Test Bank for High-Acuity Nursing, 7th Edition

High Acuity Nursing, 7e (Wagner) Chapter 2 Holistic Care of the Patient and Family 1) The spouse of a patient recently diagnosed with terminal cancer has voiced concerns about her husband’s continual denial of his disease. What should the nurse consider when planning a response to this concern? 1. It may be helpful for the patient’s emotional state at this time to be in a state of denial. 2. Denial is abnormal and the patient needs to have a consultation with a therapist. 3. It will be helpful to plan an intervention to force the patient to acknowledge his disease. 4. There is a limited amount of time left in the patient’s life so the denial must be rapidly worked through. Answer: 1 Explanation: 1. It is believed that denial may be therapeutic as it allows the patient to have a removal from worry. 2. Denial is a normal state experienced by patients having critical diagnoses. 3. It is not therapeutic to force the patient to acknowledge his disease. 4. Each patient will work through denial at an individualized pace. It is not therapeutic to rush this stage. Page Ref: 17 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Competencies: IX.21 Engage in caring and healing techniques that promote a therapeutic nursepatient relationship. | NLN Competencies: Relationship-Centered Care: Practice: Promote and accept the patient’s emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Describe the impact of illness on the high-acuity client and family. 1 Copyright © 2019 Pearson Education, Inc. 2) A patient in the anger stage of illness has become argumentative and demanding. The nursing staff is becoming frustrated with the behaviors. What actions by the nurse are indicated? 1. The nurse should accept the behaviors and attempt to open the lines of communication. 2. Rotate the nursing assignments frequently to limit each nurse’s exposure to the behaviors. 3. Confront the patient about his demeanor. 4. Consolidate care so the nurse is in the room for shorter periods. Answer: 1 Explanation: 1. The patient is acting in a manner consistent with the stage of anger. The patient is attempting to exert control over the situation and will benefit most from a supportive environment. 2. Rotating nursing assignments interrupts the therapeutic environment this patient requires. 3. Confrontation is not indicated at this time. The patient needs to move through this stage of illness with support and understanding. 4. This patient needs support to work through these feelings. Reducing the amount of time the nurse is in the room does not allow for interactions that may help with this process. Page Ref: 17 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Competencies: IX.21 Engage in caring and healing techniques that promote a therapeutic nursepatient relationship. | NLN Competencies: Relationship-Centered Care: Practice: Promote and accept the patient’s emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Describe the impact of illness on the high-acuity client and family. 2 Copyright © 2019 Pearson Education, Inc. 3) A patient says, “I’ve been hearing about aromatherapy as part of treatment for serious illness. What do you think about me trying it?” Which nursing responses are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. “Some studies have shown that using lavender oil can reduce anxiety.” 2. “I would focus my energy on more traditional forms of healing.” 3. “Other than jasmine oil, you are probably safe using aromatherapy.” 4. “You should discuss this plan with your physician before purchasing anything.” 5. “I know that some massage therapists use essential oils.” Answer: 1, 5 Explanation: 1. Some small, limited studies have shown lavender oil to reduce stress and anxiety in acutely ill patients. 2. Some studies have shown that some oils do help to reduce stress and anxiety in acutely ill patients. The nurse should not devalue this patient’s attempts at self-help. 3. Jasmine oil has been shown, in small studies, to reduce stress and anxiety in acutely ill patients. 4. The nurse should be able to discuss this topic with the patient. 5. These oils may be inhaled or used as an enhancement to massage therapy. Page Ref: 19 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.17 Develop a beginning understanding of complementary and alternative modalities and their role in healthcare. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Identify ways the nurse can help high-acuity clients cope with an illness and/or injury event. 3 Copyright © 2019 Pearson Education, Inc. 4) A newly licensed nurse has overheard a nurse telling a patient a joke. The nurse tells the preceptor, “I don’t think that nurse is being respectful of the patient’s diagnosis by telling jokes.” What response by the preceptor is indicated? 1. “When you have more experience you will understand the value of a good joke.” 2. “We try not to eavesdrop on other nurses’ conversations with patients.” 3. “Sometimes that nurse’s jokes do get old.” 4. “Sometimes laughing and joking can help us connect better with the patient.” Answer: 4 Explanation: 1. The preceptor should discuss the value of humor without demeaning the newly licensed nurse’s level of experience. 2. The preceptor should address the newly licensed nurse’s concerns as this is a teaching opportunity. 3. The preceptor should not make any statements that could be interpreted as critical of the nurse since the preceptor is not aware of the nurse’s intent. 4. The nurse and patient were engaging in humor. Humor can be used to lighten the moment and is associated with positive patient outcomes. Page Ref: 19 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.17 Develop a beginning understanding of complementary and alternative modalities and their role in healthcare. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Identify ways the nurse can help high-acuity clients cope with an illness and/or injury event. 4 Copyright © 2019 Pearson Education, Inc. 5) A patient is being kept on bedrest during treatment for deep vein thrombosis. The patient is uncomfortable because being in bed is stressful and has made her arthritis worse. Which complementary and alternative therapies might the nurse suggest to help treat this discomfort? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Aromatherapy 2. Therapeutic humor 3. Massage 4. Guided imagery 5. Music therapy Answer: 1, 2, 4, 5 Explanation: 1. The scents of lavender and jasmine have been shown in some studies to help reduce stress and anxiety. 2. Watching comedies on television or reading humorous books may help distract the patient from discomfort. 3. Because this patient is being treated for deep vein thrombosis, massage is not indicated. 4. Guided imagery may help the patient relax. 5. Music may help distract the patient from discomfort. Music can also be calming. Page Ref: 19 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.17 Develop a beginning understanding of complementary and alternative modalities and their role in healthcare. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Identify ways the nurse can help high-acuity clients cope with an illness and/or injury event. 5 Copyright © 2019 Pearson Education, Inc. 6) A patient is being treated for a massive myocardial infarction. His wife has just arrived in the emergency department and grabs the nurse’s arm demanding to know what is happening. Which initial nursing response is indicated? 1. “Your husband needs my full attention right now.” 2. “Someone call security.” 3. “Take your hands off me.” 4. “Please go back to the waiting area.” Answer: 1 Explanation: 1. The patient’s physiological needs take precedence over the psychological needs of the spouse. 2. There is no indication that security is needed at this time. 3. There is no indication that the nurse is in danger, so the therapeutic response should be directed toward the wife’s needs. 4. Telling the wife to go back to the waiting room is not the best nursing response. She does have the right to information about her husband. Page Ref: 22 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.4 Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network. | NLN Competencies: Relationship-Centered Care: Practice: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Describe the principles of client- and family-centered care in the highacuity environment as it relates to educational needs of visitation and policies. 6 Copyright © 2019 Pearson Education, Inc. 7) A newly licensed nurse says, “Every time I go into my trauma patient’s room his wife asks the same questions about his medication.” How should the preceptor evaluate this statement? 1. Anxiety about the husband’s condition has affected the wife’s ability to retain information. 2. The preceptor should present the information so that it is more understandable. 3. When serious injuries have occurred, new nurses often make the mistake of talking to the patient instead of the family. 4. The nurse and wife are not communicating well with one another. Answer: 1 Explanation: 1. When faced with serious illness or injury, patients and their families are stressed and may have problems retaining information presented. 2. There is no indication that the nurse did not present the information well. 3. The nurse should talk to the patient, so this is not a mistake. The information should be directed to the patient and the family. 4. There is no indication that the nurse is not attempting communication with the wife. Page Ref: 20 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.4 Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network. | NLN Competencies: Relationship-Centered Care: Practice: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO03: Describe the principles of client- and family-centered care in the highacuity environment as it relates to educational needs of visitation and policies. 7 Copyright © 2019 Pearson Education, Inc. 8) The nurse is attempting to provide discharge teaching to a patient recently diagnosed with a terminal illness. The patient says, “I would rather talk to my usual nurse about my discharge.” What action by the nurse is indicated? 1. Ask the patient to sign a refusal of information form. 2. Continue to provide the information to the patient. 3. Ask the patient what efforts could be taken to make her feel more comfortable. 4. Contact the healthcare provider. Answer: 3 Explanation: 1. The nurse is responsible for attempting education of this patient and would not simply ask the patient to sign a refusal form. 2. Forcing the information on the patient would be counterproductive and cause more anxiety. 3. The patient is not feeling secure. Acutely ill patients need to feel comfortable and secure in order to learn. 4. There is no reason to contact the healthcare provider. Page Ref: 20 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.17 Develop a beginning understanding of complementary and alternative modalities and their role in healthcare. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Describe the principles of client- and family-centered care in the highacuity environment as it relates to educational needs of visitation and policies. 8 Copyright © 2019 Pearson Education, Inc. 9) The nurse is conducting assessment on a patient who appears to be of Asian ancestry. Which questions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. “How long have you been in the United States?” 2. “How do you describe your ethnicity?” 3. “How does your culture influence your healthcare choices?” 4. “Do you speak English or do I need to try to find an interpreter?” 5. “Would you like for someone from your family to be in the room during your assessment?” Answer: 2, 3, 5 Explanation: 1. This question is premature until the nurse determines if the patient was not born in the U.S. 2. The nurse should base discussion of culture and ethnicity on the patient’s self-description. 3. This is an open-ended question that allows the patient to either list some examples or to say there are no influences. 4. This statement could be interpreted as indicating that accommodating language differences is a problem. The nurse should be able to assess the need for an interpreter and should provide this service if necessary and possible. 5. The nurse should ask about the desire for family presence. This is part of determining the patient’s support system. Page Ref: 24 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.A.2 Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Transcultural approaches to health. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Explain the importance of awareness of cultural diversity when caring for high-acuity patients. 9 Copyright © 2019 Pearson Education, Inc. 10) A nurse questions why socioeconomic status has been included in the admission assessment form. What response by the nurse manager is most appropriate? 1. Socioeconomic status helps the business office determine the likelihood of receiving payment. 2. Socioeconomic status will provide helpful information in choosing a room and roommate for the patient. 3. Socioeconomic status may provide information about previous access to care. 4. Socioeconomic status will reveal the patient’s healthcare priorities. Answer: 3 Explanation: 1. While the ability to manage hospital-related costs might be impacted by the socioeconomic status, it is not the primary reason for the assessment. 2. Roommate selection is not the focus of this line of questioning. 3. The socioeconomic status of a patient will provide information about the patient’s healthcare beliefs and access to healthcare. 4. The patient’s socioeconomic status does not automatically determine healthcare priorities. Page Ref: 24 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.A.2 Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Transcultural approaches to health. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Explain the importance of awareness of cultural diversity when caring for high-acuity patients. 10 Copyright © 2019 Pearson Education, Inc. 11) The nurse manager is holding educational sessions to improve staff nurse competency in providing culturally sensitive care. Which myths will the manager identify in these sessions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Cultural competence increases the cost of the nursing care provided. 2. Cultural competence is difficult to achieve when working with patients who are victims of trauma or violence. 3. Cultural competence is focused on providing sensitive care to minorities. 4. The first step of cultural competence is self-awareness. 5. The nurse who provides the same level of care to every patient is providing culturally competent care. Answer: 1, 2, 3, 5 Explanation: 1. There is no reason that providing culturally competent care will increase the cost of nursing services. 2. The nurse can provide culturally competent care to any patient with any illness or injury. 3. All people have a culture and have the right to be cared for in a culturally competent manner. 4. The nurse must be aware of personal thoughts and feelings in order to provide culturally competent care. 5. Culturally competent care requires differences in the kind and amount of care provided. Page Ref: 24 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.A.2 Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Transcultural approaches to health. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Explain the importance of awareness of cultural diversity when caring for high-acuity patients. 11 Copyright © 2019 Pearson Education, Inc. 12) Which interventions would the nurse use to help the patient get at least 2 hours of uninterrupted REM sleep? 1. Work with ancillary services such as physical therapy to establish a predictable routine. 2. Keep the lights in the unit dim at all times. 3. Turn alarms down or off during sleep periods. 4. Restrict visitation to a short time in the morning, the afternoon, and evening. Answer: 1 Explanation: 1. If the nurse is aware of the routine times ancillary services will be provided, nursing care can be arranged to allow for the patient to have extended rest periods. 2. The healthcare team must be able to see the patient well during assessment and care. Dimming the lights during portions of the day and night is indicated, but keeping them dim at all times is not possible. 3. The nurse should never turn alarms off. Alarms must be loud enough to allow the nurse to hear them from areas outside the room. 4. Strict visitation rules are not necessary, but the nurse might suggest visiting at another time if the patient is resting. Page Ref: 25 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.2 Communicate patient values, preferences, and expressed needs to other members of healthcare team. | AACN Competencies: IX.5 Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Personal and Professional Development: Practice: Apply advocacy skills and ethical decision-making models. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Identify environmental stressors, their impact on high-acuity patients, and strategies to alleviate those stressors. 12 Copyright © 2019 Pearson Education, Inc. 13) A nurse elects to assist the patient with guided imagery during dressing changes. Which question best helps the nurse design this experience? 1. “Have you ever been to the beach?” 2. “What was your favorite vacation?” 3. “How bad is your pain during your dressing changes?” 4. “How good is your imagination?” Answer: 2 Explanation: 1. Beach scenes are often used for guided imagery, but are not useful for all patients. Asking about the beach does not provide the most useful information. 2. A favorite vacation is often one that is relaxing, calming, or joyful. Asking about this time helps the nurse tailor the guided imagery to the patient rather than using a “standard” scene. 3. The amount of pain experienced is an essential assessment, but does not offer the best information for planning this intervention. 4. Asking about the quality of the patient’s imagination does not provide information useful for this intervention. A patient who has “poor” imagination may be put off by this question, setting the intervention up to fail. Page Ref: 19 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.17 Develop a beginning understanding of complementary and alternative modalities and their role in healthcare. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Identify ways the nurse can help high-acuity patients cope with an illness and/or injury event. 13 Copyright © 2019 Pearson Education, Inc. 14) The family of a critically ill patient reports to the nurse concerns that none of the healthcare team members seem to be listening to their wishes. Which nursing response is indicated? 1. “You have to stand up for yourself and for your loved one.” 2. “It is time for us to meet in a patient care conference.” 3. “I will talk to the hospital administrator about your complaint.” 4. “I know this whole thing has been very hard on your family.” Answer: 2 Explanation: 1. The family is in a time of crisis and should not be required to “stand up” for themselves and the patient. 2. A patient care conference is indicated to ensure that all members of the healthcare team are communicating actions. 3. The nurse should not characterize this report as a complaint; it is a statement of the facts as they are perceived by the family. There is no reason to contact the administrator as steps to correct this problem can begin at the unit level. 4. Offering emotional support is important but does not address the root cause of the problems being perceived by the family. Page Ref: 17 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.2 Communicate patient values, preferences, and expressed needs to other members of the healthcare team. | AACN Competencies: IX.4 Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network. | NLN Competencies: Personal and Professional Development: Practice: Apply advocacy skills and ethical decision-making models. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Describe the impact of illness on the high-acuity client and family. 14 Copyright © 2019 Pearson Education, Inc. 15) The charge nurse on a busy high-acuity care unit is reviewing the plan of care for four patients. The nurse would evaluate that which patient is at highest risk for sensory perceptual alterations (SPAs)? 1. 52-year-old male patient who has been hospitalized for complications related to diabetes 2. 41-year-old female patient admitted with severe abdominal pain 3. 65-year-old male patient diagnosed with pulmonary embolism 4. 79-year-old female patient who is unresponsive after a stroke Answer: 4 Explanation: 1. The patient is at risk for SPAs because of being cared for on a high-acuity unit. However, the patient’s diagnosis does not put him at highest risk in this group. 2. The patient is at risk for SPAs because of being cared for on a high-acuity unit. However, the diagnosis and age do not put her at highest risk in this group. 3. This patient is at risk for SPAs because of being cared for on a high-acuity unit. However, this diagnosis does not put him at highest risk in this group. 4. Patients who are very young, very old, and postoperative or unresponsive are at the greatest risk for experiencing sensory perceptual alterations (SPAs). The 79-year-old patient is at the greatest risk because of age and diagnosis. Page Ref: 25 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.12 Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Personal and Professional Development: Practice: Apply advocacy skills and ethical decision-making models. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Identify environmental stressors, their impact on high-acuity patients, and strategies to alleviate those stressors. 15 Copyright © 2019 Pearson Education, Inc. 16) The nurse manager is planning an educational program to address noise levels on the unit. What information should be given about the recommended noise levels? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. It is recommended that noise levels in patient rooms should be no greater than 35 dBA. 2. Many of the sounds in the high-acuity unit are foreign and frightening. 3. Excessive noise levels also have an impact on the staff. 4. The recommended noise levels in high-acuity areas are higher due to increased noise from alarms and machines. 5. The biggest patient complaint about noise is about staff conversation. Answer: 1, 2, 3, 5 Explanation: 1. The World Health Organization recommends sound levels of 35 dBA or less in patient rooms. 2. The alarms and equipment sounds are strange and foreign to many and add to the already higher level of “normal” sounds such as telephones and conversation. 3. Excessive noise has an adverse effect on both the physical and physiological state of the nurse. 4. The World Health Organization has set levels for hospitals in general. 5. Patients complain that staff conversations wake them from sleep. Page Ref: 25 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.5 Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Knowledge: Environmental health. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Identify environmental stressors, their impact on high-acuity patients, and strategies to alleviate those stressors. 16 Copyright © 2019 Pearson Education, Inc. 17) Which nursing teaching statement would likely be of most immediate need to a patient on the high-acuity unit? 1. “People with your condition typically stay in the hospital a week to ten days.” 2. “The beeping noise you hear is your heart monitor.” 3. “Your condition is often caused by a blockage in your intestine.” 4. “If you feel like eating in the morning, your physician will order a regular diet for you.” Answer: 2 Explanation: 1. Information about discharge is important, but is not of the most current importance. 2. The patient needs immediate information about the care environment. 3. Information about disease process is essential, but is not of the most current importance. 4. Patients are often interested in when their diet can return to normal. However, this patient may or may not “feel like eating” so this information takes on a lesser importance. Page Ref: 21 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Practice: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Describe the principles of client- and family-centered care in the highacuity environment as it relates to educational needs of visitation and policies. 17 Copyright © 2019 Pearson Education, Inc. 18) Which assessment finding would most alert the nurse that the patient might have low health literacy skills? 1. The patient reports not completing high school. 2. The patient is 65 years old. 3. The patient says, “I stopped taking the last medication because I read on the internet that it could make me have rashes.” 4. The patient says, “I called the doctor’s office to reschedule my appointment for later in the morning.” Answer: 3 Explanation: 1. The nurse would be alert that the patient might have reading difficulty, but this is not the most critical assessment present. 2. Older adults are more likely to have problems with health literacy, but this is not universally true. This is not the most critical assessment present. 3. Inability to understand health information from all sources is a finding associated with poor health literacy. 4. Ability to communicate with healthcare providers indicates some degree of health literacy. Page Ref: 20 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Practice: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO03: Describe the principles of client- and family-centered care in the highacuity environment as it relates to educational needs of visitation and policies. 18 Copyright © 2019 Pearson Education, Inc. 19) A patient who has been seriously ill has recovered sufficiently to be transferred to a monitored medical unit. Which intervention will best reduce transfer anxiety for this patient? 1. Transfer the patient immediately before bedtime so that the first few hours on the new unit will be sleeping hours. 2. Promise to frequently visit the patient on the new unit. 3. Explain some of the routines used on the new unit. 4. Offer reassurance by telling the patient you once worked on the new unit. Answer: 3 Explanation: 1. Nighttime is often a time of concern and fear for patients. It is better to transfer the patient so that there are several hours to become accustomed to the new unit before nighttime. 2. The nurse is not likely to have time to visit the patient once transfer has occurred. A broken promise may not affect the nurse, but could be devastating to the patient and family. 3. Explaining what to expect after transfer is a good way to reassure the patient and family. 4. Telling the patient that you once worked on the unit will not offer the greatest reassurance. Page Ref: 21 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Practice: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO03: Describe the principles of client- and family-centered care in the highacuity environment as it relates to educational needs of visitation and policies. 19 Copyright © 2019 Pearson Education, Inc. 20) A family of a critically injured patient is about to make their first bedside visit. Which statement, made by the nurse, is the most helpful in this situation? 1. “If you have any questions while you are at the bedside, just ask.” 2. “You will need to speak slower and in a softer voice while at the bedside.” 3. “Do not touch anything in the room.” 4. “His face is swollen and he has a lot of equipment around him.” Answer: 4 Explanation: 1. Questions should not be asked at the bedside. 2. It is important to use a normal tone of voice when speaking with the patient. 3. The family should be educated about equipment, but there is no need to tell them not to touch anything at the bedside. This only serves to increase their anxiety. 4. Explanation of the patient’s appearance and the appearance of the room is important information for the family prior to their first bedside visit. Page Ref: 22 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Practice: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO03: Describe the principles of client- and family-centered care in the highacuity environment as it relates to educational needs of visitation and policies. 20 Copyright © 2019 Pearson Education, Inc.