize the major goal for clients with sleep disturbances. 8. Discuss the importance of bedtime rituals. 9. List several of the factors that can affect sleep. 10. Discuss several techniques for reducing environmental distractions in hospitals. 1 1. Discuss three nursing responsibilities to help clients sleep. 12. List seven drugs that may disrupt REM sleep, delay onset of sleep, or decrease sleep time. 13. Describe common sleep disorders. 14. identify the components of a sleep pattern assessment. 15. Describe interventions that promote normal sleep. 16. Describe the reticular activating system (RAS) and its involvement in the sleep/wake cycle. CASE STUDY 1. A 21—year~old client presented to the clinic today complaining of difficulty sleeping. The client is a part-time college student and also works 40 to 50 hours per week at an automotive body shop. The client is not taking any prescription medications and has an occasional alcoholic beverage at special events. a. Explain the two types of sleep. b. Describe factors that affect sleep. 0. Explain the information that should be included in a sleep diary. REVIEW QUESTIONS 1. During discharge planning, the nurse is teaching the client how to maintain a sleep diary. Which of the following statements is correct? 1. Document the activities you perform 5 to 6 hours before going to bed. 2. Document the consumption of caffeinated beverages and alcohol and amounts of those beverages. 3. Do not list the bedtime rituals before bed. 4. List only the prescribed medications taken during the day. 2. A nurse is evaluating a client’s understanding of comfort measures that are essential to help fall asleep and stay asleep. Which ofthe following client statements indicates a need for further teaching? 1. “I should wear loose-fitting nightwear.” 2. “I will void before bedtime.” 3. “I will perform hygienic routines prior to bedtime.” 4. “When I’m in pain, lwill take the prescribed analgesics 1 hour before I go to sleep.” © 2016 by Pearson Education, Inc. CHAPTER 45 / Sleep 233 3. A nurse is evaluating a nursing student’s understanding of medications. Which of the following statements by the nursing student indicates a need for further teaching? 1. “Antianxiety medications decrease levels of arousal by facilitating the action of neurons in the CNS that suppress responsiveness to stimulation.” 2. “Sleep medications vary in their onset and duration of action and will impair waking function as long as they are chemically active.” 3. “Sleep medications affect NREM sleep more than REM sleep.” 4. “Initial doses of medications should be low and increases added gradually, depending on the client’s re— sponse.” 4. Hypersomnia is: 1. A condition in which the affected individual obtains sufficient sleep at night but still cannot stay awake during the day. 2. A disorder of excessive daytime sleepiness caused by the lack of the chemical hypocretin in the area of the central nervous system that regulates sleep. 3. A condition characterized by frequent short breathing pauses during sleep. 4. A behavior that may interfere with sleep and/or occurs during sleep. 5. Which stage of NREM (slow-wave) sleep lasts only about 10 to 15 minutes, during which the eyes are generally still, the heart and respiratory rates decrease slightly, and body temperature falls? 1. Stage l 2. Stage 2 3. Stage 3 4. Stage 4 6. A nurse is evaluating a nursing student who is discussing physiological changes during NREM sleep. Which of the following statements by the nursing student demonstrates a need for further teaching? 1. Arterial blood pressure falls. 2. Pulse rate decreases. 3. Peripheral blood vessels constrict, 4. Cardiac output decreases. 7. When planning interventions to reduce environmental distractions in hospitals, which of the following would NOT be included in the client’s plan of care? 1. Lower the ring tone of nearby telephones. 2. Discontinue use of the paging system after a certain hour or reduce its volume. 3. Keep required staff conversations at low levels; conduct nursing reports or other discussions in a separate area away from client rooms. 4. Perform noisy activities only during the day, never during sleeping hours. © 2016 by Pearson Education, Inc. 234 CHAPTER 45/ Sleep 8. A nurse is planning a seminar on promoting sleep. Which of the following is correct information? 1. Establish a regular bedtime and wake-up time for all days of the week to enhance biologic rhythm. 2. Complete office work or discuss family problems before bedtime. 3. Get adequate exercise during the day to reduce stress, but avoid excessive physical exertion 1 hour before bedtime. 4. Establish a regular, relaxing bedtime routine before sleep such as exercising or taking a cool shower. 9. When planning interventions to promote sleep, which of the following would be included in the client’s plan of care? 1. Create a sleep-conducive environment that is dark, quiet, comfortable, and cool. 2. Give analgesics 3 hours before bedtime to relieve aches and pains. 3. If a bedtime snack is necessary, give only high-carbohydrate snacks or a milk drink. 4. Avoid giving the client heavy meals 4 to 5 hours before bedtime. 10. A nurse is evaluating a client’s understanding of her child’s night terrors. Which ofthe following statements indicates a need for further teaching? 1. Night terrors are usually seen in children 3 to 6 years of age. 2. Children usually cannot be wakened during night terrors, but should be protected from injury, helped back to bed, and soothed back to sleep. 3. Children do not remember the night terror the next day, and there is no indication of a neurologic or emo— tional problem. 4. Night terrors are partial awakenings from non-REM stage 1 or 2 sleep. C 2016 by Pearson Education, Inc. ,. CHAPTER 46 PAIN MANAGEMENT KEY TERM REVIEW Match each term with its appropriate definition. 1. Acute pain 12. Nociceptive pain 2. Agonist analgesic 13. Nonsteroidal anti-inflammatory drugs (NSAIDS) 3. Agonist~antagonist analgesic 14. Pain threshold 4. Allodynia 15. Pain tolerance 3. Chronic pain 16. Patient—controlled analgesia (PCA) 4. Coanalgesic 17. Peripheral neuropathic pain 5. Dysesthesia l 8. Pseudoaddiction 6. Effleurage l9. Referred pain 7. Equianalgesia 20. Somatic pain 8. Hyperalgesia 21. Sympathetically maintained pain 9. Hyperpathia 22. Transcutaneous electrical nerve stimulation (TENS) 10. Nerve block 23. 7 1 1. Neuropathic pain © 2016 by Pearson Education, Inc. V Visceral pain 235 236 CHAPTER 46/ Pain Management Type of massage consisting of long, slow, gliding strokes Refers to relative potency of various opioid analgesics compared to a standard dose of parenteral morphine Experienced when an intact, properly functioning nervous Originates in skin, muscles, bone, or connective tissue system sends signals that tissues are damaged Chemical interruption of a nerve pathway, effected by injecting a local anesthetic into the nerve Prolonged, usually recurring or lasting more than 3 months; in— terferes with functioning Can act like opioids and relieve pain when given to a client who has not taken any pure opioids Condition that results from the undertreatment of pain where the client may become hyperfocused on obtaining medication May occur with abnormal connections between pain f1bers and the sympathetic nervous system Phantom limb pain A nonopioid pain medication that Pure opioid drugs that provide maximum pain inhibition has anti-inflammatory, analgesic, and anti pyretic effects Not classified as a pain medication but may reduce pain Heightened responses to a painful stimulus tentiate the effects of pain medications alone or in combination with other analgesics; may po- Sudden or slow onset, regardless Least amount of stimuli necessary for a person to label a sensation as pain of its intensity Nonpainful stimulus that produces pain Appear to arise in different areas to other parts of the body Method of applying electrical stimulation directly over identified pain areas; stimulation through to block transmission of nociceptive impulse Associated with damaged or mal— functioning nerves due to illness, injury, or undetermined reasons Hyperalgesia Unpleasant, abnormal sensation that can be either spontaneous or evoked Interactive method of pain man- The most pain an individual is willing or able to bear before taking evasive actions agement that permits clients to Pain arising from organs treat their pain by self— administering doses of analgesics KEY TOPIC REVIEW 1. Central neuropathic pain occurs occasionally when abnormal connections between pain fibers and the sympathetic nervous system perpetuate problems with both the pain and sympathetically controlled functions. a. True b. False 2. Pain tolerance is the least amount of stimulus that is needed for a person to feel a sensation he or she labels as pain. a. True b. False 3. Pain management is the alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the client. a. True b. False © 2016 by Pearson Education, Inc. CHAPTER 46/ Pain Management 237 Preemptive analgesia is the administration of analgesics prior to an invasive or operative procedure in order to treat pain before it occurs. a. True b. False . Pain threshold is the maximum amount of painful stimuli that a person is willing to withstand without seeking avoidance of the pain or relief. a. True b. False A full agonist includes morphine (e.g., Kadian, MS Contin), oxycodone (e.g. Percocet, OxyContin), and hydromorphone (e.g., Dilaudid, Palladone). Partial agonists have a effect in contrast to a full agonist. refers to the relative potency of various opioid analgesics compared to a standard dose of par— enteral morphine. is “any medication or procedure, including surgery, that produces an effect in a client because of its implicit or explicit intent and not because of its specific physical or chemical properties.” drug therapy is advantageous in that it delivers a relatively stable plasma drug level and is non- 10. invasive. ll. Match the following terms with the correct definition. Appear to arise in different areas b. Mild pain Pain arising from organs or hollow viscera 0. Physiological pain When pain lasts only through the expected recovery period D. a . Chronic pain . Peripheral neuropathic pain Prolonged, usually recurring or persisting over 6 months or longer, and interferes with functioning e. Neuropathic pain Pain in the 1—3 range of a 0-10 scale f. Referred pain Experienced when an intact, properly functioning nervous system sends signals that tissues are damaged, requiring attention and proper care g. Somatic pain Originates in the skin, muscles, bone, or connective tissue h. Visceral pain Experienced by people who have damaged or malfunctioning nerves i. Moderate pain Follow damage and/or sensitization of peripheral nerves j. Acute pain Pain in the 4—6 range of a 0-10 scale _ block is a chemical interruption of a nerve pathway, effected by injection of a local . A (An) anesthetic into the nerve. a. Nerve b. Anesthetic 0. Chemical (1. Pathway © 2016 by Pearson Education, Inc. 238 CHAPTER 46/ Pain Management 13. Which of the following is NOT a type of pain stimuli? a. Mechanical b. Thermal 0. Electrical d. Chemical 14. Which of the following terms is described as a painful sensation felt from a part of the body that has been amputated? a. Nociceptive pain b. Phantom pain 0. Neuropathic pain (1. Sensitization 15. All of the following are reasons clients may be reluctant to report pain EXCEPT: a. Unwillingness to trouble staff who are perceived as busy. b. Do not want to be labeled as “complainers” or “bad” patients. c. Concern that use of drugs now will render the drug inefficient later in life. d. Beliefthat others will think they are strong ifthey express pain. FOCUSED STUDY TIPS 1. List the four physiological processes that are involved in nociception. 2. What is the “fifth vital sign”? . Describe the World Health Organization’s step ladder approach developed for cancer pain control. Describe pharmacologic interventions for pain. . Compare and contrast barriers to effective pain management. . Identify examples of nursing diagnoses for clients with pain. . Identify subjective and objective data to collect and analyze when assessing pain. . Describe the gate control theory and its application to nursing care. . Describe how the contribution of physical, mental, spiritual, and social aspects of pain contribute to concepts such as pain tolerance, suffering, and pain behavior. . Describe the four processes involved in nociception and how pain interventions can work during each process. . Discriminate between physiological and neuropathic pain categories. . Give an example of rational polypharmacy as described by the American Pain Society. . Differentiate between tolerance, dependence, and addiction. . Identify risks and benefits of various analgesic delivery routes and analgesic delivery technologies. C) 2016 by Pearson Education, Inc. CHAPTER 46/ Pain Management 239 15. Describe nonpharmacologic pain control interventions. 16. List two interventions for reducing client’s misconceptions about pain. 17. List three methods that nurses may use to acknowledge and accept a client’s pain. CASE STUDY 1. A 43-year-old client is complaining of abdominal pain. The client locates his pain in the epigastric region. On a 0710 scale, he rates his pain as an 8. He describes the pain as “constant throbbing.” a. As the fifth vital sign, pain should be screened for every time vital signs are evaluated. Define pain. b. Identify the two major components of a pain assessment. c. Explain the pain intensity scale. REVIEW QUESTIONS 1. Which of the following statements about pain is true? 1. Pain is a sign, not a symptom. 2. Pain presents only physiological dangers to health and recovery. 3. Severe pain is viewed as an emergency situation. 4. Pain is a low-priority problem. 2. When pain lasts only through the expected recovery period, it is described as: 1. Chronic pain. 2. Acute pain. 3. Referred pain. 4. Visceral pain. 3. Pain tolerance is: l. The least amount of stimuli that is needed for an individual to feel a sensation labeled as pain. 2. The maximum amount of painful stimuli that an individual is willing to withstand without seeking avoidance of the pain or relief. 3. An unpleasant, abnormal sensation. 4. A situation in which nonpainful stimuli (e.g., contact with linen, water, or wind) produce pain. 4. A client who describes her pain as 3 on a scale of 0—10 is having: 1. Mild pain. 2. Moderate pain. 3. Severe pain. 4. Intense pain. © 2016 by Pearson Education, Inc. 240 CHAPTER 46/ Pain Management 5. The nurse is evaluating a client’s understanding of acute pain and chronic pain. The nurse recognizes that further teaching is necessary when which of the following statements is made by the client? 1. Acute pain increases a client’s pulse rate. 2. With chronic pain the client appears depressed and withdrawn. 3. With chronic pain the client exhibits behavior indicative of pain: crying, rubbing area, and holding area. 4. Acute pain increases a client’s respiratory rate. 6. Which of the following would be a misconception of pain? 1. The individual who experiences the pain is the only authority about its existence and nature. 2. Pain is a subjective experience, and the intensity and duration of pain vary considerably among individuals. 3. Even with severe pain, periods of physiological and behavioral adaptation can occur. 4. The amount of tissue damage is directly related to the amount of pain. 7. Which of the following statements about nonopioids is true? 1. Nonopioids alone are often sufficient to relieve severe pain, but they are an important part in the total analgesic plan. 2. A nonopioid should not be given at the same time as an opioid. 3. Side effects from long-term use of NSAIDs are considerably less severe and life threatening than the side effects from daily doses of oral morphine or other opioids. 4. Giving a dose of nonopioid at the same time as a dose of opioid poses no more danger than giving the doses at different times. 8. A nurse is planning a seminar on COLDERR, which is a mnemonic for pain assessment. Which of the following statements is NOT correct? 1. Character describes the sensation of the pain (e.g., sharp, aching, burning). 2. Location is where the pain hurts (all locations). 3. Onset is when the pain started and how it has changed. 4. Reliefmeans a pattern of shooting/spreading/location of pain away from its origin. 9. A nurse is evaluating a nursing student’s understanding of transcultural differences in responses to pain. Which of the following actions demonstrates a need for further teaching? 1. The African American culture believes pain and suffering is a part of life and is to be endured. 2. The Mexican American culture believes that enduring pain is a sign of strength. 3. The Asian American culture tends to be loud and outspoken in expressions of pain. 4. Native Americans are quiet, less expressive verbally and nonverbally, and may tolerate a high level of pain. 10. The nurse evaluating a practice guideline for a client with pain at a seminar, recognizes that further teaching is necessary when which of the following statements is made by a participant? l. A trusting relationship promotes expression of the client’s thoughts and feelings and enhances effectiveness of planned pain therapies. 2. Consider the client’s ability and willingness to participate actively in pain relief measures. 3. Provide measures to relieve pain before it becomes severe. 4. Maintain a biased attitude about what may relieve the pain. © 2016 by Pearson Education, Inc. CHAPTER 47 NUTRITION KEY TERM REVIEW Match each term with its appropriate definition. 1. Anabolism l4. Kilocalorie (Kcal) 2. Basal metabolic rate (BMR) l5. Kilojoule (kJ) 3. Body mass index (BMI) 16. Lipoproteins 4. Calorie 17. Malnutrition 5. Catabol ism l8. Metabolism 6. Complete proteins 19. __ Monosaccharides 7. Disaccharides 20. Monounsaturated fatty acids 8. Enzymes 21. Nitrogen balance 9. Essential amino acids 22. Nonessential amino acids 10. Fatty acids 23. Polyunsaturated fatty acids 1 l. Glycogen 24. Saturated fatty acids 12. # 7 Ideal body weight (IBW) 13. 25. _* * Unsaturated fatty acid Incomplete proteins © 2016 by Pearson Education, Inc. 241 242 CHAPTER 47/ Nutrition All biochemical and physiological processes by which the body grows and maintains itself Building tissue Breaking down tissue Single molecule sugars such as glucose Contain all of the essential amino acids plus many of the nonessential ones Unit of heat energy Those that cannot be manufactured in the human body One that could accommodate more hydrogen atoms Fatty acid with one double carbon bond Weight recommended for optimal health Rate at which the body metabolizes food to maintain the energy One in which all carbon atoms are filled to capacity with hydrogen; butter requirements of a person awake and at rest Indicator of changes in body fat stores Basic structural units of most lipids Measure of degree of protein anabolism and catabolism Double molecule sugars Lack of necessary or appropriate food substances Those that the body can manufacture Soluble end product of lipid digestion Amount of work energy required when a force of 1 newton A large compound molecule of Fatty acids with more than one double bond; vegetable oil moves 1 kilogram of weight 1 meter distance glucose stored in the body x. Lack one or more essential amino acids; usually plant based Biologic catalysts that speed up _ _ y. Large calorie chemical reactions KEY TOPIC REVIEW 1. Foods differ greatly in their nutritive value (the nutrient content of a specified amount of food), and no single food provides all essential nutrients. a. True b. False The body‘s most basic nutrient need is water. a. True b. False . Micronutrients—vitamins and minerals—are those required in small amounts (e.g., milligrams or micrograms) to metabolize the energy-providing nutrients. a. True b. False Sugars, the most complex of all carbohydrates, are fat soluble and are produced naturally by both plants and animals. a. True b. False Of the three monosaccharides (glucose, fructose, and galactose), fructose is by far the most abundant simple sugar. a. True b. False © 2016 by Pearson Education, Inc. CHAPTER 47/ Nutrition 243 6. is the sum of all the interactions between an organism and the food it consumes. In other words, nutrition is what a person eats and how the body uses it. 7. are organic and inorganic substances found in foods that are required for body functioning. 8. are the insoluble, nonsweet forms of carbohydrate. , a complex carbohydrate derived from plants, supplies roughage, or bulk, to the diet. 9. are biologic catalysts that speed up chemical reactions. 10. 1 1. Match the following terms with the correct definition. Organic molecules made up primarily of carbon, hydrogen, oxygen, and nitrogen, which combine to form proteins b. Incomplete proteins Those that cannot be manufactured in the body and must be supplied as part of the protein ingested in the diet c. Amino acids Those that the body can manufacture d. Oils Contain all of the essential amino acids plus many nonessential ones e. Monounsaturated fatty acids Lack one or more essential amino acids (most commonly lysine, methionine, or tryptophan) and are usually derived from vegetables f. Nonessential amino acids Organic substances that are greasy and insoluble in water but soluble in alcohol or ether g. Fats Lipids that are solid at room temperature h. Fatty acids Lipids that are liquid at room temperature i. Lipids Made up of carbon chains and hydrogen; are the basic structural SD . Complete proteins units of most lipids j. Essential amino acids Fatty acids with one double bond 12. Which of the following is NOT one of the three major functions of nutrients? a. Provide energy for body processes and movement. b. Provide structural material for body tissues. 0. Regulate body processes. (1. Replace the natural nutrients found in food with supplemental nutrients. 13. All of the following are considered macronutrients EXCEPT: a. Vitamins. b. Carbohydrates. c. Fats. (1. Protein. 14. Every cell in the body contains some protein, and about a. One eighth b. One fourth 0. Two thirds (1. Three quarters © 2016 by Pearson Education, Inc. of body solids are proteins. 244 CHAPTER 47/ Nutrition have (has) three fatty acids and account for more than 90% of the lipids in food and in the body. 15. a. Triglycerides b. Cholesterol c. Glycerides d. Minerals 16. Carbohydrates are composed of all of the following elements EXCEPT: a. Nitrogen. b. Carbon. c. Hydrogen. (1. Oxygen. FOCUSED STUDY TIPS 1. Discuss energy balance in terms of energy intake and energy output. 2. List several of the factors affecting nutrition. . Discuss some of the psychological factors that can affect nutrition. Describe how to correctly assist with special diets (e.g., clear liquid, full liquid, soft, diet as tolerated, and modification for disease). Describe the term body mass index (BMI) and give an example of how it is calculated. Discuss nursing interventions when caring for clients with nutritional problems. Describe nursing interventions that promote optimal nutrition. Identify risk factors for and clinical signs of malnutrition. Discuss essential components and purposes of nutritional screening and nutritional assessment. 10. Identify developmental nutritional considerations. 11. Identify factors influencing nutrition. 12. Discuss body weight and body mass standards. . Explain essential aspects of energy balance. 14. Describe normal digestion, absorption, and metabolism of carbohydrates, proteins, and lipids. 15. Identify essential nutrients and their dietary sources. 16. Describe symptoms of iron deficiency anemia. 17. List the steps involved in inserting a nasogastric tube. © 2016 by Pearson Education, Inc. CHAPTER 47/ Nutrition 245 CASE STUDIES 1. A 37—year-old African American client is experiencing loss of appetite. a. Explain the combinations of plant proteins that provide complete proteins. b. Identify ways this client can improve his or her appetite. 0. Describe possible variations in nutritional practices and preferences among this client’s culture. REVIEW QUESTIONS 1. Which of the following is considered a micronutrient? 1. Carbohydrates 2. Fats 3. Proteins 4. Vitamins 2. A nurse is evaluating a nursing student’s understanding of nutrition. Which of the following statements demonstrates a need for further teaching? I. Starches are the insoluble, nonsweet forms of carbohydrate. 2. Most sugars are produced naturally by plants, especially fruits, sugar cane, and sugar beets. 3. Fiber, a complex carbohydrate derived from plants, supplies roughage, or bulk, to the diet. 4. Fiber is present in the inner layer of grains, bran, and in the skin, seeds, and pulp of many vegetables and fruits. 3. The student nurse is learning about nutrition. Which of the following statements indicates a need for further teaching? 1. Essential amino acids are those that cannot be manufactured in the body and must be supplied as part of the protein ingested in the diet. 2. The essential amino acids are alanine, aspartic acid, cystine, glutamie acid, glycine, hydroxyproline, proline, serine, and tyrosine. 3. Nonessential amino acids are those that the body can manufacture. 4. Most animal proteins, including meats, poultry, fish, dairy products, and eggs, are complete proteins. 4. During discharge planning, the nurse is teaching the client about lipids. Which of the following statements is correct? 1. Lipids are inorganic substances that are greasy and soluble in water but soluble in alcohol or ether. 2. In common use, the terms fats and lipids are used interchangeably. 3. Fats are lipids that are liquid at room temperature. 4. Oils are lipids that are solid at room temperature. 5. The nurse is calculating a client’s BMI. The client’s height is 1.5 m and his weight is 70 kg. Which of the following calculations is the correct BMI? l. 31.11 2. 46.67 3. 30.02 4. 36.16 © 2016 by Pearson Education, Inc. 246 CHAPTER 47 / Nutrition Which of the following suggestions will NOT help parents meet the child’s nutritional needs and promote effective parentichild interactions? 1. Make mealtime a pleasant time by avoiding tensions at the table and discussions of bad behavior. 2. Routinely use sweet desserts after dinners. 3. Schedule meals, sleep, and snack times that will allow for optimum appetite and behavior. 4. Offer a variety of simple, attractive foods in small portions. A food diary is a: 1. Recall of all the food and beverages the client consumes during a typical 24-hour period when at home. 2. Detailed record of measured amounts (portion sizes) of all food and fluids a client consumes during a speci— fied period, usually 3 to 7 days. 3. Comprehensive, time-consuming assessment of a client’s food intake that involves an extensive interview by a nutritionist or dietitian. 4. Checklist that indicates how often general food groups or specific foods are eaten. . A nurse is evaluating a nursing student’s understanding of special diets. Which of the following statements demonstrates a need for further teaching? 1. A clear liquid diet is limited to water, tea, coffee, clear broths, ginger ale, or other carbonated beverages, strained and clear juices, and plain gelatin. 2. A full liquid diet contains only liquids or foods that turn to liquid at body temperature, such as ice cream. 3. A soft diet is easily chewed and digested. 4. Note that the word “clear” in clear diet means “colorless.” Enteral feedings can be given intermittently or continuously. Intermittent feedings are the administration of mL of enteral formula several times per day. l. 50 to 100 2. 100 to 200 3. 300 to 500 4. 600 to 700 10. When planning interventions to improve a client’s appetite, which of the following would be included in the client’s plan of care? 1. Unpleasant or uncomfortable treatments can be performed before or after a meal. 2. Provide unfamiliar food to try. 3. Encourage or provide oral hygiene after mealtime. 4. Provide a tidy, clean environment that is free of unpleasant sights and odors. © 2016 by Pearson Education, Inc. CHAPTER 48 URINARY ELIMINATION KEY TERM REVIEW Match each term With its appropriate definition. 1. Anuria 14. — Neurogenic bladder 2 Bladder training 15. — Oliguria 3 Blood urea nitrogen (BUN) 16. 4 Creatinine clearance 17. 5. Detrusor muscle 18. Suprapubic catheter 6 Dialysis 1 9. Uretcrostomy 7 Diuresis 20. Urgency 8 Diuretics 21. Urinary frequency 9 Dysuria 22. Urinary hesitancy 10- _ Enuresis 23. Urinary incontinence (U1) 1 1- — Glomerulus 24. Urinary retention 12. Ileal conduit 25' Urination 1 3. Nephrostomy © 2016 by Pearson Education, Inc. Polydipsia . Polyuria 247 248 CHAPTER 48 / Urinary Elimination Uses urine and serum levels to determine glomerular fil- Painful urination tration rate One or both ureters are brought to side of abdomen to form Common urinary diversion that creates a pouch and stoma small stoma Lack of urine production Impaired neurologic function that results in inability of the client to feel bladder fullness Also known as diuresis Involuntary leakage of urine Excessive thirst Increase urine formation by preventing reabsorption of water and electrolytes Measurement of end product of protein metabolism Surgically inserted through abdominal wall above sym— physis pubis into urinary bladder Voiding at frequent intervals Sudden strong desire to void Tuft of capillaries in the nephron Requires client to postpone voiding; voiding according to a timetable, in order to stabilize bladder, diminish urgency Occurs with impaired bladder emptying; may result in dis— tended bladder l. Process of emptying the urinary bladder Urine output of less than 500 mL/day for an adult Involuntary urination in children beyond the normal age The smooth muscle layer of the Delay and difficulty in initiating voiding bladder wall Filtering of the blood done in the presence of inadequate kid- of bladder control x. Diverts urine from the kidney to a stoma y. Increased production of urine ney function KEY TOPIC REVIEW 1. The most common urinary diversion is the ileal conduit or ileal loop. a. True b. False Urinary tract infections (UTIs) are the most common infection in children. a. True b. False The paired kidneys are situated on either side of the spinal column, behind the peritoneal cavity. a. True b. False The urinary bladder (vesicle) is a hollow, muscular organ that serves as a reservoir for urine and as the organ of excretion. a. True b. False The female urethra serves only as a passageway for the elimination of urine. a. True b. False © 2016 by Pearson Education, Inc. CHAPTER 48/ Urinary Elimination 249 . increase urine formation by preventing the reabsorption of water and electrolytes from the tubules of the kidney into the bloodstream. . Clients who have a bladder may use manual pressure on the bladder to promote bladder emptying. is a flushing or washing out with a specified solution. A diverts urine from the kidney to a stoma. A may be formed when the bladder is left intact but voiding through the urethra is not possible (e.g., due to an obstruction or a neurogenic bladder). 11. Match the following terms with the correct definition. a. Anuria Bed-wetting b. Polyuria (diuresis) The production of abnormally large amounts of urine by the kidneys, often several liters more than the client’s usual daily output 0. Nocturnal enuresis Low urine output d. Residual urine Refers to a lack of urine production e. Bladder training Voiding two or more times at night f. Creatinine clearance Voiding that is either painful or difficult g. Dysuria Urine remaining in the bladder following the voiding h. Habit training A test that uses 24—hour urine and serum creatinine levels to determine the glomerular filtration rate, a sensitive indicator of renal function i. Oliguria Requires that the client postpone voiding, resist or inhibit the sensation of urgency, and void according to a timetable rather than according to the urge to void j. Nocturia Referred to as timed voiding or scheduled toileting, attempts to keep clients dry by having them void at regular intervals 12. Normal bladder capacity is between mL of urine. a. 300 and 600 b. 600 and 900 c. 900 and 1,200 d. 1,200 and 1,500 . An infant may urinate as often as times a day. a. 5 b. 10 c. 15 d. 20 14. About % of all 6—year—olds experience difficulty controlling the bladder. a. 10 b. 20 c. 30 d. 40 © 2016 by Pearson Education, Inc. 250 CHAPTER 48/ Urinary Elimination 15. Although patterns of urination are highly individual, most individuals void about times a day. a. 3 to 4 b. 5 to 6 c. 7 to 8 d. 9 to 10 16. Which statement is true regarding urinary elimination and the aging process? a. Kidney function significantly decreases. b. The number of functioning nephrons remains the same. c. Excretion time is decreased d. Excretion time is increased FOCUSED STUDY TIPS 1. Discuss several practice guidelines to prevent catheter-associated urinary infections. 2. What are the accuracy and clinical benefits of using a bladder scanner? . List and discuss several factors that influence urinary elimination. . Problems of urinary elimination also may become the etiology for other problems experienced by the client. Discuss several of these other problems. . Describe and list several of the different types of urinary catheters. List several medications that may cause urinary retention. Explain the care of clients with retention catheters or urinary diversions. Discuss ways to prevent urinary infection. Develop nursing diagnoses, desired outcomes, and interventions related to urinary elimination. 10. Identify normal and abnormal characteristics and constituents of urine. 11. Describe nursing assessment of urinary function including subjective and objective data. 12. Identify common causes of selected urinary problems. 13. identify factors that influence urinary elimination. 14. Describe the process of urination, from urine formation through micturition. 15. List the various organs and elements that form the pelvic floor. © 2016 by Pearson Education, Inc. v” CHAPTER 48/ Urinary Elimination 251 CASE STUDY 1 A 68-year-old client has been experiencing urinary elimination problems. He has given you a urine specimen and asks how to maintain normal urinary elimination. a. List the steps a nurse must follow to measure fluid output. b. Identify various goals for clients with urinary elimination problems. 0. Explain how this client can maintain normal urinary elimination. REVIEW QUESTIONS 1. What is oliguria? 1. Low urine output 2. Increased urine output 3. Excessive fluid intake 4. A lack of urine production 2. What is urinary frequency? 1. Voiding two or more times at night 2. Voiding at frequent intervals 3. The sudden and strong desire to void 4. Voiding that is either painful or difficult 3. During discharge planning, the nurse is teaching the client ways to prevent a recurrence of a UTI. Which of the following actions is correct? 1. Drink six 6—ounce glasses of water per day to flush bacteria out of the urinary system. 2. Wear nylon rather than cotton underclothes. 3. Girls and women should always wipe the perineal area from back to front following urination or defecation in order to prevent introduction of gastrointestinal bacteria into the urethra. 4. Avoid tight-fitting pants or other clothing that can irritate the urethra and prevents ventilation of the perineal area. 4. A nurse is evaluating a client’s understanding of intermittent self-catheterization. Which of the following statements indicates a need for further teaching? Intermittent self-catheterization: 1. Reduces the incidence of urinary tract infection. 2. Enables the client to retain independence and gain control of the bladder. 3. Allows normal sexual relations without incontinence. 4. Protects the lower urinary tract from reflux. 5. Which of the following is an abnormal color or clarity of urine? 1. Straw 2. Amber 3. Dark amber 4. Transparent (C3 2016 by Pearson Education, Inc. 252 CHAPTER 48/ Urinary Elimination 6. A nurse is testing urine for specific gravity. Which of the following would be considered a normal range for the test result? 1. 0.100 to 0.999 2. l.000 to 1.050 3. 1.010to 1.025 4. 1.050 to 1.100 . The nurse is performing urethral urinary catheterization on a male client. Which of the following actions by the nurse is correct? 1. Lubricates the catheter l to 2 inches. 2. Picks up a cleansing ball with the forceps in the nondominant hand and wipes from the top of the meatus in a circular motion around the glans. 3. Grasps the catheter firmly 2 to 3 inches from the tip; asks the client to take a slow deep breath and inserts the catheter as the client exhales. 4. Puts on examination gloves. A nurse evaluating a class on facilitating and promoting urinary elimination recognizes that further teaching is necessary when which of the following statements is made by a participant? 1. Advise the client and family to install grab bars and elevated toilet seats as needed; 2. Teach the client to empty the bladder completely at each voiding. 3. Emphasize the importance of drinking five to six 8—0unce glasses of water daily. 4. Suggest clothing that is easily removed for toileting, such as elasticiwaist pants or pants with Velcro closures. During discharge planning, the nurse is teaching the client how to perform pelvic muscle exercises (Kegels). Which of the following actions is correct? 1. Initially perform each contraction 10 times, five times daily. Gradually increase the count to a full 10 seconds for both contraction and relaxation. 2. To control episodes of stress incontinence, perform a pelvic muscle contraction only after activities that in— crease intra—abdominal pressure, such as coughing, laughing, sneezing, or lifting. 3. Develop a schedule that will help remind you to do these exercises, for example, before getting out of bed in the morning. 4. Contract your pelvic muscles whereby you pull your rectum, urethra, and vagina up inside, and hold for a count of l to 2 seconds. Then relax the same muscles for a count of 1 to 2 seconds. 10. A nurse is evaluating a client’s understanding of preventing catheter-associated urinary infections. Which of the following statements indicates a need for further teaching? 1. Maintain a sterile closed-drainage system. 2. Always disconnect the catheter and drainage tubing. 3. Provide routine perineal hygiene, including cleansing with soap and water after defecation. 4. Prevent contamination of the catheter with feces. © 2016 by Pearson Education, Inc. CHAPTER 49 FECAL ELIMINATION KEY TERM REVIEW 1. Bowel incontinence 14. Gastrocolic reflex >9?°.\'F7‘¥":‘>P°!\3 Carminatives 15. Gastrostomy Cathartics l6. Haustra Chyme l7. Haustral churn ing Colostomy 18. Hemorrhoids Commodc 19. lleostomy Constipation 20. Jejunostomy Defecation 21. Mass peristalsis Diarrhea 22. Meconium D—‘b—d r—AO Enema 23. Ostomy Fecal impaction 24. Peristalsis »—-._. DJN Match each term With its appropriate definition. Fecal incontinence 25. Stoma Flatus © 2016 by Pearson Education, Inc. 253 254 CHAPTER 49/ Fecal Elimination Opening through the abdominal wall into the ileum Mass or collection of hardened feces in the folds of the rectum Portable chair with a toilet seat Expulsion of feces from the anus and rectum An opening for the gastrointestinal, urinary, or respiratory tract onto the skin Herbal oils known to help expel gas from the stomach and intestines Air and by-products of carbohydrate digestion Increased peristalsis of colon after food has entered the stomach Fewer than three bowel movements per week Pouches that form due to the enlarging and lengthening of the large intestine Waste products that leave the stomach and small intestine An opening through the abdomen into the jejunum Loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter Bowel incontinence Wavelike movement produced by the circular and longitudinal muscle fibers in the intestine walls Drugs that induce defecation The opening created in the abdominal wall by an ostomy Passage of liquid feces and increased frequency of defecation Distended veins in the rectum First fecal material passed by a newborn A wave of powerful muscular contraction that moves over large areas of the colon An opening through the abdominal wall into the colon An opening through the abdominal wall into the stomach A solution introduced into the rectum and large intestine Moving back and forth of the chyme within the intestinal pouches \_/ KEY TOPIC REVIEW 1. Elimination of the waste products of digestion from the body is essential to health. a. True b. False The small intestine extends from the ileocecal (ileocolic) valve, which lies between the large and small intestines, to the anus. a. True b. False . Normal feces are made of about 25% water and 75% solid materials. a. True b. False Constipation is the most common bowel—management problem in older populations. a. True b. False . The colon (large intestine) in the adult is generally about 125 to 150 cm (50 to 60 in.) long. a. True b. False © 2016 by Pearson Education, Inc. CHAPTER 49/ Fecal Elimination 255 is the presence of excessive flatus in the intestines and leads to stretching and inflation of the intestines. A(An) is an opening for the gastrointestinal, urinary, or respiratory tract onto the skin. Clients restricted to bed may need to use a A(An) , a receptacle for urine and feces. is a solution introduced into the rectum and large intestine. are drugs that induce defecation. . Match the following terms with the correct definition. a. Hemorrhoids The act of eating food b. Laxatives Waste products leaving the stomach through the small intestine and then passing through the ileocecal valve c. Bowel/fecal incontinence A condition that can occur when the veins become distended, as can occur with repeated pressure d. Constipation The expulsion of feces from the anus and rectum e. Diarrhea Increased peristalsis of the colon after food has entered the stomach f. Defecation Medications that stimulate bowel activity and so assist fecal elimination g. Fecal impaction Fewer than three bowel movements per week h. Ingestion A mass or collection of hardened feces in the folds of the rectum i. Gastrocolic reflex The passage ofliquid feces and an increased frequency of defecation j. Chyme The loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter 12. The contents of the colon normally represent foods ingested over the previous a. 2 . 3 c. 4 . 5 13. All of the following may be causes and factors that contribute to constipation EXCEPT: a. A lack of privacy. b. Daily routines. 0. Insufficient fiber intake. d. Insufficient fluid intake. m 14. All of the following are thought to contribute to constipation EXCEPT: . Overuse of laxatives. 0 b. Bland diets. . Irregular defecation habits. d. Exercise. © 2016 by Pearson Education, Inc. days. 256 CHAPTER 49/ Fecal Elimination 15. Which of the following feces consistencies would be considered abnormal? a. Soft b. Moist 0. Semisolid (1. Dry FOCUSED STUDY TIPS 1. Distinguish normal from abnormal characteristics and constituents of feces. 2. List the seven parts of the colon (large intestine). Identify factors that influence fecal elimination and patterns of defecation. Discuss the physiology of defecation. . Discuss regular exercise and how it helps clients develop a regular defecation pattern. Discuss some of the ways to reduce or expel flatus. . Describe methods used to assess the intestinal tract. . Identify examples of nursing diagnoses, outcomes, and interventions for clients with elimination problems. . List and describe the three types of movements that occur in the large intestine. . Identify measures that maintain normal fecal elimination patterns. ll. Describe the purpose and action of commonly used enema solutions. 12. List four common problems that are related to fecal elimination. 13. Describe essentials of fecal stoma care for clients with an ostomy. 14. List and discuss the three primary sources of flatus. 15. Describe how to administer an enema. 16. Discuss ways in which the nurse can provide holistic care to a client who may be uncomfortable with procedures associated with bowel elimination. 17. Describe the appropriate documentation after administering an enema to a client. CASE STUDY 1. A 37—year-old client has been experiencing diarrhea for the past 12 hours. a. Identify ways for the client to manage diarrhea. b. Provide the client with information about healthy defecation. c. Identify three major causes of diarrhea. @' 2016 by Pearson Education, Inc. CHAPTER 49/ Fecal Elimination 257 REVIEW QUESTIONS 1. What is a gastrostomy? 1. An opening through the abdominal wall into the stomach 2. An opening through the abdominal wall into thejejunum 3. An opening into the colon. 4. An opening into the ileum 2. Which type of enema is given primarily to expel flatus? 1. Retention 2. Carminative 3. Return—flow 4. Cleansing 3. Which of the following actions is NOT appropriate for the nurse removing a fecal impaction? 1. Place a bed pad under the client’s buttocks and a bedpan nearby to receive stool. 2. Ask the client to assume a right side-lying position, with the knees flexed and the back toward the nurse. 3. Drape the client for comfort and to avoid unnecessary exposure of the body. 4. Gently insert the index finger into the rectum and move the finger along the length of the rectum. 4. A nurse is evaluating a client’s understanding of healthy defecation. Which ofthe following statements indi— cates a need for further teaching? 1. “1 will include high-fiber foods, such as vegetables, fruits, and whole grains, in my diet.” 2. “1 will maintain a fluid intake 0f4,000 to 5,000 mL each day.” 3. “I will allow time to defecate, preferably at the same time each day.” 4. “I will avoid over-the-counter medications to treat constipation and diarrhea.” 5. During discharge planning, the nurse is teaching the client how to manage diarrhea. Which of the following actions is NOT correct? 1. Drink at least eight glasses of water per day to prevent dehydration. 2. Eat foods with sodium and potassium. 3. Increase foods containing insoluble fiber, such as high-fiber whole-wheat bread.. 4. Limit fatty foods. 6. A nurse is evaluating a client’s understanding of ostomy care. Which of the following client statements indicates a need for further teaching? 1. “The ostomy pouch is emptied when it is one-third to one-half full.” 2. “The ostomy pouch can be applied for up to 10 days.” 3. “Most ostomy pouches contain odor barrier material.” 4 . “1f the ostomy pouch overfills, it can cause stool to come in contact with the skin.” © 2016 by Pearson Education. Inc. 258 CHAPTER 49/ Fecal Elimination 7. A nurse is evaluating a nursing student’s understanding of colostomies. Which of the following statements demonstrates a need for further teaching? 1. “The single stoma is created when one end of bowel is brought out through an opening onto the anterior abdominal wall.” 2. “With a loop colostomy, a loop of bowel is brought out onto the abdominal wall and supported by a plastic bridge, or a piece of rubber tubing.” 3. “The divided colostomy consists of two edges of bowel brought out onto the abdomen but separated from each other.” 4. “The loop colostomy is often used in situations where spillage of feces into the distal end of the bowel needs to be avoided.” The nurse is promoting regular defecation for a client whom she is taking care of. Which of the following actions by the nurse is NOT correct? 1. A client should be encouraged to defecate when the urge is recognized. 2. Regular exercise helps clients develop a regular defecation pattern. 3. Although the squatting position best facilitates defecation, the best position for most clients seems to be leaning backward while on a toilet seat. 4. For clients who have difficulty sitting down and getting up from the toilet, an elevated toilet seat can be attached to a regular toilet. A primary care provider orders examination of stool for signs of intestinal infection. What color of stool would the nurse expect to see? 1. Red 2. Green 3. Black 4. White 10. A nurse is evaluating a nursing student’s understanding of the actions of enema solutions. Which of the following statements demonstrates a need for further teaching? 1. Hypertonic solutions draw water into the colon. 2. Hypotonic solutions distend the colon, stimulate peristalsis, and soften feces. 3. Isotonic solutions lubricate the feces and the colonic mucosa. 4. Soapsuds solutions irritate the mucosa and distend the colon. © 2016 by Pearson Education, Inc. CHAPTER 50 OXYGENATION KEY TERM REVIEW Match each term with its appropriate defin ition. 1. Apnea 14. Hypoxia 2 Atelectasis 15. Intrapleural pressure 3 Biot’s (cluster) respiration 16. 4 Intrapulmonary pressure Bradypnea 17. Kussmaul’s breathing 5. Cheyne—Stokes respirations 18. 6 Noninvasive ventilation Cyanosis 19. Orthopnea 7 Dyspnea 20. Pleural effusion 8 Emphysema 21. Pneumothorax 9 Eupnea 22. Stridor 10. Hemothorax 23. Surfactant l 1. Hypercapnia 24. Tachypnea 25. , Tidal volume 12. 2 7 7‘ Hyperinflation 13. Hypoxemia © 2016 by Pearson Education, Inc. 259 260 CHAPTER 50/ Oxygenation a. Collapsed alveoli m. Insufficient oxygen anywhere in the body b. Harsh, high-pitched sound during n. The amount of air inspired and expired with each breath mspiration 0. Oxygen concentrations play a major role in regulating respiration; decreased oxygen concentrations are the main stimuli for receptors because the increased carbon dioxide levels desensitize the central chemorece tors p d. Shallow breaths interrupted by apnea . . All‘ collected in the pleural space e. Abnorrnally slow breathing p. Faster than normal breathrng f. Marked rhythmic waxing and waning of respirations, from very shallow to very deep, with short eriods of a nea p p q' r. Pressure w1th2n the lungs Bluish discoloration of the skin, nail beds, and mucous membranes . . . . . L1poprote1n that reduces surface tens10n 1n lungs With— g. Normal respirations c. s. out which lung expansion is exceedingly difficult Excessive fluid in the pleural space t. Inability to breathe easily unless sitting upright u. Increased levels of C02 i. Accumulation of blood in the pleural space v. Low levels of oxygen in the blood j. Difficult or labored breathing w. Pressure in the pleural cav1ty surroundmg the lungs x. Delivery of air or oxygen under pressure without the . . need for an 1nvas1ve tube y. Involves giving client breaths of greater volume than set on ventilator or via manual resuscitation bag k 1. . ’ t - The body 5 attempts 0 compen sate for increased metabolic acidosis by blowing of acid in the form of C02 Absence of any breathing KEY TOPIC REVIEW 1. Postural drainage is the drainage by gravity of secretions from various lung segments. a. True b. False 2. Suctioning is aspirating secretions through a catheter connected to a suction machine or wall suction outlet. a. True b. False 3. Hyperoxygenation involves giving the client breaths that are l to 1.5 times the tidal volume set on the ventilator through the ventilator circuit or via a manual resuscitation bag. a. True b. False 4. When air collects in the pleural space, it is known as a hemothorax. a. True b. False © 2016 by Pearson Education. Inc. .,. CHAPTER 50/ Oxygenation 261 5. Hyperinflation can be done with a manual resuscitation bag or through the ventilator and is performed by increasing the oxygen flow (usually to 100%) before suctioning and between suction attempts. a. True b. False 6. _ is a clear, odorless gas that constitutes approximately 21% ofthe air we breathe, and is necessary for proper functioning of all living cells. 7. pressure (pressure within the lungs) always equalizes with atmospheric pressure. 8. is a collapse ofa portion of the lung. 9. is the movement of gases or other particles from an area of greater pressure or concentration to an area of lower pressure or concentration. is the cessation of breathing. 10. 11. Match the following terms with the correct definition. a. Surfactant A lipoprotein produced by specialized alveolar cells; acts like a detergent, reducing the surface tension of alveolar fluid b. Sputum Oxygen-carrying red pigment c. Cyanosis Red blood cells (RBCs) A condition of insufficient oxygen anywhere in the body, from d. Expectorate the inspired gas to the tissues e. Hemoglobin Bluish discoloration of the skin, nail beds, and mucous membranes, due to reduced hemoglobin-oxygen saturation f. Bradypnca An abnormally slow respiratory rate g. Humidifiers _ The inability to breathe except in an upright or standing position h. Hypoxia _ Coughed—up material i. Orthopnea _ Spit out j. Erythrocytes 7 Devices that add water vapor to inspired air is a series of vigorous quiverings produced by the hands that are placed flat against the client’s 12. chest wall in an effort to mobilize retained secretions. a. Hemoglobin b. Hematocrit P- c. Oxyhemoglobin Vibration is the continual tendency of the lungs to collapse away from the chest wall. 13. a. Atelectasis b. Lung recoil c. Diffusion (:1. Lung compliance © 2016 by Pearson Education, Inc. 262 CHAPTER 50 / Oxygenation is a condition of insufficient oxygen anywhere in the body, from the inspired gas to the tissues. 14. a. Hypoxia O . Hypercapnia refers to reduced oxygen in the blood and is characterized by a low partial pressure of oxygen in arterial blood or a low hemoglobin saturation. m 15. . Hypercarbia Q. b. Emphysema . Cyanosis b. Tachypnea c. Hypoxemia d. Bradypnea 16. Normal respiration ( ) is quiet. a. Orthopnea b. Apnea c. Dyspnea d. Eupnea FOCUSED STUDY TIPS 1. Discuss what an obstructed airway is and how to assess and maintain a patent airway. 2. List and explain some of the types of medications that can be used for clients with oxygenation problems. . Explain how chest tubes are inserted. Discuss the overall outcomes/goals for a client with oxygenation problems. . List and explain the nursing responsibilities regarding drainage systems. . Discuss some of the NANDA diagnostic labels for clients with oxygenation problems. . State outcome criteria for evaluating client responses to measures that promote adequate oxygenation. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. Describe nursing measures to promote respiratory function and oxygenation. . Identify common manifestations of impaired respiratory function. 11. Identify factors influencing respiratory function. 12. Explain the role and function of the respiratory system in transporting oxygen and carbon dioxide to and from body tissues. 13. Describe the processes ofbreathing (ventilation) and gas exchange (respiration). 14. Outline the structure and function of the respiratory system. © 2016 by Pearson Education, Inc. CHAPTER 50/ Oxygenation 263 15. Discuss the procedure for obtaining an arterial blood gas (ABG) sample. List the precautions required when performing this procedure. 16. Describe a pulmonary function test (PFT) and interventions that may be used for a client undergoing this pro— cedure. CASE STUDY 1. You are a nursing student’s preceptor today. This is the nursing student’s first semester in nursing school. When the student first arrives on the unit, she asks you several questions: a. Which factors does adequate ventilation depend on? b. Which factors affect the rate of oxygen transport from the lungs to the tissues? c. Which factors that influence oxygenation affect the cardiovascular system as well as the respiratory system? (1. What are oxygen therapy safety precautions? REVIEW QUESTIONS 1. Which of the following is NOT a factor that determines adequate ventilation? 1. Clear airways 2. Adequate pulmonary compliance and recoil 3. An intact endocrine system 4. An intact thoracic cavity capable of expanding and contracting 2. Eupnea is best defined as: 1. A normal respiration. 2. A rapid rate. 3. An abnormally slow respiratory rate. 4. The cessation of breathing. 3. Which of the following is marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea? 1. Biot’s (cluster) respirations 2. Orthopnea 3. Cheyne-Stokes respirations 4. Dyspnea 4. The nonrebreather mask delivers the highest oxygen concentration possible (95% to 100%) by means other L per minute. than intubation or mechanical ventilation, at liter flows of 1. 2t06 2. 5t08 3. 6t010 4.10t015 © 2016 by Pearson Education, Inc. 264 CHAPTER 50 / Oxygenation 5. Which type of mask delivers oxygen concentrations varying from 24% to 40% or 50% at liter flows of 4 to 10 L per minute? 1. Nonrebreather 2. Venturi 3. Simple face 4. Partial rebreather . A nurse is evaluating a nursing student’s understanding of endotracheal tubes. Which of the following statements indicates a need for further teaching? 1. Endotracheal tubes are most commonly inserted for clients who have had general anesthetics or for those in emergency situations where mechanical ventilation is required. 2. An endotracheal tube is inserted by the primary care provider, nurse, or respiratory therapist with specialized education. 3. An endotracheal tube is inserted through the mouth or the nose and into the trachea with the guide of a laryngoseope. 4. The client is able to speak while an endotracheal tube is in place but is unable to swallow. Which of the following is the amount of air remaining in the lungs after maximal exhalation? l. TLC 2. RV 3. VC 4. ERV . The spouse ofa client is explaining to the nurse what she learned about a cough reflex. Which ofthe following indicates a need for further teaching? The spouse states: 1. The epiglottis and glottis (vocal cords) close. 2. A large inspiration of approximately 3.5 L occurs. 3. Nerve impulses are sent through the vagus nerve to the medulla. 4. A strong contraction of abdominal and internal intercostal muscles dramatically raises the pressure in the lungs. A nurse is evaluating a nursing student’s understanding of oxygen therapy precautions. Which of the following statements indicates a need for further teaching? 1. Place cautionary signs reading “No Smoking: Oxygen in Use” on the client’s door, at the foot or head of the bed, and on the oxygen equipment. 2. Be sure that electric monitoring equipment, suction machines, and portable diagnostic machines are all electrically grounded. 3. Make known the location of fire extinguishers, and make sure personnel are trained in their use. 4. The use ofvolatile, flammable materials, such as oils, greases, alcohol, ether, and acetone (e.g., nail polish remover) near clients receiving oxygen is acceptable with a primary care provider’s order. 10. Which of the following actions is NOT appropriate for the nurse providing tracheostomy care? 1. Clean the lumen and entire inner cannula thoroughly using a brush or pipe cleaners moistened with sterile normal saline. 2. Rinse the inner cannula thoroughly in the sterile normal saline. 3. After rinsing, gently tap the cannula against the inside edge of the sterile saline container. 4. Put on sterile gloves. Keep your nondominant hand sterile during the procedure. © 2016 by Pearson Education, Inc. CHAPTER 51 CIRCULATION KEY TERM REVIEW ,_1 Afterload >09°>‘.O\.‘".4>P’!\3 Match each term with its appropriate definition. Atherosclerosis Atria Atrioventricular (AV) node Atrioventricular (AV) valves Automaticity Bundle of His Cardiac output (CO) Coronary arteries 10. C-reactive protein (CRP) ll. Creatine kinase (CK) 12. Diastole 13. Heart failure © 2016 by Pearson Education, Inc. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. Homocysteine Ischemia Myocardial infarction (MI) Peripheral vascular resistance (PVR) Preload Purkinje fibers Semilunar valves Sinoatrial (SA or sinus) node Stroke volume (SV) Systole Troponin Ventricles 265 266 CHAPTER 51 /Circu|ation Amino acid that may indicate an in- Primary pacemaker of the heart creased risk for circulatory events when elevated Two lower chambers within the heart The buildup of fatty plaques within the arteries Valves between the ventricles and the great vessels Contraction of heart muscle and ejection of blood tricles Ability of cardiac muscle to generate electrical impulses and contractions independently of the nerv- Amount of blood ejected with each contraction ous system Network of vessels that supply heart muscle with Valves between the atria and the ven- d. e. f. g. q. ox . Relaxation of heart muscle; characterized by ventricular filling r. Area of the heart Where electrical im— pulses from SA node converge prior to initiatin ventricular contraction g Degree to which muscle fibers in the ventricle are stretched at the end of and dies 8. t. u. Two upper chambers within the heart i. Enz me released as result of cell y membrane damage during an M1; j. k. lmpedes blood flow to the tissues . . One of three ventricular conduction pathways Inability of the heart to keep up with the body’s need for oxygen and nutrients to the tissues diastole h. en and nourishment yg Condition in which cardiac tissue becomes necrotic v. Lack of blood supply due to obstructed Circulation w. The resistance that the ventricle must overcome . . . . . during systole to eject blood into the Circulation measured with CK x. Terminate in ventricular muscle, stimulating con- Enzyme that is released into the blood as a result of cell membrane damage to cardiac muscle y. traction Amount of blood pumped by the ventricles in l minute Screening test for inflammatory process in cardiovascular disease KEY TOPIC REVIEW 1. Cardiac muscle contraction is a mechanical event that occurs in response to electrical stimulation. a. True b. False 2. Heart rates are highest and most variable in adults. a. True b. False 3. Congenital heart disease affects less than 1% of all live births, but is the leading cause of early death from all congenital anomalies. a. True b. False 4. The American Heart Association (AHA) recommends at least 100 minutes per week of moderate exercise for adults. a. True b. False © 2016 by Pearson Education, Inc. CHAPTER 51 ICirculation 267 5. Recent studies suggest that moderate alcohol use (1 to 2 oz of alcohol per day) may actually reduce the risk of heart disease. a. True b. False is a lack of blood supply due to obstructed circulation. 6. is a hollow, cone-shaped organ about the size of a fist. 7. The 8. Cardiac output is calculated by multiplying the (the amount of blood ejected with each contraction) by the heart rate (HR). 9. is the degree to which muscle fibers in the ventricle are stretched at the end of the relaxation period (diastole) and largely depends on the amount of blood returning to the heart from the venous circulation. 10. is the resistance against which the heart must pump to eject the blood into circulation. 11. Match the following terms with the correct definition. a. Blood pressure (BP) A major component of red blood cells (erythrocytes), the predominant type of cell present in blood b. Hemoglobin The buildup of fatty plaque within the arteries; is the major contributor to cardiovascular disease, the leading cause of death in North America c. Blood Serves as the transport medium within the cardiovascular system, bringing oxygen and nutrients from the environment (via the lungs and gastrointestinal system) to the cells (1. Atherosclerosis A e. Systemic The study of the forces or pressures involved in blood circulation f. Cardiovascular A lack of blood supply due to obstructed circulation g. Hemodynamics The molecule that oxygen attaches to; it gives an indication of the oxygen-carrying capacity of the blood h. Hemoglobin The heart and the blood vessels make up the arrest (pulmonary arrest) is the cessation of breathing. system that, together with blood, is the major system for transporting oxygen and nutrients to the tissues, and waste products away from the tissues for elimination. i. Ischemia A type of blood vessel that carries blood to the tissues through a system of arteries, arterioles, and capillaries and returns it to the heart through the venules, veins, and the venae cavae j. Respiratory The force exerted on arterial walls by the blood flowing within the vessel 12. Electrocardiography most commonly uses a. 6 b. 8 c. 10 d. 12 © 2016 by Pearson Education, Inc. “leads” or different views of the heart. 268 CHAPTER 51 /Circulation 13. Each health care facility has policies and procedures for announcing cardiac/respiratory arrest and initiating interventions. In many institutions this emergency is called a Code , and the announcement is referred to as “calling a code.” a. Blue b. Red 0. Green d. Yellow 14. Cardiac output (CO) is the amount of blood pumped by the ventricles in minute. a. 1 b. 2 c. 3 d. 4 15. With each contraction, a certain amount of blood, known as the stroke volume, is ejected from the ventricles into circulation. In adults, the average stroke volume is about mL per beat. a. 40 b. 50 c. 60 d. 70 16. Nearly of the adult population of the United States is overweight or obese. a. 1/4 b. 1/3 c. 1/2 d. 2/3 FOCUSED STUDY TIPS l. Explain what a modifiable risk factor is and list several examples. 2. List the signs of anemia. 3. Explain arterial circulation. Discuss the steps in cardiopulmonary resuscitation (CPR). . Describe the cardiac cycle. Discuss the importance of homocysteine levels. . Summarize Venous return. . What is cardiac monitoring and what is it used for? List the signs of impaired peripheral arterial circulation. 10. Discuss physical assessment as it relates to the cardiovascular system. © 2016 by Pearson Education, Inc. CHAPTER 51 /Clrculation 269 11. Discuss life span considerations in relation to the cardiovascular system. 12. Discuss serum lipid levels and coronary artery disease. 13. Explain what a nonmodifiable risk factor is and give some examples. l4. Define hypertension. 15. List the three cardinal signs of a cardiac arrest. 16. List the five risk factors for metabolic syndrome. 17. List the three cardiovascular risk factors that are considered nontraditional. CASE STUDY 1. A 43-year-old female client has just been diagnosed with hypertension and also has elevated serum lipid levels. The client asks you the following questions: a. Why is the health care provider concerned about my lipid levels being elevated? b. What is hypertension? 0. What are the risk factors for coronary heart disease? REVIEW QUESTIONS 1. The spouse of a client is recalling the modifiable risk factors for coronary heart disease. Which statement by the client’s spouse indicates a need for further teaching? 1. “My wife’s age is a modifiable risk factor.” 2. “Diabetes is a modifiable risk factor for my wife.” 3. “Obesity is a modifiable risk factor for my wife.” 4. “My wife’s sedentary lifestyle is a modifiable risk factor.” 2. The nurse is teaching a client about methods to decrease the client’s homocysteine level. Which statement by the client indicates a need for further teaching? 1. “Homocysteine is an amino acid that may increase my risk for developing heart disease.” 2. “Homocysteine levels may be decreased by taking a multivitamin with folate.” 3. “Homocysteine is an enzyme that increases my cholesterol level, which increases my risk for developing heart disease.” 4. “Homocysteine levels may be decreased by taking a multivitamin with B6 and B12.” 3. Normal changes of aging may contribute to problems of circulation in older adults, even when there is no actual pathology. Which of the following is NOT a correct statement regarding the aging process and the cardiovascular system? 1, A decrease of muscle tone in the heart results in a decrease in cardiac output. 2. Blood vessels become less elastic and have an increase in calcification. 3. Impaired valve function in the heart is often the result of increased stiffness and calcification and results in a decrease in cardiac output. 4. An increase in baroreceptor response to blood pressure changes makes the heart and blood vessels more responsive to exercise and stress. © 2016 by Pearson Education, Inc. 270 CHAPTER 51 /Circulation 4. A nurse is planning a seminar on promoting a healthy heart. Which of the following statements is incorrect? 1. Reduce stress and manage anger. 2. Exercise at least 20 minutes, three times a week. 3. Do not smoke. 4. Eat a diet low in total fat, saturated fats, and cholesterol. 5. A nurse is evaluating a nursing student’s understanding of the heart. Which of the following statements demonstrates a need for further teaching? 1. There are four hollow chambers within the heart: two upper atria and two lower ventricles. 2. The heart is a hollow, cone-shaped organ about the size of a fist. 3. The heart is located in the mediastinum, between the lungs and underlying the sternum. 4 . Deoxygenated blood from the veins enters the left side of the heart through the superior and inferior venae cavae. 6. Which of the following statements by the nurse is NOT correct? 1. Systole is when the heart ejects (propels) the blood into the pulmonary and systemic circulations. 2. At the end of the systolic phase, the atria contract, adding an additional volume to the ventricles. 3. The diastolic phase of the cardiac cycle is twice as long as the systolic phase. 4. Diastole is largely a passive process. 7. The primary pacemaker of the heart is the: 1. SA node. 2. Bundle ois. 3. AV node. 4. Purkinje fibers. 8. PVR is determined by all of the following EXCEPT: 1. Blood vessel length. 2. Blood vessel diameter. 3. The viscosity of the blood. 4. The fineness of the blood. 9. Which ofthe following would be a sign of heart failure? 1. Pulmonary congestion; adventitious lung sounds 2. Decreased respiratory rate 3. Warm, red extremities 4. Decreased heart rate © 2016 by Pearson Education, Inc. CHAPTER 52 FLUID, ELECTROLYTE, AND ACID—BASE BALANCE KEY TERM REVIEW Match each term with its appropriate definition. 1. Acid 14. Hydrostatic pressure 2. Acidosis 15. Hypertonic 3. Alkalosis 16. Hypervolemia 4. Anions 17. Hypotonic 18. Hypovolemia Cations 19. lsotonic 7. Colloid osmotic pressure 20. Metabolic acidosis 8. Colloids 21. Metabolic alkalosis 9. Crystalloids 22. Osmolality 10. Dehydration 23. pH 11. Extracellular fluid (ECF) 24. Respiratory acidosis 12. Fluid volume deficit (FVD) 25. Respiratory alkalosis l3. Fluid volume excess (FVE) 5. _ _ Arterial blood gases (ABGs) ’ 6. © 2016 by Pearson Education, Inc. 271 272 CHAPTER 52 / Fluid, Electrolyte, and Acid—Base Balance Pressure exerted by plasma proteins whiehpull water from the interstitial space into the vascular compartment when necessary Condition that occurs when carbonic acid levels fall, more carbon dioxide than normal is exhaled, and pH rises to greater than 7.45 Ions that carry a positive charge Same osmolality as ECF Found outside the cells Substance that releases hydrogen ions in solution Occurs when the body retains both water and sodium in similar proportions to normal ECF Occurs when body loses both water and electrolytes from the ECF in similar proportions May be caused by decreased fluid intake, bleeding Rise in pH that can be due to depletion of carbonic acid Pressure exerted by a fluid within a closed system against the walls of the container in which it is contained Negatively charged ions Happens when the ratio of bicarbonate to carbonic acid is upset With the depletion of bicarbonate Higher osmolality than ECF Provide an accurate reflection of the gas Increased blood volume; FVE exchange in the pulmonary system 11. Salts that dissolve readily into true solutions Substances that do not readily dissolve in v. Lower osmolality than ECF w. The relative acidit or alkalinit of a solution x. Occurs when bicarbonate levels are low in relation to true solutions . , Concentration of solutes in body fluids Hyperosmolar flmd imbalance; water lost from body leaving client with excess sodium Occurs when the amount ofbicarbonate y y the amount of carbonic acid in the body y. Any condition that causes carbonic acids to increase, carbon d10x1de to be retamed, and pH to fall below 7.35 in the body exceeds the normal 20—1 ratio KEY TOPIC REVIEW 1. Approximately 90% of the average healthy adult’s weight is water, the primary body fluid. a. True b. False The body fluid compartments are separated from one another by cell membranes and the capillary membrane. a. True b. False Osmosis is the movement of water across cell membranes, from the less concentrated solution to the more concentrated solution. a. True b. False Diffusion is the power ofa solution to draw water across a semipermeable membrane. a. True b. False . The kidneys are the primary regulator ofbody fluids and electrolyte balance. a. True b. False © 2016 by Pearson Education, Inc. CHAPTER 52/ Fluid, Electrolyte, and Acid—Base Balance 273 6 . The most common electrolyte imbalances are deficits or excesses in sodium, potassium, and 7 . Fluid volume excess (FVE) is also referred to as 8. Human w is commonly classified into four main groups: A, B, AB, and O. 9 . The number of drops delivered per milliliter of an intravenous solution varies with different brands and types factor. ofinfusion sets. This rate is called the , or wing—tipped, needles with plastic flaps attached to the shaft are sometimes used for IV 10. catheters. l 1. Match the following terms with the correct definition. a. Extracellular fluid (ECF) The chemical combining power of the ion, or the capacity of cations to combine with anions to form molecules b. Cations The continual interrningling of molecules in liquids, gases, or solids brought about by the random movement of the molecules c. Milliequivalent Found outside the cells and accounts for about one third of total body fluid d. Filtration Have a low hydrogen ion concentration and can accept hydrogen ions in solution e. Acid Also known as hyperosmolar imbalance, this occurs when water is lost from the body, leaving the client with excess sodium 12. f. Buffers Prevent excessive changes in pH by removing or releasing hydrogen ions g. Hyponatremia A sodium deficit, or serum sodium level ofless than 135 mEq/L h. Dehydration A substance that releases hydrogen ions (Hl) in solution i. Bases or alkalis A process whereby fluid and solutes move together across a membrane from one compartment to another j. Diffusion Ions that carry a positive charge is a potassium deficit or a serum potassium level of less than 3.5 mEq/L. a. Hypokalemia b. Hypocalcemia c. Hyperkalemia d. Hypcrcalcemia l3. Hypoventilation and carbon dioxide retention cause carbonic acid levels to increase and the pH to fall below 7.35, a condition known as: a. Compensation. b. Respiratory acidosis. c. Hyperphosphatcmia. (1. Respiratory alkalosis. © 2016 by Pearson Education, Inc. 274 CHAPTER 52 / Fluid, Electrolyte, and Acid—Base Balance is an indicator of urine concentration that can be performed quickly and easily by nursing l4. personnel. a. Arterial blood gases b. Hematocrit 0. Specific gravity d. Volume expander 15. The is inserted in the basilic or cephalic vein just above or below the antecubital space of the arm. The tip of the catheter rests in the superior vena cava. a. Central dripping catheter b. Centrally elongated catheter C. Central venous catheter d. Peripherally inserted central venous catheter (PICC) is the movement of molecules through a semipermeable membrane from an area of higher concentration to an area of lower concentration. a. Osmosis b. Diffusion c. Filtration d. Oncotic pressure FOCUSED STUDY TIPS 1. Discuss the selection and screening of blood donors. . List several examples of cations. . Discuss the pathophysiology of dehydration. Discuss gender and body size and its effects on total body water. . Compare and contrast diffusion, filtration, and osmosis. Identify three factors that generally result in fluid volume deficit. . List three of the six measurements that are commonly used to interpret arterial blood gas tests. . What is a volume expander? Give one example. . List and discuss the three main mechanisms that can cause edema. . List several of the items usually included in intravenous solution infusion sets. . Discuss lifestyle and its effect on fluid, electrolyte, and acid—base balance. . Describe acid~base balance and its regulation. . List three of the four routes of fluid output. © 2016 by Pearson Education, Inc. CHAPTER 52 / Fluid, Electrolyte, and Acid—Base Balance 275 14. List symptoms of hypokalemia. 15. List symptoms of hypercalcemia. CASE STUDY 1. A 77-year-old male client has just been admitted to the unit. His fluid intake has been about 500 mL per day. He then tells you he sometimes forgets to drink water throughout the day. a. Why is water vital to health and normal cellular function? b. Explain the thirst mechanism. 0. List the four routes of fluid output. REVIEW QUESTIONS 1. A nurse is evaluating a nursing student’s understanding of body water. Which of the following statements indicates a need for further teaching? 1. Approximately 60% of the average healthy adult’s weight is water, the primary body fluid. 2. Infants have the highest proportion of water, accounting for 70% to 80% of their body weight. 3. Men have a lower percentage of body water than women. 4. Water makes up a greater percentage of a lean individual’s body weight than an obese individual’s. 2. Which of the following information about osmosis is NOT correct? 1. Osmosis is the continual intermingling of molecules in liquids, gases, or solids brought about by the random movement of the molecules. 2. Osmosis is an important mechanism for maintaining homeostasis and fluid balance. 3. Osmosis occurs when the concentration of solutes on one side of a selectively permeable membrane, such as the capillary membrane, is higher than on the other side. 4. Osmolality is determined by the total solute concentration within a fluid compartment and is measured as parts of solute per kilogram of water. 3. Which of the following is a sodium deficit, or serum sodium level of less than 135 mEq/L? 1. Hypernatremia 2. Hypokalemia 3. Hyponatremia 4. Hyperkalemia 4. Which of the following events occurs when an individual hyperventilates? 1. Less carbon dioxide than normal is exhaled. 2. Carbonic acid levels increase. 3. pH rises to greater than 7.45. 4. More oxygen than normal is exhaled. © 2016 by Pearson Education, Inc. 276 CHAPTER 52/ Fluid, Electrolyte, and Acid—Base Balance The following are normal values of arterial blood gases EXCEPT: 1. PaOz = 50—70 mm Hg. 2. pH 2 7,354.45. 3. PaCOz : 35415 mm Hg. 4. HCO{ : 22—26 mEq/L. Which of the following actions is NOT appropriate for the nurse who is starting an intravenous (IV) infusion? The nurse: 1. Adjusts the IV pole so that the solution container is suspended about 1 m (3 ft) above the client’s head. 2. Completely fills the drip chamber with solution. 3. Uses the client’s nondominant arm, unless contraindicated. 4. Cleans the skin at the site of entry with a topical antiseptic swab. ,_.i A nurse is planning a seminar on wellness care and promoting fluid and electrolyte balance. Which of the following statements is correct? (Select all that apply.) . Consume 9 to 10 glasses of water daily. 2. Limit alcohol intake because it has a diuretic effect. 3. Avoid excess amounts of foods or fluids high in salt, sugar, and caffeine. 4. Increase fluid intake before, during, and after strenuous exercise. 5. Limit fluid intake before bedtime. The nurse who is starting an intravenous infusion should avoid using all of the following EXCEPT a vein that is: 1. Damaged by previous use, phlebitis, infiltration, or sclerosis. 2. In an area of flexion. 3. Not as visible, because it will tend to roll away from the needle. 4. Continually distended with blood, or knotted or tortuous. A nurse is evaluating a nursing student’s understanding of blood transfusions. Which of the following state— ments demonstrates a need for further teaching? 1. A blood transfusion is the introduction of whole blood or blood components into the venous circulation. 2. To avoid transfusing incompatible red blood cells, both blood donor and recipient are typed and their blood is crossmatched. 3. Stop the transfusion immediately if signs of a reaction develop. 4. Human blood is commonly classified into four main groups: A, AB, 0, and A0. 10. Which of the following actions is NOT appropriate for the nurse administering blood to a client? 1. Blood is usually administered through a #18- to #20-gauge intravenous needle or catheter. 2. Saline is used to prime the set and flush the needle before administering blood. 3. A transfusion should be completed within 4 hours of initiation. 4. An S-type blood transfusion set with an in-line or add-on filter is used when administering blood. © 2016 by Pearson Education, Inc. ANSWER KEY CHAPTER 1 13. the right to accept or refuse care; the ability to use advanced directives Key Term Review l4. 6 Continuing education (CE) in Case Study Answers 12. v 1. What role is the nurse acting in by representing the client ’5 needs and wishes and assisting the client in behavior modification 16. 18. r 22. 24 w plans? The nurse is acting as a change agent in this role. Nurses . . . . are continually dealing With change in the health care system. 2. 19. 23. The nurse is in the process ofhelping the client recognize and cope with both the asthma condition and the tobacco cessation program The nurse is acting as a change agent, and what other role is the nurse representing? The nurse is acting as a client advocate to protect the client. The nurse may represent the client’s needs to other health care providers. The nurse may suggest some medications to assist the client in his smoking cessation program, such as Zyban. Key Topic Review Answers 3. According to Banner ’s stages of nursing expertise, in what stage is the nurse functioning? The nurse has been practicing for To promote wellness, prevent illness, restore health, care for the 4 years. The nurse is thus at Stage IV, Proficient. (Refer to dying Box 1—3 in the textbook.) a,d Review Question Answers 1. Answer: 1 (Objective: 2) Rationale: The traditional nursing mic has always entailed humanistic caring, nurturing. comforting, and supporting. Religion has also played a significant role in the development of nursing. The Christian value of “love thy neighbor as f, a, M, d, g, b, i, e. c thyself” and Christ’s parable of the Good Samaritan both had a significant impact on the development of Western nursing. Wars Consumer, patient. client accentuate the need for nurses. Greater financial support provided through public and private health insurance programs has increased and the demand for nursing care. Nursing Process: Assessment Client Need: Safe, Effective Care Environment professionalization 2. Answer: 3 (Objective: 6) Rationale: A nurse who has an advanced education and is a graduate of a nurse practitioner program is consid- ered a nurse practitioner. Nurse practitioners usually deal with nonemergency acute or chronic illness and provide primary ambulato- ry care. Nursing Process: Assessment Client Need: Safe, Effective 11. diagnosisrelated groups Care Environment 12. © 2016 by Pearson Education, Inc. 277 278 Answer Key 3. Answer: 2 (Objective: 8) Rationale: Stage Ill, Competent, is able to coordinate multiple complex care demands and focuses on the im- portant aspects of care. Nursing Process: Assessment Client Need: Safe, Effective Care Environment 4, Answer: 3 (Objective: 1) Rationale: Workplace issues include inade- Key Topic Review Answers quate staffing, heavy workloads, increased use ofovcrtime, and diffi- culty recruiting and retaining nurses. Nursing Process: Assessment 1. Evidence-based practice 2. “Right not to be harmed” either physically, emotionally. legally, < 500mg detoxification or metabolism, is a process by which a drug is converted to a less active form. Most biotransformation takes .r : 5 mL X 500 mg place in the liver, where many drug-metabolizing enzymes in the 250 mg cells detoxify the drugs. Nursing Process: Assessment Client x : 10 ml, Need: Physiological Integrity 3. Answer: 2 (Objective: 3) Rationale: Drug habituation denotes a mild form of psychological dependence. The individual develops Therefore, the dose ordered is 10 mL. The nurse can also use this formula to calculate dosages: the habit of taking the substance and feels better after taking it. The habituated individual tends to continue the habit even though it may be injurious to health. Drug dependence is a person’s reli— ance on or need to take a drug or substance. The two types of de— desired dose Amount to administer (x) = ——-—— dose on hand >< quantity on hand pendence, physiological and psychological, may occur separately or together. Physiological dependence is due to biochemical Nursing Process: Implementation Client Need: Physiological changes in body tissues, especially the nervous system. These tis- Integrity sues come to require the substance for normal functioning. A de— pendent person who stops using the drug experiences withdrawal Answer: 1 (Objective: l4) Rationale: When handling a syringe, symptoms. Psychological dependence is emotional reliance on a the nurse may touch the outside of the barrel and the handle of the drug to maintain a sense of well-being, accompanied by feelings plunger; however, the nurse must avoid letting any unsterile ob— of need or cravings for that drug. There are varying degrees of ject touch the tip or inside ofthe barrel, the shaft of the plunger, psychological dependence, ranging from mild desire to craving or the shaft or tip of the needle. Nursing Process: Implementation and compulsive use of the drug. Nursing Process: Planning Client Neel]: Physiological Integrity Client Need: Psychosocial Integrity Answer: 4 (Objective: l7) Rationale: The client should remain in 4. Answer: 2 (Objective: 7) Rationale: When converting pounds to the left lateral or supine position for at least 5 minutes to help rc- kilograms: The pound is a smaller unit than the kilogram. and the tain the suppository. Assist the client to a left lateral or left Sims” nurse converts by dividing or multiplying by 2.2: position, with the upper leg flexed. Unwrap the suppository and lubricate the smooth, rounded end, or see manufacturer’s instruc— 2.2 lb: 1 kg tions. The rounded end is usually inserted first and lubricant re— llOlb=xkg for a few minutes. Nursing Process: Implementation Client duces irritation of the mucosa. Press the client’s buttocks together Need: Physiological Integrity C) 2016 by Pearson Education, Inc. Answer Key 341 8. Answer: 1 (Obiective: 17) Rationale: Explain that the client may 3. experience a feeling of fullness, warmth. and, occasionally. dis- comfort when the fluid comes in contact with the tympanic mem- 4, b. Because an inadequate intake of calories, protein, vitamins, and iron is believed to be a risk factor for pressure ulcer brane. Insert the tip of the syringe into the auditory meatus, and direct the solution gently upward against the top of the canal. The development, nutritional supplements should be considered solution will flow around the entire canal and out at the bottom. for nutritionally compromised clients. The solution is instilled gently because strong pressure from the fluid can cause discomfort and damage the tympanic membrane. 5, Straighten the ear canal prior to inserting the tip of the syringe and during the procedure. After the procedure the nurse should 6. health 7. maceration place a cotton ball, not a cotton-tipped applicator. in the auditory meatus to absorb the excess fluid. Nursing Process: Implementation Client Need: Physiological Integrity cleaning 9. Answer: 2 (Objective: l7) Rationale: The client needs to remain lying in the supine position for 5 to 10 minutes following the 9. piston insertion. Gently insert the applicator into the vagina about 5 cm (2 in.). Slowly push the plunger untilthc applicator is empty. 10. skin Remove the applicator and place it on the towel. The applicator is put on the towel to prevent the spread of microorganisms. Discard i_ A force acting parallel to the skin surface ll. the applicator ifdisposable or clean it according to the manufac- 10, turer’s directions Nursing Process: Implementation Client Need: __J Physiological Integrity movement a person has Answer: 3 (Objective: l7) Rationale: When applying a transdermal A reduction in the amount and control of a Renewal ot‘tissues b The cessation ofblecding that results from patch the nurse must select a clean, dry area that is free ofhair and matches the manufacturer’s recommendations. The nurse should then remove the patch from its protective covering, holding it with- vasoeonstriction of the larger blood vessels in the affected area, out touching the adhesive edges, and apply it by pressing firmly with retraction (drawing back) of injured blood vessels, the deposition of the palm of the hand for about 10 seconds. Nursing Process: Im— fibrin (connective tissue), and the formation of blood clots in the area plementation Client Need: Physiological Integrity It A whitish protein substance that adds tensile strength to the wound CHAPTER 36 c Key Term Review A material, such as fluid and cells, that has es- caped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces _ f The washing or flushing out of an area d A strip ofcloth used to wrap some part of the g Any lesion caused by unrelieved pressure body 7 (a compressing downward force on a body area) that results in Id u. damage to underlying tissue, as defined by the U.S. Public Health \\' Service‘s Panel for the Prediction and Prevention of Pressure Ulcers in Adults Key Topic Review Answers 2. b, Hypoproteinemia is an abnormally low protein content in the blood. © 2016 by Pearson Education, Inc. c A deficiency in the blood supply to the tissue 342 Answer Key 14. b 15. a 16. c Review Question Answers 1 Answer: 1 (Objective: 6) Rationale: A purulent exudate is thicker than serous exudate because ofthe presence of pus, which consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria. A serosanguineous (consisting ofclear and bloodtinged drainage) exudate is commonly seen in surgical incisions. Case Study Answers A serous exudate consists chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes ofthe la. Explain the local effects afcold. The physiological effects of cold body, such as the peritoneum. It looks watery and has few cells. are opposite to the effects oflreat. Cold lowers the temperature of A sanguineous (hemorrhagic) exudate consists of large amounts the skin and underlying tissues and causes vasoconstriction. of red blood cells, indicating damage to capillaries that is severe Vasoconstriction reduces blood flow to the affected area and thus enough to allow the escape of red blood cells from plasma. This reduces the supply of oxygen and metabolites. decreases the type of exudate is frequently seen in open wounds. Nursing removal ofwastes, and produces skin pallor and coolness. Process: Assessment Client Need: Physiological Integrity Prolonged exposure to cold results in impaired circulation, cell deprivation, and subsequent damage to the tissues from lack of oxygen and nourishment. The signs oftissue damage due to cold 2_ Answer: 3 (Objective: l6) Rationale: In applying electric pads, the nurse needs to teach the client the following guidelines: are a bluish—purple mottled appearance of the skin, numbness, and sometimes blisters and pain. Cold is most often used for sports injuries (e.g., sprains, strains, fractures) to limit postinjury swelling and bleeding. I Do not insert sharp objects (e.g., pins) into the pad. The pin could damage a wire and cause an electric shock. I Ensure that the body area is dry unless there is a waterproof cover on the pad. Electricity in the presence of water can lb. Explain the systemic efi’ects of cold. With extensive cold cause a shock. applications and vasoconstriction, a client’s blood pressure can increase because blood is shunted from the cutaneous circulation to the internal blood vessels. Shivering, a generalized effect of prolonged cold, is a normal response as the body attempts to warm itself. I Use pads with a preset heating switch so a client cannot in— crease the heat. I Do not place the pad under the client. Heat will not dissipate, and the client may be burned. Nursing Process: Implementation Client Need: Safe, Effective Care Environment. 1c. List some indications for applying ice to the injured ankle. Indicators include muscle spasms, inflammation, pain, and traumatic injury. Answer: 4 (Objective: l6) Rationale: The following temperatures ofthe water in the bag are considered safe in most situations and provide the desired effect: normal adult and child over 2 years, ld. Summarize the guidelines a nurse sliouldfollowfor all local cold applications. I Determine the client’s ability to tolerate the therapy. 46°C to 52°C (115°F to I250F); debilitated or unconscious adult, or child under 2 years, 405°C to 46°C (lt)5"F to 115°F). The client fills the bag two thirds full with water. After filling the bag with water the client dries the bag and holds it upside down to test I Identify conditions that might contraindicate treatment (cg, bleeding, circulatory impairment). l Explain the application to the client. I Assess the skin area to which the cold will be applied. I Ask the client to report any discomfort. I Return to the client 15 minutes after starting the cold applica- tion and observe the local skin area for any untoward signs (e.g.. redness). Stop the application if any problems occur. it for leakage. The client expels the remaining air out of the bag before securing the top. Nursing Process: Implementation Client Need: Safe, Effective Care Environment Answer: 4 (Objective: l3) Rationale: The bandage should be firm, but not too tight. Ask the client if the bandage feels comfortable. A tight bandage can interfere with blood circulation, whereas a loose bandage does not provide adequate protection. Bandages can be used to support a wound (e.g., a fractured bone). Bandages can also be used to immobilize a wound (cg, a strained shoulder). Bandages I Remove the equipment at the designated time, and dispose of it appropriately. I Examine the area to which the heat or cold was applied, and can be used to apply pressure (cg, elastic bandages on the lower extremities to improve venous blood flow). Nursing Process: Evaluation Client Need: Physiological Integrity record the client’s response. Answer: 3 (Objective: [3) Rationale: Dressings are applied for the following purposes: to protect the wotrnd from mechanical © 2016 by Pearson Education, Inc. V Answer Key 343 6. injury, to prevent hemorrhage (when applied as a pressure organisms would be found in deep wounds, tunnels, and cavities. dressing or with elastic bandages), to provide thermal insulation, Administer an analgesic 30 minutes before the procedure if the client and to protect the wound from microbial contamination. Nursing is complaining of pain at the wound sitc. Nursing Process: Process: Planning Client Need: Physiological Integrity Assesstnent Client Need: Physiological Integrity Answer: 3 (Objective: l3) Rationale: Transparent dressings are often applied to wounds including ttlcerated or burned skin areas. CHAPTER 37 These dressings offer several advantages: they are elastic; they catt be placed over ajoint without disrupting the client‘s mobility; they act as temporary skin; and they are nonporous. nonabsorbent, Key Term Review sell-adhesive dressings that do not require changing as other dressings do. They are often left in place until healing has oc— curred or as long as they remain intact, and adhere only to the skin area around the wound and not to the wound itself because they keep the wound moist. Nursing Process: Implementation Client Need: Physiological Integrity Answer: 3 (Objective: I4) Rationale: Black wounds are covered 13. 19. (13 with thick necrotic tissue, or eschar. Black wounds require deb— ridement (removal of the necrotic material). Removal ofnonvia— ble tissue from a wound mttst occur before the wound can be staged or heal. Wounds that are red are usually in the late regeneration phase oftissuc repair (i.e., developing granulation tissue). Key Topic Review Answers They need to be protected to avoid disturbance to regenerating b. tissue. Yellow wounds are characterized primarily by liquid to The preoperative phase begins when the decision to have surgery is made and ends when the client is transferred to the semiliquid “slough” that is often accompanied by purulent drain» operating table. age or previous infection. The nurse cleanses yellow wounds to Id remove nonviable tissue. Blue is not part ofthe RYB color code of wounds. Nursing Process: Assessment Client Need: Physiological Integrity it. Adequate nutrition is required for normal tissue repair. Answer: 2 (Objective: 10) Rationale: Any at-risk client confined to bedgeven when a special support mattress is used~should be re— positioned at least every 2 hours, depending on the client’s need, to allow another body surface to bear the weight. Six body positions can usually be used: prone, supine. r1ght and tell lateral (side—lying), 6. circulatory and right and left Sims positions. When a lateral position is used, the nurse should avoid positioning the client directly on the trochanter and instead position the client on a 30° angle. A written schedule should be established for turning and repositioning. A knee~chest position would ttot be appropriate. Nursing Process: Implementa— tion Client Need: Physiological Integrity Answer: I (Objective: 8) Rationale: Albumin is an important suture sedation clot closed indicator of nutritional status. A value below 3.5 g/dL indicates poor nutrition and may increase the risk ofpoor healing and in— fection. Nursing Process: Assessment Client Need: Physiological Integrity Begins with the admission ol‘the client to the postan— esthesia urea and ends when healing is complete i Answer: 2 (Objective: 8) Rationale: Check the medical orders. not the progress notes, to determine if the specimen is to be collected for an aerobic (growing only iii the presence of oxygen) or anaerobic (growing only in the absence of oxygen) culture. Aerobic organisms are generally found on the surface of the wound. whereas anaerobic © 2016 by Pearson Education. Inc. A technique in which the anesthetic agent is injected into and around a nerve or small nerve group that supplies sensation to a small area ofthc body g Used most often for procedures involving the arm. wrist. and hand 344 Answer Key h An injection of an anesthetic agent into the epidural space, the area inside the spinal column but outside the dura mater niques that preserve skin integrity. Electric clippers or a depilato» ry cream should be used to reduce the risk of traumatizing the skin during hair removal. Ifa dcpilatory is used, hypersensitivity f The passage ofblood through the vessels testing is performed prior to applying it to the surgical site. Skin trauma and abrasions increase the risk ofmicroorganisms coloa Begins when the decision to have surgery is made and ends when the client is transferred to the operating table nizing the surgical site. lfhair is to be removed, it is done as close to the time of surgery as possible and not in the vicinity ofthe sterile field to avoid dispersal ofloose hair and potential contami- e (Infiltration) is injected into a specific area and is nation ofthe sterile field. used for minor surgical procedures such as suturing a small wound or performing a biopsy Review Question Answers j Applied directly to the skin and mucous membranes, open skin surfaces, wounds, and burns Answer: 2 (Objective: 2) Rationale: The intraoperative phase begins when the client is transferred to the operating table and d The temporary interruption of the transmission of nerve impulses to and from a specific area or region of the body ends when the client is admitted to the postanesthesia care unit (PACU), also called the postanesthetic room or recovery room. The preoperative phase begins when the decision to have surgery b Begins when the client is transferred to the operating table and ends when the client is admitted to the postanesthesia is made and ends when the client is transferred to the operating table. The postoperative phase begins with the admission of the care unit (PACU), also called the postanesthetic room or recovery client to the postanesthesia area and ends when healing is I'OOlTl complete Surgery is a unique experience of a planned physical alteration encompassing three phases: preoperative, intraoperative, and postoperative. These three phases are together referred to as the perioperative period. Nursing Process: Planning Client Need: Safe, Effective Care Environment Answer: 4 (Objective: 10) Rationale: Antibiotics would not be as much ofa risk as the other medications listed. The regular use of certain medications can increase surgical risk. Consider these examples: I Anticoagulants increase blood coagulation time. Case Study Answers 1a. Define major surgery and minor surgery. Major surgery involves I Tranquilizers may interact with anesthetics, increasing the risk of respiratory depression. Diuretics may affect fluid and electrolyte balance. Corticosteroids may interfere with wound healing and increase the risk of infection. a high degree ofrisk for a variety of reasons: It may be compli— cated or prolonged, large losses of blood may occur, vital organs Clients may be unaware of the potential adverse interactions of may be involved, or postoperative complications may be likely. medications and may fail to report the use of medications for con— Minor surgery normally involves little risk, produces few compli- ditions unrelated to the indication for surgery. The astute nurse in» cations, and is often performed in an outpatient setting. terviewer should question the client and family about the use of commonly prescribed medications, over—the—counter preparations. Give two examples of major surgery and two examples of minor and any herbal remedies for specific conditions mentioned during surgery. Major surgery examples are organ transplant and open the nursing history. Nursing Process: Assessment Client Need: heart surgery. Minor surgery examples are breast biopsy and knce Safe, Effective Care Environment surgery, Answer: 1 (Objective: 7) Rationale: Clean the surgical site and Why wouldyou need to remove the hair on the client’s abdomen be are surgery? llair would be removed from the surgical site one ly if it interferes with the surgical procedure. Remove hair from the surgical site only when necessary or according to the primary care practitioner’s orders or institutional policies and procedures. Personnel skilled in hair removal should remove hair using tech— © 2016 by Pearson Education, Inc. surrounding areas. This can be accomplished before the surgical prep by having the client shower and shampoo or wash the surgical site before arriving in the surgical setting, or by washing the surgical site in the surgical setting immediately before applying an antimicrobial agent. Prepare the surgical site and surrounding area with an antimicrobial agent when indicated. A nontoxic antimicrobial agent Answer Key 345 with a broad range of germicidal action is used to inhibit the growth 8. Answer: ] (Objective: 12) Rationale: Draw up the ordered volume of microorganisms during and following the surgical procedure. The of irrigating solution in the syringe; 30 mL of solution per agent selected depends on the client’s history of hypersensitivity instillation is usual, but up to 60 mL may be given per instillation if reactions. the location ofthc surgical site, and the skin condition. The ordered. Attach the syringe to the nasogastric tube and slowly inject area prepared needs to be large enough to accommodate an extension the solution. Gently aspirate the solution. Foreet‘ul withdrawal could of the incision and any potential drain sites or additional incisions it‘ damage the gastric mucosa. Nursing Process: Implementation needed. Remove hair from the surgicai site only when necessary or Client Need: Physiological Integrity according to the primary care practitioner’s orders or institutional policies and procedures. Document surgical skin preparation in the 4. 9. Answer: 1 (Objective: 6) Rationale: The student nurse should assist client’s record. Documentation should include the skin condition, the client to a lying position in bed. Reach inside the stocking from including any growths, abrasions, or rashes: hair removal and the the top and, grasping the heel, turn the upper portion of the stocking techniques used, if performed; the skin preparation, including inside out so the foot portion is inside the stocking leg. Have the cleansing and antimicrobial agent applied; who performed the client point his or her toes, then position the stocking on the client’s preoperative skin preparation; and any adverse or hypersensitivity foot. Ease the stocking over the toes, taking care to place the toe and responses noted. Nursing Process: Assessment Client Need: Safe, heel portions of the stocking appropriately. Nursing Process: Effective Care Environment Evaluation Client Need: Physiological Integrity Answer: 4 (Objective: 1 l ) Rationale: The nurse wears sterile 10. gloves, not exam gloves. Before removing skin sutures, the nurse Answer: 4 (Objective: 6) Rationale: Atelectasis is a condition in which alveoli collapse and are not ventilated. Thrombophlebitis is needs to verify the orders for suture removal (in many instances, inflammation of the veins, usually of the legs and associated with a only alternate interrupted sutures are removed one day, and the blood clot. Pulmonary embolism is a blood clot that has moved to remaining sutures are removed a day or two later) and whether a the lungs and blocks a pulmonary artery, thus obstructing blood flow dressing is to be applied following the suture removal. The nurse to a portion ofthe lung. Pneumonia is inflammation of the alveoli. will grasp the suture at the knot with a pair offorceps. Sutures are Nursing Process: Planning Client Need: Physiological Integrity cut as close to the skin as possible on one side ofthc visible part because the suture material that is visible to the eye is in contact with resident bacteria of the skin and must not be pulled beneath CHAPTER 38 the skin during removal. Suture material that is beneath the skin is considered free from bacteria. Nursing Process: Implementation U: Client Need: Physiological Integrity Key Term Review Answer: 3 (Objective: 9) Rationale: Instruct the client to report promptly to the primary care practitioner any increasing redness, swelling, pain, or discharge from the incision or drain sites. Instruct the client to use pain medications as ordered. not allowing pain to become severe before taking the prescribed dose. Teach the client to avoid using alcohol or other central nervous system depressants while taking narcotic analgesics. Emphasize the importance of ade— quate rest for healing and immune function. Nursing Process: Plan— ning Client Need: Health Promotion and Maintenance 6. Key Topic Review Answers Answer: 2 (Objective: 10) Rationale: The proper technique is to place the bulk of the dressing over the drain area and below the drain, depending on the client‘s usual position. Sterile gloves must be worn during the procedure. The dressing should be secured with 2. b. Stereognosis refers to the ability to perceive and understand an object through touch by its size, shape, and texture. tape or ties. The sterile dressings are applied one at a time over the drain and the incision. Nursing Process: Evaluation Client Need: Physiological Integrity 7. Answer: 1 (Objective: 9) Rationale: The client should hold his or 3, a 4. a 5. b. her breath for 2 to 3 seconds. The client should be in a sitting position. The client should exhale slowly through the mouth. The Client Sensory deprivation is generally thought of as a decrease in or lack of meaningful stimuli. should inhale slowly and evenly through the nose until the greatest chest expansion is achieved. Nursing Process: Evaluation Client Need: Physiological Integrity © 2016 by Pearson Education, Inc. 6. perception 346 Answer Key stress Older adult clients with a hearing loss have difficulty understanding culture process fast verbal information is slower and that rapid speech fast speech. Research indicates that the older adult’s ability to allows for less time for the older adult to recognize the acoustic or attention auditory cues ot‘thc speech. An individual who speaks with an accent can also affect speech understanding by the older adult overload Normative English speakers may vary their pronunciation of syllables and/or words, making it challenging for the older adult. [low can environmental stimuli be atlftistctlfor this client? The client functions best when the environment is somewhat similar to that of the individual’s ordinary daily life. Sometimes nurses need to take steps to adjust the client’s environment to prevent either sensory overload or sensory deprivation. Review Question Answers 1. Case Study Answers la. ”"770! actions .S’liOll/(Iyolt take to help will? the client '3 visual Answer: 2 (Objective: 8) Rationale: The following guidelines should be adhered to by nurses: I Always announce your presence when entering the client‘s room and identify yourself by name. impairment? I Speak in a warm and pleasant tone of voice. Some people tend I Orient the client to the arrangement of room furnishings and to speak louder than necessary when talking to a blind person. maintain an uncluttered environment. I Always explain what you are about to do before touching the I Keep pathways clear and do not rearrange furniture without person. orienting the client. Ensure that housekeeping personnel are informed about this. I Organize self—care articles within the client’s reach and orient I Explain the sounds in the environment. I Stay in the client’s field of vision if the client has a partial vision loss. the client to her location. I Keep the call light within easy reach and place the bed in the low position. I Assist with ambulation by standing at the client’s side, walk— I Indicate when the conversation has ended and when you are leaving the room. The nurse should not speak in an overly loud voice in an attempt for the client to hear the nurse. ing about 1 foot ahead, and allowing her to grasp your arm. Confirm whether the client prefers grasping your arm with Nursing Process: Evaluation Client Need: Physiological Integrity the dominant or nondominant hand. lb. What actions slzoula’you take to help with the client ’s hearing Answer: 2 (Objective: 5) Rationale: Delirium alertness fluctuates. impairments? Clients with hearing impairments who are unable to The client may be alert and oriented during the day but become hear the alarms of IV pumps and cardiac monitors need to be confused and disoriented at night. The level ofalenness ofa assessed frequently. They can be taught to use their visual sense to client with dementia is generally normal. Delusions and identify kinks in the 1V tubing or a loose ECG lead, and so on. For hallucinations are not described in terms of lluctuating alertness. home safety, clients with impaired hearing need to obtain devices Nursing Process: Planning Client Need: Physiological integrity that either amplify sounds or respond with flashing lights to sounds such as a doorbell or smoke detector, 3 baby crying, or a burglar Answer: 1 (Objective: 7) Rationale: The nurse shorrld teach the alarm. The sounds of doorbells and alarm clocks may be amplified client the following: wear protective eye goggles when using or changed to a lower frequency or buzzer—like sound. These devices power tools, riding motorcycles, spraying chemicals, and so on. can be obtained from hearing aid dealers, telephone companies, and Wear ear protectors when working in an environment with high appliance stores. An important consequence ofa decline in hearing noise levels or brief loud impulse noises (e.g., blasting). Wear as an individual ages is difficulty understanding speech. Factors that dark glasses with UV protection to avoid damage from ultraviolet influence this difficulty are the environment, rate of speech, and rays and never look directly into the sun. Have regular health ex- presence of an accent. Environments that are noisy and reverberant aminations. Nursing Process: Planning Client Need: Health (echoing, hollow sounds) cause difficulty for old adult listeners. Q 2016 by Pearson Education, Inc. Promotion and Maintenance Answer Key 347 Answer: 4 (Objectives: 7. 8) Rationale: Eliminate unnecessary noise. Reinforce reality by interpreting unfamiliar sounds, sights, l Olfactory sense identification of specific aromas. l Gustatory sense—identification of three tastes such as and smells; correct any misconceptions of events or situations. lemon. salt. and sugar. Address the person by name and introduce yourself frequently: “Good morning, Mr. Richards. I am Betty Brown. I will be your I Tactile sense test light touch, sharp and dull sensation, two» nurse today.“ Identify time and place as indicated: "Today is point discrimination, hot and cold sensation, vibration sense, December 5, and it is 8:00 in the morning.” Ask the client. “Can position sense, and stereognosis. you tell me where you are right now?" and orient the client to Nursing Process: Assessment Client Need: Physiological Integrity place (eg, nursing home) ifindicated. Nursing Process: Implementation Client Need: Psychosocial Integrity Answer: 2 (Objective: 7) Rationale: The spouse should get the CHAPTER 39 following: a phone dialer with large numbers, reading material with large noncursive print, an amplified telephone, and a Key Term Review magnifying glass. Nursing Process: Evaluation Client Need: Physiological Integrity Answer: 2, 4 (Objective: 3) Rationale: The nurse should inform the client beforehand of the care to be provided, not during the care. The nurse should also provide oral care, perform range—0t1 motion exercises, and provide aromatic stimuli. Too much environmental stimuli can be very distressing to a client. The client is unconscious and should not be assisted to the commode. Key Topic Review Answers Nursing Process: Planning Client Neel]: Physiological Integrity Answer: 2 (Objective: 1) Rationale: Stereognosis is the ability to perceive and understand an object through touch by its size, b. shape, and texture. Sensory reception is the process of receiving A client's attitude to a newly acquired disability is often the determining factor in successful rehabilitation. stimuli or data. Sensory perception involves the conscious organization and translation of data or stimuli into meaningful information. Sensor-istasis is the term used to describe when an individual is in optimal arousal. Nursing Process: Assessment Client Need: Physiological Integrity Answer: I (Objectives: 7, 8) Rationale: Encourage the client to use eyeglasses and hearing aids during waking hours. Address the client by nnrne and touch the client what- speaking tram is not culturally offensive. Provide a telephone, radio and/or TV, clock, positive self and calendar. Encourage the use of self-stimulation techniques such as singing, humming, whistling, or reciting. Nursing Specific Process: Planning Client Need: Safe, Effective Care Environment strength Answer: 3 (Objective: 4) Rationale: Gustatoryi‘Have you experienced any changes in taste?" Visuali"When did you last visit an eye doctor?” Auditoryi‘llave you experienced any dizziness or vertigo?” Olfactory—"Can you distinguish foods by their odors and tell when something is burning?” Nursing Process: Assessment Client Need: Physiological Integrity Answer: 2 (Objective: I)Rationale: Specific sensory tests include: I Visual acuity «use a Snellen chart or other reading material, such as a newspaper, and visual fields. I Hearing acuityvobscrve the client‘s conversation with others and perform the whisper test and the Weber and Rinne tuning fork tests. ((5) 2016 by Pearson Education, Inc. idenl 348 Answer Key Case Study Answers in. What nursing techniques may help clients analyze the problem and enhance sol/iconcept? I Encourage clients to appraise the situation and express their feelings. I Encourage clients to ask questions, I Noticc and verbally reinforce client strengths. I Provide honest, positive feedback. . ,. I Encourage the setting of attainable goals. Nursing Process: Planning Client Need: Psychosocial Integrity Answer: 1 (Objective: 2) Rationale: Guidelines for conducting a psychosocial assessment include the following: I Provide accurate information. I Create a quiet, private environment. I Become aware of distortions, inappropriate or unrealistic I Minimize interruptions ifpossible. standards, and faulty labels in clients” speech. I Maintain appropriate eye contact. I Explore clients” positive qualities and strengths. I Encourage clients to express positive self-evaluation more than negative self—evaluation. I Sit at eye level with the Client. Nursing Process: Assessment Client Need: Psychosocial Integrity I Avoid criticism. Answer: 1 (Objective: 4) Rationale: Guidelines for conducting a I Teach clients to substitute negative self—talk (“I can’t walk to psychosocial assessment include the following: the store anymore”) with positive self—talk (“I can walk half a block each morning"). Negative self-talk reinforces a negative self-concept. I Indicate acceptance ofthe client by not criticizing, frowning, or demonstrating shock. I Ask open»cnded questions to encourage the client to talk rather lb. Listfive strevsom that afloat selficoncept. (Student trill clmoscfiva) I Change in physical appearance (cg, facial wrinkles) l Declining physical, mental, or sensory abilities I Inability to achieve goals I Relationship concerns than close-ended questions that tend to block free sharing. I Minimize the writing ol‘detailed notes during the interview because this can create client concern that confidential material is being “recorded” as well as interfere with your ability to focus on what the client is saying. l Avoid asking more personal questions than are actually needed. I Sexuality concerns I Unrealistic ideal self 1c. During your assessment, what questions snot/[dyou ask the client? Nursing Process: Assessment Client Need: Psychosocial Integrity Answer: 4 (Objective: 5) Rationale: The question “What are your responsibilities in the family?” is used to assess role performance I How would you describe your personal characteristics? or and family relationships. How do you see yourself as a person? The following are questions to determine a client’s self-esteem: I How do others describe you as a person? I What do you like about yourself? I What do you do well? I What are your personal strengths, talents, and abilities? I What would you change about yourself ifyou could? I Are you satisfied with your life? I How do you feel about yourself? I Are you accomplishing what you want? Nursing Process: Assessment Client Need: Psychosocial Integrity I Does it bother you a great deal if you think someone doesn’t like you? Answer: 1 (Objective: 5) Rationale: To enhance her son’s seltl esteem she would take the following actions: Review Question Answers I Give him opportunities to “practice” who he is. I Allow him to explore and experiment with the world around 1. Answer: 1 (Objective: 1) Rationale: Nurses can employ the him. following specific strategies to reinforce strengths: I Allow him to express himself as a unique individual. I Stress positive thinking rather than self—negation, © 2016 by Pearson Education, Inc. v" Answer Key 349 I Encouraging him to stay connected with all memories would CHAPTER 40 not be the best answer. This would be more appropriate for an elderly patient. Key Term Review Nursing Process: Evaluation Client Need: Psychosocial Integrity F. i: C relationships like with your other relatives?" is used to assess :3 (to 5 Answer: 2 (Objective: 5) Rationale: The question “What are your family relationships. The following questions are appropriate to ask a client when assessing body image: I Is there any part ot‘ your body you would like to change? I Are you comfortable discussing your surgery? I How do you feel about your appearance? Nursing Process: Assessment Client Need: Psychosocial Integrity Key Topic Review Answers Answer: 3 (Objective: 3) Rationale: The ideal selfis the individ— b. The development of sexuality begins with conception and ual’s perception of how one should behave based on certain per- continues throughout the life span. sonal standards, aspirations, goals. and wines. Global self refers to the collective beliet's and images one holds about oneself Body b) image is how a person perceives the size, appearance, and t‘unc‘ tioning ofthe body and its parts Self-concept is one‘s mental im- b, Once gender identity is established, it cannot be easily changed. age ot‘onesclt‘. Nursing Process: Assessment Client Need: Psye chosocial Integrity Answer: 4 (Objective: 2) Rationale: Erikson's stages of psychosocial development are as follows: responsibilities I Middle adulthood stage: generath ity vs. stagnation I Adolescence: identity vs. role confusion I Early adulthood: intimacy vs, isolation condom brain I Older adults: integrity vs. despair arousal Nursing Process: Assessment Client Need: Psychosocial Integrity Androgyny Answer: 2 (Objective: 4) Rationale: People undergoing role strain _g Painful menstruation _a How one values oneself as a sexual being J4_ One‘s self—image as a female or male involves socialization into a particular role, Nursing Process: 7177 The outward expression oi‘a person’s sense of Assessment Client Ne rd: Psychosocial Integrity maleness or femaleness as well as the expression ofwhat is per— are frustrated because they feel or are made to feel inadequate or unsuited to a role. Role strain is often associated with sex-role stereotypes. Role conflicts arise from opposing or incompatible expectations. Role ambiguity occurs when expectations are unclear, and people do not know what to do or how to do it and are unable to predict the reactions of others to their behaVior. Role development ceived as gender-appropriate behavior Answer: 1 (Objective: 4) Rationale: Change or loss ot'job or other significant role, loss ot‘tinancial security, abusive i Flexibility in gender roles, the beliel‘that most relationship, and unrealistic expectations are considered stressors characteristics and behaviors arc human qualities that should not affecting self-concept. Nursing Process: Assessment Client be limited to one specific gender or the other Neel]: Psychosocial Integrity h One’s attraction to people of the same sex, other sex. or both sexes C 2016 by Pearson Education, Inc. 350 Answer Key c The ongoing love affair that each ofus has with ourselves throughout our lifetime Follow safe sex practices during oral sex, including the use of a latex dental dam during cunnilingus to prevent STl transmission. 0 The involuntary climax of sexual tension, accom— panied by physiological and psychological release f The period of return to the unaroused state; may last 10 to l5 minutes after orgasm, or longer if there is no orgasm Talk openly with sexual partners about how to have “safer sex” and be honest about any history of an STl. Abstain from high-risk sexual activity with a partner known to have or suspected of having an STI. Report to a health care facility for examination whenever in d A severe distaste for sexual activity or the thought of sexual activity, which then leads to a phobic avoidance of sex doubt about possible exposure or when signs of an STI are evident. When an STI is diagnosed, notify all partners and encourage them to seek treatment. Avoid transfusions of banked blood or blood products. Use 13. autologous transfusions (donation of own blood before sur— gery) for elective surgery whenever possible. 14. Summarize the nursing strategies to deal with the client ’5 inap— Case Study Answers 1a. Explain how to provide client teachingfar testicular selfexamination, propriate sexual behavior. I Communicate that the behavior is not acceptable by saying, for example, “I really do not like the things you are saying,” or “I see you are not dressed. I will be back in 10 minutes and will Choose one day ofeach month (cg, the first or last day of each month) to examine yourself. help you with breakfast when you get your clothes on.” Tell the client how the behavior makes you feel: “When you Examine yoursell‘ when you are taking a warm shower or act like that toward me, I am very uncomfortable. lt embar- bath. rasses me and makes it hard for me to give you the kind of Support the testicle underneath with one hand. Place the fin- nursing care you need.” gers of the other hand under the testicle and the thumb on top Identify the behavior you expect: “Please call me by my (this may be easier to do ifthe leg on that side is raised). name, not ‘l-loney’” or “I expect you to keep yourself cov- Roll each testicle between the thumb and fingers of your ered when I am in the room. If you are feeling hot or some- hand, feeling for lumps, thickening, or a hardening in con- thing is uncomfortable, let me know, and I will try to make sistency. you more comfortable.” The testes should feel smooth. Palpate the epididymis, a Set firm limits: Take the client’s hand and move it away, use eordlike structure on the top and back of the testicle. The ep- direct eye contact, and say, “Don’t do that!” ididymis feels soft and not as smooth as a testicle. Try to refocus clients from the inappropriate behavior to Locate the spermatic cord, or vas deferens, which extends their real concerns and fears; offer to discuss sexuality con— upward from the scrotum toward the base of the penis. It cerns: “All morning you have been making very personal should feel firm and smooth. sexual comments about yourself. Sometimes people talk like Using a mirror, inspect your testicles for swelling, any en— largement, or lumps in the skin of the testicle. that when they are concerned about the sexual part of their life and how their illness will affect them. Are there things that you have questions about or would like to talk about?” Promptly report any lumps or other changes to your health care provider. Report the incident to your nursing instructor, charge nurse, or clinical nurse specialist. Discuss the incident, your feel- lb. Explain how to prevent the transmission ofS775 and HIV. ings, and possible interventions. Assign a nurse who will confront the behavior and relate to Limit the number ofsexual partners. the client in a consistent manner. Use condoms in nonmonogamous and homosexual relation— Clarify the consequences of continued inappropriate behav~ ships or other relationships that have the potential for ST] ior (avoidance, withdrawal of services, no chance to help re— transmission. solve underlying concerns of client). © 2016 by Pearson Education, Inc. Answer Key 351 Review Question Answers 7. Answer: 2 (Objective: 1) Rationale: The orgasmic phase is the involuntary climax of sexual tension, accompanied by physiologi— 1. Answer: 4 (Objective: 8) Rationale: When an $11 is diagnosed, cal and psychological release. The response cycle starts in the notify all partners and encourage them to seek treatment. Use ofcon- brain, with conscious sexual desires called the desire phase. The doms should occur in nonmonogamous and homosexual relation— resolution phase, the period of return to the unaroused state. may ships, or other relationships that have the potential for STI transmis- last 10 to 15 minutes after orgasm, or longer iftherc is no orgasm. sion. Follow safe sex practices during oral sex, including the use ofa Myotonia, an increase oftension in muscles, may increase until latex dental dam during cunnilingus to prevent STl transmission. Re— released by orgasm, or it may also simply fade away. Nursing port to a health care facility for examination whenever in doubt about Process: Assessment Ciient Need: Physiological Integrity possible exposure or when signs ofan STI are evident. Nursing Pro- cess: Planning Client Need: Health Promotion and Maintenance 8. Answer: 1 (Objective: 1) Rationale: Body image, a central part of the sense of self, is constantly changing. Gender identity is one’s 2. Answer: 2 (Objective: 9) Rationale: Press the breast tissue against self—image as a female or male. Gender-role behavior is the out- the chest wall firmly enough to know how your breast feels. A ridge ward expression of a person’s sense of maleness or femaleness as of firm tissue in the lower curve of each breast is normal. Use the well as the expression of what is perceived as gender-appropriate fuiger pads (tips) of the three middle fingers (held together) on your behavior. Androgyny, or flexibility in gender roles, is the belief left hand to feel for lumps. Use small circular motions systematically that most characteristics and behaviors are human qualities that all the way around the breast as many times as necessary until the should not be limited to one specific gender or the other. Nursing entire breast is covered. Look for any change in size or shape; lumps Process: Assessment Client Need: Physiological Integrity or thickenings; any rashes or other skin irritations; dimpled or puckered skin; any discharge or change in the nipples. Nursing Process: 9. Answer: 2 (Objective: 9) Rationale: “Preorgasmic women have Evaluation Client Need: Health Promotion and Maintenance experienced an orgasm“ is an incorrect statement. The following Answer: 4 (Objective: 8) Rationale: The correct statement should women have never experienced an orgasm.“ “Rapid ejaculation is have been: “I will report the incident to my nursing instructor, one of the most common sexual dysfunctions among men.” “Vul- Lu statements would not need any further education: “Preorgusmic charge nurse. or clinical nurse specialist.” The following state» vodyniu is constant, unremitting burning that is localized to the ments would be correct: “I will communicate that the behavior is vulva with an acute onset.” “Vesti/mlitis causes severe pain only not acceptable.” “1 will identify the behavior I expect.” “I will set on touch or attempted vaginal entry." Nursing Process: Evalua- firm limits with the client.” Nursing Process: Evaluation Client tion Client Need: Health Promotion and Maintenance Need: Psychosocial Integrity 10. 4. Answer: 1 (Objective: 3) Rationale: One technique nurses can use Answer: 1 (Objective: 9) Rationale: Vaginal diaphragms, cervi- to help clients with altered sexual function is the PLISSIT model. cal caps, and condoms are mechanical barriers of contracep- developed by Annon (1974) for this purpose. The model involves tion, not chemical ones. Chemical barriers include insertion of four progressive levels represented by the acronym PLISSIT: spermicidal foams, creams, jellies, or suppositories into the vagi— P Permission giving LI Limited information Vices (IUDs) may be used for contraception. Nursing Process: SS Specific suggestions Planning Client Need: Physiological Integrity IT Intensive therapy na before intercourse. Surgical sterilization . tubal ligation and vasectomy, is an effective contraception method. Intrauterine de» The following are incorrect choices: PLIISIT, PLLISSIT, PLISIT. 5. Answer: 2 (Objective: 9) Rationale: The following statement by Nursing Process: Assessment Client Need: Physiological Integrity the nurse would be correct: “Diuretics decrease vaginal lubrica— tion.” The following statements would be correct: “Antipsychot— ics decrease sexual desire.” “Narcotics inhibit sexual desire and CHAPTER 41 response.” “Barbiturates in large amounts decrease sexual desire.” Nursing Process: Planning Client Need: Physiological Integrity stimulant” is an incorrect statement. Alcohol is a relaxant and central nervous system depressant The following statements would be correct: “Sexual ability is not lost due to age.” “There is no evidence that sexual activity weakens a person.” “Chronic alcoholism is associated with erectile dysfunction.” Nursing Process: Evaluation Client Need: Physiological Integrity r“ 9 2016 by Pearson Education, Inc. f 2. j 3. m 4. b :r I. 57 Answer: 4 (Objective: 9) Rationale: “Alcohol is a sexual a. Key Term Review 6. 352 Answer Key Key Topic Review Answers b. Spirituality generally involves a belief in a relationship with Case Study Answers la. some higher power, creative force, divine being, or infinite The client asksyou to pray with him. Describe some oft/7e guidelines you s/touldfbl/ow. SOUI'CC Of energy. L) I Prayers with clients should only be done when there is mutual a agreement between the clients and those praying with them. I Nurses who are unaccustomed to praying aloud or in public a may find it helpful to have a formal prayer or a scriptural passage readily available, a I Because prayer can evoke deep feelings, the nurse may need a to spend time with the client following a prayer to enable the client to express these feelings. kosher I The nurse’s goal when praying with the client is to facilitate Presencing the client’s prayer and not to self—disclose his or her own religious beliefs. planning lb' Sacred Summarize the practice guidelines you shouldfollow to support the client ’5 religious practices. forgiveness I Create a trusting relationship with the client so that any Vf religious concerns or practices can be openly discussed and To believe in or be committed to something or addressed. someone I If unsure ot‘client religious needs. ask how nurses can assist g A concept that incorporates spirituality in having these needs met. Avoid relying on personal as— sumptions when caring for clients. Ad_ ‘ The beliefin more than one God I Do not discuss personal spiritual beliefs with a client unless ihkg The belief in the existence ofone God _ 7c77 One without belief in a God __i _ A person who doubts the existence of God or a the client requests it. I Inform clients and family caregivers about spiritual support available at your institution (e.g., chapel or meditation room, chaplain services). supreme being or believes the existence of God has not been proved I Remember the difference between facilitatirig/supporting a client’s religious practice and participating in it yourself. ¥_b_fi_ An organized system of beliefs and practices _a; A challenge to the spiritual we11«being or to the I All spiritual interventions must be done within agency guidelines. belief system that provides strength, hope, and meaning to life lc. j_ ls manifested by a feeling of being “generally Give some €.\‘fliii])lE’S ofspiritual needs that would be related to others. alive, purposeful, and fulfilled" I Need to forgive or be forgiven by others. e Refers to that part of being human that seeks incan— I Need to cope with loss ofloved ones ingfulness through intra—, inter—. and transpersonal connection Review Question Answers Answer: 4 (Objective: 5) Rationale: It is important for nurses to understand health-related information about specific religions. SeventhiDay AdventistsAAvoid unnecessary treatments on Sat- urday (Sabbath). Sabbath begins Friday sundown. ends Saturday sundown Adventists prefer restful, spirit—nurturing. family activities on Sabbaths. Buddhistsi -Facilitate meditation (may desire TC) 2016 by Pearson Education, Inc. Answer Key 353 incense, visual focal point, use breathing or chanting, etc.). Jeho— practices, and cultures of the area in which you are working.” vah’s WitnessesfiAbstain from most blood products; need to dis- Nursing Process: Evaluation Client Need: Psychosocial Integrity cuss alternative treatments such as blood conservation strategies, autologous techniques, hematopoietic agents, nonblood volume 7. Answer: 4 (Obj eetive: l) Rationale: Personalizing the prayer is an appropriate practice guideline for praying with clients. The fol» expanders. and so on; contact local Jehovah‘s Witness hospital li- aison committee. Latter-Day Saints (LDS or Mormons)— rAvoid lowing statements are also appropriate practice guidelines for alcohol, caffeine, smoking. Prefer to wear temple undergarments. praying with clients: “Clients’ preferences for prayer reflect their Arrange for priestly blessing if requested. Nursing Process: As— personalities." “Before praying, assess what they would like for sessment Client Need: Psychosocial Integrity you to pray." “Prayer may be the springboard to further discussion or catharsis.” Nursing Process: Implementation Client Need: Psychosocial Integrity Answer: 1 (Objective: 2) Rationale: Religion is an organized system of beliefs and practices. It offers a way of spiritual expression that provides guidance for believers in responding to life’s 8. Answer: 3 (Objective: 5) Rationale: Muslims follow the practice questions and challenges. Spiritual distress refers to a challenge to of prayer fives times a day, and the Muslim client may need assis- the spiritual well—being or to the belief system that provides tance to maintain this commitment. Nursing Process: Assessment strength, hope, and meaning to life. Spiritual health, or spiritual Client Need: Psychosocial Integrity well-being, is manifested by a feeling of being “generally alive, purposeful, and fulfilled.” Spirituality refers to that part of being 9. Answer: 4 (Objective: 1) Rationale: Planning in relation to human that seeks meaningfulness through intraa, inter-, and spiritual needs should be designed to do one or more of the transpersonal connection. Nursing Process: Assessment Client following: Need: Psychosocial Integrity I Promote a sense of hope. Answer: 2 (Objective: l)Rationale: An atheist is an individual I Help the client fulfill religious obligations. without beliefin a God. An agnostic is an individual who doubts I Help the client draw on and use inner resources more effec- the existence of God or a supreme being or believes the existence tively to meet the present situation. ot‘God has not been proved. Monothcism is the beliefin the ex- I Ilelp the client find meaning in existence and the present sit- istence oi‘one God, while polytheism is the belici'in more than one god. Nursing Process: Assessment Client Need: Psychoso— uation. cial Integrity Nursing Process: Planning Client Need: Psychosocial Integrity Answer: 2 (Objective: 5) Rationale: Orthodox Jews do not eat shellfish or pork. Buddhists and Hindus are generally vegetarian, 10. Answer: 4 (Objective: 3) Rationale: The need to cope with loss not wanting to take life to support life. Members ofthe Church of oi‘loved ones is a need related to others. Needs related to the self Jesus Christ ofLatter—Day Saints (LDS or Mormons) do not drink include: caffeinated or alcoholic beverages. Nursing Process: Assessment I Need for meaning and purpose Client Need: Psychosocial Integrity I Need to express creativity Answer: 2 (Objective: 1) Rationale: “Being there in a way that is I Need for hope meaningful to yourself" is incorrect. The following statements are correct: “Being there in a way that is meaningful to another per- Nursing Process: Planning Client Need: Psychosocial Integrity son,” “Giving ofself in the present moment." “Listening, with full awareness ofthe privilege ofdoing so.” “Being available with all Ofthe self." Nursing Process: Implementation Client Need: Psychosocial Integrity 6. Answer: 3 (Objective: 1) Rationale: “Always discuss personal spiritual beliefs with a client” is incorrect. The following statements would demonstrate practice guidelines that support CHAPTER 42 Key Term Review I practices can be openly discussed and addressed.” “If unsure of needs met.” “Acquaint yourselfwith the religions, spiritual ’0 2016 by Pearson Education, Inc. . k 13. client religious needs, ask how nurses can assist in having these e E 22. relationship with the client so that any religious concerns or W 5 D. 0 7 .D Create a trusting 00 a Client unless the client requests it. 0 religious practices: “Do not discuss personal spiritual beliefs with 354 Answer Key Key Topic Review Answers 12. c 1 a 13. a 2. a 14. d 3. a 15. a 4. b. 16. c Self—control (discipline) is assuming a manner and facial V expression that convey a sense of being in control or in charge. 5. b. Structuring is the arrangement or manipulation ofa situation Case Study Answers so that threatening events do not occur. 1a. 6. Suppression 7. Fantasy 8. Coping 9. intervention What level of anxietv is the client most likely experiencing? The client is most likely experiencing severe anxietyfisee Table 42 —2 in the text. lb. Describe various methods you could teach the client to minimize stress and anxiety. I Listen attentively; try to understand the client’s perspective on the situation. 1 0. I Provide an atmosphere of warmth and trust; convey a sense strategy ofcaring and empathy. 1 l. e Unconscious psychological adaptive mechanisms or, I Determine ifit is appropriate to encourage the client’s partic- according to Sigmund Freud (1946), mental mechanisms that devel— ipation in the plan of care; give the client choices about seine op as the personality attempts to defend itself, establish compromis- aspects of care but do not overwhelm the client with choices. es among conflicting impulses, and calm inner tensions I Stay with the client as needed to promote safety and feelings of f 7 security and to reduce fear. An extreme feeling of sadness, despair, dejection, lack oi‘wor’th, or emptiness; affects millions of Americans 21 year I Control the environment to minimize additional stressors, such as by reducing noise, limiting the number of individuals c An emotional state consisting ofa subjective feel- in the room, and providing care by the same nurse as much ing of animosity or strong displeasure An emotion or feeling of apprehension aroused by impending or seeming danger, pain, or other perceived threat j _h A state of mental uneasiness, apprehension, dread, or foreboding or a feeling of helplessness related to an impending or as possible. I Implement suicide precautions ifindicated. I C ommunicate in short, clear sentences. I Help the client to a. anticipated unidentified threat to self or significant relationships b. b When the body‘s adaptation takes place i When the changes produced in the body during the d. shock phase are reversed The stressor may be perceived consciously or Verbalize feelings, perceptions, and fears as appropriate. Some cultures discourage the expression of feelings. c. a Determine situations that precipitate anxiety and identify signs of anxiety. Identify personal strengths. Recognize usual coping patients and differentiate posi« tive from negative coping mechanisms. 0. identify new strategies for managing stress (cg. exercise, massage, progressive relaxation). unconsciously by the person f. g One organ or a part ofthe body reacts alone d Any event or stimulus that causes an individual to I Teach the client about: a. experience stress © 2016 by Pearson Education, Inc. Identify available support systems. The importance of adequate exercise, a balanced diet, and rest and sleep to energize the body and enhance coping abilities. Answer Key 355 b. Support groups available such as Alcoholics Anony- mous, Weight Watchers or Overeaters Anonymous, and I Develop collegial support groups to deal with feelings and anxieties generated in the work setting. parenting and child abuse support groups, c. Educational programs available such as time managc~ ment, assertiveness training, and meditation groups. I Get involved in constructive change efforts iforganizational policies and procedures cause stress. I Learn to say no. Erp/ain lite difference between anxiety ant/flan: The source of anxiety may not be identifiable; the source of fear is identifiable. I Establish a regular exercise program to direct energy outward. Anxiety is related to the future, that is. to an anticipated event. Fear is related to the present. Anxiety is vague, whereas fear is definite. Nursing Process: Iinpletnentation Client Need: Psychosocial Anxiety is the result of psychological or emotional conflict; fear is Integrity the result ofa discrete physical or psychological entity. Answer: 2 (Objective: 8) Rationale: Review Question Answers Answer: 2 (Objective: 3) Rationale: The client is experiencing moderate anxiety as evidenced by voice tremors and pitch changes, I The adolescent is characterized by changing physique, relationships involving sexual attraction, exploring independence, choosing a career. facial twitches. shakiness, and slightly elevated respiratory and I The young adult is characterized by getting married, leaving heart rates, and she told you “I feel like 1 have butterflies in my home, managing a home, getting started in an occupation, stomach.” Mild anxiety would be characterized by mild restless- continuing one’s education, having children. ness, sleeplessness, increased verbalization, feelings of increased arousal and alertness. and no changes in respiratory and heart rates. Severe anxiety is characterized by communication difficulties; in» creased motor activity; inability to relax, focus, and concentrate; case ofdistraetibility; tachycardia; and hyperventilation. Panic anx- I The middle adult is characterized by physical changes of aging, maintaining social status and standard ofliving, helping teenage children to become independent, aging parents. I The older adult is characterized by decreasing physical abili- iety is Characterized by increased motor activity, agitation, unpre— ties and health, changes in residence, retirement and reduced dictable responses, distorted or exaggerated perception, dyspnea, income, death of spouse altd friends I») palpitations, choking, chest pain, and a feeling ofimpcnding doom. Nursing Process: Assessment Client Need: Psychosocial Integrity Nursing Process: Assessment Client Need: Psychosocial Integrity Answer: 1 (Objective: 3) Rationale: The source of anxiety may Answer: 1 (Objective: 5) Rationale: Displacement is the not be identifiable; the source of fear is identifiable. Anxiety is transferring or discharging of emotional reactions from one object related to the future, that is, to an anticipated event. Fear is related or person to another object or person. An example would be when to the present. Anxiety is vague, whereas fear is definite. Anxiety a husband and wife have an argument, the husband becomes so is the result ot‘psyctioiogipat or emotional conflict: fear is the angry he hits a door instead of his wife. Denial is an attempt to result ofa discrete physical or psychological entity. Nursing screen or ignore unacceptable realities by ret'usrng to Process: Evaluation Client Need: Psychosocial Integrity acknowledge them. An example would be a woman who, though Answer: 1 (Objective: 7) Rationale: Try to understand the mean~ reunion 18 months in advance. Projection is a process in which told her father has metastatic cancer, continues to plan a family ing of the client’s anger. After the interaction is completed, take blame is attached to others or the environment for unacceptable time to process your feelings and your responses to the client with desires, thoughts, shortcomings, and mistakes. An example would your colleagues. Let clients talk about their anger. Listen to the be a mother who is told that her child must repeat a grade in client, and act as calmly as possible. Nursing Process: Implemen— school, and the mother blames this on the teacher’s poor tation Client Need: Psychosocial Integrity instruction. Substitution is the replacement ofa highly valued, Answer.- 3 (Objective: 9) Rationale: Nurses can prevent burnout or available object. An example would be a woman who wants to unacceptable. or unavailable object by a less valuable. acceptable. by using the techniques to manage stress discussed for clients. marry a man exactly like her deceased father, and settles for Nurses must first recognize their stress and become attuned to someone whose appearance resembles her father’s. . Nursing such responses as feelings of being overwhelmed, fatigue, angry Process: Assessment Client Need: Psychosocial Integrity outbursts, physical illness. and increases in coffee drinking. smoking, or substance abuse. Once attuned to stress and personal Answer: 2 (Objective: 5) Rationale: Regression is resorting to an reactions, it is necessary to identify which situations produce the earlier, more comfortable level of lunctioning that is most pronounced reactions so that steps may be taken to reduce characteristically less demanding and responsible. An example the stress. Suggestions include: © 2016 by Pearson Education, Inc. 356 Answer Key would be an adult who throws a temper tantrum when he does not I Sweat production (diaphoresis) increases to control elevated get his own way. Repression is an unconscious mechanism by body heat due to increased metabolism. which threatening thoughts. feelings, and desires are kept from I Heart rate and cardiac output increase to transport nutrients becoming conscious; the repressed material is denied entry into and by-products ofmctabolism more efficiently. consciousness. An example would be a teenager who. having seen I Skin is pallid because of constriction ofperipheral blood his best friend killed in a car crash, becomes amnesic about the vessels. an effect ofnorepinephrine. circumstances surrounding the accident. Reaction formation is a mechanism that causes people to act exactly opposite to the way Nursing Process: Evaluation Client Need: Psychosocial Integrity they feel. An example would be an executive who resents his bosses for calling in a consulting firm to make recommendations for change in his department, but verbalizes complete support of the idea and is exceedingly polite and cooperative. CHAPTER 43 Rationalization is justification of certain behaviors by faulty logic and ascribing motives that are socially acceptable but did not in fact inspire the behavior. An example would be a mother who spanks her toddler too hard and says it was all right because he Key Term Review 1. r 2. d 3. w 4. u 5. 11 couldn’t feel it through the diaper anyway. Nursing Process: Assessment Client Need: Psychosocial Integrity Answer: 4 (Objective: 9) Rationale: To minimize stress and anxiety 111 the nurse should communicate in short, clear sentences; provide an atmosphere ofwarmth and trust; convey a sense of caring and empa» thy; listen attentively; try to understand the client’s perspective on the situation; and control the environment to minimize additional stress- ors. such as by reducing noise. limiting the number ofindividuals in Key Topic Review Answers the room, and providing care by the same nurse as much as possible. Nursing Process: Planning Client Need: Psychosocial Integrity 1 a Answer: 3 (Objective: 7) Rationale: Common characteristics of 2. b. 3. a 4. a 5. a 6. mortis 7. Algor 8. mortieian/undcrtaker 9. shroud Anticipatory loss is experienced before the loss actually occurs. crises include: I All crises are experienced as sudden. The person is usually not aware of a warning signal, even if others could “see it coming.” The individual or family may feel that they had little or no preparation for the event or trauma. I The crisis is often experienced as ultimately life threatening, whether this perception is realistic or not. I Communication with significant others is often decreased or cut off. I There may be perceived or real displacement from familiar surroundings or loved ones. I All crises have an aspect ofloss, whether actual or perceived. The losses can include an object, a person, a hope, a dream, or any significant factor for that individual. Nursing Process: Planning Client Need: Psychosocial Integrity 10. Answer: 1 (Objective: 3) Rationale: The clinical manifestations 10. Hopelessness 11. c 12. c 13. d 14. c of stress include: I Pupils dilate to increase visual perception when serious threats to the body arise. C 2016 by Pearson Education, Inc. Answer Key 357 influenced by culture, spiritual beliefs, and custom. Loss is an actual or potential situation in which something that is valued is changed or no longer available. Nursing Process: Assessment Client Need: Psychosocial Integrity Answer: 1 (Objective: 9) Rationale: Rigor inortis is the stiffening ofthe body that occurs about 2 to 4 hours after death. It results from a lack of adenosine triphosphate (ATP), which causes the muscles to contract. which in turn immobilizes lhcjoints. Rigor mortis starts in the involuntary muscles (heart, bladder, and so on), then progresses to the head, neck, and trunk, and finally reaches the extremities. All other times are incorrect. Nursing Process: Assessment Client Need: Physiological Integrity Case Study Answers Answer: I (Objective: 2) Rationale: Denial occurs when an Which type afloss is the client experiencing? The Client is individual refuses to believe that loss is happening, or is unready experiencing an actual loss because it can be recognized by to deal with practical problems. such as a prosthesis after loss of others. leg. A client in denial may assume artificial checrfulness to pro- [Q long denial. Anger is when a client or family is hostile toward a Explain grief bereavement, and mourning. Grief is the total staff member about matters that normally would not bother them. response to the emotional experience related to loss. Griefis Bargaining occurs when one seeks to bargain to avoid loss. The manifested in thoughts. feelings, and behaviors associated with bargaining client may express feelings of guilt or fear of punish— overwhelming distress or sorrow. Bereavement is the subjective ment for past sins, real or imagined. Depression occurs when one response experienced by the surviving loved ones after the death gricvcs over what has happened and what cannot be. The dc« ofa person with whom they have shared a significant pressed client may talk freely (e.g.. reviewing past losses such as relationship. Mourning is the behavioral process through which money or job) or may withdraw. Nursing Process: Assessment gricfis eventually resolved or altered; it is often influenced by Client Need: Psychosocial integrity culture. spiritual beliefs, and custom, Grief and mourning are experienced not only by the individual who faces the death ofa Answer: 1 (Objective: 2) Rationale: During the shock and loved one. but also by the individual who suffers other kinds of disbeliefstage. the client refuses to accept loss, has stunned losses. Grieving is essential for good mental and physical health. feelings, and accepts the situation intellectually but denies it It permits the individual to cope with the loss gradually and to emotionally. During the developing awareness stage, reality of accept it as part ofreality. Griefis a social process; it is best loss begins to penetrate consciousness. and anger may be directed shared and carried out with the assistance ofothers. at the agency, nurses, or others. During the restitution stage, the List/bur appropriate questions to ask during the assessment. client conducts rituals ofinourning (cg, funeral). During the stage ofresolving the loss. the client attempts to deal with the I Are you having trouble sleeping? Eating? Concentrating? Breathing? I Do you have any pain or other new physical problems? painful void, is still unable to accept a new love object to replace the lost person or object. may accept a more dependent relationship with a support person, and thinks over and talks about memories of the lost person or object. Nursing Process: I What are you doing to help you deal with this loss? Assessment Client Need: Psychosocial Integrity I Are you taking any drugs or medications to help you cope with this loss? Answer: 2 (Objective: 2) Rationale: Conservanon/withdrawalduring this phase. survivors feel a need to be alone to conserve and replenish both physical and emotional energy. The social Review Question Answers support available to the bereaved has decreased, and they may ex— perience despair and helplessness. The healing phase is the turn- 1. Answer: 2 (Objective: 1) Rationale: Bereavement is the subjective response experienced by the surviving loved ones after the death of a person with whom they have shared a significant relationship. Grief is the total response to the emotional experience related to loss. Grief is manifested in thoughts, feelings. and behaviors associated with overwhelming distress or sorrow. Mourning is the behavioral pro— cess through which grief is eventually resolved or altered; it is often C 2016 by Pearson Education, Inc. ing point. During this phase. the bereaved move from distress about living without their loved one to learning to live more independently. Awareness oflossiduring this phase the friends and family resume normal activities. The bereaved experience the full significance oftlteir loss. Shock—during this phase the survivors are left with feelings of confusion, unreality, and disbelieftliat the loss has occurred. They are often unable to process the normal 358 Answer Key thought sequences. This phase may last from a few minutes to I 12 to 18 years—Fears a lingering death. many days. Nursing Process: Assessment Client Need: Psycho» 6. social Integrity Nursing Process: Assessment Client Need: Psychosocial Integrity Answer: 1 (Objective: 7) Rationale: For an unconscious client Answer: 3 (Objective: 9) Rationale: Nursing personnel may be experiencing airway clearance problems, the nursing student responsible for care ofa body after death. Normally the body is would put the client in a lateral position. For a conscious client placed in a supine position with the arms either at the sides, palms with an airway clearance problem, the nursing student would down, or across the abdomen. Dentures are usually inserted to place him in Fowler’s position. Ifthe client is diaphoretic, the help give the face a natural appearance. The mouth is then closed. nursing student would give the client frequent baths, change the One pillow is placed under the head and shoulders to prevent linen, and regularly change the client‘s position. The nursing stu- blood from discoloring the face by settling in it. The eyelids are closed and held in place for a few seconds so they remain closed. dent would provide skin care to the client in response to inconti- All jewelry is removed, except a wedding band in some instances, nence of urine or feces. Nursing Process: Implementation Client which is taped to the finger. Nursing Process: Implementation Need: Physiological Integrity Client Need: Physiological Integrity 7, Answer: 4 (Objective: 6) Rationale: The dying person’s bill of rights includes: CHAPTER 44 I I have the right not to die alone. l 3. o 2. 0‘ d .U' my approaching death in my own way. 4; Key Term Review (IO I I have the right to express my feelings and emotions about I I have the right to expect continuing medical and nursing attention even though cure goals must be changed to comfort goals. I I have the right to be free from pain. Nursing Process: Planning Client Need: Psychosocial Integrity 8. Answer: 4 (Objective: 6) Rationale: Clinical manifestations of impending clinical death include: I Slower and weaker pulse I Difficulty swallowing and gradual loss ofthe gag reflex I\) I Mottling and cyanosis of the extremities I Rapid, shallow, irregular, or abnormally slow respirations Nursing Process: Implementation Client Need: Physiological Integrity 9. Answer: I (Objective: 4) Rationale: I Infancy to 5 yearsADoes not understand concept of death. Infant’s sense ot‘separation forms basis for later understand— ing ofloss and death, Believes death is reversible, a tempo- Hypertrophy rary departure, or sleep. Emphasizes immobility and inactivity as attributes of death. I 5 to 9 years-—Understands that death is final. Believes own Osteoporosis atrophy death can be avoided. Associates death with aggression or violence, Believes wishes or unrelated actions can be respon» contracture sible for death. I 9 to 12 yearsAUnderstands death as the inevitable end of ankylosed life. Begins to understand own mortality, expressed as inter- est in afterlife or as fear of death. e The ability to move freely, easily, rhythmically, and purposefully in the environment; is an essential part of living © 2016 by Pearson Education, Inc. .H Answer Key 359 Bodily movement produced by skeletal muscle a contraction that increases energy expenditure A type ofphysieal activity defined as a planned, b structured, and repetitive bodily movement performed to improve I Instruct in the availability of assistive ambulatory devices and correct use ofthem. I Discuss pain control measures required before exercise. Preventing Injury or maintain one or more components of physical fitness I Provide assistive devices for moving and transferring, \vhcnev» Exercise in which the muscle shortens to produce 0 muscle contraction and active movement er possible, and teach safe transfer and ambulation techniques. I Discuss safety measures to avoid falls (cg, locking wheelchairs, wearing appropriate footwear. using rubber tips on i Exercise in which there is muscle contraction with» out moving thejoint (muscle length does not change) g__ Involve muscle contraction or tension against resistance; thus, they can be either isotonic or isometric crutches, keeping the environment safe, and using mechani— cal aids such as a raised toilet seat, grab bars. urinal. and bedpan or commode to facilitate toileting). I Teach the use of proper body mechanics, especially for those times when assistive equipment is not used. d Activity during which the amount ol'oxygen taken I Teach ways to prevent postural hypotension. in by the body is greater than that used to perform the activity Managing Energy to Prevent Fatigue f Involves activity in which the muscles cannot draw out enough oxygen from the bloodstream, and anaerobic pathways are used to provide additional energy for a short time I Discuss activity and rest patterns and develop a plan as indicated; intersperse rest periods with activity periods. I Discuss ways to minimize fatigue such as performing activi- i Air circulating into and out ofthe lungs ties more slowly and for shorter periods, resting more often. and using more assistance as required. _ h A condition in which the bones become brittle and fragile due to calcium depletion I Provide information about available resources to help with ADLs and home maintenance management. I Teach ways to increase energy (cg, increasing intake of high~energy foods, ensuring adequate rest and sleep. controlling pain, sharing feelings with a trusted listener). I Teach techniques to monitor activity tolerance as appropriate. Preventing Back Injuries I Understand that the use of body mechanics will not necessarily prevent injury ifmanually handling a load greater than Case Study Answers 51 pounds without the use ot’assistive (lcvrccs. I Avoid lifting anything greater than 51 pounds' use assistive Provide the client and the client 'rflzmily education about the equipment, get help from coworkers, and participate in the following topics: purchasing/ordering process of appropriate assistive equipment for your work setting. Maintaining Museuloskeletal Function I Become consciously aware of your posture and body I Teach the systematic performance of passive or assistive mechanics. ROM exercises to maintainjoint mobility. I When standing for a period ot‘time, periodically move legs and I Demonstrate, as appropriate, the proper way to perform iso— tonic, isometric, or isokinetic exercises to maintain muscle hips, and flex one hip and knee and rest your foot on an object ifpossible. mass and tone (collaborate with the physical therapist about these). Incorporate ADLs into exercise program if appropriate. I Provide a written schedule for the type, frequency. and duration of exercises; encourage the use ofa progress graph or Chart to facilitate adherence with the therapy. I Offer an ambulation schedule. I When sitting, keep your knees slightly higher than your hips. I Use a firm mattress and soft pillow that provide good body supp01t at natural body curvatures. I Exercise regularly to maintain overall physical condition and regulate weight; include exercises that strengthen the pelvic. abdominal. and spinal muscles. © 2016 by Pearson Education, Inc. 360 Answer Key I Avoid movements that cause pain or require spinal flexion with I Never leave a client unattended on a stretcher unless the wheels straight legs (e.g., toe-touching and sit»ups) or spinal rotation are locked and the side rails are raised on both sides and/or the (twisting). safety straps are securely fastened across the client. I When moving an object, spread your feet apart to provide a I Always push a stretcher from the end where the client’s head wide base of support. I is positioned. This position protects the client’s head in the event ofa collision. When lifting an object, distribute the weight between the large muscles of the legs and arms, limiting the load to 15 to I 25 pounds held at elbow height. I Wear comfortable low-heeled shoes that provide good foot Support and reduce the risk of slipping, stumbling, or turning Fasten safety straps across the client on a stretcher, and raise the side rails. Nursing Process: Evaluation Client Need: Safe, Effective Care Environment your ankle. Answer: 1 (Objective: 2) Rationale: Active ROM exercises Review Question Answers guidelines include: I Perform each ROM exercise as taught to the point of slight re— 1. Answer: 4 (Objective: 3) Rationale: The following statements sistance, but not beyond, and never to the point of discomfort. would be correct when providing client teaching about preventing back injuries: I Perform the movements systematically, using the same se— quence during each session. I Exercise regularly to maintain overall physical condition and I Perform each exercise three times. regulate weight; include exercises that strengthen the pelvic, abdominal, and spinal muscles. I When standing for a period of time, periodically move legs and hips, flex one hip and knee and rest your foot on an ob— I Perform each series of exercises twice daily. Nursing Process: Implementation Client Need: Safe, Effective Care Environment ject if possible. Answer: 3 (Objective: 5) Rationale: During client teaching about I When sitting, keep your knees slightly higher than your hips. I Use a firm mattress and soft pillow that provide good body support at natural body curvatures. controlling postural hypotension, the client should verbalize the following: I Use a rocking chair to improve circulation in the lower extremities. Nursing Process: Planning Client Need: Physiological Integrity I Never bend down all the way to the floor or stand up too 2. Answer: 2 (Objective: 7) Rationale: Practice guidelines for quickly after stooping. wheelchair safety include: I Raise the footplates before transferring the client into the wheelchair. I Always lock the brakes on both wheels of the wheelchair when the client transfers in or out of it. I Lower the footplates after the transfer, and place the client’s feet on them. I Ensure the client is positioned well back in the seat ofthe wheelchair. Nursing Process: Evaluation Client Need: Safe, Effective Care Environment I Wear elastic stockings at night to inhibit venous pooling in the legs. I Get out of a hot bath very slowly, because high temperatures can lead to venous pooling. Nursing Process: Planning Client Need: Safe, Effective Care Environment Answer: 4 (Objective: 2) Rationale: Isotonic (dynamic) exercises are those in which the muscle shortens to produce muscle contraction and active movement. Isometric (static or setting) exercises are those in which there is muscle contraction without moving the joint (muscle length does not change). lsokinetic (resistive) exercises 3. Answer: 3 (Objective: 7) Rationale: The following are correct statements that indicate understanding of stretcher safety: involve muscle contraction or tension against resistance; thus, thcy can be either isotonic or isometric. Aerobic exercise is activity dur— ing which the amount of oxygen taken in by the body is greater I Maneuver the stretcher when entering the elevator so that the client’s head goes in first. © 2016 by Pearson Education, Inc. than that used to perform the activity. Nursing Process: lmplcmcn~ tation Client Need: Physiological Integrity Answer Key 361 Answer: I (Objective: 7) Rationale: Positioning a client in good Key Topic Review Answers body alignment and changing the position regularly (every 2 hours) and systematically are essential aspects of nursing practice. Any position, correct or incorrect, can be detrimental if maintained for a prolonged period. For all clients, it is important b. Stage 3 is the deepest stage ofsleep. to assess the skin and provide skin care before and after a position change. Frequent change of position helps to prevent muscle discomfort. undue pressure resulting in pressure ulcers, damage to superficial nerves and blood vessels, and contractures. Nursing Process: Evaluation Client Need: Physiological Integrity b. Answer: 1 (Objective: 4) Rationale: Fowler’s position, or a semisitting position, is a bed position in which the head and trunk Sleep hygiene is a term referring to interventions used to promote sleep. Sleep are raised 45° to 60". In the dorsal recumbent (back—lying) position, the client’s head and shoulders are slightly elevated on a small rhythms pillow. In the prone position, the client lies on the abdomen with the head turned to one side. In the lateral (side-lying) position. the 90 person lies on one side of the body. Flexing the top hip and knee and placing this leg in front of the body creates a wider, triangular base Insomnia of support and achieves greater stability, Nursing Process: Implementation Client Need: Safe, Effective Care Environment Answer: 2 (Objective: 7) Rationale: Always support or hold the Narcolepsy _j_ The study of sleep _i_ The basic organization of normal sleep client rather than the equipment and ensure the client’s safety and dignity. Obtain essential equipment before starting (cg, transfer belt. wheelchair), and check its function. Remove obstacles from the area used for the transfer. Explain the transfer to the nursing personnel who are helping: specify who will give directions (one a person needs to be in charge). Nursing Process: Implementation Client Need: Safe. Effective Care Environment A pattern of symptoms (eg. agitation. anxious. ag- gressive, and sometimes delusional) that occur in the late afternoon (:1 A subjective characteristic. often determined by whether or not a person wakes up feeling energetic or not Answer: 2 (Objective: 7) Rationale: When nurses measure clients g The total time the individual sleeps for axillary crutches, it is most important to obtain the correct length for the crutches and the correct placement of the hand piece. The fib— The most common sleep complaint in America nurse must measure for the crutches and determine the correct placement of the hand bar. The nurse measures the angle of elbow flexion. It should be about 30°. The client lies in a supine position cf Learning to develop positive thoughts and beliefs about steep and the nurse measures from the anterior fold ofthe axilla to the heel h of the foot and adds 2.5 cm (I in.). The client stands erect and Creating a sleep environment that promotes sleep positions the crutch. The nurse makes sure the shoulder rest of the Conditions where the affected individual obtains crutch is at least three fingerwidths, that is, 2.5 to 5 cm (1 to 2 in). below the axilla. The client stands upright and supports the body weight by the hand grips of the crutches. Nursing Process.- sufficient sleep at night but still cannot stay awake during the day e A disorder of excessive daytime sleepiness caused Implementation Client Need: Safe, Effective Care Environment by the tack ofthe chemical hypocretin in the area ofthe central nervous system that regulates sleep CHAPTER 45 C) Key Term Review 2016 by Pearson Education, Inc. Case Study Answers .— 362 Answer Key Ci Explain the ill/bl‘lllfllloll that Should be included in a Sleep diam: A sleep diary may include all or selected aspects of the following la. Etplain the two types afsleep. The two types of sleep are NREM information that pertain to the client’s specific problem: (nonerapid-eyc—movcment) sleep and REM (rapid-cye—movement) sleep. During sleep, NREM and REM sleep alternate in cycles. I Time of(a) going to bed, (b) trying to fall asleep. (c) falling asleep (approximate time), (d) any instances of waking up NREM sleep occurs when activity in the RAS is inhibited. About 75% to 80% ofsleep during a night is NREM sleep. NREM sleep is and duration of these periods, (e) waking up in the morning, divided into four stages, each associated with distinct brain activity and (1) time and duration ofany naps and physiology. Stage 1 is the stage of very light sleep and lasts only a I Activities performed 2 to 3 hours before going to bed (type. few minutes. During this stage, the individual fecls drowsy and re- duration. and time) laxed, the eyes roll from side to side, and the heart and respiratory rates drop slightly. The individual can be readily awakened and may I Consumption of caffeinated beverages and alcohol and amounts of those beverages deny that he or she was sleeping. Stage 2 is the stage of light sleep during which body processes continue to slow dovm. The eyes are generally still, the heart and respiratory rates decrease slightly, and body temperature falls. Stage 2 lasts only about 10 to 15 minutes but I Any prescribed and over-the-counter medications, and herbal remedies, taken during the day I Bedtime rituals before bed constitutes 44% to 55% oftotal sleep. An individual in stage 2 re— quires more intense stimuli than in stage 1 to awaken. Stages 3 and 4 are the deepest stages of sleep, differing only in the percentage ofdelta waves recorded during a 30—seccnd period. During deep sleep or I Any difficulties remaining awake during the day and times when difficulties occurred I Any worries that the client believes may affect sleep delta sleep, the individual’s heart and respiratory rates drop 20% to 30% below those exhibited during waking hours. The sleeper is difficult to arouse. The individual is not disturbed by sensory stimuli, the I Factors that the client believes have a positive or negative ef» fect on sleep skeletal muscles are very relaxed, reflexes are diminished. and snoring is most likely to occur. Even swallowing and saliva production are reduced during delta sleep. These stages are essential for restoring ener- Review Question Answers gy and releasing important growth hormones. REM sleep usually rccurs about every 90 minutes and lasts 5 to 30 minutes. Most dreams take place during REM sleep, but usually will not be remembered un— less thc individual arouses briefly at the end of the RPM period. During REM sleep, the brain is highly active, and brain metabolism may increase as much as 20%. For example. during REM sleep, levels of acetylcholine and dopamine increase, with the highest levels of ace— tylcholine release occurring during REM sleep. Since both ofthese neurotransmitters are associated with cortical activation, it makes sense that these neurotransmitter levels would be high during dream- ing sleep. This type of sleep is also called paradoxical sleep because EEG activity resembles that of wakefulness. Distinctive eye move- ments occur. voluntary muscle tone is dramatically decreased, and deep tendon reflexes are absent. In this phase, the individual may be difficult to arouse or may wake spontaneously, gastric secretions in» crease, and heart and respiratory rates often are irregular. It is thought that the regions of the brain that are used in learning, thinking, and organizing information are stimulated during REM sleep. Answer: 2 (Objective: 7) Rationale: Clients may be asked to keep a sleep diary or log for 1 to 2 weeks in order to get a more corn— plete picture of their sleep complaints. A sleep diary may include all or selected aspects ofthe following information that pertain to the client’s specific problem: consumption of caffeinatcd bevcr— ages and alcohol and amounts ofthese beverages; activities per— formed 2 to 3 hours before going to bed (type, duration, and time); bedtime rituals before bed; any prescribed and over-thecounter medications, and herbal remedies taken during the day. Nursing Process: Planning Client Need: Physiological Integrity Answer: 4 (Objective: 7) Rationale: “When I’m in pain, I will take the prescribed analgesics 30 minutes before I go to sleep” would have been a correct statement. The following statements by the client would be correct: “I should wear loose»f1tting night— wear.” "I will void before bedtimc.” “I will perform hygienic routines prior to bedtime." Nursing Process: Evaluation Client Need: Physiological Integrity Describefaclom that affect sleep. Both the quality and the quantity ofslccp are affected by a number of factors. Sleep quality is a sub— jective characteristic and is often determined by whether or not an individual wakes up feeling energetic or not. Quantity ol‘sleep is the total time the individual sleeps. Illness. emironment, lifestyle, emotional stress, stimulants and alcohol, diet, smoking, motivation, and medications are some ofthe factors that affect sleep. Answer: 3 (Objective: 8) Rationale: Sleep medications affect REM slccp more than NREM sleep. The following statements are correct: Antianxiety medications decrease levels ofarousal by facilitating the action of neurons in the CNS that suppress responsiveness to stimulation. Sleep medications vary in their onset and duration of action and will impair waking function as long as they are chemically active. Initial doses ofmedications should be low and increases added gradually, depending on the ’6 2016 by Pearson Education, Inc. Answer Key 363 client’s response. Nursing Process: Evaluation Client Need: avoid excessive physical exertion at least 3 hours before bedtime; Physiological Integrity establish a regular bedtime routine before sleep such as reading. Answer: 1 (Objective: 5) Rationale: Hypersomnia refers to a Nursing Process: Planning Client Need: Physiological Integrity listening to relaxing music. and taking a warm bath or shower, 4. condition in which the affected individual obtains sufficient sleep at night but still cannot stay awake during the day. Narcolepsy is 9. t1. a disorder of excessive daytime sleepiness caused by the lack of Answer: I (Objective: 8) Rationale: Interventions to promote sleep can include the following: Create a sleep-conducive environment the chemical hypocretin in the area ofthe central nervous system that is dark. quiet, comfortable, and cool. Give analgesics before that regulates sleep. Sleep apnea is characterized by frequent short bedtime to relieve aches and pains. If a bedtime snack is necessary, breathing pauses during sleep. A parasomnia is behavior that may give only low»carbohydrate snack or a milk drink, Avoid giving the interfere with sleep and/or occurs during sleep, Nursing Process: client heavy meals 2 to 3 hours before bedtime. Nursing Process.- Assessment Client Need: Physiological Integrity Planning Client Need: Physiological Integrity Answer: 2 (Objective: 2) Rationale: NREM sleep is divided into 10. Answer: 4 (Objective: 1) Rationale: Night terrors are partial four stages, each associated with distinct brain activity and awakenings from non—REM stage 3 or 4 sleep, They are usually physiology. Stage 2 lasts only about 10 to 15 minutes but seen in children 3 to 6 years of age. The child may sieepwalk. or constitutes 44% to 55% of total sleep. An individual in stage 2 may sit up in bed screaming and thrashing about. Children requires more intense stimuli than in stage I to awaken. Stage 1 is experiencing night terrors usually cannot be wakened, but should the stage ofvery light sleep and lasts only a few initiates. Stage 2 be protected from injury, helped back to bed, and soothed back to is the stage of light sleep during which body processes continue to sleep. Baby-sitters should be alerted to the possibility ofa night slow down. The eyes are generally still, the heart and respiratory terror occurring. Children do not remember the incident the next rates decrease slightly, and body temperature falls. Stages 3 and 4 day, and there is no indication ofa neurologic or emotional are the deepest stages of sleep, differing only in the percentage of problem. Excessive fatigue and a full bladder may contribute to the delta waves recorded during a 30-second period. During deep problem. Having the child take an afternoon nap and empty the sleep or delta sleep, the individual’s heart and respiratory rates bladder before going to sleep at night may be helpful. Nursing drop 20% to 3( "0 below those exhibited during waking hours. Process: Evaluation Client Need: Physiological Integrity The individual is difficult to arouse. Nursing Process: Assessment Client Need: Physiological Integrity CHAPTER 46 6. Answer: 3 (Objective: 2) Rationale: Physiological changes during NREIVI sleep include: Key Term Review I Peripheral blood vessels dilate. I Arterial blood pressure falls. I Pulse rate decreases. I Cardiac output decreases. Nursing Process: Evaluation Client Need: Physiological Integrity 7. Answer: 4 (Objective: 8) Rationale: To reduce environmental distractions in hospitals the following should be practiced: Perform 25. y only essential noisy activities during sleeping hours; lower the ring tone ofnearby telephones; discontinue use of the paging system after a certain hour (e.g., 2100 hours} or reduce its volume; keep re- Key Topic Review Answers quired staff conversations at low levels; conduct nursing reports or Sympathetieally maintained pain occurs occasionally when other discussions in a separate area away from client rooms. Nurs- abnormal connections between pain fibers and the ing Process: Assessment Client Need: Physiological Integrity sympathetic nervous system perpetuate problems with both 8. the pain and sympathetically controlled functions (e.g.. Answer: 1 (Objective: 8) Rationale: The following are sugges— edema, temperature, and blood flow regulation), tions to promote sleep: Establish a regular bedtime and wake-up performing office work or discussing family problems before bedtime; get adequate exercise during the day to reduce stress, but Q 2016 by Pearson Education, Inc. 9’ to time for all days ofthe week to enhance biological rhythm; avoid Pain threshold is the least amount ol‘stimulus that is needed for an individual to label a sensation as pain. 364 Answer Key Case Study Answers la. As t/iefifr/z vital sign, pom should be screenedfor every time vital signs are evaluated. Define pain. Pain is an unpleasant and highly 5. b. Pain tolerance is the maxinium amount of painful stimuli that personal experience that may be imperceptible to others, while a person is willing to withstand without seeking avoidance of consuming all parts of the person’s life. The widely agreed-on the pain or relief. definition of pain is “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or 6. described in terms of such damage.” Three parts of this definition analgesic have important implications for nurses. First, pain is a physical and 7. ceiling emotional experience, not all in the body or all in the mind. 8. Equianalgesia there may not be abnormal lab or radiographic reports, despite real Placebo component is aligned with McCaffery’s often-quoted definition of Transdermal whenever he says it does.” Given that some clients are reluctant to Second, it is in response to actual or potential tissue damage, so pain. Finally, pain is described in terms of such damage. This final 9. pain: “Pain is whatever the experiencing person says it is, existing 10. disclose the presence of pain unless prompted, nurses will not 11. _f_‘ Appear to arise in different areas know of the client‘s pain until they assess for it. Additionally, it is clear that even nonverbal clients (e.g., preverbal children, intubated _h_ Pain arising from organs or hollow viscera clients, the cognitively impaired) experience pain that demands nursing assessment and treatment even if clients are unable to _'i__ When pain lasts only through the expected recovery “describe in terms” the nature of their discomfort. period Identifi' the two major components ofa pain assessment. Pain as_a__ Prolonged, usually recurring or persisting over 6 months or longer, and interferes with functioning sessments consist oftwo major components: (1) a pain history to obtain facts from the client and (2) direct observation ofbehaviors, physical signs oftissue damage, and secondary physiological Pain in the 173 range ofa 0-10 scale b #c_fifi Experienced when an intact, properly functioning nervous system sends signals that tissues are damaged, requiring attention and proper care V responses ofthe client. Explain the pain intensity scale. The use ofpain intensity scales is an easy and reliable method of determining the client's pain intensity. Such scales provide consistency for nurses to communicate with the client and other health care providers. To g Originates in the skin, muscles, bone, or connective avoid confusion, pain scales should use a 0 to 10 range with 0 indicating “no pain“ and the highest number indicating the "worst tissue pain possible” for that individual. e Experienced by people who have damaged or malfunctioning nerves Ad_ Follow damage and/or sensitization of peripheral [ICI'VCS i Review Question Answers Answer: 3 (Objective: 1) Rationale: Severe pain is viewed as an emergency situation deserving attention and prompt professional Pain in the 4. 6 range ofa 0-10 scale treatment. Pain is tnore than a symptom ofa problem; it is a highpriority problem in itself. Pain presents both physiological and 12. d 13. c 14. b 15. d psychological dangers to health and recovery. Nursing Process: Assessment Client Need: Physiological Integrity Answer: 2 (Objective: 1) Rationale: When pain lasts only through the expected recovery period, it is described as acute pain, whether it has a sudden or slow onset and regardless of the intensity, Chron— ic pain, on the other hand, is prolonged, usually recurring or persisting over 6 months or longer, and interferes with functioning. Pain may be referred (appear to arise in different areas) to other parts of the body. Visceral pain (pain arising from organs or hollow © 2016 by Pearson Education, Inc. J Answer Key 365 viscera) often presents this way, being perceived in an area remote 6. Answer: 4 (Objective: 5) Rationale: That the amount oftissue from the organ causing the pain. Nursing Process: Assessment damage is directly related to the amount of pain is a Client Need: Physiological Integrity misconception about pain. The following are correct statements about pain: The individual who experiences the pain is the only Answer: 2 (Objective: 1) Rationale: Pain tolerance is the maxi— authority about its existence and nature. Pain is a subjective mum amount of painful stimuli that an individual is willing to experience, and the intensity and duration of pain vary withstand without seeking avoidance of the pain or relief. Pain considerably among individuals. Even with severe pain, periods threshold is the least amount of stimuli that is needed for a person of physiological and behavioral adaptation can occur. Nursing to feel a sensation he or she labels as pain. Dysesthesia is an un- Process: Assessment Client Need: Physiological Integrity pleasant abnormal sensation Allodynia is the condition in which nonpainful stimuli (e.g., contact with linen, water, or wind) pro- 7. Answer: 4 (Objective: IO) Rationale: Giving a dose of nonopioid duce pain. Nursing Process: Assessment Client Need: Physiolog- at the same time as a dose ofopioid poses no more danger than ical Integrity giving the doses at different times. In fact, many opioids are compounded with a nonopioid (e.g., Percocet [oxycodone and aceta— Answer: 1 (Objective: 1) Rationale: Linking the rating to health and fianctioning scores, pain in the l to 3 range is deemed mild pain, a rating of 4 to 6 is moderate pain, and pain reaching 7 to 10 is ranked severe pain and is associated with the worst outcomes. Uh Nursing Process: Assessment Client Need: Physiological Integrity Answer: 3 (Objective: 1) Rationale: minophen]). It is safe to administer a nonopioid and opioid at the same time. The following statements are true about nonopioids: Nonopioids alone are rarely sufficient to relieve severe pain, but they are an important part in the total analgesic plan. Side effects from long—term use of NSAIDs are considerably more severe and life threatening than the side effects from daily doses of oral mor— phine or other opioids. Nursing Process: Assessment Client Acute Pain Need: Physiological Integrity Mild to severe Answer: 4 (Objective: 7) Rationale: The COLDERR mnemonic Sympathetic nervous system responses: I Increased pulse rate for pain assessment is defined as follows: Character: Describe the sensation (cg, sharp, aching. burning) Onset: When it started, how it has changed I Increased respiratory rate I Elevated blood pressure I Diaphoresis I Dilated pupils Related to tissue injury; resolves with healing Location: Where it hurts (all locations) Duration: Constant versus intermittent in nature Exacerbation: Factors that make it worse Relief: Factors that make it better (medications and other factors) Client appears restless and anxious Radiation: Client reports pain Client exhibits behavior indicative of pain: crying, rubbing area, Pattern of shooting/ spreading/location of pain away from its origin Nursing Process: Planning Client Need: Physiological Integrity holding area Chronic Pain Answer: 3 (Objective: 3) Rationale: The Puerto Rican culture tends to be loud and outspoken in their expressions of pain. Do Mild to severe Parasympathetic nervous system responses: not judge or disapprove. This is a socially learned way to cope with the pain. The Asian American culture values silence, Some clients may be quiet when in pain. Becoming verbally loud may I Vital signs normal I Dry, warm skin be viewed as causing dishonor to themselves and their family. The African American culture believes pain and suffering is a part ot‘life and is to be endured. The Mexican American culture I Pupils normal or dilated Continues beyond healing Client appears depressed and withdrawn believes that enduring pain is a sign ofstrength. Native Americans are quiet, less expressive verbally and nonverbally, and may tolerate a high level ol‘pain. Nursing Process: Assessment Client Need: Psychosocial Integrity Client often does not mention pain unless asked Pain behavior often absent Answer: 4 (Objective: 8) Rationale: Maintain an unbiased attitude (open mind) about what may relieve the pain. New ways Nursing Process: Assessment Client Need: Physiological Integrity © 2016 by Pearson Education, Inc. to relieve pain are continually being developed. It is not always 366 Answer Key possible to explain the effectiveness of particular pain relief 1 1. measures; however, the use of approaches the patient believes c Organic molecules made up primarily ofcarbon, hydrogen, oxygen, and nitrogen, which combine to form proteins will work should be considered. Provide measures to relieve pain before it becomes severe. Consider the client's ability and ' Those that cannot be manufactured in the body and must be supplied as part of the protein ingested in the diet willingness to participate actively in pain relief measures. Clients who are excessively fatigued, sedated, or have altered levels of consciousness are less able to participate actively. Establish a f Those that the body can manufacture a Contain all of the essential amino acids plus many trusting relationship. Convey your concern, and acknowledge that you believe that the client is experiencing pain. A trusting relationship promotes expression 0fthe client’s thoughts and nonessential ones feelings and enhances effectiveness of planned pain therapies Lack one or more essential amino acids (most _b Nursing Process: Assessment Client Need: Physiological integrity commonly lysine, methionine, or tryptophan) and are usually de— rived from vegetables CHAPTER 47 i Organic substances that are greasy and insoluble in water but soluble in alcohol or ether Key Term Review g Lipids that are solid at room temperature d Lipids that are liquid at room temperature h Made up of carbon chains and hydrogen; are the basic structural units ofmost lipids 19. 7 '5‘ I 20. n 21. s 22. u 23. w 24. q e 12. 0 Key Topic Revrew Answers 1‘ l a 14. 2 a 15 3 '1 16. 4. b Sugars, the simplest of all carbohydrates, are water soluble and are produced naturally by both plants and animals. Case Study Answers la. 5 b. Fatty acids with one double bond Of the three monosaccharides (glucose, fructose, and Explain the combinations ofplant proteins that provide complete proteins. The combinations of plant proteins that provide complete galactose), glucose is by far the most abundant simple sugar. proteins are grains plus legumes; legumes plus nuts or seeds; and grains, legumes, nuts or seeds plus milk or milk products. 6. Nutrition 7. Nutrients 8. Starchcs lb. Identify ways this client can improve his or her appetite. I Provide familiar food that the individual likes. Often the relatives ofclients are pleased to bring food from home but may need some guidance about special diet requirements. 9. 10. Fiber Enzymes I Select small portions so as not to discourage the client. I Avoid unpleasant or uncomfortable treatments immediately before or after a meal. © 2016 by Pearson Education, Inc. Answer Key 367 I Provide a tidy, clean environment that is free of unpleasant Answer: 2 (Objective: 2) Rationale: In common use, the terms sights and odors. A soiled dressing, a used bcdpan, an un- fats and lipids are used interchangeably. Lipids are organic sub— covered irrigation set, or even used dishes can negatively at"— stances that are greasy and insoluble in water but soluble in alco- fect the appetite. hol or ether. Fats are lipids that are solid at room temperature. I Encourage or provide oral hygiene before mealtime. This improves the client’s ability to taste. I Relieve illness symptoms that depress appetite before Oils are lipids that are liquid at room temperature. Nursing Process: Assessment Client Need: Physiological Integrity Answer.- 1 (Objective: 4) Rationale: mealtime; for example, give an analgesic for pain or an anti- pyrctic for a fever or allow rest for fatigue. To calculate the BMI use the following formula: I Reduce psychological stress. A lack of understanding of Weight in kilograms BMI = any, 7 ,7 A“. , therapy. the anticipation of an operation, and fear ofthe (Height in meters)2 unknown can cause anorexia. Often, the nurse can help by discussing feelings with the client, giving information and assistance, and allaying fears. Ic, or Discuss possible variations in nutritional practices and preferences among this client 's culture. 70 kilograms fi—ZMII l.5> Which of the following is an example of an expected outcome statement in measurable terms?The nurse writes an expected-outcome statement in measurable terms. An example is: A. Patient will be pain free.
Which type of planning will be least useful during the first shift on the orthopedic unit?Which type of planning will be least useful during the first shift on the orthopedic unit? Answer#4 because strategic planning is an ongoing process focused on organizational change rather than individual patients so it is least useful and not relevant in this case.
Which of the following is the primary purpose of the evaluating phase of the care planning process?The purpose of evaluation is to determine the effectiveness of nursing care. The other options are not true statements. During evaluation, you do not simply determine whether nursing interventions were completed.
What does the nurse perform first in initiating the implementation phase of the nursing process?When initiating the implementation phase of the nursing process, the nurse performs which of the following phases first? Rationale: The first step of implementing is reassessing the client to determine that the activity is still indicated and safe.
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“client will ambulate 20 yards without assistance in 8 weeks” is an example of a:
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