Kozier & Erb’s Fundamentals Of Nursing 8th Edition By Shirlee – Test Bank

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1)
An infant has been admitted to the pediatric unit. The parents are quite worried and upset, and the
grandmother is also present. In this situation, what would be the best source of data? 1) A) Admitting physician B) Parents C) Grandmother, since the parents are upset D) Medical record from the child’s birth Answer: B
Explanation: A)
The best source of data is usually the client, unless the client is too ill, young, or
confused to communicate clearly. Even though the parents are upset, they would
be able to provide the nurse with the most accurate, current information regarding
the baby (diet, schedule, symptoms, etc.). The grandmother can support the
parents during this time and may be able to offer some helpful information. The
baby’s birth record and admitting physician will also be able to provide necessary
information, but not to the extent as the parents.
Assessment
Safe, effective care environment
Application B)
The best source of data is usually the client, unless the client is too ill, young, or
confused to communicate clearly. Even though the parents are upset, they would
be able to provide the nurse with the most accurate, current information regarding
the baby (diet, schedule, symptoms, etc.). The grandmother can support the
parents during this time and may be able to offer some helpful information. The
baby’s birth record and admitting physician will also be able to provide necessary
information, but not to the extent as the parents.
Assessment
Safe, effective care environment
Application C)
The best source of data is usually the client, unless the client is too ill, young, or
confused to communicate clearly. Even though the parents are upset, they would
be able to provide the nurse with the most accurate, current information regarding
the baby (diet, schedule, symptoms, etc.). The grandmother can support the
parents during this time and may be able to offer some helpful information. The
baby’s birth record and admitting physician will also be able to provide necessary
information, but not to the extent as the parents.
Assessment
Safe, effective care environment
Application D)
The best source of data is usually the client, unless the client is too ill, young, or
confused to communicate clearly. Even though the parents are upset, they would
be able to provide the nurse with the most accurate, current information regarding
the baby (diet, schedule, symptoms, etc.). The grandmother can support the
parents during this time and may be able to offer some helpful information. The
baby’s birth record and admitting physician will also be able to provide necessary
information, but not to the extent as the parents.
Assessment
Safe, effective care environment
Application 1
2)
When learning how to implement the nursing process into a plan of care for a client, the student
nurse realizes that part of the purpose of the nursing process is to: 2) A) Identify client needs and deliver care to meet those needs. B) Make sure that standardized care is available to clients. C) Deliver care to a client in an organized way. D) Implement a plan that is close to the medical model. Answer: A
Explanation: A)
The purpose of the nursing process is to identify a client’s health status and actual
or potential health care problems or needs, to establish plans to meet the identified
needs, and to deliver specific nursing interventions to meet those needs. Delivery
or organized care is not part of the nursing process, though each phase is
interrelated. The nursing process is not part of the medical model as nurses treat
the client’s response to the disease or problem. The nursing process is
individualized for each client’s care plan. It is not about standardizing care.
Implementation
Health promotion and maintenance
Application B)
The purpose of the nursing process is to identify a client’s health status and actual
or potential health care problems or needs, to establish plans to meet the identified
needs, and to deliver specific nursing interventions to meet those needs. Delivery
or organized care is not part of the nursing process, though each phase is
interrelated. The nursing process is not part of the medical model as nurses treat
the client’s response to the disease or problem. The nursing process is
individualized for each client’s care plan. It is not about standardizing care.
Implementation
Health promotion and maintenance
Application C)
The purpose of the nursing process is to identify a client’s health status and actual
or potential health care problems or needs, to establish plans to meet the identified
needs, and to deliver specific nursing interventions to meet those needs. Delivery
or organized care is not part of the nursing process, though each phase is
interrelated. The nursing process is not part of the medical model as nurses treat
the client’s response to the disease or problem. The nursing process is
individualized for each client’s care plan. It is not about standardizing care.
Implementation
Health promotion and maintenance
Application D)
The purpose of the nursing process is to identify a client’s health status and actual
or potential health care problems or needs, to establish plans to meet the identified
needs, and to deliver specific nursing interventions to meet those needs. Delivery
or organized care is not part of the nursing process, though each phase is
interrelated. The nursing process is not part of the medical model as nurses treat
the client’s response to the disease or problem. The nursing process is
individualized for each client’s care plan. It is not about standardizing care.
Implementation
Health promotion and maintenance
Application

3)
A nurse has just been informed that a new admission is coming to the unit. According to the 2005
JCAHO requirements, how long does the nurse have to complete a physical assessment and have a
documented history and physical on the chart? 3) A) 1 hour B) 48 hours C) 12 hours D) 24 hours Answer: D
Explanation: A)
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
requires that each client have an initial assessment consisting of a history and
physical performed and documented within 24 hours of admission as an inpatient.
Assessment
Safe, effective care environment
Application B)
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
requires that each client have an initial assessment consisting of a history and
physical performed and documented within 24 hours of admission as an inpatient.
Assessment
Safe, effective care environment
Application C)
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
requires that each client have an initial assessment consisting of a history and
physical performed and documented within 24 hours of admission as an inpatient.
Assessment
Safe, effective care environment
Application D)
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
requires that each client have an initial assessment consisting of a history and
physical performed and documented within 24 hours of admission as an inpatient.
Assessment
Safe, effective care environment
Application 4)
A client was admitted just prior to the shift change. The admitting nurse reported most of the
information to oncoming staff, but did not have all of the client’s past records. The second nurse is
completing the assessment and database and continues to question the client about much of the
same information as the previous nurse. The client says, “Why don’t you people talk to each other
and quit asking the same things over and over?” The best response of the nurse is: 4) A) “You’re right. Let me know if there’s anything you need right now.” B) “You shouldn’t be upset. We’re only doing our jobs.” C) “In order to make sure all of your information is complete, I need to ask these questions.” D) “I’ll be done shortly, just give me a few more minutes.” Answer: A
Explanation: A)
Repeated questioning can be stressful and annoying, especially for hospitalized
clients, and cause concern about the lack of communication among health
professionals. The nurse should review previous records that contain data about
the client’s occupation, religion, and marital status, as well as take time to review
all the information the previous nurse collected. Validating the client’s feelings is
always a good idea and helps to build rapport between the nurse and client. Before
asking more questions, the nurse should review what is already at hand. Telling
the client “we’re only doing our jobs” is belittling to the client and doesn’t offer any
therapeutic response.
Implementation
Psychosocial integrity
Analysis 3
B)
Repeated questioning can be stressful and annoying, especially for hospitalized
clients, and cause concern about the lack of communication among health
professionals. The nurse should review previous records that contain data about
the client’s occupation, religion, and marital status, as well as take time to review
all the information the previous nurse collected. Validating the client’s feelings is
always a good idea and helps to build rapport between the nurse and client. Before
asking more questions, the nurse should review what is already at hand. Telling
the client “we’re only doing our jobs” is belittling to the client and doesn’t offer any
therapeutic response.
Implementation
Psychosocial integrity
Analysis C)
Repeated questioning can be stressful and annoying, especially for hospitalized
clients, and cause concern about the lack of communication among health
professionals. The nurse should review previous records that contain data about
the client’s occupation, religion, and marital status, as well as take time to review
all the information the previous nurse collected. Validating the client’s feelings is
always a good idea and helps to build rapport between the nurse and client. Before
asking more questions, the nurse should review what is already at hand. Telling
the client “we’re only doing our jobs” is belittling to the client and doesn’t offer any
therapeutic response.
Implementation
Psychosocial integrity
Analysis D)
Repeated questioning can be stressful and annoying, especially for hospitalized
clients, and cause concern about the lack of communication among health
professionals. The nurse should review previous records that contain data about
the client’s occupation, religion, and marital status, as well as take time to review
all the information the previous nurse collected. Validating the client’s feelings is
always a good idea and helps to build rapport between the nurse and client. Before
asking more questions, the nurse should review what is already at hand. Telling
the client “we’re only doing our jobs” is belittling to the client and doesn’t offer any
therapeutic response.
Implementation
Psychosocial integrity
Analysis 5)
During an assessment interview, the nurse understands that the client has decided not to take the
physician’s advice about an elective surgical procedure. The client shares that this is “just not part
of what I have in mind for my life’s goals.” This would fall into which of Gordon’s functional health
patterns? 5) A) Health-perception/health-management pattern B) Value/belief pattern C) Coping/stress-tolerance pattern D) Cognitive/perceptual pattern Answer: B
4
Explanation: A)
The value/belief pattern describes the patterns of values, beliefs (including
spiritual), and goals that guide the client’s choices or decisions. The client in this
situation has decided against a surgical procedure because it doesn’t coincide with
the client’s beliefs and goals. Cognitive perceptual patterns describe
sensory-perceptual and cognitive patterns. Coping/stress-tolerance patterns
describe the client’s general coping pattern and the effectiveness of the patterns in
terms of stress tolerance. Health-perception/health-management pattern describes
the client’s perceived pattern of health and well-being and how health is managed.
Assessment
Health promotion and maintenance
Analysis B)
The value/belief pattern describes the patterns of values, beliefs (including
spiritual), and goals that guide the client’s choices or decisions. The client in this
situation has decided against a surgical procedure because it doesn’t coincide with
the client’s beliefs and goals. Cognitive perceptual patterns describe
sensory-perceptual and cognitive patterns. Coping/stress-tolerance patterns
describe the client’s general coping pattern and the effectiveness of the patterns in
terms of stress tolerance. Health-perception/health-management pattern describes
the client’s perceived pattern of health and well-being and how health is managed.
Assessment
Health promotion and maintenance
Analysis C)
The value/belief pattern describes the patterns of values, beliefs (including
spiritual), and goals that guide the client’s choices or decisions. The client in this
situation has decided against a surgical procedure because it doesn’t coincide with
the client’s beliefs and goals. Cognitive perceptual patterns describe
sensory-perceptual and cognitive patterns. Coping/stress-tolerance patterns
describe the client’s general coping pattern and the effectiveness of the patterns in
terms of stress tolerance. Health-perception/health-management pattern describes
the client’s perceived pattern of health and well-being and how health is managed.
Assessment
Health promotion and maintenance
Analysis D)
The value/belief pattern describes the patterns of values, beliefs (including
spiritual), and goals that guide the client’s choices or decisions. The client in this
situation has decided against a surgical procedure because it doesn’t coincide with
the client’s beliefs and goals. Cognitive perceptual patterns describe
sensory-perceptual and cognitive patterns. Coping/stress-tolerance patterns
describe the client’s general coping pattern and the effectiveness of the patterns in
terms of stress tolerance. Health-perception/health-management pattern describes
the client’s perceived pattern of health and well-being and how health is managed.
Assessment
Health promotion and maintenance
Analysis