Nursing Study Guide Answer Key

Study Guide Answer Key 0
Potter & Perry: Fundamentals of Nursing, 7th Edition
Study Guide Answer Key
Chapter 1: Nursing Today
1. the protection, promotion and optimization of health and abilities, prevention of illness
and injury, alleviation of suffering through the diagnosis and treatment of human response
and advocacy in the care of individuals, families, communities and populations.
2. the role of nursing as being in charge of a client’s health based on the knowledge of how
to put the body in such a state as to be free of disease or to recover from disease.
3. d
4. c
5. b
6. a
7. Demographic changes (rural areas to urban centers, increased life span, higher incidence
of chronic long-term illness, increased incidence of alcoholism and lung cancer). Women’s
health care issues (new specialties). Human rights movement (minorities, terminal illness,
pregnant women, older adults). Medically underserved (poor and on Medicaid, working poor,
mentally ill with little to no access to health care). Threat of bioterrorism (nuclear, chemical
or biological).
8. Rising health care costs (challenge is to use health care and client resources wisely).
Evidence-based practice (a problem-solving approach to clinical practice that uses the best
available evidence along with your expertise and client preferences and values in making
decisions about care). Nursing and biomedical research. Nursing shortage (global).
9.
a. A profession requires an extended education of its members as well as a basic
liberal foundation.
b. has a theoretical body of knowledge leading to defined skills, abilities, and
norms.
c. provides a specific service.
d. has autonomy in decision making and practice
e. has a code of ethics for practice
10.
a. Assessment
b. Diagnosis
c. outcome identification
d. planning implementation
e. Evaluation
11. Quality of practice, education, professional practice evaluation, collegiality,
collaboration, ethics, research, resource utilization, leadership
12. the philosophical ideals of right and wrong that define the principles you will use to
provide care to your clients
13. c
14. d
15. b
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.
16. e
17. a
18. g
19. f
20. To protect public health, safety, and welfare
21. Novice, advanced beginner, competent, proficient, expert
22. b
23. d
24. n
25. g
26. c
27. f
28. m
29. i
30. k
31. j
32. l
33. h
34. e
35. a
36. o
37. 3. Nursing is a combination of knowledge from the physical sciences, humanities, and
social sciences, along with clinical competencies.
38. 2. Candidates are eligible to take the NCLEX-RN to become registered nurses in the state
in which they will practice.
39. 2. The ANA’s purpose is to improve the professional development and general welfare of
nurses.
Chapter 2: The Health Care Delivery System
1. b
2. f
3. a
4. e
5. c
6. d
7. h
8. g
9. Primary care focuses on health services that are provided on an individual basis while
primary health care focuses on improved health outcomes for an entire population.
10. work redesign
11. case management
12. The nurse coordinates the efforts of all disciplines to achieve the most efficient and
appropriate plan of care for the client.
13. Discharge planning
14. is a multidisciplinary treatment plan that shows what treatments or interventions clients
need to have while in the hospital for a specific reason
15.
a. safe and effective use of medications
b. instruction and counseling on food-drug interactions, nutrition, and modified
diets
c. rehabilitation techniques
d. access to appropriate community resources
e. when and how to obtain further treatment
f. the responsibilities of the client and the families with ongoing health care
needs
16. is to help individuals regain maximal functional status and to enhance quality of life
through promotion of independence and self-care
17. wound care, respiratory care, monitoring of vital signs, elimination care, nutrition,
rehabilitation, monitoring compliance of medications, blood glucose monitoring
18. rehabilitation
19. extensive supportive care until they are able to move back into the community or into a
residential-care facility
20. minimum data set (MDS), resident assessment protocols (RAPs), utilization guidelines of
each state
21. d
22. c
23. a
24. b
25. the integration of best research evidence with clinical expertise and patient values
26. Quality improvement (QI)
27. nursing-sensitive outcomes
28.
a. respect values, preferences, and needs
b. coordination and integration of care

c. information, communication, and education
d. physical comfort
e. emotional support
f. involvement of family and friends
g. transition and continuity
29. 4. Activities that develop human attitudes and behaviors to maintain or enhance well-
being
30. 1. initially focuses on the prevention of complications related to the illness or injury.
Once the condition stabilizes, rehabilitation helps to maximize the client’s level of
independence.
31. 2. where they receive supportive care until they are able to move back into the
community
32. 1. focus is palliative care, not curative treatment
Chapter 3: Community-Based Nursing Practice
1. focuses on primary rather than institutional or acute care and provides knowledge about
health and health promotion and models of care to the community
2. gathering information on incident rates for identifying and reporting if new infections or
diseases, adolescent pregnancy rates, MVAs by teenage drivers
3.
a. focus requires understanding the needs of a population (e.g., high-risk infants,
older adults, or cultural groups)
b. is a nursing practice in the community, with the primary focus on the health care of
individuals, families, and groups in the community
4. in community settings such as the home or a clinic, where the focus is on the needs of the
individual or family
5.
a. the inner circle of the client and the family
b. people and settings that have frequent contact with the client and family
c. local communities’ values and policies
d. larger social systems
6.
a. clients who are more likely to develop health problems as a result of excess
risks
b. who have limits in access to health care services
c. are dependent on others for care
7. access to health care is limited because of lack of benefits, resources, language barriers,
and transportation
8. live in hazardous environments, work at high-risk jobs, eat less nutritious foods, have
multiple stressors
9. mental health problems, substance abuse, socioeconomic stressors, dysfunctional
relationships
10. socioeconomic problems result from financial strain of the cost of drugs, criminal
convictions, communicable diseases, and family breakdown
11. homeless or live in poverty, lack the ability to maintain employment or to care for
themselves
12. suffer from chronic diseases, have a greater demand for health care services
13. together with the family you develop a caring partnership to recognize actual and
potential health care needs and identify community resources
14. assumes responsibility for the case management of multiple clients
15. acts to empower individuals and their families to creatively solve problems or become
instrumental in creating change within a health care agency
16. often is the one who presents the client’s point of view to obtain appropriate resources
17. is essential for exploring client issues, knowing the contributions of each profession,
clarifying roles, and developing a plan of care
18. assists clients in identifying and clarifying health problems and in choosing appropriate
courses of action
19. goal is to help clients assume the skills and knowledge needed to care for themselves
20. may be involved in case finding, health teaching, and tracking incident rates
21.
a. structure (geographical boundaries, emergency services, housing, economic
status)
b. population (age and sex distribution, growth trends, education level, ethnic
and religious groups)
c. social (education and communication systems, government, volunteer
programs, welfare system)
22. 3. Because nurses provide direct care services where clients live and work, it is important
to focus on the individual and family and respect and incorporate the values of the
community.
23. 3. They are usually jobless and do not have the advantage of shelter and cope with
finding a place to sleep at night and finding food.
24. 4. the coordinating of activities of multiple providers and payers in different settings
throughout a client’s continuum of care
25. 3. observe the community’s design, location of services, and locations where the
residents meet
Chapter 4: Theoretical Foundations of Nursing Practice
1. c
2. d
3. e
4. f
5. a
6. b
7. e
8. f
9. a
10. d
11. h
12. i
13. j
14. c
15. g
16. b
17. Piaget’s theory of cognitive development helps to explain how children think, reason, and
perceive the world.
18. Neuman defines a total-person model of holism and an open-systems approach. As an
open system, a person interacts with the environment.
19.
a. physiological needs (air, water, food)
b. safety and security needs (physical and psychological)
c. love and belonging needs (friends, social relationships, and sexual love)
d. esteem and self-esteem needs (self-confidence, usefulness, achievement, and
self-worth)
e. self-actualization
20. d
21. e
22. g
23. I
24. C
25. B
26. F
27. H
28. A
29. 4. The 4 dimensions (energy fields, openness, pattern and organization, and
dimensionality) aid in the development of principles related to human development.
30. 4. Nurses needing to know all about the disease process were early attempts to
differentiate between nursing and medicine.
31. 3.
32. 2. nursing science, basic social sciences, physical sciences, biobehavioral sciences,
ethics, and health policy
Chapter 5: Evidence-Based Practice
1. is a problem-solving approach to clinical practice that integrates the conscientious use of

best evidence in combination with a clinician’s expertise, client preferences, and values in
making decisions about client care
2.
a. ask a clinical question.
b. collect the most relevant evidence
c. clinically appraise the evidence
d. integrate all the evidence with one’s clinical expertise, client preferences, and values
in making a practice decision
e. evaluate the practice decision
3.
a. P = patient/population of interest
b. I = intervention of interest
c. C = comparison of interest
d. O = outcome
4. agency policy and procedure manuals, quality improvement data, existing clinical practice
guidelines, or computerized databases
5. means that a panel of experts familiar with the article’s topic or subject matter has
reviewed the article
6. systematically developed statements about a plan of care for a specific set of clinical
circumstances involving a specific client population
7. Controlled trials without randomization are studies that test interventions, but researchers
have not randomized the subjects into the control or treatment groups.
8. summarizes the purpose of the study or clinical query, the major themes or findings, and
the implications for nursing practice
9. contains information about its purpose and the importance of the topic for the reader
10. a detailed background of the level of science or clinical information that exists about the
topic of the article
11. A clinical article can contain a description of the population, the health alteration, how
clients are affected, or a new therapy or technology. A research article contains a purpose
statement, methods, or design.
12. In a clinical article, the author will explain the clinical implications for the topic
presented. In a research article, the author will detail the results of the study and explain
whether a hypothesis is proven or how a research question is answered.
13. A research article will include a section that explains if the findings from the study have
clinical implications.
14. apply the research in your plan of care for a client, use the evidence you find as a
rationale for an intervention you plan to try, such as teaching tools, clinical practice
guidelines, policies and procedures, new tools.
15. is a way to identify new knowledge, improve professional education and practice, and
use resources effectively
16. is research designed to assess and document the effectiveness of health care services and
interventions
17. is a systematic step-by-step process that ensures that the findings from a study are valid,
reliable, and generalizable to subjects
18.
a. identify the problem area to be studied
b. steps of planning occur in an orderly fashion
c. control external factors that may influence a relationship between the phenomena that
are being studied
d. empirical data is gathered
e. goal is to understand the phenomena
19. the conditions are tightly controlled to eliminate bias and to ensure that findings can be
generalizable to similar subjects
20. obtain information from populations regarding the frequency, distribution, and
interrelation of variables among the subjects
21. it involves finding out how well a program, practice, procedure, or policy is working
22. involves inductive reasoning to develop generalizations or theories from specific
observations or interviews
23.
a. involves the description and interpretation of cultural behavior
b. with a focus on what people experience in regard to daily practices or experiences
and how they interpret those experiences
c. is a method of collecting and analyzing data with the aim of developing theories and
propositions that are grounded in the real world
24.
a. identify the area of interest or clinical problem
b. design the study protocol
c. obtain necessary approvals, recruit subjects, and implement the study
d. analyze the results of the study
e. formulate recommendations for future research
25. an approach to the continuous study and improvement of the processes of providing
health care services to meet the needs of clients and others
26. The organization evaluates and analyzes current performance to use results to develop
focused improvement actions.
27. 3. Together, the abstract and introduction tell you if the topic of the article is similar to
your PICO question or related closely enough to provide you with useful information.
28. 3. The summary details the results of the study and explains whether a hypothesis is
supported. The results of other studies are not presented.
29. 4. systemically developed statements about a plan of care for a specific set of clinical
circumstances involving a specific client population
Chapter 6: Health and Wellness
1. Different attitudes about illness cause people to react in different ways to the illness of a
family member.
2.
a. to increase quality and years of healthy life
b. to eliminate health disparities
3.
a. promote healthy behaviors
b. promote healthy and safe communities
c. improve systems for personal and public health
d. prevent and reduce disease and disorders
4. a state of complete physical, mental, and social well-being.
5. Positive: activities related to maintaining, attaining, or regaining good health and
preventing illness
Negative: practices that actually or potentially are harmful to health
6.
a. individual’s perception of susceptibility to an illness
b. individual’s perception of the seriousness of the illness
c. the likelihood that a person will take preventative action
7.
a. the individual characteristics and experiences
b. behavior-specific knowledge and affect
c. behavioral outcomes
8. The clients are the ultimate experts regarding their own health, and one should respect
clients’ subjective experience as relevant in maintaining health or assisting in healing
9.
a. developmental stage (finding the patterns or general principles that apply to
most people most of the time; the concept of illness is dependent on the
developmental stage of the individual)
b. intellectual background (shaped by the person’s knowledge or lack of
knowledge or incorrect information)
c. perception of functioning (subjective data about the way clients perceive their
physical functioning)
d. emotional (the degree of stress, depression, fear)
e. spiritual factors (values and beliefs exercised by the patient)
10.
a. family practice: the way in which clients’ families use health care services
generally affects their health practices
b. psychosocial variables: the stability of the person’s marital or intimate
relationship, lifestyle habits, and occupational environment
c. influences beliefs, values, and customs that will influence their personal
health practices, their approach to the system, and the nurse-client relationship
11. Activities such as routine exercise and good nutrition help clients maintain or enhance
their present levels of health.
12. strategies that are designed to help persons achieve new understanding and control over
their lives
13. activities that motivate people to avoid declines in health or functional levels
14.
a. individuals gain from the activities of others without acting themselves
b. individuals are motivated to adopt specific health programs
15.
a. is true prevention; it precedes disease
b. focuses on the individuals who are experiencing health problems or illnesses
and who are at risk for developing complications or worsening conditions
c. occurs when a defect or disability is permanent and irreversible; it involves
minimizing the effects of the illness or disability
16. is any situation, habit, social or environmental condition, physiological or psychological
condition, developmental or intellectual condition, or spiritual or other variable that increases
the vulnerability of an individual or group to an illness or accident
17.
a. pregnant or overweight, diabetes mellitus, cancer, heart disease, kidney
disease or mental illness
b. premature infant, heart disease, and cancer with increased age
c. industrial workers and the risk of cancer
d. habits that have risk factors (sunbathing, overweight)
18.
a. not intending to make changes within the next 6 months
b. considering a change within the next 6 months
c. making small changes in preparation for a change in the next month
d. actively engaged in strategies to change behavior
e. sustained change over time
19. a state in which a person’s physical, emotional., intellectual, social, developmental, or
spiritual functioning is diminished or impaired compared with the previous experience
20.
a. usually has a short duration and is severe; symptoms appear abruptly, are
intense, and often subside after a relatively short period
b. usually lasts longer than 6 months; can also affect functioning in any
dimension
21. how people monitor their bodies, define and interpret their symptoms, take remedial
actions, and use the health care system
22.
a. their perceptions of symptoms and the nature of their illness--a person
experiencing chest pain in the middle of the night seeking assistance
b. the visibility of symptoms, social group, cultural background, economic
variables, accessibility of the system, and social support
23.
a. depend on the nature of the illness, the client’s attitude toward it, the reaction
of others to it, and the variables of the illness behavior
b. reaction to the changes in body image depend on the type of changes, their
adaptive capacity, the rate at which changes takes place, and the support services
available
c. depends in part on body image and roles but also includes other aspects of
psychology and spirituality
d. role reversal can lead to stress, conflicting responsibilities for the adult or
child, or direct conflict over decision making
e. is the process by which the family functions, makes decisions, gives support
to individual members, and copes with everyday changes and challenges
24. 4. Internal variables include all of the ones cited.
25. 1. any situation, habit, or social or environmental condition that increases the
vulnerability of the individual to an illness
26. 2. Illness behavior involves how people monitor their bodies, define and interpret their
symptoms, take action, and use the health care system.
27. 1. The health belief model helps nurses understand factors influencing clients’
perceptions, beliefs, and behavior.
Chapter 7: Caring for the Cancer Survivor
1.
a. due to cancer treatment, genetic or other susceptibility, or an interaction between
treatment and susceptibility
b. osteoporosis, congestive heart failure, diabetes, amenorrhea, sterility, impaired
immune function, paresthesias, and hearing loss
c. treatment for the cancer or the cancer itself can cause pain and neuropathy
d. associated sleep disturbances are the most frequent and disturbing complaints
e. in systemic cancer treatment, including chemotherapy or biotherapy, there are
generalized, subtle effects ranging from small deficits in information processing to
acute delirium
2. numbness in the chest wall or axilla, tightness, pulling in the arm or axilla, fatigue,
difficulty sleeping, and hot flashes
3.
a. range along a continuum from sadness to disabling depression, long-term fatigue, and
sleep disturbances leading to depression
b. is a psychiatric disorder characterized by an acute emotional response to a traumatic
event or situation. Females who are young, less educated, low-income, and less social
and who lack emotional support are at high risk for PTSD.
c. a client’s body image or altered sexual function
4.
a. alters a young person’s social skills, sexual development, body image, and the ability
to think about and plan for the future
b. every family member’s role, plans, and abilities change; added job responsibilities for
the spouse; changes in sexuality, intimacy, and fertility; employment opportunities are
affected; economic burdens
c. retire prematurely, fixed income, limitations of Medicare reimbursement, retirement
residences, isolated from social supports
5.
a. energy-consuming anxiety
b. inability to forgive
c. low self-esteem
d. maturational losses
e. mental illness
6. Caregivers report a lower quality of life than that of their other family members, find
themselves ill-prepared to deal with the diagnosis, struggle with interpersonal problem-
solving, and struggle to maintain core functions.
7. Some examples may be: Have you had any pain or discomfort in the area where you had
surgery or radiation? Are you experiencing fatigue, sleeplessness, or shortness of breath?
How distressed are you feeling at this point on a scale of 0-10? How do you think your
family is doing with the cancer? If you have had sexual changes, what strategies have you
tried to make things better?
8. Reinforce their health care provider’s explanations of the risks related to their cancer and
treatment, what they need to self-monitor, and what to discuss with health care providers in
the future.
9.
a. prevention and detection of new cancers and recurrent cancer
b. surveillance for cancer spread, recurrence, or second cancers
c. intervention for consequences of cancer and its treatments
d. Review survivorship care plan with client at time of discharge.
10. 4. Cognitive changes can occur during all phases of the cancer experience, from small
deficits in information processing to acute delirium.
11. 4. Many older adults have very limited Medicare reimbursement.
12. 2. Coordination should be between the specialists and the primary care providers for
ongoing clinical care.
Chapter 8: Caring in Nursing Practice
1. A universal phenomenon influencing the ways in which people think, feel, and behave in
relation to one another.
2. the concept of care as the essence and central, unifying, and dominant domain that
distinguishes nursing from other health disciplines. Care is the essential human need and is
necessary for the health and survival of all individuals.
3. looks beyond the client’s disease and its treatment by conventional means. It looks for
deeper sources of inner healing to protect, enhance, and preserve a person’s dignity,
humanity, wholeness, and inner harmony.
4. a connection between the one cared for and the one caring. The relationship influences
both the nurse and the client, for better or worse.
5.
a. striving to understand an event as it has meaning in the life of the other
b. being emotionally present to the other
c. doing for the other as he or she would do for the self if it were at all possible
d. facilitating the other’s passage through life transitions
e. sustaining faith in the other’s capacity to get through an event or transition
and face a future with meaning
6. the nurse as the client’s advocate, solving ethical dilemmas by attending to relationships
and by giving priority to each client’s unique personhood.
7. person-to-person encounter that conveys a closeness and a sense of caring. Presence
involves being there and being with.
8.
a. when performing a task or a procedure, the skillful and gentle performance of
a nursing procedure conveys security and a sense of competence
b. a form of nonverbal communication, which successfully influences the
client’s comfort and security, enhances self-esteem, and improves reality orientation
c. used to protect the nurse and/or client, it can be positive or negatively viewed
9. taking in what a client says, as well as an interpretation and understanding of what the
client is saying and giving back that understanding to the person who is speaking.
10.
a. mobilizing hope for the client and for the nurse
b. finding an interpretation or understanding of illness, symptoms, or emotions
that is acceptable
c. assisting the client using social, emotional, or spiritual resources
d. recognizing that caring relationships connect us in a human-to-human, spirit-
to-spirit way
11.
a. being honest
b. advocate for the client’s care preferences
c. giving clear explanations
d. keeping family members informed
e. make the patient comfortable
f. showing interest in answering questions honestly
g. provide necessary emergency care

h. client privacy
i. all nursing services will be available
j. helping clients to do as much for themselves as possible
k. teach the patient how to keep the relative physically comfortable
12. Nurses are torn between the human caring model and the task-oriented biomedical model
and the institutional demands that consume their practice.
13. 2. Even though human caring is a universal phenomenon, the expressions, processes, and
patterns of caring vary among cultures.
14. 4. There is a mutual give-and-take that develops as nurse and client begin to know and
care for one another.
15. 3. Listening involves paying attention to the individual’s words and the tone of his or her
voice.
16. 4. depends on the family’s willingness to share information about the client, their
acceptance and understanding of therapies, whether the interventions fit the family’s daily
practices, and whether the family supports and delivers the therapies recommended
Chapter 9: Culture and Ethnicity
1. c
2. e
3. h
4. f
5. d
6. i
7. l
8. m
9. j
10. k
11. b
12. g
13. a
14.
a. attribute illness to natural, impersonal, and biological forces that cause
alteration in the equilibrium of the human body
b. believe that an external agent, which can be human or nonhuman, causes
health and illness
15. c
16. e
17. a
18. b
19. d
20. is a systematic and comprehensive examination of the cultural care values, beliefs, and
practices of individuals, families, and communities
21. aim is to encourage clients to describe values, beliefs, and practices that are significant to
their care that health care providers will take for granted unless otherwise uncovered
22. knowledge of a client’s country of origin and its history and ecological contexts.
Similarities shared by an immigrant group with the dominant culture in society are strong
predictors of assimilation.
23. Some distinct health risks are due to the ecological context of the culture; certain genetic
disorders are also linked with specific ethnic groups.
24. Although different configurations of a family exist, the most common is the nuclear
household made up of parents and their young children. Collectivistic groups often regard
members of their ethnic groups as closest kin and want to consult them. Social hierarchy and
roles are further defined by the culture.
25. Religious and spiritual beliefs are major influences on the client’s views about health,
illness, pain and suffering, and life and death.
26. Different cultural groups have distinct linguistic and communication patterns that reflect
core cultural values.
27. Differences exist in the dimensions of time that cultures emphasize and also in the
manner of expressing time.
28. Caring expressions integrate the central values and collectivistic active involvement of
the group, emphasizing mutual and reciprocal obligations of members. American culture
(self-care ideology and individualism).
29.
a. respect for and about
b. concern for and about
c. attention to details
d. helping and assisting
e. active listening
f. presence
g. understanding
h. connectedness
i. protection
j. touching
k. comfort measures
30.
a. retains and/or preserves relevant care values
b. adapt or negotiate with others for satisfying health outcomes
c. reorder, change, or modify client’s lifestyle
31. 1. Involves racial, ethnic, religious, and social groups
32. 2. Nurses need to determine how much an individual’s life patterns are consistent with
his or her heritage.
33. 2. Due to the changing demographic profile of the United States in relation to
immigration and significant culturally diverse populations
34. 1. Due to the fact that different cultural groups have distinct linguistic and
communication patterns
Chapter 10: Caring for Families
Define the three important attributes that characterize contemporary families

1. Durability: is the intrafamilial system of support and structure that extends beyond the
walls of the household
2. Resiliency: the ability of the family to cope with expected and unexpected stressors
3. Diversity: the uniqueness of each family unit; each person has specific needs, strengths,
and important developmental considerations
4. A family is defined as: defined biologically, legally, or as a social network with
personally constructed ties and ideologies
Current Trends and New Family Forms

Summarize the various family forms
5. Nuclear family: consists of the husband and the wife (and perhaps one or more children)
6. Extended family: includes relatives in addition to the nuclear family
7. Single-parent family: one parent leaves the nuclear family because of death, divorce, or
desertion, or when a single person decides to have or adopt a child
8. Blended family: Parents bring unrelated children from prior or foster-parenting
relationships into a new, joint living situation.
9. Alterantive patterns of relationships: multi-adult households, skip-generation families
and communal groups with children, nonfamilies, cohabiting partners and homosexual
partners
Explain the following threats and concerns facing the family

10. Changing economic status: Two-income families have become the norm, but the
incomes have not increased. Families at the lower end of the income scale have been
particularly affected, and single- parent families are especially vulnerable.
11. Homelessness: absolute: people without physical shelter who sleep outdoors in places
that are not intended for human habitation. Relative: those who have physical shelter but one
that does not meet the standards of health and safety.
12. Family violence: emotional, physical, and sexual abuse occurs toward spouses, children,
and older adults across all social classes. Factors are complex and may include stress,
poverty, social isolation, psychopathology, and learned family behavior.
13. Acute and chronic illness: acute: family members are left in waiting rooms to anticipate
information about their loved one. Chronic: family patterns and interactions, social activities,
work and household schedules; economic resources must be reorganized around the illness or
disability.
Explain how the following examples impact the family

14. Trauma: Family members need to cope with the challenges of a severe, life-threatening
event that includes many stressors and may impact the family’s functioning and decision-
making.
15. Human immunodeficiency virus (HIV): While the epidemic has slowed, high-risk
behaviors continue to rise, especially among men who have sex with men.
16. End of life: The family’s need for information, support, assurance, and presence are
great. The more you know about the family, how they interact, and their strengths and their
weaknesses, the better.
Theoretical Approaches: An Overview

Summarize the following general perspectives when working with or studying families
17. Family health system: Interactive, developmental, coping, integrity, and health
18. Developmental stages: Each stage has its own challenges, needs, and resources and
includes tasks that need to be completed before the family is able to successfully move on to
the next stage.
Attributes of Families
19. Structure may enhance or detract from the family’s ability to respond to stressor.
Briefly explain each of the following.
a. Rigid Structure: dictates who is able to accomplish a task and may limit the
number of persons outside the immediate family who assumes these tasks
b. Developmental stages: consistent patterns of behavior that lead to automatic
action do not exist, and enactment of roles is overly flexible
20. Family functioning focuses on the processes used by the family to achieve its goals.
Identify these process: communication among family members, goal setting, conflict
resolution, caregiving, nurturing, and use of internal and external resources
21. Identify the variables that affect the structure, functions, and health of a family:
class and ethnicity (different life chances for its members); distribution of wealth greatly
affects the capacity to maintain health; family’s beliefs, values, and practices influence health
behaviors.
22. Explain the following attributes of healthy families.

a. hardinesss is the internal strengths and durability of the family unit
b. resiliency helps to evaluate healthy responses when individuals and families
are experiencing stressful events
Family Nursing
Identify the three levels and focuses proposed for family nursing practice. Briefly
explain each.
23. Family as context: The primary focus is on the health and development of an individual
member existing within a specific environment.
24. Family as client: Family processes and relationships are the primary focus of nursing
care. Need to focus on family patterns versus individual characteristics.
25. Family as system: Use both family as context and family as client simultaneously.
Nursing Process for the Family
26. Three factors underlie the family approach to the nursing process. Name them
a. the nurse views all individuals within the family context
b. that families have an impact on individuals
c. that individuals have an impact on the families
27. Identify areas to include in the family assessment: Interactive, developmental, coping,
integrity, and health processes
28. Summarize the challenges for family nursing in relation to each of the following:
a. Discharge planning: an accurate assessment of what will be needed for care
at the time of discharge, along with any shortcomings in the home setting
b. Cultural diversity: in the family requires recognizing not only the diverse
ethnic, cultural, and religious backgrounds of clients but also the differences and
similarities within the same family
29. When implementing family-centered care, the following need to be addressed.
Briefly explain.
a. Health promotion: improve or maintain the physical, social emotional and
spiritual well-being of the family unit and its members
b. Family strengths: clear communication, adaptability, healthy child-rearing
practices, support and nurturing among family members, and the use of crisis for
growth
c. Acute care: challenges to the family in relation to early discharge and
employment outside the home.
d. Restorative care: maintain client’s functional abilities within the context of
the family, as well as find ways to better the lives of the chronically ill and disabled
Identify the conflicts that affect the “sandwich generation”

30. Conflicting responsibilities for aging parents, children, spouse, and job. Frequently tries
to do it all. May not recognize need for help or may not request help.
Chapter 11: Developmental Theories

1. Briefly explain the following processes that affect growth and developement
a. Biologic processes: produce changes in an individual’s physical growth and
development
b. Cognitive processes: comprise changes in intelligence, ability to understand
and use language, and the development of thinking
c. Socioemotional processes: consist of variations that occur in an individual’s
personality, emotions, and relationships with others during their lifetime
Developmental Theories
2. Briefly summarize Gesell’s theory of development: is that although each child’s
pattern if growth is unique, this pattern is directed by gene activity
3. Explain the five psychosexual developmental stages of Freud’s theroy

a. Stage 1: (oral) sucking and oral satisfaction is not only vital to life, but
pleasurable
b. Stage 2: (anal) children become increasing aware of the pleasurable
sensations of this body region with interest in the products of their effort
c. Stage 3: (phallic) the genital organs become the focus of pleasure
d. Stage 4: (latency) sexual urges are repressed and channeled into productive
activities that are socially acceptable
e. Stage 5: (genital) time of turbulence when earlier sexual urges reawaken and
are directed to an individual outside the family circle
4. Trust versus mistrust: Sensorimotor period
5. Autonomy versus shame: Preoperational period
6. Initiative versus guilt: Use of symbols; egocentric
7. Industry versus inferiority: Conrete operations period
8. Identity versus role confusion: Formal operations period
9. Define temperament: is a behavioral style that affects the individual’s emotional

interactions with others
Gould’s research supports stage theory in adult development with a set of themes.
Briefly explain the five themes identified.
10. First Theme: the move away from parental influence is gradual as young adults establish
themselves as adults (20s)
11. Second Theme: experience the consequences of the decisions of their independence
(early 30s)
12. Third Theme: the impact of a growing family and aging parents influences this time
(late 30s)
13. Fourth Theme: resignation and the belief that possibilities are limited (40s)
14. Fifth Theme: a decrease in negativism occurs; a realization of mortality (50s)
15. Contemporary Life-events approach considers: the individual’s personal
circumstances, how the person views and adjusts to changes, and the current social and
historical context in which the individual is living
16. Explain the two stages of Piaget’s moral development theroy

a. Heteronomous morality: occurs between 4-7 years and is characterized by a
belief that rules are unchangeable and that when a rule is broken, there is imminent
justice
b. Autonomous morality: child understands that people make rules and that
they can be changed
Kohlberg identified six stages of moral development under three levels. Briefly explain
each.
17. Level I: Preconventional level: The person reflects on moral reasoning based on
personal gain.
Stage 1: Punishment and obedience orientation (in terms of absolute obedience to authority
and rules)
Stage 2: Instrumental relativist orientation (more then one right view)
18. Level II: Conventional Level: Sees moral reasoning based on his or her own personal
internalization of societal and others’ expectations
Stage 3: Good boy-nice girl orientation (good motives, showing concern for others, and
keeping mutual relationships)
Stage 4: Society-maintaining orientation (expand their focus from a relationship with others
to societal concerns)
19. Level III: Post-conventional Level: Balance between human rights and obligations and
societal rules and regulations
Stage 5: Social contract orientation (follows the societal law but recognizes the possibility
of changing the law to improve society)
Stage 6: Universal ethical principle orientation (right by the decision of conscience in accord
with self-chosen ethical principles)
Chapter 12: Conception Through Adolescence

1. Nagele’s rule: Computes the length of preegnancy
2. Fertilization: Sperm penetrates the ovum
3. Germinal period: First 2 weeks after conception
4. Zygote: newly formed organism with its full genetic complement
5. Embryonic period: The beginning of the third week through the eighth week after
conception
6. Fetal period: ninth week after conception; ends with birth
7. Teratogens: Factors that are capable of producing functional or structural damage to the
fetus
8. Prematurity: infant between 20 to 37 weeks gestation
9. Neonatal period: first month of life
10. Molding: Overlapping of the soft skull bones
11. Fontanels: diamonds and triangular shapes between the unfused bones of the skull
12. Cognitive development: Innate behavior, reflexes, and sensory functions
13. Hyperbilirubinemia: Excessive amount of bilirubin in the blood
14. Inborn errors of metabolism: Genetic disorders caused by the absence of deficiency of
a substance essential to cellular metabolism
15. Circumcision: benefits include prevention of penile cancer and urinary tract infectiosn
(UTIs)
16. Safety concerns: Car seats and cribs
The Infant
17. the period from 1 month to 1 year of age
18. Summarize the physical changes that occur in the infant: size increases rapidly during
the first year of life; birth weight doubles (5 months) and triples (12 months). Height
increases an average of 1 inch every 6 months until 12 months.
19. Describe the cognitive changes that occur in the infant: learns by experiencing and
manipulating the environment; sensorimotor period
20. Identify the language development in the infant and how to help parents further
develop the infant’s language: by 1 year, they not only recognize their own names but are
able to say three to five words and understand 100 words. The nurse can promote language
development by encouraging parents to name objects on which the infant is focusing.
21. Explain the following psychosocial changes that occur
a. Separation and individuation: infants are unaware of the boundaries of self,
but they learn where the self ends and the external world begins
b. Play: much of the play is exploratory as they use their senses to observe and
examine their own bodies and objects of interest in their surroundings
22. Explain the following in relation to health risks of the infant
a. Injury Prevention: MVA, aspiration, falls, or poisoning are major causes of
death
b. Child maltreatment: intentional physical abuse or neglect, emotional abuse
or neglect, and sexual abuse
23. Briefly explain health concerns related to the following
a. Nutrition: feeding alternatives: breast feeding is recommended; the use of

whole cow’s milk is not recommended before 12 months
b. Immunization: recommended that the administration of the primary series
begin after birth and be completed during early childhood
c. Sleep: infants are nocturnal and sleep between 9 and 11 hours, averaging 15
hours a day
The Toddler
24. Toddlerhood ranges from 12-36 months
25. Describe language ability at this stage: 10 words to 300 words and is able to speak in
two-word sentences.
26. Describe the moral development of a toddler: they do not understand the concepts of
right and wrong; they do grasp pleasant and unpleasant results
27. Identify the health risks of a toddler: locomotion abilities and curiosity; poisoning
occurs frequently; drowning, MVA
The preschooler
28. The preschool period ranges from years between 3 and 5
29. Describe the cognitive changes that occur with the preschooler demonstrate their
ability to think in a more complex manner by classifying objects, increased social interaction,
cause-and-effect relationships; the world remains closely linked to concrete experiences;
their greatest fear is bodily harm
30. Explain the following
a. Moral development: begins to understand behaviors that are considered
socially right or wrong
b. Language: increases rapidly, is more social, and asks questions for
information
31. Describe the concept of play for the preschooler engage in similar if not identical
activity; there is no division of labor or rigid organization or rules
32. Explain health concerns related to the following for this group
a. Nutrition: the quality of food is more important than the quantity
b. Sleep: average 12 hours a night, infrequent naps
c. Vision: regular intervals of screening
The School-Age Child

33. The school-age year range from 6 years until 12 years (puberty)
34. Define the cognitive skills that develop in the school-age child: Define the cognitive
skills that develop in the school-age child the ability to think in a logical manner about the
here and now and to understand the relationship between things and ideas. They have the
ability to concentrate on more than one aspect of a situation and are able to reason about the
relationships between classes.
35. Summarize psychosocial development in relation to the following
a. Moral – need for moral code and social rules becomes more evident
b. Peers – become more important; play involves peers and the pursuit of group
goals
c. Sexual – latency period
d. Stress – from parental expectations, peer expectations, school environment,

violence in the community
36. Identify the health risks for the school-age child: MVA, drowning, burns, substance
abuse and poisoning, bodily damage, stranger safety
37.
a. food guide pyramid
b. mechanics of dental hygiene, biannual check-ups
c. immunization information and prevention practices
d. prevention programs
e. discuss with parents the learning needs of their child; provide age- appropriate
education
38. 13-20 years
39.
a. Increased growth rate of skeleton, muscle and viscera
b. Sex-specific changes
c. Alteration in distribution of muscle and fat
d. Development of the reproductive system
40. the onset of menstruation
41. ability to determine possibilities, rank and solve problems, and make decisions through
logical operations. They can think abstractly and deal effectively with hypothetical problems.
They can move beyond the physical or concrete properties of a situation and use reasoning
powers to understand the abstract.
42. Do not avoid discussing sensitive issues. Ask open-ended questions. Look for meaning
behind the words or actions. Be alert to clues to their emotional state. Involve other
individuals and resources.
43.
a. puberty enhances sexual identity; physical evidence of maturity encourages
the development of behaviors
b. similarity in dress or speech and popularity are major concerns
c. movement toward stronger peer relationships is contrasted with adolescents'
movement from parents
d. provides a goal; need to select action that promotes self-satisfaction, identity,
and continued opportunity for growth
e. depends heavily on cognitive and communication skills and peer interaction.
Regarding rules, they learn to use their own judgment rather than use the rules to
avoid punishment as in earlier years.
f. evaluate their own health according to feelings of well-being, ability to
function normally, and absence of symptoms
44.
a. accidents
b. homicide
c. suicide
45.
a. decrease in school performance
b. withdrawal
c. loss of initiative
d. loneliness, sadness, and crying

e. appetite and sleep disturbances
f. verbalization of suicidal thought
46.
a. physical and psychosocial components that involve the pursuit of thinness
through starvation
b. binge eating and behaviors to prevent weight gain (vomiting, laxatives,
exercise)
47.
a. driver’s education and wear seat belts
b. screen for use and inform of the risks for use
c. education about STDs; encourage abstinence
d. teach conflict resolution
48. limited access to health care, limited health care insurance, lack of transportation to
health care, poverty, and farming accidents
49. learning or emotional difficulties, death related to violence, unintentional injuries,
increased rate of adolescent pregnancy, poverty, and limited access
50. 4. toddlers often develop food jags or the desire to eat one food repeatedly; continue to
offer a variety of nutritious foods
51. 1. do not understand what is right or wrong, but they do understand positive and negative
reinforcement, thus learning self control
52. 1. The school and home influence growth and development. If they are positively
recognized for success, they feel a sense of worth.
53. 4. They establish close relationships and make choices about their vocation; morality
comes from individual principles of conscience.
Chapter 13: Young to Middle Adult
1. the period between the late teens and the mid to late 30s
2. general life satisfaction, hobbies and interests, habits, home conditions and pets,
economics, occupational environment, physical and mental strain
3. formal and informal educational experiences, general life experiences, and occupational
opportunities increase conceptual problem-solving and motor skills
4.
a. the person refines self-perception and ability for intimacy
b. the person directs enormous energy toward achievement and mastery of the
world
c. time of vigorous examination of life goals and relationships
5.
a. identification of modifiable factors that increase the risk for health problems
and provide education and support
b. the two-career family has benefits and liabilities with resulting stressors
c. psychodynamic aspect of sexual activity is as important as the type or
frequency of sexual intercourse
d. conception, pregnancy, birth, and the puerperium are the major phases
6.
a. many do not marry until late 20s or early 30s; remain single; expanding
careers for women; and divorce
b. availability of contraception, economic considerations, general health status
and age
c. cohabitation without marriage; gay and lesbian
7. the presence of certain chronic illnesses in the family increases the patient’s risk of
developing a disease, distinct frrm hereditary disease
8. sharing utensils, poor dental hygiene
9. due to poverty, family breakdown, child abuse and neglect, repeated exposure to
violence, and access to guns
10. intoxicated MVAs, stimulants, excessive caffeine use
11. exploration of situational factors that affect the progress and outcome (financial, career,
living accommodations, family support systems, parenting disorders, depression, and coping
mechanisms)
12. major health problem and leads to chronic disorders, infertility, or death
13. exposure to work-related hazards or agents, which can cause disease and cancer
14. a prolonged time to conceive, comprehensive histories of both the female and male
partners to determine factors that affect fertility as well as pertinent physical findings
15. important to prevent or decrease the development of chronic health conditions that
develop later in life
16. need to perform monthly skin, breast, or male self examinations
17. job stress (situational), family stress (multiplicity of changing relationships and
structures), pregnant woman and childbearing
18. prenatal care is the routine thorough physical examination of the pregnant woman
19. irregular, short contractions
20. is the period of approximately 6 weeks after delivery
21. breast feeding

22. early to mid 30s and last through the late 60s
23. most visible changes are graying of the hair, wrinkling of the skin, thickening of the
waist, and decreases in hearing and visual acuity, which may have a impact on self-concept
and body image
24.
a. is the period during which ovulation declines, resulting in a diminished
number of ova and irregular menstrual cycles
b. is the disruption of this cycle, primarily because of the inability if the
neurohormonal system to maintain its periodic stimulation of the endocrine system.
c. occurs in men in their late 40s or early 50s due to decreased levels of
androgens
25. middle adults having the responsibility of raising their own children while caring for
aging parents
26. changes occur by choice or as a result of changes in the workplace or society (limited
upward mobility, decreasing availability of jobs, need for challenge)
27. couples recultivate their relationships, menopausal symptoms, stresses due to sexual
changes or conflicts
28. choice and freedom; delayed marriage and delayed parenthood, adoption
29. death of a spouse, separation, divorce, and the choice of remarrying or remaining single
30. departure of the last child is a stressor, leading to a readjustment phase
31. goals of wellness and guides clients to evaluate health behaviors, lifestyle, and
environment by minimizing the frequency of stress-producing situations, increasing stress
resistance, and avoiding physiological response to stress
32. evaluate health behaviors and lifestyle; counseling related to physical activity and
nutrition
33.
a. related to change, conflict, and perceived control of environment, which may
motivate the adult to rethink life goals and stimulates creativity or precipitates
psychosomatic illness and preoccupation with death
b. risk factors: female, disappointments or losses at work, school or
relationships, departure of the last child, and family history
34. 1. factors that predispose include poverty, family breakdown, child abuse and neglect,
repeated exposure to violence, and access to guns
35. 3. the most visible changes are the graying of hair, wrinkling of the skin, and thickening
of the waist
36. 1. inability of the neurohormonal system to maintain its periodic stimulation of the
endocrine system
Chapter 14: Older Adult
1. age 65 and over

2. d
3. c
4. a
5. b
6.
a. ill, disabled, and physically unattractive
b. forgetful, confused, rigid, bored and unfriendly
c. mistaken ideas about living arrangements
d. undervaluing due to unattractiveness
7. as the result of random cellular damage that occurs over time
8. genetically programmed physiological mechanisms within the body control the process
of aging
9.
a. the oldest; states that aging individuals withdraw from customary roles and
engage in more introspective, self-focused activities
b. continuation of activities performed during middle age as necessary for aging
c. that personality remains the same and behavior becomes more predictable as
people age
10.
a. adjusting to decreasing health and physical strength
b. adjusting to retirement and reduced or fixed outcome
c. adjusting to the death of a spouse
d. accepting self as aging person
e. maintaining satisfactory living arrangements
f. redefining relationships with adult children
g. finding ways to maintain quality of life
11.
a. home (should not feel like a hospital)
b. care (staff actively assisting and interacting socially)
c. family involvement (should encourage involvement)
d. environment (ample lighting, minimal noise, plants, pets)
e. communication (respectful and considerate)
f. staff (attentive to resident requests)
12. the interrelation between physical and psychosocial aspects of aging
13. the effects of disease and disability on functional status
14. the decreased efficiency of homeostatic mechanisms
15. the lack of standards for health and illness norms
16. altered presentation and response to specific disease
17.
a. change in mental status
b. falls
c. dehydration
d. decrease in appetite
e. loss of function
f. dizziness and incontinence
18. d
19. f
20. g
21. b
22. i
23. j
24. h
25. e
26. a
27. c
28. Functional status refers to the capacity and safe performance of activities of daily living
(ADLs) and is a sensitive indicator of health and illness.
29.
a. acute confusional state; potentially reversible; often due to a physiological
cause
b. generalized impairment of intellectual functioning that interferes with social
and occupational functioning
c. not a normal part of aging
30.
a. stage of life characterized by transitions and role changes (health status,
option to continue working, sufficient income)
b. by choice (desire not to interact with others) or a response to conditions that
inhibit the ability or the opportunity to interact with others
c. whether healthy or frail there is a need to express sexual feelings (love,
warmth, sharing and touching)
d. the ability to live independently strongly determines housing choices (social
roles, family responsibilities, health status)
e. death of a spouse affects more older women then men
31.
a. heart disease
b. cancer
c. CVA
d. lung disease
e. accidents/falls
f. diabetes
g. kidney disease
h. liver disease
32.
a. participation in screening activities
b. regular exercise
c. weight reduction.
d. eating a low fat, well-balanced diet
e. regular dental visits
f. smoking cessation
g. immunizations
33. c
34. h
35. e
36. g
37. k
38. i
39. l
40. m
41. a
42. f
43. b
44. d
45. j
46. c
47. e
48. d
49. b
50. f
51. a
52. causes include delirium, untreated UTIs, excessive urine production, medications,
depression, restricted mobility, and constipation
53. related to changes in aging and to immobility, incontinence, and malnutrition
54. intrinsic (gait and balance problems, weakness, or cognitive impairment) or extrinsic
(polypharmacy, poor lighting, cluttered environment)
55.
a. continues the recovery from acute illness or surgery that began in the acute
care setting
b. addresses chronic conditions that affect day-to-day functioning
56. 4. It potentially is a reversible cognitive impairment that is often due to physiological
causes.
57. 3. Beyond caloric requirements, therapeutic diets restrict fat, sodium, or simple sugars or
increase fiber or foods high in calcium, iron, and vitamins A or C.
58. 1. Often due to the result of retinal damage, reduced pupil size, development of opacities
in the lens or loss of lens elasticity
59. 4. It is the stage of life characterized by transitions and role changes.
Chapter 15: Critical Thinking in Nursing Practice
1. Is an active, organized, cognitive process used to examine one’s thinking and the thinking
of others.
2. based on research or clinical expertise
3.
a. seek the true meaning of a situation
b. be tolerant of different views and own prejudices
c. anticipate possible results or consequences
d. be organized
e. trust in your own reasoning processes
f. be eager to acquire new knowledge and value learning
g. reflect upon your own judgments
4.
a. trust that experts have the right answers for every problem; thinking is
concrete and based on a set of rules or principles
b. begin to separate themselves from authorities, analyze and examine choices
more independently
c. anticipate the need to make choices without assistance from others,
accountability
5. c
6. d
7. a
8. g
9. b
10. f
11. e
12.
a. knowledge base
b. experience
c. critical-thinking competencies
d. attitudes
e. standards
13. c
14. g
15. j
16. a
17. e
18. h
19. d
20. f
21. b
22. i
23. k
24.
a. is a guideline or principle for rational thought
b. refers to ethical criteria for nursing judgments; evidence-based used for

evaluation and criteria for professional responsibility
25. is the process of purposefully thinking back or recalling a situation to discover its
purpose or meaning
26. is a visual representation of client problems and interventions that shows their
relationships to one another
27. 4. involves recognizing an issue exists, analyzing information, evaluating information,
and making conclusions
28. 4. the 5 steps are assessment, diagnosis, plan, interventions, evaluation
29. 3. identifying a client’s health care needs
30. 4. implementation
Chapter 16: Nursing Assessment
1. d
2. e
3. b
4. c
5. a
6. health perception-health management pattern
7. nutritional-metabolic pattern
8. elimination pattern
9. activity-exercise pattern
10. sleep-rest pattern
11. cognitive-perceptual pattern
12. self-perception-self-concept pattern
13. role-relationship pattern
14. sexuality-reproductive pattern
15. coping-stress tolerance pattern
16. value-belief pattern
17.
a. subjective – clients’ verbal descriptions of their health problems
b. objective – observations or measurements of a client’s health status
18.
a. client
b. family and significant others
c. health care team
d. medical records
e. literature
19.
a. introduce yourself, explain your role
b. establish a caring therapeutic relationship
c. get insight about the client’s concerns
d. determine the client’s goals and expectations
e. obtain cues about which parts of the data collection phase require further
investigation
20.
a. an individual’s past, present, or future physical or mental health or condition
b. the provision of health care to the individual
c. the past, present, or future payment for provision of health care to the
individual
21. data about the client’s current level of wellness, review of systems, family history,
sociocultural history, spiritual history, and mental and emotional reactions to illness
22.
a. open ended: prompts clients to describe a situation in more than one or two
words
b. back-channeling: active listening prompts
c. closed-ended: limit the client’s answers to one or two words
23. f
24. g
25. e
26. h
27. i
28. c
29. j
30. b
31. a
32. d
33. is the comparison of data with another source to determine data accuracy
34. involves recognizing patterns or trends in the clustered data, comparing them with
standards, and then coming to a conclusion about the client’s responses to a health problem
35. timely, thorough, and accurate; record all observations; pay attention to facts and be
descriptive; record objective information in accurate terminology; do not generalize or form
judgments
36. 4. Prompts clients to describe a situation in more than one or two words
37. 1. Some may be focused, and others may be comprehensive.
38. 3. Takes information provided in the client’s story and then more fully describes and
identifies specific problem areas
39. 2. asking questions about the normal functioning of each system and the changes are
usually subjective data perceived by the client
Chapter 17: Nursing Diagnosis
1. d
2. e
3. f
4. b
5. c
6. g
7. a
8. is the name of the diagnosis as approved by NANDA; it describes the essence of the
client’s response to health conditions
9. is a condition or etiology identified from the client’s assessment data, actual or potential
responses to the health problem
10. the cause of the nursing diagnosis within the domain of nursing practice
11. describes the characteristics of the human response identified
12. are environmental, physiological, psychological, genetic, or chemical
13. is the one way to graphically represent the connections between concepts and ideas that
are related to a central subject
14. Review your level of comfort and competence with interview and physical assessment
skills.
15. Approach assessment in steps.
16. Review your clinical assessment skills.
17. Determine the accuracy of your data.
18. Be organized in any examination.
19. Review your data base to decide if it is accurate and complete; be careful to consider any
conflicting cues or if there is insufficient cues to confirm a diagnosis.
20. Avoid premature clustering of data; always identify the nursing diagnosis from the data,
not the reverse.
21. Word the diagnostic statement in appropriate, concise, and precise language; use correct
terminology; identify the client problem rather than the goal; make professional rather than
prejudicial judgments; avoid legally inadvisable statements.
22. 4. Provide the basis for the selection of nursing interventions to achieve outcomes for
which the nurse is responsible.
23. 4. is the diagnostic label that describes the essence of a client’s response to health
conditions
24. 4. It is associated with the client’s actual or potential response to the health problem.
25. 2. the client’s actual or potential response to the health problem
Chapter 18: Planning Nursing Care
1.
a. if untreated, result in harm to the client or others
b. involve nonemergent, non-threatening needs of the client
c. are not always directly related to a specific illness or prognosis
2. d
3. b
4. e
5. c
6. f
7. a
8. outcomes and goals reflect the client’s behavior and responses expected as a result of
nursing interventions
9. precise in evaluating a client response to a nursing action; addresses only one behavior or
response per goal
10. be able to observe if a change takes place in a client’s status
11. terms describing quality, quantity, frequency, length, or weight allow you to evaluate
outcomes precisely
12. indicates when you expect the response to occur
13. ensure that the client and nurse agree on the direction and time limits of care
14. that a client is able to reach
15. nurse-initiated interventions that do not require direction or an order from another health
care professional
16. physician-initiated interventions that require an order for a physician or other health care
professional
17. interdependent nursing interventions that require the combined knowledge, skill, and
expertise of multiple care professionals
18.
a. characteristics of the nursing diagnosis
b. goals and expected outcomes
c. evidence-based interventions
d. feasibility of the interventions
e. acceptability to the client
f. your own competency
19. direct clinical nursing care and to decrease the risk of incomplete, incorrect, or inaccurate
care; identifies and coordinates resources for delivering care; lists the interventions needed to
achieve the goals of care
20. useful for learning the problem-solving technique, nursing process, skills of written
communication, and organizational skills needed for nursing care
21. are part of the client’s legal record and differ by setting and the evolving client situation
22. format is standardized plans, which the nurses are able to individualize for a specific
client
23. multidisciplinary treatment plans that outline treatments or interventions clients need to
have; most are based on medical diagnoses rather then nursing
24. Gather the clinical assessment data base from the client’s medical record.
25. Review all of the information about the client’s problems, treatments, and medication in
the literature.
26. Review any standardized care plans, critical pathways, protocols, or client education
material.
27. First, develop a skeleton diagram of the client’s chief medical diagnosis and patterns of
assessment data. Identify and group the related patterns.
28. Review your assessment patterns and identify nursing diagnoses.
29. When planning, analyze relationships among the nursing diagnoses.
30. List the nursing interventions to attain the outcomes for each nursing diagnosis.
31. Use the map to write down the responses to each nursing activity.
32. Revise, take notes, and add or delete nursing interventions.
33. is a process in which you seek the expertise of a specialist to identify ways to handle
problems in client management or the planning and implementation of therapies
34.
a. identify the general problem area
b. direct the consultation to the right professional
c. provide the consultant with relevant information about the problem area
d. do not prejudice or influence the consultants
e. be available to discuss the findings and recommendations
f. incorporate the recommendations into the plan of care
35. 2. is an objective behavior or response that you expect a client to achieve in a short time,
usually less than a week
36. 4. is the measurable change in a client’s condition that you expect to occur in response to
the nursing care
37. 3. The nurse sets client-centered goals and expected outcomes and plans nursing
interventions.
Chapter 19: Implementing Nursing Care
1.
a. is any treatment, based upon clinical judgment and knowledge, that a nurse
performs to enhance client outcomes
b. are treatments performed through interactions with clients
c. are treatments performed away from the client but on behalf of the client
2.
a. review the set of all possible interventions for the client’s problem
b. review all of the possible consequences associated with each possible nursing
action
c. determine the probability of all possible consequences
d. make a judgment of the value of that consequence to the client
3. or protocol is a document that guides decisions and interventions for specific health care
problems or conditions.
4. is a preprinted document containing orders for the conduct of routine therapies,
monitoring guidelines, and/or diagnostic procedures for clients with identified clinical
problems
5. offer a level of standardization to enhance communication of nursing care across settings
and to compare outcomes
6. continuous process that occurs each time you interact with a client; you collect new data,
identify a new client need, and modify the care plan
7. If the client’s status has changed and the nursing diagnosis and related nursing
interventions are no longer appropriate, modify the nursing care plan.
8. organization of equipment, skilled personnel, and the environment
9. Risks to patients come from both the illness and the treatments.
10. includes cognitive (application of critical thinking in the nursing process), interpersonal
(trusting relationship, level of caring and communication) and psychomotor skills
(integration of cognitive and motor activities)
11. activities usually performed in the course of a normal day (ambulation, eating, dressing,
bathing, grooming)
12. skills such as shopping, preparing meals, writing checks, taking medications
13. involve the safe and competent administration of nursing procedures
14. is a direct care method that helps the client use a problem-solving process to recognize
and manage stress and to facilitate interpersonal relationships
15. the focus of change is intellectual growth or the acquisition of new knowledge or
psychomotor skills
16. is a harmful or unintended effect of a medication, diagnostic test, or therapeutic
intervention
17. promote health and prevent illness to avoid the need for acute or rehabilitative health care
18. represents the contributions of all disciplines caring for the client
19. noninvasive and frequently repetitive interventions can be assigned to assistive personnel
(nurse assistant). The nurse is responsible for ensuring that each task is appropriately
assigned and is completed according to the standard of care.
20. that clients and families invest time in carrying out required treatments to achieve client
goals
21. 4. the nurse needs to exercise good judgment and decision-making before actually
delivering any interventions
22. 2. certain nursing situations require you to obtain assistance by seeking additional
personnel, knowledge, and/or nursing skills. You will need assistance with this patient to help
turn and position the client safely.
23. 1. guides decisions and interventions for specific health care problems or conditions
24. 1. an acquisition of new knowledge or psychomotor skills
Chapter 20: Evaluation
1. to determine if you met the expected outcomes, not if the nursing interventions were
completed. They are the standards against which the nurse judges if goals have been met and
if care is successful.
2.
a. identifying evaluative criteria and standards
b. collecting data to determine whether the criteria or standards are met
c. interpreting and summarizing findings
d. documenting findings and any clinical judgment
e. terminating, continuing, or revising the care plan
3.
a. examine the outcome criteria to identify the exact desired client behavior
b. assess the client’s actual behavior or response
c. compare the established outcome criteria with the actual behavior
d. judge the degree of agreement between outcome criteria and the actual
behavior
e. if there is no agreement between the outcome criteria and the actual behavior,
what are the barriers?
4. Determine if your goals have been met, and then adjust the plan of care accordingly.
5. If the nurse and the patient agree that the expected outcomes and goals have been met,
then discontinue that portion of the care plan.
6. Identify the factors that interfere with goal achievement or an error in nursing judgment
or failure to follow each step of the nursing process.
7. Determine if the goals were appropriate, realistic, and time-appropriate
8. the appropriateness of the interventions selected and the correct application of the
intervention
9. an approach to the continuous study and improvement of the processes of providing
health care services to meet the needs of clients and others
10. managing the individual clinical outcomes of clients as a result of prescribed treatments
11. 2. Determines whether the client’s condition or well-being has improved after the
application of the nursing process
12. 2. Whenever you have contact with a client, you continually make clinical decisions and
redirect nursing care; this is an ongoing process
13. 2. They are the expected favorable and measurable results of nursing care.
14. 3. If the goals have not been met, you may need to adjust the plan of care by the use of
interventions, modify or add nursing diagnoses with appropriate goals and expected
outcomes, and redefine priorities.
Chapter 21: Managing Client Care
1. d
2. e
3. b
4. a
5. j
6. c
7. f
8. h
9. i
10. g
11. establishment of nursing practice or problem-solving committees or professional shared
governance councils
12. nurse/physician collaborative practice
13. interdisciplinary collaboration
14. staff communication
15. staff education
16. The first activity involves a focused and complete assessment of the client’s condition to
allow for an accurate clinical decisions as to the client’s health problems and required
nursing therapies.
17. need to set priorities: high (immediate threat), intermediate (non-emergent, non-life-
threatening), low (actual or potential problems)
18. effective use of time doing the right things
19. Administration of client care occurs more smoothly when staff members work together.
20. goal setting, time analysis, priority setting, interruption control, evaluation
21. is an ongoing process that compares actual client outcomes with expected outcomes
22. A professional environment is one in which staff members respect one another’s ideas,
share information, and keep one another informed.
23.
a. right task
b. right circumstances
c. right person
d. right direction/communication
e. right supervision
24.
a. assess the knowledge and skills of the delegate
b. match tasks to the delegate’s skills
c. communicate clearly
d. listen attentively
e. provide feedback
25. 4. As a student nurse, you have a responsibility for the care given to your clients, and you
assume accountability for that care.
Chapter 22: Ethics and Values
1. d
2. b
3. e
4. c
5. a
6.
a. responsibility
b. accountability
c. confidentiality
d. advocacy
7. personal belief about the worth of a given idea, attitude, custom, or object that sets
standards that influence behavior
8. development of values begins in childhood; shaped by experiences within the family unit
with individual experiences influencing further value formation
9. need to distinguish between value, facts, and opinion
10. a system of ethics that defines actions as right or wrong based on their “right-making
characteristics such as fidelity to promises, truthfulness, and justice”; does not look at the
consequences of actions
11. value of something is determined by its usefulness; the main emphasis is on the outcome
or consequence of actions
12. focuses on inequalities between people; it looks to the nature of relationships for
guidance
13. focuses on understanding relationships, especially personal narratives
14. You are able to resolve it solely through a review of scientific data.
15. It is perplexing.
16. The answer to the problem will have a profound relevance for areas of human concern.
17.
a. ask the question
b. gather information relevant to the case
c. clarify values
d. verbalize the problem
e. identify possible causes of action
f. negotiate a plan
g. evaluate the plan over time
18. education, policy recommendation, and case consultation
19. helps a client and family decide on the merits of certain risky interventions
20. conditions that are not yet evident but that are certain to develop in the future
21. interventions unlikely to produce benefit for the client
22. 2. Ethical problems come from controversy and conflict.
23. 4. The ethics committee is an additional resource for clients and health care professionals.
24. 4. Incorporate as much information as possible from a variety of sources such as lab and
test results, clinical state of the client, current literature about the condition, and the client’s
religious, cultural, and family situation.
Chapter 23: Legal Implications in Nursing Practice
1. e
2. h
3. f
4. b
5. c
6. g
7. d
8. a
9. It protects the rights of disabled people. It also is the most extensive law on how
employers must treat health care workers and clients infected with HIV.
10. that when a client comes to the ER/hospital, an appropriate medical screening occurs
within the hospital’s capacity. If an emergency exists, the hospital is not to discharge or
transfer the client until the condition stabilizes.
11. forbids health plans from placing lifetime or annual limits on mental health coverage that
are less generous than those placed on medical or surgical benefits
12. requires health care institutions to provide written information to clients concerning their
rights under state law to make decisions, including the right to refuse treatment and
formulate advance directives
13. written documents that direct treatment in accordance with a client’s wishes in the event
of a terminal illness or condition
14. legal document that designates a person or persons of one’s choosing to make health care
decisions when the client is no longer able to make decisions on his or her own behalf
15. An individual over the age of 18 has the right to make an organ donation; needs to make
the gift in writing with his or her signature.
16. provides rights to clients (protects individuals from losing their health insurance when
changing jobs by providing portability) and protects employees. It also establishes the basis
for privacy and confidentiality.
17.
a. only to ensure the physical safety of the resident or other residents
b. when less restrictive interventions are not successful
c. only on the written order of a physician, which includes a specific episode
with start and end times
18. The Board of Nursing licenses all RNs in the state in which they practice and can
suspend or revoke a license if a nurse’s conduct violates provisions in the licensing statute
based on administrative law rules that implement and enforce the statute.
19. law that encourages health care professionals to assist in emergencies, limits liability, and
offers legal immunity for nurses who help at the scene of an accident
20. protection of the public’s health, advocating for the rights of people, regulating health
care and health care financing, and ensuring professional accountability for the care provided
21. Determination of death requires irreversible cessation of circulatory and respiratory
functions or that there is irreversible cessation of all functions of the entire brain, including
the brain stem.
22. Statute that stated that a competent individual with a terminal disease could make an oral
and written request for medication to end his or her life in a humane and dignified manner.
23. d
24. g
25. e
26. h
27. i
28. c
29. f
30. j
31. b
32. a
33. Inform their supervisor; they need to make a written protest to nursing administrators.
Keep a copy of this document in your own personal file.
34. need to inform the supervisor of any lack of experience in caring for the type of clients
on said unit. They also need to request an orientation to the unit.
35. Nurses must follow the physician’s orders unless they believe the orders are in error or
will harm the clients. If there is any controversy with the order, the nurse needs to also
inform the supervising nurse or follow the established chain of command.
36. system of ensuring appropriate nursing care that attempts to identify potential hazards
and eliminate them before harm occurs
37. provides a database for further investigation in an attempt to determine deviations from
standards of care; corrective measures needed to prevent recurrence and to alert risk
management to a potential claim situation
38. 1. Determines the legal boundaries within each state
39. 3. Need to perform only those tasks that appear in the job description for a nurse’s aide or
assistant
40. 4. conduct that falls below the standards of care
41. 1. unintentional touching without consent
42. 4. need to follow the institution’s policies and procedures on how to handle these
situations and utilize the chain of command
Chapter 24: Communication
1. is a lifelong learning process that is an essential attribute of professional nursing practice

2.
a. through the 5 senses
b. individual’s culture and education
3. c
4. d
5. b
6. e
7. a
8. g
9. c
10. f
11. j
12. l
13. m
14. a
15. h
16. b
17. i
18. k
19. n
20. e
21. d
22.
a. intimate zone (0 –18 inches)
b. personal zone (18 in.– 4 ft)
c. social zone (9 – 12 ft)
d. public zone (12 ft and greater)
23.
a. social zone (permission not needed)
b. consent zone (special care needed)
c. intimate zone (great sensitivity needed)
d. vulnerable zone
24. before meeting the client (review data, talk to caregivers, anticipate health concerns, plan
enough time for interaction)
25. when the nurse and client meet and get to know one another (set the tone for the
relationship, expect to be tested and closely observed, clarify the roles of the client and the
nurse)
26. when the nurse and the client work together to solve problems and accomplish goals
(help the client to express feelings; self-exploration, set goals, take action, self-disclosure,
and confrontation used appropriately)
27. during the ending of the relationship (termination is near, goal achievement, relinquishing
responsibility, transition to other caregivers as needed)
28. includes the understanding of the complexities of family dynamics, needs, and
relationships
29. focuses on team-building, facilitating group processes, collaboration, consultation,
delegation, supervision, leadership, and management
30. through channels such as neighborhood newsletters, public bulletin boards, newspapers,
radio, TV, and electronic sites to discuss issues important to community health
31.
a. courtesy
b. use of names
c. trustworthiness
d. autonomy and responsibility
e. assertiveness
32.
a. psychophysiological (the internal factors influencing communication)
b. relational (the nature of the relationship between the participants)
c. situational (the reason for the communication)
d. environmental (physical surroundings in which the communication takes
place)
e. cultural (sociocultural elements that affect the interaction)
33.
a. tend to use less verbal communication but are more likely to initiate
communication and address issues more directly
b. disclose more personal information and use more active listening
34. impaired verbal communication (state in which the individual experiences a decreased,
delayed, or absent ability to receive, process, transmit, and use symbols)
35. inability to articulate words, inappropriate verbalization, difficulty forming words, and
difficulty in comprehending
36. physiological, mechanical, anatomical, psychological, cultural, or developmental
37.
a. client initiates conversation about the diagnosis
b. client is able to attend to appropriate stimuli
c. client conveys clear and understandable messages with team
d. client will express increased satisfaction with the process
38. e
39. g
40. m
41. o
42. f
43. a
44. p
45. n
46. l
47. k
48. b
49. j
50. i
51. c
52. d
53. h
54. g
55. k
56. j
57. f
58. h
59. c
60. e
61. d
62. a
63. i
64. b
65. Listen attentively, do not interrupt, ask simple questions, allow time, use visual cues, do
not shout, use communication aids.
66. Reduce distractions, get client’s attention prior to speaking, use simple sentences, ask one
question at a time, allow time.
67. Check for hearing aids, reduce noise, get client’s attention, face client, don’t chew gum,
speak in a normal voice, rephrase, provide sign language.
68. Check for glasses, identify yourself, speak in normal tone, do not rely on gestures or
nonverbal communication, use indirect lighting, use14-font print.
69. Call client by name, verbally and by touch; speak to client as though he can hear; explain
all procedures; provide orientation.
70. Speak to client in normal tone, establish method to signal desire to communicate, provide
an interpreter, avoid using family, develop communication aids.
71. Determine whether he encourages openness and allow the client to “tell his story”
expressing both thoughts and feelings.
72. Identify any missed verbal or nonverbal cues or conversational themes.
73. Examine whether nursing responses blocked or facilitated the client’s efforts to
communicate.
74. Determine whether nursing responses were positive and supportive or superficial and
judgmental.
75. Examine the type and number of questions asked.
76. Determine the type and number of therapeutic communication techniques used.
77. Discover any missed opportunities to use humor, silence, or touch.
78. 4. means of conveying and receiving messages through visual, auditory, and tactile
senses
79. 1. awareness of the tone of verbal response and the nonverbal behavior results in further
exploration
80. 3. meaning of a word’s meaning influenced by the thoughts, feelings, or ideas people
have about the word
81. 3. motivates one person to communicate with the other
82. 4. personal zone when taking a client’s history
Chapter 25: Client Education
1. The nurse is a visible, competent resource (information and skills) for clients who want
to improve their physical and psychological well-being.
2. The nurse learns to identify client’s willingness to learn and motivate interest in learning
3. New knowledge and skills are often necessary for clients to continue ADLs and learn to
cope with permanent health alterations.
4. c
5. h
6. f
7. i
8. g
9. e
10. a
11. d
12. b
13.
a. denial or disbelief
b. anger
c. bargaining
d. resolution
e. acceptance
14. depends on the child’s maturation; intellectual growth moves from the concrete to the
abstract as the child matures. Information presented to children needs to be understandable
and based on the child’s developmental stage.
15. Adults tend to be self-directed learners; they often become dependent in new learning
situations. The amount of information provided and the amount of time varies depending on
the client’s personal situation and readiness to learn.
16. To learn psychomotor skills, the following physical characteristics are necessary: size,
strength, coordination, and sensory acuity.
17.
a. requires assessment of all sources to date to determine a client’s total health
care needs
b. focuses on the client’s learning needs and willingness and capability to learn
18.
a. information or skills needed by the client to perform self-care and to
understand the implications of a health problem
b. client’s experiences that influence the need to learn
c. information that the family members require
19.
a. behavior
b. health beliefs and sociocultural background
c. perception of severity and susceptibility of a health problem and the benefits
and barriers to treatment
d. perceived ability to perform behaviors
e. desire to learn
f. attitudes about providers

g. learning style preference
20.
a. physical strength, movement, dexterity, and coordination
b. sensory deficits
c. reading level
d. developmental level
e. cognitive function
f. physical symptoms that interfere
21.
a. distractions or persistent noise
b. comfort of the room
c. room facilities and available equipment
22.
a. willingness to have family members and others involved in the teaching plan
b. family members’ perceptions and understanding of the illness and its
implications
c. willingness and ability to participate in care
d. financial or material resources
e. teaching tools
23. the inability to read above a fifth-grade level
24. The diagnostic statement describes the specific type of learning need and its cause;
classifying the nursing diagnoses by the 3 learning domains helps the nurse focus specifically
on subject matter and teaching methods.
25. Base the priorities on the client’s immediate needs (perception of what is most important,
anxiety level, and amount of time available), nursing diagnoses, and the goals and outcomes
established for the client.
26. Plan for when a client is most attentive, receptive, and alert, and organize the activities to
provide time for rest and teaching learning interactions.
27. Organize information into a logical sequence progressing from simple to complex ideas.
28. c
29. e
30. i
31. j
32. h
33. a
34. g
35. d
36. f
37. b
38. legally responsible for providing accurate, timely client information that promotes
continuity of care. Documentation of client teaching supports quality improvement efforts
and promotes third-party reimbursement.
39. 2. It is a force that acts on or within a person that causes the person to behave in a
particular way.
40. 4. involves acquiring skills that integrate mental and muscular activity
41. 4. A mild level of anxiety motivates learning, whereas a high level of anxiety prevents
learning from occurring.
42. 3. Teaching complicated skills, such as learning to use a syringe, takes considerable
practice but is developmentally appropriate.
43. 4. Outcomes describe a behavior that identifies the client’s ability to do something upon
completion of teaching with realistic time frames.
Chapter 26: Documentation and Informatics
1. anything written or printed that you rely on as record or proof for authorized persons
2. Joint Commission specifies guidelines for documentation.
3. a series of decision trees designed to cluster groups of clients together by diagnosis,
surgical procedures, complications, co-morbidities, and age
4.
a. client education on privacy protections
b. ensuring client’s access to his or her medical records
c. receiving client consent before information is released
d. providing recourse if privacy protections are violated
5. requires documentation within the context of the nursing process, as well as evidence of
client and family teaching and discharge planning
6. is a confidential, permanent legal documentation of information relevant to a client’s
health care
7. oral, written, or audiotaped exchanges between caregivers
8. form of discussion whereby one professional caregiver gives formal advice about the
level of care of a client to another caregiver
9. an arrangement for services by another care provider
10. c
11. e
12. f
13. b
14. d
15. a
16. descriptive, objective information about what a nurse sees, hears, feels, and smells
17. the use of accepted abbreviations, symbols, and system of measures that are clear and
easy to understand
18. containing appropriate and essential information
19. timely entries; immediate documentation of information as it is collected from the client
20. Communicate information in a logical order
21. j
22. c
23. i
24. f
25. h
26. g
27. e
28. b
29. a
30. d
31. c
32. e
33. b
34. a
35. f
36. d
37. Provide only essential background information.
38. Identify the client’s nursing diagnosis or health care problems and their related causes.
39. Describe objective measurements or observations about condition and responses to health
problem.
40. Share significant information about family members.
41. Continuously review ongoing discharge plan.
42. Relay to staff any significant changes in the way therapies are to be given.
43. Describe instructions given in teaching plan and the responses to instructions.
44. Evaluate results of nursing or medical care measures.
45. Be clear about priorities to which oncoming staff must attend.
46. The nurse includes when the call was made, who made it, who was called, to whom
information was given, what information was given, and what information was received.
47.
a. clearly determine the client’s name, room number, and diagnosis
b. repeat any prescribed orders back to the physician
c. use clarification questions
d. write TO or VO, including the date and time, name of the client, and the
complete order, and sign the physician name and the nurse
e. follow agency policies
f. physician must co-sign the order within the time frame required by the
institution
48.
a. client’s name, age, primary physician, and medical diagnosis
b. summary of progress
c. current health status
d. allergies
e. emergency code status
f. family support
g. current nursing diagnoses or problem and care plan
h. any critical assessments or interventions to be completed
i. need for any additional equipment
49. 4. should be most current and accurate continuous source of information about a client’s
health care status
50. 4. When recording subjective data, document the client’s exact words within quotation
marks whenever possible.
51. 2. An effective report describes each client’s health status and lets staff on the next shift
know what care the clients will require.
52. 3. An incident is any event that is not consistent with the routine operation of a health
care unit or routine care of a client.
53. 3. Do not erase, apply correction fluid, or scratch out errors made while recording; it may
appear as if you were attempting to hide information or deface the record.
Chapter 27: Self-Concept
1. Is an individual’s conceptualization of himself or herself. It is a complex mixture of

unconscious and conscious thoughts, attitudes, and perceptions.
2.
a. sense of competency
b. perceived reactions of others to one’s body
c. ongoing perceptions and interpretations of the thoughts and feelings of others
d. personal and professional relationships
e. academic and employment-related identity
f. personality characteristics
g. perceptions of events
h. mastery of prior experiences
i. ethnic, racial, and spiritual identity
3. i
4. f
5. e
6. b
7. g
8. a
9. h
10. d
11. c
12. any real or perceived change that threatens identity, body image, or role performance.
The individual’s perception of the stressor is the most important factor in determining his or
her response.
13. g
14. d
15. f
16. c
17. h
18. b
19. e
20. a
21. thoughts and feelings about lifestyle, health, and illness
22. awareness of how one’s own nonverbal communication affects clients and families
23. personal values and expectations and how these affect clients
24. ability to convey a nonjudgmental attitude toward clients
25. preconceived attitudes toward cultural differences
26. focus on identity, body image, and role performance; actual and potential self-concept
stressors and coping patterns (nature, number, and intensity of stressors and internal and
external resources)
27. if the person expresses a predominantly negative self-appraisal, including inability to
handle situations or events and difficulty making decisions
28. The client will discuss a minimum of 3 areas of her life where she is functioning well.
Will be able to voice the recognition that losing her job is not reflective of her worth as a
person. Will attend a support group for out-of-work professionals.
29. proper nutrition, regular exercise within client’s capabilities, adequate sleep and rest,
stress-reducing practices
30. nonverbal behaviors indicating positive self-concept, statements of self-acceptance, and
acceptance of change in appearance or function
31. 3. Adolescence is a particularly critical time when many variables affect self-concept and
self-esteem.
32. 4. involves attitudes related to the body, including physical appearance, structure, or
function, which is affected by cognitive and physical development as well as cultural and
societal attitudes
33. 4. Certain behaviors become common depending on whether they are approved and
reinforced.
34. 2. Attitudes toward body image can occur as a result of situational events such as the loss
of or change in a body part.
35. Refer to Figure 27.5 in the text.
Chapter 28: Sexuality
1. f
2. h
3. g
4. i
5. e
6. d
7. j
8. k
9. l
10. b
11. c
12. a
13. contaminated IV needles, anal intercourse, vaginal intercourse, oral-genital sex, and
transfusion of blood products
14.
a. impact of pregnancy and menstruation on sexuality
b. discussing sexual issues
15.
a. contraception
b. abortion
c. STD prevention
16.
a. infertility
b. sexual abuse
c. personal and emotional conflicts
d. sexual dysfunction
17.
a. physical
b. functional
c. relationship
d. lifestyle
e. developmental factors
f. self-esteem factors
18. Permission, limited, information, specific, suggestions, intensive, therapy
19.
a. history of surgery of reproductive organs
b. changes in the appearance or body image
c. a history of or current physical or sexual abuse
d. chronic illness or developmental milestones (puberty or menopause)
20.
a. consistently use a water-soluble lubricant before sexual intercourse within 1
week
b. discuss stressors that contribute to sexual dysfunction with partner within 2
weeks
c. identify alternative, satisfying, and acceptable sexual practices for self and
partner within 4 weeks
21.
a. contraception
b. safe sex practices
c. prevention of STDs
d. women (regular breast self-exams, mammograms, Pap smears
e. men (testicular exams)
22. Avoid alcohol and tobacco.
23. Eat well-balanced meals.
24. Plan sexual activity for times when couple feels rested.
25. Take pain medication if needed.
26. Use pillows and alternate positioning to enhance comfort.
27. Encourage touch, kissing, hugging, and other tactile stimulation.
28. Communicate your concerns and fears with partner.
29. Individuals experience major physical changes, the effects of drugs and treatments,
emotional stress of a prognosis, concern about future functioning, and separation from
others.
30.
a. ask clients questions about risk factors, sexual concerns, and their level of
satisfaction
b. note behavioral cues
31. 4. The child identifies with the parent of the same sex and develops a complementary
relationship with the parent of the opposite sex.
32. 4. Normal sexual changes occur as people age.
33. 1. Methods that are effective for contraception do not always reduce the risk of STDs.
34. Refer to Figure 28-2 in your text.
Chapter 29: Spiritual Health
1. as an awareness of one’s inner self and a sense of connection to a higher being, nature, or
to some purpose other than oneself
2. e
3. f
4. d
5. b
6. g
7. c
8. h
9. a
10. i
11.
a. the strength of a client’s spirituality influences how he or she copes with
sudden illness and how quickly he or she moves to recovery
b. dependence on others for routine self-care needs often creates feelings of
powerlessness; this along with the loss of a sense purpose in life impairs the ability to
cope with alterations in functioning
c. creates an uncertainty about what death means and thus makes clients
susceptible to spiritual distress
d. psychological phenomenon of people who either have been close to clinical
death or have recovered after being declared dead.
12. Belief system, ethics or values, lifestyle, involvement in a spiritual community,
education, future events
13. Individuals have some source of authority (supreme being, code of conduct, a specific
religious leader, family or friends, oneself, or a combination) and guidance in their lives that
lead them to choose and act on their beliefs.
14. Individuals who accept change in life, make decisions about their lives, and are able to
forgive others in times of difficulty have a higher level of spiritual well-being.
15. People who are connected to themselves, others, nature, and God or another supreme
being cope with the stress brought on by crisis and chronic illness.
16. When people are satisfied with life, more energy is available to deal with new difficulties
and to resolve problems.
17. Remaining connected with their cultural heritage often helps clients define their place in
the world and to express their spirituality.
18. a type of relationship that an individual has with other persons
19. Rituals include participation in worship, prayer, sacraments, fasting, singing, meditating,
scripture reading, and making offerings or sacrifices.
20. Expression of spirituality is highly individual and includes showing an appreciation for
life in the variety of things that people do, living in the moment and not worrying about
tomorrow, appreciating nature, expressing love toward others, and being productive.
21. readiness for enhanced spiritual well-being; show a person’s ability to experience and
integrate meaning and purpose in life through connectedness with self and others
22. spiritual distress; patterns reflect a person’s actual or potential dispiritedness
23. risk for spiritual distress; have poor relationships, have experienced a recent loss, or who
are suffering from some form of mental or physical illness
24.
a. the client will express an acceptance of his or her illness
b. the client reports the ability to rely on family members for support
c. the client initiates social interactions with family and friends
25. giving attention, answering questions, listening and having a positive and encouraging
(but realistic) attitude, being with rather then doing for
26.
a. mobilizing hope for the nurse, as well as the client
b. finding an interpretation or understanding of the illness, pain, anxiety, or other
stressful emotion that is acceptable to the client
c. assisting the client in using social, emotional, and spiritual resources
27. serve as a human link connecting the client, the nurse, and the client’s lifestyle before an
illness. The support system is a source of faith and hope and often is an important resource in
conducting meaningful religious rituals.
28. Food and rituals are sometimes important to a person’s spirituality.
29. Plan care to allow time for religious readings, spiritual visitations, or attendance at
religious services.
30. offers an opportunity to renew personal faith and belief in a higher being in a specific,
focused way that is either highly ritualized and formal or spontaneous and informal
31. creates a relaxation that reduces daily stress, lowers blood pressure, slows the aging
process, reduces pain, and enhances the function of the immune system
32. The nurse’s ability to enter into a therapeutic and spiritual relationship with the client will
support a client during times of grief.
33. reveal the client developing an increased or restored sense of connectedness with family;
maintaining, renewing, or reforming a sense of purpose in life and for a some a confidence
and trust in a supreme being or power
34. 3. Must be able to practice the five pillars of Islam; health and spirituality are connected
35. 2. Their belief is not to kill any living creature.
36. 3. Muslims wash the body of the dead family member and wrap it in white cloth with the
head turned to the right shoulder.
37. 2. The defining characteristics reveal patterns that reflect a person’s actual or potential
dispiritedness.
38. 3. When clients use meditation in conjunction with their spiritual beliefs, they often
report an increased spirituality that they commonly describe as experiencing the presence of
power, force or energy, or what was perceived as God.
39. Figure 29-6 in the text
Chapter 30: The Experience of Loss, Death, and Grief
1. m
2. o
3. n
4. p
5. g
6. l
7. b
8. k
9. j
10. e
11. i
12. d
13. h
14. f
15. a
16.
17.
a. denial (a person acts as though nothing has happened and refuses to accept the
fact of the loss)
b. anger (adjustment to loss; person expresses resistance and feels intense anger
at others)
c. bargaining (make promises to God or loved ones)
d. depression (sad, hopeless, and lonely)
e. acceptance (person incorporates the loss into life and finds ways to move
forward)
18.
a. numbing (stunned or unreal)
b. yearning and searching (for the lost person or object)
c. disorganization and despair (endlessly examines how and why the loss
occurred)
d. reorganization (accepts change, assumes roles, acquires new skills)
19.
a. accepts the reality of the loss
b. works through the pain of grief
c. adjusts to the environment in which the deceased is missing
d. emotionally relocates the deceased and moves on with life
20.
a. a grieving person comes to recognize the loss
b. reacts to, experiences, and expresses the pain of separation
c. reminiscing (telling and retelling stories)
d. relinquishes old attachments
e. readjusts and reinvests
21.
a. human development
b. personal relationships
c. nature of the loss
d. coping strategies
e. socioeconomic status
f. culture and ethnicity
g. spiritual and religious beliefs
h. hope
22. client’s coping style, the nature of the family relationships, personal goals, cultural and
spiritual beliefs, sources of hope, availability of support systems
23.
a. death anxiety
b. readiness for enhanced comfort
c. ineffective denial
d. fear
e. hopelessness
f. spiritual distress
g. readiness for enhanced spiritual well-being
24.
a. will participate in treatment decisions
b. will be able to continue parental responsibilities in care of toddler
c. will communicate treatment side effects or concerns to the health care team
25. is the prevention, relief, reduction, or soothing of symptoms of disease or disorders
throughout the entire course of an illness, including care of the dying and bereavement
follow-up for the family
26.
a. affirm life and regard dying as a normal process
b. neither hasten nor postpone death
c. provide relief from pain and other distressing symptoms
d. integrate psychological and spiritual aspects of client care
e. offer a support system to help clients live as actively as possible until death
f. offer a support system to help families cope
g. enhance the quality of life
27.
a. use therapeutic communication
b. provide psychosocial care
c. manage symptoms
d. promote dignity and self-esteem
e. maintain a comfortable and peaceful environment
f. promote spiritual comfort and hope
g. protect against abandonment and isolation
h. support the grieving family
i. assist with end-of-life decision making
28. help the survivor accept that the loss is real
29. support efforts to adjust to the loss, using a problem-solving approach
30. encourage establishment of new relationships
31. allow time to grieve

32. interpret normal behavior
33. provide continuing support
34. be alert for signs of ineffective, harmful coping mechanisms
35. client and family are the unit of care; coordinate home care with access to available
nursing home beds, control of symptoms, physician-directed services, provision of an
interdisciplinary care team, medical and nursing services, bereavement follow-up, use of
trained volunteers for frequent visitation, acceptance into the program based on need
36. provides information about who can legally give consent, which organs or tissues can be
donated, associated costs, and how donation will affect burial or cremation
37. surgical dissection of a body after death to determine the cause and circumstances of
death or discover the pathway of a disease
38. the care of the body after death, maintaining the integrity of rituals and mourning
practices
39. talking about the loss without feeling overwhelmed, improved energy level, normalized
sleep and dietary patterns, reorganization of life patterns, improved ability to make decisions,
and finding it easier to be around people
40. return of a sense of humor and normal life patterns, renewed or new personal
relationships, and decrease of inner pain
41. 1. Life changes are natural and often positive, which are learned as change always
involves necessary losses.
42. 3. care of the terminally ill client and their families
43. 2. cushions and postpones awareness of the loss by trying to prevent it from happening
44. 3. is to help clients and families achieve the best possible quality of life, determining the
goals of care and selection of the appropriate interventions
45. Figure 30-6 in your text
Chapter 31: Stress and Coping
1. j
2. c
3. k
4. m
5. g
6. f
7. n
8. o
9. r
10. p
11. d
12. q
13. s
14. i
15. a
16. e
17. h
18. b
19. l
20. t
21.
a. medulla oblongata
b. the reticular formation
c. the pituitary gland
22. views nursing as being responsible for developing interventions to prevent or reduce
stressors on the client or to make them more bearable for the client (focus is on primary,
secondary, and tertiary prevention)
23. increasing the level of well-being of an individual or group; primary, secondary, and
tertiary prevention focus on avoiding negative events
24. arises frrm job changes (one’s own or family) and relocation
25. vary with life stage: children (relate to physical appearance), preadolescent (self-esteem
issues), adolescent (identity), adults (major changes in life circumstances)
26. poverty and physical handicaps, loss of parents and caregivers (children), violence,
homelessness
27.
a. perception of the stressor
b. maladaptive coping used
c. adherence to healthy practices
28.
a. grooming and hygiene
b. gait
c. characteristics of the handshake
d. actions while sitting
e. quality of speech
f. eye contact
g. the attitude of the client
29. verbalization of an inability to cope and an inability to ask for help
30.
a. effective coping
b. family coping
c. caregiver emotional health
d. psychosocial adjustment: life change
31.
a. decrease stress-producing situations
b. increase resistance to stress
c. learn skills that reduce physiological response to stress
32.
a. regular exercise
b. support systems
c. time management
d. guided imagery and visualization
e. progressive muscle relaxation
f. assertiveness training
g. journal writing
h. stress management in the workplace
33. is a specific type of brief psychotherapy with prescribed steps; more directive
34. reports of feeling better when the stressor is gone; sleep patterns, appetite, and ability to
concentrate have improved
35. 1. Stress is an experience a person is exposed to through a stimulus or stressor.
36. 1. Neurophysiological responses to stress function through negative feedback.
37. 1. alarm reaction, resistance stage, and the exhaustion stage
38. 3. The nurse helps the client make the mental connection between the stressful event and
the client’s reaction to it.
39. Figure 31-8 in your text
Chapter 32: Vital Signs
1. The nurse may delegate the measurement of vital signs but is responsible for analyzing
and interpreting their significance and select appropriate interventions.
2. Equipment needs to be appropriate and functional.
3. Equipment needs to be based on the client’s condition and characteristics.
4. Know the client’s usual range of vital signs.
5. Know the client’s medical history.
6. Control or minimize environmental factors.
7. systematic approach
8. collaborate with health care providers to decide on the frequency
9. use measurements to determine the indications for medication administration
10. analyze the results
11. verify and communicate significant changes
12. develop a teaching plan
13. h
14. j
15. f
16. e
17. a
18. g
19. b
20. i
21. c
22. d
23.
a. age
b. exercise
c. hormone level
d. circadian rhythm
e. stress
f. environment
24. e
25. h
26. b
27. f
28. c
29. g
30. d
31. a
32.
a. a constant body temperature continuously over 38 degrees C that has little
fluctuation
b. fever spikes interspersed with usual temperature levels
c. fever spikes and falls without a return to normal
d. periods of febrile episodes and periods of acceptable temperature values
33. Examples of answers can be found in the Box 32-5.

34.
a. subtract 32 from the Fahrenheit reading and multiply the result by 5/9
b. multiply the centigrade reading by 9/5 and add 32 to the product
35.
a. risk for imbalanced body temperature
b. hyperthermia
c. hypothermia
d. ineffective thermoregulation
36.
a. attaining fluid and electrolyte balance within 24 hours
b. obtaining appropriate clothing to wear in cold weather
37. very young and very old, trauma, stroke, diabetes, drug or alcohol intoxication, sepsis,
inadequate home heating and shelter, fatigue, skin color, malnutrition, hypoxemia
38.
a. have immature temperature-control mechanisms and temperatures can rise
rapidly and are at risk for fluid-volume deficit
b. often accompanied by other allergy symptoms such as rash or pruritus
39.
a. nonsteroidal drugs and corticosteroids
b. tepid sponge baths, bathing with alcohol water solutions, applying ice packs
to axillae and groin sites, and cooling fans
40. Move the client to a cooler environment, remove excess body clothing, place cool wet
towels over the skin, and use fans.
41. Remove wet clothes; wrap the client in blankets
42. After each intervention measure the client’s temperature to evaluate for change, palpate
the skin, and assess the pulse and respirations.
43.
a. radial
b. apical
44. Refer to Table 32-2 for answers.
45.
a. rate, rhythm, strength, and equality
b. rate and rhythm only
46.
a. 120-160
b. 90-140
c. 80-110
d. 75-100
e. 60-90
f. 60-100
47. See answers in Table 32-4.
48. abnormal elevated heart rate, above 100 beats per minute in adults
49. slow rate, below 60 beats per minute in adults
50. an inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral
site; the difference between the apical and the radial pulse rate
51. An interval interrupted by an early or late beat or a missed beat indicates an abnormal
rhythm.
52. movement of gases in and out of the lungs
53. the movement of oxygen and carbon dioxide between the alveoli and the red blood cells
54. the distribution of red blood cells to and from the pulmonary capillaries
55. low levels of arterial O2
56.
a. active
b. passive
57. See Table 32-11 for answers.
58.
a. 30-60
b. 30-50
c. 25-32
d. 20-30
e. 16-19
f. 12-20
59. Rate of breathing is regular but slow; < 12 breaths per minute.
60. Rate of breathing is regular but rapid; > 20 breaths per minute.
61. Respirations are labored, increased in depth, and rate is > 20 breaths per minute.
62. Respirations cease for several seconds.
63. Rate and depth of respirations increase.
64. Respiratory rate is abnormally low, and depth of ventilation is depressed.
65. Respiratory rate and depth are irregular; alternating periods of apnea and
hyperventilation.
66. abnormally deep, regular, and increased in rate
67. abnormally shallow for 2-3 breaths followed by irregular period of apnea
68. The percent of hemoglobin that is bound with oxygen in the arteries is the percent of
saturation of hemoglobin, usually between 95% and 100%.
69. the force exerted on the walls of an artery by the pulsing blood under pressure from the
heart
70. peak of maximum pressure when ejection occurs
71. When the ventricles relax, the blood remaining in the arteries exerts a minimum pressure.
72. the difference between systolic and diastolic pressure
73. increases as a result of an increase in heart rate, greater heart muscle contractility, or an
increase in blood volume
74. is the resistance to blood flow determined by the tone of vascular musculature and
diameter of blood vessels
75. the volume of blood circulating (increased or decreased) affects the blood pressure
76. the thickness affects the ease with which blood flows through blood vessels, determined
by the hematocrit
77. With reduced elasticity there is greater resistance to blood flow and the systemic pressure
rises (systolic pressure).
78.
a. age
b. stress
c. ethnicity
d. gender
e. daily variations
f. medications
g. activity and weight
h. smoking
79.
a. 40 (mean)
b. 85/54
c. 95/65
d. 105/65
e. 110/65
f. 120/75
g. <120/80
80. See Table 32-8.
81. family history, obesity, cigarette smoking, heavy alcohol consumption, high sodium,
sedentary lifestyle, exposure to continuous stress, diabetics, older, African Americans
82. dehydrated, anemic, experienced prolonged bed rest, recent blood loss, medications
83.
1st – clear, rhythmical tapping corresponding to the pulse rate that gradually increases in
intensity (systolic pressure)
2nd – blowing or swishing sound as the cuff deflates
3rd – a crisper and more intense tapping
4th – muffled and low-pitched as the cuff is further deflated (diastolic pressure in infants and
children)
5th – the disappearance of sound (diastolic pressure in adolescents and adults)
84. palpation technique; usually occurs between the first and second Korotkoff sounds
87. 4. The skin regulates the temperature through insulation of the body, vasoconstriction,
and temperature sensation.
88. 3. is the transfer of heat from one object to another with direct contact (solids, liquids,
and gases)
89. 3. Victims of heat stroke do not sweat.
90. 2. 156 is the onset of the first Korotkoff sound (systolic pressure) and 88 is the fifth
sound that corresponds with the diastolic pressure.
Chapter 33: Health Assessment and Physical Examination
1.
a. gather baseline data about the client’s health status
b. supplement, confirm, or refute data
c. confirm and identify nursing diagnoses
d. make clinical judgments about a client’s changing health status
e. evaluate the outcomes of care
2.
a. adequate lighting is available
b. position and expose body parts to be viewed
c. inspect each area for size, shape, color, symmetry, position, and abnormalities
d. compare each area inspected with the same area on the opposite side
e. use additional lighting to inspect body cavities
f. do not hurry; pay attention to detail
3. involves the use of the hands to touch body parts to make sensitive assessments
4. produces a vibration that travels through the body tissues, which determines the location,
size, and density of underlying structures to verify abnormalities assessed
5. involves listening to sounds the body makes with the use of a stethoscope
6.
a. infection control
b. environment
c. equipment
d. physical preparation of the client
e. psychological preparation of the client
7.
a. gather all or part of the histories of infants and children from parents
b. perform the examination in a nonthreatening area
c. offer support to the parents during the examination
d. call children by their first name and address the parents as Mr. and Mrs.
e. use open-ended questions to allow parents to share more information
f. treat adolescents as adults
g. confidentiality for adolescents; speak alone with them
8.
a. do not stereotype
b. sensory or physical limitations (more time)
c. adequate space is needed
d. use patience; allow for pauses
e. certain types of information may be stressful to give
f. perform the exam near bathroom facilities
g. be alert for signs of increasing fatigue
9. gender and race
10. age
11. signs of distress
12. body type
13. posture
14. gait
15. body movements
16. hygiene and grooming
17. dress
18. body odor
19. affect and mood
20. speech
21. physical injury or neglect are signs of possible abuse (evidence of malnutrition or
presence of bruising); fear of the spouse or partner, caregiver, or parent
22.
C – have you ever felt the need to cut down on your use?
A – have people annoyed you by criticizing your use?
G – have you ever felt bad or guilty about your use?
E – have you ever used or had a drink first thing in the morning as an eye-opener to steady
your nerves or feel normal?
23.
a. need to weigh clients at the same time of day
b. on the same scale
c. in the same clothes to allow an objective comparison of subsequent weights
24. trauma to skin during care, exposure to pressure during immobilization, reaction to
various medications , neurologically impaired, chronically ill and orthopedic clients,
diminished mental status, poor tissue oxygenation, low cardiac output, or inadequate
nutrition
25. aggressive form of skin cancer
26. discolored skin that occurs unevenly, especially in the older adult
27. Answers can be found in Table 33-10.
28.
a. eczema
b. dermatitis
29. hardened
30. skin’s elasticity
31. areas of the skin swollen or edematous form a buildup of fluid in the tissues
32. thickening of the skin
33. ruby-red papules
34-42. Answers can be found in Box 33-8.
43.
a. pediculus humanus capitis (head lice)
b. pediculus humanus corporis (body lice)
c. pediculus pubis (crab lice)
44. change in the angle between nail and nail base, softening and flattening and enlargement
of the fingertips
45. transverse depressions in nails
46. concave curves
47. splinter hemorrhages
48. inflammation of the skin at base of the nail
49. congenital anomaly or the buildup of cerebrospinal fluid in the ventricles
50. enlarged jaws and facial bones

51. a refractive error causing farsightedness
52. a refractive error causing nearsightedness
53. impaired near vision in middle-age and older adults, caused by loss of elasticity of the
lens
54. noninflammatory eye disorder resulting from changes in retinal blood vessels
55. congenital condition in which both eyes do not focus on an object simultaneously
56. increased opacity of the lens
57. intraocular structural damage resulting from increased intraocular pressure
58. blurred central vision often occurring suddenly, caused by progressive degeneration of
the center of the retina
59.
a. visual acuity
b. visual fields
c. extraocular movements
d. external eye structures
e. internal eye structures
60.
a. position and alignment
b. eyebrows
c. eyelids
d. lacrimal apparatus
e. conjunctivae
f. sclerae
g. pupils and irises
61. bulging eyes
62. lid margins that turn out
63. lid margins that turn in
64. presence of redness, which indicates and allergy or an infection
65. a thin white ring along the margin of the iris
66. Pupils Equal, Round, Reactive to Light and Accommodation
67. retina, choroids, optic nerve disc, macula, fovea centralis, and retinal vessels
68.
a. external (auricle, outer ear canal and tympanic membrane)
b. middle (3 bony ossicles)
c. inner ear (cochlea, vestibule, and semicircular canals)
69.
a. enter the external ear, pass through the outer ear canal
b. waves reach the tympanic membrane (vibrate)
c. vibrations are transmitted through the middle ear by the bony occicular chain
to the oval window of the inner ear
d. cochlea receive the vibration
e. nerve impulses from the cochlea travel to the auditory nerve (8th) and to the
cerebral cortex
70.
a. conduction
b. sensorineural
c. mixed
71. lateralization of sound equally in both ears
72. comparison of air and bone conduction (AC>BC)
73. skin breakdown, characterized by redness and skin sloughing
74. tumor-like growths
75. thick white patches that are often precancerous lesions seen in heavy smokers and
alcoholics
76. swollen, tortuous veins that are common in the older adult
77. extra bony growth between the 2 palates
78. neck muscles, lymph nodes of the head and neck, carotid arteries, jugular veins, thyroid
gland, and trachea
79. sound waves that create vibrations that can be palpated externally
80. air movement through smaller airways that is soft, breezy, and low-pitched
81. air moving through larger airways that is blowing, medium-pitched, and intensity
82. air moving through trachea which is loud and high-pitched, with hollow quality
83. Answers can be found in Table 33-22.
84. apex touching the anterior chest wall at approximately the fourth to fifth intercostal
space, just medial to the left midclavicular line
85. Mitral and tricuspid valve closure causes the first heart sound.
86. Aortic and pulmonic valve closure causes the second heart sound.
87. rapid ventricular filling
88. Atria contract to enhance ventricular filling.
89. lies between the sternal body and manubrium and feels the ridge in the sternum
approximately 5 cm below the sternal notch
90. second intercostal space on the right
91. left second intercostal space
92. left third intercostal space
93. Fourth or fifth intercostal space along the sternum
94. Fifth intercostal space just to the left of the sternum, left midclavicular line
95. tip of the sternum
96. sustained swishing or blowing sounds heard at the beginning, middle, or end of the
systolic or diastolic phase
97.
a. auscultate all valve areas for placement in the cardiac cycle (timing), where
best heard (location) and radiation, loudness, pitch and quality
b. between S1 and S2 (systolic) and S2 and S1 (diastolic)
c. location is not necessarily over the valves
d. assess for radiation
e. intensity or loudness and record in grading 1-6
f. low-pitched murmur best heard with the diaphragm
98. caused by a drop in heart rate and blood pressure
99. absent pulse wave (blockage)
100. diminished or unequal carotid pulsations
101. blood passing through a narrowed section, creating turbulence
102.
a. semi-Fowler’s position
b. expose the neck; align the head
c. lean client back into a supine position; level of venous pulsations begin to rise
as the patient reaches 45-degree angle
d. use 2 rulers
e. repeat the same measurement on the other side
103. Refer to Table 33-26 for the answers.
104. Inspect the calves for localized redness, tenderness, and swelling over vein sites.
105.
a. BSE monthly
b. women aged 20 years and older need to report any breast changes
c. clinical breast exam every 3 years (20-40) and yearly over the age of 40
d. family history: need a yearly exam
e. mammogram: age 40 annually (asymptomatic)
f. additional testing (increased risks)
106. spreading to the nodes
107. bilateral lumpy, painful breast, sometimes with nipple discharge
108. stretch marks
109. protusion of abdominal organs through the muscle wall
110. swelling by intestinal gas, tumor, or fluid in the abdominal cavity
111. movement of contents through the intestines, which is a normal function of the small
and large intestine
112. absent sounds that may indicate a lack of peristalsis
113. growling sounds, which are hyperactive bowel sounds
114. occurs in clients with peritoneal irritation
115. localized dilation of a vessel wall
116. syphilitic lesions, which appear as small,open ulcers that drain serous material
117. a test for cervical and vaginal cancer
118. a painless enlargement of one testis and the appearance of a palpable, small, hard lump
on the side of the testicle
119. to detect colorectal cancer in the early stages and prostatic tumors
120. hunchback, an exaggeration of the posterior curvature of the thoracic spine
121. swayback, an increased lumbar curvature
122. lateral spinal curvature
123. metabolic bone disease that causes a decrease in quality and quantity of bone
124. measures the precise degree of motion in a particular joint
125. movement decreasing angle between 2 adjoining bones
126. increasing angle between 2 adjoining bones
127. beyond its normal resting extended position
128. that the frontal or ventral surfaces face downward
129. front or ventral surface faces upward
130. away from the midline
131. toward the midline
132. rotation of the joint inward
133. rotation of the joint outward
134. turning of the body part away from the midline
135. turning the body part toward the midline

136. flexion of toes and foot upward
137. bending of toes and foot downward
138. increased muscle tone
139. a muscle with little tone
140. a muscle reduced in size that feels soft and boggy
141. measures orientation and cognitive function
142. confusion, disorientation, and restlessness
143. an objective measurement of consciousness on a numerical scale over time
144.
a. a person cannot understand written or verbal speech
b. a person understands written and verbal speech but cannot write or speak
appropriately when attempting to communicate
145.
a. olfactory
b. optic
c. oculomotor
d. trochlear
e. trigeminal
f. abducens
g. facial
h. auditory
i. glossopharyngeal
j. vagus
k. spinal accessory
l. hypoglossal
146. pain, temperature, position, vibration, and crude and finely localized touch
147. pain, light touch, vibration, position, 2-point discrimination
148. Muscular activity maintains balance and equilibrium and helps to control posture.
149.
a. deep tendon reflexes (biceps, triceps, patellar, Achilles)
b. cutaneous reflexes (plantar, gluteal, abdominal)
150. 4. A thorough explanation of the purpose and steps of each assessment lets clients
know what to expect and what to do so that they can cooperate.
151. 3. normally the skin lifts easily and snaps back immediately to its resting position; the
back of the hand is not the best place to test for turgor
152. 3. circumscribed elevation of skin filled with serous fluid, smaller than 1 cm
153. 2. Use a systematic pattern when comparing the right and left sides. You need to
compare lung sounds in one region on one side of the body with sounds in the same region
on the opposite of the body.
154. 3. high-velocity airflow through severely narrowed or obstructed airway
155. 4. After the ventricles empty, ventricular pressure falls below that in the aorta and
pulmonary artery, allowing the valves to close and causing the second heart sound.
Chapter 34: Infection Prevention and Control
1. d
2. m
3. o
4. l
5. g
6. n
7. k
8. p
9. a
10. f
11. j
12. b
13. e
14. h
15. c
16. i
17.
a. an infectious agent or pathogen
b. a reservoir or source
c. a portal of exit from the reservoir
d. a mode of transmission
e. a portal of entry to a host
f. a susceptible host
18. direct – person-to-person or physical source and susceptible host
19. indirect – personal contact of susceptible host with contaminated inanimate object
20. droplet – large particles that travel up to 3 ft and come in contact with the host
21. airborne – droplets that suspend in air
22. vehicles –contaminated items
23. vector – internal and external transmissions
24. depends on the individual degree of resistance to a pathogen (immune response)
25.
a. wound infection; patient experiences localized symptom
b. an infection that affects the entire body instead of just a single organ
26. The body contains microorganisms that reside on the surface and deep layers of the skin,
in saliva and oral mucosa, and the intestinal walls and GU tract that maintain health.
27. The skin, mouth, eyes, respiratory tract, urinary tract, GU tract, and vagina have unique
defenses against infection.
28. the body’s response to injury, infection, or irritation; is a protective vascular reaction that
delivers fluid, blood products, and nutrients to an area of injury
29. acute inflammation: rapid vasodilatation that causes redness at the site and localized
warmth allowing phagocytosis to occur
30. accumulation of fluid and dead tissue cells and WBCs forms at the site. Exudate may be
serous, sanguineous, or purulent.
31. Healing involves the defensive, reconstructive, and maturative stages.
32. comes from microorganisms outside the individual that do not exist in normal floras
33. occurs when part of the client’s flora becomes altered and an overgrowth results
34.
a. urinary tract
b. surgical or traumatic wounds
c. respiratory tract
d. bloodstream
35. COPD, heart disease, diabetes
36. exposure to communicable/infectious disease, use of IV drugs/substances
37. miner, unemployed, homeless
38. invasive radiology, transplant
39. sickle cell disease, diabetes
40. West Nile virus, SARS, avian flu, hantavirus
41. fractures, internal bleeding
42. obesity, anorexia
44.
a. risk for infection
b. imbalanced nutrition
c. impaired oral mucous membrane
d. impaired skin integrity
e. ineffective tissue perfusion
f. impaired tissue integrity
45.
a. preventing exposure to infectious organisms
b. controlling or reducing the extent of infection
c. maintaining resistance to infection
d. educating the client and family about infection control techniques
46. strengthen their defenses
a. nutrition
b. immunizations
c. personal hygiene
d. regular rest and exercise
e. eliminate reservoirs of infection
f. control portals of exit and entry
47. the absence of pathogenic microorganisms; the technique refers to the

practices/procedures that assist in reducing the risk for infection
48. clean technique: hand hygiene, using clean gloves, cleaning the environment routinely
49. removal of all soil (organic and inorganic material) from objects and surfaces with the
use of water and mechanical action with detergents or enzymatic products
50. a process that eliminates many or all microorganisms with the exception of bacterial
spores from inanimate objects
51. the complete elimination or destruction of all microorganisms, including spores
52. need to eliminate sources of body fluids, drainage, or solutions that may harbor
organisms; discard contaminated articles
53. teach patient respiratory hygiene

54. prevent transmission of organisms through indirect and direct contact –use disinfectant
on stethoscopes, soiled linens,handling of catheters and drainage sets, IV tubing, wound
cleansing
55. applies to hand washing, antiseptic hand wash, antiseptic hand rub, or surgical hand
antisepsis
56. is designed for all clients in all settings regardless of the diagnosis; apply to contact with
blood, body fluid, nonintact skin, and mucous membranes
57. based on the mode of transmission of disease that is termed airborne; droplet; contact;
protective environment
58. gowns – to prevent soiling clothes during contact with the client
59. masks – when you anticipate splashing or spraying of blood or bloody fluid into the face;
droplet or airborne precautions
60. eyewear – procedures that generate splash or splatter
61. gloves – to prevent the transmission of pathogens by direct and indirect contact
62.
a. cultures
b. pathological wastes
c. blood and blood products
d. sharps
e. selected isolation material
63.
a. provide staff and client education
b. develop and review infection prevention and control policies and procedures
c. recommend appropriate isolation procedures
d. screen client records
e. consult with health departments
f. gather statistics regarding the epidemiology
g. notify the public health department of incidences of communicable diseases
h. consult with all departments to investigate unusual events or clusters
i. monitor antibiotic-resistant organisms
64.
a. during procedures that require intentional perforation of the client’s skin
b. when the skin’s integrity is broken
c. during procedures that involve insertion of catheters
65. A sterile object remains sterile only when touched by another sterile object.
66. Place only sterile objects on a sterile field
67. A sterile object or field out of the range of vision or an object held below a person’s waist
is contaminated.
68. A sterile object or field becomes contaminated by prolonged exposure to air.
69. When a sterile surface comes in contact with a wet, contaminated surface, the sterile
object or field becomes contaminated by capillary action.
70. Because fluid flows in the direction of gravity, a sterile object becomes contaminated if
gravity causes a contaminated liquid to flow over the object’s surface.
71. The edges of a sterile field or container are considered to be contaminated.
72.
a. assemble all equipment

b. surgical scrub
c. donning caps, masks, and eyewear
d. preparing a sterile field
e. open sterile packages on a flat surface
f. pouring sterile solutions
g. applying sterile gloves
h. donning a sterile gown
73.
a. monitor clients postoperatively –surgical sites, invasive sites, respiratory tract,
and urinary tract
b. all invasive and surgical sites for swelling, erythema, or purulent drainage
c. monitor breath sounds
d. review lab results
74. 3. Infection occurs in a cycle that depends on the presence of certain elements.
75. 1. The incubation period is the interval between the entrance of the pathogen into the
body and appearance of first symptoms.
76. 4. occurs when part of the client’s flora becomes altered and an overgrowth results
77. 1. If moisture leaks through a sterile package’s protective covering, organisms can travel
to the sterile object.
78. 1. Clients who are transported outside of their rooms need to wear a surgical mask to
protect other clients and personnel.
Chapter 35: Medication Administration
1. a. is to protect the health of the people by ensuring that medications are safe and
effective. Currently the FDA ensures that all medications undergo vigorous testing before
they are sold. b. conform to federal legislation but also have additional controls such as
alcohol and tobacco. c. individual policies to meet federal and state regulations. d. define the
scope of a nurse’s professional functions and responsibilities.
2. provides an exact description of the medication’s composition and molecular structure
3. manufacturer who first develops the medication, which becomes the official name
4. the manufacturer has trademarked the medication’s name
5. indicates the effect of the medication on a body system, the symptoms the medication
relieves, or the medication’s desired effect
6. determines its route of administration
7. is the study of how medications enter the body, reach their site of action, metabolize, and
exit the body
8. refers to the passage of medication molecules into the blood from the site of
administration
9. a. route of administration b. ability of the medication to dissolve c. blood flow to the site
of administration d. body surface area e. lipid solubility
10. a. circulation b. membrane permeability c. protein binding
11. occurs under the influence of enzymes that detoxify, degrade, and remove biologically
active chemicals, mostly in the liver
12. the kidneys; when renal function declines, a client is at risk for medication toxicity
13. is the expected or predictable physiological response to a medication
14. are the unintended, secondary effects a medication predictably will cause
15. are severe responses to medication
16. develop after prolonged intake of a medication or when a medication accumulates in the
blood because of impaired metabolism or excretion
17. unpredictable effects in which a client overreacts or underreacts to a medication or has a
reaction different from normal
18. are predictable responses to a medication
19. allergic reactions that are life-threatening and characterized by sudden constriction of
bronchiolar muscles, edema of the pharynx and larynx, and severe wheezing and shortness of
breath
20. when one medication modifies the action of another medication
21. The combined effect of the 2 medications is greater than the effect of the medications
when given separately.
22. constant blood level within a safe therapeutic range
23. highest serum concentration
24. is the time it takes for excretion processes to lower the serum medication concentration
by half
25. time it takes after a medication is administered for it to produce a response
26. time it takes for a medication to reach its highest effective concentration
27. minimum blood serum concentration of medication reached just before the next
scheduled dose
28. time during which the medication is present in concentration great enough to produce a
response
29. blood serum concentration of a medication reached and maintained after repeated fixed
doses
30. a. oral b. buccal c. sublingual
31. a. intradermal b. subcutaneous c. intramuscular d. intravenous
32. administered in the epidural space via a catheter, usually used for post-op analgesia
33. a catheter that is in the subarachnoid space or one of the ventricles of the brain
34. infusion of medication directly into the bone marrow, commonly used in infants and
toddlers
35. into the peritoneal cavity such as chemotherapeutic agents, insulin, and antibiotics
36. directly into the pleural space, commonly chemotherapeutics
37. directly into the arteries
38. injection directly into the cardiac tissue
39. injection of a medication into a joint
40. a. directly applying a liquid or ointment b. inserting a medication into a body cavity c.
instilling fluid into a body cavity d. irrigating a body cavity e. spraying
41. They are readily absorbed and work rapidly because of the rich vascular alveolar
capillary network present in the pulmonary tissue.
42. a. metric b. apothecary c. household
43. given mass of solid substance dissolved in a known volume of fluid or a given volume of
liquid dissolved in a known volume of another fluid
44. dose ordered/dose on hand x amount on hand = amount to administer
45. child’s dose = surface of child/1.7 m2 x normal adult dose
46. if the order is given verbally to the nurse by the provider
47. is carried out until the prescriber cancels it by another order or until a prescribed number
of days elapse
48. a medication that is given only when a client requires it
49. a medication that is given only once at a specified time
50. single dose of a medication to be given immediately and only once
51. is used when a client needs a medication quickly but not right away; nurse has up to 90
minutes to administer
52. a. unit dose b. automated medication dispensing systems (AMDS)
53. inaccurate prescribing, administration of the wrong medicine, giving the medication
using the wrong route or time interval, and administering extra doses or failing to administer
a medication
54. a. verify b. clarify c. reconcile d. transmit
55. a. the right medication b. the right dose c. the right client d. the right route e. the right
time f. the right documentation
56. a. be informed of the medication’s name, purpose, action, and potential undesired effects
b. refuse a medication regardless of the consequences c. have qualified nurses or physicians
assess a medication history d. be properly advised of the experimental nature of medication
therapy and give written consent e. receive labeled medications safely without discomfort f.
receive appropriate supportive therapy g. not receive unnecessary medications h. be informed
if medications are a part of a research study
57. a. history b. history of allergies c. medication data d. diet history e. client’s perceptual
coordination problems f. client’s current condition g. client’s attitude about medication use h.
client’s knowledge and understanding of medication therapy i. client’s learning needs
58. anxiety
59. health maintenance, ineffective
60. health-seeking behaviors
61. deficient knowledge
62. noncompliance
63. disturbed visual sensory perception
64. impaired swallowing
65. effective therapeutic regimen management
66. ineffective therapeutic regimen management
67. a. will verbalize understanding of desired effects and adverse effects of medications b.
will state signs, symptoms, and treatment of hypoglycemia c. to monitor blood sugar to
determine if medication is appropriate to take d. establish a daily routine that will coordinate
timing of medication with meal times
68. health beliefs, personal motivations, socioeconomic factors, and habits
69. a. client’s full name b. date and time that the order is written c. medication name d. dose
e. route of administration f. time and frequency of administration g, signature of provider
70. the name of the medication, dose, route, and the exact time of administration and site
71. a. when clients need to take several medications to treat their illnesses b. happens when
people take more medications then needed
72. a. client and family understand medication therapy b. client safely self-administers
medications
73.
a. Determine the client’s ability to swallow.
b. Assess the client’s cough.
c. Determine the presence of a gag reflex.
d. Prepare oral medications in the form that is easiest to swallow.
e. Allow the client to self-administer medications if possible.
f. If the client has unilateral weakness, place the medication in the stronger side of the
mouth.
g. Administer pills one at a time, ensuring that each medication is properly swallowed
before the next one is introduced.
h. Thicken regular liquids or offer fruit nectars if the client cannot tolerate thin liquids.
i. Avoid straws because they decrease the control the client has over volume intake,
which increases the risk of aspiration.
j. Have client hold cup and drink from cup if possible.
k. Time medications to coincide with mealtimes or when the client is well-rested and
awake if possible.
l. Administer medications using another route if risk of aspiration is severe.
74. a. document where the medication was placed on the MAR b. assess if patient has an
existing patch before application c. assess the skin thoroughly d. medication history/
reconciling medications e. apply a noticeable label to the patch f. document removal of
medication on the MAR
75. decongestant spray or drops

76. a. avoid instilling any eye medication directly onto the cornea b. avoid touching the
eyelids or other eye structures with eye droppers or ointment tubes c. use medication only for
the client’s affected eye d. never allow a client to use another client’s eye medications
77. vertigo, dizziness, nausea
78. suppositories, foam, jellies, or creams
79. exerting local effects (promoting defecation) or systemic effects (reducing nausea)
80. a. delivers a measured dose of medication with each push of a canister often used with a
spacer b. hold dry, powdered medication and create an aerosol when the client inhales
through a reservoir that contains the medication
81. Draw medication from ampule quickly; do not allow to stand open.
82. Avoid letting needle touch contaminated surface.
83. Avoid touching length of plunger or inner part of barrel.
84. Prepare skin, use friction and a circular motion while cleaning with an antiseptic swab,
and start from the center and move outward.
85. a. the client’s size and weight b. type of tissue into which the medication is to be injected
86. a. contain single doses of medications in a liquid b. is a single dose or multidose
container with a rubber seal at the top (closed system)
87. a. do not contaminate one medication with another b. ensure that the final dose is
accurate c. maintain aseptic technique
88. rate of action (rapid, short, intermediate, and long-acting); each has a different onset,
peak, and duration of action
89. a. need to maintain their individual routine when preparing and administering their
insulin b. do not mix insulin with any other medication or diluents c. never mix insulin
glargine or insulin detemir with other types of insulin d. inject rapid-acting insulin mixed
with NPH within 15 minutes before a meal e. do not mix short-acting and lente insulins
unless the blood glucose levels are currently under control with this mixture f. do not mix
phosphate-buffered insulins with lente insulins
90. a. use a sharp beveled needle in the smallest suitable length and gauge b. position the
client as comfortably as possible to reduce muscle tension c. select the proper injection site d.
divert the client’s attention from the injection e. insert the needle quickly and smoothly f.
hold the syringe while the needle remains in tissues g. inject the medication slowly and
steadily
91. the outer posterior aspect of the upper arms, the abdomen (below the costal margins to
the iliac crests), and the anterior aspects of the thighs
92. 0.5 to 1 ml
93. 25-gauge, 5/8 inch needle inserted at a 45-degree angle or a ½ inch needle inserted at a
90-degree angle
94. 90 degrees
95. a. 3 ml into a large muscle b. 2 ml c. 1 ml
96. lacks major nerves and blood vessels; rapid absorption; frequently used in infants, older
children, and toddlers (immunizations)
97. deep site away from nerves and blood vessels, less chance of contamination, easily
identified landmarks, preferred site for medications
98. easily accessible but muscle not well developed, use small amounts, not used in infants or
children, potential for injury to radial and ulnar nerves, immunizations for children,
recommended site for hepatitis B and rabies injections
99. minimizes local skin irritation by sealing the medication in muscle tissue
100. skin testing, injected into the dermis where medication is absorbed slowly
101. a. as mixtures within large volumes of IV fluids b. injection of a bolus or small volume
of medication c. piggyback infusion
102. a. fast-acting medications must be delivered quickly b. constant therapeutic blood
levels
103. a. most dangerous method because there is not time to correct errors b. a bolus may
cause direct irritation to the lining of blood vessels
104. a. it reduces risk for rapid-infusion by IV push b. allows for administration of
medications that are stable for a limited time in solution c. it allows for control of IV fluid
intake
105. a small (25-250 ml) IV bag connected to short tubing lines that connects to the upper Y
port of a primary infusion line
106. small (25-100 ml) IV bag connected to a short tubing line to the lower Y port of a
primary infusion
107. small (50-150 ml) containers that attach below the primary infusion bag
108. battery-operated and allows medications to be given in very small amounts of fluid (5-
60 ml)
109. a. cost-saving, convenience, increased mobility, safety, and comfort for the client
110. 3. definition of pharmacokinetics
111. 1. absorption refers to the passage of medication molecules into the blood from the site
of administration
112. 1. definition of onset
113. 1. is an oral route
114. 2. child’s dose = surface of child/1.7 m 2 x normal adult dose
115. 2. if mixing rapid- or short-acting insulin with intermediate or long-acting insulin, take
insulin syringe and aspirate volume of air equivalent to the dose of insulin to be withdrawn
from the long-acting insulin first.
Chapter 36: Complementary and Alternative Therapies
1. are therapies used in addition to conventional treatment recommended by the client’s

provider
2. include the same interventions as complementary but frequently become the primary
treatment that replaces allopathic medical care
3.
a. Acupuncture: A traditional Chinese method of producing analgesia or altering
the function of a body system by inserting thin needles along a series of lines or
channels, called meridians. Direct needle manipulation of energetic meridians
influences deeper internal organs by redirecting Chi.
b. Ayurveda: Traditional Hindu system of medicine practiced in India since the
first century A.D. A combination of remedies such as herbs, purgative, and rubbing
oils that treat disease.
c. Homeopathic medicine: System of medical treatments based on the theory
that certain diseases can be cured by giving small doses of substances that in a
healthy person would produce symptoms like those of the disease. Prescribed
substances called remedies are made from naturally occurring plant, animal, or
mineral substances.
d. Latin American practices: Curanderismo medical system, which includes a
humoral model for classifying food, activity, drugs, and illnesses and a series of folk
illnesses.
e. Native American practices: Therapies include sweating and purging, herbal
remedies, and shamanic healing (healer makes contact with spirits to ask their
direction in bringing healing to people).
f. Naturopathic medicine: System of therapeutics based on natural foods, light,
warmth, massage, fresh air, regular exercise, and avoidance of medications.
Recognizes inherent healing ability of the body. Treatments integrate traditional
natural therapies with modern diagnostic science; includes botanical (plant) medicine.
g. Traditional Chinese medicine: Set of systematic techniques and methods
including acupuncture, herbal medicines, massage, acupressure, moxibustion (use of
heat from burning herbs), Qigong (balancing energy flow through body movement),
and oriental massage. Fundamental concepts from Taoism, Confucianism, and
Buddhism.
4.
a. the “Zone”: Dietary program that requires eating protein, carbohydrates, and
fat in a 30:40:30 ratio: 30% of calories from protein, 40% from carbohydrates, and
30% from fat. Used to balance insulin and other hormones for optimal health.
b. macrobiotic diet: Predominantly a vegan diet (no animal products except
fish). Initially used in the management of a variety of cancers. Emphasis placed on
whole cereal grains, vegetables, and unprocessed foods.
c. orthomolecular medicine: Increased intake of nutrients such as vitamin C and
beta-carotene. Diet treats cancer, schizophrenia, autism, and certain chronic diseases
such as hypercholesterolemia and coronary artery disease.
d. European phytomedicines: Products developed under strict quality control in
sophisticated pharmaceutical factories, packaged professionally in tablets or capsules.
Examples of well-studied herbal medicines include gingko biloba, milk thistle, and
bilberry. Herbs have a wide variety of uses.
e. traditional Chinese herbal medicines: Over 50,000 medicinal plant species,
many of which have been studied extensively. Herbs considered the backbone of
medicine.
f. Ayurvedic herbs: Traditional Hindu system of herbs used for over 2000 years.
5.
a. acupressure: Therapeutic technique of applying digital pressure in a specified way on
designated points on the body to relieve pain, produce analgesia, or regulate a body
function.
b. chiropractic medicine: System of therapy that involves manipulation of the spinal
column and includes physiotherapy and diet therapy.
c. Feldenkrais method: Alternative therapy based on establishment of good self-image
through awareness and correction of body movements. Technique integrates the
understanding of the physics of the body’s movement patterns with an awareness of
the way people learn to move, behave, and interact.
d. Tai chi: Technique that incorporates breath, movement, and meditation to cleanse,
strengthen, and circulate vital life energy and blood. Therapy stimulates the immune
system and maintains external and internal balance.
e. massage therapy: Manipulation of soft tissue through stroking, rubbing, or kneading
to increase circulation, improve muscle tone, and relaxation.
f. simple touch: Touching the client in appropriate and gentle ways to make connection,
display acceptance, and give appreciation.
6.
a. art therapy: Use of art to reconcile emotional conflicts, foster self-awareness, and
express clients’ unspoken and frequently unconscious concerns about their disease.
b. biofeedback: A process providing a person with visual or auditory information about
autonomic physiological functions of the body, such as muscle tension, skin
temperature, and brain wave activity, through the use of instruments.
c. dance therapy: Intimate and powerful medium for therapy because it is a direct
expression of the mind and body. Therapy treats persons with social, emotional,
cognitive, or physical problems.
d. breathwork: Using any of a variety of breathing patterns to relax, invigorate, or open
emotional channels.
e. guided imagery: Therapeutic technique for treating pathological conditions by
concentrating on an image or series of images.
f. meditation: Self-directed practice for relaxing the body and calming the mind using
focused rhythmic breathing
g. music therapy: Uses music to address physical, psychological, cognitive, and social
needs of individuals with disabilities and illnesses. Therapy improves physical
movement and/or communication, develops emotional expression, evokes memories,
and distracts people who are in pain.
h. healing intention: Variety of techniques used in multiple cultures that incorporate
caring, compassion, love, or empathy with the target of prayer.
i. psychotherapy: Treatment of emotional and mental disorders by psychological
techniques.
j. yoga: Discipline that focuses on the body’s musculature, posture, breathing

mechanisms, and consciousness. Goal of yoga is attainment of physical and mental
well-being through mastery of body achieved through exercise, holding of postures,
proper breathing, and meditation.
7.
a. biofield: intended to affect energy fields that purportedly surround and penetrate the
human body.
b. bioelectromagnetic-based therapies: involve the unconventional use of
electromagnetic fields, such as pulsed fields, magnetic fields, or alternating current or
direct current fields.
8. increased heart and respiratory rates, tightened muscles, increased metabolic rate, general
sense of fear, nervousness, irritability and negative mood
9. is the state of generalized decreased cognitive, physiological, and/or behavioral arousal
10. teaches the individual how to effectively rest and reduce tension in the body
11. teaches the individual to relax individual muscle groups passively
12. lower heart rate and blood pressure, decrease muscle tension, improve well-being, and
reduce symptom distress
13. fearing loss of control, feeling like they are floating, and experiencing induced anxiety
related to these feelings
14. is any activity that limits stimulus input by directing attention to a single unchanging or
repetitive stimulus
15. anxiety states, chronic bereavement, chronic fatigue syndrome, chronic pain, drug abuse,
hypertension, irritability, low self-esteem, mild depression, sleep disorders
16. contraindicated for people who have a strong fear of losing control or who are
hypersensitive; medication use
17. visualization techniques that use the conscious mind to create mental images to stimulate
physical changes in the body, improve perceived well-being, and/or enhance self-awareness
18. one form of self-directed imagery that is based on the principle of mind-body
connectivity
19. used to visualize cancer cells being destroyed by cells of the immune system, control or
relieve pain, and achieve calmness and serenity
20. a group of therapeutic procedures that uses electronic or electromechanical instruments to
measure, process, and provide information to persons about their neuromuscular and ANS
activity
21. treating migraines, strokes, and a variety of gastrointestinal and urinary tract disorders
22. Repressed emotions or feelings are sometimes uncovered, and the client has difficulty
coping.
23. involves the practitioner scanning the body of the client and diagnosing areas of
accumulated tensions and redirecting these energies to bring the person back into balance
24. a. the process whereby the practitioner becomes aware and fully present during the entire
treatment b. moves their hands in a rhythmic and symmetrical movement from head to toes,
noticing the quality of energy flow c. facilitates the symmetrical and rhythmical flow of
energy through the body d. directs and balances the energy, attempting to rebalance the
energy flow e. reassessment of the energy field
25. increased Hb levels, reduces anxiety levels, reduces headaches, improves mood
26. contraindicated in persons who are sensitive to human interaction and touch and
sensitivity to energy repatterning
27. spinal manipulation directed at certain joints; a holistic therapy
28. restoring structural and functional imbalances
29. malignancy, bone and joint infections, fractures, dislocations, and arthritis
30. comprises several modalities, herbs, acupuncture, moxibustion, diet, exercise, and
meditation
31. a. opposing yet complementary phenomena that exist in a state of dynamic equilibrium b.
vital energy of the body c. channels of energy that run in regular patterns through the body
and over its surface d. holes through which qi can be influenced by the insertion of needles e.
stimulating certain points on the body by the insertion of special needles to modify the
perception of pain, normalize physiological functions, or treat and prevent disease
32. low back pain, myofascial pain, headaches, sciatica, shoulder pain, tennis elbow,
osteoarthritis, whiplash, and musculoskeletal sprains
33. infections, broken needles, puncture of internal organ, bleeding, fainting, seizures,
miscarriage, and post-treatment drowsiness
34. The goal is to restore balance within the individual by facilitating the person’s self-
healing ability.
35. treatment of liver and gallbladder conditions, depression, antivirals
36. contamination with other chemicals or herbs, toxic agents, a variety of standards utilized
from one company to another
37. multiple-practitioner treatment group; a pluralistic, complementary health care system; is
consistent with the holistic approach nurses learn to practice
38. 2. the perception that the treatments offered by the medical profession do not provide
relief for a variety of common illnesses
39. 3. They have not received approval for use a drugs and are not regulated by the FDA;
therefore, they can be sold as food or food supplements only.
40. 2. It is important for the nurse to know the current research being done in this area to
provide accurate information not only to clients but also to other health care professionals.
Chapter 37: Activity and Exercise
1. k
2. d
3. p
4. n
5. l
6. m
7. e
8. q
9. o
10. s
11. t
12. f
13. g
14. r
15. b
16. h
17. i
18. j
19. c
20. a
21. The wider the base of support, the greater the stability of the nurse.
22. The lower the center of gravity, the greater the stability.
23. The equilibrium of an object is maintained as long as the line of gravity passes through
its base of support.
24. Facing the direction of movement prevents abnormal twisting of the spine.
25. Dividing balanced activity between arms and legs reduces the risk of back injury.
26. Leverage, rolling, turning, or pivoting requires less work than lifting.
27. When friction is reduced between the object to be moved and the surface on which it is
moved, less force is required to move it.
28.
a. congenital defects
b. disorders of bones, joints, and muscles
c. central nervous system damage
d. musculoskeletal trauma
29. The infant’s spine is flexed and lacks the anteroposterior curves; as growth and stability
increase, thoracic spine straightens, and the lumbar spinal curve appears, which allows for
sitting and standing.
30. Posture is awkward due to the slight swayback and protruding abdomen; toward the end
of toddlerhood, posture appears less awkward, curves in the cervical and lumbar vertebrae
are accentuated, and foot eversion disappears.
31. tremendous growth spurt in girls – hips widen, fat is deposited in upper arms, thighs and
buttocks; boys –long bone growth and increased muscle mass
32. Normal changes in posture and alignment occur in pregnant women.
33. a progressive loss of total bone mass due to physical inactivity, hormonal changes,
increased osteoclastic activity
34. the head is erect and midline, body parts are symmetrical, spine is straight with normal
curvatures, abdomen is comfortably tucked, knees are in a straight line between the hips and
ankles and slightly flexed, feet are flat on the floor
35. the head is erect and the neck and vertebral column are in straight alignment, body
weight is distributed on the buttocks and thighs, the thighs are parallel and in a horizontal
plane, feet are supported on the floor
36. vertebrae are in straight alignment without observable curves; head and neck should be
aligned without excessive flexion or extension
37. determine the degree of damage or injury to a joint, joint stiffness, swelling, pain, limited
movement, and unequal movement
38. manner or style of walking, including rhythm, cadence, and speed; observing balance,
posture, and ability to walk without assistance
39. activity for conditioning the body, improving health, maintaining fitness, or providing
therapy for correcting a deformity or restoring the overall body to a maximal state of health
40. See Box 37-7 for answers.
41.
a. activity intolerance
b. ineffective coping
c. impaired gas exchange
d. risk for injury
e. impaired physical mobility
f. imbalanced nutrition
g. acute or chronic pain
42.
a. participates in prescribed physical activity while maintaining appropriate heart rate,
blood pressure, and breathing rate
b. verbalizes an understanding of the need to gradually increase activity based on
tolerance and symptoms
c. expresses understanding of balancing rest and activity
43. subtracting their current age from 220 and then obtain their target heart rate by taking
60% to 90% of the maximum
44.
a. walking, running, bicycling, aerobic dance, jumping rope, and cross-country skiing
b. active ROM and stretching all muscle groups and joints
c. increases muscle strength and endurance; includes weight training, raking leaves,
shoveling snow, and kneading bread
45. muscle groups used for walking should be exercised isometrically 4 times per day until
the client is ambulatory
46. active –the client is able to move his or her joints independently; passive – the nurse
moves each joint
47. increases joint mobility
48.
a. single straight-legged cane that is used to support and balance a client with decreased
leg strength
b. quad cane provides more support and is used for partial or complete leg paralysis or
some hemiplegia
49.
a. each leg is moved alternatively with each opposing crutch so that three points are on
the floor at all times
b. bears weight on both crutches and then on the uninvolved leg, repeating the sequence
c. least partial weight bearing on each foot
d. weight is placed on supportive legs; crutches are one stride in front and then swings
through with the crutches, supporting the client’s weight
50. reduced mortality and morbidity, improved quality of life, improved left ventricular
function, increased functional capacity, decreased blood lipids, and increased psychological
well-being
51. reduces systolic and diastolic blood pressure
52. helping clients reach an optimal level of functioning
53. improved cardiovascular fitness and psychological well-being
54.
a. pulse
b. blood pressure
c. strength
d. endurance
d. psychological well-being
55. 4. definition
56. 2. it increases cardiac output
57. Refer to Figure 37-3 in the text for answers.
Chapter 38: Client Safety

1. Environment: Includes all of the physical and psychosocial factors that influence the life
and the survival of the client.
2. Carbon monoxide: Colorless, odorless, poisonous gas
3. Food poisoning: Staphylococcal and clostridial bacteria are the most common types
4. Food and Drug Administration (FDA): Federal agency responsible for regulating the
manufacture, processing, and distribution of foods, drugs, and cosmetics
5. Hypothermia: Core temperature is 35ᵒ C or below
6. Relative humidity: Amount of water vapor in the air compared with the maximum
amount of water vapor that the air could contain
7. Immunization: Process by which resistance to an infectious disease is produced
8. Air pollution: Contamination of the atmosphere with a harmful chemical
9. Land pollution: Caused by improper disposal of radioactive waste products
10. Water pollution: Contamination of lakes, rivers, and streams by industrial pollutants
11. Noise pollution: Uncomfortable noise level
12. Bioterrorism: The use of anthrax, smallpox, pneumonic plague, and botulism
13. In addition to being knowledgeable about the environment, nurses must be familiar
with:
a. client’s developmental level
b. mobility, sensory, and cognitive status
c. lifestyle choices
d. knowledge of common safety precautions
14. Identify the individual risk factors that can pose a threat to safety:
a. lifestyle
b. impaired mobility
c. sensory or communication impairment
d. lack of sensory awareness
15. List the four major risks to client safety in the health care environment
a. falls
b. client-inherent accidents (seizures, burns, inflicted cuts)
c. procedure-related accidents (medication administrations, improper procedures)
d. equipment-related accidents (rapid IV infusions, electrical hazards)
Safety and the Nursing Process
Assessment
16. Identify the specific client assessments to perform when considering possible threats
to the client’s safety.
a. nursing history
b. client’s home environment
c. health care environment
d. risk for falls

e. risk for medical errors
Identify the features that should alert nurses to the possibility of a bioterrorism-related
out-break.
17. a rapidly increasing incidence of a disease in a normally healthy population
18. an unusual increase in the number of people seeking care with fever, respiratory, or GI
symptoms
19. an endemic disease rapidly emerging at an uncharacteristic time, location, or in an
unusual pattern
20. lower attack rates among clients are primarily indoors, in areas with filtered or closed
ventilation, compared with people who had been outdoors
21. clusters of clients arriving from a single locale
22. large number of rapidly fatal cases
23. any client presenting with a disease that is relatively uncommon to the geographic area
and has bioterrorism potential
24. atypical clinical presentation
Nursing Diagnosis
Identify actual or potential nursing diagnoses that apply to clients whose safety is
threatened.
25. risk for imbalanced body temperature
26. impaired home maintenance
27. risk for injury
29. risk for poisoning
30. disturbed sensory/perception
31. risk for suffocation
32. disturbed thought processes
33. risk for trauma
Planning
34. Identify the expected outcomes that focus on the client’s need for safety.
a. modifiable hazards will be reduced in the home environment by 100% within 1 month
b. client does not suffer a fall or injury
c. client identifies risks associated with visual impairment
Implementation
Health promotion
35. Identify general preventive measures to ensure a safer environment.
Meet the basic needs related to oxygen, nutrition, temperature, and humidity
Acute Care
36. List eight measures to prevent falls in the health care setting
a. Place disoriented clients in room near nurses’ station.
b. Maintain close supervision of confused clients.
c. Show the client how to use the call light at the bedside and in bathroom, and place
within easy reach.
d. Place bedside tables and over-bed tables close to client.
e. Remove clutter from bedside tables, hallways, bathrooms, and grooming areas.
f. Leave one side rail up and one down on the side where the oriented and ambulatory
client gets out of bed.
g. Lock beds and wheelchairs when transferring a client from a bed to a wheelchair or
back to bed.
h. Place side rails in the up position, and secure safety straps around the client on a
stretcher.
37. A physical restraint is:

is a human, mechanical, and/or physical device that is used with or without the client’s
permission to restrict his/her freedom of movement or normal access to a person’s body and
is not a usual part of the treatment plan
38. Use of restraints must meet the following objectives

a. reduce the risk of client injury from falls
b. prevent interruption of therapy
c. prevent the confused or combative client from removing life support equipment
d. reduce the risk of injury to others by the client
39. Explain why an ambularm is used: a device that signals when the leg is in a dependent
position
40. Explain the mnemonic RACE to set priorities in case of fire:

R – rescue and remove all clients in immediate danger
A – activate the alarm
C –confine the fire by closing doors and windows and turning off oxygen and electrical
equipment
E – extinguish the fire using an extinguisher
41. A poison is: is any substance that impairs health or destroys life when ingested, inhaled,
or absorbed by the body
42. Explain seizure precautions to take: are nursing interventions to protect clients from
traumatic injury, positioning for adequate ventilation and drainage or oral secretions, and
providing privacy and support following the event
43. Identify the measures with which the nurse must be familiar to reduce exposure to
radiation: limit the time spent near the source, make the distance from the source as great as
possible, and use shielding devices
44. process to determine hazard vulnerability for the hospital’s service area
45. steps taken to increase a hospital’s ability to manage effects of an attack
46. steps taken by the staff in the event of an attack
47. steps taken to restore essential services and resume normal agency operations
48. 3. physiological needs , including the need for oxygen, nutrition, and optimum
temperature and humidity; influence a person’s safety
49. 4. due to the physiological changes that occur during the aging process, increase the
client’s risk for falls
50. 3. Use the RACE to set priorities in case of fire.
51. 4. The related factor becomes the basis for the selection of nursing therapies.
52.
a. Ms. Cohen states, “I bump into things, and I’m afraid I’m going to fall.” Cabinets
in kitchen are disorganized and full of breakable items that could fall out. Throw
rugs are on floors; bathroom lighting is poor (40-watt bulbs); bathtub lacks safety
strips or grab bars; home cluttered with furniture and small objects. Ms. Cohen has
kyphosis and has a hesitant, uncoordinated gait. She frequently holds walls for
support. Ms. Cohen’s left arm and leg are weaker than those on the right. Ms.
Cohen has trouble reading and seeing familiar objects at a distance while wearing
current glasses.
b. In the case of safety, the nurse integrates knowledge from nursing and other scientific
disciplines and previous experiences in caring for clients who had an injury or were at
risk.
c. The American Nurses Association (ANA) standards for nursing practice address the
nurse’s responsibility in maintaining client safety.
d. Critical-thinking attitudes such as perseverance and creativity would be applicable in
this case.
Chapter 39: Hygiene
1. a. outer layer b. thicker layer containing bundles of collagen and elastic fibers c. contains
blood vessels, nerves, lymph, and loose connective tissue with fat cells
2. a. protection b. sensation c. temperature regulation d. excretion and secretion
3. a. fold of skin at the nail groove b. crescent-shaped white area
4. a. found in the mucosa lining the cheeks and mouth, which maintain the hygiene and
comfort of oral tissues b. chewing c. gum inflammation
5. a. social practices b. personal preferences c. body image d. socioeconomic status e. health
beliefs and motivation f. cultural variables g. physical condition
6. the color, texture, thickness, turgor, temperature, and hydration
7.
a. Dry skin: Bathe less frequently and rinse body of all soap because residue left on skin
can cause irritation and breakdown. Add moisture to air through use of humidifier.
Increase fluid intake when skin is dry. Use moisturizing cream to aid healing. (Cream
forms protective barrier and helps maintain fluid within skin.) Use cream such as
Eucerin. Use creams to clean skin that is dry or allergic to soaps and detergents.
b. Acne: Wash hair and skin thoroughly each day with warm water and soap to remove
oil. Use cosmetics sparingly because oily cosmetics or creams accumulate in pores
and tend to make condition worse. Implement dietary restrictions, if necessary.
(Eliminate foods that aggravate condition from diet.) Use prescribed topical
antibiotics for severe forms of acne.
c. Skin rashes: Wash area thoroughly and apply antiseptic spray or lotion to prevent
further itching and aid in healing process. Apply warm or cold soaks to relieve
inflammation, if indicated.
d. Contact dermatitis: Avoid causative agents (e.g., cleansers and soaps).
e. Abrasion: Be careful not to scratch client with jewelry or fingernails. Wash abrasions
with mild soap and water; dry thoroughly and gently. Observe dressing or bandage
for retained moisture because it increases risk of infection.
8.
a. Immobilization: When restricted from moving freely, dependent body parts are
exposed to pressure, reducing circulation to affected body parts. Know which clients
require assistance to turn and change positions.
b. Reduced sensation: Clients with paralysis, circulatory insufficiency, or local nerve
damage are unable to sense an injury to the skin. During a bath, assess the status of
sensory nerve function by checking for pain, tactile sensation, and temperature
sensation.
c. Nutrition and hydration: Clients with limited caloric and protein intake develop
thinner, less elastic skin, with loss of subcutaneous tissue. This results in impaired or
delayed wound healing.
d. Secretions and excretions: Moisture on the skin’s surface serves as a medium for
bacterial growth and causes irritation, softens epidermal cells, and leads to skin
maceration. Presence of perspiration, urine, watery fecal material, and wound
drainage on the skin results in breakdown and infection.
e. Vascular insufficiency: Inadequate arterial supply to tissues and impaired venous

return decrease circulation to the extremities. Inadequate blood flow causes ischemia
and breakdown. Risk of infection also exists because delivery of nutrients, oxygen,
and white blood cells to injured tissues is inadequate.
f. External devices: An external device applied to or around the skin exerts pressure or
friction on the skin. Assess all surfaces exposed to casts, cloth restraints, bandages
and dressings, tubing, or orthopedic braces.
9.
a. Calluses: Thickened portion of epidermis consists of mass of horny, keratotic cells.
Callus is usually flat, painless, and found on undersurface of foot or on palm of hand.
b. Corns: Friction and pressure from ill-fitting or loose shoes cause keratosis. Corns are
seen mainly on or between toes, over bony prominences. Corns are usually cone-
shaped, round, and raised. Soft corns are macerated.
c. Plantar warts: Fungating lesion appears on sole of foot and is caused by the
papilloma virus.
d. Tinea pedis: Athlete’s foot is fungal infection of foot; scaliness and cracking of skin
occurs between toes and on soles of feet. Small blisters containing fluid appear.
e. Ingrown nails: Toenail or fingernail grows inward into soft tissue around nail.
Ingrown nail often results from improper nail trimming.
f. Foot odors: Foot odors are the result of excess perspiration promoting
microorganism growth.
10. bad breath
11.
a. Dandruff: Scaling of scalp is accompanied by itching. In severe cases, dandruff is on
eyebrows.
b. Ticks: Small, gray-brown parasites burrow into skin and suck blood.
c. Pediculosis: Tiny, grayish-white parasite insects infest mammals.
d. Pediculosis capitis: Parasite is on scalp attached to hair strands. Eggs look like oval
particles, similar to dandruff. Bites or pustules may be observed behind ears and at
hairline.
e. Pediculosis corporis: Parasites tend to cling to clothing, so they are not always easy to
see. Body lice suck blood and lay eggs on clothing and furniture.
f. Pediculosis pubis: Parasites are in pubic hair. Crab lice are grayish white with red
legs.
g. Alopecia: Alopecia occurs in all races. Balding patches are in periphery of hair line.
Hair becomes brittle and broken.
12.
a. Oral problems: Clients who are unable to use upper extremities due to paralysis,
weakness, or restriction (e.g., cast or dressing); Dehydration, inability to take fluids or
food by mouth (NPO); Presence of nasogastric or oxygen tubes; mouth breathers;
Chemotherapeutic drugs; Lozenges, cough drops, antacids, and chewable vitamins
over-the-counter (OTC); Radiation therapy to head and neck; Oral surgery, trauma to
mouth, placement of oral airway; Immunosuppression; altered blood clotting;
Diabetes mellitus
b. Skin problems: Immobilization; Reduced sensation due to stroke, spinal cord injury,
diabetes, local nerve damage; Limited protein or caloric intake and reduced hydration
(e.g., fever, burns, gastrointestinal alterations, poorly fitting dentures); Excessive
secretions or excretions on the skin from perspiration, urine, watery fecal material,
and wound drainage; Presence of external devices (e.g., casts, restraints, bandage,
dressing); Vascular insufficiency
c. Foot problems: Client unable to bend over or has reduced visual acuity
d. Eye care problems: Reduced dexterity and hand coordination
13. chronic low self-esteem
14. deficient knowledge about hygiene practices
15. fatigue
16. impaired dentition
17. impaired oral mucous membrane
18. impaired physical mobility
19. ineffective health maintenance
20. ineffective tissue perfusion
21. risk for impaired skin integrity
22. risk for infection
23. a. client’s skin is clean, dry, and intact without signs of inflammation b. skin remains
elastic and well-hydrated c. range of joint motion remains within normal limits on both
affected and unaffected side
24. a. make all instructions relevant after assessing knowledge, motivations, and health
beliefs b. adapt instruction of any techniques to the client’s personal bathing facilities c. teach
the client steps to avoid injury d. reinforce infection-control practices
25.
a. complete bed bath: Bath administered to totally dependent client in bed (Skill 39-1)
b. partial bed bath: Bed bath that consists of bathing only body parts that would cause
discomfort if left unbathed, such as the hands, face, axillae, and perineal area. Partial
bath also includes washing back and providing back rub. Dependent clients in need of
partial hygiene or self-sufficient bedridden clients who are unable to reach all body
parts receive a partial bath.
c. sponge bath: Involves bathing from a bath basin or sink with the client sitting in a
chair. Client is able to perform a portion of the bath independently. Assistance is
needed for hard-to- reach areas.
d. tub bath: Involves immersion in a tub of water that allows more thorough washing
and rinsing than a bed bath. Client may still require the nurse’s assistance. Some
institutions have tubs equipped with lifting devices that facilitate positioning
dependent clients in the tub.
e. bed bath/travel bath: Developed by Skewes (1994), the Bag Bath contains several
soft, nonwoven cotton cloths that are premoisted in a solution of no-rinse surfactant
cleanser and emollient. The Bed Bath offers an alternative because of the ease of use,
reduced bathing time, and client comfort.
26. a. provide privacy b. maintain safety c. maintain warmth d. promote independence e.

anticipate needs
27. greatest risk are those males who are uncircumcised, clients who have indwelling
catheters, or clients recovering from rectal or genital surgery or childbirth
28. promotes relaxation, relieves muscular tension, and decreases perception of pain
29. Inspect the feet daily, using a mirror.
30. Instruct client to wash feet daily in lukewarm water and dry thoroughly.
31. foot examination yearly
32. unscented foot powder for perspiration
33. clean, dry socks
34. apply lanolin, baby oil to dry areas of feet
35. file the toenails straight across and square
36. do not use OTCs to treat foot conditions; consult with physician
37. Avoid wearing elastic stockings.
38. Wear properly fitted shoes.
39. Do not wear new shoes for an extended time.
40. Exercise regularly to improve circulation.
41. Wash minor cuts immediately and dry thoroughly.
42. Thorough tooth brushing at least 4 times a day is basic; obtain new brushes every 3
months.
43. removes plaque and tartar between teeth
44. need to be cleaned on a regular basis to avoid gingival infection and irritation
45. helps to keep hair clean and distributes oil evenly along hair shafts; prevents hair from
tangling
46. frequency depends on a person’s daily routines and the condition of the hair
47. Shave facial hair after the bath or shampoo; to avoid causing discomfort, gently pull the
skin taut and use short, firm razor strokes in the direction the hair grows.
48. They require daily grooming due to food particles and mucus that collect on the hair.
49. Unconscious clients will require more frequent eye care; wash with a clean washcloth
moistened in water.
50. daily wear, extended wear, and disposable
51. a. use a small, rubber bulb syringe to create a suction effect; place directly over the eye;
squeezing lifts the eye from the socket b. warm normal saline c. retract the upper and lower
lids and gently slip the eye into the socket d. in a labeled container filled with tap water or
saline
52. Instill 3 drops of glycerin at bedtime to soften the wax and 3 drops of hydrogen peroxide
twice a day to loosen the wax; then instill 250 cc of warm water into the ear, which will wash
away the loosened wax.
53. a. it requires adequate ear diameter and depth for proper fit; it does not accommodate
progressive hearing loss and requires manual dexterity to operate b. fits into the external ear
and allows for more fine tuning, powerful, easy to adjust c. hooks around and behind the ear
and is connected to an ear mold, allows for fine tuning, useful for clients with progressive
hearing loss
54.
a. Fowler’s: Head of bed raised to angle of 45 degrees or more; semi-sitting position;
foot of bed may also be raised at knee
b. Semi-Fowler’s: Head of bed raised approximately 30 degrees; inclination less than
Fowler’s position; foot of bed may also be raised at knee
c. Trendelenburg’s: Entire bed frame tilted with head of bed down
d. Reverse Trendlenburg’s: Entire bed frame tilted with foot of bed down
e. Flat: Entire bed frame horizontally parallel with floor
55. 2. a bath that is administered to totally dependent client in bed

56. 2. The condition of the skin depends on the exposure to environmental irritants; with
frequent bathing or exposure to low humidity, the skin becomes very dry and flaky.
57. 3. Each client has individual desires and preferences about when to bathe, shave, and
perform hair care.
58. 2. File the toenails straight across and square; do not use scissors or clippers; consult a
podiatrist as needed.
59. 3. Use a medicated shampoo for eliminating lice, which is easily able to spread to
furniture and other people if not treated.
60.
Mrs. Edith Wyatt is a 77-year-old female with a history of degenerative arthritis and diabetes
mellitus for 3 years and complains of pain in the joints, weakness, and mobility limitations in
the dominant hand. Mrs. Wyatt is a widow with her only child, a daughter, living in a city
200 miles away. Mrs. Wyatt lives in a first-floor apartment in a retirement center. She moved
in three weeks earlier. The nurse, Jeannette, makes the initial home visit for Mrs. Wyatt.
Jeannette’s assessment reveals defining characteristics of an inability to wash body parts,
unkempt appearance, difficulty turning and regulating a water faucet, and limited motion of
arms. Jeannette also observes Mrs. Wyatt to have a right limp. Her shoes are worn and ill-
fitting.
Jeannette synthesizes information that she has obtained from her assessment to develop a
plan of care. She involves Mrs. Wyatt in the plan by asking her what is important to her to
gain from her visit. She wants to continue to be independent in making decisions about her
care. She tells Jeannette, “It is important for me to be able to care for myself.” Jeannette
assesses the client’s tolerance for activity, discomfort level, cognitive ability, and
musculoskeletal function, which determines client’s ability to perform self-care and level of
assistance required from nurse. Assess range of motion of upper extremities. She states, “it
hurts to move my arms above my head.” Jeannette also assesses the client’s bathing
preferences: frequency and time of day, type of hygiene products. Mrs. Wyatt states, “I
cannot get used to the new bathroom. The floor in the shower is slippery. I cannot
reach my towels and soap. I have not been to the hair dresser since I arrived here.”
Mrs. Wyatt’s hair is not washed or combed.
Current bathroom has a shower with handgrips; levers turn up and down versus clockwise,
and shower seat is available. The handles on the shower are levers versus faucets. The room
also has a small closet for linens with a large counter top adjunct to sink. Jeannette asked
Mrs. Wyatt how long she has limped and if she has any pain. Mrs. Wyatt replies “My right
foot hurts, especially by the little toe. This has been going on for about two weeks.”
Jeannette assesses the condition of Mrs. Wyatt’s feet and her knowledge about prevention
and routine foot care. Both feet are dry and toenails evenly trimmed at end of toe. The
outer aspect of the little toe on right foot is reddened, tender to touch with intact skin. Mrs.
Wyatt states, “I have my doctor trim my toenails every month, because of my sugar
problems.”
Jeannette involved Mrs. Wyatt when making decisions regarding her care. She became
creative in adapting an approach to her self-care by setting up an appointment with a home
health-care agency to provide a home-care assistant to assist Mrs. Wyatt with her bathing and
hair care. Mrs. Wyatt states that she has a monthly appointment scheduled for the next 6
months for toenail trimming and care.
Chapter 40: Oxygenation
1. c
2. e
3. h
4. f
5. b
6. g
7. a
8. d
9. conduction thru both atria
10. impulse travel time through the AV node (.012 -.20 seconds)
11. the impulse traveled through the ventricles (0.06 – 0.12 seconds)
12. time needed for ventricular depolarization and repolarization (0.12-0.42 seconds)
13. e
14. g
15. i
16. j
17. h
18. d
19. f
20. b
21. a
22. c
23.
a. cardiac disorders: disturbances in conduction, impaired valvular function, myocardial
hypoxia, cardiomyopathic conditions, and peripheral tissue hypoxia Respiratory
disorders (hyperventilation, hypoventilation, hypoxia)
b. alterations that affect the oxygen-carrying capacity (anemia)
c. decreased inspired oxygen concentration (high altitudes, drug overdoses)
d. hypovolemia (shock and severe dehydration) e. increased metabolic rate (pregnancy,
fever, infection)
24.
a. pregnancy (inspiratory capacity declines)
b. obesity (reduced lung volumes)
c. musculoskeletal abnormalities (structural configurations, trauma, muscular disease,
CNS)
d. trauma (flail chest, incisions)
e. neuromuscular diseases (decrease the ability to expand and contract the chest wall)
f. CNS (reduced inspiratory lung volumes)
g. chronic diseases (chronic hypoxemia)
25.
a. Regular rhythm, rate greater than 100
b. Regular rhythm, rate less than 60
c. Electrical impulse in the atria is chaotic and originates from multiple sites
d. Life threatening, impulse originates in ventricles, QRS complex is usually widened

and bizarre
e. Uncoordinated electrical activity, no identifiable P, QRS, or T wave
26.
a. decreased functioning of the left ventricle (fatigue, breathlessness, dizziness, and
confusion)
b. impaired functioning on the right ventricle (weight gain, distended neck veins,
hepatomegaly and splenomegaly, and dependent peripheral edema)
27.
a. flow of blood through the valve is obstructed
b. back flow of blood into an adjacent chamber
28. results when the supply of blood to the myocardium from the coronary arteries is
insufficient to meet the myocardial oxygen demand
29. transient imbalance between myocardial oxygen supply and demand
30. results from a sudden decrease in coronary blood flow or an increase in myocardial
oxygen demand without adequate coronary perfusion
31. includes unstable angina, non-ST segment elevation MI, and ST-segment elevation, MI
(nonocclusive thrombus, coronary vasospasm, atherosclerosis, inflammation, or infection)
32. excess ventilation required to eliminate the carbon dioxide produced (anxiety, infections,
drugs, or an acid-base imbalance)
33. alveolar ventilation is inadequate to meet the body’s oxygen demand
34. collapse of the alveoli which prevents normal exchange of oxygen and carbon dioxide
35. inadequate tissue oxygenation at the cellular level (decreased hemoglobin levels, high
altitudes, poisoning, pneumonia, shock, chest trauma)
36. blue discoloration of the skin and mucous membranes caused by the presence of
desaturated hemoglobin in capillaries
37. upper respiratory tract infections due to frequent exposures and secondhand smoke
38. exposure to respiratory infections, secondhand smoke, and smoking
39. unhealthy diet, lack of exercise, stress, OTCs, illegal substances, smoking
40. aging changes, osteoporosis
41.
a. smoking cessation
b. weight reduction
c. low-cholesterol and low-sodium diet
d. management of hypertension
e. moderate exercise
42.
a. asbestos
b. talcum powder
c. dust
d. airborne fibers
43.
a. cardiac function – pain, dyspnea, fatigue, peripheral circulation, cardiac risk factors
b. respiratory function – cough, SOB, wheezing, pain, environmental exposure,
frequency of infections, risk factors, medication use, smoking use
44.
a. does not occur with respiratory variations

b. is peripheral and radiates to the scapular regions
c. often present following exercise, trauma, prolonged coughing episodes
45. is a subjective sensation (loss of endurance)
46. clinical sign of hypoxia, usually associated with exercise or excitement associated with
many medical and environmental factors
47. abnormal condition in which the client uses multiple pillows when lying down
48. sudden, audible expulsion of air from the lungs; a protective reflex to clear the trachea,
bronchi, and lungs of irritants and secretions
49. high-pitched musical sound caused by high-velocity movement of air through a narrowed
airway
50. observe the client for skin and mucous membrane color, general appearance, level of
consciousness, systemic circulation, breathing patterns, and chest wall movement
51. type of thoracic excursion; areas of tenderness; identifies tactile fremitus, thrills, heaves,
and PMI
52. detects the presence of abnormal fluid or air in the lungs
53. identify normal and abnormal heart and lung sounds
54.
a. Holter monitor: Portable ECG worn by the client. The test produces a continuous
ECG tracing over a period of time. Clients keep a diary of activity, noting when they
experience rapid heartbeats or dizziness. Evaluation of the ECG recording along with
the diary provides information about the heart’s electrical activity during activities of
daily living.
b. Exercise stress test: ECG is monitored while the client walks on a treadmill at a
specified speed and duration of time. Used to evaluate the cardiac response to
physical stress. The test is not a valuable tool for evaluation of cardiac response in
women due to an increased false-positive finding.
c. Thallium stress test: An ECG stress test with the addition of thallium-201 injected IV.
Determines coronary blood flow changes with increased activity.
d. Electrophysiological studies (EPS): Invasive measure of intracardiac electrical
pathways. Provides more specific information about difficult-to-treat dysrhythmias.
Assesses adequacy of antidysrhythmic medication.
e. Echocardiography: Noninvasive measure of heart structure and heart wall motion.
Graphically demonstrates overall cardiac performance.
f. Scintigraphy: Radionuclide angiography. Used to evaluate cardiac structure,
myocardial perfusion, and contractility.
g. Cardiac catheterization and angiography: Used to visualize cardiac chambers, valves,
the great vessels, and coronary arteries. Pressures and volumes within the four
chambers of the heart are also measured.
55.
a. Pulmonary function tests: Determine the ability of the lungs to efficiently exchange
oxygen and carbon dioxide. Used to differentiate pulmonary obstructive disease from
restrictive disease.
b. Peak expiratory flow rate (PEFR): The PEFR reflects changes in large airway sizes
and is an excellent predictor of overall airway resistance in the client with asthma.
Daily measurement is for early detection of asthma exacerbations.
c. Bronchoscopy: Visual examination of the tracheobronchial tree through a narrow,

flexible fiberoptic bronchoscope. Performed to obtain fluid, sputum, or biopsy
samples; remove mucous plugs or foreign bodies.
d. Lung scan: Used to identify abnormal masses by size and location. Identification of
masses is used in planning therapy and treatments.
e. Thoracentesis: Specimen of pleural fluid is obtained for cytological examination. The
results may indicate an infection or neoplastic disease. Identification of infection or a
type of cancer is important in determining a plan of care.
56. activity intolerance
57. anxiety
58. decreased cardiac output
59. fatigue
60. impaired gas exchange
61. impaired spontaneous ventilation
62. impaired verbal communication
63. ineffective airway clearance
64. ineffective breathing pattern
65. ineffective health maintenance
66. risk for imbalanced fluid volume
68.
a. lungs are clear to auscultation
b. achieves maintenance and promotion of bilateral lung expansion
c. coughs productively
d. pulse oximetry is maintained or improved
69.
a. exercise
b. breathing techniques
c. cough control
d. relaxation techniques
e. biofeedback
f. meditation
70.
a. humidification
b. nebulization
c. chest physiotherapy
d. postural drainage
71.
a. oropharyngeal and nasopharyngeal
b. orotracheal and nasotracheal
c. artificial airway
72. frequent changes of position are effective for reducing stasis of pulmonary secretions and
decreased chest wall expansion (Semi-Fowler’s is the most effective position)
73. encourages voluntary deep breathing and prevents atelectasis by using visual feedback
74.
a. to remove air and fluids from the pleural space
b. to prevent air or fluid from reentering the pleural space

c. to reestablish normal intrapleural and intrapulmonic pressures
75.
a. accumulation of blood and fluid in the pleural cavity between the parietal and visceral
pleurae usually due to trauma
b. collection of air in the pleural space, caused by loss of negative intrapleural pressure
76. is to prevent or relieve hypoxia
77.
a. Nasal cannula: A nasal cannula is a simple, comfortable device used for oxygen
delivery (Skill 40-4). The two cannulas, about 1.5 cm (½ inch) long, protrude from
the center of a disposable tube and are inserted into the nares (Figure 40-13).
Advantages include: safe and simple; easily tolerated; delivers low concentrations
while allowing the client to eat, speak, and drink; does not impede eating or talking;
is inexpensive and disposable. Disadvantages include: unable to use with nasal
obstruction; drying to mucous membranes; can dislodge easily; causes skin irritation
or breakdown; client’s breathing pattern will affect exact FIO2.
b. Face mask: An oxygen face mask is a device used to administer oxygen, humidity, or
heated humidity. It fits snugly over the mouth and nose and is secured in place with a
strap and it assists in providing humidified oxygen. Disadvantages include: exact
FIO2 level is difficult to estimate; requires high FIO2 levels to prevent re-breathing of
carbon dioxide; client inhales room air through the side holes in the mask.
c. Venturi mask: The Venturi mask delivers oxygen concentrations of 24% to 60% with
oxygen flow rates of 4 to 12 L/min, depending on the flow-control meter selected.
Advantages include: controls the amount of specified oxygen concentration. Delivers
percentage of FIO2 from 24-60%; does not dry mucous membranes; delivers humidity
with oxygen concentration.
78. a PaO2 of 55 mm Hg or less or an SaO2 of 88% or less on room air at rest, on exertion, or
with exercise
79. A-airway B-breathing C-circulation
80.
a. physical exercise
b. nutrition counseling
c. relaxation and stress management techniques
d. prescribed medications and oxygen
e. compliance
81. cascade cough – promotes airway clearance and patent airway in clients with large
volumes of sputum. Huff cough – stimulates a natural cough reflex and is effective only for
clearing central airways
82. improves muscle strength and endurance
83. involves deep inspiration and prolonged expiration through pursed lips to prevent
alveolar collapse
84. improves efficiency of breathing by decreasing air trapping and reducing the work of
breathing
85.
a. evaluation of ABGs
b. PFTs
c. VS
d. ECG
e. physical assessment data
86. 1. These are the 3 steps in the process of oxygenation.
87. 1. The heart must work to overcome this resistance to fully eject blood from the left
ventricle.
88. 2. Gases move into and out of the lungs through pressure changes (intrapleural and
atmospheric).
89. 3. All other answers are related to the subjective sensation of dyspnea.
90. 2. CPT includes postural drainage, percussion, and vibration.
91.
Mr. Edwards’ statement indicates that he has a cough, does not exercise, is fatigued, and
continues to smoke ½ pack of cigarettes a day. Mr. Edwards’ skin and mucus membranes are
dry; he has abnormal breath sounds in the lower lobes and has a productive cough of thick
and discolored yellow-to-yellow green sputum. His SpO2 ranges from 78-84%, and his vital
signs are 100.4, 130/90, 88, 26 SpO2 87%. Interventions based upon the data would include
increasing fluids to 1000 mL in 24 hours to liquefy secretions, have Mr. Edwards deep-
breathe and cough every 2 hours 4 to 5 times, and teach Mr. Edwards effective cough
techniques to clear secretions. Initiate chest physiotherapy (CPT) if there is evidence of
infiltrates on chest X-ray. Help identify community resources and support systems for both
the client and family in preventing and managing symptoms related to his COPD upon
discharge from the hospital.
Chapter 41: Fluid, Electrolyte, and Acid-Base Balance
1. a. comprises all fluid within the cells of the body (42% of body weight) b. is the fluid
outside the cell (interstitial, intravascular, and transcellular fluid)
2. positively charged electrolytes (sodium, potassium, and calcium)
3. negatively charged electrolytes (chloride, bicarbonate, and sulfate)
4. represents the number of grams of the specific electrolyte dissolved in a liter of plasma
5. are electrolytes, oxygen, carbon dioxide, glucose, and proteins
6. involves the movement of a pure solvent across a semipermeable membrane from an area
of lesser solute concentration to an area of greater solute concentration
7. The concentration of a solution is measured, which reflects the amount of a substance in
the form of molecules, ions, or both.
8. is the drawing power of water and depends on the number of molecules in solution
9. the osmotic pressure of a solution
10. another term that describes the concentration of solution
11. the solutions on both sides of the semipermeable membrane are equal in concentration
(expand the body’s fluid volume without causing a fluid shift from one compartment to
another)
12. a solution of higher osmotic pressure (pulls fluid from cells, causing them to shrink)
13. a solution of lower osmotic pressure (moves fluids into the cells, causing them to
enlarge)
14. random movement of a solute in a solution across a semipermeable membrane from an
area of higher concentration to an area of lower concentration
15. the difference between 2 concentrations
16. is the process by which water and diffusible substances move together across a
membrane, in response to fluid pressure, moving from an area of higher pressure to one of
lower pressure
17. requires metabolic activity and expenditure of energy to move substances across the cell
membrane
18. a. fluid intake b. hormonal controls c. fluid output
19. continually monitor the serum osmotic pressure
20. excess fluid is lost
21. at risk are clients who are unable to perceive or respond to the thirst mechanism
22. ADH – is stored in the pituitary gland and is released in response to changes in the blood
osmolarity
23. a. causes vasoconstriction b. massive selective vasoconstriction of blood vessels;
relocates blood flow to kidneys and stimulates the release of aldosterone (when the sodium is
low) c. adrenal cortex releases in response to increased plasma potassium levels
24. plays a critical role in the balance of fluid and electrolytes and the maintenance of
vascular tone
25. kidneys, skin, lungs, gastrointestinal tract
26. a. is continuous and occurs through the skin and lungs; not perceived by the person b.
occurs through excess perspiration and can be perceived by the client
27.
Electrolyte Values Function Regulatory Mechanism

Sodium 135-145 mEq/L Major contributor to maintaining Dietary intake and
water balance aldosterone secretion

Potassium 3.5-5.0 mEq/L Is necessary for glycogen Dietary intake and renal
deposits in the liver and skeletal excretion regulate
muscle, transmission and potassium.
conduction of nerve impulses,
normal cardiac conduction, and
skeletal and smooth muscle
contraction
Calcium 4.5-5.5 mg/dl Bone and teeth formation, blood Absorbed from intestine,
clotting, hormone secretion, cell excreted by the kidneys
membrane integrity, cardiac and resorption or
conduction, transmission of deposition in bone.
nerve impulses, and muscle Regulated by parathyroid
contraction hormone, vitamin D &
calcitonin.
Magnesium 1.5-2.5 mEq/L Essential for enzyme activities, Serum magnesium is
neurochemical activities, and regulated by dietary
cardiac and skeletal muscle intake, renal
excitability mechanisms, and actions
of the parathyroid
hormone (PTH).
Chloride 95-105 mEq/L Chloride is the major anion in Serum chloride is
ECF. The transport of chloride regulated by dietary
follows sodium. intake and the kidneys.
Bicarbonate 22-26 (arterial) The bicarbonate ion is an The kidneys regulate
mEq/L essential component of the bicarbonate.
carbonic acid-bicarbonate
24-30 (venous)
buffering system essential to
mEq/L
acid-base balance.
Phosphate 2.8-4.5 mg/dl It assists in acid-base regulation. Phosphate is normally
Phosphate and calcium help to absorbed through the GI
develop and maintain bones and tract. It is regulated by
teeth. Phosphate also promotes dietary intake, renal
normal neuromuscular action and excretion, intestinal
participates in carbohydrate absorption, and PTH.
metabolism.
28. a. chemical b. biological c. physiological buffering
29.
Imbalance Lab Finding Signs and Symptoms
Hyponatremia serum sodium level below apprehension, personality
135 mEq/L, serum osmolality change, postural
280 mOsm/kg, and urine hypotension, postural
specific gravity below 1.010 dizziness, abdominal
(if not caused by SIADH) cramping, nausea and
vomiting, diarrhea,
tachycardia, dry mucous
membranes, convulsions,
and coma
Hypernatremia serum sodium levels above extreme thirst, dry and
145 mEq/L, serum osmolality flushed skin, dry and sticky
300 mOsm/kg, and urine tongue and mucous
specific gravity 1.030 (if not membranes, postural
caused by diabetes insipidus) hypotension, fever, agitation,
convulsions, restlessness,
and irritability
Hypokalemia serum potassium level below weakness and fatigue;
3.5 mEq/L and muscle weakness; nausea
electrocardiogram (ECG) and vomiting; intestinal
abnormalities: flattened T distention; decreased bowel
wave; ST segment sounds; decreased deep
depression; u wave; tendon reflexes; ventricular
potentiated digoxin effects dysrhythmias; paresthesias;
(e.g., ventricular and weak, irregular pulse
dysrhythmias)
Hyperkalemia serum potassium level above anxiety, dysrhythmias,
5.0 mEq/L and ECG paresthesia, weakness,
abnormalities: peaked T abdominal cramps, and
wave and widened QRS diarrhea
complex (bradycardia, heart
block, dysrhythmias);
eventually QRS pattern
widens, and cardiac arrest
occurs
Hypocalcemia serum ionized calcium level numbness and tingling of
below 4.5 mEq/L or total fingers and circumoral
serum calcium below 8.5 (around mouth) region,
mg/dl and ECG hyperactive reflexes,
abnormalities: ventricular positive Trousseau’s sign
tachycardia (carpopedal spasm with
hypoxia), positive
Chvostek’s sign (contraction
of facial muscles when facial
nerve is tapped), tetany,

muscle cramps, and
pathological fractures
(chronic hypocalcemia)
Hypercalcemia serum ionized calcium level anorexia, nausea and
above 5.5 mEq/L or total vomiting, weakness,
serum calcium level above hypoactive reflexes,
10.5 mg/dl; x-ray lethargy, flank pain (from
examination showing kidney stones), decreased
generalized osteoporosis, level of consciousness,
widespread bone cavitation, personality changes, and
radiopaque urinary stones; cardiac arrest
and elevated blood urea
nitrogen (BUN) level 25
mg/100 ml and elevated
creatinine level 1.5 mg/100
ml caused by fluid volume
deficit (FVD) or renal
damage caused by
urolithiasis; ECG
abnormalities: heart block
Hypomagnesemia serum magnesium level muscular tremors,
below 1.5 mEq/L hyperactive deep tendon
reflexes, confusion and
disorientation, tachycardia,
hypertension, dysrhythmias,
and positive Chvostek’s sign
and Trousseau’s sign
Hypermagnesemia serum magnesium level acute elevations in
above 2.5 mEq/L; ECG magnesium levels:
abnormalities: prolonged QT hypoactive deep tendon
interval, AV block reflexes, decreased depth
and rate of respirations,
hypotension, and flushing
30. a. measures the hydrogen ion concentration in the body fluids (7.35-7.45) b. is the partial
pressure carbon dioxide in arterial blood (35-45) c. is the partial pressure of oxygen in the
blood (80-100) d. is the point at which hemoglobin is saturated by oxygen (95-99% ) e. is the
amount of blood buffer (hemoglobin and bicarbonate) that exists
(+/- 2) f. is the major renal component of acid-base balance (22-26)
31.
Acid-Base Imbalance Lab Findings Signs and Symptoms
Respiratory acidosis arterial blood gas alterations: confusion, dizziness,
pH < 7.35, PaCO2 > 45 mm lethargy, headache,
Hg, PaO2 < 80 mm Hg, and ventricular dysrhythmias,
bicarbonate level normal (if warm and flushed skin,
uncompensated) or > 26 muscular twitching,
mEq/L (if compensated) convulsions, and coma
Respiratory alkalosis arterial blood gas alterations: dizziness, confusion,
pH > 7.45, PaCO2 < 35 mm dysrhythmias, tachypnea,
Hg, PaO2 normal, and numbness and tingling of
bicarbonate level normal (if extremities, convulsions, and
short lived or coma
uncompensated) or < 22
mEq/L (if compensated)
Metabolic acidosis arterial blood gas alterations: headache, lethargy,
pH < 7.35, PaCO2 normal (if confusion, dysrhythmias,
uncompensated) or < 35 mm tachypnea with deep
Hg (if compensated), PaO2 respirations, abdominal
normal or increased (with cramps, and flushed skin
rapid, deep respirations),
bicarbonate level < 22
mEq/L, and oxygen
saturation normal
Metabolic alkalosis arterial blood gas alterations: Dizziness; dysrhythmias;
pH > 7.45, PaCO2 normal (if numbness and tingling of
uncompensated) or > 45 mm fingers, toes, and circumoral
Hg (if compensated), PaO2 region; muscle cramps;
normal, and bicarbonate level tetany
> 26 mEq/L
32.
a. Age – Very young; very old
b. Gender – Women
c. Environment – Diet, exercise, and hot weather and sweating
d. Chronic Diseases – Cancer; cardiovascular disease, such as congestive heart failure;
endocrine diseases such as Cushing’s disease and diabetes mellitus; malnutrition;
chronic obstructive pulmonary disease; and renal disease
e. Trauma – Crash injuries; head injuries; burns
f. Therapies – Diuretics, steroids, intravenous (IV) therapy, and total parenteral
nutrition (TPN)
33. Infants and children have greater water needs and are more vulnerable to fluid volume
alterations; fever in children creates an increase in the rate of insensible water loss;
adolescents have increased metabolic processes; older adults have decreased thirst
sensation that often causes electrolyte imbalances.
34. Surgery, head and chest trauma, shock, and second- and third-degree burns place the
clients at risk.
35. The more extensive the surgery and fluid loss, the greater the body’s response.
36. The greater the body surface burned, the greater the fluid loss.
37. predispose to respiratory acidosis and/or respiratory alkalosis
38. can result in cerebral edema and diabetes insipidus
39. cancer, CHF, or renal disease
40. depends on the type and progression of the cancer and its treatment (diarrhea and
anorexia)
41. diminished cardiac output, which reduces kidney perfusion and decreases urine output
42. causes an abnormal retention of sodium chloride, potassium and water (metabolic
acidosis)
43. gastroenteritis and nasogastric suctioning result in the loss of fluid, potassium, and
chloride ions
44. vigorous exercise or exposure to extreme temperatures
45. recent changes in appetite or the ability to chew and swallow (breakdown of glycogen
and fat stores, metabolic acidosis, hypoalbuminemia, edema)
46. history of smoking or alcohol consumption (respiratory acidosis)
47. Diuretics—metabolic alkalosis, hyperkalemia, and hypokalemia
Steroids—metabolic alkalosis
Potassium supplements—GI disturbances, including intestinal and gastric ulcers and
diarrhea
Respiratory center depressants(e.g., opioid analgesics)— decreased rate and depth of
respirations, resulting in respiratory acidosis
Antibiotics—nephrotoxicity (e.g., vancomycin, methicillin, aminoglycosides);
hyperkalemia and/or hypernatremia (e.g., azlocillin, carbenicillin, piperacillin, ticarcillin,
unasyn)
Calcium carbonate (Tums)— mild metabolic alkalosis with nausea and vomiting
Magnesium hydroxide (Milk of Magnesia)—hypokalemia
Nonsteroidal anti-inflammatory drugs—nephrotoxicity
48.
a. Weight loss of 5% to 8%: Mild-to-moderate fluid volume deficit
(FVD)
b. Irritability: Metabolic or respiratory alkalosis, hyperosmolar
imbalance, hypernatremia, hypokalemia
c. Lethargy: FVD, metabolic acidosis or alkalosis, respiratory acidosis,
hypercalcemia
d. Periorbital edema: FVE
e. Sticky, dry mucous membranes: FVD, hypernatremia
f. Chvostek’s sign: hypocalcemia
g. Distended neck veins: FVE
h. Dysrhythmias: Metabolic acidosis, respiratory alkalosis and acidosis,
potassium imbalance, hypomagnesemia
i. Weak pulse: FVD, hypokalemia
j. Low blood pressure: FVD, hyponatremia, hyperkalemia,
hypermagnesemia
k. Third heart sound: FVE

l. Increased respiratory rate: FVE, respiratory alkalosis, metabolic
acidosis
m. Crackles: FVE
n. Anorexia: Metabolic acidosis
o. Abdominal cramps: Metabolic acidosis
p. Poor skin turgor: FVD
q. Oliguria or anuria: FVD, FVE
r. Increased specific gravity: FVD
s. Muscle cramps, tetany: Hypocalcemia, metabolic or respiratory
alkalosis
t. Hypertonicity of muscles on palpation: Hypocalcemia,
hypomagnesemia, metabolic alkalosis
u. Decreased or absent deep tendon reflexes: Hypokalemia,
hypercalcemia
v. Increased temperature: Hypernatremia, hyperosmolar imbalance,
metabolic acidosis
w. Distended abdomen: Third-space syndrome
x. Cold, clammy skin: FVD
y. 2 edema: FVE
49. decreased cardiac output
50. acute confusion
51. deficient fluid volume
52. excess fluid volume
53. impaired gas exchange
54. risk for injury
55. deficient knowledge regarding disease management
56. impaired oral mucous membrane
57. impaired skin integrity
59. a. will be free of complications associated with the IV device throughout the duration of
IV therapy b. will demonstrate fluid balance as evidenced by moist, mucous membranes;
balanced I & O; and stable weights within 48 hours c. will have serum electrolytes within
the normal range within 48 hours
60. may be appropriate when the client’s GI tract is healthy but the client cannot ingest fluids
61. clients who retain fluids and have fluid volume excess require restriction of fluids
62. include TPN, crystalloids, and colloids
63. is a nutritionally adequate hypertonic solution consisting of glucose, nutrients, and
electrolytes administered peripherally, percutaneously or implanted or tunneled
64. is to correct or prevent fluid and electrolyte imbalances
65. VADs are catheters, cannulas, or infusion ports designed for repeated access to the
vascular system.
66.
a. Isotonic: Dextrose 5% in water, 0.9% sodium chloride (normal saline),
lactated Ringer’s
b. Hypotonic: 0.45% sodium chloride (half normal saline), 0.33%

sodium chloride (one-third normal saline)
c. Hypertonic: Dextrose 10% in water, 3%-5% sodium chloride, dextrose
5% in 0.9% sodium chloride, dextrose 5% in 0.45% NaCl sodium chloride, dextrose
5% in lactated Ringer’s
67.
Infiltration Scale
Grade Clinical Criteria
0 No symptoms
1 Skin blanched
Edema, < 1 inch in any direction
Cool to touch
With or without pain
2 Skin blanched
Edema 1-6 inches in any direction
Cool to touch
With or without pain
3 Skin blanched, translucent
Gross edema >6 inches in any direction
Cool to touch
Mild to moderate pain
Possible numbness
4 Skin blanched, translucent
Skin tight, leaking
Skin discolored, bruised, swollen
Gross edema >6 inches in any direction
Deep pitting tissue edema
Circulatory impairment
Moderate to severe pain
Infiltration of any amount of blood product,
irritant, or vesicant
Phlebitis Scale
Grade Clinical Criteria
0 No symptoms
1 Erythema at access site with or without pain
2 Pain at access site with erythema and/or edema
Streak formation
Palpable venous cord
Streak formation
Palpable venous cord >1 inch in length
Purulent drainage
68. a technique in which a vein is punctured through the skin by a rigid stylet (butterfly), a
stylet covered with a plastic cannula (ONC), or a needle attached to a syringe
69. are necessary for administering small hourly volumes (<20 ml/hr) and for clients who are
at risk for volume overloads
70. a. keeping the system sterile b. changing solutions, tubing, and site dressings c. assisting
the client with self-care activities
71. a. increase circulating blood volume after surgery, trauma, or hemorrhage b. increase the
number of RBCs and to maintain hemoglobin levels in clients with severe anemia c.
provide selected cellular components as replacement therapy
72. A, B, O, AB blood types
73. type O
74. AB individual
75. is an antigen antibody reaction and can range form mild response to severe anaphylactic
shock, which can be life threatening
76. is the collection and reinfusion of a client’s own blood
77. a. an 18-gauge or 19-gauge cannula b. in line filter tubing c. explain the procedure and
instruct the client to report any side effects d. signed informed consent e. baseline vital
signs f. Two RNs must check the labels on the blood product to the client’s identification
number, blood group, and complete name g. begin transfusion slowly; stay with client for
the first 15 minutes h. packed RBCs transfused in 2–4 hours
78.
Reaction Cause Clinical Manifestations
Acute Infusion of ABO-incompatible Chills, fever, low back pain,
hemolytic whole blood, RBCs, or flushing, tachycardia,
components containing 10 ml tachypnea, hypotension,
or more of RBCs vascular collapse,
hemoglobinuria,
Antibodies in the recipient’s
hemoglobinemia, bleeding,
plasma attach to antigens on
acute renal failure, shock,
transfused RBCs, causing
cardiac arrest, death
RBC destruction
Febrile, Sensitization to donor white Sudden chills and fever (rise in
nonhemoly blood cells, platelets, or temperature of greater than
-tic (most plasma proteins 1° C), headache, flushing,
common) anxiety, muscle pain
Mild allergic Sensitivity to foreign plasma Flushing, itching, urticaria
proteins (hives)
Anaphylactic Infusion of IgA proteins to IgA- Anxiety, urticaria, wheezing
deficient recipient who has progressing to cyanosis,
developed IgA antibody shock, possible cardiac arrest
Circulatory Fluid administered faster than Cough, dyspnea, pulmonary
overload the circulation can congestion (rales), headache,
accommodate hypertension, tachycardia,
distended neck veins
Sepsis Transfusion of contaminated Rapid onset of chills, high
blood components fever, vomiting, diarrhea,
and marked hypotension and
shock
79. sudden chills and fever, headache, flushing, anxiety, muscle pain
80. Keep the IV line open with 0.9% NS.
81. Do not turn off the blood, and turn on NS that is connected to the Y-tubing infusion set.
82. Notify health care provider.
83. Remain with client, observing signs and symptoms; monitor VS every 5 minutes.
84. Prepare to administer emergency drugs per protocol.
85. Prepare to perform cardiopulmonary resuscitation.
86. Obtain a urine specimen and send to lab (RBC hemolysis).
87. The blood container, tubing, attached labels, and transfusion record are saved and
returned to the lab.
88. 4. Extracellular fluid is all the fluid outside of the cell and has 3 compartments.
89. 3. a combination of increased PaCo2, excess carbonic acid, and an increased hydrogen
ion concentration
90. 1. Any condition that results in the loss of GI fluids predisposes the client to the
development of dehydration and a variety of electrolyte disturbances.
91. 3. is marked by a decreased PaCO2 and an increased pH; anxiety with hyperventilation is
a cause
92.
a. Steroid use – metabolic alkalosis
b. Fad dieting – metabolic acidosis
c. Hyperventilation – hyperventilation that occurs with conditions such as fever
or anxiety causes the client to experience respiratory alkalosis by blowing off too
much carbon dioxide with the increased respiratory rate.
d. Chronic alcoholism – respiratory acidosis
Chapter 42: Sleep
1. f
2. I
3. h
4. j
5. g
6. k
7. a
8. n
9. b
10. d
11. m
12. l
13. c
14. q
15. p
16. o
17. e
18.
Developmental Stage Sleep Patterns Usual Rituals
Neonates The neonate up to the age of Quieting activities, such as
3 months averages about 16 holding them snugly in
hours of sleep a day, sleeping blankets, singing or talking
almost constantly during the softly, and gentle rocking,
first week. The sleep cycle is help infants fall asleep.
generally 40 to 50 minutes
with wakening occurring
after one to two sleep cycles.
Approximately 50% of this
sleep is REM sleep, which
stimulates the higher brain
centers. This is essential for
development because the
neonate is not awake long
enough for significant
external stimulation.
Infants Infants usually develop a Quieting activities, such as
nighttime pattern of sleep by holding them snugly in
3 months of age. The infant blankets, singing or talking
normally takes several naps softly, and gentle rocking,
during the day but usually help infants fall asleep.
sleeps an average of 8 to 10
hours during the night for a
total daily sleep time of 15
hours. About 30% of sleep
time is in the REM cycle.

Awakening commonly occurs
early in the morning,
although it is not unusual for
an infant to awaken during
the night.
Toddlers By the age of 2, children A bedtime routine (e.g.,
usually sleep through the same hour for bedtime,
night and take daily naps. snack, or quiet activity) used
Total sleep averages 12 hours consistently helps young
a day. After 3 years of age, children avoid delaying
children often give up sleep. Parents need to
daytime naps (Hockenberry reinforce patterns of
and Wilson, 2006). It is preparing for bedtime. Quiet
common for toddlers to activities such as reading
awaken during the night. The stories, coloring, reading,
percentage of REM sleep allowing children to sit in a
continues to fall. During this parent’s lap while listening
period the toddler may be to music or listening to a
unwilling to go to bed at prayer are routines that are
night due to a need for often associated with
autonomy or a fear of preparing for bed. Reading
separation from their parents. the child a bedtime story,
rocking the child to sleep, or
engaging in quiet play. Some
young children need a
special blanket or stuffed
animal when going to sleep.
Preschoolers On average a preschooler A bedtime routine (e.g.,
sleeps about 12 hours a night same hour for bedtime,
(about 20% is REM). By the snack or quiet activity) used
age of 5, the preschooler consistently helps young
rarely takes daytime naps children avoid delaying
except in cultures where a sleep. Parents need to
siesta is the custom reinforce patterns of
(Hockenberry and Wilson, preparing for bedtime. Quiet
2006). The preschooler activities such as reading
usually has difficulty relaxing stories, coloring, reading,
or quieting down after long, allowing children to sit in a
active days and has problems parent’s lap while listening
with bedtime fears, waking to music or listening to a
during the night, or prayer are routines that are
nightmares. Partial wakening often associated with
followed by normal return to preparing for bed.
sleep is frequent
(Hockenberry and Wilson,
2006). In the waking period,

the child exhibits brief
crying, walking around,
unintelligible speech,
sleepwalking, or bed-wetting.
School-age children The amount of sleep needed
during the school years. A 6-
year-old averages 11 to 12
hours of sleep nightly,
whereas an 11-year-old
sleeps about 9 to 10 hours
(Hockenberry and Wilson,
2006). The 6- or 7-year-old
will usually go to bed with
some encouragement or by
doing quiet activities. The
older child often resists
sleeping because of an
unawareness of fatigue or a
need to be independent.
Adolescents On average, teenagers get
about 7½ hours of sleep per
night. The typical adolescent
is subject to a number of
changes such as school
demands, after-school social
activities, and part-time jobs
that reduce the time spent
sleeping (National Sleep
Foundation, 2006b). This
shortened sleep time often
results in EDS. Performance
in school, vulnerability to
accidents, behavior and mood
problems, and increased use
of alcohol are often the result
of EDS due to insufficient
sleep (Spilsbury and others,
2004; Walsh and others,
2005).
Young adults Most young adults average 6 Adults need to avoid
to 8½ hours of sleep a night. excessive mental stimulation
Approximately 20% of sleep just before bedtime. Reading
time is REM sleep, which a light novel, watching an
remains consistent enjoyable television
throughout life. It is common program, or listening to
for the stresses of jobs, music helps a person relax.

family relationships, and Relaxation exercises such as
social activities frequently to slow, deep breathing for 1 or
lead to insomnia and the use 2 minutes relieve tension and
of medication for sleep. prepare the body for rest (see
Daytime sleepiness Chapter 43). Guided imagery
contributes to an increased and praying also promote
number of accidents, sleep for some clients.
decreased productivity, and
interpersonal problems in this
age-group. Pregnancy
increases the need for sleep
and rest. Insomnia, periodic
limb movements, restless leg
syndrome, and sleep-
disordered breathing are
common problems during the
third trimester of pregnancy
(Wolfson and Lee, 2005).
Middle adults During middle adulthood the Adults need to avoid
total time spent sleeping at excessive mental stimulation
night begins to decline. The just before bedtime. Reading
amount of stage 4 sleep a light novel, watching an
begins to fall, a decline that enjoyable television
continues with advancing program, or listening to
age. Insomnia is particularly music helps a person relax.
common, probably because Relaxation exercises such as
of the changes and stresses of slow, deep breathing for 1 or
middle age. Anxiety, 2 minutes relieve tension and
depression, or certain prepare the body for rest (see
physical illnesses cause sleep Chapter 43). Guided imagery
disturbances. Women and praying also promote
experiencing menopausal sleep for some clients
symptoms often experience
insomnia.
Older adults Complaints of sleeping Adults need to avoid
difficulties increase with age. excessive mental stimulation
More than 50% of adults 65 just before bedtime. Reading
years or older report a light novel, watching an
problems with sleep enjoyable television
(Hoffman, 2003). Episodes program, or listening to
of REM sleep tend to music helps a person relax.
shorten. There is a Relaxation exercises such as
progressive decrease in slow, deep breathing for 1 or
stages 3 and 4 NREM sleep; 2 minutes relieve tension and
some older adults have prepare the body for rest (see
almost no stage 4 sleep, or Chapter 43). Guided imagery

deep sleep. An older adult and praying also promote
awakens more often during sleep for some clients
the night, and it takes more
time for an older adult to fall
asleep. The tendency to nap
seems to increase
progressively with age
because of the frequent
awakenings experienced at
night.
The presence of chronic
illness often results in sleep
disturbances for the older
adult. For example, an older
adult with arthritis frequently
has difficulty sleeping
because of painful joints.
Changes in sleep pattern are
often due to changes in the
CNS that affect the
regulation of sleep. Sensory
impairment reduces an older
person’s sensitivity to time
cues that maintain circadian
rhythms.
19. Sleepiness, insomnia, and fatigue often result as a direct effect of commonly prescribed
medications, including hypnotics, diuretics, alcohol, caffeine, beta-adrenergic blockers,
benzodiazepines, narcotics, anticonvulsants, antidepressants, and stimulants.
20. rotating shifts will cause difficulty adjusting to the altered sleep schedule, performing
unaccustomed heavy work, engaging in late-night social activities, and changing evening
mealtime
21. Most persons are sleep-deprived and experience excessive sleepiness during the day,
which can become pathological when it occurs at times when individuals need or want to be
awake.
22. personal problems or certain situations frequently disrupt sleep; retirement, physical
impairment, or the death of a loved one
23. Good ventilation is essential for a restful sleep, as are the size and firmness of the bed;
light levels affect the ability to fall asleep.
24. Exercise 2 hours or more before bedtime allows the body to cool down and maintain a
state of fatigue that promotes relaxation.
25. eating a large, heavy, or spicy meal at night often results in indigestion that interferes
with sleep; caffeine, alcohol and nicotine produce insomnia; weight loss or weight gain
26. clients, bed partners, and parents of children
27. a. description of sleeping problems b. usual sleep pattern c. physical and psychological
illness d. current life events e. emotional and mental status f. bedtime routines g. bedtime
environment h. behaviors of sleep deprivation
28. anxiety
30. acute confusion
31. family coping
32. ineffective coping
33. fatigue
34. ineffective protection
35. disturbed sensory perception
36. sleep deprivation
37. disturbed sleep pattern
38. Client will identify factors in the immediate home environment that disrupt sleep in 2
weeks.
39. Client will report having a discussion with family members about environmental barriers
to sleep in 2 weeks.
40. Client will report changes made in the bedroom to promote sleep within 4 weeks.
41. Client will report having fewer than 2 awakenings per night within 4 weeks.
42. Eliminate distracting noises; promote comfortable room temperature, ventilation, bed and
mattress to provide support and firmness
43. sleep when fatigued or sleepy, bedtime routines for children, adults need to avoid
excessive mental stimulation before bedtime
44. small night light, a bell at the bedside to alert family members
45. clothing, extra blankets, void before retiring
46. increasing daytime activity lessens problems with falling asleep
47. pursue a relaxing activity for adults; children need comforting and night lights
48. a dairy product that contains L-tryptophan is often helpful to promote sleep; do not drink
caffeine, tea, colas, and alcohol before bedtime
49. melatonin (nutritional supplement to aid in sleep), valerian, kava
50. lights, reduce noise; also refer to Box 42-12 in the text for other examples
51. keep beds clean and dry and in a comfortable position; application of dry or moist heat;
splints; and proper positioning
52. plan care to avoid awakening clients for nonessential tasks; allow clients to determine the
timing and methods of delivery of basic care
53. reduce the risk of post-op complications for clients with sleep apnea (airway); use of
CPAP
54. giving clients control over their health care minimizes uncertainty and anxiety; back rubs;
cautious use of sedatives
55. a. observe whether a client falls asleep after reducing noise and darkening a room b. ask a
client to describe the number of awakenings during the previous night c. evaluate the level of
understanding that clients and families gain after receiving instructions on sleep habits
56. 2. definition of, influences the pattern of major biological and behavioral functions
57. 3. a natural protein found in milk, cheeses, and meats
58. 4. See Box 42-4 in the text for other symptoms of sleep deprivation; most physiological
symptoms are decreased, not increased.
59. 4. The related factor of the sleep disturbance is physiological for this client (leg pain).
60. 2. A sleep-promotion plan frequently requires many weeks to accomplish.
61. Julie’s statement that she is having difficulty sleeping due to her husband’s snoring is an
indication of an additional sleep problem. A more in-depth assessment of David’s sleep
problem, sleep habits, history, and sleep hygiene habits is needed. A 1 – 2 week sleep log or
diary with entries by both Julie and David can provide additional assessment data related to
the problem.
Chapter 43: Pain Management
1. c
2. f
3. b
4. j
5. h
6. a
7. I
8. e
9. g
10. k
11. d
12. a. is protective, has a cause, is of short duration, and has limited tissue damage and
emotional response b. lasts longer than anticipated, does not always have a cause, and leads
to great personal suffering
13. a. pain that occurs sporadically over an extended duration of time b. is chronic in the
absence of an identifiable physical or psychological cause or pain perceived as excessive for
the extent of an organic pathological condition
14.
Nociceptive pain: Normal processing of stimuli that damages normal tissues or has the
potential to do so if prolonged; usually responsive to nonopioids and/or opioids.
Somatic: comes from bone, joint, muscle, skin, or connective tissue. It is usually aching or
throbbing in quality and is well-localized.
Visceral pain: Arises from visceral organs, such as the gastrointestinal tract and pancreas.
Categories include:
a. Tumor involvement of the organ capsule that causes aching and fairly well-
localized pain.
b. Obstruction of hollow viscus, which causes intermittent cramping and poorly
localized pain.
Neuropathic pain: Abnormal processing of sensory input by the peripheral or central
nervous system; treatment usually includes adjuvant analgesics.
Deafferentation pain: Injury to either the peripheral or central nervous system. Examples:
Phantom pain reflects injury to the peripheral nervous system; burning pain below the level
of a spinal cord lesion reflects injury to the central nervous system.
Sympathetically maintained pain: Associated with dysregulation of the autonomic nervous
system. Examples: pain associated with reflex sympathetic dystrophy/causalgia (complex
regional pain syndrome, type I, type II).
Polyneuropathies: Client feels pain along the distribution of many peripheral nerves.
Examples: diabetic neuropathy, alcohol-nutritional neuropathy, and Guillain-Barré syndrome.
Mononeuropathies: Usually associated with a known peripheral nerve injury, and pain is
felt at least partly along the distribution of the damaged nerve. Examples: nerve root
compression, nerve entrapment, trigeminal neuralgia.
15. a. age b. fatigue c. genes d. neurological function
16. a. attention b. previous experience c. family and social support
17. active searching for meaning, concerns of loss of independence and becoming a burden
to the family
18. a. anxiety b. coping styles
19. a. meaning of the pain b. ethnicity
20.
A: Ask about pain regularly. Assess pain systematically.
B: Believe the client and family in their report of pain and what relieves it.
C: Choose pain-control options appropriate for the client, family, and setting.
D: Deliver interventions in a timely, logical, and coordinated fashion.
E: Empower clients and their families. Enable them to control their course to the greatest
extent possible.
21. a. onset and duration b. location c. intensity d. quality e. pain pattern f. relief measures g.
contributing symptoms h. effects of pain on the client i. behavioral effects j. influence on
activities of daily living
22. anxiety
23. fatigue
24. hopelessness
26. imbalanced nutrition: less than
27. powerlessness
28. chronic low self-esteem
30. impaired social interaction
31. spiritual distress
32. reports that pain is a 3 or less on a scale of 0-10, does not interfere with ADLs, or
personal pain intensity goal attained
33. identifies factors that intensify pain and modifies behavior accordingly
34. uses pain-relief measures safely
35. a. find such interventions appealing b. express anxiety or fear c. will possibly benefit
from avoiding or reducing drug therapy d. are likely to experience and need to cope with a
prolonged interval of postoperative pain e. have incomplete pain relief after use of
pharmacological interventions
36. is mental and physical freedom from tension or stress that provides individuals with a
sense of self-control
37. directs a client’s attention to something other than pain and thus reduces the awareness of
pain
38. diverts the person’s attention away from the pain and creates a relaxation response
39. a massage, warm bath, ice bag, and TENS stimulates the skin to reduce pain perception
by the release of endorphins, which block the transmission of painful stimuli
40. not sufficiently studied; however, many use herbals such as echinacea, ginseng, gingko
biloba, and garlic supplements
41. One simple way to promote comfort is by removing or preventing painful stimuli; also
distraction, prayer, relaxation, guided imagery, music, and biofeedback
42. a. nonopioids b. opioids c. adjuvants/coanalgesics
43. a variety of medications that enhance analgesics or have analgesic properties that were
originally unknown
44. allows clients to self-administer opioids with minimal risk of overdose; the goal is to
maintain a constant plasma level of analgesic to avoid the problems of prn dosing
45. manage pain from a variety of surgical procedures with a pump that is set as a demand or
continuous mode and left in place for 48 hours
46. EMLA via a disc or thick cream to the skin for 30 to 60 minutes before minor procedures
47. local infiltration of an anesthetic medication to induce loss of sensation to a body part
48. is the injection of a local anesthetic to block a group of sensory nerve fibers
49. it permits control or reduction of severe pain and reduces the client’s overall opioid
requirement; can be short- or long-term
50. nausea and vomiting, urinary retention, constipation, respiratory depression, and pruritus
51.
a. Prevent catheter displacement: Secure catheter (if not connected to implanted reservoir)
carefully to outside skin.
b. Maintain catheter function: Check external dressing around catheter site for dampness or
discharge. (Leak of cerebrospinal fluid may develop.)
c. Prevent infection: Use strict aseptic technique when caring for catheter (see Chapter 33).
d. Monitor for respiratory depression: Monitor vital signs, especially respirations, per policy.
e. Prevent undesirable complications: Assess for pruritus (itching) and nausea and vomiting.
f. Maintain urinary and bowel function: Monitor intake and output.
52. a. 100 times more potent than morphine in predetermined doses that provide analgesic for
48-72 hours; useful when unable to take oral medications b. to treat breakthrough pain in
opioid-tolerant clients, the unit is placed in the mouth and dissolved, not chewed
53.
Incident pain: Pain that is predictable and elicited by specific behaviors such as physical
therapy or wound-dressing changes
End-of-dose failure pain: Pain that occurs toward the end of the usual dosing interval of a
regularly scheduled analgesic
Spontaneous pain: Pain that is unpredictable and not associated with any activity or event
54.
Client: Fear of addiction, Worry about side effects, Fear of tolerance (won’t be there when I
need it), Take too many pills already, Fear of injections, Concern about not being a “good”
client, Don’t want to worry family and friends, May need more tests, Need to suffer to be
cured, Pain is for past indiscretions, Inadequate education, Reluctance to discuss pain, Pain is
inevitable, Pain is part of aging, Fear of disease progression, Primary health care providers
and nurses are doing all that they can, Just forget to take analgesics, Fear of distracting
primary health care providers from treating illness, Primary health care providers have more
important or ill clients to see, Suffering in silence is noble and expected
Health care provider: Inadequate pain assessment, Concern with addiction, Opiophobia
(fear of opioids), Fear of legal repercussions, No visible cause of pain, Clients must learn to
live with pain, Reluctance to deal with side effects of analgesics, Fear of giving a dose that
will kill the client, Not believing the client’s report of pain, Primary health care provider time
constraints, Inadequate reimbursement, Belief that opioids “mask” symptoms, Belief that
pain is part of aging, Overestimation of rates of respiratory depression
Health care system barriers: Concern with creating “addicts,”, Ability to fill prescriptions,
Absolute dollar restriction on amount reimbursed for prescriptions, Mail order pharmacy
restrictions, Nurse practitioners and physician assistants not used efficiently, Extensive
documentation requirements, Poor pain policies and procedures regarding pain management,
Lack of money, Inadequate access to pain clinics, Poor understanding of economic impact of
unrelieved pain
55.
physical dependence: A state of adaptation that is manifested by a drug class-specific
withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood
level of the drug, and/or administration of an antagonist.
drug tolerance: A state of adaptation in which exposure to a drug induces changes that result
in a diminution of one or more of the drug’s effects over time.
Addiction: A primary, chronic, neurobiologic disease, with genetic, psychosocial, and
environmental factors influencing its development and manifestations. Addictive behaviors
include one or more of the following: impaired control over drug use, compulsive use,
continued use despite harm, and craving.
Pseudoaddiction: Client behaviors (drug seeking) that occur when pain is undertreated.
Pseudotolerance: Need to increase opioid dose for reasons other than opioid tolerance:
progression of disease, onset of new disorder, increased physical activity, lack of adherence,
change in opioid formulation, drug-drug interaction, drug-food interaction.
56. a medication or procedure that produces positive or negative effects in clients that are not
related to the placebo’s specific physical or chemical properties
57. treat persons on an inpatient or outpatient basis; multidisciplinary approach to find the
most effective pain-relief measures
58. the goal is to live life fully with an incurable condition
59. care of clients at the end of life, which emphasizes quality of life over quantity
60. evaluate the client for the effectiveness of the pain management after an appropriate
period of time; entertain new approaches if no relief; evaluate the client’s perception of pain
61. 2. Only the client knows whether pain is present and what the experience is like.
62. 1. Once the brain perceives pain, there is a release of inhibitory neurotransmitters such as
endogenous opioids (e.g., endorphins) which hinder the transmission of pain and help
produce an analgesic effect.
63. 2. A client’s self-report of pain is the single most reliable indicator of the existence and
intensity of pain.
64. 2. The reticular activating system inhibits painful stimuli if a person receives sufficient or
excessive sensory input; with sufficient sensory stimulation a person is able to ignore or
become unaware of pain.
65. 3. Developmental differences are found between age groups; therefore, the nurse needs to
adapt approaches for assessing a child’s pain and how to prepare a child for a painful
procedure.
66.
Mrs. Mays, 75 years old, was diagnosed with a cancerous tumor in her left lung 2 months
ago. She also has a history of osteoarthritis. After chemotherapy and radiation therapy, she
was taking ibuprofen 200mg on a prn basis. Until today she was able to clean her home and
climb the stairs to her bedroom without difficulty. She also maintained her body weight and
slept well through the night. However, she is now admitted to the hospital with
uncontrollable chest pain and possible pneumonia. Prior to being admitted to the hospital, her
pain escalated from a 3 to a 10, so she doubled her medication and went to bed, but this did
not help. Currently her pain is a 9 on a 1-10 scale. She responds that she is unable to
complete her own hygiene activities, sleep, or eat well. She is restless, unable to stay
focused, and remains very still, muscles tense and frowning, during the history taking. She
says that a pain intensity of 5 out of 10 helps her function better right now, although a goal of
3 is preferable.
Chapter 44: Nutrition
1. c
2. h
3. I
4. n
5. o
6. j
7. k
8. v
9. d
10. s
11. p
12. f
13. m
14. e
15. r
16. q
17. n
18. g
19. l
20. u
21. t
22. a
23. b
24. f
25. h
26. b
27. g
28. l
29. k
30. j
31. m
32. d
33. e
34. c
35. a
36. i
37.
a. is the recommended amount of nutrition that appears sufficient to maintain a specific
body function for 50% of the population based on age and gender
b. is the average needs of 98% of the population, not the individual
c. suggested intake for individuals based on observed or experimental determined
estimates of nutrient intakes
d. is the highest level that likely poses no risk of adverse health events
38.
a. Adopt a balanced eating pattern with a variety of nutrient-dense food and beverages
among the basic food groups.
b. Maintain body weight in a healthy range.
c. Encourage physical activity, and decrease sedentary activities.
d. Encourage fruits, vegetables, whole-grain products, and fat-free or low-fat milk while
staying within energy needs.
e. Keep total fat intake between 20-35 % of total calories, with most fats coming from
polyunsaturated or monosaturated fatty acids.
f. Choose and prepare foods and beverages with little added sugars or sweeteners.
g. Choose and prepare foods with little salt while at the same time eating potassium-rich
foods.
h. Limit intake of alcohol.
i. Practice food safety to prevent microbial food-borne illness.
39.
a. reduced food allergies and intolerances
b. fewer infant infections
c. easier digestion
d. convenient, correct temperature, available and fresh
e. economical
f. increases time for mother and infant interaction
40. causes GI bleeding, is too concentrated for infant’s kidneys to manage, increases the risk
of mild product allergies, poor source of iron and vitamin C and E
41. are potential sources of botulism toxin and should not be used in the infant’s diet
42.
a. the infant’s needs
b. physical readiness to handle different forms of foods
c. detect and control allergic reactions
43.
a. diet rich in high-calorie foods
b. inactivity
c. genetic predisposition
c. use of food for coping mechanism for stress or boredom
d. family and social factors
44.
a. body image and appearance
b. desire for independence
c. eating at fast-food restaurants
d. peer pressure
e. fad diets
45.
a. Anorexia nervosa: Refusal to maintain body weight over a minimal normal weight for
age and height, e.g., weight loss leading to maintenance of body weight less than 85%
of IBW; or failure to make expected weight gain during period of growth, leading to
body weight less than 85% of that expected; Intense fear of gaining weight or
becoming fat, although underweight; Disturbance in the way in which one’s body
weight, size, or shape is experienced, e.g., the person claims to “feel fat” even when
emaciated, believes that one area of the body is “too fat” even when obviously
underweight; In females, absence of at least 3 consecutive menstrual cycles when
otherwise expected to occur (primary or secondary amenorrhea). (A woman is
considered to have amenorrhea if her periods occur only following hormone, e.g.,
estrogen, administration.)
b. Bulimia nervosa: Recurrent episodes of binge eating (rapid consumption of a large
amount of food in a discrete period of time); A feeling of lack of control over eating
behavior during the eating binges; The person regularly engages in either self-induced
vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise in
order to prevent weight gain; A minimum average of 2 binge eating episodes a week
for at least 3 months.
46. is important for DNA synthesis and the growth of RBCs, inadequate intake will lead to
possible neural tube defects, anencephaly or maternal; megaloblastic anemia
47.
a. Age-related gastrointestinal changes that affect digestion of food and maintenance of
nutrition include changes in the teeth and gums, reduced saliva production, atrophy of
oral mucosal epithelial cells, increased taste threshold, decreased thirst sensation,
reduced gag reflex, and decreased esophageal and colonic peristalsis
b. The presence of chronic illnesses (e.g., diabetes mellitus, end-stage renal disease,
cancer) often affect nutrition intake.
c. Malnutrition in older adults has multiple causes, such as income, educational level,
physical functional level to meet activities of daily living (ADLs), loss, dependency,
loneliness, and transportation.
d. Adverse effects of medications cause problems such as anorexia, xerostomia, early
satiety, and impaired smell and taste perception.
e. Factors affecting nutrient needs: Calcium, vitamin D, or phosphorus for basic
metabolic demand (BMD). B12 may not be synthesized because of lack of intrinsic
factor in terminal ileum, decreased lean muscle mass, lower basic energy expenditure
(BEE)
f. Cognitive impairments such as delirium, dementia, and depression affect ability to
obtain, prepare, and eat healthy foods.
48. avoid meat, fish, and poultry but eat eggs and milk
49. drink milk but avoid eggs
50. eat primarily brown rice, other grains, and herb teas
51. eat only fruits, nuts, honey, and olive oil
52.
a. screening for malnutrition for risk factors (unintentional weight loss, presence of a
modified diet, presence of nutrition impact symptoms
b. anthropometry (size and make- up of the body)
c. BMI
d. lab and biochemical tests (albumin, transferring, prealbumin, retinal binding protein,
total iron-binding capacity, and hemoglobin)
e. dietary history
53. difficulty swallowing (neurogenic, myogenic, and obstructive causes)
54.
a. general appearance: Listless, apathetic, cachectic
b. weight: Obesity (usually 10% above IBW) or underweight (special concern for
underweight)
c. posture: Sagging shoulders; sunken chest; humped back
d. muscles: Flaccid, poor tone, underdeveloped tone; “wasted” appearance; impaired
ability to walk properly
e. nervous system: Inattention; irritability; confusion; burning and tingling of hands and
feet (paresthesia); loss of position and vibratory sense; weakness and tenderness of
muscles (may result in inability to walk); decrease or loss of ankle and knee reflexes;
absent vibratory sense
f. gastrointestinal: Anorexia; indigestion; constipation or diarrhea; liver or spleen
enlargement
g. cardiovascular: Rapid heart rate (above 100 beats/min), enlarged heart; abnormal
rhythm; elevated blood pressure
h. general vitality: Easily fatigued; no energy; falls asleep easily, tired and apathetic
i. hair: Stringy, dull, brittle, dry, thin, and sparse, depigmented; easily plucked
j. skin: Rough, dry, scaly, pale, pigmented, irritated; bruises; petechiae; subcutaneous
fat loss
k. face and neck: Greasy, discolored, scaly, swollen; dark skin over cheeks and under
eyes; lumpiness or flakiness of skin around nose and mouth
l. lips: Dry, scaly, swollen; redness and swelling (cheilosis); angular lesions at corners
of mouth; fissures or scars (stomatitis)
m. mouth, oral membranes: Swollen, boggy oral mucous membranes
n. gums: Spongy gums that bleed easily; marginal redness, inflammation; receding
o. tongue: Swelling, scarlet and raw; magenta, beefiness (glossitis); hyperemic and
hypertrophic papillae; atrophic papillae
p. teeth: Unfilled caries; missing teeth; worn surfaces; mottled (fluorosis),
malpositioned
q. eyes: Eye membranes pale (pale conjunctivas); redness of membrane (conjunctival
injection); dryness; signs of infection; Bitot’s spots, redness and fissuring of eyelid
corners (angular palpebritis); dryness of eye membrane (conjunctival xerosis); dull
appearance of cornea (corneal xerosis); soft cornea (keratomalacia)
r. neck (glands): Thyroid or lymph node enlargement
s. nail: Spoon shape (koilonychia); brittleness; ridges
t. legs, feet: Edema; tender calf; tingling; weakness
u. skeleton: Bowlegs; knock-knees; chest deformity at diaphragm; prominent scapulae
and ribs
55. risk for aspiration
56. constipation
57. diarrhea
58. health-seeking behaviors
60. imbalanced nutrition: less than body requirements
61. imbalanced nutrition: more than body requirements

62. risk for imbalanced nutrition: more than body requirements
63. readiness for enhanced nutrition
64. feeding self-care deficit
65.
a. nutritional intake meets the minimal DRIs
b. fat nutritional intake is less than 30%
c. removes sugared beverages from the diet
d. refrains from eating unhealthy foods between meals and after dinner
e. loses at least ½ to 1 pound per week
66.
a. botulism: Improperly home-canned foods, smoked and salted fish, ham, sausage,
shellfish
b. escherichia: Undercooked meat (ground beef)
c. listeriosis: Soft cheese, meat (hot dogs, pate, lunch meats), unpasteurized milk,
poultry, seafood
d. perfringens enteritis: Cooked meats, meat dishes held at room or warm temperature
e. salmonellosis: Milk, custards, egg dishes, salad dressings, sandwich fillings, polluted
shellfish
f. shigellosis: Milk, milk products, seafood, salads
g. staphylococcus: Severe abdominal cramps, pain, vomiting, diarrhea, perspiration,
headache, fever, prostration. Appears 1-6 hours after ingestion and lasts 1-2 days
67. decreased level of alertness, decreased gag and/or cough reflexes, and clients who have
difficulty managing saliva
68.
a. dysphagia puree
b. dysphagia mechanically altered
c. dysphagia advanced
d. regular
69.
a. thin liquids (low viscosity)
b. nectar-like liquids (medium viscosity)
c. honey-like liquids
d. spoon-thick liquids (pudding)
70.
a. (1.0-2.0 kcal/mL) milk-based blenderized foods
b. (3.8 – 4.0 kcal/mL) single macronutrient preparations, not nutritionally complete
c. (1.0-3.0 kcal/mL) predigested nutrients that are easier for a partially dysfunctional GI
tract to absorb
d. (1.0-2.0 kcal/mL) designed to meet specific nutritional needs in certain illnesses
71.
a. reduces sepsis
b. minimizes the hypermetabolic response to trauma
c. maintains intestinal structure and function
72.
a. appropriate assessment of nutrition needs
b. meticulous management of the CVC line

c. careful monitoring to prevent or treat metabolic complications
73. provide supplemental kcal and prevent fatty acid deficiencies
74.
a. Pulmonary aspiration: Regurgitation of formula, Feeding tube displaced, Deficient
gag reflex, Delayed gastric emptying
b. Diarrhea: Hyperosmolar formula or medications, Antibiotic therapy, Bacterial
contamination, Malabsorption
c. Constipation: Lack of fiber, Lack of free water, Inactivity
d. Tube occlusion: Pulverized medications given per tube, Sedimentation of formula,
Reaction of incompatible medications or formula
e. Tube displacement: Coughing, vomiting, Not taped securely
f. Abdominal cramping, nausea/vomiting: High osmolality of formula, Rapid increase
in rate/volume, Lactose intolerance, Intestinal obstruction, High-fat formula used,
Cold formula used
g. Delayed gastric emptying: Diabetic gastroparesis, Serious illnesses, Inactivity
h. Serum electrolyte imbalance: Excess GI losses, Dehydration, Presence of disease
states such as cirrhosis, renal insufficiency, heart failure, or diabetes mellitus
i. Fluid overload: Refeeding syndrome in malnutrition, Excess free water or diluted
(hypotonic) formula
j. Hyperosmolar dehydration: Hypertonic formula with insufficient free water
75.
a. Electrolyte imbalance: Monitor Na, Ca, K, Cl, PO4, Mg, and CO2 levels
b. Hypercapnia: Increased oxygen consumption, increased CO2, respiratory quotient
>1.0, minute ventilation
c. Hypoglycemia: Diaphoresis, shakiness, confusion, loss of consciousness
d. Hyperglycemia: Thirst, headache, lethargy, increased urination
e. Hyperglycemic hyperosmolar nonketotic dehydration/coma (HHNC): Hyperglycemia
(>500 mg/dl), glycosuria, serum osmolarity >350 mOsm/L, confusion, azotemia,
headache, severe signs of dehydration (see Chapter 41), hypernatremia, metabolic
acidosis, convulsions, coma
76. once the client meets 1/3 to ½ of their kcal needs per day, PN is usually decreased to ½
the original volume; increase the EN to meet needs (75%)
77. is the use of nutritional therapies to treat an illness, injury, or condition
78. is a bacteria that causes peptic ulcers and is confirmed by lab tests, treated with
antibiotics
79. Crohn’s disease and ulcerative colitis: treat with elemental diets or PN, supplemental
vitamins, and iron. Manage by increasing fiber, reducing fat, avoiding large meals, and
avoiding lactose,
80. celiac disease, gluten-free diet
81. treat with moderate-to-low residue and high-fiber diet
82. carbohydrates 45-75%, limit fat to less than 7%, cholesterol less than 200 mg/day
83. balancing caloric intake with exercise; diet high in fruits, vegetables, and whole-grain
fiber; fish at least twice per week; limit food high in added sugar and salt
84. goal is to meet the increased metabolic needs of the client by maximizing intake of
nutrients and fluids
85. small, frequent, nutrient-dense meals that limit fatty foods and overly sweet foods
86. ongoing comparisons need to be made with baseline measures of weight, serum albumin,
and protein and kcal intake, changes in condition
87. 4. Each gram of CHO produces 4 kcal and serves as the main source of fuel (glucose) for
the brain, skeletal muscles during exercise , erythrocyte and leukocyte production, and cell
function of the renal medulla
88. 3. is when the intake of nitrogen is greater than the output, which is used for building,
repairing, and replacing body tissues
89. 4. the growth rate slows during the toddler years (1-3) and therefore needs fewer kcal but
an increased amount of protein in relation to body weight; appetite often decreases at 18
months of age
90. 1. All of the other clients are at risk for a nutritional imbalance.
91. 2. The measurement of pH of secretions withdrawn from the feeding tubes helps to
differentiate the location of the tube.
92. 2. the recommended diet from the AHA to reduce risk factors for the development of
hypertension and coronary heart disease
93. Mrs. Cooper, who is 68 years old and has a history of congestive heart failure. Recently
Mrs. Cooper noticed a weight loss (15%). Three months have passed since Mrs. Cooper
started taking sertraline for depression related to the loss of her husband 6 months ago.
Mrs. Cooper was also referred for counseling 3 months ago for help with grief and
depression through a local senior service agency. When Maria inquired as to her
financial situation, Mrs. Cooper responded that it was tight living on a small pension
and Social Security, but she was able to manage. Mrs. Cooper states that she drinks
some juice in the morning and two or three cups of coffee. In addition, she often has a
sandwich in the late afternoon. Mrs. Cooper states, “I’m just not interested in food. It
has no taste.” Mrs. Cooper complains of loneliness and said she does not get out much,
although her psychologist recommended more socializing. Her friends at church call
her to come back to meetings, but she is just not ready. She says she tires easily. She
has lost 24 pounds over the past 6 months. Her weight is 20% below her IBW and her
BMI is 17. Mrs. Cooper has stooped posture; dull, thinning hair; dry, scaling skin; pale
conjunctivae and mucous membranes; 2+ bilateral pitting ankle edema; and generalized
poor muscle tone. Goals for this patient include gaining 1 to 2 pounds per month until
goal of 130 pounds is reached by consuming 1900 kcal/day, including 50 g of protein
per day. Her physical assessment and laboratory values will be within normal limits. In
order to accomplish these goals, the nurse practitioner will coordinate plan of care with
healthcare provider, psychologist, and registered dietitian. She will individualize her
menu plans and teach Mrs. Cooper about the food pyramid. Mrs. Cooper will be
monitored monthly for weight gain, anemia, serum albumin level, and total lymphocyte
count (TLC). She will encourage client to eat small meals and to increase dietary
intake, including fluids and fiber, to help offset anorexia secondary to sertraline. The
nurse practitioner will encourage Mrs. Cooper to eat lunch at the senior center 5 times
per week.
Chapter 45: Urinary Elimination
1. d
2. c
3. g
4. f
5. b
6. e
7. a
8. a. pathological conditions (acute, chronic) b. sociocultural factors c. psychological factors
d. fluid balance e. surgical and diagnostic procedures
9. an increase in nitrogenous wastes in the blood, marked fluid and electrolyte
abnormalities, nausea, vomiting, headache, coma, and convulsions
10.
Renal failure that can no longer be controlled by conservative management (i.e., dietary
modifications and administration of medications to correct electrolyte abnormalities),
Worsening of uremic syndrome associated with ESRD (i.e., nausea, vomiting, neurological
changes, pericarditis), Severe electrolyte and/or fluid abnormalities that cannot be controlled
by simpler measures (e.g., hyperkalemia, pulmonary edema)
11. awakening to void one or more times at night b. an excessive amount of urine c. urine
output < intake d. no urine
12. surgical formation (temporary or permanent) that bypasses the bladder, has a stoma on
the abdomen to drain the urine
13. is an accumulation of urine resulting from an inability of the bladder to empty properly
14. hospital-acquired result from catheterization or surgical manipulation, Escherichia coli
most common pathogen
15. retained urine in the bladder from kinked, obstructed, or clamped catheter
16. dysuria, fever, chills, nausea, vomiting and malaise, cystitis, hematuria
17. trauma, cancer of the bladder, radiation to the bladder, fistulas, or chronic cystitis
18. ureters are implanted into the isolated segment of ileum and used as a conduit for
continuous drainage, the client wears a stomal pouch continuously
19. a tube is placed directly into the renal pelvis to drain urine directly from one or both of
the kidneys
20. a. pattern of urination b. symptoms of urinary alterations c. factors affecting urination
21. j
22. e
23. g
24. I
25. h
26. k
27. l
28. b
29. d
30. f
31. a
32. c
33. skin and mucosal membranes, kidneys, bladder, urethral meatus

34. pale, straw-colored to amber-colored depending on its concentration
35. appears transparent at voiding; becomes more cloudy on standing in a container
36. has a characteristic odor; the more concentrated the urine, the stronger the odor
37.
a. Random: Collect during normal voiding from an indwelling catheter or urinary
diversion collection bag. Use a clean specimen cup.
b. Clean-voided or midstream: Use a sterile specimen cup. Female – After donning
sterile gloves, spread labia with thumb and forefinger of nondominant hand. Cleanse
area with cotton ball or gauze, moving from front (above urethral orifice) to back
(toward anus). Using a fresh swab each time, repeat front-to-back motion three times
(begin with center, then left side then right side). If agency policy indicates, rinse area
with sterile water, and dry with dry cotton ball or gauze.While continuing to hold
labia apart, have client initiate stream. After client achieves a stream, pass container
into stream and collect 30 to 60 ml. Remove specimen container before flow of urine
stops and before releasing labia or penis. Client finishes voiding in bedpan or toilet.
Male – After donning sterile gloves, hold penis with one hand, and using circular
motion and antiseptic swab, cleanse end of penis, moving from center to outside (see
illustration). In uncircumcised men, retract the foreskin before cleansing. If agency
procedure indicates, rinse area with sterile water, and dry with cotton or gauze. After
client has initiated urine stream, pass specimen collection container into stream, and
collect 30 to 60 ml. Remove specimen container before flow of urine stops and before
releasing labia or penis. Client finishes voiding in bedpan or toilet.
c. Sterile: If the client has an indwelling catheter, collect a sterile specimen by using
aseptic technique through the special sampling port (Figure 45-7) found on the side of
the catheter. Clamp the tubing below the port, allowing fresh, uncontaminated urine
to collect in the tube. After the nurse wipes the port with an antimicrobial swab, insert
a sterile syringe hub and withdraw at least 3 to 5 ml of urine (check agency policy).
Using sterile aseptic technique, transfer the urine to a sterile container.
d. Timed urine: Time required may be 2-, 12-, or 24-hour collections. The timed period
begins after the client urinates and ends with a final voiding at the end of the time
period. The client voids into a clean receptacle, and the urine is transferred to the
special collection container, which often contains special preservatives. Each
specimen must be free of feces and toilet tissue. Missed specimens make the whole
collection inaccurate. Check with agency policy and the laboratory for specific
instructions.
38. will analyze values of pH (4.6-8.0), protein (none or up to 8 mg/100 ml), glucose (none),
ketones (none), blood, specific gravity (1.0053-1.030) and microscopic values for RBCs (up
to 2), WBCs (0-4 per low-power field), bacteria (none), casts (none), and crystals (none).
39. is the weight or degree of concentration of a substance compared with an equal volume
of water
40. sterile or clean voided sample of urine and can report bacterial growth in 24-48 hours
41.
a. Abdominal roentgenogram: Determine the size, shape, symmetry, and location of the
kidneys.
b. Intravenous pyelogram (IVP): View the collecting ducts and renal pelvis and outline
the ureters, bladder, and urethra. A special intravenous injection (iodine-based) that
converts to a dye in urine is injected intravenously.
c. urodynamic testing: Determine bladder muscle function. This procedure is indicated
to evaluate causes of urinary incontinence. Generally the client urinates into a toilet
equipped with a funnel and uroflowmeter. Voiding activates the uroflowmeter, and
electronic data is recorded and analyzed.
d. CT scan: Obtain detailed images of structures within a selected plane of the body. The
computer reconstructs cross-sectional images and thus allows the health care provider
to view pathologic conditions such as tumors and obstructions.
e. Ultrasound: Renal – Identify gross renal structures and structural abnormalities in the
kidney using high-frequency, inaudible sound waves. Bladder – Identify structural
abnormalities of bladder or lower urinary tract. Can also be used to estimate the
volume of urine in the bladder.
42.
endoscopy: Direct visualization, specimen collection, and/or treatment of the interior of
the bladder and urethra. Although this procedure is usually performed using local
anesthesia, general anesthesia or conscious sedation is more common to avoid
unnecessary anxiety and trauma for the client. Surgery on the male prostate is also
performed using a special endoscope.
Arteriogram: Visualizes the renal arteries and/or their branches to detect narrowing or
occlusion. A catheter is placed in one of the femoral arteries and introduced up to the
level of the renal arteries. Radio-opaque contrast is injected through the catheter while x-
ray images are taken in rapid succession.
43. disturbed body image
44. urinary incontinence (functional, stress, urge)
45. pain (acute, chronic)
47. self-care deficit, toileting
49. impaired urinary elimination
50. urinary retention
51. a. client will void within 8 hours b. urinary output of 300 ml or greater will occur with
each voiding c. client’s bladder is not distended to palpation
52. a. normal positioning b. running water c. stroking the inner aspect of the thigh d. warm
water over the client’s perineum
53.
functional: Clothing modifications, environmental alterations, scheduled toileting, absorbent
products
stress: Pelvic floor exercises (Kegel), surgical interventions, biofeedback, electrical
stimulation, absorbent products
urge: Antimuscarinic agents, behavioral interventions, biofeedback, bladder retraining,
pelvic floor exercises, lifestyle modifications (smoking cessation, weight loss, and fluid
modifications), absorbent products
mixed: Main treatments will usually be based on the symptoms that are most bothersome to
client
reflex: Intermittent catheterization, condom catheter (male), Credé’s method

54. meat, eggs, whole-grain breads, cranberries, and prunes
55.
intermittent: Relief of discomfort of bladder distention, provision of decompression;
Obtaining sterile urine specimen when clean-catch specimen is unobtainable; Assessment of
residual urine after urination; Long-term management of clients with spinal cord injuries,
neuromuscular degeneration, or incompetent bladders
short-term indwelling: Obstruction to urine outflow (e.g., prostate enlargement); Surgical
repair of bladder, urethra, and surrounding structures; Prevention of urethral obstruction from
blood clots after genitourinary surgery; Measurement of urinary output in critically ill clients;
Continuous or intermittent bladder irrigations
long-term indwelling: Severe urinary retention with recurrent episodes of UTI; Skin rashes,
ulcers, or wounds irritated by contact with urine; Terminal illness when bed linen changes are
painful for client
56. personal hygiene at least BID for a client with an indwelling catheter with soap and water
57. special care TID and after defecation
58. 2000-2500 ml if permitted
59. to maintain the patency of indwelling catheters; blood, pus, or sediment can collect
within the tubing and result in bladder distention and buildup of stagnant urine
60. surgical placement of a catheter through the abdominal wall above the symphysis pubis
and into the urinary bladder
61. suitable for incontinent or comatose men who still have complete and spontaneous
bladder emptying
62. improves the strength of pelvic muscles and consists of repetitive contractions of muscle
groups; effective in treating stress incontinence, overactive bladders, and mixed causes of
urinary incontinence
63. is to reduce the voiding frequency and to increase the bladder capacity, specific for
clients with urge incontinence related to overactive bladder
64. benefits clients with functional incontinence, by improving voluntary control over
urination
65. clients with chronic disorders such as spinal cord injuries; must be able to physically
manipulate equipments and assume positions
66. evaluate for change in the client’s voiding pattern and continued presence of urinary tract
alterations
67. 2. involuntary leakage of urine during increased abdominal pressure in the absence of
bladder muscle contraction
68. 1. pain or burning (dysuria) as well as fever, chills, N/V, and malaise
69. 3. symptoms of an allergic response
70. 4. Antibiotics help the situation; the other choices are interventions to teach the client to
prevent UTI.
71.
Mrs. Grayson is a 55-year-old woman who has had problems with stress incontinence for the
past 2 years. She has not spoken to anyone about her problems because she is embarrassed.
She has recently begun Kegel’s exercises to attempt improvement in her urinary control. The
nurse had the client describe situations that accompany urine leakage. Mrs. Grayson finally
confides to her healthcare practitioner that the problem is causing her to avoid social
situations and that she would like help to regain urinary control. She responds, “I find myself
being embarrassed and frustrated for losing control. If my bladder is a little full, I dribble
easily just picking something up or when I’m on my way to the bathroom. I’m afraid to laugh
any more as that is another time I leak urine. At work I try to avoid being close to my co-
workers because I am afraid I might have an odor.” The nurse asks Mrs. Grayson what she
has been doing about her condition. She states that she has been wearing “one of those little
pads” all the time now. The nurse asks Mrs. Grayson about any other effects that her leakage
has caused. Mrs. Grayson begins to cry and states, “You know, I don’t even like to go out to
the movies or a party anymore. It is safer to stay home. I have problems being intimate with
my husband because of leaking. We used to go to dancing occasionally but we don’t do that
anymore.” The nurse takes a focused nursing history, addressing urinary leakage and other
lower urinary tract symptoms. The report of urine leakage upon physical exertion, sneezing,
and laughing increases the likelihood of a diagnosis of stress incontinence. Her risk factors
for this condition include a history of three pregnancies, being postmenopausal, and being
overweight (200 lbs and 5’ 1” tall). The history will help define the proper interventions.
Chapter 46: Bowel Elimination
1. Teeth masticate food, breaking it down to swallow, and saliva is produced to dilute and
soften the food for easier swallowing
2. The bolus of food travels down and is pushed along by peristalsis, which propels the food
through the length of the GU tract.
3. stores swallowed food and liquid, mixing of food, liquid and digestive juices, and
empties its contents into the small intestine; produces HCL, mucus, and pepsin and intrinsic
factor, which is essential for the absorption of Vitamin B12
4. segmentation and peristaltic movement facilitate both digestion and absorption; chime
mixes with digestive juices
5. lower GI tract (colon) divided into the cecum, colon, and rectum. It is the primary organ
of elimination.
6. contraction and relaxation of the internal and external sphincters, innervated by
sympathetic and parasympathetic stimuli, aid in control of defecation
7. at the time of defecation, the external sphincter relaxes and the abdominal muscles
contract, increasing intrarectal pressure and forcing the stool out. Pressure can be exerted to
expel forces through a voluntary contraction of the abdominal muscles while maintaining
forced expiration against a closed airway.
8.
a. mouth: Decreased chewing and decreased salivation, including oral dryness
b. esophagus: Reduced motility, especially in lower third
c. stomach: Decrease in acid secretions, motor activity, mucosal thickness, nutrient
absorption
d. small intestine: Increase in pouches on the weakened intestinal wall called
diverticulosis
e. large intestine: Constipation, Missed defecation signal increasing risk for fecal
incontinence
f. liver: Size decreased
9. a non-digestible residue in the diet that provides the bulk of fecal material (whole grains,
fresh fruits, and vegetables)
10. persons who lack the enzyme needed to digest the milk sugar
11. fluid liquefies the intestinal contents, easing its passage through the colon, reduced fluid
intake slows the passage of food through the intestine and results in hardening of stool
contents
12. promotes peristalsis; weakened abdominal and pelvic floor muscles impair the ability to
increase intra-abdominal pressure and to control the external sphincter
13. ulcerative colitis, irritable bowel syndrome, certain gastric and duodenal ulcers, and
Crohn’s disease
14. a. a busy work schedule b. hospitalized clients who lack privacy C. sights and sounds and
odors of toilet facilities d. embarrassment of using bedpans
15. hemorrhoids, rectal surgery, rectal fistulas, and abdominal surgery
16. general anesthetic agents used during surgery cause temporary cessation of peristalsis;
direct manipulation of the bowel temporarily stops peristalsis (paralytic ileus)
17.
a. Dicyclomine HCl (Bentyl): Suppresses peristalsis and decreases gastric emptying
b. Narcotics: Slow peristalsis and segmental contractions, often resulting in constipation

c. Anticholinergics: Inhibit gastric acid secretion and depress GI motility. Although
useful in treating hyperactive bowel disorders, anticholinergics cause constipation.
d. Antibiotics: Produce diarrhea by disrupting the normal bacterial flora in the GI tract.
An increase in the use of fluoroquinolones in recent years has provided a selective
advantage for the epidemic of C. difficile.
e. NSAIDs: Cause gastrointestinal irritation that increases the incidence bleeding with
serious consequences to the elderly
f. aspirin: A prostaglandin inhibitor, it interferes with the formation and production of
protective mucus and causes GI bleeding.
g. Histamine2 (H2) antagonists: Suppress the secretion of hydrochloric acid and
interfere with the digestion of some foods
h. iron: Causes discoloration of the stool (black), nausea, vomiting, constipation,
(diarrhea is less commonly reported), and abdominal cramps.
18. colonoscopy and endoscopy
19. improper diet, reduced fluid intake, lack of exercise, certain medications
20. infrequent bowel movements < 3 days, difficulty passing stools, excessive straining,
inability to defecate at will, hard feces
21.
a. Irregular bowel habits and ignoring the urge to defecate
b. Chronic illnesses (e.g., Parkinson’s disease, multiple sclerosis, rheumatoid arthritis,
chronic bowel diseases, depression, diabetic neuropathy, eating disorders)
c. Low-fiber diet high in animal fats (e.g., meats, dairy products, eggs). Also, low fluid
intake slows peristalsis.
d. Anxiety, depression, cognitive impairment
e. Lengthy bed rest or lack of regular exercise
f. Laxative misuse
g. Older adults experience slowed peristalsis, loss of abdominal muscle elasticity, and
reduced intestinal mucus secretion. Older adults often eat low-fiber foods.
h. Neurological conditions that block nerve impulses to the colon (e.g., spinal cord
injury, tumor)
i. Organic illnesses such as hypothyroidism, hypocalcemia, or hypokalemia
j. Medications such as anticholinergics, antispasmodics, anticonvulsants,
antidepressants, antihistamines, antihypertensives, antiparkinsonism drugs, bile acid
sequestrants, diuretics, antacids, iron supplements, calcium supplements, and opioids
slow colonic action.
22. a. abdominal, GYN, or rectal surgery b. cardiovascular disease c. elevated intraocular
pressure d. increased intracranial pressure
23. a collection of hardened feces wedged in the rectum that a person cannot expel as a result
of unrelieved constipation
24. a. oozing of diarrhea b. loss of appetite (anorexia) c. nausea and/or vomiting d.
abdominal distention and cramping e. rectal pain
25. is an increased number of stools and the passage of liquid, unformed feces associated
with disorders affecting digestion, absorption, and secretion
26. a. contamination and risk of skin ulceration b. fluid and electrolyte or acid-base
imbalances
27. a causative agent of mild diarrhea to severe colitis acquired by the use of antibiotics,
chemotherapy, invasive bowel procedures, or from a health care worker’s hands or direct
contact with environmental surfaces
28. a. is the inability to control passage of feces and gas from the anus caused by physical
conditions that impair anal sphincter function or control b. a gas accumulation in the lumen
of the intestine; stretches and distends (a common cause of abdominal fullness, pain, and
cramping)
29. increased venous pressure from straining and defecation, pregnancy, heart failure, and
chronic liver disease
30. artificial opening in the abdominal wall
31. surgical opening in the ileum
32. surgical opening in the colon
33. loop colostomy, end colostomy, and a double-barrel colostomy
34. a. determination of the usual elimination pattern b. client’s description of usual stool
characteristics c. identification of routines followed to promote normal elimination d.
assessment of the use of artificial aids at home e. presence and status of bowel diversions f.
changes in appetite g. diet history h. description of daily fluid intake i. history of surgery or
illness j. medication history k. emotional state l. history of exercise m. history of pain or
discomfort n. social history o. mobility and dexterity
35. all 4 quadrants for contour, shape, symmetry, and skin color
36. assess bowel sounds in all 4 quadrants
37. for masses or areas of tenderness
38. detects lesions, fluid, or gas
39. or guaiac test, which measures microscopic amounts of blood in feces; useful as a
screening tool for colon cancer
40.
a. Color: Infant: yellow; adult: brown
b. Odor: Pungent; affected by food type
c. Consistency: Soft, formed
d. Frequency: Varies: Infant, 4 to 6 times daily (breast-fed) or 1 to 3 times daily (bottle-
fed); adult, daily or 2 to 3 times a week
e. Amount: 150 g per day (adult)
f. Shape: Resembles diameter of rectum
g. Constituents: Undigested food, dead bacteria, fat, bile pigment, cells lining intestinal
mucosa, water
41.
a. Plain Film of Abdomen/Kidneys, Ureter, Bladder
b. Upper GI/Barium Swallow
c. Upper Endoscopy
d. Barium Enema
e. Ultrasound
f. Colonoscopy
g. Flexible Sigmoidoscopy
h. Computerized Tomography Scan
i. Magnetic Resonance Imaging
j. Enteroclysis
42. bowel incontinence

43. constipation
44. risk for constipation
45. perceived constipation
46. diarrhea
47. self-care deficit: toileting
48. client sets regular defecation habits
49. client is able to list proper fluid and food intake needed to achieve elimination
50. client implements a regular exercise program
51. client reports daily passage of soft, formed brown stool
52. client does not report any discomfort associated with defecation
53. a. sitting position b. positioning on bedpan c. privacy d. medications
54. have the short-term action of emptying the bowel (bulk forming, emollient or wetting,
saline, stimulant, lubricant)
55. Antidiarrheal opiate agents decrease intestinal muscle tone to slow passage of feces.
56. temporary relief of constipation, emptying the bowel before diagnostic tests, and bowel
training
57. include tap water, normal saline, soapsuds solution, and low-volume hypertonic saline
58. is hypotonic and exerts a lower osmotic pressure than fluid in interstitial spaces
59. safest solution; it exerts the same osmotic pressure as fluids in interstitial spaces
surrounding the bowel
60. exert osmotic pressure that pulls out of interstitial spaces; contraindicated in clients who
are dehydrated and in young infants
61. creates the effect of interstitial irritation to stimulate peristalsis
62. lubricate the rectum and the colon and make the feces softer and easier to pass
63. provide relief from gaseous distention; improve the ability to pass flatus
64. that the enema is repeated until the client passes fluid that is clear and contains no fecal
material
65. can cause irritation to the mucosa, bleeding, and stimulation of the vagus nerve, which
results in a reflex slowing of the heart rate
66.
a. Decompression
b. Enteral Feeding
c. Compression
d. Lavage
67. assess the condition of the nares and mucosa for inflammation and excoriation, frequent
changing of the tape and lubrication of the nares, frequent mouth care
68. assessing the normal elimination pattern and recording times when the client is
incontinent
69. incorporating principles of gerontologic nursing when providing bowel training programs
for older adults
70. choosing a time in the client’s pattern to initiate defection-control measures
71. giving stool softeners orally every day or a cathartic at least a half an hour before the
selected defecation time
72. offering a hot drink or fruit juice before the defecation time
73. assisting the client to the toilet at the designated time
74. avoiding medications that increase constipation

75. providing privacy and setting a time limit for defecation
76. instruct the client to lean forward at the hip when on the toilet, to apply manual pressure
with the hands over the abdomen, and to bear down but not strain to stimulate colon
emptying
77. able to have regular, pain-free defecation of soft, formed stool
78. 4. Reabsorption in the small intestine is very efficient.
79. 1. See Box 46-5 for rationale.
80. 1. An infant’s stool is yellow, and adult stool is brown.
81. 2. In a supine position, it is impossible to contract the muscles used during defecation;
raising the HOB assists the client to a more normal sitting position, enhancing that ability to
defecate.
82. 3. correct volume for a school-aged child
83.
Javier, a home care nurse, is visiting Larry at his home on one of the local cattle ranches.
Larry lives 20 miles from town. He is 22 years old and had surgery 6 days ago for repair of a
badly broken right leg, from being thrown from a horse. Larry also tells Javier that he “just
doesn’t feel good.” His past history includes a trauma abdominal surgery repair after being
struck by a bull’s horns last summer. The nurse asks Larry about his recent bowel elimination
patterns over the last 5 days. Larry tells Javier that he has not had a bowel movement since
he left the hospital 4 days ago and that he feels like his abdomen is tight and sore. The nurse
reviews dietary intake over last day. Diet included eggs, bacon, and toast for breaksfast; soup
for lunch; and chicken, rice, and corn for dinner. He drinks about six cups of coffee each day;
no water, but he will drink a Coke. The nurse asks about any nausea or vomiting, which
Larry denies. The nurse then auscultates client’s abdomen and finds decreased bowel sounds
throughout all four abdominal quadrants. On palpation, left lower quadrant is tender and
firm. Larry states, “It really hurts.”
The goals are that the client will establish normal defecation, will voice relief from
constipation, and will identify measures that will prevent constipation. The goals will be
accomplished by Javier by encouraging fluid intake of appropriate fluids, fruit juice, and
water; encouraging activity within the limits of client’s mobility regimen; adding 20g/day of
wheat bran to diet; providing stool softeners or laxatives as ordered; and providing privacy
when defecating.
Chapter 47: Mobility and Immobility
1. c
2. e
3. d
4. f
5. b
6. a
7. r
8. g
9. h
10. e
11. s
12. f
13. l
14. k
15. n
16. q
17. c
18. o
19. b
20. j
21. m
22. p
23. a
24. I
25. d
26.
a. torticollis: Inclining of head to affected side, in which sternocleidomastoid muscle is
contracted
b. lordosis: Exaggeration of anterior convex curve of lumbar spine
c. kyphosis: Increased convexity in curvature of thoracic spine
d. scoliosis: Lateral S- or C-shaped spinal column with vertebral rotation, unequal
heights of hips and shoulders
e. congenital hip dysplasia: Hip instability with limited abduction of hips and,
occasionally, adduction contractures (head of femur does not articulate with
acetabulum because of abnormal shallowness of acetabulum)
f. knock knee: Legs curved inward so that knees come together as person walks
g. bowlegs: One or both legs bent outward at knee, which is normal until 2 to 3 years of
age
h. clubfoot: 95%: medial deviation and plantar flexion of foot (equinovarus) 5%: lateral
deviation and dorsiflexion (calcaneovalgus)
i. footdrop: Inability to dorsiflex and invert foot because of peroneal nerve damage
j. pigeon-toes: Internal rotation of forefoot or entire foot; common in infants
27. impaired body alignment, balance, and mobility
28. bruises, contusions, sprains, and fractures
29. to the person’s ability to move about freely

30. inability to move freely
31.
a. Reducing physical activity and the oxygen needs of the body
b. Reducing pain, including postoperative pain or after acute injury, to the lower back
c. Allowing ill or debilitated clients to rest
d. Allowing exhausted clients the opportunity for uninterrupted rest
32. decreases the metabolic rate; alters the metabolism of CHO, fats, and proteins; causes
fluid and electrolyte and calcium imbalances; and causes GI disturbances
33. a. collapse of alveoli b. inflammation of the lung from stasis or pooling of secretions
34. a. increase in heart rate of more than 15% and a drop of 15 mm Hg or more in SBP b.
accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached
to the interior wall of a vein or artery that occludes the lumen of the vessel
35. a. loss of endurance, strength, and muscle mass and decreased stability and balance b.
impaired calcium metabolism c. impaired joint mobility d. osteoporosis e. joint contractures
f. footdrop
36. a. urinary stasis (renal pelvis fills before urine enters the ureters) b. renal calculi (calcium
stones that lodge in the renal pelvis)
37. a. pressure ulcers (impairment of the skin as a result of prolonged ischemia in tissues)
38. a. emotional and behavioral responses b. sensory alterations c. changes in coping
39. is the maximum amount of movement available at a joint in one of the three planes of the
body: sagittal, frontal, or transverse
40. particular manner or style of walking
41. physical activity for conditioning the body, improving health, and maintaining fitness
42. identifies deviations, learning needs, identifies trauma, risk factors
44. ineffective individual coping
45. risk for injury
48. social isolation
49. impaired urinary elimination
50. a. skin color and temperature return to normal baseline within 20 minutes of position
change b. changes position at least every 2 hours
51. a. prevention of work-related injury b. fall prevention measures c. exercise d. early
detection of scoliosis
52. a. a high caloric diet b. vitamin B and C supplements
53. a. deep breathe and cough every 1-2 hours b. CPT c. ensure intake of 2000 mL of fluid
per day
54. a. reduce orthostatic hypotension – early mobilization b. reduce cardiac workload –avoid
Valsalva movements c. prevent thrombus formation – prophylaxis (heparin, SCDs, and
TEDs)
55. a. perform active and passive ROM exercises b. CPM machines
56. a. positioning and skin care b. use of therapeutic devices to relieve pressure
57. a. well-hydrated b. prevent urinary stasis and calculi and infections
58. a. anticipate change in the client’s status and provide routine and informal socialization b.
stimuli to maintain client’s orientation
59. a. prevents external rotation of the hips when the client is in supine position b. maintain
the thumb in slight adduction and in opposition to the fingers c. allows the client to pull with
the upper extremities to raise the trunk off the bed, assist in transfer, or to perform exercises
60. HOB elevated 45-60 degrees and the knees are slightly elevated
61. rest on their backs; all the body parts are in relation to each other
62. lies face or chest down
63. the client rests on the side with body weight on the dependent hip and shoulder
64. client places the weight on the anterior ileum humerus and clavicle
65. are activities beyond ADLs that are necessary to be independent in society
66. Always stand on the client’s affected side and support the client by using a gait belt.
67. the client’s ability to maintain or improve body alignment, improve mobility; protect the
client from the hazards of immobility
68. 1. footdrop. Allowing the foot to be dorsiflexed at the ankles prevents this.
69. 3. due to immobility causing decreased lung elastic recoiling and secretions accumulating
in portions of the lungs
70. 4. need to measure bilateral calf circumference
71. 4. this technique produces a forceful, productive cough without excessive fatigue
72.
Ms. Barbara Adams, an 84-year-old client, has been admitted to a skilled care unit for
rehabilitation after a total hip replacement (THR) for osteoarthritis. She has a history of
smoking and hypertension. She experiences “aches” and “stiffness” in her joints, especially
in her knees and fingers. The wound is clean, dry, and intact. Staples will be removed in 2
days. She states, “I am afraid I am going to fall.” She takes pain medication to help her sleep
during the night but does not need any during the day. She is to start physical therapy
tomorrow. Ms. Adams’ pain level, as reported to the nurse, is rated as a 2 on a scale of 0 to 10
at rest, but it increases to an 8 with activity. The nurse assesses Ms. Adams’ ability to transfer
and finds that she is not able to transfer with help from chair to bed. When the nurse asks Ms.
Adams how her surgery has affected her mobility, she responds that she does not like to get
out of bed and that she needs help to get dressed in the morning.
In order to adjust Ms. Adams’ care, the nurse instructs Ms. Adams about safe transfer and
ambulation techniques in an environment with few distractions. In addition, the nurse will
provide written materials that reinforce verbal instructions. The nurse understands that
providing instruction in a quiet environment and giving written instructions in large, easy-to-
read print enhances learning in the older client. The nurse will also establish realistic
increments for transferring and increasing distance for ambulation because gradually
increasing physical activity and setting realistic goals for ambulation encourages activity in
older adults.
The nurse will perform a comprehensive assessment of pain including location,
characteristics, onset/duration, frequency, quality, severity and precipitating factors. A
thorough assessment is essential in managing pain in older adults. The nurse will be able to
determine if pain is being caused by a chronic condition (e.g., osteoarthritis) or by the
surgery. The nurse can encourage Ms. Adams to use nonpharmacological techniques (e.g.,
guided imagery) before, after and, if possible, during painful activities to decrease pain and
increase mobility. The nurse can also encourage Ms. Adams to use adequate pain medication,
as aggressive pain management is needed following surgery to decrease the effects of pain
and increase mobility in the elderly client.
Chapter 48: Skin Integrity and Wound Care
1. e
2. f
3. a
4. b
5. d
6. c
7. a. pressure intensity b. pressure duration c. tissue tolerance
8. a. impaired sensory perception b. impaired mobility c. alteration in level of consciousness
d. shear e. friction f. moisture
9. I – intact skin with non-blanchable redness of a localized area over a bony prominence II
– partial-thickness skin loss involving epidermis, dermis, or both III – full- thickness with
tissue loss IV – full-thickness tissue loss with exposed bone, tendon, or muscle
10. red, moist tissue comprised of new blood vessels, which indicates wound healing
11. stringy substance attached to wound bed that is soft, yellow, or white tissue
12. black or brown necrotic tissue
13. describes the amount, color, consistency, and odor of wound drainage
14. wound that is closed by epithelialization with minimal scar formation
15. wound edges are not approximated; the wound heals by granulation tissue formation,
wound contract, and epithilialization
16. Wound is left open for several days; then the wounds are approximated.
17. inflammatory response, epithelial proliferation (reproduction), and migration with
reestablishment of the epidermal layers
18. begins minutes after the injury and continues for up to 3 days. Hemostasis; injured blood
vessels constrict and platelets gather to stop bleeding, clots form a fibrin matrix. Damaged
tissues and mast cells secrete histamine (vasodilates) with exudation of serum and WBC into
damaged tissues.
19. new blood vessels as reconstruction progresses, begins, and lasts 3-24 days. Filling of the
wound with granulation tissue, contraction of the wound, and the resurfacing of the wound
by epithelialization
20. Maturation, the final stage, may take up to a year; the collagen scar continues to
reorganize and gain strength for several months.
21. occurs after hemostasis indicates a slipped surgical suture, a dislodged clot, infection, or
erosion of a blood vessel by a foreign object (internal or external)
22. Second most common nosocomial infection; purulent material drains from the wound
(yellow, green, or brown, depending on the organism)
23. a partial or total separation of wound layers; risks are poor nutritional status, infection, or
obesity
24. total separation of wound layers with protrusion of visceral organs through a wound
opening requiring surgical repair
25. abnormal; passage between 2 organs or between an organ and the outside of the body
26. a. Norton scale b. Braden scale
27. a. nutrition b. tissue perfusion c. infection d. age e. wound healing
28. potential effects of impaired mobility; muscle tone and strength
29. malnutrition is a major risk factor; a loss of 5% of usual weight, weight less than 90% of
IDW, or a decrease of 10 lbs in a brief period
30. Continuous exposure of the skin to body fluids, especially gastric and pancreatic
drainage, increases risk for breakdown.
31. Adequate pain control and client comfort will increase mobility, which in turn reduces
risk.
32. a. abrasion – is superficial with little bleeding and is considered a partial-thickness
wound b. laceration – sometimes bleeds more profusely depending on depth and location
(greater than 5 cm or 2.5 cm in depth) c. puncture – bleeds in relation to the depth and size,
with high risk of internal bleeding and infection
33. whether the wound edges are closed, the condition of tissue at the wound base; look for
complications and skin coloration
34. amount, color, odor, and consistency of drainage, which depends on the location and the
extent of the wound
35. Observe the security of the drain and its location with respect to the wound, character of
the drainage; measure the amount.
36. Surgical wounds are closed with staples, sutures, or wound closures.
38. imbalanced nutrition: less than body requirements
39. acute or chronic pain
42. risk for impaired skin integrity
44. impaired tissue integrity
45. a. higher percentage of granulation tissue in the wound base b. no further skin breakdown
in any body location c. an increase in the caloric intake by 10%
46.
decreased sensory perception: Assess pressure points for signs of nonblanching reactive
hyperemia. Provide pressure redistribution surface.
moisture: Assess need for incontinence management. Following each incontinent episode,
cleanse area with no-rinse perineal cleanser and protect skin with a moisture barrier
ointment.
friction and shear: Reposition client using a drawsheet and lifting off of surface. Provide a
trapeze to facilitate movement. Position client at a 30-degree lateral turn and limit head
elevation to 30 degrees.
decreased activity/mobility: Establish and post individualized turning schedule.
poor nutrition: Provide adequate nutritional and fluid intake; assist with intake as necessary.
Consult dietitian for nutritional evaluation.
47. removal of nonviable necrotic tissue to rid the ulcer of a source of infection, to enable
visualization of the wound bed, and to provide a clean base necessary for healing
48. a. mechanical b. autolytic c. chemical d. sharp/surgical
49. control bleeding by applying direct pressure in the wound site with a sterile or clean
dressing, usually after trauma, for 24-48 hours
50. gentle cleansing rather than vigorous cleansing with NS (physiological and will not harm
tissue)
51. applying sterile or clean dressings and immobilizing the body part
52. a. protects a wound from microorganism contamination b. aids in hemostasis c. promotes
healing by absorbing drainage and debriding a wound d. supports or splints the wound site e.
protects the client from seeing the wound f. promotes thermal insulation of the wound
surface g. provides a moist environment
53. a. use a dressing that will continuously provide a moist environment b. perform wound
care using topical dressings as determined by assessment c. choose a dressing that keeps the
surrounding skin dry d. choose a dressing that controls exudates e. consider caregiver time,
availability, and cost f. eliminate wound dead space by loosely filling all cavities with
dressing material
54. a, adheres to undamaged skin b. serves as a barrier to external fluids and bacteria but
allows the wound surface to breathe c. promotes a moist environment d. can be removed
without damaging underlying tissues e. permits viewing
55. a. absorbs drainage through the use of exudate absorbers b. maintains wound moisture c.
slowly liquefies necrotic debris d. impermeable to bacteria e. self-adhesive and molds well f.
acts as a preventative dressing for high-risk friction areas g. may be left in place for 3-5 days,
minimizing skin trauma and disruption of healing
56. a. soothing and reduces pain b. provides a moist environment, debrides the wound d. does
not adhere to the wound base and is easy to remove
57. a. assessment of the skin beneath the tape b. performing thorough hand hygiene before
and after wound care c. wear sterile gloves d. removing or changing dressings over closed
wounds when they become wet or if the client has signs and symptoms of infection
58. assess the size, depth, and shape of the wound; dressing (moist) needs to be flexible and
in contact with all of the wound surface; do not pack tightly (overpacking causes pressure);
do not overlap the wound edges (maceration of the tissue)
59. applies localized negative pressure to draw the edges of a wound together by evacuating
wound fluids and stimulating granulation tissue formation and reduces the bacterial burden
of a wound and maintains a moist environment
60. a. cleanse in a direction from the least contaminated area to the surrounding skin b. use
gentle friction when applying solutions locally to the skin c. when irrigating, allow the
solution to flow from the least to most contaminated area
61. use of an irrigating syringe to flush the area with a constant low-pressure flow of solution
of exudates and debris. Never occlude a wound opening with a syringe.
62. portable units that connect tubular drains lying within a wound bed and exert a safe,
constant low pressure vacuum to remove and collect drainage
63. a. creating pressure over a body part b. immobilizing a body part c. supporting a wound
d. reducing or preventing edema e. securing a splint f. securing dressings
64. a. inspecting the skin for abrasions, edema, discoloration, or exposed wound edges b.
covering exposed wounds or open abrasions with a sterile dressing c. assessing the condition
of underlying dressings and changing if soiled d. assessing the skin for underlying areas that
will be distal to the bandage for signs of circulatory impairment
65. a. heat – improves blood flow to an injured part; if applied > 1 hour the body reduces
blood flow by reflex vasoconstriction to control heat loss from the area b. cold – diminishes
swelling and pain, prolonged results in reflex vasodilation
66. A person is better able to tolerate short exposure to temperature extremes.
67. more sensitive to temperature variations – neck, inner aspect of the wrist and forearm,
and perineal region
68. Exposed skin layers are more sensitive to temperature variations.
69. The body responds best to minor temperature adjustments.
70. A person has less tolerance to temperature changes to which a large area of the body is
exposed.
71. Tolerance to temperature variations changes with age.
72. physical conditions that reduce the reception or perception of sensory stimuli; tolerance
to temperature extremes is high but the risk is also
73. Uneven temperature distribution suggests that the equipment is functioning improperly.
74.
very young or older clients: Thinner skin layers in children increase risk of burns. Older
clients have reduced sensitivity to pain.
open wounds: Subcutaneous and visceral tissues are more sensitive to temperature variations.
They also contain no temperature and fewer pain receptors.
areas of edema: Reduced sensation to temperature stimuli occurs because of thickening of
skin layers from fluid buildup or scar formation.
PVD: Body’s extremities are less sensitive to temperature and pain stimuli because of
circulatory impairment and local tissue injury. Cold application further compromises blood
flow.
Confusion: Perception of sensory or painful stimuli is reduced.
Spinal cord injury: Alterations in nerve pathways prevent reception of sensory or painful
stimuli.
Abscessed tooth: Infection is highly localized. Application of heat causes rupture with spread
of microorganisms systematically.
75. improve circulation, relieve edema, and promote consolidation of pus and drainage
76. promotes circulation, lessens edema, increases muscle relaxation, and provides a means
to debride wounds and apply medicated solutions
77. the pelvic area is immersed in warm fluid
78. used for treating muscle sprains and inflammation and edema
79. disposable hot packs that apply warm, dry heat to an area
80. relieves inflammation and swelling
81. immersing a body part for 20 minutes
82. used for muscle sprain, localized hemorrhage, or hematoma
83. a. Was the etiology of the skin impairment addressed? B. Was wound healing supported
by providing the wound base with a moist, protected environment? C. Were issues such as
nutrition assessed and a plan of care developed ?
84. 3. is the force exerted parallel to the skin resulting from both gravity pushing down on
the body and resistance between the client and the surface
85. 1. Perception, moisture, activity, mobility, nutrition, friction, and shear are the subscales .
86. 3. Recommended protein intake for adults is 0.8g/kg; a higher intake of up to 1.8g/kg/day
is necessary for healing.
87. 2. See Table 48-9 for choice and rationale for dressings for ulcer stages.
88.
Mrs. Stein, a 76-year-old, is 7 days postoperative for a total hip replacement. She developed
redness and oozing of foul-smelling, tan-colored drainage from the hip incision on
postoperative day four. Significant medical history includes arthritis and mild hypertension.
Because of surgical pain at the incision site, she did not easily transfer from her bed to the
chair. Now on day seven, she notes some pain at the incision and complains of a painful,
burning sensation in the sacral region. She is continent of urine and stool but continues to
“scoot” over to the side of the bed when preparing for bed-to-chair transfers. The nurse
obtains an oral temperature and determines that it is elevated. The nurse then asks Ms. Stein
how the surgical site limits her mobility, to which she relates that her hip always aches and
the pain increases upon movement. She tells the nurse that she prefers to keep the hip
immobile to keep the pain level down. Position of comfort is supine, and Mrs. Stein resists
position changes. The nurse performs a total body skin assessment, paying special attention
to the sacral area. The nurse notes that the client has reactive hyperemia around the sacral
area; this area does not blanch upon palpation. There is a partial-thickness ulcer directly over
the sacral area. No other areas are open, with the exception of the surgical site.
Key areas covered during the assessment included: Sensation, Mobility, Continence,
Presence of Wound.
Chapter 49: Sensory Alterations
1. c
2. f
3. d
4. b
5. a
6. e
7. c
8. f
9. h
10. j
11. l
12. d
13. I
14. k
15. b
16. g
17. a
18. e
19. a. sensory input (deficit from visual or hearing loss) b. elimination of patterns or meaning
from input (exposure to strange environment) c. restrictive environments that produce
monotony and boredom
20.
cognitive: Reduced capacity to learn; Inability to think or problem-solve; Poor task
performance; Disorientation; Bizarre thinking; Increased need for socialization, altered
mechanisms of attention
affective: Boredom; Restlessness; Increased anxiety; Emotional liability; Panic; Increased
need for physical stimulation
perceptual: Changes in visual/motor coordination; Reduced color perception; Less tactile
accuracy; Ability to perceive size and shape; Changes in spatial and time judgment
21. when a person receives multiple sensory stimuli and cannot perceptually disregard or
selectively ignore some stimuli
22. age, meaningful stimuli, amount of stimuli, social interaction, environmental factors,
cultural factors
23. older adults due to normal physiological changes, individuals that live in confined
environments, acutely ill clients
24.
a. Physical appearance and behavior: Motor activity, posture, facial expression, hygiene
b. Cognitive ability: Level of consciousness, abstract reasoning, calculation, attention,
judgment; Ability to carry on conversation and ability to read, write, and copy figure;
Recent and remote memory
c. Emotional stability: Agitation, euphoria, irritability, hopelessness, or wide mood
swings; Auditory, visual, or tactile hallucinations, illusions, delusions
25.
Sense Assessment Child Behavior Adult Behavior
Technique
Vision Ask client to read Self-stimulation, Poor coordination,
newspaper, including eye squinting,
magazine, or rubbing, body underreaching or
lettering on rocking, sniffing or overreaching for
menu. smelling, arm objects, persistent
twirling; hitching repositioning of
Ask client to identify
(using legs to propel objects, impaired
colors on color
while in sitting night vision,
chart or crayons.
position) instead of accidental falls
Observe client crawling
performing ADLs.
Hearing Assess client’s Frightened when Blank looks,
hearing acuity unfamiliar people decreased attention
and history of approach, no reflex or span, lack of reaction
tinnitus. purposeful response to loud noises,
to sounds, failure to increased volume of
Observe client
be awakened by loud speech, positioning of
conversing with
noise, slow or absent head toward sound,
others.
development of smiling and nodding
Inspect ear canal for speech, greater of head in approval
hardened response to when someone
cerumen. movement than to speaks, use of other
Observe client sound, avoidance of means of
behaviors in a group. social interaction communication such
with other children as lip-reading or
writing, complaints of
ringing in ears
Touch Check client’s ability Inability to perform Clumsiness, over
to discriminate developmental tasks reaction or under
between sharp related to grasping reaction to painful
and dull stimuli. objects or drawing, stimulus, failure to
repeated injury from respond when
Assess whether client
handling of harmful touched, avoidance of
is able to
objects (e.g., hot touch, sensation of
distinguish
stove, sharp knife) pins and needles,
objects (coin or
numbness
safety pin) in the
hand with eyes Unable to identify
closed. object placed in hand
Ask whether client
feels unusual
sensations.
Smell Have client close Difficult to assess Failure to react to
eyes and identify until child is 6 or 7 noxious or strong
several nonirritating years old, difficulty odor, increased body
odors (e.g., coffee, discriminating odor, increased
vanilla). noxious odors sensitivity to odors

Taste Ask client to sample Inability to tell Change in appetite,
and distinguish whether food is salty excessive use of
different tastes (e.g., or sweet, possible seasoning and sugar,
lemon, sugar, salt). ingestion of strange- complaints about taste
(Have client drink or tasting things of food, weight
sip water and wait 1 change
minute between each
taste.)
Position sense Observe client in the Clumsiness, Clumsiness,
environment. The disorientation, disorientation,
blind or severely accidental falls accidental falls
visually impaired
often touch the
boundaries or objects
to gain a sense of
their surroundings.
26. a. uneven, cracked walkways leading to doors b. doormats with slippery backing c.
extension and phone cords in walkways d. loose area rugs and runners e. bathrooms without
shower or tub grab bars f. unmarked water faucets g. slippery bathroom floors h. absence of
smoke detectors i. unlit stairways, lack of railings j. cluttered floors k. kitchen equipment
with hard-to-read settings
27. a. (motor) inability to name common objects or to express simple ideas in words or
writing b. (sensory) the inability to understand written or spoken language
28. impaired adjustment
29. impaired verbal communication
30. risk for injury
32. self-care deficit
33. situational low self-esteem
34. disturbed sensory perception
35. social isolation
36. disturbed thought processes
37. a. use communication techniques for improved reception of messages b. demonstrate
technique for cleansing hearing aid within 1 week c. use proper communication skills to send
and receive messages d. self-report improved hearing acuity
38. a. screening for rubella or syphilis in women who are considering pregnancy b. advocate
adequate prenatal care to prevent premature birth c. periodic screening of children, especially
newborns through preschoolers, for congenital blindness and visual impairment caused by
refractive error and strabismus
39. refractive error such as nearsightedness
40. a. family history b. prenatal infection c. low birth weight d. chronic ear infection e. Down
syndrome
41.
Senses Physiological Change Interventions
Vision Presbyopia: A gradual Assess for the presence of

decline in the ability of social networks and
the lens to accommodate supportive relationships.
or to focus on close Complete a thorough health
objects. Individual is history and physical
unable to see near objects assessment to identify health
clearly. problems that complicate life
with visual impairment.
Cataract: Cloudy or opaque
areas in part of the lens or Encourage client to discuss
what goals are important to
the entire lens that
him or her.
interfere with passage of
Provide factual information
light through the lens,
about the disease and answer
causing problems with
questions truthfully.
glare and blurred vision.
Cataracts usually develop Assist with identification of
creative strategies to promote
gradually, without pain,
self-care.
redness, or tearing in the
Explore the client’s ability to
eye.
cope with the loss of vision
Dry eyes: Result when tear and encourage expression of
glands produce too few feelings (e.g., denial, anger,
tears, resulting in itching, hopelessness).
burning, or even reduced
vision.
Glaucoma: A slowly
progressive increase in
intraocular pressure that
causes progressive
pressure against the optic
nerve, resulting in
peripheral visual loss,
decreased visual acuity
with difficulty adapting to
darkness, and a halo
effect around lights, if left
untreated.
Diabetic retinopathy:
Pathological changes
occur in the blood vessels
of the retina, resulting in
decreased vision or vision
loss due to hemorrhage
and macular edema.
Macular degeneration:
Condition in which the
macula (specialized
portion of the retina
responsible for central
vision) loses its ability to
function efficiently. First
signs include blurring of
reading matter, distortion
or loss of central vision,
and distortion of vertical
lines.
Hearing Presbycusis: A common Irrigation of the canal with
progressive hearing two to three ounces of tepid
disorder in older adults. water in a 60ml syringe (see
Chapter 39) will remove
Cerumen accumulation:
cerumen and significantly
Buildup of earwax in the
improve the client’s hearing
external auditory canal.
ability.
Cerumen becomes hard
The screening version of the
and collects in the canal
Hearing Handicap Inventory
and causes a conduction
for the Elderly (HHIE-S) is a
deafness.
5-minute, 10-item
questionnaire developed to
assess how the individual
perceives the social and
emotional effects of hearing
loss.
Prevention involves regular
immunization of children
against diseases capable of
causing hearing loss (e.g.,
rubella, mumps, and measles).
Nurses who work in
physicians’ offices, schools,
and community clinics need
to reinforce the importance of
early and timely
immunization. Advise
pregnant women to seek early
prenatal care and to undergo
testing for syphilis and
rubella. In all populations, use
caution when administering
drugs that are ototoxic.
Taste and smell Xerostomia: Decrease in Good oral hygiene keeps the
salivary production that taste buds well hydrated.
leads to thicker mucus Well-seasoned, differently
and a dry mouth. Often textured food eaten separately

interferes with the ability heightens taste perception.
to eat and leads to Flavored vinegar or lemon
appetite and nutritional juice adds tartness to food.
problems. Always ask the client what
foods are most appealing.
Improvement in taste
perception improves food
intake and appetite as well.
Stimulation of the sense of
smell with aromas such as
brewed coffee, cooked garlic,
and baked bread heightens
taste sensation. The client
needs to avoid blending or
mixing foods, because these
actions make it difficult to
identify tastes. Older persons
need to chew food thoroughly
to allow more food to contact
remaining taste buds.
You improve smell by
strengthening pleasant
olfactory stimulation. Make a
client’s environment more
pleasant with smells such as
cologne, mild room
deodorizers, fragrant flowers,
and sachets. The removal of
unpleasant odors (e.g.,
bedpans, soiled dressings)
will also improve the quality
of a client’s environment.
Touch With aging, there are Providing touch therapy
decreased skin receptors. stimulates existing function.
Clients with reduced tactile If the client is willing to be
sensation usually have the touched, hair brushing and
impairment over a limited combing, a back rub, and
portion of their bodies. touching of the arms or
shoulders are ways of
increasing tactile contact.
When sensation is reduced, a
firm pressure is often
necessary for the client to feel
the nurse’s hand. Turning and
repositioning will also

improve the quality of tactile
sensation. When performing
invasive procedures, it is
important to use touch by
holding the client’s hands and
keeping them warm and dry.
If a client is overly sensitive
to tactile stimuli
(hyperesthesia), minimize
irritating stimuli. Keeping bed
linens loose to minimize
direct contact with the client
and protecting the skin from
exposure to irritants are
helpful measures.
Trachea In hospitalized clients The client is sometimes
needing an artificial airway, completely alert and able to
oftentimes an endotracheal hear and see the nurse
tube is inserted into the normally. Giving the client
oropharynx and down time to convey any needs or
through the vocal cords of the requests is very important.
larynx into the upper Use creative communication
bronchus. The placement of techniques (e.g., a
the tube prevents a client communication board or a
from speaking. laptop computer) to foster and
strengthen the client’s
interactions with health care
personnel, family, and friends.
42.
clients with aphasia – Listen to the client and wait for the client to communicate. Do not
shout or speak loudly (hearing loss is not the problem). If the client has problems with
comprehension, use simple, short questions and facial gestures to give additional clues.
Speak of things familiar and of interest to the client. If the client has problems speaking, ask
questions that require simple yes or no answers or blinking of the eyes. Offer pictures or a
communication board so that the client can point. Give the client time to understand; be calm
and patient; do not pressure or tire the client. Avoid patronizing and childish phrases.
clients with an artificial airway – Use pictures, objects, or word cards so that the client can
point. Offer a pad and pencil or Magic Slate for the client to write messages. Do not shout or
speak loudly. Give the client time to write messages, because these clients become easily
fatigued. Provide an artificial voice box (vibrator) for the client with a laryngectomy to use to
speak.
clients with a hearing impairment –Get the client’s attention. Do not startle the client when
entering the room. Do not approach a client from behind. Be sure the client knows that you
wish to speak. Face the client and stand or sit on the same level. Be sure your face and lips
are illuminated to promote lip-reading. Keep hands away from mouth. Be sure that clients
keep eye glasses clean so that they are able to see your gestures and face. If the client wears a
hearing aid, make sure it is in place and working. Speak slowly and articulate clearly. Older
adults often take longer to process verbal messages. Use a normal tone of voice and
inflections of speech. Do not speak with something in your mouth. When you are not
understood, rephrase rather than repeat the conversation. Use visible expressions. Speak with
your hands, your face, and your eyes. Do not shout. Loud sounds are usually higher pitched
and often impede hearing by accentuating vowel sounds and concealing consonants. If you
need to raise your voice, speak in lower tones. Talk toward the client’s best or normal ear.
Use written information to enhance the spoken word. Do not restrict a deaf client’s hands.
Never have IV lines in both of the client’s hands if the preferred method of communication is
sign language. Avoid eating, chewing, or smoking while speaking. Avoid speaking from
another room or while walking away.
43. a. orientation to the environment – name tags are visible, address the client by name,
explain to the client any transfers, note physical boundaries b. communication – depending
on the type of aphasia (Box 49-9) c. control sensory stimuli – prevent overload by organizing
client’s care with periods of rest; control extraneous noise d. safety measures – help with
ambulation, sighted guide, frequent repositioning
44.
a. Spend time with a person in silence or conversation.
b. Use physical contact (holding a hand, embracing a shoulder) to convey caring.
c. Help recommend alterations in living arrangements if physical isolation is a factor.
d. Assist older adults in keeping in contact with people important to them.
e. Help obtain information about mutual help groups.
f. Arrange for security escort services as needed.
g. Bring a pet that is easy to care for into the home.
h. Link a person with religious organizations attuned to the social needs of older adults.
45. the nature of a client’s alterations influence how the nurse would evaluate the outcome of
care; if the expected outcomes have not been achieved, there needs to be a change in the
interventions or an alteration in the client’s environment; also need to evaluate the integrity
of the sensory organs and the client’s ability to perceive stimuli
46. 1. due to sensory deprivation related to restrictive environment of the hospital
47. 4. the presence or absence of meaningful stimuli (constant TV) influences alertness and
the ability to participate in care
48. 3. Priorities need to be set in regard to the type and extent of the sensory alteration, and
safety is always a top priority.
49. 4. motor type of aphasia
50.
Judy was released from the hospital in good health one week after admission. Following the
recommendation of her health care provider, she regularly attends a heart-failure support
group. She has asked the nurse to speak with the heart-failure support group regarding age-
related visual changes, as well as signs and symptoms that may indicate problems.
Some of the selected strategies to assist Judy in remaining functional in her home would
include removing any potential safety hazards (e.g., uneven, cracked walkways, slippery
doormats, rugs or other floor surfaces, extension or phone cords in the main route of walking
traffic, bathrooms without shower or tub grab-bars, poorly lit areas, absence of smoke
detectors, clutter in the home, kitchen equipment with hard-to-read settings). The nurse will
assist Judy in planning transportation to and from social activities and her support group. The
nurse will also involve family in assisting Judy to adjust to her limitations and referring Judy
to the appropriate health care, professional, and community agencies for assistance.
Chapter 50: Care of Surgical Clients
1. preoperative (before), intraoperative (during), postoperative (after surgery)

2. a. anesthetic drugs that metabolize rapidly with few after-effects allow for shorter
operative times and faster recovery time b. offers cost savings by eliminating the need for
hospital stay c. use of laparoscopic procedures instead of traditional surgical procedures
decreases the length of surgery, hospitalization, and costs
3. d
4. h
5. j
6. c
7. g
8. I
9. b
10. l
11. f
12. k
13. a
14. e
15.
thrombocytopenia: Increase risk of hemorrhaging during and after surgery.
diabetes mellitus: Increases susceptibility to infection and impairs wound healing from
altered glucose metabolism and associated circulatory impairment (Furnary and others 2003).
Stress of surgery often causes increases in blood glucose levels.
heart disease: Stress of surgery causes increased demands on myocardium to maintain
cardiac output. General anesthetic agents depress cardiac function.
obstructive sleep apnea: Administration of opioids increases risk of airway obstruction
postoperatively. Clients will desaturate as revealed by drop in O2 saturation by pulse
oximetry.
upper respiratory infection: Increases risk of respiratory complications during anesthesia
(e.g., pneumonia and spasm of laryngeal muscles).
liver disease: Alters metabolism and elimination of drugs administered during surgery and
impairs wound healing and clotting time because of alterations in protein metabolism.
fever: Predisposes client to fluid and electrolyte imbalances and may indicate underlying
infection.
emphysema: Reduces client’s means to compensate for acid-base alterations (see Chapter
41). Anesthetic agents reduce respiratory function, increasing risk for severe hypoventilation.
AIDS: Increases risk of infection and delayed wound healing after surgery.
Abuse of street drugs: Persons abusing drugs sometimes have underlying disease
(HIV/hepatitis), which affects healing.
Chronic pain: Regular use of pain medications often results in higher tolerance. Increased
doses of analgesics are sometimes necessary to achieve postoperative pain control.
16. a. poor tolerance to anesthesia b. negative nitrogen balance from the lack of protein c.
delayed clotting mechanisms d. infection e. poor wound healing f. multiple organ failure
17. a difficulty resuming activity after surgery b. reduced ventilatory and cardiac function c.
poor wound healing and wound infection d. high risk of dehiscence and evisceration
18.
cardiovascular system:
 Degenerative change in myocardium and valves: Reduced cardiac reserve
 Rigidity of arterial walls and reduction in sympathetic and parasympathetic innervation
to heart: Alterations predispose client to postoperative hemorrhage and rise in systolic
and diastolic blood pressure.
 Increase in calcium and cholesterol deposits within small arteries; thickened arterial
walls: Predispose client to clot formation in lower extremities
integumentary system:
 Decreased subcutaneous tissue and increased fragility of skin: Prone to pressure ulcers
and skin tears
pulmonary system:
 Rib cage stiffened and reduced in size renal system: Reduced vital capacity
 Reduced range of movement in diaphragm: Greater residual capacity (volume of air is
left in lung after normal breath) increases, reducing amount of new air brought into lungs
with each inspiration
 Stiffened lung tissue and enlarged air spaces: Alteration reduces blood oxygenation.
neurological system:
 Sensory losses, including reduced tactile sense and increased pain tolerance: Decreased
ability to respond to early warning signs of surgical complications
 Decreased reaction time: Confusion after anesthesia
metabolic system:
 Lower basal metabolic rate: Reduced total oxygen consumption
 Reduced number of red blood cells and hemoglobin levels: Ability to carry adequate
oxygen to tissues is reduced.
 Change in total amounts of body potassium and water volume: Greater risk for fluid or
electrolyte imbalance occurs.
 Impaired thermoregulatory mechanisms: Cold operating rooms; exposure of body parts
during procedure, IV fluids, medications
19.
Antibiotics: Antibiotics potentiate (enhance action) of anesthetic agents. If taken within 2
weeks before surgery, aminoglycosides (gentamycin, tobramycin, neomycin) may cause mild
respiratory depression from depressed neuromuscular transmission.
Antidysrhythmias: Antidysrhythmics (for example, beta blockers such as metoprolol
[Lopressor®]),, can reduce cardiac contractility and impair cardiac conduction during
anesthesia.
Anticoagulants: Anticoagulants, such as warfarin (Coumadin®), alter normal clotting factors
and thus increase risk of hemorrhaging. Discontinued at least 48 hours before surgery.
Aspirin is a commonly used medication that alters clotting mechanisms.
Anticonvulsants: Long-term use of certain anticonvulsants (e.g., phenytoin [Dilantin®] and
phenobarbital) alters metabolism of anesthetic agents.
Antihypertensives: Antihypertensives, such as beta blockers and calcium channel blockers,
interact with anesthetic agents to cause bradycardia, hypotension, and impaired circulation.
They inhibit synthesis and storage of norepinephrine in sympathetic nerve endings.
Corticosteroids: With prolonged use, corticosteroids, such as prednisone, cause adrenal

atrophy, which reduces the body’s ability to withstand stress. Before and during surgery,
dosages are often temporarily increased.
Insulin: Diabetic clients’ need for insulin changes after surgery. Stress response and
intravenous (IV) administration of glucose solutions often increase dosage requirements after
surgery. Decreased nutritional intake often decreases dosage requirements.
Diuretics: Diuretics such as furosemide (Lasix®) potentiate electrolyte imbalances
(particularly potassium) after surgery.
NSAIDs: NSAIDs (for example, ibuprofen) inhibit platelet aggregation and prolong bleeding
time, increasing susceptibility to postoperative bleeding.
Herbal therapies: These herbal therapies have the ability to affect platelet activity and
increase susceptibility to postoperative bleeding. Ginseng is reported to increase
hypoglycemia with insulin therapy.
20. a. greater risk for pulmonary complication due to increased amount and thickness of
mucous secretions in the lungs b. predisposes the client to adverse reactions to anesthetic
agents and cross-tolerance to anesthetic agents; malnourishment also leads to delayed wound
healing
21. a. family expectations for pain management following surgery b. perceived tolerance to
pain c. past experiences and interventions used
22. have client identify personal strengths and weaknesses; poor self-concept hinders the
ability to adapt to the stress of surgery and aggravates feelings of guilt or inadequacy
23. assess for body image alterations that clients perceive will result, taking into
consideration culture, age, self-concept, and self-esteem; removal of body parts often leaves
permanent disfigurement, alteration in body function or concern over mutilation, loss of body
function
24. of feelings and self-concept reveals whether the client is able to cope with the stress of
surgery, past stress management and behaviors utilized, and coping resources
25. a. general survey b. head and neck c. integument d. thorax and lungs e. heart and vascular
system f. abdomen g. neurological status
26.
a. CBC: Peripheral venous sample of blood may reveal infection, low blood volume,
and potential for oxygenation problems. Surgeon may order blood replacement.
b. Serum electrolytes: Peripheral venous sample of blood may reveal significant fluid
and electrolyte imbalances preoperatively. Attention is given to Na, K, and Cl levels.
IV fluid replacement may be indicated preoperatively.
c. Coagulation studies: Prothrombin time (PT), International Normalized Ratio (INR),
activated partial thromboplastin time (APTT), and platelet counts reveal clotting
ability of blood. Reveals clients at risk for bleeding tendencies and thrombus
formation.
d. Serum creatinine: Ability of kidneys to excrete creatinine, by-product of muscle
metabolism, assesses renal function. Elevated level can indicate renal failure.
e. BUN: Ability of kidneys to excrete urea and nitrogen indicates renal function. BUN
becomes elevated if client is dehydrated. Preoperative IV fluid replacement is often
necessary.
f. glucose: Finger stick or peripheral blood sample. Clients often require treatment of
low or high levels preoperatively and postoperatively.

28. risk for latex allergy response
29. anxiety
30. disturbed body image
31. risk for imbalanced body temperature
33. ineffective coping
34. fear
35. risk for deficient fluid volume
37. risk for perioperative-positioning injury
40. nausea
41. acute pain
42. powerlessness
45. delayed surgical recovery
46. a. prevention of lung congestion and pneumonia as reasons for deep breathing and
coughing exercises and incentive spirometer b. promotion of blood flow to prevent leg clots
as reason for postoperative leg exercises and ambulation c. improves lung function, assists
with return of bowel function, and promotes recovery
47. understands the need for a procedure, the steps involved, risks, expected results and
alternative treatments
48. a. reasons for preoperative instructions and exercises b. the time of surgery c. the
postoperative unit and location of the family during surgery and recovery d. discusses
anticipated postoperative monitoring and therapies e. describes surgical procedures and
postoperative treatment f. postoperative activity resumption g. verbalizes pain-relief
measures
49. a. maintenance of normal fluid and electrolyte balance b. reduction of risk of surgical
wound infection c. prevention of bowel and bladder incontinence d. promotion of rest and
comfort
50. a. hygiene b. hair and cosmetics c. removal of prostheses d. safeguarding valuables e.
preparing the bowel and bladder f. vital signs g. documentation h. performing special
procedures i. administering preoperative medications j. latex sensitivity/allergy k. eliminating
the wrong site and wrong procedure surgery
51. range from urticaria and flat or raised red patches to vesicular, scaling, or bleeding
eruptions; rhinitis and rhinorrhea are also common.
52. a. sphygmomanometer, stethoscope, and thermometer b. emesis basin c. clean gown d.
washcloth, towel and tissues e. IV pole f. suction equipment g. oxygen equipment and
oximetry monitor h. extra pillows for positioning i. bed pads to protect j. bed raised to
stretcher height to accommodate transfer
53. a. review of the preoperative assessment, establishing and implementing the
intraoperative plan of care, evaluating the care, and providing for continuity of care
postoperatively b. maintains a sterile field during the surgical procedure and assists with
supplies
54. a. will have intact skin and show no signs of redness b. will be free of burns at the
grounding pad
55. a. anesthesia b. surgery c. positioning d. equipment use
56. Given by IV and inhalation routes through 3 phases (induction, maintenance, and
emergence), resulting in an immobile, quiet client who does not recall the surgical procedure
57. results in loss of sensation in an area of the body via spinal, epidural, or a peripheral
nerve block with no loss of consciousness
58. involves the loss of sensation at the desired site; common for minor procedures
59. routinely used for procedures that do not require complete anesthesia but rather a
depressed level of consciousness
60. a. recovery period b. postoperative convalescence (both vary depending on outpatient
versus inpatient )
61. maintaining airway, respiratory, circulatory, and neurological status and on managing
pain
62. vital sign stability, temperature control, good ventilatory function and oxygenation status,
orientation to surroundings, absence of complications, minimal pain and nausea, controlled
wound drainage, adequate output, and fluid and electrolyte balance
63. every 15 minutes, then hourly for 4 hours then every 4 hours, basing always on the
frequency of assessment on the client’s current condition
64. a. history of OSA b. weak pharyngeal/laryngeal muscle tone from anesthetics c.
secretions in the pharynx, bronchial tree, or trachea d. subglottic edema
65. heart rate and rhythm, BP and capillary refill, pulses, and the color and temperature of the
nail beds and skin
66. hypercabia, tachypnea, tachycardia, PVCs, unstable blood pressure, cyanosis, skin
mottling, and muscular rigidity
67. a. assess the hydration status and monitor cardiac and neurological function b. monitor
can compare lab values c. maintain patency of IV lines d. record accurately the I & O, daily
weights
68. a. is oriented to self and the hospital b. papillary and gag reflexes, hand grips, and
movement of all extremities c. client’s sensations along dermatomes d. extremity strength
69. a. indicates a drug sensitivity or allergy b. result from inappropriate positioning or
restraining that injures skin layers or from a clotting disorder c. may indicate that a electrical
cautery grounding pad was incorrectly placed
70. a. accumulation of gas b. internal bleeding (late) c. develops a paralytic ileus
71. a. frequency of VS assessments b. types of IV fluids and rates c. postoperative
medications d. resumption of preoperative medications e. fluid and food allowed f. level of
activity g. positions h. intake and output i. lab tests and x-ray studies j special directions
related to drains, irrigations, and dressings
72. a. VS return to preoperative baseline b. airway is patent, and respirations are even and
unlabored c. temperature returns to baseline and remains stable d. fluid and electrolyte levels
remain balanced e. returns to previous level of activity
73. encourage diaphragmatic breathing exercises every hour
74. administer CPAP or NIPPV to clients who use this modality at home
75. use incentive spirometer for maximum inspiration
76. early ambulation

77. Turn patient on their sides every 1-2 hours and to sit when possible.
78. Keep the client comfortable.
79. Encourage coughing exercises every 32 hours and maintain pain control.
80. Provide oral hygiene.
81. Initiate orotracheal ornasotracheal suction for inability to cough.
82. Administer oxygen and monitor saturation.
83.
a. atelectasis: Collapse of alveoli with retained mucous secretions. Signs and symptoms
include elevated respiratory rate, dyspnea, fever, crackles auscultated over involved
lobes of lungs, and productive cough. Cause: Inadequate lung expansion. Anesthesia,
analgesia, and immobilized position prevent full lung expansion. There is greater risk
in clients with upper abdominal surgery who have pain during inspiration and repress
deep breathing.
b. pneumonia: Inflammation of alveoli. It may involve one or several lobes of lung.
Development in lower dependent lobes of lung is common in immobilized surgical
client. Signs and symptoms include fever, chills, productive cough, chest pain,
purulent mucus, and dyspnea. Cause: Poor lung expansion with retained secretions or
aspirated secretions. Common resident bacterium in respiratory tract is Diplococcus
pneumoniae, which causes most cases of pneumonia.
c. hypoxemia: Inadequate concentration of oxygen in arterial blood. Signs and
symptoms include restlessness, confusion, dyspnea, high or low blood pressure,
tachycardia or bradycardia, diaphoresis, and cyanosis. Cause: Anesthetics and
analgesics depress respirations. Increased retention of mucus with impaired
ventilation occurs because of pain or poor positioning. Clients with OSA are at
increased risk for hypoxemia.
d. pulmonary embolism: Embolus blocking pulmonary arterial blood flow to one or
more lobes of lung. Signs and symptoms include dyspnea, sudden chest pain,
cyanosis, tachycardia, and drop in blood pressure. Cause: Same factors lead to
formation of thrombus or embolus. Immobilized surgical client with preexisting
circulatory or coagulation disorders is at risk.
e. hemorrhage: Loss of large amount of blood externally or internally in short period of
time. Signs and symptoms include hypotension, weak and rapid pulse, cool and
clammy skin, rapid breathing, restlessness, and reduced urine output. Cause: Slipping
of suture or dislodged clot at incisional site. Clients with coagulation disorders are at
greater risk.
f. hypovolemic shock: Inadequate perfusion of tissues and cells from loss of circulatory
fluid volume. Signs and symptoms are same as for hemorrhage. Cause: In surgical
client, hemorrhage usually causes hypovolemic shock.
g. thrombophlebitis: Inflammation of vein often accompanied by clot formation. Veins
in legs are most commonly affected. Signs and symptoms include swelling and
inflammation of involved site and aching or cramping pain. Vein feels hard, cordlike,
and sensitive to touch. Cause: Prolonged sitting or immobilization aggravates venous
stasis. Trauma to vessel wall and hypercoagulability of blood increase risk of vessel
inflammation.
h. thrombus: Formation of clot attached to interior wall of a vein or artery, which can
occlude the vessel lumen. Symptoms include localized tenderness along distribution
of the venous system, swollen calf or thigh, calf swelling >3 cm compared to
asymptomatic leg, pitting edema in symptomatic leg and collateral superficial veins,
and decrease in pulse below location of thrombus (if arterial). Cause: Venous stasis
(see discussion of thrombophlebitis) and vessel trauma. Venous injury is common
after surgery of hips and legs, abdomen, pelvis, and major vessels. Clients with pelvic
and abdominal cancer or traumatic injuries to the pelvis or lower extremities are at
high risk for thrombus formation.
i. embolus: Piece of thrombus that has dislodged and circulates in bloodstream until it
lodges in another vessel, commonly lungs, heart, brain, or mesentery. Cause:
Thrombi form from increased coagulability of blood (e.g., polycythemia and use of
birth control pills containing estrogen).
j. paralytic ileus: Nonmechanical obstruction of the bowel caused by physiological,
neurogenic, or chemical imbalance associated with decreased peristalsis. Common in
initial hours after abdominal surgery. Cause: Handling of intestines during surgery
leads to loss of peristalsis for a few hours to several days.
k. abdominal distention: Retention of air within intestines and abdominal cavity during
gastrointestinal surgery. Signs and symptoms include increased abdominal girth,
tympanic percussion over abdominal quadrants, client complaints of fullness and “gas
pains.” Cause: Slowed peristalsis from anesthesia, bowel manipulation, or
immobilization. During laparoscopic surgeries, influx of air for procedure causes
distention and pain up to shoulders.
l. nausea and vomiting: Symptoms of improper gastric emptying or chemical
stimulation of vomiting center. Client complains of gagging or feeling full or sick to
stomach. Cause: Abdominal distention, fear, severe pain, medications, eating or
drinking before peristalsis returns, and initiation of gag reflex.
m. urinary retention: Involuntary accumulation of urine in bladder as result of loss of
muscle tone. Signs and symptoms include inability to void, restlessness, and bladder
distention. It appears 6-8 hours after surgery. Cause: Effects of anesthesia and
narcotic analgesics. Local manipulation of tissues surrounding bladder and edema
interfere with bladder tone. Poor positioning of client impairs voiding reflexes.
n. urinary tract infection: An infection of the urinary tract as a result of bacterial or
yeast contamination. Signs and symptoms include dysuria, itching, abdominal pain,
possible fever, cloudy urine, WBCs, and leukocyte esterase positive on urinalysis.
Cause: Most frequently a result of catheterization of the bladder.
o. wound infection: An invasion of deep or superficial wound tissues by pathogenic
microorganisms; signs and symptoms include warm, red, and tender skin around
incision; fever and chills; purulent material exiting from drains or from separated
wound edges. Infection usually appears 3-6 days after surgery. Cause: Infection is
caused by poor aseptic technique or contaminated wound or surgical site before
surgical exploration. For example, with a bowel perforation, the client is at increased
risk for a wound infection because of bacterial contamination from the large intestine.
p. wound dehiscence: Separation of wound edges at suture line. Signs and symptoms
include increased drainage and appearance of underlying tissues. This usually occurs
6-8 days after surgery. Cause: Malnutrition, obesity, preoperative radiation to surgical
site, old age, poor circulation to tissues, and unusual strain on suture line from
coughing or positioning cause dehiscence.
q. wound evisceration: Protrusion of internal organs and tissues through incision.
Incidence usually occurs 6-8 days after surgery. Cause: Client with dehiscence is at
risk for developing evisceration.
r. skin breakdown: Result of pressure or shearing forces. Surgical clients are at
increased risk if alterations in nutrition and circulation are present, resulting in edema
and delayed healing. Cause: Prolonged periods on the OR table and in the bed
postoperatively lead to pressure breakdown. Skin breakdown results from shearing
during positioning on the OR table and improper pulling of the client up in bed.
s. intractable pain: Pain that is not amenable to analgesics and pain-alleviating
interventions. Cause: Intractable pain may be related to the wound or dressing,
anxiety, or positioning.
84. encourage to perform leg exercises
85. apply elastic antiembolism stockings or pneumatic compression stockings
86. encourage early ambulation
87. avoid positioning client in a manner that interrupts blood flow to the extremities
88. administer anticoagulant drugs as ordered
89. provide adequate fluid intake orally or IV
90. incision area, drainage tubes, tight dressing or casts, muscular strains caused by
positioning
91. a. maintain a gradual progression in dietary intake (clear liquids, full liquids, light diet,
usual diet) b. promote ambulation and exercise c. maintain and adequate fluid intake d.
stimulate the client’s appetite (remove noxious odors, positioning, desired foods, oral
hygiene) e. fiber supplements, stool softeners f. provide meals when client is rested and free
from pain
92. a. assume normal positioning during voiding c. check frequently for the need to void c.
assess for bladder distention d. monitor I & O
93. a. provide privacy with dressing changes or inspection of the wound b. maintain client’s
hygiene c. prevent drainage devices from overflowing d. pleasant environment e. offer
opportunities for the client to discuss fears or concerns f. promote client’s self- concept
94. 1. Increases susceptibility to infection and impairs wound healing from altered glucose
metabolism and associated circulatory impairment
95. 1. That is a medical decision and the responsibility of the provider.
96. 3. All of the other clients are predisposed to an imbalance either to existing loses, fluid
overload, or the inability to obtain po fluids.
97. 2. promotes normal venous return and circulatory blood flow
98. 2. not always a sign of hypothermia but rather a side effect of certain anesthetic agents
99.
Mrs. Campana is an 80-year-old client scheduled to be admitted in 5 days for elective bowel
resection. You are the nurse in the ASC assigned to prepare Mrs. Campana for surgery.
During your initial discussion with Mrs. Campana, you assess that she is alert and oriented.
Mrs. Campana states that she has severely reduced visual acuity but is able to hear your
questions clearly. Mrs. Campana has had previous surgery. She lives alone and has a
daughter who lives out of town. When the nurse asked Mrs. Campana about previous
surgeries and her experience with them, she replied, “I had surgery over 20 years ago, and I
was in the hospital for 10 days. I remember having more pain than I expected.” The nurse
asks Mrs. Campana what she has been told regarding her surgery to which she responds that
her surgeon explained the procedure with a drawing of the bowel and the location of the part
to be removed. The nurse asks Mrs. Campana what she has been told regarding preoperative
preparation and what to expect postoperatively to which she states that she received
information from the surgeon’s office about medicines to take the morning of surgery, her
diet before surgery and when to stop eating, and whom to call for questions. She does not
recall receiving information about what to expect postoperatively. Upon assessment of Mrs.
Campana’s ability to read typical font type, the nurse determines that she is unable to read
the font on the newspaper but that she can read the headlines with her glasses. The nurse
assesses Mrs. Campana’s family/support system for preoperative and postoperative and
determines that her daughter will be coming in town the day of surgery and will stay with her
for two weeks after the surgery.
Preoperative teaching included providing Mrs. Campana with an audiotape program that
explains preoperative and postoperative routines. An instruction booklet designed for the
visually impaired was also provided. The nurse will make a follow-up call to client and her
daughter encouraging them to ask questions and voice concerns and will document the
education provided. The nurse understands that preadmission education often results in less
teaching time and better performance of exercises on admission. Education has a beneficial
effect in reducing postoperative anxiety. On admission to the hospital, the nurse demonstrates
to Mrs. Campana and her daughter the performance of postoperative exercises and how to
get out of bed with assistance, as demonstration is an effective method to reinforce
instruction. The nurse also explains sensations to expect postoperatively (e.g., incisional
pain, IV, nasogastric tube, wound care). Teaching about sensory aspects (what the client sees,
feels, smells) needs to be structured. Reassure client that adequate pain management will be
available. The nurse will have Mrs. Campana demonstrate postoperative exercises before
surgery to assess learning and provide an opportunity to reinforce instruction. The nurse has
the opportunity to correct any unrealistic expectations Mrs. Campana or daughter have
regarding surgery because unrealistic expectations, when unmet, contribute to client’s
anxiety. Psychological preparation for surgery reduces anxiety.
The nurse asked Mrs. Campana to describe typical monitoring and care activities following
surgery and documented evaluation of her understanding. Mrs. Campana is able to verbalize
typical monitoring and care following surgery. She states that the booklet and audiotape were
both helpful and that she has a good understanding of the typical postoperative course. The
nurse observed Mrs. Campana’s demonstration of postoperative exercises. She correctly
demonstrates leg exercises and TC & DB but is having difficulty with IS use, indicating that
she needs further teaching and practice on IS use. The nurse explores with Mrs. Campana
and her daughter if they have any remaining fears or concerns. Both Mrs. Campana and her
daughter deny any fears or concerns at the present time; the informational and psychological
needs of Mrs. Campana and her daughter have been met.

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Potter & Perry: Fundamentals of Nursing, 7th Edition

Study Guide Answer Key

Chapter 1: Nursing Today

Chapter 2: The Health Care Delivery System

b. coordination and integration of care

Chapter 3: Community-Based Nursing Practice

Chapter 4: Theoretical Foundations of Nursing Practice

Chapter 5: Evidence-Based Practice

1. is a problem-solving approach to clinical practice that integrates the conscientious use of

Chapter 6: Health and Wellness

Chapter 7: Caring for the Cancer Survivor

Chapter 8: Caring in Nursing Practice

g. provide necessary emergency care

Chapter 9: Culture and Ethnicity

Chapter 10: Caring for Families

Define the three important attributes that characterize contemporary families

Current Trends and New Family Forms

Explain the following threats and concerns facing the family

Explain how the following examples impact the family

Theoretical Approaches: An Overview

22. Explain the following attributes of healthy families.

Nursing Process for the Family

Identify the conflicts that affect the “sandwich generation”

Chapter 11: Developmental Theories

3. Explain the five psychosexual developmental stages of Freud’s theroy

9. Define temperament: is a behavioral style that affects the individual’s emotional

16. Explain the two stages of Piaget’s moral development theroy

Chapter 12: Conception Through Adolescence

a. Nutrition: feeding alternatives: breast feeding is recommended; the use of

The School-Age Child

d. Stress – from parental expectations, peer expectations, school environment,

d. loneliness, sadness, and crying

Chapter 13: Young to Middle Adult

21. breast feeding

Chapter 14: Older Adult

1. age 65 and over

Chapter 15: Critical Thinking in Nursing Practice

b. refers to ethical criteria for nursing judgments; evidence-based used for

Chapter 16: Nursing Assessment

Chapter 17: Nursing Diagnosis

Chapter 18: Planning Nursing Care

Chapter 19: Implementing Nursing Care

Chapter 20: Evaluation

Chapter 21: Managing Client Care

Chapter 22: Ethics and Values

Chapter 23: Legal Implications in Nursing Practice

Chapter 24: Communication

1. is a lifelong learning process that is an essential attribute of professional nursing practice

Chapter 25: Client Education

f. attitudes about providers

Chapter 26: Documentation and Informatics

Chapter 27: Self-Concept

1. Is an individual’s conceptualization of himself or herself. It is a complex mixture of

Chapter 28: Sexuality

Chapter 29: Spiritual Health

Chapter 30: The Experience of Loss, Death, and Grief

31. allow time to grieve

Chapter 31: Stress and Coping

Chapter 32: Vital Signs

33. Examples of answers can be found in the Box 32-5.

Chapter 33: Health Assessment and Physical Examination

50. enlarged jaws and facial bones