Ramont2e Rev TIF Ch11

8/20/2019 Ramont2e Rev TIF Ch11

http://slidepdf.com/reader/full/ramont2e-rev-tif-ch11 1/34

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank

Chapter 11Question 1

Type: MCSA

The nurse is preparing a client to be discharged from the acute care facility. The appropriate healthcare professional to initiate the discharge process is:

1. The nurse

2. The social worker

3. The physician

. The nurse manager

Corre!t "ns#er: 3

Rationa$e 1: The nurse is responsible for completing the teaching process, and assisting with referrals as needed.

Rationa$e 2: The social worker is responsible for facilitating referrals to home health agencies, and transportation

if necessary.

Rationa$e 3: The physician, or other primary care proider, is responsible for initiating the discharge order,

referrals and follow!up appointments.

Rationa$e : The nurse manager does not initiate the discharge process" the manager can facilitate the process, or

assist if difficulties are encountered.

%$o&a$ Rationa$e:

Cogniti'e (e'e$: #nderstanding

C$ient Need: Safe $ffectie Care $nironment

C$ient Need )u&:

Nursing*+ntegrated Con!epts: %ursing &rocess: 'mplementation

(earning ut!ome:

Question 2Type: MCSA

The nurse is admitting an adult client to the hospital that seems to be withdrawn. The nurse interprets this as a

response to the admission, knowing that one of the most common responses to hospital admission is

1. (ear of the unknown

)amont, %iedringhous, Comprehensive Nursing Care *nd $dition #pdate Test +ank

Copyright *-* by &earson $ducation, 'nc.



2. Crying

3. )egression

. Anger

Corre!t "ns#er: -

Rationa$e 1: (ear of the unknown causes a sense of insecurity.

Rationa$e 2: Some clients may respond to aniety with crying.

Rationa$e 3: )egression is not a common reaction in adults to hospital admission.

Rationa$e : Anger is not a common reaction to hospital admission.

%$o&a$ Rationa$e:


C$ient Need: &sychosocial 'ntegrityC$ient Need )u&:

Nursing*+ntegrated Con!epts: %ursing &rocess: Assessment

(earning ut!ome:

Question 3

Type: MCSA

/uring the admission process, clients are informed about

1. Their diagnosis

2. Treatment plans

3. Their legal rights

. Aailability of translators

Corre!t "ns#er: 3

Rationa$e 1: Clients are not routinely gien information about their diagnosis during the admitting process.

Rationa$e 2: Treatment plans are not routinely discussed during the admitting process.

Rationa$e 3: /uring the initial contact in the admitting office the client is informed about his or her legal rights,

including information about a durable power of attorney and /%)s.

Rationa$e : Translators are obtained only if there is a language barrier.





%$o&a$ Rationa$e:


C$ient Need: &sychosocial 'ntegrity

C$ient Need )u&:


(earning ut!ome:

Question Type: MCMA

The nurse safeguards the client0s safety by ensuring which of the following is carried out during the admission

process1

)tandard Te-t: Select all that apply.

1. #sing an interpreter if the client has difficulty understanding the language

2. 2erifying the client0s name with the name on the door

3. 2erifying any allergies the client reports

. rienting the client to the hospital unit

. $plaining all procedures as the admission process progresses

Corre!t "ns#er: -,3,4,5

Rationa$e 1: #se of an interpreter will ensure the client understands the 6uestions being asked and directions

being gien.

Rationa$e 2: The name on the door may not hae been updated. The best source of erification is the clientsidentification band.

Rationa$e 3: (acilities may utili7e wrist bands for allergy alerts" howeer it is safer to ask the client to be sure it

wasn0t omitted.

Rationa$e : rienting the client to the operation of the bedside unit will help to aoid in8uries.

Rationa$e : $plain all procedures and actiities as the admission progresses will help to ease client aniety and

fear of the unknown.

%$o&a$ Rationa$e:

Cogniti'e (e'e$: Applying


C$ient Need )u&:






(earning ut!ome:

Question

Type: MCMA

The nursing student obseres seeral admissions during the course of the clinical rotation. 9hich of the following

would the student want to include during the admission of his first client1


1. Complete documentation fully

2. )espect client0s dress and dietary customs

3. eae the physical eam for the net shift

. Allow time for the client to rest after the process

. Complete the process as 6uickly as possible

Corre!t "ns#er: -,*,4

Rationa$e 1: Complete admission documentation will ensure aailability of the information to all caregiers.

Rationa$e 2: Clients from different cultures may re6uire special clothing or foods. Communicate these needs to

appropriate staff.

Rationa$e 3: The admission process should be completed in a timely fashion, so that baseline documentation isrecorded.

Rationa$e : The admitting process can be stressful and tiring, especially for the client who re6uires a translator.

Rationa$e : Completing the admission process in a timely, unhurried fashion will help to keep the client0s

aniety reduced. This gies the client time to ask 6uestions, and clarify concerns.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question /

Type: MCSA





The ;ealth 'nsurance &ortability and Accountability Act of -<<= mandated regulations to goern which of the

following1

1. &riacy standards for healthcare information

2. &riacy standards for healthcare employee personal information

3. >eeping medical records priate for ? years

. &assword protection specifics

Corre!t "ns#er: -

Rationa$e 1: ;'&AA regulations specify purposes for which information may and may not be released without

authori7ation from the client.

Rationa$e 2: ;'&AA does not apply to employee information.

Rationa$e 3: ;'&AA does not specify a time limit" records must be kept priate under the guidelines.

Rationa$e : $lectronic medical records must be kept priate, and password protection on computers is one leel

of protection. ;'&AA does not detail specifics.

%$o&a$ Rationa$e:

Cogniti'e (e'e$: )emembering


C$ient Need )u&:


(earning ut!ome:

Question 0

Type: MCMA

/uring the admission of a client to the unit, the nursing student answers a phone call from a @friend of the client

9hich of the following information about the client is the student allowed to gie the phone caller1


1. Client0s diagnosis

2. Client0s condition

3. Client0s location

. Cause of death

. /ischarge location





Corre!t "ns#er: *,3

Rationa$e 1: The client0s diagnosis may not be released without written authori7ation from the client.

Rationa$e 2: A one word description of the client0s condition can be released if the in6uirer identifies the clientspecifically by name and the client has not opted out of release of that information.

Rationa$e 3: The client0s location can be released, giing location such as inpatient, outpatient, unless the

information could embarrass or endanger the client, if the indiidual identifies the client by name

Rationa$e : Cause of death must come from the client0s physician and legal representatie of the deceased mustapproe the release of information.

Rationa$e : /ischarge date can be released, if the client is identified by name, but the discharge location is not

released..

%$o&a$ Rationa$e:


C$ient Need: Safe $ffectie Care $nironmentC$ient Need )u&:


(earning ut!ome:

Question

Type: MCSA

;'&AA and the American )ecoery and )einestment Act of *< specify that personal health records must be

protected. %urses can protect client priacy by

1. 9hispering when discussing clients in the eleator

2. &lacing flow sheets on the client0s bed

3. %ot posting clients0 names where they can be iewed by isitors

. Sharing passwords with floating nurses

Corre!t "ns#er: 3

Rationa$e 1: ;ealthcare professionals should not discuss clients in public places.

Rationa$e 2: (low sheets and charts should be kept at the nurse0s station.

Rationa$e 3: Clients0 names should not be posted where they can be iewed.

Rationa$e : &asswords should not be shared.





%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question Type: MCMA

The nurse is transferring a client from an acute care facility to a skilled nursing facility. 9hich of the following

needs to accompany the client1


1. Medications

2. Current medication list

3. /ocumentation of surgical procedures

. /ocumentation of decubitus si7e and condition

. Medical record

Corre!t "ns#er: *,3,4,5

Rationa$e 1: Medications do not need to accompany the client, unless there is a speciali7ed, difficult to obtain

medication.

Rationa$e 2: A current medication list needs to accompany the client, so that the receiing facility knows what is being administered.

Rationa$e 3: /ocumentation of procedures and dates is important, especially if client is transferring for

rehabilitation from the surgery.

Rationa$e : /ocumentation of decubitus is necessary for continuing ealuation.

Rationa$e : The medical record, either part or the entire record, should accompany the client, or be sent

electronically.

%$o&a$ Rationa$e:

Cogniti'e (e'e$: Analy7ing


C$ient Need )u&:






(earning ut!ome:

Question 1

Type: MCSA

The nurse is preparing to transfer a client from the 'C# to the general surgical unit. The client seems anious.

+efore helping the client into the wheelchair for transfer, which of the following is the most appropriate response

by the nurse1

1. @ Bou seem nerous about moing to the new unit. 's there something worrying you1

2. @Bou will like the new unit. 't is much 6uieter than the 'C#.

3. @Bour family will be so happy that you are moing out of the 'C#.

. @9e hae all your belongings. /id you send anything to security1

Corre!t "ns#er: -

Rationa$e 1: (ear of the unknown may be causing increased aniety, een though the transfer to a stepdown unitindicates progress.

Rationa$e 2: This response does not address the client0s feelings.


Rationa$e : This response does not address the client0s feelings.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 11

Type: MCSA

The nursing care plan addresses discharge planning

1. 9hen nursing outcomes and client goals are met

2. The first postoperatie day

3. The day the client is admitted





. After teaching is completed

Corre!t "ns#er: 3

Rationa$e 1: %ursing outcomes and client goals may be long term, and inappropriate to meet in the currentsetting.

Rationa$e 2: %ot all clients hae surgery, and the recoery goals may be long term.

Rationa$e 3: /ischarge planning begins with admission, and the planning and teaching continue until clients are

safe in their transportation home.

Rationa$e : &lanning and teaching should be ongoing through the recoery process.

%$o&a$ Rationa$e:



C$ient Need )u&:

Nursing*+ntegrated Con!epts: %ursing &rocess: &lanning(earning ut!ome:

Question 12

Type: MCMA

The &%2% collects data prior to discharge about the following issues:


1. The client0s understanding of the discharge instructions

2. Support system for the client

3. Accompanying the client to transportation on discharge

. &rinted discharge instructions

. ;ome enironment and safety


Rationa$e 1: Assessing how the client interprets the instructions is essential" confusion about diet, medication,special procedures, or eercise and actiity may be present.

Rationa$e 2: Significant others must become part of the discharge process.

Rationa$e 3: Accompanying the client to the transportation is not part of the data collection process.





Rationa$e : &rinted discharge instructions are part of client teaching, and not part of data collection.

Rationa$e : Clients may feel insecure about home safety" they may feel that their liing space will notaccommodate the medical supplies and e6uipment they need.

%$o&a$ Rationa$e:



Nursing*+ntegrated Con!epts: %ursing &rocess: &lanning

(earning ut!ome:

Question 13

Type: MCMA

The discharge process is completed when the nurse:


1. Closes the door on the client0s transportation ehicle

2. )eport that the discharge is complete is gien to the nurse manager

3. Client0s reaction to discharge is recorded on the client0s medical record

. /ischarge time, transportation and who accompanied client are recorded in the client0s medical record

. Client signs the discharge instructions

Corre!t "ns#er: *,3,4

Rationa$e 1: The person who accompanies the client to the transportation is not finished with the process at that

time. /ocumentation needs to be done.

Rationa$e 2: )eport that the client is safely in transportation is gien to the nurse manager.

Rationa$e 3: /ocumentation of the client0s reaction is made in the client0s medical record.

Rationa$e : /ate and time and other pertinent details about the discharge are documented in the client0s record.

Rationa$e : The client has not been officially discharged when the discharge instruction sheet is signed. #ntil th

client is safely in transportation, the client remains the nurse0s responsibility.

%$o&a$ Rationa$e:







C$ient Need )u&:

Nursing*+ntegrated Con!epts: %ursing &rocess: $aluation

(earning ut!ome:

Question 1

Type: MCSA

The nurse is preparing a client to be discharged from the acute care facility. The appropriate healthcare

professional to initiate the discharge process is:

1. The nurse.

2. The social worker.

3. The physician.

. The nurse manager.

Corre!t "ns#er: 3

Rationa$e 1: The nurse is responsible for completing the teaching process and assisting with referrals as needed.

Rationa$e 2: The social worker is responsible for facilitating referrals to home health agencies, and transportation

if necessary.

Rationa$e 3: The physician, or other primary care proider, is responsible for initiating the discharge order,referrals, and follow!up appointments.

Rationa$e : The nurse manager does not initiate the discharge process" the manager can facilitate the process, or

assist if difficulties are encountered.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 1

Type: MCSA

The nurse is admitting an adult client to the hospital who seems to be withdrawn. The nurse interprets this as aresponse to the admission, knowing that one of the most common responses to hospital admission is:

1. (ear of the unknown.

2. Crying.

3. )egression.





. Anger.

Corre!t "ns#er: -

Rationa$e 1: (ear of the unknown causes a sense of insecurity.

Rationa$e 2: Some clients respond to aniety with crying.

Rationa$e 3: )egression is not a common reaction in adults to hospital admission.

Rationa$e : Anger is not a common reaction to hospital admission.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 1/

Type: MCSA

/uring the admission process, clients are informed about:

1. Their diagnosis.

2. Treatment plans.

3. Their legal rights.

. Aailability of translators.

Corre!t "ns#er: 3

Rationa$e 1: Clients are not routinely gien information about their diagnosis during the admitting process.

Rationa$e 2: Treatment plans are not routinely discussed during the admitting process.

Rationa$e 3: /uring the initial contact in the admitting office, the client is informed about her legal rights,

including information about a durable power of attorney and /%)s.

Rationa$e : Translators are obtained only if there is a language barrier.

%$o&a$ Rationa$e:



C$ient Need )u&:






(earning ut!ome:

Question 10

Type: MCMA

The nurse safeguards the client0s safety by ensuring that which of the following is carried out during the

admission process1


1. #sing an interpreter if the client has difficulty understanding the language

2. 2erifying the client0s name with the name on the door

3. 2erifying any allergies the client reports

. rienting the client to the hospital unit

. $plaining all procedures as the admission process progresses

Corre!t "ns#er: -,3,4,5

Rationa$e 1: #se of an interpreter will ensure that the client understands the 6uestions being asked and directions being gien.

Rationa$e 2: The name on the door might not hae been updated. The best source of erification is the client0s

identification band.

Rationa$e 3: (acilities may utili7e wrist bands for allergy alerts" howeer, it is safer to ask the client to be sure it

wasn0t omitted.

Rationa$e : rienting the client to the operation of the bedside unit will help to aoid in8uries.

Rationa$e : $plaining all procedures and actiities as the admission progresses will help to ease client aniety

and fear of the unknown.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 1

Type: MCMA

The nursing student obseres seeral admissions during the course of the clinical rotation. 9hich of the following

would the student want to include during the admission of his first client1






1. Complete documentation fully.

2. )espect client0s dress and dietary customs.

3. eae the physical eam for the net shift.

. Allow time for the client to rest after the process.

. Complete the process as 6uickly as possible.


Rationa$e 1: Complete admission documentation will ensure aailability of the information to all caregiers.

Rationa$e 2: Clients from different cultures might re6uire special clothing or foods. Communicate these needs toappropriate staff.

Rationa$e 3: The admission process should be completed in a timely fashion, so that baseline documentation isrecorded.

Rationa$e : The admitting process can be stressful and tiring, especially for the client who re6uires a translator.

Rationa$e : Completing the admission process in a timely, unhurried fashion will help to keep the client0saniety reduced. This gies the client time to ask 6uestions and clarify concerns.

%$o&a$ Rationa$e:




(earning ut!ome:

Question 1

Type: MCSA

The ;ealth 'nsurance &ortability and Accountability Act of -<<= mandated regulations to goern which of thefollowing1

1. &riacy standards for healthcare information

2. &riacy standards for healthcare employee personal information

3. >eeping medical records priate for ? years

. &assword protection specifics





Corre!t "ns#er: -

Rationa$e 1: ;'&AA regulations specify purposes for which information may and may not be released withoutauthori7ation from the client.

Rationa$e 2: ;'&AA does not apply to employee information.

Rationa$e 3: ;'&AA does not specify a time limit" records must be kept priate under the guidelines.

Rationa$e : $lectronic medical records must be kept priate, and password protection on computers is one leel

of protection. ;'&AA does not detail specifics.

%$o&a$ Rationa$e:

Cogniti'e (e'e$: )emembering


C$ient Need )u&:


(earning ut!ome:

Question 2

Type: MCMA

/uring the admission of a client to the unit, the nursing student answers a phone call from a @friend of the client

9hich of the following information about the client is the student allowed to gie the phone caller1


1. Client0s diagnosis

2. Client0s condition

3. Client0s location

. Cause of death

. /ischarge location

Corre!t "ns#er: *,3

Rationa$e 1: The client0s diagnosis may not be released without written authori7ation from the client.

Rationa$e 2: A one!word description of the client0s condition can be released if the in6uirer identifies the clientspecifically by name and the client has not opted out of release of that information.

Rationa$e 3: The client0s location can be released, giing location such as inpatient or outpatient, if the indiidua

identifies the client by name, unless the information could embarrass or endanger the client.





Rationa$e : Cause of death must come from the client0s physician, and a legal representatie of the deceasedmust approe the release of information.

Rationa$e : /ischarge date can be released, if the client is identified by name, but the discharge location is not

released.

%$o&a$ Rationa$e:

Cogniti'e (e'e$: ApplyingC$ient Need: Safe $ffectie Care $nironment

C$ient Need )u&:


(earning ut!ome:

Question 21

Type: MCSA

;'&AA and the American )ecoery and )einestment Act of *< specify that personal health records must be

protected. %urses can protect client priacy by:

1. 9hispering when discussing clients in the eleator.

2. &lacing flow sheets on the client0s bed.

3. %ot posting clients0 names where they can be iewed by isitors.

. Sharing passwords with floating nurses.

Corre!t "ns#er: 3

Rationa$e 1: ;ealthcare professionals should not discuss clients in public places.

Rationa$e 2: (low sheets and charts should be kept at the nurse0s station.

Rationa$e 3: Clients0 names should not be posted where they can be iewed.

Rationa$e : &asswords should not be shared.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 22

Type: MCMA





The nurse is transferring a client from an acute care facility to a skilled nursing facility. 9hich of the followingneeds to accompany the client1


1. Medications

2. Current medication list

3. /ocumentation of surgical procedures

. /ocumentation of decubitus si7e and condition

. Medical record


Rationa$e 1: Medications do not need to accompany the client, unless there is a speciali7ed, difficult!to!obtain

medication.

Rationa$e 2: A current medication list needs to accompany the client, so that the receiing facility knows what is

being administered.

Rationa$e 3: /ocumentation of procedures and dates is important, especially if client is transferring forrehabilitation from surgery.

Rationa$e : /ocumentation of decubitus is necessary for continuing ealuation.

Rationa$e : The medical record, either part or the entire record, should accompany the client, or be sent

electronically.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 23

Type: MCSA

The nurse is preparing to transfer a client from the 'C# to the general surgical unit. The client seems anious.+efore helping the client into the wheelchair for transfer, which of the following is the most appropriate response by the nurse1

1. @Bou seem nerous about moing to the new unit. 's there something worrying you1

2. @Bou will like the new unit. 't is much 6uieter than the 'C#.





3. @Bour family will be so happy that you are moing out of the 'C#.

. @9e hae all your belongings. /id you send anything to Security1

Corre!t "ns#er: -

Rationa$e 1: (ear of the unknown might be causing increased aniety, een though the transfer to a stepdown un

indicates progress.



Rationa$e : This response does not address the client0s feelings.

%$o&a$ Rationa$e:



C$ient Need )u&:Nursing*+ntegrated Con!epts: %ursing &rocess: 'mplementation

(earning ut!ome:

Question 2

Type: MCSA

The nursing care plan addresses discharge planning:

1. 9hen nursing outcomes and client goals are met.

2. The first postoperatie day.

3. The day the client is admitted.

. After teaching is completed.

Corre!t "ns#er: 3

Rationa$e 1: %ursing outcomes and client goals can be long!term, and inappropriate to meet in the current setting

Rationa$e 2: %ot all clients hae surgery, and the recoery goals might be long!term.

Rationa$e 3: /ischarge planning begins with admission, and the planning and teaching continue until clients are

safe in their transportation home.

Rationa$e : &lanning and teaching should be ongoing through the recoery process.

%$o&a$ Rationa$e:







C$ient Need )u&:


(earning ut!ome:

Question 2

Type: MCMA

The &%2% collects data prior to discharge about the following issues:


1. The client0s understanding of the discharge instructions

2. Support system for the client

3. Accompanying the client to transportation on discharge

. &rinted discharge instructions

. ;ome enironment and safety


Rationa$e 1: Assessing how the client interprets the instructions is essential" confusion about diet, medication,

special procedures, or eercise and actiity might be present.

Rationa$e 2: Significant others must become part of the discharge process.

Rationa$e 3: Accompanying the client to the transportation is not part of the data!collection process.

Rationa$e : &rinted discharge instructions are part of client teaching, and not part of data collection.

Rationa$e : Clients might feel insecure about home safety" they might feel that their liing space will not

accommodate the medical supplies and e6uipment they need.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 2/

Type: MCMA

The discharge process is completed when:






1. The nurse closes the door on the client0s transportation ehicle.

2. The nurse report that the discharge is complete is gien to the nurse manager.

3. The client0s reaction to discharge is recorded on the client0s medical record.

. The discharge time, transportation, and who accompanied client are recorded in the client0s medical record.

. The client signs the discharge instructions.


Rationa$e 1: The person who accompanies the client to the transportation is not finished with the process at that

time. /ocumentation needs to be done.

Rationa$e 2: )eport that the client is safely in transportation is gien to the nurse manager.

Rationa$e 3: /ocumentation of the client0s reaction is made in the client0s medical record.

Rationa$e : /ate and time and other pertinent details about the discharge are documented in the client0s record.

Rationa$e : The client has not been officially discharged when the discharge instruction sheet is signed. #ntil th

client is safely in transportation, the client remains the nurse0s responsibility.

%$o&a$ Rationa$e:



C$ient Need )u&:Nursing*+ntegrated Con!epts: %ursing &rocess: $aluation

(earning ut!ome:

Question 20

Type: MCSA

9hen admitting a client to the unit, the nurse would do which of the following to help the client feel a greater

leel of control oer the situation in order to reduce aniety1

1. Call him Charles, so he feels that he is among friends.

2. Ask him whether he would like his shaing kit in the bathroom or by his bed.

3. Tell him that he has to take off all his clothes and put on a hospital gown.

. Show him to his room, and then leae him alone for a while to ad8ust.





Corre!t "ns#er: *

Rationa$e 1: +y giing the client choices, the nurse helps to reliee some of the clientDs aniety by giing theclient a measure of control for how his care will be proided. Calling the client by his first name is disrespectful.

&lacing the client in a hospital gown, while necessary, makes the client feel like less of an indiidual. eaing the

client alone in a strange enironment could make him feel more anious and alone.

Rationa$e 2: +y giing the client choices, the nurse helps to reliee some of the clientDs aniety by giing the

client a measure of control for how his care will be proided. Calling the client by his first name is disrespectful.&lacing the client in a hospital gown, while necessary, makes the client feel like less of an indiidual. eaing the


Rationa$e 3: +y giing the client choices, the nurse helps to reliee some of the clientDs aniety by giing theclient a measure of control for how his care will be proided. Calling the client by his first name is disrespectful.

&lacing the client in a hospital gown, while necessary, makes the client feel like less of an indiidual. eaing the


Rationa$e : +y giing the client choices, the nurse helps to reliee some of the clientDs aniety by giing theclient a measure of control for how his care will be proided. Calling the client by his first name is disrespectful.

&lacing the client in a hospital gown, while necessary, makes the client feel like less of an indiidual. eaing theclient alone in a strange enironment could make him feel more anious and alone.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:


9hen admitting a * -*!year!old child, the nurseDs priority interention to reduce aniety would be which of the

following1

1. rienting her to the unit

2. +ringing toys to the room to distract her

3. 'ntroducing the staff to the child

. $ncouraging the mother to remain with the child

Corre!t "ns#er: 4





Rationa$e 1: The *!year!old is most concerned with separation from the parent. $ncouraging the mother to staywill help decrease the childDs leel of aniety. ffering toys, introducing staff, and orienting the girl to the unit are

tactics that might be helpful once the initial aniety is allayed but would not be the nurseDs first actions.

Rationa$e 2: The *!year!old is most concerned with separation from the parent. $ncouraging the mother to stay

will help decrease the childDs leel of aniety. ffering toys, introducing staff, and orienting the girl to the unit aretactics that might be helpful once the initial aniety is allayed but would not be the nurseDs first actions.

Rationa$e 3: The *!year!old is most concerned with separation from the parent. $ncouraging the mother to staywill help decrease the childDs leel of aniety. ffering toys, introducing staff, and orienting the girl to the unit are


Rationa$e : The *!year!old is most concerned with separation from the parent. $ncouraging the mother to stay

will help decrease the childDs leel of aniety. ffering toys, introducing staff, and orienting the girl to the unit are


%$o&a$ Rationa$e:


C$ient Need: &sychosocial 'ntegrityC$ient Need )u&:


(earning ut!ome:

Question 2

Type: MCSA

9hile admitting a client who speaks no $nglish, the nurse opts to use the hospital translator instead of a family

member for which of the following reasons1

1. The family does not speak $nglish well enough to interpret medical terms.

2. The client looks scared, and probably does not want the family in the room.

3. The interpreter has more eperience in the medical field.

. The family is too emotionally inoled, and might not be accurate in their interpretations.

Corre!t "ns#er: 4

Rationa$e 1: 't is usually best not to use the family, because they are emotionally inoled with the client, andmight add information that is not true, or might not gie the client all the information to spare feelings. 'noling

the family is a breach of client confidentiality. An interpreter will be ob8ectie, and will report eactly what the

health care proider says. The nurse is not likely to know yet what capabilities the family has regarding medicalterminology, and could not identify the clientDs fear as coming from the presence of family in the room.

Rationa$e 2: 't is usually best not to use the family, because they are emotionally inoled with the client, and

might add information that is not true, or might not gie the client all the information to spare feelings. 'noling





the family is a breach of client confidentiality. An interpreter will be ob8ectie, and will report eactly what thehealth care proider says. The nurse is not likely to know yet what capabilities the family has regarding medical

terminology, and could not identify the clientDs fear as coming from the presence of family in the room.

Rationa$e 3: 't is usually best not to use the family, because they are emotionally inoled with the client, and

might add information that is not true, or might not gie the client all the information to spare feelings. 'nolingthe family is a breach of client confidentiality. An interpreter will be ob8ectie, and will report eactly what the

health care proider says. The nurse is not likely to know yet what capabilities the family has regarding medical

terminology, and could not identify the clientDs fear as coming from the presence of family in the room.

Rationa$e : 't is usually best not to use the family, because they are emotionally inoled with the client, andmight add information that is not true, or might not gie the client all the information to spare feelings. 'noling

the family is a breach of client confidentiality. An interpreter will be ob8ectie, and will report eactly what the

health care proider says. The nurse is not likely to know yet what capabilities the family has regarding medicalterminology, and could not identify the clientDs fear as coming from the presence of family in the room.

%$o&a$ Rationa$e:




(earning ut!ome:

Question 3

Type: MCSA

9hen preparing the room for a new clientDs admission, the nurseDs priority action is which of the following1

1. Compile forms in the the clientDs chart, and hae it ready in the room.

2. btain a wheelchair, and go to Admissions to get the client.

3. Check the clientDs chart for physicianDs orders.

. $nsure that the room is ade6uately prepared for the client.

Corre!t "ns#er: 4

Rationa$e 1: The first priority is to see that the client has a clean, properly prepared room upon arrial to the unitThis will help the client feel welcome and will improe the efficiency of the admission process. The chart will

come with the client with the physicianDs orders, so it would not be aailable to the nurse until the client arries.

The client is transported to the unit by the Admitting /epartment, whether that is the $mergency /epartment orthe business office.

Rationa$e 2: The first priority is to see that the client has a clean, properly prepared room upon arrial to the unit

This will help the client feel welcome and will improe the efficiency of the admission process. The chart will

come with the client with the physicianDs orders, so it would not be aailable to the nurse until the client arries.





The client is transported to the unit by the Admitting /epartment, whether that is the $mergency /epartment orthe business office.

Rationa$e 3: The first priority is to see that the client has a clean, properly prepared room upon arrial to the unit

This will help the client feel welcome and will improe the efficiency of the admission process. The chart will

come with the client with the physicianDs orders, so it would not be aailable to the nurse until the client arries.The client is transported to the unit by the Admitting /epartment, whether that is the $mergency /epartment or

the business office.

Rationa$e : The first priority is to see that the client has a clean, properly prepared room upon arrial to the unit

This will help the client feel welcome and will improe the efficiency of the admission process. The chart willcome with the client with the physicianDs orders, so it would not be aailable to the nurse until the client arries.

The client is transported to the unit by the Admitting /epartment, whether that is the $mergency /epartment or

the business office.

%$o&a$ Rationa$e:




(earning ut!ome:

Question 31

Type: MCSA

The nurse obseres the unit clerk proiding the hospital chaplain with clientsD religious affiliations. The nurseDs

priority action is to:

1. /o nothing.

2. Stop the unit clerk and reprimand her priately for sharing priileged information.

3. 'nform the chaplain that signed permission will be re6uired to proide that information.

. /o nothing, but speak to the unit clerk later about ;'&AA priacy laws.

Corre!t "ns#er: -

Rationa$e 1: According to the ;'&AA laws, it is acceptable to gie clergy a list of clientDs names and their locatio

if they are affiliated with the clergymanDs religion. The client does not need to be notified in this case, and signed

consent is not re6uired.

Rationa$e 2: According to the ;'&AA laws, it is acceptable to gie clergy a list of clientDs names and their locatioif they are affiliated with the clergymanDs religion. The client does not need to be notified in this case, and signed






Rationa$e 3: According to the ;'&AA laws, it is acceptable to gie clergy a list of clientDs names and their locatioif they are affiliated with the clergymanDs religion. The client does not need to be notified in this case, and signed


Rationa$e : According to the ;'&AA laws, it is acceptable to gie clergy a list of clientDs names and their locatio

if they are affiliated with the clergymanDs religion. The client does not need to be notified in this case, and signedconsent is not re6uired.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 32

Type: MCSA

9hile eating lunch in the cafeteria, a nurse asks the respiratory therapist for an update on the condition of a client

transferred off the unit yesterday. The respiratory therapist relates that the clientDs condition worsened this

morning. 9hich of the following is true regarding ;'&AA regulations in this instance1

1. There are no ;'&AA iolations.

2. The nurse iolated the clientDs confidentiality.

3. The respiratory therapist iolated the clientDs confidentiality.

. +oth the respiratory therapist and the nurse iolated the clientDs confidentiality.

Corre!t "ns#er: 4

Rationa$e 1: +oth the nurse and the respiratory therapist iolated the clientDs confidentiality when they held a

discussion, containing priate client information, in a public place, and the nurse no longer has a need to know

about the clientDs status.

Rationa$e 2: +oth the nurse and the respiratory therapist iolated the clientDs confidentiality when they held a

discussion, containing priate client information, in a public place, and the nurse no longer has a need to know


Rationa$e 3: +oth the nurse and the respiratory therapist iolated the clientDs confidentiality when they held adiscussion, containing priate client information, in a public place, and the nurse no longer has a need to know


Rationa$e : +oth the nurse and the respiratory therapist iolated the clientDs confidentiality when they held a

discussion, containing priate client information, in a public place, and the nurse no longer has a need to knowabout the clientDs status.





%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:


The nurse admits a client, and begins by orienting the client to the room and measuring ital signs. 9hat does the

nurse say net1

1. E't has been nice meeting you, and 'Dll see you later.E

2. E' will be your nurse for today, so use the call bell if you need something.E

3. EMrs. Fones, do you hae any 6uestions1 ' hae time now.E

. EMrs. Fones, would you like a tour of the unit1E

Corre!t "ns#er: 3

Rationa$e 1: 9hen orientation for the client is completed, it is important to allow the client to ask 6uestions in an

unhurried manner. A tour of the unit is not usually indicated. 'nstructing the client to use the call bell or saying

that it was nice to meet them indicates the admission process is completed, which is not true in this case.


unhurried manner. A tour of the unit is not usually indicated. 'nstructing the client to use the call bell or sayingthat it was nice to meet them indicates the admission process is completed, which is not true in this case.


unhurried manner. A tour of the unit is not usually indicated. 'nstructing the client to use the call bell or sayingthat it was nice to meet them indicates the admission process is completed, which is not true in this case.

Rationa$e : 9hen orientation for the client is completed, it is important to allow the client to ask 6uestions in an

unhurried manner. A tour of the unit is not usually indicated. 'nstructing the client to use the call bell or saying

that it was nice to meet them indicates the admission process is completed, which is not true in this case.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:





Question 3

Type: MCSA

The nurse, during the admission process, finds the client has brought his watch and wallet with him. The best

action by the nurse is which of the following1

1. Send the aluables home with the family.

2. &lace the aluables in the bedside table.

3. ock the aluable in a drawer at the nurseDs station.

. Make a list of the items, including descriptions, and place the list in the chart.

Corre!t "ns#er: -

Rationa$e 1: The best action is to send the aluables home with family. 'f the client has no family, most hospitalshae proisions for the aluable to be gien to Security for safekeeping in a locked safe in the business office. Th

client may opt to keep the items, but might need to sign a waier of facility liability in case anything is stolen or

lost. The nurseDs station is not an option for keeping clientsD aluables.







Rationa$e : The best action is to send the aluables home with family. 'f the client has no family, most hospitalshae proisions for the aluable to be gien to Security for safekeeping in a locked safe in the business office. Th



%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 3

Type: MCSA





After completing orientation to the facility, the nurse recogni7es further instructions are re6uired when the client

makes which of the following statements1

1. E' will send my aluables home with my wife.E

2. E' will take my prescription medications as ' took them at home.E

3. EMy wife may isit any time she chooses.E

. E' should ring my call bell if ' need the nurse.E

Corre!t "ns#er: *

Rationa$e 1: nce the client enters the hospital, the client home medications are discontinued, and the client is

encouraged to send the medications home with the aluables. The clientDs medications will be ordered by the physician and dispensed by the nurse. The remaining comments made by the client are correct.


encouraged to send the medications home with the aluables. The clientDs medications will be ordered by the

physician and dispensed by the nurse. The remaining comments made by the client are correct.


encouraged to send the medications home with the aluables. The clientDs medications will be ordered by the


Rationa$e : nce the client enters the hospital, the client home medications are discontinued, and the client isencouraged to send the medications home with the aluables. The clientDs medications will be ordered by the


%$o&a$ Rationa$e:



C$ient Need )u&:

Nursing*+ntegrated Con!epts: %ursing &rocess: $aluation

(earning ut!ome:

Question 3/

Type: MCMA

The nurse is transferring a client to another unit because the client has improed, and no longer re6uires acutecare. 9hen preparing the clientDs transfer, the nurse includes which of the following1 Select all that apply.


1. Signing physicianDs orders

2. 'nforming the client of the reason for transfer





3. Assisting the client to gather belongings

. &reparing report for the receiing unit

. Gathering the clientDs medications and medical record


Rationa$e 1: 9hen transferring a client to another unit, the need for transfer should be eplained to the client, andshe should be assisted to gather their belongings. The nurse proides report to the receiing unit, gathers

medications and the medical record, and prepares the client from transfer. The physician must sign orders, not thenurse.

Rationa$e 2: 9hen transferring a client to another unit, the need for transfer should be eplained to the client, and

she should be assisted to gather their belongings. The nurse proides report to the receiing unit, gathers


Rationa$e 3: 9hen transferring a client to another unit, the need for transfer should be eplained to the client, and

she should be assisted to gather their belongings. The nurse proides report to the receiing unit, gathersmedications and the medical record, and prepares the client from transfer. The physician must sign orders, not thenurse.

Rationa$e : 9hen transferring a client to another unit, the need for transfer should be eplained to the client, and



Rationa$e : 9hen transferring a client to another unit, the need for transfer should be eplained to the client, and



%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:


The nurse is transferring a client from the 'C# to a medical!surgical floor because his condition has improed.

9hich of the following is the nurseDs highest priority when transferring this client1

1. $nsuring that the client is greeted on the new unit





2. $nsuring that the client is comfortable and not in pain

3. Securing the clientDs belongings

. Maintaining the safety of the client

Corre!t "ns#er: 4

Rationa$e 1: The priority of the nurse during transfer is the safety of the client. The nurse is responsible fornotifying the staff when they arrie so the client can be greeted, should assure that the clientDs pain is controlled,

and should secure the clientDs belongings. ;oweer, the primary concern is for the safety of the client.

Rationa$e 2: The priority of the nurse during transfer is the safety of the client. The nurse is responsible fornotifying the staff when they arrie so the client can be greeted, should assure that the clientDs pain is controlled,

and should secure the clientDs belongings. ;oweer, the primary concern is for the safety of the client

Rationa$e 3: The priority of the nurse during transfer is the safety of the client. The nurse is responsible for

notifying the staff when they arrie so the client can be greeted, should assure that the clientDs pain is controlled,and should secure the clientDs belongings. ;oweer, the primary concern is for the safety of the client.

Rationa$e : The priority of the nurse during transfer is the safety of the client. The nurse is responsible for

notifying the staff when they arrie so the client can be greeted, should assure that the clientDs pain is controlled,and should secure the clientDs belongings. ;oweer, the primary concern is for the safety of the client.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 3

Type: MCMA

The client informs the nurse that he is going home in the absence of a physicianDs order for discharge. The priority

nursing actions include which of the following1 Select all that apply.


1. )e6uire the client to wait until the physician can arrie to talk with the client.

2. %otify the physician that the client is planning to leae.

3. ;ae the client sign a form stating that he has been adised not to leae.

. %otify the charge nurse or superisor.





. %otify the pharmacy.


Rationa$e 1: The client must sign a form stating that he has been adised not to leae, and the physician andcharge nurse should be notified immediately, preferably before the client leaes the unit. Some facilities might

re6uire the nursing superisor to obtain the clientDs signature on the AMA form, while others allow the staff nurse

to perform this task. The client cannot be re6uired to wait, as that would constitute false imprisonment. The

pharmacy can be notified to discontinue the medications after the client has left the hospital" this is not a priorityinterention.

Rationa$e 2: The client must sign a form stating that he has been adised not to leae, and the physician and

charge nurse should be notified immediately, preferably before the client leaes the unit. Some facilities mightre6uire the nursing superisor to obtain the clientDs signature on the AMA form, while others allow the staff nurse



Rationa$e 3: The client must sign a form stating that he has been adised not to leae, and the physician and

charge nurse should be notified immediately, preferably before the client leaes the unit. Some facilities mightre6uire the nursing superisor to obtain the clientDs signature on the AMA form, while others allow the staff nurseto perform this task. The client cannot be re6uired to wait, as that would constitute false imprisonment. The

pharmacy can be notified to discontinue the medications after the client has left the hospital" this is not a priority

interention.

Rationa$e : The client must sign a form stating that he has been adised not to leae, and the physician andcharge nurse should be notified immediately, preferably before the client leaes the unit. Some facilities might

re6uire the nursing superisor to obtain the clientDs signature on the AMA form, while others allow the staff nurse

to perform this task. The client cannot be re6uired to wait, as that would constitute false imprisonment. The pharmacy can be notified to discontinue the medications after the client has left the hospital" this is not a priority

interention.

Rationa$e : The client must sign a form stating that he has been adised not to leae, and the physician and

charge nurse should be notified immediately, preferably before the client leaes the unit. Some facilities mightre6uire the nursing superisor to obtain the clientDs signature on the AMA form, while others allow the staff nurse



%$o&a$ Rationa$e:

Cogniti'e (e'e$: ApplyingC$ient Need: Safe $ffectie Care $nironment

C$ient Need )u&:


(earning ut!ome:

Question 3





Type: MCSA

9hile discharging a client newly diagnosed with heart disease, the family asks about support groups in the area.

The nurseDs best response would be to:

1. Call the physician and ask for a referral.

2. Call the charge nurse and ask for a referral.

3. Call the American ;eart Association and obtain information about support groups to proide to the client.

. Tell the client that the staff cannot gie out that information.

Corre!t "ns#er: 3

Rationa$e 1: 9hen a client asks the nurse for help with referrals for self!help groups or groups related to

education of a particular disease process, the nurse is capable of assisting the client without consulting the

physician or nurse manager. Community referrals are a nursing responsibility.

Rationa$e 2: 9hen a client asks the nurse for help with referrals for self!help groups or groups related toeducation of a particular disease process, the nurse is capable of assisting the client without consulting the


Rationa$e 3: 9hen a client asks the nurse for help with referrals for self!help groups or groups related toeducation of a particular disease process, the nurse is capable of assisting the client without consulting the


Rationa$e : 9hen a client asks the nurse for help with referrals for self!help groups or groups related to

education of a particular disease process, the nurse is capable of assisting the client without consulting the physician or nurse manager. Community referrals are a nursing responsibility.

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question

Type: MCSA

The nurse is discharging the client who is a newly diagnosed diabetic. 9hich of the following is a priority for the

nurse1

1. %otifying the business office that the client is leaing

2. %otifying the physician that the client is leaing)amont, %iedringhous, Comprehensive Nursing Care *nd $dition #pdate Test +ank




3. /etermining the clientDs leel of understanding of home care

. )eturning all client aluables

Corre!t "ns#er: 3

Rationa$e 1: The nursing priorities for any client at discharge are completing client teaching and ealuating the

clientDs leel of understanding. The physician already knows the client is leaing because an order is re6uired for

discharge. %otifying the business office and returning aluables are important aspects of discharge, but are not thnursing priority.






discharge. %otifying the business office and returning aluables are important aspects of discharge, but are not th

nursing priority.

Rationa$e : The nursing priorities for any client at discharge are completing client teaching and ealuating the



%$o&a$ Rationa$e:




(earning ut!ome:

Question 1

Type: MCSA

The nurse is preparing to document the discharge of the client after the client has left. 9hich of the following is

the proper discharge documentation1

1. /ischarged by wheelchair at <45. 9ife collected belongings.

2. /ischarged by wheelchair at <45 accompanied by wife. Assisted into car. Client states he is ready to go home

3. /ischarged by wheelchair to car with belongings.

. /ischarged by wheelchair at <45.





Corre!t "ns#er: *

Rationa$e 1: 9hen documenting a discharge, the nurse charts how the client was discharged, with whom theclient was discharged, and how the client tolerated the procedure.

Rationa$e 2: 9hen documenting a discharge, the nurse charts how the client was discharged, with whom the

client was discharged, and how the client tolerated the procedure.

Rationa$e 3: 9hen documenting a discharge, the nurse charts how the client was discharged, with whom theclient was discharged, and how the client tolerated the procedure.

Rationa$e : 9hen documenting a discharge, the nurse charts how the client was discharged, with whom the

client was discharged, and how the client tolerated the procedure.

%$o&a$ Rationa$e:



C$ient Need )u&:

Nursing*+ntegrated Con!epts: %ursing &rocess: 'mplementation(earning ut!ome:

Ramont2e Rev TIF Ch11

Documents

Transcript of Ramont2e Rev TIF Ch11