Fundamentals of Nursing Practice Quiz 24

Answer: D – The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.

Explanation: Studies have shown that patients and nurses both respond well to primary nursing care units. Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. Nurses feel personal satisfaction, much of it related to positive feedback from the patients. They also seem to gain a greater sense of achievement and esprit de corps.

Answer: A – Assault and battery

Explanation: Assault is the unjustifiable attempt or threat to touch or injure another person. Battery is the unlawful touching of another person or the carrying out of threatened physical harm. Thus, any act that a nurse performs on the patient against his will is considered assault and battery.

Answer: A – Slander

Explanation: Oral communication that injures an individual’s reputation is considered slander, Written communication that does the same is considered libel.

Answer: D – Malpractice

Explanation: Malpractice is defined as injurious or unprofessional actions that harm another. It involves professional misconduct, such as omission or commission of an act that a reasonable and prudent nurse would or would not do. In this example, the standard of care was breached; a 3-month-old infant should never be left unattended on a scale.

Answer: A – The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia.

Explanation: The three elements necessary to establish a nursing malpractice are nursing error (administering penicillin to a patient with a documented allergy to the drug), injury (cerebral damage), and proximal cause (administering the penicillin caused the cerebral damage).

Answer: C – Immobility, diaphoresis, and avoidance of deep breathing or coughing

Explanation: An Asian patient is likely to hide his pain. Consequently, the nurse must observe for objective signs. In an abdominal surgery patient, these might include immobility, diaphoresis, and avoidance of deep breathing or coughing, as well as increased heart rate, shallow respirations (stemming from pain upon moving the diaphragm and respiratory muscles), and guarding or rigidity of the abdominal wall. Such a patient is unlikely to display emotion, such as crying.

Answer: B – Guaiac test

Explanation: To assess for GI tract bleeding when frank blood is absent, the nurse has two options: She can test for occult blood in vomitus, if present, or in stool – through guaiac (Hemoccult) test, A complete blood count does not provide immediate results and does not always immediately reflect blood loss, Changes in vital signs may be caused by factors other than blood loss, Abdominal girth is unrelated to blood loss.

Answer: D – Auscultation, percussion, and palpation

Explanation: Because percussion and palpation can affect bowel motility and thus bowel sounds, they should follow auscultation in abdominal assessment, Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen, Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis.

Answer: C – Normal bowel sounds

Explanation: High-pitched gurgles head over the right lower quadrant are normal bowel sounds, Hyperactive sounds indicate increased bowel motility, Two or three sounds per minute indicate decreased bowel motility, Abdominal cramping with hyperactive, high pitched tinkling bowel sounds can indicate a bowel obstruction.

Answer: C – Supine

Explanation: The supine position (also called the dorsal position), in which the patient lies on his back with his face upward, allows for easy access to the abdomen, In the prone position, the patient lies on his abdomen with his face turned to the side, In the Trendelenburg position, the head of the bed is tilted downward to 30 to 40 degrees so that the upper body is lower than the legs, In the lateral position, the patient lies on his side.