Foundations Of Maternal-Newborn And Women's Health Nursing, 5th Edition Test Bank

Murray: Foundations of Maternal-Newborn and Women’s Health Nursing, 5th Edition Chapter 02: The Nurse’s Role in Maternity and Women’s Health Care Test Bank MULTIPLE CHOICE 1. Which principle of teaching should the nurse use to ensure learning in a family situation? a. Motivate the family with praise and positive feedback. b. Present complex subject material first, while the family is alert and ready to learn. c. Families should be taught using medical jargon so they will be able to understand the technical language used by physicians. d. Learning is best accomplished with the lecture format. ANS: A Praise and positive feedback are particularly important when a family is trying to master a frustrating task such as breastfeeding. Learning is enhanced when the teaching is structured to present the simple tasks before the complex material. Even though a family may understand English fairly well, they may not understand the medical terminology or slang terms. A lively discussion stimulates more learning than a straight lecture, which tends to inhibit questions. DIF: Cognitive Level: Application OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance REF: 26 2. a. b. c. d. Which nursing intervention is an independent function of the nurse? Administering oral analgesics Teaching the client perineal care Requesting diagnostic studies Providing wound care to a surgical incision ANS: B Nurses are now responsible for various independent functions including teaching, counseling, and intervening in nonmedical problems. Interventions initiated by the physician and carried out by the nurse are called dependent functions. Administrating oral analgesics is a dependent function; it is initiated by a physician and carried out by a nurse. Requesting diagnostic studies is a dependent function. Providing wound care is a dependent function; it is usually initiated by the physician through direct orders or protocol. Elsevier items and derived items © 2010, 2006, 2002, 1998, 1994 by Saunders, and imprint of Elsevier Inc. Test Bank 2-2 DIF: Cognitive Level: Comprehension OBJ: Nursing Process Step: Assessment MSC: Client Needs: Safe and Effective Care Environment REF: 25 3. Which response to the client’s statement, “I’m afraid to have a cesarean birth” would be the most therapeutic? a. “What concerns you most about a cesarean birth?” b. “Everything will be OK.” c. “Don’t worry about it. It will be over soon.” d. “The physician will be in later and you can talk to him.” ANS: A Focusing on what the client is saying and asking for clarification is the most therapeutic response. This response is belittling the client’s feelings. This response will indicate that the client’s feelings are not important. This response does not allow the client to verbalize her feelings when she desires. DIF: Cognitive Level: Comprehension OBJ: Nursing Process Step: Implementation MSC: Client Needs: Psychosocial Integrity REF: 25 4. a. b. c. d. To evaluate the client’s learning about performing infant care, the nurse should: Demonstrate infant care procedures. Allow the client to verbalize the procedure. Observe the client as she performs the procedure. Routinely assess the infant for cleanliness. ANS: C The client’s correct performance of the procedure under the nurse’s supervision is the best proof of her ability. Demonstration is an excellent teaching method, but not an evaluation method. During verbalization of the procedure, the nurse may not pick up on techniques that are incorrect. It is not the best tool for evaluation. This will not ensure that the proper procedure is carried out. The nurse may miss seeing unsafe techniques being used. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance REF: 26 5. a. b. c. d. Which situation is most conducive to learning? A teacher who speaks very little Spanish is teaching a class of Latino students. A class is composed of students of various ages and educational backgrounds. An auditorium is being used as a classroom for 300 students. An Asian nurse provides nutritional information to a group of pregnant Asian women. Elsevier items and derived items © 2010, 2006, 2002, 1998, 1994 by Saunders, and imprint of Elsevier Inc. Test Bank 2-3 ANS: D A client’s culture influences the learning process; thus a situation that is most conducive to learning is one in which the teacher has knowledge and understanding of the client’s cultural beliefs. The ability to understand the language in which teaching is done determines how much the client learns. Clients for whom English is not their primary language may not understand idioms, nuances, slang terms, informed usage of words, or medical words. The teacher should be fluent in the language of the student. Developmental levels and educational levels influence how a person learns best. In order for the teacher to best present the information, it is best for the class to be of the same levels. A large class is not conducive to learning. It does not allow questions, and the teacher is not able to see the nonverbal cues from the students to ensure understanding. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity REF: 26 6. The step of the nursing process in which the nurse determines the appropriate interventions for the identified nursing diagnosis is called: a. Assessment. b. Planning. c. Intervention. d. Evaluation. ANS: B The third step in the nursing process involves planning care for problems that were identified during assessment. During the assessment phase, data are collected. The intervention phase is when the plan of care is carried out. The evaluation phase is determining if the goals have been met. DIF: Cognitive Level: Knowledge OBJ: Nursing Process Step: Planning MSC: Client Needs: Safe and Effective Care Environment: Coordinated Care 30 7. a. b. c. d. REF: Which goal is most appropriate for the collaborative problem of wound infection? The client will have a temperature of 98.6° F within 2 days. Maintain the client’s fluid intake at 1000 ml per 8 hours. The client will not exhibit further signs of infection. Monitor the client to detect therapeutic response to antibiotic therapy. ANS: D In a collaborative problem, the goal should be nurse oriented and reflect the nursing interventions of monitoring or observing. Monitoring a client’s temperature is an independent nursing role. Intake and output is an independent nursing role. Elsevier items and derived items © 2010, 2006, 2002, 1998, 1994 by Saunders, and imprint of Elsevier Inc. Test Bank Monitoring for complications is an independent nursing role. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Client Needs: Safe and Effective Care Environment: Coordinated Care 34 8. a. b. c. d. 2-4 REF: Which nursing intervention is correctly written? Encourage turning, coughing, and deep breathing. Force fluids as necessary. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM. Observe interaction with the infant. ANS: C Interventions might not be carried out if they are not detailed and specific. This intervention does not state how often this procedure should be done. “Force fluids” is not specific; it does not state how much. This intervention is not detailed and specific. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Client Needs: Safe and Effective Care Environment: Coordinated Care 32 REF: 9. The client makes the statement: “I’m afraid to take the baby home tomorrow.” Which response by the nurse would be the most therapeutic? a. “You’re afraid to take the baby home?” b. “I was scared when I took my first baby home, but everything worked out.” c. “You should read the literature I gave you before you leave.” d. “Don’t you have a mother who can come and help?” ANS: A This response uses reflection to show concern and open communication. The other choices are blocks to communication. This response does not allow the client to further express her feelings. This response blocks further communication with the client. This response is belittling to the client. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Client Needs: Psychosocial Integrity REF: 24 Elsevier items and derived items © 2010, 2006, 2002, 1998, 1994 by Saunders, and imprint of Elsevier Inc.