Test Bank All - MULTIPLE CHOICE 1. The nurse is caring for a gr...

Understanding Medical-Surgical Nursing, 6e Linda Williams, Paula Hopper (Test Bank All Chapters)

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Chapter 1. Critical Thinking and the Nursing Process

MULTIPLE CHOICE

• The nurse is caring for a group of patients on a medical-surgical unit. Which patient should

the licensed practical nurse/licensed vocational nurse (LPN/LVN) assess first?

• A patient with a blood glucose of 42 mg/dL
• A patient who reports a pain level of 2
• A patient who has just received a diagnosis of cancer
• A patient who has a respiratory rate of 22

ANS: 1

Chapter: Chapter 1 Critical Thinking and the Nursing Process

Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs.

Pages: 6–7

Heading: Prioritize Care

Integrated Process: Clinical Problem-Solving Process (Nursing Process)

Client Need: SECE—Coordinated Care

Cognitive Level: Application [Applying]

Concept: Patient-Centered Care

Difficulty: Difficult

Feedback

• This patient has a dangerously low blood glucose level and requires immediate

intervention.

• This patient will need to be assessed, but is not as high a priority.
• According to Maslow, psychosocial needs are not as high of a priority as

physiological needs.

• A respiratory rate of 22 is within normal range.

PTS: 1 CON: Patient-Centered Care

• The LPN/LVN enters the room of a patient who is angry and yells, “I asked 5 minutes ago

for my pain medication. I’m going to call the CEO of the hospital if you don’t get it for me now.” Which statement by the nurse demonstrates intellectual empathy?

• “We are short-staffed today, so it will take me longer to meet your needs.”
• “I am sorry you had to wait, I know you must be in a lot of pain.”
• “I had another patient who had severe pain, and I had to get to them first.”
• “I will get you the number for the CEO, but he is aware of how busy we are.”

ANS: 2

Chapter: Chapter 1 Critical Thinking and the Nursing Process

Objective: 2. Describe attitudes and skills that promote good critical thinking

Page: 2

Heading: Intellectual Empathy

Integrated Process: Communication and Documentation

Client Need: Psychosocial Integrity 2 / 4

Cognitive Level: Application [Applying]

Concept: Communication

Difficulty: Moderate

Feedback

• This statement does not consider an individual’s situation.
• This statement demonstrates intellectual empathy by considering this patient’s

situation and will likely alleviate the patient’s anger.

• This statement does not consider a patient’s situation and does not demonstrate

intellectual empathy.

• This statement addresses the patient’s statement of wanting to call the CEO, but

does not demonstrate intellectual empathy by considering the patient’s situation.

PTS: 1 CON: Communication

• The nurse is collecting data on a patient. Which data are described as subjective?
• Respiratory rate of 26 per minute
• Patient report of shortness of breath
• Coarse lung sounds bilaterally
• Cough producing green sputum

ANS: 2

Chapter: Chapter 1 Critical Thinking and the Nursing Process

Objective: 5. Differentiate between objective and subjective data.

Page: 4

Heading: Subjective Data

Integrated Process: Communication and Documentation

Client Need: Communication and Documentation

Cognitive Level: Application (Applying)

Concept: Communication

Difficulty: Moderate

Feedback

• Respiratory rate of 26 per minute is an example of objective data.
• A patient reporting symptoms to the nurse is an example of subjective data.
• Coarse lung sounds is an example of objective data.
• A productive cough is an example of objective data.

PTS: 1 CON: Communication

• A patient with a newly fractured femur reports a pain level of 8/10 and analgesic medication

is not due for another 50 minutes. Which action should the nurse take first?

• Reposition the patient.
• Give the medication in 30 minutes.
• Notify the registered nurse (RN) or physician.
• Tell the patient it is too early for pain medication.

ANS: 3

Chapter: Chapter 1 Critical Thinking and the Nursing Process 3 / 4

Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using the nursing process.

Page: 3

Heading: Clinical Judgement

Integrated Process: Clinical Problem-solving Process (Nursing Process)

Client Need: SECE—Coordinated Care

Cognitive Level: Application [Applying]

Concept: Patient-Centered Care

Difficulty: Moderate

Feedback

• The patient who has a fractured femur is having acute pain. Repositioning a

patient with a new fracture is not likely to relieve pain.

• Giving the medication before the prescribed time is beyond the nurse’s scope of

practice.

• The patient should not have to wait for pain relief, so the LPN should inform the

RN or physician so new pain relief orders can be obtained.

• The nurse needs to do more than expect the patient to wait for pain relief.

PTS: 1 CON: Patient-Centered Care

• The nurse is prioritizing care based on Maslow hierarchy of needs. Which need does the

nurse identify as having the highest priority?

• Job-related stress
• Feeling of loneliness
• Pain level of 9 on 0-to-10 scale
• Lack of confidence

ANS: 3

Chapter: Chapter 1 Critical Thinking and the Nursing Process

Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs

Page: 7

Heading: Prioritize Care

Integrated Process: Caring

Client Need: SECE – Coordinated Care

Cognitive Level: Application [Applying]

Concept: Patient-Centered Care

Difficulty: Moderate

Feedback

• Job-related stress falls under safety according to Maslow and is addressed after

physiological needs.

• According to Maslow, loneliness is addressed under social needs following

physiological and safety.

• Pain is a physiological need and is the highest priority.
• Lack of confidence falls under esteem according to Maslow and is addressed

following physiological, safety, and social needs.

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