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TEST BANK
Concepts for nursing practice
4th edition by Giddens
Chapter 1 to 60
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TABLE OF CONTENT

1. Development
2. Functional Ability
3. Family Dynamics
4. Culture
5. Self-Management
6. Fluid and Electrolytes
7. Acid-Base Balance
8. Thermoregulation
9. Sleep
10. Cellular Regulation
11. Intracranial Regulation
12. Hormonal Regulation
13. Glucose Regulation
14. Nutrition
15. Elimination
16. Perfusion
17. Clotting — NEW!
18. Gas Exchange
19. Reproduction
20. Sexuality
21. Immunity
22. Inflammation
23. Infection
24. Mobility
25. Tissue Integrity
26. Sensory Perception
27. Pain
28. Fatigue
29. Stress and Coping
30. Mood and Affect
31. Anxiety
32. Cognition
33. Psychosis
34. Substance Misuse and Addiction
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35. Interpersonal Violence
36. Professional Identity
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37. Well-Being and Resilience — NEW!
38. Leadership
39. Evidence
40. Clinical Judgment
41. Person-Centered Care — NEW!
42. Ethics
43. Diversity, Equity, and Inclusion — NEW!
44. Communication
45. Collaboration
46. Safety
47. Health Care Quality
48. Technology and Informatics
49. Health Disparities and Health Equity
50. Care Coordination
51. Health Promotion
52. Patient Education
53. Palliative Care
54. Population Health
55. Public Health Emergencies — NEW!
56. Spheres of Practice — NEW!
57. Health Systems
58. Health Care Economics
59. Health Policy
60. Health Care Law
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Concept 01: Development
Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

1. The nurse manager of a pediatric clinic could confirm that the new nurse
recognized the purpose of the HEADSS Adolescent Risk Profile when the new
nurse responds that it is used to assess for needs related to
a. anticipatory guidance.
b. low-risk adolescents.
c. physical development.
d. sexual development.
ANS: A
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool
which assesses home, education, activities, drugs, sex, and suicide for the purpose
of identifying high-risk adolescents and the need for anticipatory guidance. It is
used to identify high-risk, not low-risk, adolescents. Physical development is
assessed with anthropometric data.
Sexual development is assessed using physical examination.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

2. The nurse preparing a teaching plan for a preschooler knows that, according to
Piaget, the expected stage of development for a preschooler is
a. concrete operational.
b. formal operational. N
c. preoperational.
d. sensorimotor.
ANS: C
The expected stage of development for a preschooler (3–4 years old) is pre-
operational. Concrete operational describes the thinking of a school-age child (7–11
years old). Formal operational describes the thinking of an individual after about 11
years of age. Sensorimotor describes the earliest pattern of thinking from birth to 2
years old.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

3. The school nurse talking with a high school class about the difference between
growth and development would best describe growth as
a. processes by which early cells specialize.
b. psychosocial and cognitive changes.
c. qualitative changes associated with aging.
d. quantitative changes in size or
weight. ANS: D

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Growth is a quantitative change in which an increase in cell number and size
results in an increase in overall size or weight of the body or any of its parts. The
processes by which early cells specialize are referred to as differentiation.
Psychosocial and cognitive changes are referred to as development. Qualitative
changes associated with aging are referred to as maturation.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

4. The most appropriate response of the nurse when a mother asks what the Denver
II does is that it
a. can diagnose developmental disabilities.
b. identifies a need for physical therapy.
c. is a developmental screening tool.
d. provides a framework for health teaching.
ANS: C
The Denver II is the most commonly used measure of developmental status used
by healthcare professionals; it is a screening tool. Screening tools do not provide a
diagnosis. Diagnosis requires a thorough neurodevelopment history and physical
examination.
Developmental delay, which is suggested by screening, is a symptom, not a diagnosis.
The need for any therapy would be identified with a comprehensive evaluation, not a
screening tool. Some providers use the Denver II as a framework for teaching about
expected development, but this is not the primary purpose of the tool.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

5. To plan early intervention a n Nd care for an infant with Down syndrome, the
nurse considers knowledge of other physical development exemplars such as
a. cerebral palsy.
b. autism.
c. attention-deficit/hyperactivity disorder (ADHD).
d. failure to thrive.
ANS: D
Failure to thrive is also a physical development exemplar. Cerebral palsy is an
exemplar of motor/developmental delay. Autism is an exemplar of social/emotional
developmental delay. ADHD is an exemplar of a cognitive disorder.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

6. To plan early intervention and care for a child with a developmental delay, the
nurse would consider knowledge of the concepts most significantly impacted by
development, including
a. culture.
b. environment.
c. functional status.
d. nutrition.
ANS: C
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Function is one of the concepts most significantly impacted by development. Others
include sensory-perceptual, cognition, mobility, reproduction, and sexuality.
Knowledge of these concepts can help the nurse anticipate areas that need to be
addressed. Culture is a concept that is considered to significantly affect
development; the difference is the concepts that affect development are those that
represent major influencing factors (causes); hence determination of development
would be the focus of preventive interventions. Environment is considered to
significantly affect development. Nutrition is considered to significantly affect
development.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

7. A mother complains to the nurse at the pediatric clinic that her 4-year-old child
always talks to her toys and makes up stories. The mother wants her child to have
a psychological evaluation. The nurse’s best initial response is to
a. refer the child to a psychologist immediately.
b. explain that playing make believe is normal at this age.
c. complete a developmental screening using a validated tool.
d. separate the child from the mother to get more information.
ANS: B
By the end of the fourth year, it is expected that a child will engage in fantasy, so
this is normal at this age. A referral to a psychologist would be premature based
only on the complaint of the mother. Completing a developmental screening would
be very appropriate but not the initial response. The nurse would certainly want to
get more information, but separating the child from the mother is not necessary at
this time.

OBJ: NCLEX Client NeedsNCategory: Health Promotion and Maintenance

8. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse
why she is so needy and acting like a child. The best response of the nurse is
that in the hospital, adolescents
a. have separation anxiety.
b. rebel against rules.
c. regress because of stress.
d. want to know everything.
ANS: C
Regression to an earlier stage of development is a common response to stress.
Separation anxiety is most common in infants and toddlers. Rebellion against
hospital rules is usually not an issue if the adolescent understands the rules and
would not create childlike behaviors. An adolescent may want to “know everything”
with their logical thinking and deductive reasoning, but that would not explain why
they would act like a child.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

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Concept 02: Functional Ability
Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

1. The nurse is assessing a patient’s functional ability. Which patient best

demonstrates the definition of functional ability?
a. Considers self as a healthy individual; uses cane for stability
b. College educated; travels frequently; can balance a checkbook
c. Works out daily, reads well, cooks, and cleans house on the weekends
d. Healthy individual, volunteers at church, works part time, takes care of
family and house
ANS: D
Functional ability refers to the individual’s ability to perform the normal daily
activities required to meet basic needs; fulfill usual roles in the family, workplace,
and community; and maintain health and well-being. The other options are good;
however, healthy individual, church volunteer, part time worker, and the patient
who takes care of the family and house fully meets the criteria for functional
ability.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

2. The nurse is assessing a patient’s functional performance. What assessment

parameters will be most important in this assessment?
a. Continence assessment, gait assessment, feeding assessment, dressing assessment,
transfer assessment N
b. Height, weight, body mass index (BMI), vital signs assessment
c. Sleep assessment, energy assessment, memory assessment,
concentration assessment
d. Health and well-being, amount of community volunteer time, working
outside the home, and ability to care for family and house
ANS: A
Functional impairment, disability, or handicap refers to varying degrees of an
individual’s inability to perform the tasks required to complete normal life activities
without assistance. Height, weight, BMI, and vital signs are part of a physical
assessment. Sleep, energy, memory, and concentration are part of a depression
screening. Healthy, volunteering, working, and caring for family and house are
functional abilities, not performance.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk

Potential

3. The nurse is assessing a patient with a mobility dysfunction and wants to gain
insight into the patient’s functional ability. What question would be the most
appropriate?
a. “Are you able to shop for yourself?”
b. “Do you use a cane, walker, or wheelchair to ambulate?”
c. “Do you know what today’s date is?”
d. “Were you sad or depressed more than once in the last 3

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days?” ANS: B

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“Do you use a cane, walker, or wheelchair to ambulate?” will assist the nurse in
determining the patient’s ability to perform self-care activities. A nutritional health
risk assessment is not the functional assessment. Knowing the date is part of a
mental status exam. Assessing sadness is a question to ask in the depression
screening.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is developing an interdisciplinary plan of care using the Roper-Logan-

Tierney Model of Nursing for a patient who is currently unconscious. Which
interventions would be most critical to developing a plan of care for this patient?
a. Eating and drinking, personal cleansing and dressing, working and playing
b. Toileting, transferring, dressing, and bathing activities
c. Sleeping, expressing sexuality, socializing with peers
d. Maintaining a safe environment, breathing, maintaining temperature
ANS: D
The most critical aspects of care for an unconscious patient are safe environment,
breathing, and temperature. Eating and drinking are contraindicated in unconscious
patients. Toileting, transferring, dressing, and bathing activities are BADLs. Sleeping,
expressing sexuality, and socializing with peers are a part of the Roper-Logan-Tierney
Model of Nursing; however, these are not the most critical for developing the plan
of care in an unconscious patient.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. The home care nurse is trying to determine the necessary services for a 65-year-old
patient who was admitted to the home care service after left knee replacement.
Which tool is the best for the nurse to utilize? N
a. Minimum Data Set (MDS)
b. Functional Status Scale (FSS)
c. 24-Hour Functional Ability Questionnaire (24hFAQ)
d. The Edmonton Functional Assessment Tool
ANS: C
The 24hFAQ assesses the postoperative patient in the home setting. The MDS is for
nursing home patients. The FSS is for children. The Edmonton is for cancer patients.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse is assessing a patient’s functional abilities and asks the patient, “How would
you
rate your ability to prepare a balanced meal?” “How would you rate your ability to
balance a checkbook?” “How would you rate your ability to keep track of your
appointments?” Which tool would be indicated for the best results of this patient’s
perception of their abilities?
a. Functional Activities Questionnaire (FAQ)
b. Mini Mental Status Exam (MMSE)
c. 24hFAQ
d. Performance-based functional
measurement ANS: A

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The FAQ is an example of a self-report tool which provides information about the
patient’s perception of functional ability. The MMSE assesses cognitive impairment.
The 24hFAQ is used to assess functional ability in postoperative patients.
Performance-based tools involve actual observation of a standardized task,
completion of which is judged by objective criteria.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. A 65-year-old female patient has been admitted to the medical/surgical unit. The
nurse is assessing the patient’s risk for falls so that falls prevention can be
implemented if necessary. Select all the risk factors that apply from this patient's
history and physical. (Select all that apply.)
a. Being a woman
b. Taking more than six medications
c. Having hypertension
d. Having cataracts
e. Muscle strength 3/5 bilaterally
f. Incontinence
ANS: B, D, E, F
Adverse effects of medications can contribute to falls. Cataracts impair vision,
which is a risk factor for falls. Poor muscle strength is a risk factor for falls.
Incontinence of urine or stool increases risk for falls. Men have a higher risk for
falls. Hypertension itself does not contribute to falls. Taking meNdications to treat
hypertension that may lead to hypotension
and dizziness is a fall risk. Dizziness does contribute to falls.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk
Potential

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Concept 03: Family Dynamics
Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

1. The most appropriate initial nursing intervention when the nurse notes
dysfunctional interactions and lack of family support for a patient would be
to
a. enforce hospital visiting policies.
b. monitor the dysfunctional interactions.
c. notify the primary care provider.
d. role model appropriate support.
ANS: D
Nurses can, at times, role model more appropriate interactions or provide
suggestions for improving communication and interactions among family members.
If the nurse determines that the number of visitors has a negative impact on the
patient, hospital policy may be to limit visitors, but that would not be the initial
action. Monitoring the dysfunctional interactions would not be an adequate
response. The primary care provider should certainly be notified, but that would
not be the initial response.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity

2. The nurse caring for a patient would identify a need for additional interventions
related to family dynamics when
a. extended family offers to help.
b. family members express cNoncern.
c. the ill member demands attention.
d. memories are shared.
ANS: C
It is not uncommon for the ill family member to become demanding and indicate
that they deserve special treatment and care, and the supportive family may need
assistance in understanding the dynamics of the illness in order to continue to be
supportive. Offers from extended family to help can be indicative of positive
dynamics. Concern expressed by family members can be indicative of positive
dynamics. Sharing of family memories can be indicative of positive dynamics.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity

3. Two women have an established long-term relationship and are attending parenting
classes in anticipation of finalizing adoption of a baby. The nurse identifies them
as which type of family?
a. Cohabiting
b. Nuclear
c. Same-sex
d. Single
parent ANS:
C
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This family would be considered a same-sex family. Cohabiting refers to a couple
who live together with no legal bond. Nuclear refers to the traditional male and
female core family with one or more children. Single parent refers to a family
with one adult and one or more children.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity

4. The nurse identifies the family with a child graduating from college as having
which effect on the family life cycle?
a. Minimal impact
b. Considered to be a negative impact on the family unit
c. Leads to role confusion
d. Expectation of role change
ANS: D
The family life cycle developmental theory focuses on the growth and development
of changes in role relationships during transitional periods. A child graduating from
college is an example of a transition which requires a role change. As this is a
transition, one would expect to see a change so minimal impact would not be
expected. Graduation does not imply that it will be a negative change on the family
life cycle or lead to role confusion.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity

5. When reviewing the purposes of a family assessment, the nurse educator would
identify a need for further teaching if the student responded that family assessment
is used to gain an understanding of which aspect of the family?
a. Development N
b. Function
c. Political views
d. Structure
ANS: C
An understanding of the political views of family members is not a primary purpose
of a family assessment. A family assessment provides the nurse with information
and an understanding of family dynamics. This is important to nurses for the
provision of quality health care. A family assessment provides an understanding of
family development, function, and structure.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

6. A nurse is planning to assess the structure of a family. Which question should the
nurse ask?
a. “Who lives with you in this home?”
b. “Who does the grocery shopping?”
c. “Who provides support in your family?”
d. “How old are the members of your
family?” ANS: A

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The structure of the family includes who is in the family and what their
relationship is. “Who does the shopping?” would provide information about family
functioning. “Who provides support?” would provide information about family
functioning. “How old are the members?” would provide information about family
development.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity

7. Which factors which would alert the nurse to negative/dysfunctional family dynamics?
a. Aging of family members
b. Chronic illness of a family member
c. Disability of a family member
d. Intimate partner violence
ANS: D
Intimate partner violence is an exemplar of negative/dysfunctional family dynamics.
Aging of family members is an exemplar of changes to family dynamics. Chronic
illness of a family member is an exemplar of changes to family dynamics.
Disability of a family member is an exemplar of changes to family dynamics.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity

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Concept 04: Culture
Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

1. The nurse is caring for an older Chinese adult male who is grimacing and appears
restless after abdominal surgery. What is the nurse’s best action?
a. Ask the patient if he is anxious about his hospital stay.
b. Ask a translator to conduct a FACES pain scale assessment.
c. Ask the patient about pain and assess vital signs.
d. Ask the patient about any history of depression or anxiety.
ANS: C
In the Chinese culture, elderly Chinese people believe that they must be stoic about
pain and there is a stigma about talking about any mental health problems. The
nurse should ask the patient about pain and also assess vital signs for physiological
signs of pain, since the patient may not admit to any pain. Assuming the patient
is depressed or anxious is not the best action when considering individual cultural
differences and the risk of pain after major surgery. The registered nurse should
never delegate assessment to any unlicensed member of the healthcare team such
as a translator. The translator may assist with communication, but the nurse is
responsible for the pain assessment.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity | NCLEX Client

Needs Category: Physiological Integrity: Basic Care and Comfort

2. Understanding cultural differNences in health care is important because it will help the
nurse to understand the manner in which people decide on obtaining treatments and
medical care.
In independent cultures an individual will
a. put himself first.
b. consult family members for advice.
c. ask for a second opinion.
d. travel great distances to receive the best care.
ANS: A
In independent cultures, an individual will put himself first in the case of a life-
threatening illness, whereas even in dire circumstances, members of collectivist
cultures may still consult other family members for the best course of action. In
independent cultures, an individual will not consult with other family members, ask
for a second opinion, or travel great distances to receive the best care.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity

3. When teaching an Asian patient with newly diagnosed diabetes, the nurse notes the
patient nodding yes to everything that is being said. With a better understanding
of cultural interdependence in self-concept, a nurse should immediately
a. write everything down for the patient to refer to later.
b. prompt further to elicit additional questions or concerns.
c. call the recognized elder for this patient.
d. call the oldest male relative for help with decision making.

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ANS: B
When a nurse provides nutritional education to a patient who is from a culture that
values greater power distance, it might appear that the patient is willing to accept
all that the nurse suggests, when further prompting would elicit additional questions
or concerns. The patient from a collectivist culture will usually consult family
members for a best course of action. It is not acceptable for nurses to take it upon
themselves to call the recognized elder or oldest male relative for help with
decision making. While writing everything down may be OK for some cultures,
with Asian patients it may be best to prompt further to elicit additional questions
or concerns.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity

4. Women who are given the job of caretaker for aging relatives are subject to
caregiver strain due to
a. feminine attributes.
b. unequal gender.
c. fixed gender roles.
d. female inequality.
ANS: C
In cultures with more fixed gender roles, women are usually given the role of
caretaker for aging relatives and may suffer the stresses of caregiver strain.
Feminine attributes refers to harmonious relationships, modesty, and taking care of
others. Unequal gender refers to roles of males and females being unevenly
distributed. Female inequality refers to female gender and roles being less than or
unequal to male roles.
N
OBJ: NCLEX Client Needs Category: Psychosocial Integrity

5. A 60-year-old Italian immigrant presents for an annual physical. He is

counseled about diagnostic testing including laboratory testing, colonoscopy,
influenza vaccination, and pneumococcal vaccination. His reply is “If it ain’t
broke, don’t try to fix it.” When developing a plan of care, the nurse should
consider which cultural orientation for this patient?
a. Short term
b. Long term
c. Leisurely term
d. Noncommittal
ANS: A
Short-term cultural orientation focuses on the present or past and emphasizes quick
results. Long-term cultural orientation focuses the future and long-term rewards.
Long-term-oriented cultures favor thrift, perseverance, and adopting to changing
circumstances. Leisurely term and noncommittal are undefined in cultural orientation.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity

6. The emphasis on understanding cultural influence on health care is important because

of
a. disability entitlements.
b. HIPAA requirements.
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c. increasing global diversity.
d. litigious society.
ANS: C
Culture is an essential aspect of health care because of increasing diversity.
Disability entitlements refer to defined benefits for eligible mental or physically
disabled beneficiaries in relation to housing, employment, and health care. HIPAA
requirements refers to the HIPAA Privacy Rule, which protects the privacy of
individually identifiable health information; the HIPAA Security Rule, which sets
national standards for the security of electronic protected health information; and the
confidentiality provisions of the Patient Safety Rule, which protect identifiable
information being used to analyze patient safety events and improve patient safety.
Litigious society refers to excessively ready to go to law or initiate a lawsuit.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

7. What interrelated constructs facilitate a nurse to become culturally competent?

a. Cultural diversity, self-awareness, cultural skill, and cultural knowledge
b. Cultural desire, self-awareness, cultural knowledge, and cultural identity
c. Cultural desire, self-awareness, cultural knowledge, and cultural diversity
d. Cultural desire, self-awareness, cultural knowledge, and cultural skill
ANS: D
The process of cultural competence consists of four interrelated constructs: cultural
desire, self-awareness, cultural knowledge, and cultural skill. Cultural diversity in
the context of health care refers to achieving the highest level of health care for
all people by addressing
societal inequalities and histoNrical and contemporary injustices. Cultural identity is the
norms, values, beliefs, and behaviors of a culture learned through families and
group
members.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity

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Concept 05: Spirituality
Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

1. The nurse is assessing a patient's spirituality and observes the patient meditating
before any treatments. What is the nurse’s best action?
a. Document that the patient is not religious.
b. Offer the patient a copy of the Bible to read.
c. Arrange for quiet time for the patient as needed.
d. Limit the time patient can meditate before procedures.
ANS: C
The nurse can best promote the patient’s spirituality practices by arranging for the
patient to be left alone when possible to meditate. Meditation is an exemplar of
spirituality, not necessarily of the Christian faith. The Bible is most often read by
believers in the Christian faith. Meditation does not imply that the patient is not
religious. Time for meditation should not be limited, whenever possible.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment:
Health Promotion and Maintenance

2. When conducting a spiritual assessment of a hospitalized patient, the nurse should

remain aware of which potential barrier to effective communication?
a. Clarifying the meaning of a patient’s statement.
b. Multi-tasking while talkinNg to the patient.
c. Listening to patients’ complete statements.
d. Discussing patient’s feelings while hospitalized.
ANS: B
Several barriers may result in the nurse’s inability to be totally present and
communicate effectively with the patient. First, the nurse may be distracted by
other things and may not pay attention to the patient. Multi-tasking while trying to
listen to a patient may be a barrier to effective communication. Second, the nurse
may miss the meaning of the patient’s message because of failure to clarify the
meaning of a word, a phrase, or a facial expression. Third, the nurse may interject
personal feelings and reactions into the patient’s situation rather than allow the
patient to explore and discuss his own feelings and reactions. The last barrier
occurs when the nurse is busy formulating a response while the patient is still
talking. In this instance, the nurse never hears the patient’s message.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment:
Psychosocial Integrity

3. A patient uses rosary beads and attends mass once a week. This expression of
spirituality is best described with which term?
a. Religiosity
b. Faith
c. Belief
d. Authenticity

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ANS: A
There are a few similar and related terms to spirituality worth mentioning to provide
distinction and clarification. Faith, as defined by Dyess, refers to an “evolving
pattern of believing, that grounds and guides authentic living and gives meaning in
the present moment of inter-relating.” Religiosity, another similar term, is an
external expression (public or private), in the form of practicing a belief or faith,
whereas spirituality is an internalized spiritual identity (or experiential). Specifically,
religiosity is defined as “the adherence to religious dogma or creed, the expression
of moral beliefs, and/or the participation in organized or individual worship, or
sacred practices.”

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment:
Psychosocial Integrity

4. When developing a plan of care, the nurse should consider which attribute of the
concept of spirituality?
a. Spirituality is not a well-known universal concept.
b. Chronic versus acute illnesses affect spirituality.
c. Convincing patients to pray is a priority intervention.
d. Referrals may be needed to spiritual counselors.
ANS: D
The attributes of the concept of spirituality in the context of nursing care are
described below.
 Spirituality is universal. All individuals, even those who profess no religious
belief, are driven to derive meaning and purpose from life.
 Illness impacts spirituNality in a variety of ways. Some patients and families will
draw closer to God or however they conceive that higher Power to be in an
effort to seek
support, healing, and comfort. Others may blame and feel anger toward that
Higher Power for any illness and misfortune that may have befallen a loved
one or their entire family. Still others will be neutral in their spiritual
reactions.
 There has to be willingness on the part of patient and/or family to share
and/or act on spiritual beliefs and practices.
 The nurse needs to be aware that specific spiritual beliefs and practices are
impacted by family and culture.
 The nurse needs to be willing to assess the concept of spirituality in
patients and families and based on this ongoing assessment to integrate
the spiritual beliefs of patients and families into care.
 The nurse needs to be willing to refer the patient or family to a Spiritual
Expert i.e., a Minister, Priest, Rabbi, an Imam.
 Community-based religious organizations can provide supportive care to
families and patients and nurses need to be aware of these resources.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment:
Psychosocial Integrity

MULTIPLE RESPONSE

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1. When completing the FICA tool for spiritual assessment, which questions should
the nurse ask the patient? (Select all that apply.)
a. What things do you believe in that give meaning to life?
b. Are you connected with a faith center in your community?
c. How has your illness affected your personal beliefs?
d. When was the last time you have been to church?
e. What can I do for you?
ANS: A, B, C, E
The FICA tool for spiritual assessment stands for Faith or beliefs, Importance and
influence, Community, and Address. “When was the last time you have been to
church?” is not a question included in the FICA assessment. The patient may attend
community activities, besides church, that foster his/her spiritual well-being.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

2. Which are true statements about the definition of spirituality in nursing? (Select
all that apply.)
a. Patient’s quality of life, health, and sense of wholeness are affected by spirituality.
b. An exact definition was developed and adopted in the late 1980s.
c. Encompasses principle, an experience, attitudes, and belief regarding God
d. Head knowledge affects spirituality more than heart knowledge.
e. Mind, body, spirit, love, and caring are interconnected.
ANS: A, C, E
The concept of Spirituality is an elusive concept to define. Authors who write about
spirituality in nursing advocaNte the position that a patient’s quality of life, health, and
sense
of wholeness are affected by spirituality, yet still the profession of nursing struggles to
define it. Why? There are a number of explanations for this. One explanation is that
spirituality represents “heart” not “head” knowledge and “heart” knowledge is
difficult to encapsulate into words. A second explanation is that spirituality is
unique to each person so a precise definition is somewhat elusive. The definitions
of spirituality encompass the following: a principle, an experience, attitudes and
belief regarding God, a sense of God, the inner person. Most descriptions of
spirituality include not only transcendence but also the connection of mind, body,
and spirit, plus love, caring, and compassion and a relationship with the Divine.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment:
Health Promotion and Maintenance

3. Which life events should the nurse recognize as being spiritually life changing?
(Select all that apply.)
a. Births
b. Weddings
c. Medical diagnoses
d. Career day to day job duties
e. Loss of
independence ANS:
A, B, C, E

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The meaning and significance of the event might only be experienced by one
individual; others who might be participants in the event might be left virtually
untouched and unchanged. These life changing spiritual events include just about
any occurrence that has intense and personal relevance to those involved in the
event. Examples of spiritually life changing events include births, deaths, weddings,
divorces, illnesses, diagnoses, and loss of abilities, loss of independence, death and
so many more. These events, having the power to change individuals and families,
also have the power to draw people toward the transcendent—for many people that
transcendent is known as God but this is not universal. Day-to-day activities are
not the best examples of spiritually life changing events.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment:
Psychosocial Integrity

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Concept 06: Adherence
Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

1. A patient has been newly diagnosed with hypertension. The nurse assesses the
need to develop a collaborative plan of care that includes a goal of adhering to
the prescribed regimen. When the nurse is planning teaching for the patient,
which is the most important initial learning goal?
a. The patient will select the type of learning materials they prefer.
b. The patient will verbalize an understanding of the importance of
following the regimen.
c. The patient will demonstrate coping skills needed to manage hypertension.
d. The patient will verbalize the side effects of treatment.
ANS: A
Adults learn best when given information they can understand that is tailored to
their learning styles and needs. Verbalizing an understanding is important; however,
the nurse will first need to teach the patient.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

2. After the nurse implements a teaching plan for a newly diagnosed patient with
hypertension, the patient can explain the information but fails to take the
medications as prescribed. What is the nurse’s next action?
a. Reeducate the patient, be N cause learning did not occur because the
patient’s behavior did not change.
b. Assess the patient’s perception and attitude toward the risks associated
with not taking their anti-hypertensives.
c. Take full responsibility for helping the patient make dietary changes.
d. Ask the provider to prescribe a different medication, because the patient
does not want to take this medication.
ANS: B
Although the patient behavior has not changed, the patient’s ability to explain the
information indicates that learning has occurred. The nurse would need to ask what
the
patient’s perceptions are of taking the medications to determine if the patient
understands the ramifications of not taking the medication. The patient may be in
the contemplation or preparation state (see Health Belief Model). The nurse should
reinforce the need for change and continue to provide information and assistance
with planning for change.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

3. A diabetic patient presents to the diabetes clinic with A1c levels of 7.5%. The
nurse has met this patient for the first time. When applying principles of Theory
of Planned Behavior (TPB), which teaching strategy by the nurse is most likely to
be effective?
a. Provide information on the importance of blood glucose control in
maintenance of long-term health and evaluate how the patient has been
following the prescribed regime.
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b. Establish a rapport with the patient by complimenting them on what
they did correctly, and ask what strategies they have tried thus far.
c. Refer the patient to a certified diabetic educator, because the educator is an
expert on management of diabetes complications.
d. Have the patient explain what medications they are on and what diet they
should be following.
ANS: B
Principles of a TPB indicate that the patient will need to establish a good rapport
with the nurse in order to talk about nonadherence. If the patient finds it difficult
to discuss their diabetes self-management and adherence with the nurse, the patient
may not open up to the nurse. Although a referral to an educator is a good idea,
it would be better to use this resource as a follow-up for this visit. Having the
patient verbalize medications and diet is not part of the TPB method.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

4. The nurse is assessing a newly diagnosed diabetic, and the patient’s readiness to
learn about glucose monitoring. Before planning teaching activities, which approach
would be most effective?
a. Assist the patient with long-term goals and plan teaching according to these goals.
b. Provide the patient with all the latest research from the Internet on
glucose monitoring.
c. Refer the patient to the diabetic specialist who can assist the patient
with the glucometer.
d. Assist the patient in developing realistic short-term goals.
N
ANS: D
Concordance reflects development of an alliance with patients based on realistic
expectations. Providing the patient with the research will not help with the practical
skill of using the glucometer. Long-term goals are useful; however, the goals need
to be immediate with a newly diagnosed patient learning a new skill. Referring the
patient would be useful if the patient has not been able to grasp the concept after
several attempts.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

5. The nurse is developing a care plan for a patient who has low motivation and
nonadherence with blood glucose monitoring. Which statement by the patient would
indicate to the nurse that the patient is not motivated and will most likely not
comply?
a. “I do not like to test my sugar, but I do it because my wife nags me.”
b. “I forget to check my sugar once in a while.”
c. “I don’t see or feel any different when I do keep my blood sugars under control.”
d. “I have no idea what the signs of low blood sugar are.”
ANS: C
If patients do not perceive any benefit from changing their behavior, sustaining the
change becomes very difficult. Having someone remind the patient is more likely
to reinforce compliance. Forgetting to check glucose occasionally may indicate the
patient needs memory cues or joggers. The patient who does not know the signs of
low glucose will need further teaching.

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OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse is preparing a discharge teaching plan for a patient who has peripheral
vascular disease and has poor circulation to the feet. Which learning goal should
the nurse include in the teaching plan?
a. The nurse will demonstrate the proper technique for trimming toenails.
b. The patient will understand the rationale for proper foot care after instruction.
c. The nurse will instruct the patient on appropriate foot care before discharge.
d. The patient will post reminder stickers on the calendar to check feet every
day and record scheduled appointments with podiatrist.
ANS: D
To improve the patient adherence to treatment, it will be important to help them
develop reminder strategies that fit into their lifestyle. Options A and C describe
actions that the nurse will take, rather than behaviors that indicate that patient
learning has occurred. Option B is too vague and nonspecific to measure whether
learning has occurred.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

7. A patient with hypertension is prescribed a low-sodium diet. The patient’s teaching

plan
includes this goal: “The patient will select a 2-gram sodium diet from the hospital
menu for the next 3 days.” Which intervention would be most effective at
increasing the patient’s compliance with the diet?
a. Check the sodium content of the patient’s menu choices over the next 3 days.
b. Ask the patient to identify which foods on the hospital menus are high in sodium.
c. Have the patient list favo N rite foods that are high in sodium and foods that
could be substituted for these favorites.
d. Compare the patient’s sodium intake over the next 3 days with the sodium
intake before the teaching was implemented.
ANS: C
Including a patient’s favorite foods will most likely increase compliance, because the
patient is not being deprived. Checking the sodium will be useful for teaching
strategies but will not be the most effective means of increasing adherence.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

8. The nurse is evaluating the need to refer a patient with osteoarthritis for a home
care visit to be sure the patient can function in accomplishing daily activities
independently. What is the nurse’s first priority?
a. Determine if the patient has had home visits before and if the
experience was positive.
b. Check the patient’s ability to bathe without any assistance the next day.
c. Have the patient demonstrate the learned skills at the end of the teaching session.
d. Arrange a physical therapy visit before the patient is discharged from the
hospital. ANS: A

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To begin the assessment of adherence, it is first important to clarify with the patient
(a) their beliefs and perceptions about their health risk status, (b) their existing
knowledge about cardiovascular disease risk reduction, (c) any prior experience with
healthcare professionals, and (d) their degree of confidence with controlling the
disease. The other actions allow evaluation of the patient’s short-term response to
teaching.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

9. A 73-year-old male patient is seen in the home setting for a routine physical.
The nurse notes which behavior as the most reassuring sign that the patient has
been following the treatment plan for the diagnoses of hypertension, diabetes,
and hyperlipidemia?
a. The patient has a list of glucose readings for the past 10 days.
b. The patient has a list of medications along with newly refilled meds.
c. The patient has a list of all foods and beverages for a 3-day period.
d. The patient verbalizes the side effects of all his medications.
ANS: B
Confirming how often a patient renews or refills his/her prescriptions is a measurement
of
the patient’s persistence with continuation of the treatment. Having a list of glucose
readings or verbalizing side effects does not necessarily mean that the patient is
compliant unless the readings were all normal, which is not indicated. Listing foods
may not indicate the patient is following the treatment plan.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

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Concept 07: Self-Management
Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

1. The nurse is developing a plan of care for a newly diagnosed hypertensive patient
who is being discharged on medications and given the Dietary Approaches to Stop
Hypertension (DASH) diet to follow. What statement by the patient signals to the
nurse that the patient is motivated to learn?
a. “I am sure the medications will help to bring down my blood pressure.”
b. “I can’t wait to try the new recipes, and I’m hopeful I will lose weight.”
c. “Do I really need to follow the diet and take medications?”
d. “I have my parents to blame for this. They both have high blood pressure.”
ANS: B
A patient who is motivated will see what the benefits of following the teaching will
do for them and will most likely be able to manage their own care. The patient who
believes medications are the only solution may not be motivated to follow the
prescribed diet.
Blaming the parents for their condition does not show accountability or motivation
for change.

OBJ: NCLEX Client Needs Category: Physiological Integrity | NCLEX Client

Needs Category: Physiological Integrity: Physiological Adaptation

2. The nurse is assessing a patient’s readiness to be discharged and ability to manage

care at home. What is the most approNpriate question for the nurse to ask to
determine the patient’s learning needs before planning teaching activities?
a. “What are your hobbies and occupation?”
b. “What do you need to know before you go home from the hospital?”
c. “Do you have any cultural or religious beliefs that you would like
incorporated into your plan of care?”
d. “What were your grades and learning style when you were in school?”
ANS: B
Motivation and readiness to learn depend on what the patient values. The other
questions are also important but do not address what information interests the patient
most at present and will assist the patient in managing his own care.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

3. Which acute medical event should the nurse identify as requiring self-management
when planning care for a patient?
a. Prenatal care
b. Depression
c. Diabetes
d. Femur
fracture ANS:
D

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A femur fracture is considered an acute medical event. Pregnancy is an expected and
normal life event/condition. Depression and diabetes are considered disease states.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

4. An 8-year-old child is newly diagnosed with asthma. Which nursing intervention best
promotes self-efficacy for the parents to help the child follow the prescribed
treatments?
a. Ask parents to list all possible triggers for asthma.
b. Request a spacer for the metered dose inhaler.
c. Suggest the parents enforce a strict exercise regimen.
d. Recommend replacing carpeting in the home with wood flooring.
ANS: B
The most realistic and helpful interventions will promote self-management. A spacer
is helpful for children learning to use inhaled medication. Listing all the triggers
for asthma may be overwhelming. The parents should focus on the individual
triggers for the child. Enforcing a strict exercise regimen is restrictive and will not
promote self-management. Environmental changes must be feasible and cost-
effective. Replacing carpeting is optimal but may not be affordable.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

5. When developing a plan of care to promote self-management, which patient is least

likely to be affected by depression?
a. A 55-year-old employed female
b. A 35-year-old Hispanic male
c. A 40 year old with 5th grN ad e education
d. A 42 year old with private insurance
ANS: D
Individuals most affected by depression are midlife adults ages 45–64, women,
minorities, individuals without a high school education, and individuals without health
insurance.
Treatment for depression includes the use of medication and psychological therapy.
Additionally, patients must learn to manage moods including suicidal thoughts,
recognize triggers and relapse, and set goals for behavioral management of their
disease.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse is assisting an older adult patient, diagnosed with type 2 diabetes,
with self-injection of insulin. What is the most appropriate intervention for
this patient at discharge?
a. Arrange daily home visits for injections.
b. Request an insulin pen prescription.
c. Recommend upper arm injection sites.
d. Supply patient with 100 unit insulin
syringes. ANS: B

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An insulin pen will be the most effective method for injection for an older adult
secondary to reduced eyesight and dexterity compared to using syringes. A 100
unit syringe has very small calibration marks and numbers, making it more
difficult for older adults to see the appropriate doses. Daily home visits are not
usually paid for by insurance. Most patients must learn to administer medications
themselves. The upper arm subcutaneous site is too difficult for self-administration
and may not be feasible for an older adult.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. The nurse is developing a teaching plan for a patient diagnosed with

congestive heart failure. Which are the most appropriate teaching points to
include that will assist in self-management of the disease? (Select all that
apply.)
a. Side effects of medications
b. Activity restrictions
c. Daily weights
d. Increased sodium intake
e. Blood pressure monitoring
ANS: A, B, C, E
Congestive heart failure (CHF) is one of the most common complications of
coronary artery disease in which the heart fails to pump efficiently enough to meet
the metabolic demands of the body. Fluid overload is a common complication. As
with most chronic conditions, patients with CHF benefit from education about their
disease and self-managing diet, physical activity, weight, andNmedication
adherence.
Fluid retention occurs with increased
sodium intake; therefore sodium is usually restricted in a congestive heart failure diet.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

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Concept 08: Fluid and Electrolytes
Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

1. The nurse is admitting an older adult with decompensated congestive heart

failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and
orthopnea. Which physician order should the nurse question?
a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
b. Furosemide (Lasix) 20 mg PO now
c. Oxygen via face mask at 8 L/min
d. KCl 20 mEq PO two times per day
ANS: A
A patient with decompensated heart failure has extracellular fluid volume (ECV)
excess. The IV of 0.9% NaCl is normal saline, which should be questioned because
it would expand ECV and place an additional load on the failing heart. Diuretics
such as furosemide are appropriate to decrease the ECV during heart failure.
Increasing the potassium intake with KCl is appropriate, because furosemide
increases potassium excretion. Oxygen administration is appropriate in this situation
of near pulmonary edema from ECV excess.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological

and Parenteral Therapies

2. The nurse assessed four patients at the beginning of the shift. Which finding
should the nurse report immediately to t hNe physician?
a. Swollen ankles in patient with compensated heart failure
b. Positive Chvostek sign in patient with acute pancreatitis
c. Dry mucous membranes in patient taking a new diuretic
d. Constipation in patient who has advanced breast cancer
ANS: B
Positive Chvostek sign indicates increased neuromuscular excitability, which can
progress to dangerous laryngospasm or seizures and thus needs to be reported first.
The other assessment findings are less urgent and need further assessment. Bilateral
ankle edema is a sign of ECV excess, and follow-up is needed, but the situation
is not immediately
life-threatening. Dry mucous membranes in a patient taking a diuretic may be
associated with ECV deficit; however, additional assessments of ECV deficit are
required before reporting to the physician. Constipation has many causes, including
hypercalcemia and opioid analgesics, and it needs action, but not as urgently as a
positive Chvostek sign.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk

Potential

3. The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with
KCl in it. Which assessment finding should cause the nurse to hold the IV
solution and contact the physician?
a. Weight gain of 2 pounds since last week
b. Dry mucous membranes and skin tenting
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c. Urine output 8 mL/hr

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d. Blood pressure 98/58
ANS: C
Administering IV potassium to a patient who has oliguria is not safe, because
potassium intake faster than potassium output can cause hyperkalemia with
dangerous cardiac dysrhythmias. Dry mucous membranes, skin tenting, and blood
pressure 98/58 are consistent with the need for IV 0.9% NaCl. Weight gain of 2
pounds in a week does not necessarily indicate fluid overload, because it can be
from increased nutritional intake. An overnight weight gain indicates a fluid gain.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological

and Parenteral Therapies

4. At change-of-shift report, the nurse learns the medical diagnoses for four patients.
Which patient should the nurse assess most carefully for development of
hyponatremia?
a. Vomiting all day and not replacing any fluid
b. Tumor that secretes excessive antidiuretic hormone (ADH)
c. Tumor that secretes excessive aldosterone
d. Tumor that destroyed the posterior pituitary gland
ANS: B
ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive
ADH thus causes hyponatremia. Excessive aldosterone causes ECV excess rather
than hyponatremia. The posterior pituitary gland releases ADH; lack of ADH causes
hypernatremia. Vomiting without fluid replacement causes ECV deficit and
hypernatremia.

OBJ: NCLEX Client NeedsNCategory: Physiological Integrity: Reduction of

RiskPotential
5. The patient is receiving tube feedings due to a jaw surgery. What change in
assessment findings should prompt the nurse to request an order for serum
sodium concentration?
a. Development of ankle or sacral edema
b. Increased skin tenting and dry mouth
c. Postural hypotension and tachycardia
d. Decreased level of consciousness
ANS: D
Tube feedings pose a risk for hypernatremia unless adequate water is administered
between tube feedings. Hypernatremia causes the level of consciousness to decrease.
The serum sodium concentration is a laboratory measure for osmolality imbalances,
not ECV imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin
tenting, dry mouth, postural hypotension, and tachycardia all can be signs of ECV
deficit.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. The patient with which diagnosis should have the highest priority for teaching
regarding foods that are high in magnesium?
a. Severe hemorrhage
b. Diabetes insipidus
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c. Oliguric renal disease
d. Adrenal insufficiency

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ANS: C
When renal excretion is decreased, magnesium intake must be decreased also, to
prevent hypermagnesemia. The other conditions are not likely to require adjustment of
magnesium intake.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. The patient’s laboratory report today indicates severe hypokalemia, and the nurse has
notified the physician. Nursing assessment indicates that heart rhythm is regular.
What is the priority nursing intervention?
a. Raise bed side rails due to potential decreased level of
consciousness and confusion.
b. Examine sacral area and patient’s heels for skin breakdown due to potential edema.
c. Establish seizure precautions due to potential muscle twitching, cramps,
and seizures.
d. Institute fall precautions due to potential postural hypotension and
weak leg muscles.
ANS: D
Hypokalemia can cause postural hypotension and bilateral muscle weakness,
especially in the lower extremities. Both of these increase the risk of falls.
Hypokalemia does not cause edema, decreased level of consciousness, or seizures.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk

Potential

MULTIPLE RESPONSE N
1. The home health nurse is caring for a patient with a diagnosis of acute
immunodeficiency syndrome (AIDS) who has chronic diarrhea. Which assessments
should the nurse use to detect the fluid and electrolyte imbalances for which the
patient has highest risk? (Select all that apply.)
a. Bilateral ankle edema
b. Weaker leg muscles than usual
c. Postural blood pressure and heart rate
d. Positive Trousseau sign
e. Flat neck veins when upright
f. Decreased patellar reflexes
ANS: B, C, D
Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia,
and hypomagnesemia because it increases fecal excretion of sodium-containing fluid,
potassium, calcium, and magnesium. Appropriate assessments include postural blood
pressure and heart rate for ECV deficit; weaker leg muscles than usual for
hypokalemia; and positive Trousseau sign for hypocalcemia and hypomagnesemia.
Bilateral ankle edema is a sign of ECV excess, which is not likely with chronic
diarrhea. Flat neck veins when upright is a normal finding. Decreased patellar
reflexes is associated with hypermagnesemia, which is not likely with chronic
diarrhea.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk

Potential
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2. The patient has recent bilateral, above-the-knee amputations and has developed C.
difficile diarrhea. What assessments should the nurse use to detect ECV deficit in
this patient? (Select all that apply.)
a. Test for skin tenting.
b. Measure rate and character of pulse.
c. Measure postural blood pressure and heart rate.
d. Check Trousseau sign.
e. Observe for flatness of neck veins when upright.
f. Observe for flatness of neck veins when supine.
ANS: A, B, F
ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck
veins when supine, which can be assessed in this patient. Although ECV deficit
also causes postural blood pressure drop with tachycardia, this assessment is not
appropriate for a patient with recent bilateral, above-the-knee amputations. Trousseau
sign is a test for increased neuromuscular excitability, which is not characteristic of
ECV deficit. Flat neck veins when upright is a normal finding.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

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Concept 09: Acid–Base Balance
Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

1. The patient had diarrhea for 5 days and developed an acid-base imbalance. Which
statement would indicate that the nurse’s teaching about the acid-base imbalance
has been effective?
a. “To prevent another problem, I should eat less sodium during diarrhea.”
b. “My blood became too acid because I lost some base in the diarrhea fluid.”
c. “Diarrhea removes fluid from the body, so I should drink more ice water.”
d. “I should try to slow my breathing so my acids and bases will be balanced.”
ANS: B
Diarrhea causes metabolic acidosis through loss of bicarbonate, which is a base.
Eating less sodium during diarrhea increases the risk of ECV deficit. Although
diarrhea does remove fluid from the body, it also removes sodium and bicarbonate
which need to be replaced.
Rapid deep respirations are the compensatory mechanism for metabolic acidosis and
should be encouraged rather than stopped.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. The patient has type B chronic obstructive pulmonary disease (COPD) exacerbated
by an acute upper respiratory infection. Which blood gas values should the nurse
expect to see?
a. pH high, PaCO2 high, HCO3– high
b. pH low, PaCO2 low, HCO3– low
c. pH low, PaCO2 high, HCN O 3 – high
d. pH low, PaCO2 high, HCO3– normal
ANS: C
Type B COPD is a chronic disease that causes impaired excretion of carbonic acid,
thus causing respiratory acidosis, with PaCO2 high and pH low. This chronic disease
exists long enough for some renal compensation to occur, manifested by high HCO3–.
Answers that include low or normal bicarbonate are not correct, because the renal
compensation for respiratory acidosis involves excretion of more hydrogen ions than
usual, with retention of bicarbonate in the blood. High pH occurs with alkalosis, not
acidosis.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. The patient has severe hyperthyroidism and will have surgery tomorrow. What
assessment is most important for the nurse to perform in order to detect
development of the highest risk acid-base imbalance?
a. Urine output and color
b. Level of consciousness
c. Heart rate and blood pressure
d. Lung sounds in lung
bases ANS: B

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Thyroid hormone increases metabolic rate, causing a patient with severe
hyperthyroidism to have high risk of metabolic acidosis from increased production of
metabolic acids.
Metabolic acidosis decreases level of consciousness. Changes in urine output, urine
color, and lung sounds are not signs of metabolic acidosis. Although metabolic
acidosis often causes tachycardia, many other factors influence heart rate and blood
pressure, including thyroid hormone.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk

Potential

4. The nurse is making a home visit to a child who has a chronic disease. Which
finding has the most implication for acid-base aspects of this patient’s care?
a. Urine output is very small today.
b. Whites of the eyes appear more yellow.
c. Skin around the mouth is very chapped.
d. Skin is sweaty under three blankets.
ANS: A
Oliguria decreases the excretion of metabolic acids and is a risk factor for
metabolic acidosis. Jaundice requires follow-up but is not an acid-base problem.
Perioral chapped skin needs intervention but is not an acid-base issue. With three
blankets, diaphoresis is not unusual.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. The nurse has telephone messages from four patients who requested information
and assistance. Which one should the nurse refer to a social worker or community
agency first?
a. “Is there a place that I canNdispose of my unused morphine pills?”
b. “I want to lose at least 20 pounds without getting sick this time.”
c. “I think I have asthma because I cough when dogs are near.”
d. “I ran out of money and am cutting my insulin dose in half.”
ANS: D
Decreasing an insulin dose by half creates high risk of diabetic ketoacidosis, and this
patient has the highest priority. The other patients have less priority due to lower
risk situations with longer time course before development of an acid-base
imbalance. The coughing when dogs are near is not a sign of a severe asthma
episode that causes respiratory acidosis, although this patient does need attention
after the insulin situation is handled. Disposing of morphine properly helps prevent
respiratory acidosis from opioid overdose. Guidance regarding weight loss helps
prevent starvation ketoacidosis.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Management:
Management of Care

MULTIPLE RESPONSE

1. The patient is hyperventilating from anxiety and abdominal pain. Which

assessment findings should the nurse attribute to respiratory alkalosis?
(Select all that apply.)
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a. Skin pale and cold
b. Tingling of fingertips

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c. Heart rate of 102
d. Numbness around mouth
e. Cramping in feet
ANS: B, D, E
Hyperventilation is a risk factor for respiratory alkalosis. Respiratory alkalosis can
cause perioral and digital paresthesias and pedal spasms. Pallor, cold skin, and
tachycardia are characteristic of activation of the sympathetic nervous system,
not respiratory alkalosis.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological

Adaptation

2. Which statements said by patients indicate that the nurse’s teaching regarding
prevention of acid-base imbalances is successful? (Select all that apply.)
a. “Baking soda is an effective and inexpensive antacid.”
b. “I should take my insulin on time every day.”
c. “My aspirin is on a high shelf away from children.”
d. “I have reliable transportation to dialysis sessions.”
e. “Fasting is a great way to lose weight rapidly.”
ANS: B, C, D
Taking insulin as prescribed helps prevent diabetic ketoacidosis. Safeguarding aspirin
from children prevents metabolic acidosis from increased acid intake. Regular
dialysis reduces the risk of metabolic acidosis from decreased renal excretion of
metabolic acid. Baking soda is sodium bicarbonate and should not be used as an
antacid due to the risk of metabolic alkalosis. Fasting without carbohydrate intake
is a risk factor for starvation ketoacidosis.

OBJ: NCLEX Client NeedsNCategory: Health Promotion and Maintenance

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Concept 10: Thermoregulation
Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

1. Which newborn should the nursery nurse identify as being at significant

risk for hypothermic alteration in thermoregulation?
a. Large for gestational age
b. Low birth weight
c. Born at term
d. Well nourished
ANS: B
Low birth weight and poorly nourished infants (particularly premature infants) and
children are at greatest risk for hypothermia. A large for gestational age infant
would not be malnourished. An infant born at term is not considered at significant
risk. A well-nourished infant is not at significant risk.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A volunteer at the senior center asks the visiting nurse why the senior citizens
always seem to be complaining about the temperature. What is the nurse’s best
response?
a. Older people have a diminished ability to regulate body temperature
because of active sweat glands.
b. Older people have a diminished ability to regulate body temperature because of
increased circulation. N
c. Older people have a diminished ability to regulate body temperature
because of peripheral vasoconstriction.
d. Older people have a diminished ability to regulate body temperature
because of slower metabolic rates.
ANS: D
Slower metabolic rates are one factor that reduces the ability of older adults to
regulate temperature and be comfortable when there are any temperature changes.
As the body ages, the sweat glands decrease in number and efficiency. Older
adults have reduced circulation. The body conserves heat through peripheral
vasoconstriction, and older adults have a decreased vasoconstrictive response, which
impacts ability to respond to temperature changes.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. The nurse admitting a patient to the emergency department on a very hot summer
day would suspect hyperthermia when the patient demonstrates which assessment
finding?
a. Decreased respirations
b. Low pulse rate
c. Red, sweaty skin
d. Slow capillary
refill ANS: C

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With hyperthermia, vasodilatation occurs causing the skin to appear flushed and
warm or hot to touch. There is an increased respiration rate with hyperthermia.
The heart rate increases with hyperthermia. With hypothermia there is slow
capillary refill.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. What is the priority nursing action for a patient suspected to be hypothermic?

a. Assess vital signs.
b. Hydrate with intravenous (IV) fluids.
c. Provide a warm blanket.
d. Remove wet clothes.
ANS: D
The first thing to do with a patient suspected to be hypothermic is to remove wet
clothes, because heat loss is five times greater when clothing is wet. Assessing
vital signs is important, but the wet clothes should be removed first. Hydration is
very important with hyperthermia and the associated danger of dehydration, but
there is not a similar risk with hypothermia. A warm blanket over wet clothes
would not be an effective warming strategy.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. Which strategies should the nurse include in a community program for senior
citizens related to dealing with cold winter temperatures?
a. Avoiding hot beverages
b. Shopping at an indoor mall
c. Using a fan at low speed
d. Walking slowly in the p a N rk
ANS: B
Shopping indoors where there is protection from the elements and temperature
control is one strategy to avoid cold temperatures. Hot beverages can help an
individual deal with cold weather. Avoiding breezes and air currents is
recommended to conserve body temperature. Physical activity can increase body
temperature, and if the senior is going to walk in the park, weather-appropriate
(warm) clothing and a usual or brisk pace, not a slow pace, would be
recommended.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. During orientation to an emergency department, the nurse educator would be

concerned if the new nurse listed which of the following as a risk factor for
impaired thermoregulation?
a. Impaired cognition
b. Occupational exposure
c. Physical agility
d. Temperature
extremes ANS: C

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Physical agility is not a risk factor for impaired thermoregulation. The nurse educator
would use this information to plan additional teaching to include medical conditions
and gait disturbance as risk factors for hypothermia, because their bodies have a
reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or
occupational exposure is a risk factor. Temperature extremes are risk factors for
impaired thermoregulation.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. What is the most appropriate measure for a nurse to use in assessing core body
temperature when there are suspected problems with thermoregulation?
a. Oral thermometer
b. Rectal thermometer
c. Temporal thermometer scan
d. Tympanic membrane sensor
ANS: B
The most reliable means available for assessing core temperature is a rectal
temperature, which is considered the standard of practice. An oral temperature is a
common measure but not the most reliable. A temporal thermometer scan has some
limitations and is not the standard. The tympanic membrane sensor could be used
as a second source for temperature assessment.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

8. Which similar exemplar should the nurse consider when planning care for a
patient with hypothermia?
a. Heat exhaustion N
b. Heat stroke
c. Infection
d. Prematurity
ANS: D
Prematurity, frost bite, environmental exposure, and brain injury are considered
exemplars of hypothermia. Heat exhaustion is an exemplar of hyperthermia. Heat
stroke is an exemplar of hyperthermia. Infection is an exemplar of hyperthermia.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

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