Solutions - Chapter U10 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

1Q. Develop an expected outcome for this client related to chapters in this unit including activity and exercise, pain management, fecal elimination, and circulation.
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2Q. What risks can you identify for this client related to activity and exercise, sleep, nutrition, and oxygenation?
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3Q. When planning care with Agnes related to activity and exercise, pain management, nutrition, fecal elimination, oxygenation, and circulation, establish the priorities of care.
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4Q. Of activity and exercise, sleep, pain management, nutrition, urinary elimination, fecal elimination, oxygenation, circulation, and fluid, electrolyte, and acid–base balance, which one carries the greatest risk to Agnes’s independence and quality of life?
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5Q. What actions can the nurse take to promote and maximize Agnes’s independence?
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Solutions - Chapter U9 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

1Q. How might you respond to Christina? What have you learned about stress, loss and grieving, spirituality, and other similar concepts in this unit that can assist you in providing a helpful response?
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2Q. What response might you make that exemplifies the two competencies above and your learning from this unit?
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3Q. Considering the standard, what categories of possible interventions might you consider for a nursing diagnosis and goal focused on Christina’s need for a healing environment?
Another competency in the Environmental Health standard states that the nurse demonstrates commitment to continuous, lifelong learning and education for self and others.
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4Q. During your care of Christina, you realize that you are insufficiently knowledgeable about breast cancer treatment effects. You wonder about the sensation in the breast after radiation therapy (for both Christina and her husband) and the support systems that would be in place for the many breast cancer survivors who might be worrying about a recurrence. Describe the various ways you might investigate answers to these questions by interacting with your colleagues.
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Solutions - Chapter U8 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

1Q. To assist Fairuz in meeting her hygiene needs, what questions will you want to ask in order to collect appropriate data for planning her care?
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2Q. What important assessment data related to her risk for infection will be required to serve as baseline data for comparison purposes throughout her admission?
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3Q. What are the nurse’s priority assessments during the immediate postoperative period when Fairuz first returns to the unit after open reduction of her left leg fracture?
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5Q. How do treatments, including medications, typically used with clients who have fractures influence your choice of diagnoses?
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Solutions - Chapter U7 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

1Q. How does this situation relate to Standard #10? Do you see opportunities to improve the quality of practice? Beyond the care of this individual client, what might you do to ensure that the nurses on this unit meet the competencies of the standard?
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2Q. Imagine that when you assess the peripheral pulses of the client with a suspected thrombus, you have difficulty feeling the dorsalis pedis or posterior tibial pulses on either leg. Considering the standard, what actions would be consistent with professional practice evaluation? Would your actions differ if this was the first time you had such difficulty or if you frequently find you are unable to palpate pedal pulses?
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3Q. The assistant measures vital signs at 1600 and reports to you immediately that the client receiving chemotherapy has an oral temperature of 40°C (104°F). Describe your thinking in interpreting this data. What would be your response/next steps? List at least four things you would do and explain why they are necessary and appropriate.
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4Q. In retrospect, do you think you should not have delegated measuring the vital signs on this client to the assistant? Why or why not?
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Solutions - Chapter U6 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

1Q. Using Roach’s six C’s of caring discussed in Chapter 25, how would you demonstrate caring to Michael and his wife?
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2Q. Using the nonverbal communication methods discussed in Chapter 26, how can the nurse communicate caring to this family?
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3Q. The hospice nurse sees that Michael’s death is imminent within the next few hours or days and wants to teach his wife about what to expect. Based on what you learned in Chapter 27, what factors would the nurse interpret as indicating his wife’s readiness to learn?
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4Q. The hospice nurse arranges for 24-hour care during Michael’s final days. Using the decision tree on pages 469–470, what types of care will the nurse delegate to the unlicensed assistive personnel (UAP)? What care will only the registered nurse perform?
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5Q. What instructions will the nurse provide the UAP related to things to report immediately if they occur?
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6Q. On the next visit to the family, the nurse reviews the UAP’s care of the client and notes that the client is not being repositioned and is developing signs of a pressure ulcer. What should the nurse do?
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Solutions - Chapter U5 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

1Q. What health promotion teaching would you provide this family?
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2Q. What recommendations would you make to each family member to promote health based on each member’s current developmental level?
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3Q. How will Carmelita’s condition impact her own development and health promotion needs?
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Solutions - Chapter U4 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

1Q. What are some outcomes for Manuela that would reflect this focus?
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2Q. Do you need to know her personal definitions of health and health beliefs (Chapter 17) before you can work with her to set expected outcomes?
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3Q. What are some aspects of Manuela’s situation that you would consider incorporating into a teaching plan to maximize a safe environment for her?
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4Q. Which health care team members other than physicians and nurses would likely be important to include in Manuela’s care plan?
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5Q. What evidence might you have or seek to support the use of alternative or complementary treatment modalities in Manuela’s care?
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Solutions - Chapter U3- Kozier Erb's Fundamentals Nursing - 10 Ed

 

1Q. As discussed in Chapter 11, the standard states that the nurse “collects comprehensive data including but not limited to physical, functional, psychosocial, emotional, cognitive sexual, cultural, age-related, environmental, spiritual/transpersonal, and economic assessments in a systematic and ongoing process while honoring the uniqueness of the person” (ANA, 2010, p. 32). How would you determine the best way to conduct Benjamin’s assessment that will provide the most useful findings?
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2Q. Describe the thinking process you would use to seek validation that this diagnosis is appropriate. What data would you use? What questions would you ask, and of whom?
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3Q. How might you individualize and add to the care plan to address the psychosocial needs identified for Benjamin that are related to his family and employment?
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4Q. If you were caring for Benjamin on the evening of the day he had surgery, describe at least three different places in the medical record where you would document his care and what you might record there.
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Solutions - Chapter U2- Kozier Erb's Fundamentals Nursing - 10 Ed

 

1Q. What would be the advantages and disadvantages of using technology for the purposes Rhett suggested? Include both general considerations and those unique to this client.
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2Q. In coordinating care to meet the competency, the nurse must consider if the client requires primary, secondary, or tertiary prevention as described in Chapter 6. How would you describe Rhett’s needs? Is an HMO an effective insurance plan based on his history and current health status?
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3Q. Chapter 7 discusses community-based health resources. What are some categories of community resources that may be appropriate for Rhett?
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4Q. Chapter 8 describes home health. If Rhett requests that a nurse come to his home to check his blood pressure, how might you respond?
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5Q. Rhett’s knowledge and skill in technology may be greater than your own. How might you answer his question about online submission of blood pressure information?
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6Q. The clinic has a policy that requires all reports of client data to be submitted in hard copy with an original signature. Does this policy meet the expected competency? If not, what action would you take next?
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Solutions - Chapter U1- Kozier Erb's Fundamentals Nursing - 10 Ed

 

1Q. Megan’s mother asks the nurse to call Megan’s doctor so she can speak with him and asks what the x-ray and diagnostic studies have indicated about her daughter’s condition. What information can the nurse legally share with Megan’s mother about Megan’s condition?
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2Q. Megan’s doctor explains to Megan and her parents that her condition has worsened, and recommends intubation and placement on a mechanical ventilator. Megan says “No, I do not want to be placed on a ventilator,” but her mother urges compliance with the recommended treatment. Megan’s mother turns to the nurse and says, “Tell her she must agree to follow the doctor’s recommendations!” What is the nurse’s best response?
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3Q. The doctor suggests Megan be included in a research study for people with cystic fibrosis who want to avoid mechanical ventilation. What are the nurse’s responsibilities in protecting Megan’s rights based on your reading in Chapter 2?
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4Q. What is the nurse’s responsibility when caring for Megan once she is enrolled in the research study?
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5Q. If the nurse questions the currency of an assessment technique found in the hospital’s policy and procedure manual, what steps can the nurse take to ensure that evidence-based practice is used?
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Solutions - Chapter 52 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. The nurse would assess for signs of hypomagnesemia in which of the following clients? Select all that apply.
1.  A client with renal failure
2.  A client with pancreatitis
3.  A client taking magnesium-containing antacids
4.  A client with excessive nasogastric drainage
5.  A client with chronic alcoholism
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1ACT. Offer suggestions for ways to help Mrs. Chapman increase her oral intake.
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1TYK. An older nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect which assessment finding?
1.  Increased blood pressure
2.  Weak, rapid pulse
3.  Moist mucous membranes
4.  Jugular vein distention
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2ACT. Mrs. Chapman asks why you weigh her every morning. How do you respond?
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2TYK. A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past 2 days. She appears lethargic and is complaining of leg cramps. What should the nurse do first?
1.  Start an IV.
2.  Review the results of serum electrolytes.
3.  Offer the woman foods that are high in sodium and potassium content.
4.  Administer an antiemetic.
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3TYK. The nurse administers an IV solution of D5 1/2NS to a postoperative client. This is classified as what type of intravenous solution? __________
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4TYK. An older client comes to the emergency department experiencing chest pain and shortness of breath. An arterial blood gas is ordered. Which of the following ABG results indicates respiratory acidosis?
1.  pH 7.54; PaCO2 28 mmHg; HCO3 22 mEq/L
2.  pH 7.32; PaCO2 46 mmHg; HCO3 24 mEq/L
3.  pH 7.31; PaCO2 35 mmHg; HCO3 20 mEq/L
4.  pH 7.50; PaCO2 37 mmHg; HCO3 28 mEq/L
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5TYK. The intake and output (l&O) record of a client with a nasogastric tube who has been attached to suction for 2 days shows greater output than input. Which nursing diagnoses are most applicable? Select all that apply.
1.  Deficient Fluid Volume
2.  Risk for Deficient Fluid Volume
3.  Impaired Oral Mucous Membranes
4.  Impaired Gas Exchange
5.  Decreased Cardiac Output
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6TYK. Which client statement indicates a need for further teaching regarding treatment for hypokalemia?
1.  “I will use avocado in my salads.”
2.  “I will be sure to check my heart rate before I take my digoxin.”
3.  “I will take my potassium in the morning after eating breakfast.”
4.  “I will stop using my salt substitute.”
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7TYK. An older man is admitted to the medical unit with a diagnosis of dehydration. Which sign or symptom is most representative of a sodium imbalance?
1.  Hyperreflexia
2.  Mental confusion
3.  Irregular pulse
4.  Muscle weakness
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8TYK. The client’s arterial blood gas results are pH 7.32; PaCO2 58; HCO3 32. The nurse knows that the client is experiencing which acid-base imbalance?
1.  Metabolic acidosis
2.  Respiratory acidosis
3.  Metabolic alkalosis
4.  Respiratory alkalosis
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9TYK. A client is admitted to the hospital for hypocalcemia. Nursing interventions relating to which system would have the highest priority?
1.  Renai
2.  Cardiac
3.  Gastrointestinal
4.  Neuromuscular
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Solutions - Chapter 51 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. A client with severe mitral stenosis is having surgery tomorrow. While teaching the client, the nurse shows the client a diagram of the heart. Identify with an “X” which valve the client will have replaced.
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1CTC. What are the circulatory causes of her leg pain? Which risk factors would you expect to find in her history to support this conclusion?
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1Q.
From Medical Language, 3rd ed., by S. M.Turley, © 2014. Reproduced with permission ot Pearson Education, Inc. Upper Saddle River, New Jersey.
Preload is affected by the amount of blood returning to the heart from the venous circulation. Review the figure.
Which side of the heart is primarily affected by preload?
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1TYK. The home health nurse has developed a teaching guide for a client with cardiovascular risk factors that focuses on the importance of regular physical activity with gradually increasing activity levels. This teaching guide specifically promotes which topic?
1.  Cardiac output and tissue perfusion
2.  Renal perfusion and formation of urine
3.  Oxygen-carrying capacity of white blood cells
4.  Effective breathing and airway clearance
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2CTC. Name two nursing diagnoses appropriate for Mrs. Papadopolis. Which would have the highest priority and why?
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2Q.
From Medical Language, 3rd ed., by S. M.Turley, © 2014. Reproduced with permission ot Pearson Education, Inc. Upper Saddle River, New Jersey.
Preload is affected by the amount of blood returning to the heart from the venous circulation. Review the figure.
What could cause an increase of venous blood return to the heart?
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2TYK. The client’s electrocardiogram (ECG) monitor reflects normal electrical activity through the heart’s conduction system.
The nurse knows that the electrical impulse travels in which sequence?
1.  Atrioventricular node
2.  Bundle branches
3.  Sinoatrial node
4.  Bundle of His
5.  Purkinje fibers
Place the numbers in the correct sequence: ______________
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3CTC. The primary care provider suggests that Mrs. Papadopolis cease her visits to the cemetery since she has to walk a long way there to reach the grave site. Would you agree with this plan? Why or why not? What considerations or viewpoints influence your choice?
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3Q.
From Medical Language, 3rd ed., by S. M.Turley, © 2014. Reproduced with permission ot Pearson Education, Inc. Upper Saddle River, New Jersey.
Preload is affected by the amount of blood returning to the heart from the venous circulation. Review the figure.
When would an increase in preload have a positive effect/ outcome for the client?
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3TYK. Which would most likely be included in the evaluation of the client goal of “Demonstrate adequate tissue perfusion”?
1.  Symmetrical chest expansion
2.  Use of pursed-lip breathing
3.  Brisk capillary refill
4.  Activity intolerance
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4CTC. Mrs. Papadopolis says that she wears support stockings because her friend told her they help the circulation in her legs. How would you respond to this information?
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4Q.
From Medical Language, 3rd ed., by S. M.Turley, © 2014. Reproduced with permission ot Pearson Education, Inc. Upper Saddle River, New Jersey.
Preload is affected by the amount of blood returning to the heart from the venous circulation. Review the figure.
When does an increase in preload have a negative effect/ outcome for the client?
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4TYK. A client is admitted with acute crushing chest pain that radiates down his left arm. The nurse expects which blood tests to be ordered for this client? Select all that apply.
1.  Blood urea nitrogen (BUN)
2.  Hemoglobin and hematocrit
3.  Creatine kinase (CK)
4.  Homocysteine level
5.  Troponin
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5TYK. A client is admitted with acute crushing chest pain that radiates down his left arm. The nurse expects which blood tests to be ordered for this client? Select all that apply.
1.  Blood urea nitrogen (BUN)
2.  Hemoglobin and hematocrit
3.  Creatine kinase (CK)
4.  Homocysteine level
5.  Troponin
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6Q.
From Medical Language, 3rd ed., by S. M.Turley, © 2014. Reproduced with permission ot Pearson Education, Inc. Upper Saddle River, New Jersey.
Afterload is the resistance against which the heart must pump. Review the figure.Which side of the heart is primarily affected by aftcrload?
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7Q.
From Medical Language, 3rd ed., by S. M.Turley, © 2014. Reproduced with permission ot Pearson Education, Inc. Upper Saddle River, New Jersey.
Afterload is the resistance against which the heart must pump. Review the figure.What can cause an increase in afterload (e.g., what can cauic the left side of the heart to work harder}?
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7TYK. Which set of assessment data best validates that the nurse should initiate cardiopulmonary resuscitation on a comatose client?
1.  Cool, pale skin; unconsciousness; absence of radial pulse
2.  Cyanosis, slow pulse, dilated pupils
3.  Absent pulses, flushed skin, pinpoint pupils
4.  Apnea, absence of carotid or femoral pulses, dilated pupils
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8Q.
From Medical Language, 3rd ed., by S. M.Turley, © 2014. Reproduced with permission ot Pearson Education, Inc. Upper Saddle River, New Jersey.
Afterload is the resistance against which the heart must pump. Review the figure.Based on the physiology, afterload can be decreased by medications that would have what physiological result/ outcome?
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8TYK. Which diagnoses would be most appropriate for clients with cardiovascular disease? Select all that apply.
1.  Ineffective Peripheral Tissue Perfusion
2.  Acute Confusion
3.  Decreased Cardiac Output
4.  Sleep Pattern Disturbance
5.  Activity Intolerance
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9TYK. The surgeon ordered sequential compression devices (SCDs) to be applied postoperatively. The client asks why the SCDs are needed. Which is the best response by the nurse when teaching the client about the purpose of SCDs?
1.  They promote arterial circulation.
2.  They promote venous return from the legs.
3.  They decrease afterload.
4.  They decrease postoperative pain.
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Solutions - Chapter 50 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. The nurse is planning to perform percussion and postural drainage. Which is an important aspect of planning the client’s care?
1.  Percussion and postural drainage should be done before lunch.
2.  The order should be coughing, percussion, positioning, and then suctioning.
3.  A good time to perform percussion and postural drainage is in the morning after breakfast when the client is well rested.
4.  Percussion and postural drainage should always be preceded by 3 minutes of 100% oxygen.
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1ACT. What factors may have led the medical staff to suspect that Ms. Singh had more than a very bad cold? Would you have come to the same conclusion?
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1Q. The larynx, trachea, bronchi, and lungs with an expanded view showing the structures of an alveolus anti the pulmonary blood vessels.
From Medical Terminology: A Word-Bunding Approach, 7th ed. (Figure 11.5), by J. Rice. 2012, Upper Saddle River. NJ: Pearson Education, Inc. Reproduced by permission of Pearson Education, Inc., Upper Saddle Hiver, New Jersey.
Pneumonia occurs when microorganisms get into the lower respiratory tract and overwhelm the body’s defenses. Name at least two normal defense mechanisms present in the upper airway that help prevent microorganisms getting into the lower respiratory tract.
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1TYK. A client with chronic pulmonary disease has a bluish tinge around the lips. The nurse charts which term to most accurately describe the client’s condition?
1.  Hypoxia
2.  Hypoxemia
3.  Dyspnea
4.  Cyanosis
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2ACT. The care plan appropriately focuses on the acute care of this client. Once she is significantly improved, the nurse will perform discharge teaching. What areas should be included?
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2Q. The larynx, trachea, bronchi, and lungs with an expanded view showing the structures of an alveolus anti the pulmonary blood vessels.
From Medical Terminology: A Word-Bunding Approach, 7th ed. (Figure 11.5), by J. Rice. 2012, Upper Saddle River. NJ: Pearson Education, Inc. Reproduced by permission of Pearson Education, Inc., Upper Saddle Hiver, New Jersey.
Microorganisms can travel past the upper respiratory tract defense mechanisms. What defense mechanisms are present in the lower respiratory tract that may help the client?
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2TYK. To prevent postoperative complications, the nurse assists the client with coughing and deep-breathing exercises. This is best accomplished by implementing which of the following?
1.  Coughing exercises 1 hour before meals and deep breathing 1 hour after meals
2.  Forceful coughing as many times as tolerated
3.  Huff coughing every 2 hours or as needed
4.  Diaphragmatic and pursed-lip breathing 5 to 10 times, four times a day
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3Q. The larynx, trachea, bronchi, and lungs with an expanded view showing the structures of an alveolus anti the pulmonary blood vessels.
From Medical Terminology: A Word-Bunding Approach, 7th ed. (Figure 11.5), by J. Rice. 2012, Upper Saddle River. NJ: Pearson Education, Inc. Reproduced by permission of Pearson Education, Inc., Upper Saddle Hiver, New Jersey.
The microorganisms have quickly multiplied and overpowered the clients defense mechanisms. The client has pneumonia and the alveoli are filled with infectious fluid. How will this affect gas exchange at the respiratory or alveolar/ capillary membrane?
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3TYK. The nurse is preparing to perform tracheostomy care. Prior to beginning the procedure the nurse performs which action?
1. Tells the client to raise two fingers to indicate pain or distress.
2.  Changes the twill tape holding the tracheostomy in place.
3. Cleans the incision site.
4. Checks the tightness of the ties and knot.
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4ACT. It appears that the client’s sputum has not been cultured. In caring for this client, what infection control guidelines would be needed?
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4TYK. Which action by the nurse represents proper nasopharyngeal/ nasotracheal suction technique?
1. Lubricate the suction catheter with petroleum jelly before and between insertions.
2. Apply suction intermittently while inserting the suction catheter.
3. Rotate the catheter while applying suction.
4. Hyperoxygenate with 100% oxygen for 30 minutes before and after suctioning.
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5ACT. Ms. Singh’s oxygen order is for a face mask at 6 L/min. She repeatedly pulls it off and you find it lying in the sheets. How might you intervene?
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5TYK. Which client statement informs the nurse that his teaching about the proper use of an incentive spirometer was effective?
1. “I should breathe out as fast and hard as possible into the device.”
2.  “I should inhale slowly and steadily to keep the balls up.”
3.  “I should use the device three times a day, after meals.”
4. “The entire device should be washed thoroughly in sudsy water once a week.”
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7TYK. The nurse makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues? A client who has
1. Anemia.
2. An infection.
3. A fractured rib.
4. A tumor of the medulla.
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8TYK. Which term does the nurse document to best describe a client experiencing shortness of breath when lying down who must assume an upright or sitting position to breathe more comfortably and effectively?
1.  Dyspnea
2.  Hyperpnea
3.  Orthopnea
4.  Acapnea
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9TYK. A client with emphysema is prescribed corticosteroid therapy on a short-term basis for acute bronchitis. The client asks the nurse how the steroids will help him. The nurse responds by saying that the corticosteroids will do which of the following?
1.  Promote bronchodilation.
2.  Help the client to cough.
3.  Prevent respiratory infection.
4.  Decrease inflammation in the airways.
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Solutions - Chapter 49 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. A student nurse is assigned to care for a client with a sigmoidostomy. The student will assess which ostomy site?
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1ACT. You learn that Mrs. Brown's stools have been liquid, in very small amounts, and at infrequent intervals, generally occurring when She feels the urge to defecate. What additional data are important to obtain from her?
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1TYK. Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following?
1.  Constipation
2.  Diarrhea
3.  Incontinence
4.  Hemorrhoids
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2ACT. What nursing intervention is most appropriate Before making suggestions to correct or prevent the problem she is experiencing?
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2TYK. Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching?
1.  “I need to drink one and a half to two quarts of liquid each day.”
2.  “I need to take a laxative such as Milk of Magnesia if I don’t have a BM every day.”
3.  “If my bowel pattern changes on its own, I should call you.”
4.  “Eating my meals at regular times is likely to result in regular bowel movements.”
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3ACT. What suggestions can you give her about maintaining a regular bowel pattern?
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3TYK. A client is scheduled for a colonoscopy. The nurse will provide information to the
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4ACT. Explain why cathartics and laxatives are generally contraindicated for people in Mrs. Brown’s situation?
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4TYK. The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?
1.  The stoma extends 1/2 in. above the abdomen.
2.  The skin under the appliance looks red briefly after removing the appliance.
3.  The stoma color is a deep red-purple.
4.  The ascending colostomy delivers liquid feces.
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5TYK. Which goal is the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection?
1.  The client will wear a medical alert bracelet for antibiotic allergy.
2.  The client will return to his or her previous fecal elimination pattern.
3.  The client will verbalize the need to take an antidiarrheal medication pm.
4.  The client will increase intake of insoluble fiber such as grains, rice, and cereals.
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6TYK. A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action?
1.  Prepare to irrigate the colostomy.
2.  After assessing the stoma and surrounding skin, notify the surgeon.
3.  Assess bowel sounds and administer antiemetic.
4.  Administer a bulk-forming laxative, and encourage increased fluids and exercise.
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7TYK. The nurse assesses a client’s abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling “bloated.” The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema?
1.  Soapsuds
2.  Retention
3.  Return flow
4.  Oil retention
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8TYK. Which of the following is most likely to validate that a client is experiencing intestinal bleeding?
1.  Large quantities of fat mixed with pale yellow liquid stool
2.  Brown, formed stools
3.  Semisoft black-colored stools
4.  Narrow, pencil-shaped stool
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9TYK. Which nursing diagnoses is/are most applicable to a client fecal incontinence? Select all that apply.
1.  Bowel Incontinence
2.  Risk for Deficient Fluid Volume
3.  Disturbed Body Image
4.  Social Isolation
5.  Risk for Impaired Skin Integrity
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Solutions - Chapter 48 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. Which of the following behaviours indicates that the client on a bladder training program has met the expected outcomes? Select all that apply.
1.  Voids each time there is an urge.
2.  Practices slow, deep breathing until the urge decreases.
3.  Uses adult diapers, for “just in case.”
4.  Drinks citrus juices and carbonated beverages.
5.  Performs pelvic muscle exercises.
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1ACT. Considering Mr. Baker’s history and assessment data, what other physical conditions could explain his symptoms?
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1TYK. The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following?
1.  The bladder distends and its capacity increases.
2.  Older adults ignore the need to void.
3.  Urine becomes more concentrated.
4.  The amount of urine retained after voiding increases.
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2ACT. The primary care provider has recommended surgery. What assumptions will the nurse need to validate in helping prepare Mr. and Mrs. Baker for this surgery?
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2TYK. During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply.
1.  Perineal skin irritation
2.  Fluid intake of less than 1,500 midday
3.  History of antihistamine intake
4.  History of frequent urinary tract infections
5.  A focal impaction
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3ACT. It does not appear that other alternatives have been considered. Why might this be so?
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3TYK. Which action represents the appropriate nursing management of a client wearing a condom catheter?
1.  Ensure that the tip of the penis fits snugly against the end of the condom.
2.  Check the penis for adequate circulation 30 minutes after applying.
3.  Change the condom every 8 hours.
4.  Tape the collecting tubing to the lower abdomen.
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4ACT. Incontinence can lead to client decisions to limit social interactions. What would be an appropriate response if Mr. Baker states that he will just stay home until he has his surgery?
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4TYK. The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action?
1.  Leaves the catheter in place and gets a new sterile catheter.
2.  Leaves the catheter in place and asks another nurse to attempt the procedure.
3.  Removes the catheter and redirects it to the urinary meatus.
4.  Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus.
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5TYK. Which statement indicates a need for further teaching of the home care client with a long-term indwelling catheter?
1.  “I will keep the collecting bag below the level of the bladder at all times.”
2.  “Intake of cranberry juice may help decrease the risk of infection.”
3.  “Soaking in a warm tub bath may ease the irritation associated with the catheter.”
4.  “I should use clean technique when emptying the collecting bag.”
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6TYK. During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate?
1.  Stress Urinary Incontinence
2.  Reflex Urinary Incontinence
3.  Functional Urinary Incontinence
4.  Urge Urinary Incontinence
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7TYK. A female client has a urinary tract infection (UTI). Which teaching points by the nurse would be helpful to the client? Select all that apply.
1.  Limit fluids to avoid the burning sensation on urination.
2.  Review symptoms of UTI with the client.
3.  Wipe the perineal area from back to front.
4.  Wear cotton underclothes.
5.  Take baths rather than showers.
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8TYK. The nurse will need to assess the client’s performance of clean intermittent self-catheterization (CISC) for a client with which” urinary diversion?
1.  Ileal conduit
2.  Kock pouch
3.  Neobladder
4.  Vesicostomy
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9TYK. Which focus is the nurse most likely to teach for a client with a flaccid bladder?
1.  Habit training: Attempt voiding at specific time periods
2.  Bladder training: Delay voiding according to a prescheduled timetable.
3.  Crede’s maneuver: Apply gentle manual pressure to the lower abdomen.
4.  Kegel exercises: Contract the pelvic muscles.
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Solutions - Chapter 47 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. Which of the following meals would the nurse recommend to the client as highest in calcium, iron, and fiber?
1.  3 ounces cottage cheese with 1/3 cup raisins and 1 banana
2.  1/2 cup broccoli with 3 ounces chicken and 1/2 cup peanuts
3.  1/2 cup spaghetti with 2 ounces ground beef and 1/2 cup lima beans plus 1/2 cup ice cream
4.  3 ounces tuna plus 1 ounce cheese sandwich on whole-wheat bread plus a pear
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1ACT. How do Mrs. Santini’s personal characteristics influence her nutritional needs?
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2ACT. What further information do you need regarding Mrs. Santini’s present diet?
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2TYK. An adult reports usually eating the following each day: 3 cups dairy, 2 cups fruit, 2 cups vegetables, 5 ounces grains, and 5 ounces meat. The nurse would counsel the client to:
1.  Maintain the diet; the servings are adequate.
2.  Increase the number of servings of dairy.
3.  Decrease the number of servings of vegetables.
4.  Increase the number of servings of grains.
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3ACT. Offer suggestions for ways to modify Mrs. Santini's tendency to snack.
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3TYK. Which of the following are allowed on a full liquid diet? Select all that apply.
___________ 1. Scrambled eggs
___________ 2. Chocolate pudding
___________ 3. Tomato juice
___________ 4. Hard candy
___________ 5. Mashed potatoes
___________ 6. Cream of Wheat cereal
___________ 7. Oatmeal cereal
___________ 8. Fruit “smoothies”
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4ACT. Mrs. Santini asks what her weight should be. How do you respond?
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4TYK. What is the best indication of proper placement of a nasogastric tube in the stomach?
1.  Client is unable to speak.
2.  Client gags during insertion.
3.  pH of the aspirate is less than 5.
4.  Fluid is easily instilled into the tube.
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5TYK. What is the proper technique with gravity tube feeding?
1.  Hang the feeding bag 1 foot higher than the tube’s insertion point into the client.
2.  Administer the next feeding only if there is less than 25 mL of residual volume from the previous feeding.
3.  Place client in the left lateral position.
4.  Administer feeding directly from the refrigerator.
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6TYK. A 55-year-old female is about 9 kg (20 lb) over her desired weight. She has been on a “low-calorie” diet with no improvement. Which statement reflects a healthy approach to the desired weight loss? “I need to:
1.  Increase my exercise to at least 30 minutes every day.”
2.  Switch to a low-carbohydrate diet.”
3.  Keep a list of my forbidden foods on hand at all times.”
4.  Buy more organic and less processed foods.”
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7TYK. An older Asian client has mild dysphagia from a recent stroke. The nurse plans the client’s meals based on the need to:
1.  Have at least one serving of thick dairy (e.g., pudding, ice cream) per meal.
2.  Eliminate the beer usually ingested every evening.
3.  Include as many of the client’s favourite foods as possible.
4.  Increase the calories from lipids to 40%.
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8TYK. Two months ago a client weighed 195 pounds. The current weight is 182 pounds. Calculate the client’s percentage of weight loss and determine its significance.
1.  % weight loss
2.  Not significant
3.  Significant weight loss
4.  Severe weight loss
Get Solution


9TYK. Which of the sites on the diagram below indicates the correct location for the tip of a small-bore nasally placed feeding tube?
Gastrointestinal tract
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Solutions - Chapter 46 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. A client recovering from abdominal surgery refuses analgesia, saying that he is “fine, as long as he doesn’t move.” Which nursing diagnosis should be a priority?
1.  Deficient Knowledge (pain control measures)
2.  Ineffective Health Maintenance
3.  Risk for Ineffective Airway Clearance
4.  Impaired Physical Mobility
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1ACT. Is there any other assessment data you would want to gather to help plan Mr. C.'s pain management?
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1CTC. Mrs. Lundahl underwent abdominal surgery approximately 6 hours ago. She has a 15-cm midline incision that is covered with a dry, intact surgical dressing. On assessment, you note that Mrs. Lundahl is perspiring. lying in a rigid position, holding her abdomen, and grimacing. Her blood pressure is 150/90 mmHg, heart rate 100 beats/min, and respiratory rate 32/min. When asked to rate her pain on a scale of 0 to 10, Mrs. Lundahl rates her pain as 5 as long as she remains perfectly still, There is a sharp area of pain at her incision; however, the most bothersome pain is crampy and dull, like she was “kicked in the stomach” with severe exacerbations that come in unpredictable waves.
What conclusions, if any, can be drawn about Mrs. Lundahl’s pain status?
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1TYK. During the transduction phase of nociception, which method of pain control is most effective?
1.  Tricyclic antidepressants
2.  Opioids
3.  Ibuprofen
4.  Distraction
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2ACT. Mr. C. does not have a PCA. What nursing interventions are important?
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2CTC. Mrs. Lundahl underwent abdominal surgery approximately 6 hours ago. She has a 15-cm midline incision that is covered with a dry, intact surgical dressing. On assessment, you note that Mrs. Lundahl is perspiring. lying in a rigid position, holding her abdomen, and grimacing. Her blood pressure is 150/90 mmHg, heart rate 100 beats/min, and respiratory rate 32/min. When asked to rate her pain on a scale of 0 to 10, Mrs. Lundahl rates her pain as 5 as long as she remains perfectly still, There is a sharp area of pain at her incision; however, the most bothersome pain is crampy and dull, like she was “kicked in the stomach” with severe exacerbations that come in unpredictable waves.
Does Mrs. Lundahl’s rating her pain as 5 mean that she is not experiencing pain severe enough to warrant intervention?
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2TYK. When a client has arrived at the nursing unit from surgery, the nurse is most likely to give priority to which of the following assessments?
1.  Pain tolerance
2.  Pain intensity
3.  Location of pain
4.  Pain history
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3ACT. What kind of data would you gather prior to having a discussion with the primary care provider about options for improving pain control in this client?
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3CTC. Mrs. Lundahl underwent abdominal surgery approximately 6 hours ago. She has a 15-cm midline incision that is covered with a dry, intact surgical dressing. On assessment, you note that Mrs. Lundahl is perspiring. lying in a rigid position, holding her abdomen, and grimacing. Her blood pressure is 150/90 mmHg, heart rate 100 beats/min, and respiratory rate 32/min. When asked to rate her pain on a scale of 0 to 10, Mrs. Lundahl rates her pain as 5 as long as she remains perfectly still, There is a sharp area of pain at her incision; however, the most bothersome pain is crampy and dull, like she was “kicked in the stomach” with severe exacerbations that come in unpredictable waves.
What type of pain is Mrs. Lundahl experiencing?
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3TYK. A client who describes his pain as 7 on a scale of 0 to 10 is classified as having which of the following?
1.  No pain
2.  Mild pain
3.  Moderate pain
4.  Severe pain
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4CTC. Mrs. Lundahl underwent abdominal surgery approximately 6 hours ago. She has a 15-cm midline incision that is covered with a dry, intact surgical dressing. On assessment, you note that Mrs. Lundahl is perspiring. lying in a rigid position, holding her abdomen, and grimacing. Her blood pressure is 150/90 mmHg, heart rate 100 beats/min, and respiratory rate 32/min. When asked to rate her pain on a scale of 0 to 10, Mrs. Lundahl rates her pain as 5 as long as she remains perfectly still, There is a sharp area of pain at her incision; however, the most bothersome pain is crampy and dull, like she was “kicked in the stomach” with severe exacerbations that come in unpredictable waves.
What interventions, in addition to pain medication, may be useful in reducing Mrs. Lundahl’s pain?
Get Solution


4TYK. A client who had abdominal surgery 4 hours ago is receiving a continuous epidural infusion of an analgesic. Which of the following observations indicates the nurse should monitor the client closely?
1.  Drowsy; drifts off to sleep before completing a sentence
2.  Respirations = 18/min
3.  Drowsy; easily aroused
4.  Pain rating 1-2/10
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5CTC. Mrs. Lundahl underwent abdominal surgery approximately 6 hours ago. She has a 15-cm midline incision that is covered with a dry, intact surgical dressing. On assessment, you note that Mrs. Lundahl is perspiring. lying in a rigid position, holding her abdomen, and grimacing. Her blood pressure is 150/90 mmHg, heart rate 100 beats/min, and respiratory rate 32/min. When asked to rate her pain on a scale of 0 to 10, Mrs. Lundahl rates her pain as 5 as long as she remains perfectly still, There is a sharp area of pain at her incision; however, the most bothersome pain is crampy and dull, like she was “kicked in the stomach” with severe exacerbations that come in unpredictable waves.
How will you know if your interventions have been effective in reducing Mrs. Lundahl’s pain?
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5TYK. The client has an order of morphine 2.5 to 5.0 mg intravenous (IV) every 4 hours. He received 2.5 mg IV 4 hours ago for pain rated at 3 on a scale of 0 to 10. He is now watching television and visiting with family members. When asked about his pain, he rates it as a 5. His vital signs are stable. What nursing intervention is the most appropriate?
1. Give morphine 3.5 mg IV and inform him to continue watching TV because it is a distraction from the pain.
2.  Give 2.5 mg of morphine IV to avoid the client becoming addicted.
3.  Give nothing at this time because he is not exhibiting any signs of pain.
4.  Give morphine 5.0 mg IV and reassess in 20 minutes.
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6TYK. During an admission nursing assessment, a client with diabetes describes his leg pain as a “dull, burning sensation.” The nurse recognizes this description to be characteristic of which type of pain?
1.  Physiological
2.  Somatic
3.  Visceral
4.  Neuropathic
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7TYK. Which interventions, when implemented by the nurse, would apply the gate control theory of pain? Select all that apply.
1.  Oral analgesics around the clock
2.  Massage
3.  Patient-controlled analgesia
4.  Heat or cold application
5.  Acupressure
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8TYK. Which statement best reflects the nurse’s assessment of the fifth vital sign?
1.  “Do you have any complaints?”
2.  “Are you experiencing any discomfort right now?”
3.  “Is there anything I can do for you now?”
4.  “Do you have any complaints of pain?”
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9TYK. When planning care for pain control of older clients, which principles should the nurse apply? Select all that apply.
1.  Pain is a natural outcome of the aging process.
2.  Pain perception increases with age.
3.  The client may deny pain.
4.  The nurse should avoid use of opioids.
5.  The client may describe pain as an “ache” or “discomfort.”
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Solutions - Chapter 45 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. During admission to a hospital unit, the client tells the nurse that her sleep tends to be very light and that it is difficult for her to get back to sleep if she’s awakened at night. Which interventions should the nurse implement? Select all that apply.
1.  Remind colleagues to keep their conversation to a minimum at night.
2.  Encourage the client’s family members to bring in a radio to play soft music at night.
3.  Deliver necessary medications and procedures at 1.5-or 3-hour intervals between 11 pm and 6 am.
4.  Encourage the client to ask family members to bring in a fan to provide white noise.
5.  Increase the temperature in the room.
Get Solution


1ACT. What further information would be helpful to obtain from Mr. Harrison about his sleep problem?
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1TYK. A client is admitted for a sleep disorder. The nurse knows that the reticular activating system (RAS) is involved in the sleep/ wake cycle. In the accompanying illustration, which letter indicates the location of the RAS?
1.  A
2.  B
3.  C
4.  D
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2ACT. What suggestions can you make that may help him develop better sleep habits?
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2TYK. A client has a history of sleep apnea. Which is the most appropriate question for the nurse to ask?
1.  Do you have a history of cardiac irregularities?
2.  Do you have a history of any kind of nasal obstruction?
3.  Have you had chest pain with or without activity?
4.  Do you have difficulty with daytime sleepiness?
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3ACT. What are the most common problems that interfere with clients' ability to sleep?
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3TYK. Because of significant concerns about financial problems, a middle-aged client complains of difficulty sleeping. Which outcome would be the most appropriate for the nursing care plan? “By day 5, the client will:
1.  Sleep 8 to 10 hours per day.”
2.  Report falling asleep within 20 to 30 minutes.”
3.  Have a plan to pay all the bills.”
4.  Decrease worrying about financial problems and will keep busy until bedtime.”
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4TYK. A client reports to the nurse that she has been taking barbiturate sleeping pills every night for several months and now wishes to stop taking them. Which statement is the most appropriate advice for the nurse to provide the client?
1.  Take the last pill on a Friday night so disrupted sleep can be compensated on the weekend.
2.  Continue to take the pills since sleeping without them after such a long time will be difficult and perhaps impossible.
3.  Discontinue taking the pills.
4.  Continue taking the pills and discuss tapering the dose with the primary care provider.
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5TYK. During a well-child visit, a mother tells the nurse that her 4-year-old daughter typically goes to bed at 10:30 pm and awakens each morning at 7 am. She does not take a nap in the afternoon. Which is the best response by the nurse?
1.  Encourage the mother to consider putting her daughter to bed between 8 and 9 pm.
2.  Reassure the mother that it is normal for 4-year-olds to resist napping, but encourage her to insist that she rest quietly each afternoon.
3.  Recommend that her daughter be allowed to sleep later in the morning.
4.  Reassure her that her daughter’s sleep pattern is normal and that she has outgrown her need for an afternoon nap.
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6TYK. A college student was referred to the campus health service because of difficulty staying awake in class. What should be included in the nurse’s assessment? Select all that apply.
1.  Amount of sleep he usually obtains during the week and on weekends
2.  How much alcohol he usually consumes
3.  Onset and duration of symptoms
4.  Whether or not his classes are boring
5.  What medications, including herbal remedies, he is taking
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7TYK. During a yearly physical, a 52-year-old male client mentions that his wife frequently complains about his snoring. During the physical exam, the nurse notes that his neck size is 18 inches, his soft palate and uvula are reddened and swollen, and he is overweight. What is the most appropriate nursing intervention for the nurse to recommend to this client?
1.  Recommend that he and his wife sleep in separate bedrooms so that his snoring does not disturb his wife.
2.  Refer him to a dietician for a weight loss program.
3.  Caution him not to drink or take sleeping pills since they may make his snoring worse.
4.  Refer him to a sleep disorders center for evaluation and treatment of his symptoms.
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8TYK. A new nursing graduate’s first job requires 12-hour night shifts. Which strategy will make it easier for the graduate to sleep during the day and remain awake at night?
1.  Wear dark wrap-around sunglasses when driving home in the morning, and sleep in a darkened bedroom.
2.  Exercise on the way home to avoid having to stand around waiting for equipment at the gym.
3.  Drink several cups of strong coffee or 16 oz of caffeinated soda when beginning the shift.
4.  Try to stay in a brightly lit area when working at night.
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9TYK. The nurse is answering questions after a presentation on at a local senior citizens center. A woman in her late 70s asks for an opinion about the advisability of allowing her husbandS nap for 15 to 20 minutes each afternoon. Which is the nurse’s best response?
1.  “Taking an afternoon nap will interfere with his being able to sleep at night. If he’s tired in the afternoon, see if you can interest him in some type of stimulating activity to keep him, awake.”
2.  “He shouldn’t need to take an afternoon nap if he’s getting enough sleep at night.”
3.  “Unless your husband has trouble falling asleep at night a brief afternoon nap is fine.”
4.  “Encourage him to consume coffee or some other caffeinated beverage at lunch to prevent drowsiness in the afternoon.”
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Solutions - Chapter 44 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. The nurse is performing an assessment of an immobilized client. Which assessment causes the nurse to take action?
1.  Heart rate 86 beats/min
2.  Reddened area on sacrum
3.  Nonproductive cough
4.  Urine output of 50 ml/h
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1ACT. What assessment findings alert you that Mr. Chan is developing problems associated with his current state of decreased mobility?
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1TYK. To increase stability during client transfer, the nurse increases the base of support by performing which action?
1.  Leaning slightly backward
2.  Spacing the feet farther apart
3.  Tensing the abdominal muscles
4.  Bending the knees
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2ACT. Mr. Chan may benefit from using a walker to assist with ambulation at home. What teaching should be done in regard to use of a walker?
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2TYK. Isotonic exercises such as walking are intended to achieve which of the following? Select all that apply.
1.  Increase muscle tone and improve circulation.
2.  Increase blood pressure.
3.  Increase muscle mass and strength.
4.  Decrease heart rate and cardiac output.
5.  Maintain joint range of motion.
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3ACT. The care plan does not address one of Mr. Chan’s risk factors—obesity. Would you add this to the plan?
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3TYK. Five minutes after the client’s first postoperative exercise, the client’s vital signs have not yet returned to baseline. Which is an appropriate nursing diagnosis?
1.  Activity Intolerance
2.  Risk for Activity Intolerance
3.  Impaired Physical Mobility
4.  Risk for Disuse Syndrome
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4ACT. What assumptions has the nurse made in assigning the desired outcome of “Immobility Consequences: Psycho-Cognitive”?
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4TYK. Which statement from a client with one weak leg regarding use of crutches when using stairs indicates a need for increased teaching?
1.  “Going up, the strong leg goes first, then the weaker leg with both crutches.”
2.  “Going down, the weaker leg goes first with both crutches, then the strong leg.”
3.  “The weaker leg always goes first with both crutches.”
4.  “A cane or single crutch may be used instead of both crutches if held on the weaker side.”
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5ACT. How are the choices of outcomes influenced by the cause of his nursing diagnosis (a chronic illness)?
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5TYK. A nurse is teaching a client about active range-of-motion (ROM) exercises. The nurse then watches the client demonstrate these principles. The nurse would evaluate that teaching was successful when the client does which of the following?
1.  Exercises past the point of resistance.
2.  Performs each exercise one time.
3.  Performs each series of exercises once a day.
4.  Uses the same sequence during each exercise session.
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6TYK. When assessing a client’s gait, which does the nurse look for and encourage?
1.  The spine rotates, initiating locomotion.
2.  Gaze is slightly downward.
3.  Toes strike the ground before the heel.
4.  Arm on the same side as the swing-through foot moves forward at the same time.
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7TYK. Performance of activities of daily living (ADLs) and active range-of-motion (ROM) exercises can be accomplished simultaneously as illustrated by which of the following? Select all that apply.
1.  Elbow flexion with eating and bathing
2.  Elbow extension with shaving and eating
3.  Wrist hyperextension with writing
4.  Thumb ROM with eating and writing
5.  Hip flexion with walking
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8TYK. A client weighs 250 pounds and needs to be transferred from the bed to a chair. Which instruction by the nurse to the unlicensed assistive personnel (UAP) is most appropriate?
1.  “Using proper body mechanics will prevent you from injuring yourself.”
2.  “You are physically fit and at lesser risk for injury when transferring the client.”
3.  “Use the mechanical lift and another person to transfer the client from the bed to the chair.”
4.  “Use the back belt to avoid hurting your back.”
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9TYK. The client is ambulating for the first time after surgery. The client tells the nurse, “I feel faint.” Which is the best action by the nurse?
1.  Find another nurse for help.
2.  Return the client to her room as quickly as possible.
3.  Tell the client to take rapid, shallow breaths.
4.  Assist the client to a nearby chair.
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Solutions - Chapter 43 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. In working with a dying client, the nurse demonstrate assisting the client to die with dignity when performing which action
1. Allows the client to make as many decisions about care as is possible
2.  Shares with the client the nurse’s own views about life after death
3.  Avoids talking about dying and focuses on the present
4.  Relieves the client of as much responsibility for self care as possible
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1CTC. Mrs. Govinda, 75, was admitted to the hospital after repeated episodes of pneumonia. Despite aggressive antibiotic therapy, her condition rapidly deteriorated and she died unexpectedly 1 week after being admitted to the hospital. Mrs. Govinda’s oldest son who Rived nearby and frequently cared for his mother, arranged for the funeral and visited with relatives. He misses his mother and cries occasionally but managed to return to work the following week. The youngest son had difficulty attending the funeral, has been unable to sleep or eat cannot concentrate at work, and cannot believe that his mother Is dead. The middle son did not weep at the funeral and had title to say to his brothers or other relatives. He returned home to another state but has remained distant. He is back to work but feels very fatigued and apathetic.
From the data provided, describe the phase of bereavement being experienced by each of the three surviving sons.
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1TYK. Which of the following may be considered normal or “healthy” types of grief? Select all that apply.
1.  Abbreviated grief
2.  Anticipatory grief
3.  Disenfranchised grief
4.  Complicated grief
5.  Unresolved grief
6.  Inhibited grief
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2CTC. Mrs. Govinda, 75, was admitted to the hospital after repeated episodes of pneumonia. Despite aggressive antibiotic therapy, her condition rapidly deteriorated and she died unexpectedly 1 week after being admitted to the hospital. Mrs. Govinda’s oldest son who Rived nearby and frequently cared for his mother, arranged for the funeral and visited with relatives. He misses his mother and cries occasionally but managed to return to work the following week. The youngest son had difficulty attending the funeral, has been unable to sleep or eat cannot concentrate at work, and cannot believe that his mother Is dead. The middle son did not weep at the funeral and had title to say to his brothers or other relatives. He returned home to another state but has remained distant. He is back to work but feels very fatigued and apathetic.
What factors may have affected how each of the sons reart the death of their mother?
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2TYK. A client’s family tells the nurse that their culture does not permit a dead person to be left alone before burial. Hospital policy states that after 6:00 pm when mortuaries are closed, bodies are to be stored in the hospital morgue refrigerator until the next day. How would the nurse best manage this situation?
1.  Gently explain the policy to the family and then implement it.
2.  Inquire of the nursing supervisor how an exception to the policy could be made.
3.  Call the client’s primary care provider for advice.
4.  Move the deceased to an empty room and assign an aide to stay with the body.
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3CTC. Mrs. Govinda, 75, was admitted to the hospital after repeated episodes of pneumonia. Despite aggressive antibiotic therapy, her condition rapidly deteriorated and she died unexpectedly 1 week after being admitted to the hospital. Mrs. Govinda’s oldest son who Rived nearby and frequently cared for his mother, arranged for the funeral and visited with relatives. He misses his mother and cries occasionally but managed to return to work the following week. The youngest son had difficulty attending the funeral, has been unable to sleep or eat cannot concentrate at work, and cannot believe that his mother Is dead. The middle son did not weep at the funeral and had title to say to his brothers or other relatives. He returned home to another state but has remained distant. He is back to work but feels very fatigued and apathetic.
What cues, other than physical signs, might have indicated that Mrs. Govinda was dying, even though her death was unexpected?
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3TYK. The shift changed while the nursing staff was waiting for the adult children of a deceased client to arrive. The oncoming nurse has never met the family. Which of the following initial greetings is most appropriate?
1.  “I’m very sorry for your loss.”
2.  “I’ll take you in to view the body.”
3.  “I didn’t know your father but I am sure he was a wonderful person.”
4.  “How long will you want to stay with your father?”
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4CTC. Mrs. Govinda, 75, was admitted to the hospital after repeated episodes of pneumonia. Despite aggressive antibiotic therapy, her condition rapidly deteriorated and she died unexpectedly 1 week after being admitted to the hospital. Mrs. Govinda’s oldest son who Rived nearby and frequently cared for his mother, arranged for the funeral and visited with relatives. He misses his mother and cries occasionally but managed to return to work the following week. The youngest son had difficulty attending the funeral, has been unable to sleep or eat cannot concentrate at work, and cannot believe that his mother Is dead. The middle son did not weep at the funeral and had title to say to his brothers or other relatives. He returned home to another state but has remained distant. He is back to work but feels very fatigued and apathetic.
With the diagnosis of pneumonia, a respiratory infection, what physiological (palliative) needs might she have had?
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4TYK. At which age does a child begin to accept that he or she will someday die?
1.  Less than 5 years old
2.  5-9 years old
3.  9-12 years old
4.  12-18 years old
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5CTC. Mrs. Govinda, 75, was admitted to the hospital after repeated episodes of pneumonia. Despite aggressive antibiotic therapy, her condition rapidly deteriorated and she died unexpectedly 1 week after being admitted to the hospital. Mrs. Govinda’s oldest son who Rived nearby and frequently cared for his mother, arranged for the funeral and visited with relatives. He misses his mother and cries occasionally but managed to return to work the following week. The youngest son had difficulty attending the funeral, has been unable to sleep or eat cannot concentrate at work, and cannot believe that his mother Is dead. The middle son did not weep at the funeral and had title to say to his brothers or other relatives. He returned home to another state but has remained distant. He is back to work but feels very fatigued and apathetic.
How might your own feelings about death affect the care you provide to the dying client?
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5TYK. An 82-year-old man has been told by his primary care provider that it is no longer safe for him to drive a car. Which statement by the client would indicate beginning positive adaptation to this loss?
1.  “I told the doctor I would stop driving, but I am not going to yet.”
2.  “I always knew this day would come, but I hoped it wouldn’t be now.”
3.  “What does he know? I’m a better driver than he will ever be.”
4.  “Well, at least I have friends and family who can take me places.”
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7TYK. A nursing care plan includes the desired outcome of “quality of life” for a client with a chronic degenerative illness who is likely to live for many more years. Which of the following is one example that would indicate the outcome has been met?
1.  The client demonstrates having adequate financial resources to pay for health care for many more years.
2.  The client spends the majority of his or her time in spiritual reflection.
3.  The client has no signs or symptoms of preventive complications of the illness.
4.  The client verbalizes satisfaction with current relationships with other people.
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8TYK. The nurse is caring for a family in a shelter 2 days after the loss of their home due to a fire. The fire caused minor burns to several members of the family but no life-threatening conditions. Which of the following is the most important assessment data for the nurse to gather at this time?
1.  Availability of insurance coverage for rebuilding the house
2.  Family members’ understanding of the extent of their physical injuries
3.  Psychological support resources available from friends or other sources
4.  Family members’ grief responses and coping behaviours
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9TYK. The client has been close to death for some time and the family asks how the nurse will know when the client has actually died. Which of the following would be the most accurate response from the nurse?
1.  When the blood pressure can no longer be measured
2.  When the gag reflex is no longer present
3.  When there is no apical pulse
4.  When the extremities are cool and dark in color
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