Chapter 27 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 27

Question 1

Type: MCSA

The nurse has completed client teaching regarding medication administration. Which client statement best illustrates compliance?

1. Im glad to know about my medications. It makes taking them a lot easier.

2. I already knew most of what you told me.

3. I think you should have waited until I was ready to go home. Maybe Id remember better.

4. If I take my medications as prescribed, Ill feel better.

Correct Answer: 1

Rationale 1: Compliance is best illustrated when the person recognizes and accepts the need to learn, then follows through with appropriate behaviors that reflect learning. Learning about the medications helps the client understand why theyre prescribed and improves the possibility for following the prescribed regimen.

Rationale 2: Statements of prior knowledge do not necessarily lead to compliance.

Rationale 3: Following the advice of the health care prescriber does not necessarily lead to compliance.

Rationale 4: Following the advice of the health care prescriber does not necessarily lead to compliance.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1. Discuss the importance of the teaching role of the nurse.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 440

Question 2

Type: MCSA

A nurse is planning a community health education project that deals with organ donation, and the target audience is a group of adults. When following andragogy concepts, the nurse should make sure that the teaching includes which information?

1. Past statistics about organ donors

2. Written pamphlets

3. Directions about how to become an organ donor

4. Information on how this group can influence their children

Correct Answer: 3

Rationale 1: An adult is more oriented to learning when the material is useful immediately, not sometime in the future.

Rationale 2: Written information may or may not be helpful, depending on what types of learners are included in the group.

Rationale 3: An adult is more oriented to learning when the material is useful immediately, not sometime in the future. For this audience, giving clear directions on how to become an organ donor would be more helpful than past information and future activities such as influencing their children.

Rationale 4: For this audience, giving clear directions on how to become an organ donor would be more helpful than past information and future activities such as influencing their children.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2. Compare and contrast andragogy, pedagogy, and geragogy.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 440

Question 3

Type: MCSA

The nurse is instructing a client on self-administration of a subcutaneous injection. The nurse is using which theoretical construct of learning?

1. Thorndikes behaviorism

2. Skinners positive reinforcement

3. Pavlovs conditioning response

4. Banduras imitation

Correct Answer: 4

Rationale 1: Edward Thorndike originally advanced the theory of behaviorism and maintained that learning should be based on the learners behavior.

Rationale 2: Skinner focused his work on conditioning behavioral responses to a stimulus that causes the response or behavior.

Rationale 3: Pavlov focused his work on conditioning behavioral responses to a stimulus that causes the response or behavior.

Rationale 4: Bandura claims that most learning comes from observation and instruction. Imitation is the process by which individuals copy or reproduce what they have observed.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Discuss the learning theories of behaviorism, cognitivism, and humanism and how nurses can use each of these theories.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 440

Question 4

Type: MCSA

A nursing student is presenting a teaching project to the class using each of Blooms domains. The student has several activities included in the project. Which activity is an example of the affective domain?

1. Each member of the class must identify two attitudinal changes that have occurred in their lives since beginning their nursing education.

2. All members must list the technical skills theyve learned.

3. Members must demonstrate a favorite nursing skill at the end of the class period.

4. Members must read a paragraph about a new clinical trial, summarize the information, and present it to the rest of the class.

Correct Answer: 1

Rationale 1: The affective domain of Blooms theory of learning is also known as the feeling domain. It includes emotional responses to tasks such as feelings, emotions, interests, attitudes, and appreciations.

Rationale 2: Listing technical skills and reading or summarizing information is part of the thinking domain, which includes knowing, comprehending, application, analysis, synthesis, and evaluation.

Rationale 3: The psychomotor domain is the skill domain and includes hands-on motor skills such as demonstration.

Rationale 4: Listing technical skills and reading or summarizing information is part of the thinking domain, which includes knowing, comprehending, application, analysis, synthesis, and evaluation.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Describe the three learning domains.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 440

Question 5

Type: MCSA

A client is practicing using an incentive spirometer after surgery. The nurse has explained the use, demonstrated how it works, and also given the rationale for the client to continue to use this device. When mastering the use of this device, the client will demonstrate learning in which of Blooms domains?

1. Cognitive

2. Psychomotor

3. Affective

4. Imitation

Correct Answer: 2

Rationale 1: Cognitive abilities include the thinking process that begins with knowing, comprehending, and applying knowledge.

Rationale 2: The psychomotor domain is the skill domain and includes motor skills, such as being able to use an incentive spirometer.

Rationale 3: The affective domain involves attitudes or emotional responses and includes feelings, emotions, interests, and appreciations.

Rationale 4: Imitation is not one of Blooms domains of learning.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 3. Describe the three learning domains.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 440

Question 6

Type: MCSA

A nurse is presenting teaching sessions to a group of residents in a home for long-term physical rehabilitation. Which client exhibits the highest motivation?

1. An individual who has been struggling with following nursing directives regarding discharge goals

2. The client who has just moved in and is already waiting for discharge

3. A client who is excited to learn about his new prosthesis

4. A client who has been there the longest and is a great coach for newcomers

Correct Answer: 3

Rationale 1: Clients who struggle with rules or following prescribed courses of treatment are not motivated to learn the best reason for their particular plan of action. They may be bucking the system.

Rationale 2: The client who is already waiting to go home may be motivated for that, but not to the extent of being ready to learn how to achieve this end.

Rationale 3: Motivation is the desire to learn and influences how quickly and to what extent a person learns. It is generally greatest when a person recognizes a need and believes the need will be met through learning. The client who is excited to learn about his prosthesis understands that learning about it will help take his recovery to a high level.

Rationale 4: Motivation must be experienced by the client, not by someone else (as in being a coach for newcomers).

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Identify factors that affect learning.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 441

Question 7

Type: MCSA

A nurse is working in a neonatal intensive care unit, teaching parents how to care for their tiny babies while they are still in the hospital. Which statement by a parent reflects a readiness to learn?

1. Im so afraid Ill hurt my baby with all these tubes.

2. I want to make sure my spouse is here, in case I dont hear everything thats said.

3. When my baby is just a little bigger, Ill be able to handle him.

4. Youll give us written instructions before we go home, correct?

Correct Answer: 2

Rationale 1: Statements about fear of the situation need to be addressed so the fear will not inhibit the learning process.

Rationale 2: Readiness to learn is the demonstration of behaviors or cues that reflect a learners motivation, desire, and ability to learn at a specific time. The client who wants the spouse involved is demonstrating motivation and willingness, but also wants support from the spouse as well.

Rationale 3: Wanting to wait until the baby is older reflects uncertainty and possibly fear and should be addressed before learning can occur.

Rationale 4: Wanting to wait until discharge reflects uncertainty and possibly fear and should be addressed before learning can occur.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5. Identify factors that affect learning.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 441

Question 8

Type: MCSA

The nurse is instructing a client on self-administration of insulin. Which statement regarding feedback will be most beneficial to the client?

1. You know, there are children who can learn to do this.

2. Maybe it would be better if we taught your spouse to help you with this.

3. Next time, dart the needle in your skin, instead of pushing it in.

4. If you dont learn this, you cant be discharged.

Correct Answer: 3

Rationale 1: Ridicule or sarcasm can lead to withdrawal from learning, as in reminding an adult client that a child can perform the task or of not being discharged until the skill is learned.

Rationale 2: Statements about having somebody else learn the technique may also cause the learner to avoid the teaching moment and to

avoid learning the technique altogether.

Rationale 3: Feedback should be meaningful to the learner and should support the desired behavior through praise, positively worded corrections, and suggestions of alternative methods.

Rationale 4: Ridicule or sarcasm can lead to withdrawal from learning, as in reminding an adult client that a child can perform the task or of not being discharged until the skill is learned.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5. Identify factors that affect learning.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 442

Question 9

Type: MCSA

A home health client having difficulty keeping his medication schedule organized says There are so many pills and the names are all confusing to me. I dont even understand what theyre for. What should the nurse do?

1. Help the client remember color and size in relationship to dosing time.

2. Write out the generic and trade name of all the pills for the client.

3. Fill a pill bar and tell the client not to worry, and just take the pills according to that system.

4. Have the physician talk to the client about his medications.

Correct Answer: 1

Rationale 1: Learning is facilitated by material that is logically organized and proceeds from the simple to the complex. This helps the learner comprehend new information, apply it to previous learning, and form new understandings. Naming the pills by color and size and dosing time helps the client move from that level to learning what each medication is for and why he is taking itsimple to complex.

Rationale 2: Learning generic and trade names is memorization and may not make sense for this client.

Rationale 3: Filling a pill box or bar is not helping the client learn about his meds; it merely puts them into an order without information.

Rationale 4: Nurses must rely on their own creativity and resourcefulness, not depend on physician input.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Identify factors that affect learning.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 442

Question 10

Type: MCSA

At the end of a busy clinical day a staff nurse asks the instructor if a student would like to administer a Z-track injected medication. This is a skill that the students have not yet been exposed to yet. What should the instructor respond to the staff nurse that supports timing and learning environment?

1. It will take me a moment to explain the procedure to the students because weve not practiced this, but Ill find somebody to administer it.

2. Would it be OK if the students observed today? Then, well do it next time were here.

3. Were leaving now, but thanks for asking.

4. Ill check with the students and see if one of them would like to volunteer.

Correct Answer: 2

Rationale 1: After a busy day in the clinical area, students may not be ready for the learning experience, even though it would be a good opportunity for them. Taking time to explain the procedure first might put the learning moment in the wrong time and environment, and the students may not retain the information as best they could.

Rationale 2: Allowing them to observe the staff nurse, then coming back when they are more refreshed would allow a better learning experience for the students.

Rationale 3: Simply declining the opportunity doesnt make for good rapport with the staff nurse.

Rationale 4: Allowing a student to simply volunteer puts the instructors license at risk, especially if it is a skill the student has not learned or practiced.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Assess learning needs of learners and the learning environment.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 442

Question 11

Type: MCSA

A client with an incision necessitating a complex dressing change is being discharged and will require continued dressings at home. Which statement by the client indicates a need to postpone teaching?

1. Its going to take time for me to understand this whole thing.

2. Lets make sure my spouse is around before you start explaining.

3. I wish my doctor would have explained this more in depth.

4. Im feeling nauseous, but go ahead and start anyway.

Correct Answer: 4

Rationale 1: This statement shows interest as well as realism in attitude toward learning. The nurse should be attentive to cues that may enhance the learning experience, such as amount of time spent on the process.

Rationale 2: This statement shows interest as well as realism in attitude toward learning. The nurse should be attentive to cues that may enhance the learning experience, such as having the spouse available to learn along with the client.

Rationale 3: This statement shows interest as well as realism in attitude toward learning. The nurse should be attentive to cues that may enhance the learning experience, such as giving thorough explanations about the rationale for the treatment.

Rationale 4: Learning can be inhibited by physiologic events such as illness, pain, or sensory deficits. The client must be able to concentrate and apply adequate energy to the learning or the learning itself will be impaired. If the client is experiencing nausea, the nurse should first try to reduce this symptom before beginning the teaching session.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5. Identify factors that affect learning.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 442

Question 12

Type: MCSA

A nurse is working with the family of a child who is hospitalized with asthma. The family members speak little English, and the child is being sent home on nebulizer treatments as well as an inhaler. In addition to enlisting an interpreter to help with the language barrier, the nurse should

1. provide written instructions before discharge.

2. address any healing beliefs the family has.

3. make sure the child comes back for the follow-up appointment.

4. make sure the parents can set up the treatments for their child.

Correct Answer: 2

Rationale 1: It is important to provide written material, but the first priority is ascertaining any belief conflicts that may interfere with the treatment.

Rationale 2: If the prescribed treatment conflicts with the client/familys cultural healing beliefs, the client may not be compliant with the recommended treatments. To be effective, nurses must deal directly with any conflicts and differing values held by the client.

Rationale 3: If the prescribed treatment conflicts with the client/familys cultural healing beliefs, the client may not be compliant with the recommended treatments.

Rationale 4: The client who does not understand will learn little, and providing an interpreter to assist with communication is extremely important in this situation. However, if the prescribed treatment conflicts with the client/familys cultural healing beliefs, the client may not be compliant with the recommended treatments.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials 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; Knowledge; The role of family, culture, and community in a persons development

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12. Discuss strategies to use when teaching clients of different cultures.

MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.

Page Number: 443

Question 13

Type: MCSA

A client who is legally blind requires vitamin B12 injections every 2 weeks and insists on self-administration. What is the best way for the nurse to assist this client?

1. Teach the spouse to draw up the medication, then the client can give the injection.

2. Make sure that the injection is scheduled during a visit, so the nurse can supervise.

3. Prefill syringes with the correct dose, so the client can use them for self-administration.

4. Schedule the clients clinic appointments in accordance with the dosing schedule, then give the injection when the client is at the clinic.

Correct Answer: 3

Rationale 1: Teaching a spouse is demeaning and does not support the clients wishes for independence.

Rationale 2: Scheduling injections and visits to coincide is demeaning and does not support the clients wishes for independence.

Rationale 3: Clients who have visual impairment may need the assistance of a support person or creative care in order to remain compliant with their treatment. Because the client insists on self-administration, prefilling syringes (and keeping them away from light and heat) would be a plausible solution. The client is concerned with independence, and allowing the client to maintain that would be quite important.

Rationale 4: Scheduling injections and visits to coincide when the dose is due is demeaning and does not support the clients wishes for independence.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Assess learning needs of learners and the learning environment..

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 443

Question 14

Type: MCSA

A client has been diagnosed with diabetes mellitus and must learn how to do his own finger stick blood sugar analysis as part of his treatment. The client has been sullen and uncommunicative since receiving the diagnosis. How can the nurse best increase the clients motivation to learn?

1. Demonstrating the finger stick on the nurse

2. Offering to do the procedure for the client each time it is scheduled

3. Teaching the clients support system how to perform the procedure

4. Encouraging the clients participation each time the procedure is performed

Correct Answer: 4

Rationale 1: Demonstrating the procedure on the nurse may or may not help the client become interested in the learning process.

Rationale 2: Offering to do the procedure only allows the clients current state of mind to continue.

Rationale 3: Giving the responsibility to someone else does not encourage the client to learn it.

Rationale 4: Nurses can increase a clients motivation in several ways, including encouragement of self-direction and independence.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Identify factors that affect learning.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 447

Question 15

Type: MCSA

The nurse is working with a group of older clients through a community senior citizens center. Utilizing an understanding of health literacy, the nurse will make sure that

1. information given to this group is written at a third-grade level.

2. teaching includes a variety of approaches.

3. information includes pictures.

4. there is ample time for teaching.

Correct Answer: 4

Rationale 1: The average reading ability of many American adults is at the fifth-grade level. Information provided to this group should be presented at the fifth- to sixth-grade reading level.

Rationale 2: A variety of approaches should be included regardless of the audience, as people learn by different methods.

Rationale 3: A variety of approaches should be included regardless of the audience, as people learn by different methods.

Rationale 4: When working with the older population, the nurse must realize that increased time for teaching is necessary because processing of information is slower. Health literacy skills are often limited in older adults.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Discuss the implications of low health literacy skills.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 446

Question 16

Type: MCSA

A client being discharged after a myocardial infarction has been prescribed several new medications and a low-fat diet. The client states: Im never going to understand what to do, when to do it, and why I should be doing all these things. Which nursing diagnosis should the nurse formulate for this client?

1. Health-Seeking Behavior related to desire to prevent heart problems

2. Deficient Knowledge (diet and medication regimen) related to inexperience

3. Noncompliance related to situational factors

4. Risk for Myocardial Infarction related to deficient knowledge

Correct Answer: 2

Rationale 1: Health-Seeking Behavior is a diagnostic label used when the client is seeking health information.

Rationale 2: The NANDA label Deficient Knowledge is used when the client is seeking health information or when the nurse has identified a learning need, as in this case. The area of deficiency (diet and medication regimen) should always be included in the diagnosis.

Rationale 3: Noncompliance is used when the client or caregiver fails to follow a plan, which is too early to tell in this case.

Rationale 4: Risk for Myocardial Infarction is not a NANDA label. If a risk exists, the label could be Risk for Noncompliance related to deficient knowledge.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 9. Identify nursing diagnoses, outcomes, and interventions that reflect the learning needs of clients.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 448

Question 17

Type: MCSA

The nursing diagnosis Readiness for Enhanced Knowledge (Nutrition) related to desire to improve nutritional intake has been formulated for a client who has decided to change his eating habits to be more nutritionally sound. What would be an appropriate outcome for this client?

1. Client will understand the importance of eating healthy.

2. Client will be able to lose weight.

3. Client will list foods that are nutritionally sound, low fat, and high fiber.

4. Client will appreciate the value of using the Food Guide Pyramid.

Correct Answer: 3

Rationale 1: Learning outcomes, like client outcomes, must be specific and observable so they can be measured. Words like understand are not measurable and are not observable.

Rationale 2: Be able to lose weight is not specific enough, and with the information given, it is not known if that is really what the client wants to attain.

Rationale 3: Learning outcomes, like client outcomes, must be specific and observable so they can be measured.

Rationale 4: Words like appreciate are not measurable and are not observable.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9. Identify nursing diagnoses, outcomes, and interventions that reflect the learning needs of clients.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 451

Question 18

Type: MCSA

A home health nurse is working with a client who has pulmonary fibrosis. Of the following teaching priorities, which will take the highest priority?

1. Client will be able to set up and administer a nebulizer treatment by the end of the day.

2. Client will have increased activity level by the end of the week.

3. Client will be able to do activities of daily living (ADLs) without shortness of breath in 3 days.

4. Client will have a positive attitude about the diagnosis by the end of the month.

Correct Answer: 1

Rationale 1: Learning outcomes state the client behavior and are ranked according to priority. Nurses can use theoretical frameworks such as Maslows hierarchy of needs to establish priorities. In this case, the physiological need of learning how to administer medication takes priority over activity and attitudinal needs.

Rationale 2: This outcome cannot be measured.

Rationale 3: In this case, the physiological need of learning how to administer medication takes priority over activity needs.

Rationale 4: In this case, the physiological need of learning how to administer medication takes priority over attitudinal needs.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9. Identify nursing diagnoses, outcomes, and interventions that reflect the learning needs of clients.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 452

Question 19

Type: MCMA

A school nurse is putting together a program for adolescents about positive lifestyle choices. What should the nurse keep in mind when preparing content to present to this age group?

Standard Text: Select all that apply.

1. Based on learning outcomes

2. Current

3. Adjusted to the adolescent client

4. Based on sources available within the school system

5. Consistent with the teaching topics

Correct Answer: 1, 2, 3, 5

Rationale 1: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be based on learning outcomes.

Rationale 2: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be current.

Rationale 3: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be adjusted to the learners age.

Rationale 4: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be selected with consideration of how much time and what resources are available for teaching.

Rationale 5: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be consistent with the information that the nurse is teaching.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Assess learning needs of learners and the learning environment.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 452

Question 20

Type: MCSA

The nurse is going to be working with a client who has a permanent colostomy and is ready to go home within the next several days. When organizing the teaching/learning experience, the nurse should

1. start from the beginning and proceed through all material.

2. break up sessions into shortened time periods.

3. discover what the learner knows before proceeding with further teaching.

4. make sure the clients spouse is present before the teaching session begins.

Correct Answer: 3

Rationale 1: Going over information already taught and learned isnt practicing good time management for the nurse or the client.

Rationale 2: Unless the client has attention problems or may be elderly, breaking up the sessions may not be necessary.

Rationale 3: Nurses should save time in constructing their own teaching sessions and should follow basic guidelines when sequencing the learning experience. The nurse should find out what the learner knows, and then proceed to the unknown. This gives the learner confidence. This information can be elicited either by asking questions or by having the client take a pretest or fill out a form.

Rationale 4: Having the spouse present is always a good idea, but may not be possible all the time.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Assess learning needs of learners and the learning environment.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 453

Question 21

Type: MCSA

A client needs discharge teaching regarding the use of a walker before going home. The clients room is small and adjacent to a soda machine and small lounge area. In planning a teaching session, which is the best thing the nurse can do?

1. Wait until just prior to discharge, then do the teaching in the hospital lobby.

2. Close the door to the clients room and make sure there is no clutter on the floor before the teaching session begins.

3. Take the client to a larger area (treatment room, for example) for teaching, then evaluate on the way back to the clients room.

4. Make sure a physical therapist is available to do the teaching and can see the client before discharge.

Correct Answer: 3

Rationale 1: Noise or interruptions can interfere with concentration, whereas a comfortable environment can promote learning. The hospital lobby does not provide privacy and can be noisy. There also would be little time to reinforce any teaching needs that might be necessary.

Rationale 2: Noise or interruptions can interfere with concentration, whereas a comfortable environment can promote learning.

Rationale 3: Going to a larger area and then evaluating the learning by watching the client ambulate back to the room would be the best way to implement teaching in this particular situation.

Rationale 4: Not all hospitals have a physical therapist available to help implement teaching for clients.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Assess learning needs of learners and the learning environment.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 454

Question 22

Type: MCSA

A community health nurse runs a clinic that provides health screening to mainly Mexican American and Native American clients. The nurse wants to have a class on smoking cessation for interested adults of this group. In order to adjust to their time orientation, what is the best action of the nurse?

1. Make sure that the classes are held at specific times.

2. Begin classes when a group of clients are gathered.

3. Mail letters ahead of time to make sure clients are informed about the upcoming class.

4. Make posters and place them in areas of the community frequented by these groups.

Correct Answer: 2

Rationale 1: Cultures with a predominant orientation to the present include the Mexican American and Navajo Native American. Schedules have to be very flexible in present-oriented societies.

Rationale 2: The nurse must be quite flexible, treat the cultures beliefs with respect, and not expect that cultural practices will change to reflect the nurses needs.

Rationale 3: Time constraints are not significant for cultures that are oriented to the present, so advertising about specific classes may not be effective.

Rationale 4: Time constraints are not significant for cultures that are oriented to the present, so advertising about specific classes may not be effective.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials 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; Knowledge; The role of family, culture, and community in a persons development

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12. Discuss strategies to use when teaching clients of different cultures.

MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.

Page Number: 457

Question 23

Type: MCSA

At the completion of a teaching session, the nurse wants to evaluate the effectiveness of instruction. In a situation where the client was learning a bandaging technique, which would be the most effective evaluation?

1. Shared by the nurse and client

2. A return demonstration by the client

3. When the nurse is satisfied that the client can complete the technique

4. If the wound heals

Correct Answer: 1

Rationale 1: Both the client and the nurse should evaluate the learning experience. The client can tell the nurse what was helpful and provide a demonstration that shows mastery of the skill. The nurse needs to evaluate whether the client has an understanding of the rationale behind the technique.

Rationale 2: Using only the return demonstration is one sided. The evaluation is of the bandaging technique, and it may or may not be covering a wound.

Rationale 3: Focusing on the nurses satisfaction with the clients performance is one sided.

Rationale 4: The evaluation is of the bandaging technique, and it may or may not be covering a wound.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 13. Identify methods to evaluate learning.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 458

Question 24

Type: MCMA

The nurse has completed a teaching session for a client with a tracheostomy. Documentation of the session should include what information?

Standard Text: Select all that apply.

1. Diagnosed learning needs

2. Supplies required

3. Client outcomes

4. Need for additional teaching

5. Topics taught

Correct Answer: 1, 3, 4, 5

Rationale 1: The parts of the teaching process that should be documented in the clients chart include diagnosed learning needs.

Rationale 2: The parts of the teaching process that should be documented in the clients chart include resources provided.

Rationale 3: The parts of the teaching process that should be documented in the clients chart include client outcomes.

Rationale 4: The parts of the teaching process that should be documented in the clients chart include need for additional teaching.

Rationale 5: The parts of the teaching process that should be documented in the clients chart include topics taught.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14. Describe effective documentation of teachinglearning activities.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 458

Question 25

Type: MCMA

When making an assessment of the clients learning needs, the nurse will focus on which elements?

Standard Text: Select all that apply.

1. Nurses own knowledge

2. Clients age

3. Clients understanding of health problem

4. Sensory acuity

5. Learning style

Correct Answer: 2, 3, 4, 5

Rationale 1: The nurses own knowledge of common learning needs is a source of information but not part of the nurses assessment of the clients learning needs.

Rationale 2: The clients age provides information on the persons developmental status that might indicate health teaching content and teaching approaches.

Rationale 3: The clients understanding of health problems might indicate deficient knowledge or misinformation.

Rationale 4: Sensory acuity is part of the psychomotor ability of which the nurse must be aware when planning a teaching session.

Rationale 5: Learning style identifies the clients best way to learn so that the nurse can adapt teaching accordingly.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Assess learning needs of learners and the learning environment.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 444

Question 26

Type: MCMA

A school nurse is planning a program for adolescents about positive lifestyle choices. The nurse should keep in mind that content presented to this age group must be

Standard Text: Select all that apply.

1. based on learning outcomes.

2. current.

3. adjusted to the adolescent client.

4. based on sources available within the school system.

5. accurate.

Correct Answer: 1, 2, 3, 5

Rationale 1: Whatever sources the nurse chooses, content should be based on learning outcomes.

Rationale 2: Whatever sources the nurse chooses, content should be current.

Rationale 3: Whatever sources the nurse chooses, content should be adjusted to the learners age.

Rationale 4: Nurses can select among many sources of information, not just those available within the school system.

Rationale 5: Whatever sources the nurse chooses, content should be accurate.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7. Assess learning needs of learners and the learning environment.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 452

Question 27

Type: MCMA

A client is being discharged after a 23-hour stay for a surgical procedure. When preparing the instructions for this client, what does the nurse need to do?

Standard Text: Select all that apply.

1. Ensure the clients safe transition to home.

2. Include information about what the client has been taught.

3. Include what the client still needs to learn when discharged.

4. Check the clients insurance for hospitalization coverage.

5. Call the clients prescriptions in to the clients local pharmacy.

Correct Answer: 1, 2, 3

Rationale 1: Because of decreased lengths of stay, time constraints on client education can occur. The nurse needs to provide education that will ensure the clients safe transition to home.

Rationale 2: Discharge plans must include information about what the client has been taught.

Rationale 3: Discharge plans must include what the client still needs to learn when discharged.

Rationale 4: The nurse does not need to check the clients insurance for hospitalization coverage when preparing discharge instructions.

Rationale 5: The nurse does not call the clients prescriptions in to the clients local pharmacy when preparing discharge instructions.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7. Assess learning needs of learners and the learning environment.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 438

Question 28

Type: MCMA

The nurse serves as an educator of other health care personnel. In what capacity will this nurse participate in education?

Standard Text: Select all that apply.

1. Preceptor of new graduate nurses

2. Instructing a part of the critical care course

3. Clinical instruction of nursing students

4. One-to-one teaching of clients

5. Teaching grandparents how to care for children

Correct Answer: 1, 2, 3

Rationale 1: Nurses are involved in the instruction of professional colleagues, such as functioning as preceptors for new graduate nurses.

Rationale 2: Nurses with specialized knowledge and experience may share that knowledge and experience with nurses by instructing a part of the critical care course.

Rationale 3: Nurses in nursing practice settings are often involved in the clinical instruction of nursing students.

Rationale 4: One-to-one teaching of clients is not an example of being an educator of other health care personnel.

Rationale 5: Teaching grandparents how to care for children is not an example of being an educator of other health care personnel.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Discuss the importance of the teaching role of the nurse.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 439

Question 29

Type: MCMA

The nurse planning an educational session for adult clients should include which andragogy concepts?

Standard Text: Select all that apply.

1. People move from dependence to independence with maturity.

2. Previous experiences can be used as a resource for learning.

3. Learning is related to an immediate need or problem.

4. Learning is reinforced by prompt feedback.

5. Adults are oriented to learning when the material is useful sometime in the future.

Correct Answer: 1, 2, 3, 4

Rationale 1: An andragogy concept about adult learners is that as people mature, they move from dependence to independence.

Rationale 2: An andragogy concept about adult learners is that an adults previous experiences can be used as a resource for learning.

Rationale 3: An andragogy concept about adult learners is that learning is related to an immediate need or problem.

Rationale 4: An andragogy concept about adult learning is that learning is reinforced by prompt feedback.

Rationale 5: An andragogy concept about adult learning is that an adult is more oriented to learning when the material is useful immediately, and not sometime in the future.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2. Compare and contrast andragogy, pedagogy, and geragogy.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 440

Question 30

Type: MCMA

The nurse is utilizing humanistic theory when instructing a client. What will the nurse demonstrate when utilizing this theory?

Standard Text: Select all that apply.

1. Empathy

2. Encouraging the client to establish goals

3. Encouraging the client to participate in self-directed learning

4. Multisensory teaching strategies

5. Providing a physical environment conducive to learning

Correct Answer: 1, 2, 3

Rationale 1: Conveying empathy is a characteristic of humanism.

Rationale 2: Encouraging the client to establish goals is a characteristic of humanism.

Rationale 3: Encouraging the client to participate in self-directed learning is a characteristic of humanism.

Rationale 4: Selecting multisensory teaching strategies is a characteristic of cognitivism.

Rationale 5: Providing a physical environment conducive to learning is a characteristic of cognitivism.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Discuss the learning theories of behaviorism, cognitivism, and humanism and how nurses can use each of these theories.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 441

Question 31

Type: MCSA

A client tells the nurse that he has no questions about his illness, as he did a search for information on the Internet. What should the nurse do?

1. Ask the client to share the information obtained from the Internet search.

2. Document that the client has received instruction.

3. Tell the client that the Internet is a form of entertainment, not instruction.

4. Document that the client refused instruction.

Correct Answer: 1

Rationale 1: The Internet is an important source of health information for many adult clients in the United States. Nurses need to know and be able to integrate this technology into the teaching plans for those clients who use the Internet. The nurse should ask the client to share the information obtained from the Internet search in order to integrate the content into the clients teaching plan.

Rationale 2: The nurse needs to ask the client to share the information, and not just document that the client has received instruction. The nurse does not know what instruction the client has received.

Rationale 3: The Internet is a source of information, and not just a form of entertainment.

Rationale 4: The client did not refuse instruction.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IV. 6. Evaluate data from all relevant sources, including technology, to inform the delivery of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Discuss the implications of using the Internet as a source of health information.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 444

Question 32

Type: MCMA

The nurse instructs the older client to access the Internet to complete a post-hospitalization survey and update health information. The client tells the nurse that he does not have a computer and would not know how to use one. What should the nurse do?

Standard Text: Select all that apply.

1. Suggest the client learn how to use a computer through classes held at a local library.

2. Provide times for the client to attend basic computer use classes through the community learning center.

3. Document that the client is resistant to instruction.

4. Notify the physician that the client will not be adhering to medical instruction as planned.

5. Identify the client as being noncompliant with instruction.

Correct Answer: 1, 2

Rationale 1: The older client might not own a computer or have Internet access. The nurse could suggest that the client learn how to use a computer through classes held at a local learning center.

Rationale 2: The nurse should provide times for the older client to attend basic computer use classes though the community learning center.

Rationale 3: The client who does not have a computer or does not know how to use one is not resistant to instruction.

Rationale 4: The physician does not need to be notified. The client is not refusing to adhere to medical instruction as planned.

Rationale 5: The client who does not have a computer or does not know how to use one is not being noncompliant with instruction.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IV. 2. Use telecommunication technologies to assist in effective communication in a variety of healthcare settings

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Discuss the implications of using the Internet as a source of health information.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 444

Question 33

Type: MCMA

The nurse suspects a client has low literacy. What did the nurse assess to come to this conclusion?

Standard Text: Select all that apply.

1. Incorrect completion of previous hospitalizations form

2. Client refusing to sign forms because eyeglasses are at home

3. Client saying he forgot to report for laboratory testing

4. Score of 6 on the Newest Vital Sign assessment tool

5. Questioning the dosage pattern on a newly prescribed medication

Correct Answer: 1, 2, 3

Rationale 1: The nurse should suspect a literacy problem when a client incorrectly completes forms.

Rationale 2: The nurse should suspect a literacy problem when a client refuses to sign forms because of lack of eyeglasses.

Rationale 3: The nurse should suspect a literacy problem when appointments are missed.

Rationale 4: A score of 6 on the Newest Vital Sign assessment tool indicates adequate literacy.

Rationale 5: Questioning a medication would indicate that the client read the prescription, and would not suggest a literacy problem.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Assess learning needs of learners and the learning environment.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 447

Question 34

Type: MCMA

The nurse is designing a teaching plan for a client to learn a new psychomotor skill. What strategies can the nurse use to facilitate learning for this client?

Standard Text: Select all that apply.

1. Demonstration

2. Practice

3. Modeling

4. Discovery

5. Role playing

Correct Answer: 1, 2, 3

Rationale 1: Demonstration is used to learn a psychomotor skill.

Rationale 2: Practice is used to learn a psychomotor skill.

Rationale 3: Modeling is used to learn a psychomotor skill.

Rationale 4: Discovery is used to learn concepts within the affective and cognitive domains.

Rationale 5: Role playing is used to learn concepts within the affective and cognitive domains.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Describe the three learning domains.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 453

Question 35

Type: MCMA

The nurse instructs a client on self-care for a new ostomy. Which client behaviors demonstrate that instruction has been effective?

Standard Text: Select all that apply.

1. Client provides skin care and changes ostomy device.

2. Client states what items are needed to perform ostomy care.

3. Client is unable to identify changes in skin around the stoma.

4. Client tells the nurse that he does not want to do the care.

5. Client asks his wife to learn how to perform the care so he will not have to do it.

Correct Answer: 1, 2

Rationale 1: The acquisition of psychomotor skills is best evaluated by observing how well the client carries out a procedure such as self-care for an ostomy.

Rationale 2: In cognitive learning, the client demonstrates acquisition of knowledge by responding appropriately to oral questions.

Rationale 3: The inability to identify changes in the skin around the stoma would indicate that instruction has not been effective.

Rationale 4: The clients stating he does not want to perform self-care to the ostomy would indicate that effective learning did not occur.

Rationale 5: The clients asking his wife to learn the care would indicate that effective learning did not occur.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 13. Identify methods to evaluate learning.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 453

Question 36

Type: MCMA

The nurse is documenting the teaching plan for a client. What should be included in this documentation?

Standard Text: Select all that apply.

1. Actual information to be taught

2. Teaching strategies to use

3. Skills to be taught

4. Amount of time needed to teach each topic

5. Vital signs before and after each teaching session

Correct Answer: 1, 2, 3, 4

Rationale 1: The written teaching plan that the nurse uses to guide future teaching sessions can include the actual information to be taught.

Rationale 2: The written teaching plan that the nurse uses to guide future teaching sessions can include the teaching strategies to use.

Rationale 3: The written teaching plan that the nurse uses to guide future teaching sessions can include the skills to be taught.

Rationale 4: The written teaching plan that the nurse uses to guide future teaching sessions can include the amount of time needed to teach each topic.

Rationale 5: Vital signs before and after each teaching session do not need to be included in the clients teaching plan.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14. Describe effective documentation of teachinglearning activities.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 451

Question 37

Type: MCMA

The nurse has completed a teaching session for a client with a tracheostomy. What should the documentation include?

Standard Text: Select all that apply.

1. Diagnosed learning needs

2. Supplies required

3. Client outcomes

4. Need for additional teaching

5. Topics taught

Correct Answer: 1, 3, 4, 5

Rationale 1: The parts of the teaching process that should be documented in the clients chart include diagnosed learning needs.

Rationale 2: The supplies needed for instruction do not need to be documented.

Rationale 3: The parts of the teaching process that should be documented in the clients chart include client outcomes.

Rationale 4: The parts of the teaching process that should be documented in the clients chart include need for additional teaching.

Rationale 5: The parts of the teaching process that should be documented in the clients chart include topics taught.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14. Describe effective documentation of teachinglearning activities.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 458

Question 38

Type: MCMA

The nurse is creating a teaching plan for a client recovering from total hip replacement surgery. What should the nurse include in this clients plan?

Standard Text: Select all that apply.

1. The content to be included

2. The outcome for the teaching

3. The approaches used to teach the content

4. The evaluation of the effectiveness of teaching

5. The amount of time needed to cover the content

Correct Answer: 1, 2, 3, 5

Rationale 1: Elements of a teaching plan include the content.

Rationale 2: Elements of a teaching plan include learning outcomes.

Rationale 3: Elements of a teaching plan include teaching strategies.

Rationale 4: Evaluation of the effectiveness of the teaching occurs after the teaching has been completed.

Rationale 5: Elements of a teaching plan include the time frame needed for teaching.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10. Describe the essential aspects of a teaching plan.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 451

Question 39

Type: MCMA

The nurse is preparing to teach a client on skin care and application of a stoma device. What should the nurse keep in mind when teaching the client this information?

Standard Text: Select all that apply.

1. Address the clients concerns first.

2. Assess what the client knows already.

3. Address anxietyproducing issues last.

4. Teach the basics before complicated tasks.

5. Leave time for review and answering questions.

Correct Answer: 1, 2, 4, 5

Rationale 1: The nurse should start with something that the client is concerned about.

Rationale 2: The nurse should assess what the client knows and then proceed to the unknown. This gives the learner confidence.

Rationale 3: Issues that are causing anxiety should be addressed first. A high level of anxiety can impair learning.

Rationale 4: The nurse should teach the basics before proceeding to variations, adjustments, or complicated steps.

Rationale 5: The nurse should schedule time for the review of content and any questions the client may have to clarify information.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Discuss guidelines for effective teaching.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 453

 

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