Fundamentals EAQ 4 - Answers PDF

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11/11/2020

Elsevier Adaptive Quizzing - Quiz performance

Performance Exit

EAQ 4 Fall 2020 Due Nov 17, 2020 by 1:00 pm

Final Score

90% 18 out of 20 questions answered correctly

Completed on Nov 11, 2020 12:04 am

Incorrect (2)

A postoperative patient is advised to take clear fluids. Which types of fluids would the nurse provide to the patient? Select all that apply. Some correct answers were not selected

Gelatin Popsicles https://eaqng.elsevier.com/#/quizPerformance/14792898

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Vegetable juices Blended cream soups

Rationale Some patients who are chronically ill or who have undergone surgery may need to resume their diet gradually. They are usually started on clear fluids and then progressed to other diets. Clear fluids include apple and cranberry juice, gelatin, and popsicles. These fluids are easy to digest and do not leave any residue after digestion. Vegetables and blended cream soups are full liquids and are usually given once the patient is able to tolerate clear fluids. p. 665

The nurse is caring for an older adult patient with severe hearing alterations. To prevent sensory deprivation in the patient, which information would the nurse teach to the patient’s caregiver? Select all that apply. Some correct answers were not selected

"Install smoke detectors at home." "Raise the volume of the doorbell." "E "I

"

Rationale The nurse encourages the patient to engage in enjoyable activities such as watching television or reading books and newspapers. The nurse must teach the caregiver to encourage the patient to use hearing aids at home to facilitate conversation. The nurse https://eaqng.elsevier.com/#/quizPerformance/14792898

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provides information about public transportation so that the patient can maintain independence. The nurse recommends that the patient and caregiver install visual signals for doorbells and smoke detectors at home, as doorbells and smoke detectors rely on auditory signals. An older adult loses the ability to hear high-pitched sounds; therefore raising the volume of the doorbell would not help this patient. Recommending the installation of a low-pitched doorbell would be beneficial to a hearing-impaired patient. pp. 690, 700

Correct (18)

The nurse is caring for a patient with dysphagia. Which nursing interventions are beneficial for the patient while feeding? Select all that apply.

Waiting 5 seconds between bites Feeding the patient in the supine position E

Rationale Patients with dysphagia have difficulty swallowing. Tucking the patient’s chin while swallowing helps reduce the gap between the pharynx and epiglottis and reduces the risk for aspiration. Checking the patient’s mouth frequently for retention (pocketing) of food in the cheeks and elevating the patient’s bed to a 45-degree angle also helps prevent aspiration. The nurse should wait for 10 seconds between bites to help the patient chew and swallow properly. Feeding the patient in the supine position may cause gagging or choking. https://eaqng.elsevier.com/#/quizPerformance/14792898

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p. 661

The nurse is preparing a dietary plan for the patient who has osteoporosis. Which food choices would be recommended by the nurse to increase the calcium level? Select all that apply. Fruits Legumes Yogurt Cheese Spinach

Rationale The patient with osteoporosis requires a calcium-rich diet to replenish the lost calcium. Yogurt, cheese, and spinach are rich in calcium and should be added to the dietary plan. A diet that contains fruits and legumes is good for health, but they are not good sources of calcium. STUDY TIP: Keep track of your food intake for a few days and check the amount of calcium in various foods as you do so. You will notice how high dairy products and leafy green vegetables are in calcium. There are some online applications that will total various nutrients for you as you enter the foods and quantities you have consumed. p. 650

The nurse uses the PLISSIT model while working with a couple experiencing sexual health problems. Which action would the nurse take first? Refer the couple to make an appointment with a sex therapist. https://eaqng.elsevier.com/#/quizPerformance/14792898

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Recommend methods to improve the couple’s sexual health. Inform the couple about all of the available treatment options.

Rationale The PLISSIT model is a tool that is helpful in the assessment of sexual problems and designing the treatment plan accordingly. Before starting the assessment, the nurse seeks permission from the couple to help them feel comfortable about discussing their sexual issues. The nurse would refer the couple to a sex therapist only if any major problems are identified during the assessment. The nurse would also give suggestions to improve the couple’s sexual health only after completing a thorough assessment. Information about available treatment options would be provided only after a diagnosis. Test-Taking Tip:Look for the choice that supports patient-centered care. Not everyone has the same comfort level in discussing sexual concerns. You may be open to discussions about sex, but not all your patients will be. As part of patient-centered, individualized care, you must ask permission from the couple before beginning a discussion of sexual issues. This gives the couple the option to not discuss them; but by asking, you have acknowledged it is their option. This step may be the one that allows them to talk with you! Patient-centered in this case means to ask permission. p. 435

A parent of a 3-year-old child reports to the nurse, "It embarrasses me when my child explores his body parts in front of everyone." Which nursing response is best ? "Isolate the child from others for some time."

"Consult with the health care provider." "Punish the child appropriately for such behavior." https://eaqng.elsevier.com/#/quizPerformance/14792898

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Rationale Children begin to explore their genitals out of sexual curiosity. Parents should patiently teach their child not to explore his or her private parts in front of other people. Exploration of body parts is natural in this age group and does not require any medical intervention. Therefore the parent need not consult the health care provider. Isolation may hurt and make the child upset; therefore this would not be the best response to correct the child’s behavior. Strict discipline and punishments for something that is normal at that age will traumatize the child, so the child should not be punished. p. 425

The nurse is caring for a patient with end-stage liver cirrhosis who declared himself an atheist at the time of admission. The patient now asks to see the chaplain. Which action by the nurse would be appropriate? Inform the patient’s family about the request. Allow the patient time to reconsider the request. Inquire about the reason for the sudden change.

Rationale The nurse must be compassionate and nonjudgmental and arrange for the chaplain to meet the patient. The nurse need not inform the family. This would be a violation of confidentiality. Spiritual assessments are subjective and may change according to circumstances. The nurse need not give the patient time to think about the request. The nurse must be understanding and not question the patient’s change in beliefs. Test-Taking Tip: Look for the answer that allows the nurse to provide patient-centered care. https://eaqng.elsevier.com/#/quizPerformance/14792898

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p. 402

Which questions would help the nurse assess a patient’s spirituality? Select all that apply.

Have you assigned a power of attorney? Do you wish to change your profession?

Rationale When assessing a patient’s spirituality, the nurse should enquire about the patient’s feelings and views on life, the level of connectedness with self and others, and the practice of religion. Asking if the patient attends church (religious practice), the one person the patient is closest to (connectedness), and the patient’s aim in life (view of life) would help the nurse identify the patient’s spiritual needs. Assignment of power of attorney and desire to change profession would not shed light on the patient’s spirituality. p. 403

Which interventions does the nurse teach a patient about time management to reduce work-related stress? Select all that apply. Shift from one task to another frequently.

E

.

P Use technology to execute many tasks at the same time. https://eaqng.elsevier.com/#/quizPerformance/14792898

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Rationale The nurse must teach the patient to avoid procrastination and set limits for tasks. This can be accomplished by setting clear goals for the tasks at hand and prioritizing them. Important tasks must be completed within a set time limit. This helps the individual complete the most important tasks first. The individual must practice techniques such as meditation or yoga to increase concentration. The nurse does not teach the patient to shift from one task to another, as this reduces cognitive ability and productivity. Likewise, the nurse does not encourage the use of technology for multitasking. It has been observed that multitasking causes significant stress and actually increases the time needed to complete tasks by 25 percent. STUDY TIP: Turn off the TV, your phone, your headphones, and other devices while you are studying. Your mind is more efficient if it is not shifting from external input to the content you are studying. p. 714

The nurse is assessing a family in which a wife is providing care for her husband, who is bedridden due to a chronic ailment. Which observations made by the nurse confirm that the wife is experiencing caregiver stress? Select all that apply. d

Changes in the patient’s treatment Improvement in patient’s health

Rationale A caregiver experiencing role stress may have mood changes due to stress. The relationship between the patient and his wife may become tense due to the demands https://eaqng.elsevier.com/#/quizPerformance/14792898

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of caregiving. A change in the caregiver’s health indicates that the caregiver is stressed by the responsibilities. A change in the patient’s treatment may be due to the improvement or aggravation in health. p. 710

A patient is suffering from chronic stress. Which gland in the patient’s body will initiate general adaptation syndrome (GAS)? Parotid Pituitary Pineal Adrenal

Rationale GAS is a three-stage reaction that describes how the body responds to stressors through different stages. When the body encounters a physical demand such as an injury, the pituitary gland initiates the GAS. The parotid gland secrets saliva and is not related to GAS. Pineal and adrenal glands do not initiate GAS. STUDY TIP: Remember that the pituitary gland is also called the master gland because it controls so many functions. It is vital in the process of homeostasis, and adapting to chronic stress is definitely part of homeostasis. p. 705

Which sign is an indicator of fluid volume imbalance in a patient? Moist tongue R Pink mucous membranes Absence of edema in the legs https://eaqng.elsevier.com/#/quizPerformance/14792898

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Rationale Skin turgor acts as an indicator of fluid volume imbalance. If fluid volume deficit is present, the skin remains pinched, or tented, after pinching, which indicates decreased skin turgor. The tongue and mucous membranes can also indicate the patient’s hydration status; a moist tongue and pink mucous membranes indicate a normal condition. Absence of edema in the legs is normal; edema in the legs can indicate a fluid excess imbalance. p. 968

Which nursing interventions are included in a patient’s care plan to prevent an air embolism during intravenous (IV) therapy? Select all that apply. Position the patient in a high Fowler’s position.

Monitor all gravity flow sets during the infusion. P Apply ice and elevate the extremity for 24 to 48 hours.

Rationale Air emboli occur due to the accidental entry of air into the bloodstream due to improper preparation of IV tubing or loose connections. To prevent this, the nurse clamps the IV catheter before changing the tubing. Priming all tubing with IV solution before attaching it to the catheter removes all air from the tubing and prevents its entry into the bloodstream. Placing the patient in a high Fowler’s position helps during fluid overload. Monitoring the gravity flow sets during infusion is done to prevent speed shock in the patient. Applying ice to the extremity for 24 to 48 hours and elevating the extremity is helpful if extravasation occurs during the IV infusion. p. 983

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What are the best ways to evaluate an elevated serum potassium level in a patient with renal failure? Select all that apply. Measure urine output.

Evaluate the patient’s level of consciousness.

Evaluate muscle strength.

Rationale Hyperkalemia is abnormally high potassium ion content in the blood. Hyperkalemia can be determined by assessing serum potassium levels. A plasma potassium level greater than 5 mEq/L is diagnostic for hyperkalemia. The ECG is the most reliable tool for identifying potassium imbalances. Urine output does not help in assessment of potassium levels in renal failure. The patient’s level of consciousness does not indicate serum potassium levels. Muscle weakness can be indicative of many problems and is not specific to hyperkalemia. p. 960

While receiving a blood transfusion, the patient develops chills, chest pain, and facial flushing. Which action by the nurse is priority? Notify the health care provider. Insert an indwelling catheter. Alert the blood bank.

Rationale https://eaqng.elsevier.com/#/quizPerformance/14792898

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Development of chills, fever, facial flushing, burning along the vein, lumbar or flank pain, chest pain, and shock during a blood transfusion is an indication of an acute hemolytic reaction. You stop the transfusion immediately so no more of the incompatible blood reaches the patient. Afterward, the following steps should be followed. Remove tubing and replace with new intravenous tubing and normal saline solution at keep-vein-open rate. Notify ordering physician immediately. Notify the blood bank. Monitor vital signs. Have emergency equipment available. Send remaining blood, blood tubing and filter, and a sample of patient’s blood and urine to the laboratory. Document the reaction, subsequent treatment, and patient response. Test-Taking Tip: Remember your #1 priority is the patient’s safety! Although notifying the health care provider and alerting the blood bank may also be eventual responses, stopping the transfusion is the first priority and thus the best response. p. 989

The nurse is using Kübler-Ross’s five stages of grief to assess a patient whose son was murdered. Which response might the patient give during the anger stage? "I will have to lead the rest of my life without him." "I talked with my son this morning." "I lost my only son; is there any reason to live?" "I

Rationale Kübler-Ross’s five stages of grief stage explain the emotional stages experienced by an individual during the process of grieving. The five stages are denial, anger, bargaining, depression, and acceptance. Anger is the second stage, during which the patient truly recognizes the circumstances of the loss. Patients may become angry with themselves or others and declare that they will punish the person responsible. Acceptance is the fifth stage, during which the person comes to the reality of loss and understands that https://eaqng.elsevier.com/#/quizPerformance/14792898

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he or she should lead the remaining part of life without the person who has died. Denial is the first stage. In this case, the reality of the son’s death is hard to face, so the patient may refuse to accept the situation. Depression is the fourth stage, during which the person comes to terms with the death of the son, becomes sad, cries, and may declare that there is no reason to live. p. 1071

The nursing instructor is teaching student nurses about anticipatory grief. Which example does the nurse give for anticipatory grief? A woman who has lost her husband in a bomb blast A woman who had an abortion at her partner’s insistence

A father committing suicide because his only son was murdered

Rationale Anticipatory grief is grief experienced by an individual before the loss occurs. It can occur when an individual is diagnosed with any terminal disease; therefore a person who is expected to live only a few more months due to cancer experiences anticipatory grief. The death of a person in a bomb blast is not an expected event, and a woman who lost her husband in this manner may experience complicated grief. A woman who underwent an abortion under duress may not be able to share her grief because abortion is an uncomfortable subject; she may experience disenfranchised grief. A person being murdered is not an example of expected death, and a father committing suicide after losing his son in this manner is an example of exaggerated grief. STUDY TIP: When you anticipate an event, it has not yet happened. Anticipatory (the adjective form of the verb anticipate) grief occurs before the loss. p. 1070

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Which nursing interventions are most appropriate for ensuring the safety of a patient with an unsteady gait? Select all that apply. Provide the patient a diet that is high in protein. Arrange for small frequent meals for the patient. P

.

Rationale Priority nursing interventions to ensure patient safety and minimize falls include making sure that floors are free of hazards (such as spills or other obstacles), providing nonskid slippers to the patient, and using transfer or gait belts with higher risk patients. Providing a protein-rich diet or small frequent meals does not enhance patient safety for a patient with unsteady gait. A protein-rich diet and small, frequent meals are appropriate for a patient who is immobilized and at risk for decreased appetite and negative nitrogen balance due to protein catabolism. p. 554

The nurse is preparing a care plan for a patient on bed rest. Which nursing interventions should the nurse include? Select all that apply. Instruct the patient to refrain from coughing exercises. . P

.

Encourage the patient to consume a diet low in protein.

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